Community pharmacists have an opportunity to address the healthcare disparities experienced by transgender and gender diverse patients, say Swapna Chaudhary and colleagues
Despite the unique healthcare needs of transdgender patients, the availability of appropriate healthcare services for these patients is scarce.¹
A lack of well-trained healthcare professionals in transgender care may put the already vulnerable population at risk of adverse health outcomes.² These patients are also less likely to access required care due to experiences of hardship, stigmatisation, marginalisation and sometimes denial of care in various healthcare settings, including pharmacy.³
As accessible health professionals, community pharmacists with an understanding of gender diversity have an opportunity to address healthcare disparities (see Table 1) to improve health outcomes for these patients.
A more visible population
With the increase in social acceptance and visibility of transgender and gender diverse (TGD) people, more TGD people are choosing to live their lives authentically.
The availability of safer and effective treatment options for gender affirmation has significantly increased the demand for transgender healthcare worldwide, including in Australia.4
Between 2011 and 2016, an endocrinology clinic in Melbourne reported a tenfold rise in TGD patient visits.5 The number of new referrals for TGD children at Royal Children’s Hospital, Melbourne surged to 104 in 2014 from fewer than 10 before 2011.6
On this basis, if you have not had a TGD patient visit your pharmacy yet, you soon will. When TGD patients receive culturally appropriate, respectful patient-centred care, they are most likely to engage with your pharmacy for the long term.
Table 1: Risks to health and healthcare disparities for TGD population1,3
Gender affirmation treatment: Access to treatment, lack of well-trained health professionals
High-risk behaviours: Needle sharing, unprotected sex, tobacco use, alcohol, and substance abuse
Mental health: Anxiety, Depression, Suicidal ideation and attempts
Sexual health: HIV and other STIs, Hepatitis, PrEP access, Contraception, Fertility preservation
*HIV: Human Immunodeficiency Virus, STIs: Sexually Transmitted Infections, PrEP: Pre-exposure prophylaxis
Two real-life scenarios of Australian pharmacists’ experiences of interacting with transgender patients—are we ready for the role?
Betty, a 22-year-old female, assigned male at birth, presents to her local pharmacy in her pretty dress with a script for 2mg estradiol valerate tablets. The Medicare card indicates her name as Mr Brian Hogg.
When Betty responds to intake questions, the male pharmacy assistant is surprised to hear a male voice.
This puzzles the assistant, and he stumbles in his conversation with this woman as he does not know which pronouns to use. He describes the situation to the female pharmacist.
Although the pharmacist is aware that hormonal treatment can be used for gender transition, she is also confused about Betty’s pronouns. When Betty asks for more information about the effects of the medication, the pharmacist does not feel confident in her knowledge including the effects of the medicine and its side effects in a transgender woman.
Although Betty receives the medication, the pharmacist is unsure about the most appropriate advice to give and feels that she has not delivered the best care to Betty.
A pharmacist on duty answers a phone call from a patient requesting emergency medication. The patient asks for an emergency contraceptive pill.
Hearing a male voice, the pharmacist asks to speak to their partner so that he can ask specific questions and decide whether this medication would be appropriate for her.
“Oh, but it is for me, not for my partner,” says the male voice over the phone. “I am sorry, but we don’t have contraceptive pills for men,” replies the pharmacist. “But I have female parts,” says the patient.
The pharmacist has not dealt with this before, and he is confused and responds: “Oh, I am sorry, I have no idea whether I can supply the pill to you. I think it would be better to see your doctor.”
Pharmacists’ role in TGD healthcare
In the UK and USA, pharmacists are an integral part of the multidisciplinary transgender healthcare team consisting of endocrinologists, GPs, nurses, psychologists, and speech therapists.7-9
Pharmacists in these teams individualise the gender affirmation treatment according to patient’s goals, their co-morbidities, and concurrent medications. Pharmacists in the UK who have completed an advanced practitioner course in non-medical prescribing are independently prescribing gender affirmation hormonal treatments to transgender patients.
Although pharmacists are integral members of most healthcare teams, the role of Australian pharmacists in a multidisciplinary team providing transgender healthcare is unclear.
Australian community pharmacies are already providing preventative services such as PrEP provision, smoking cessation, weight management, cardiovascular screenings and needle-syringe programs that are paramount to improve the healthcare outcomes of TGD patients. However, there is a lack of information about the cultural competency of Australian pharmacists and pharmacy staff, their attitudes towards TGD patients, and their training requirements.
Education in TGD healthcare
Training in transgender healthcare is not routinely included in undergraduate, postgraduate, and continuing professional development levels of pharmacy education in Australia.
Although all healthcare professionals, including pharmacists, have an important role in minimising the systemic barriers of accessing healthcare for TGD patients, many pharmacists have reported feeling uncomfortable and less confident while providing care to such patients.10,11
This may be due to a lack of both the pharmacotherapeutic knowledge in transgender healthcare and communication skills to establish a rapport with these patients.
