The Pharmacist as an LGBTQ Ally

• LGBTQ
• curriculum
• campus diversity
• health outcomes

The Oath of a Pharmacist as adopted by the American Association of Colleges of Pharmacy (AACP) states that a pharmacist will “consider the welfare of humanity and relief of suffering my primary concerns” and “apply my knowledge, experience, and skills to the best of my ability to assure optimal outcomes for my patients.”¹ As the vow considers all humanity, it does not discriminate based on creed, ethnicity, gender, sexual orientation, gender expression, or the like, yet members of minority groups do face challenges in accessing adequate health care resources and achieving the same health outcomes. The latest AACP Center for the Advancement of Pharmacy Education (CAPE) Educational Outcomes released in 2013 recognizes sexual orientation and gender expression as social determinants of health among the cultural sensitivity learning outcomes essential to a pharmacist’s practice and care approach and thus are part of the necessary knowledge and skills for the profession.² The American Society of Health-System Pharmacists (ASHP) is another major pharmacy organization that supports cultural competency, as do other organizations such as the American Pharmacists Association (APhA) and the American College of Clinical Pharmacy (ACCP).^3-5 The ASHP, for example, advocates for “providing culturally congruent care to achieve quality care and patient engagement”⁶ as part of education and training of pharmacists and creating an inclusive and diverse workforce.³

Health care disparities among members of the lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) community remain a major concern in the US health care system, and are often further complicated by racial and socioeconomic inequalities.⁷ Within the past decade, cultural shifts have raised awareness within society and instilled a heightened sense of inequality around personal rights for members of the LGBTQ community.⁸ In part through changes in laws and a growing realization of LGBTQ issues, health care providers recognize that members of this community face specific challenges that mirror those of other minorities.^7,9 Dissemination of knowledge about commonly perceived health burdens, such as human immunodeficiency virus (HIV), other sexually transmitted infections (STIs), and safer sex practices facing LGBTQ youth and adults is widely available. Research is now starting to investigate more specific problems facing this population.^9,10 Members of the LGBTQ community face a range of challenges in accessing health care, including mental health care (specifically for reassuring sexual orientation, transitioning for transgendered patients, drug misuse or abuse treatment), and chronic disease management.⁹ Beyond the oath of a pharmacist to “consider the welfare of humanity” there is a deeper meaning in educating future pharmacists to serve members of the LGBTQ community because this community, like many other minority communities, needs an ally in their pharmacist that has an understanding of their specific needs and has a voice.

According to the Centers for Disease Control and Prevention (CDC), lesbian, gay, and bisexual youth are five times more likely to attempt suicide compared to their heterosexual peers.¹¹ Gay and bisexual adult men have a lifetime suicide risk four times that of their heterosexual counterparts, while 19%-25% of transgender individuals reported an attempted suicide before undergoing gender reassignment surgery.¹² Among young adults, access to health care is significantly easier for white gays and lesbians than for their racial or ethnic minority counterparts. Transgender and questioning/queer patients report a significantly higher rate of negative experiences compared to cisgender individuals disclosing their sexual and gender identity to their health care providers and subsequently being denied service.⁷ In the same survey, among young LGBTQ patients, access to health care was rated as relatively easy by only 68% of participants. Furthermore, higher rates of uninsured respondents (42.7% vs 20.4% of the general population from national data) and lower rates of respondents with private insurance (32.0% vs 61.5% of the general population from national data) were reported.⁷ These health disparities cannot be resolved overnight and there have been ongoing discussions among College of Pharmacy deans and the AACP on how to better serve the LGBTQ+ population.⁵ However, each institution and college is left to their own devices to implement changes and adapt to an increasingly diverse and inclusive patient population. Colleges must ensure that future generations of pharmacists are well prepared to meet a more diversified patient population.

