Strategies to Bring Transgender and Non-binary Health Care into Pharmacy Education

Health Disparities Among Transgender and Non-binary Persons

The term transgender is frequently used as an umbrella term describing someone whose gender identity differs from the sex they were assigned at birth. The term cisgender, or non-TNB, describes someone whose gender identity is the same as their sex assigned at birth. Typically, sex is assigned at birth based on genitals. Gender identity, however, is the brain’s understanding of “self” as a woman, a man, a combination of both, or neither, and is usually established at around two to six years of age.¹² Non-binary persons identify as being other than a man or woman or not exclusively a man or woman. Gender nonconforming people have gender expressions and/or identities outside of societal norms. Not all non-binary people identify as transgender. Thus, we have chosen the term TNB to ensure inclusion of a broader range of people with transgender and non-binary identities. Because many non-binary people also identify as transgender, we chose to use TNB rather than the term transgender when discussing published studies that did not specifically delineate between transgender and non-binary identities.

The TNB community experiences significant disparities across all determinants of health, including higher rates of homelessness, unemployment, and poverty.^12-14 Additionally, experiences of violence and victimization are frequent for TNB individuals and result in long-lasting effects on both the individual and the community.^12,15,16 According to the National Transgender Discrimination Survey, 40% of TNB people reported suicide attempts, as compared with 4.6% of the general population.¹³ There is strong evidence that gender affirming care, including pharmacotherapy, is highly effective at resolving gender dysphoria while also improving the patient’s quality of life. However, TNB patients often face barriers when seeking medical care.¹⁷ One in four adult TNB patients will delay necessary health care for fear of discrimination.¹² Transgender and non-binary youth have also reported avoiding doctor check-ups more frequently than their non-TNB counterparts.¹⁸ In addition to dealing with discrimination and bias, more than half of TNB patients describe feeling obligated to educate their provider in order to receive appropriate care.¹² For instance, a recent US survey reported that 71% of TNB patients found it necessary to enlighten providers at some point. Roughly 20% of respondents obtained prescription medications from close contacts or online pharmacies that do not require a prescription. Moreover, 46% chose to use natural products to avoid needing a prescription altogether.¹⁰

Current Status of TNB Care in Health Care Professional Education

Health care professional education programs, including medicine, nursing, and physical therapy, have identified curriculum gaps in patient care education regarding lesbian, gay, bisexual, TNB, and queer (LGBTQ+) persons. ^6,19-21 Nearly a decade ago, Parkhill and colleagues described the need for TNB health content in pharmacy curricula.²¹ The Association of American Medical Colleges (AAMC) released a report in 2007 recommending incorporation of educational activities addressing the needs of LGBTQ+ students and patients.²² In 2014, the AAMC released another report detailing curricular and institutional climate change recommendations necessary to improve health care for LGBTQ+ individuals.²³ This report encouraged schools to teach excellent communication skills and comprehensive care for the LGBTQ+ population. The report included 30 competencies that could be integrated into schools’ curricula. Medical schools that added more hours of LGBTQ+ topics into existing classes ascertained that students were more prepared and comfortable caring for the LGBTQ+ patient population.^24,25 In 2018, the American Nursing Association released a position statement titled, “Nursing Advocacy for LGBTQ+ Populations” which “affirms the need for nurses in all roles and settings to provide culturally congruent, competent, sensitive, safe, inclusive, and ethical care to members of LGBTQ+ populations, as well as to be informed and educated about the provision of culturally competent care.”²⁶ However, while the gaps in LGBTQ+ curricula have been identified and schools have begun integrating this curricula into their programs, inadequate acknowledgement or inclusion of TNB-specific health care needs and education still remains throughout all health professions.^6-9,27

Overcoming Barriers to Including TNB Health Care in Pharmacy Curricula

Reasons for the lack of TNB-related instruction in pharmacy curricula may be multifactorial. Eckstein and colleagues reported that 47% of pharmacy programs had no access to qualified faculty able to teach TNB-related care in their curricula.⁶ While faculty may not have received specific training or have extensive experience caring for TNB people, it is possible for them to educate themselves in this area so that they are able to teach students. It is not uncommon for faculty, especially junior faculty, to lecture on topics in which they possess limited first-hand clinical experience. Free resources available to faculty for self-education on appropriate terminology and practice guidelines related to serving TNB patients are listed in Table 1. Furthermore, faculty can have outside experts and consultants present on the topic or faculty can collaborate with an expert to develop content. Ideally, pharmacy education in TNB patient care should be accurate and comprehensive. For example, if non-binary patients are left out of the discussion, students may not be able to provide quality care for these individuals.