According to the Professional Practice Standards (PPS) developed by the Pharmaceutical Society of Australia (PSA), pharmacists are required to deliver equitable and culturally respectful healthcare to every patient.
Pharmacists are also responsible for regularly reviewing themselves and staff for social and cultural responsiveness and maintaining a culturally safe practice environment.12 These standards align with the requirements of the Australian Pharmacy Council for education providers similarly to enable future pharmacists to provide culturally responsive and safe patient-centred care.13
Additionally, such care should be provided in an optimised physical environment. While pharmacy students and pharmacists are required to provide TGD patients with culturally responsive patient-centred care, the necessary educational activities in TGD healthcare that would prepare them for this role are lacking.
American pharmacists have called for extra training in transgender healthcare, and a few pharmacy schools in the US have integrated transgender healthcare training modules into their curricula.14,15
Other health professionals in Australia, such as doctors and nurses, have recognised the need for additional training in transgender healthcare and are working towards bridging the knowledge gap.16,17
In Australia, a transgender care training module has recently been made available for health professionals.18 Although this training may be beneficial to pharmacists, it does not include pharmacy-specific content.
What can pharmacists do?
As pharmacists, we frequently engage in patient interactions, educate patients about medications, and advocate for affordable care for all patients.
We are required to actively seek out learning opportunities to develop expertise in treatments for gender affirmation. Pharmacists and pharmacy students must be encouraged to familiarise themselves with available guidelines and protocols for gender affirmation treatments. Some available resources are listed below.
Pharmacists need to increase their awareness about available transgender healthcare resources, such as local TGD support groups and services or TGD-friendly general practitioners to assist these patients in navigating the healthcare system for support and affordable care.
TGD patients seeking hormonal therapy require long-term therapy along with appropriate preventative care and monitoring.
When these patients visit a pharmacy to fill their prescriptions, pharmacists can initiate conversations about the importance of preventive healthcare measures and engage these patients in preventive healthcare services available through pharmacies.
What can pharmacists do to provide better care?
- Provide culturally appropriate care to their TGD patients in a welcoming and inclusive environment.
- Train staff to provide culturally respectful and inclusive care to all patients. Think beyond binary and expand the vocabulary of gender identities. Ask for preferred names and pronouns and use those in the conversation to avoid misgendering TGD patients. Display non-judgemental attitudes and use gender-affirmative language to create a safe space for all patients, including TGD patients.
- Display rainbow or TGD flag stickers and other materials targeted at the LGBTQ community to create an inclusive environment.
- Install (if possible) a single-use, gender-neutral bathroom.
- Update the intake forms and dispensing software to include different gender categories
We would like to invite you to participate in an online survey on the attitudes, practices, and training needs of pharmacists in transgender healthcare via the following link: https://jcu.syd1.qualtrics.com/jfe/form/SV_0SzuPS9iIobf8rA
Or: Please scan the QR code to participate in the survey.
There will be an opportunity to express interest in participating in training at the end of the survey.
Advice for pharmacists
- Use gender-neutral language until you have asked for the pronouns. For example: Hi, how can I help you? Instead of Hi, how can I help you Sir or Madam?
- Introduce yourself with your pronouns and then ask for patient’s preferred name and pronouns. For example: My name is Samantha, and I use she and her pronouns. What is your preferred name and what pronouns do you use?
- Use patient’s preferred name and pronouns in your conversation with the patient. If you make a mistake, apologise, and move on with your conversation. Most TGD patients will see your effort and correct you if needed. For example: I apologise for using a wrong pronoun. I did not mean to disrespect you.
- Tell the patient that you have not dealt with this situation before, but you are happy to look up some resources and get back to them.
- Familiarise yourself with gender terminology, available gender affirmation guidelines and other transgender healthcare resources to provide appropriate advice.
Swapna Chaudhary, BPharm (Hons), GradCertAppPharmPrac, PhD Candidate, Lecturer, College of Medicine and Dentistry, James Cook University, Townsville
Associate Professor Robin Ray, RN, BEd, MHlthSc, PhD, Adjunct Associate Professor, College of Medicine and Dentistry, James Cook University, Townsville
Professor Beverley Glass, BPharm, BSc (Hons-Chemistry), PhD, NHD (Marketing), Professor of Pharmacy, College of Medicine and Dentistry, James Cook University, Townsville
Transgender Healthcare Resources:
- WPATH (World Professional Association for Transgender Health) Standards of Care19
- Endocrine Society Clinical Practice Guidelines20
- Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people21
- Position statement on the hormonal management of adult transgender and gender diverse individuals4
- Australian Standards of Care and Treatment Guidelines for trans and gender diverse children and adolescents22
- Zwickl S, Wong A, Bretherton I, et al. Health needs of trans and gender diverse adults in australia: A qualitative analysis of a national community survey. Int J Environ Res Public Health. 2019;16(24):5088. doi: http://dx.doi.org/10.3390/ijerph16245088.