Pharmacists are in a unique position as health care providers to counsel patients regarding medication use and offer a final crosscheck to ensure optimal adherence and health outcomes. As such, they are able to connect with patients in a personal manner to advise on sensitive matters that require both enhanced cultural and communication skills tailored to the individual patient. This includes applicable knowledge about the unique needs of members of the LGBTQ community. Several surveys conducted at US pharmacy schools found that a majority of faculty members and administrators thought that current pharmacy curricula did not provide adequate or sufficient knowledge on LGBT health and most would like to see more hours dedicated to topics such as mental health, LGBT adolescent health, and transgender health care.^9,13,14 Furthermore, many Doctor of Pharmacy (PharmD) students and pharmacists do not feel adequately prepared or trained to counsel members of the LGBTQ community in their practice setting, regardless of whether it be community, hospital, or other work environment.^14,15 Another situation that may impact health care access by LGBTQ patients can occur when a pharmacist or other health care professional allows their personal perceptions of the individuals perceived lifestyle or morality of their patients to influence their judgements.¹⁶ If pharmacists devalue the needs of the LGBTQ community and morally disengage with them, it adds to the stigma these patients feel and creates a cognitive dissonance with the pharmacist’s code of ethics. Research has shown that a single negative experience, especially for transgender patients, can lead to cessation of any further interaction with health care professionals.^17,18

In a study of community pharmacists and transgender patients both cohorts agreed that better knowledge of and positive attitudes towards transgender patients among health care providers is needed. Furthermore, the researchers found an association between pharmacists’ attitude/perception of LGBTQ patients and their religious affiliation, and that having certain religious views may contribute to pharmacists’ willingness to serve transgender patients.¹⁵ Surveys that evaluated the perceived need for inclusion of LGBTQ-specific content in the PharmD curriculum reported, depending on how the question was phrased, support in the range of 60%-85% independent of public or privately held organizational structures of the institution.^9,10,13 In order to serve LGBTQ patients adequately, future pharmacists need to be trained not only on general topics related to health care but also how to appropriately address and interact with this patient population. Transgender, questioning/queer, or intersexual patients may want to be addressed either according to their identified gender, as “they” rather than he or she, or by other preferred pronouns. In the event of a patient changing their name, prescriptions written before the name change was made can be confusing when a patient requests a refill. Such situations require sensitive communication between the pharmacist and the patient to avoid mistakes and offending or embarrassing the patient.

The necessity to train future pharmacists affects the current faculty, as potential faculty training needs require assessment of additional resources within the college. This assessment should encompass both a current evaluation of the college climate in regard to perceived biases towards members of the LGBTQ community as well as future needs of incorporating LGBTQ-specific content into the PharmD curriculum and the willingness of both students and faculty members to embrace such change. Several pharmacy schools have followed the Accreditation Council for Pharmacy Education (ACPE) standards on cultural competence to incorporate LGBTQ cultures and health issues into the PharmD curriculum. Per ACPE recommendations, the use of standardized patient scenarios, didactic lectures, student reflections, and guest panel discussions led to increased knowledge and higher confidence for students interacting with transgender, gay, and lesbian patients.^19-21 Such curricular changes are within the desired ACPE guidelines of cultural competency and do not require replacement of other existing content but rather modification to recognize the unique needs of the LGBTQ patient population. As such, expanding on specific LGBTQ health care topics can be part of existing cultural competency training, while relevant pharmacotherapy interventions and management can be integrated into existing lectures, active-learning sessions, ongoing curricular training events, and relevant introductory and advanced pharmacy practice experiences.

In the interest of serving our patients while ensuring their health and safety we should dedicate ourselves to the welfare of humanity, serving as an ally to those who need it most and are at greatest risk of being marginalized. Through combined efforts in academia, corporate settings, and clinical practice pharmacists can impact and improve lives within their communities and at times transcend the essential patient care to assist in a more holistic manner. By recognizing each other as human, by caring for each other.

• Received September 1, 2019.
• Accepted December 22, 2019.

• © 2020 American Association of Colleges of Pharmacy