Health Equity
Loren Bonner
One out of three transgender individuals have had a negative experience at a medical visit, according to the most recent statistics that date back to 2015. Twenty-three percent don’t engage in medical care due to fear of mistreatment, and 25% to 55% have issues with insurance covering their care.
“All of these things can lead into health disparities,” said Kelsea Gallegos Aragon, PharmD, CDCES, BCACP, assistant professor of pharmacy practice and administration at the University of New Mexico College of Pharmacy, who presented at APhA2022 on providing quality care to LGBTQ+ patients.
“We need to make sure we are creating safe practice spaces for these patients [for them] to interact with the health care system,” she said.
Even if the health care system is not adequately prepared to address the unique needs of transgender patients, pharmacists and other health care providers can learn how to best care for this population.
“We are not taught any of this, but we have an obligation to learn,” said Aragon.
A good place to start is with pronouns and communication. “I can’t overstate the importance of pronouns,” said Aragon. “Research has found that using correct pronouns [with transgender individuals] can decrease [their] rates of severe depression by 70% and decrease suicide attempts by 65%.”
“I always introduce myself with my pronouns and ask them to tell me a little bit about ‘you,’” Aragon said.
She said some patients may identify as one gender, but are not yet ready to use pronouns for that gender. Providers should periodically check in and make sure the patient is still using the same pronouns as before. (It is also no longer appropriate to ask for someone’s “preferred” pronoun because “preferred” suggests that using those pronouns is optional and not obligatory.)
Electronic medical records and other systems of care typically don’t have a place to put pronouns. In these cases, providers should determine how to record sex assigned at birth and affirmed gender. For any intake forms, Aragon said pharmacists and staff can collect sex and gender as separate markers on intake forms.
Overall, Aragon said she tries to use gender-neutral pronouns in daily life all of the time. “Get used to [the singular] ‘they’ is what I’ve been trying to do as well as being gender affirming in everyday life is the goal,” she said.
Medication therapies
“As pharmacists, we are interested in the pharmacology of it all,” said Aragon.
Treatment is available for gender dysphoria, and the number and type of options is completely individualized.
“There is no right way to be gender-ex-pansive. Some patients might want hormone therapy; some may not. Some might want gender affirming surgeries.
These services can be covered; it’s just the language we use to make sure medications are being covered and the surgeries are also covered,” Aragon said.
The general approach of feminizing hormone therapy is a combination of estrogen with an antiandrogen, the common one being spironolactone. The approach for masculinizing hormone therapy is testosterone monotherapy. “Testosterone is a powerful drug and the only hormone we have for masculinizing,” said Aragon.
Subcutaneous injections of both estradiol and testosterone are guideline-recommended therapies.
“When I work with patients, I tell them ‘you tell me how you feel on your hormone therapy, and my job is just to make sure we keep you safe,’” said Aragon. “We adjust [their] hormones based on how [they] feel. We don’t have to push [them] to the completely full level of female or male hormones because that might not feel right for them. We want to make sure we are individualizing care as much as we can,” she said. ■
Guide on inclusivity
The Human Rights Campaign Foundation and APhA released a guide for pharmacies on transgender and gender-diverse inclusion, “Providing Inclusive Care and Services for the Transgender and Gender Diverse Community: A Pharmacy Resource Guide” (www.thehrcfoundation.org/professional-resources/transgender-pharmacy-guide). The guide serves as an educational tool and a resource for pharmacists and pharmacy staff on how to be inclusive to transgender, nonbinary, and gender-diverse patients.