- Cocohoba J. Pharmacists caring for transgender persons. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists. 2017;74(3):170-174. doi: 10.2146/ajhp151053.
- Redfern JS, Jann MW. The Evolving Role of Pharmacists in Transgender Health Care. Transgender health. 2019;4(1):118-130. doi: 10.1089/trgh.2018.0038.
- Cheung AS, Wynne K, Erasmus J, Murray S, Zajac JD. Position statement on the hormonal management of adult transgender and gender diverse individuals. Medical Journal of Australia. 2019;211:127-133. doi: http://dx.doi.org/10.5694/mja2.50259.
- Cheung AS, Ooi O, Shalem L, et al. Sociodemographic and clinical characteristics of transgender adults in australia. Transgender Health. 2018;3(1):229-238. doi: http://dx.doi.org/10.1089/trgh.2018.0019.
- Telfer M, Tollit M, Feldman D. Transformation of health‐care and legal systems for the transgender population: The need for change in Australia. Journal of paediatrics and child health. 2015;51(11):1051-1053. doi: 10.1111/jpc.12994.
- Kaigle A, Sawan-Garcia R, Firek A. Approach to the provision of transgender health care in a veteran population. The mental health clinician. 2017;7(4):176-180. doi: 10.9740/mhc.2017.07.176.
- Newsome C, Colip L, Sharon N, Conklin J. Incorporating a pharmacist into an interprofessional team providing transgender care under a medical home model. Am J Health Syst Pharm. Feb 1 2017;74(3):135-139. doi: 10.2146/ajhp160322.
- Tatum M. Transcending boundaries: the role of pharmacists in gender identity services. The Pharmaceutical Journal. May 2020 2020. doi: 10.1211/PJ.2020.20207614.
- Leach C, Layson-Wolf C. Survey of community pharmacy residents’ perceptions of transgender health management. J Am Pharm Assoc. 2016;56(4):441-445.e446. doi: 10.1016/j.japh.2016.03.008.
- Aragon KG, Conklin J, Lenell A, Rhodes LA, Marciniak MW. Examining community-based pharmacist perceptions on the care of transgender patients. J Am Pharm Assoc. 2019;59(4S):S62-S66. doi: 10.1016/j.japh.2019.03.014.
- Pharmaceutical Society of Australia. National Competency Standards Framework for Pharmacists in Australia 2016. website. https://www.psa.org.au/wp-content/uploads/2018/06/National-Competency-Standards-Framework-for-Pharmacists-in-Australia-2016-PDF-2mb.pdf. Published 2016. Accessed 21/09/2020.
- Australian Pharmacy Council. Accrediation Standards for Pharmacy Programs in Australia and New Zealand. website. https://www.pharmacycouncil.org.au/resources/pharmacy-program-standards/. Published 2020. Accessed 14/04/2021.
- Newsome C, Chen LW, Conklin J. Addition of Care for Transgender-Related Patient Care into Doctorate of Pharmacy Curriculum: Implementation and Preliminary Evaluation. Pharmacy (Basel). 2018;6(4). doi: 10.3390/pharmacy6040107.
- Ostroff JL, Ostroff ML, Billings S, Nemec EC, 2nd. Integration of transgender care into a pharmacy therapeutics curriculum. Curr Pharm Teach Learn. Apr 2018;10(4):463-468. doi: 10.1016/j.cptl.2017.12.016.
- Boucher I, Bourke SL, Green J, Johnson E, Jones LK. Addressing the health care needs of people who identify as transgender: what do nurses need to know? International Journal of Healthcare. 2020;6(2):14-22.
- Bretherton I, Grossmann M, Leemaqz SY, Zajac JD, Cheung AS. Australian endocrinologists need more training in transgender health: A national survey. Clinical Endocrinology. 2020;92(3):247-257. doi: http://dx.doi.org/10.1111/cen.14143.
- Andrews C, McNair R, Callegari B. The Trans GP module. website. https://nwmphn.org.au/for-primary-care/clinical-support/lgbtiq-support/. Published 2010. Accessed 14 Apr, 2021.
- Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. International Journal of Transgenderism. 2012;13(4):165-232. doi: 10.1080/15532739.2011.700873.
- Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-Incongruent persons: an Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism. 2017;102(11):3869-3903. doi: 10.1210/jc.2017-01658.
- Deutsch MB, ed. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. website. https://transcare.ucsf.edu/guidelines. Published 2016. Accessed 14 Apr, 2021.
- Telfer MM, Tollit MA, Pace CC, Pang KC. Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents Version 1.1. website. https://auspath.org/standards-of-care/. Published 2018. Accessed 14 Apr, 2021.