Other barriers cited by pharmacy programs to incorporating content on TNB patient care in the curriculum include difficulty in changing the curriculum (33%) and not having enough time to teach TNB patient care within the curriculum (21%).⁶ While a complete overhaul to the Doctor of Pharmacy curricula in general remains a long-term goal, it is possible to immediately integrate material regarding TNB patients within existing courses. For example, instructional patient cases can introduce TNB patients for any disease state to facilitate student exposure and familiarity. This could include commonly described disease states such as hypertension, diabetes, or pneumonia. Specifically, it is vital that educators avoid relevant communication about TNB being limited to discussions surrounding sexually transmitted infections or hormonal pharmacotherapy. There are several journals articles that describe ways in which pharmacy schools have incorporated transgender pharmacy care into their curriculum that can serve as useful resources.^28-31

Additional obstacles to further development or implementation of TNB content in pharmacy curricula are an absence of interest in including these topics (15%) and lack of support from the faculty (8%).⁶ It is important to acknowledge that faculty are not required to fully understand or morally agree with a TNB patient’s choices in order to be supportive and provide them with evidence-based medicine and life-saving affirming care. Faculty can empower students to be empathetic and provide quality care regardless of their personal beliefs.

The inclusion of TNB health care meets several of the Accreditation Council for Pharmacy Education (ACPE) Standards 2016.⁵ In case-based learning, educators can create cases with a TNB patient and require the student to evaluate the patient as a whole to make specific recommendations for gender affirming care or other conditions to meet Standard 2.1 (Patient-centered Care). Standard 2.4 (Population based care) and Standard 3.5 (Cultural sensitivity) can be met by discussing health disparities among TNB patients and guiding students regarding the value of using non-gendered language or pronouns.

Appropriately inquiring about and being supportive of a patient's gender identity enhances the patient-provider interaction and encourages regular use of care. ³² Students should reflect on their beliefs and attitude about TNB people for their awareness and personal growth and to be able to meet Standard 4.1 (Self-Awareness). Having students examine their own gender identity offers powerful opportunities to gain self-awareness of implicit biases and learn how these often subconscious preconceptions impact patient care. Two examples of thought-provoking questions are “How did you know what your gender was?” and “What reactions arise in you when you meet a person who tells you they are transgender or non-binary?” Table 2 lists recommended TNB patient care topics to include in pharmacy curricula.

Treating the Whole TNB Patient

As noted earlier, several health care professions have identified ways to increase awareness of the LGBTQ+ population. However, TNB patients have medical needs that reach beyond cultural competency. Discussion of increased prevalence of HIV, depression, suicide, and substance abuse is often found in the medical and pharmacy literature regarding the TNB community and the majority of research focuses on these areas. Nonetheless, the association between marginalized gender identities and other physical health outcomes is lesser known. In a study comparing TNB and cisgender Medicare beneficiaries, TNB people were younger but had more chronic conditions than their non-transgender counterparts. These conditions included higher rates of asthma, neurological/chronic pain conditions, obesity, chronic obstructive pulmonary disease (COPD), and hepatitis and other liver conditions.³³ Additionally, a 2014 study found that TNB individuals were at higher risk for having poor general health, more days per month with poor physical health, and myocardial infarction, regardless of hormone use. Transgender and non-binary individuals were also less likely to utilize primary or dental care services or have access to health insurance. However, contrary to the findings of other studies, TNB individuals were no more likely to smoke or binge drink than non-TNB individuals.³⁴

Ideally, TNB patient care should be woven throughout the curriculum so students have multiple exposures to reinforce and expand on previously learned materials. While there are components of TNB patient care that are specific to the TNB population, TNB patients are susceptible to the same disease states as cisgender patients. By focusing solely on conditions related to gender identity, students may not view TNB patients holistically or recognize health care needs outside of their gender identity.