A Critical Takeaway
When Newsome joined the faculty at WSU a few years ago, she began teaching three hours of transgender care in a required course. She taught the terminology and pharmacotherapy of transgender care, elaborating on patient interaction and pronoun etiquette. Other faculty members took notice and followed suit, creatively weaving LGBTQ+ content into their courses.
Last year Newsome added a case study on masculine hormone therapy for trans masculine individuals to the men’s health session in the P3 year. It serves as a refresher for students and gives them the opportunity to ask more questions. In the fall she expanded on cancer screening discussions in the oncology block, describing how easily cancer screenings can be missed in trans people, how a person who presents as male may have a cervix and need a Pap smear. Her fellow faculty members added a two-hour lab session to the first-year communications course on gender minorities, focusing on women and trans people. They plan to add a transgender case to the applied patient care lab in the spring, where students will identify pharmacotherapy-related concerns as they work through the patient case.
But what has had the greatest impact on students has been facilitating opportunities for them to see how pharmacists can make a difference. Newsome’s students rank discussion with a guest speaker as the thing that has helped them the most. Newsome noted that when schools bring in a respectable community member who is transgender, students are able to hear a personal story and make a connection that opens their eyes and inspires them to care for LGBTQ+ individuals. That’s what Newsome believes students need to know most: the impact they can make.
“My guest speaker has had good experiences with pharmacy and bad experiences with pharmacy. He shares the experiences his trans friends have had with healthcare professionals, too,” she said. “When students hear from an individual who has had a bad experience or a good experience, they begin to understand the impact they can make by being a trans-competent provider. It helps them see why it’s important to learn this material and it helps them feel more comfortable and confident stepping up to be a good provider. Obviously, the medications are important, but they are not complicated and that information is readily available. Pharmacists are good at looking things up, so I think the key piece is helping students build that empathy and desire to help trans people.”
UF has also modernized its Pharm.D. curriculum, increasing the number of diverse case studies, including LGBTQ-specific cases, during active learning sessions. “When we talk about hormone therapy, we talk about transgender patients. When we talk about the different stages of aging, we include either a lesbian woman or gay male, maybe in a case relating to prostate cancer, but we don’t want to stereotype here, we don’t want to bring out a gay male case when it comes to HIV/AIDS. We want to be diverse in that as well,” Grundmann said.
He would like to see a more holistic approach to the pharmacy curriculum that underscores that a person’s sexual orientation or gender expression—while only one element that defines someone’s identity—may impact daily life and well-being. And when it comes to LGBTQ+ issues, he would like programs to look at the social, economic and medical disparities that jeopardize the long-term health of this population. “What I want to see is that LGBTQ+ issues are consistent throughout the curriculum, that we do not only look at it in one course and then make a checkmark, because it really stretches from medication care to health insurance coverage to inequities in disadvantaged areas, depending on where you live,” Grundmann emphasized. “There are many different factors that impact a person. We need to be aware of that and think about how we as pharmacists can provide overall care to patients.”
The First Step
Before pharmacists can provide holistic care, they must create an environment where LGBTQ+ patients feel comfortable, safe, welcome and affirmed. “Sexual gender minorities face health disparities in every arena of life, whether it’s related to substance use disorders or just access to care. Those disparities are real and prevalent,” said Dr. Kyle Melin, associate professor at the University of Puerto Rico School of Pharmacy. “Until we as a profession learn how to create an environment where LGBTQ individuals feel safe and welcome in our healthcare settings, we are not going to be able to address their healthcare needs and those disparities which come out of those needs. Until we undo that barrier and create an environment where they feel safe and respected, we are not going to be able to help people the way we want to.”
At the University of Puerto Rico, the majority of LGBTQ+ education has centered on cultivating such cultural competency. Melin is working on ways to incorporate LGBTQ+ issues into the therapeutics curriculum, particularly concerning transgender and gender nonbinary patient care, improving instruction relating to hormone therapy and gender affirming therapy to better build the capacity of pharmacists. While Melin has not seen much movement at any official level to accredit LGBTQ+ content as a national standard, he has seen movement among students. Students are seeking out this content and training and have identified it as an area that they want to work on to be better prepared as pharmacists to provide care for all patients. “The students have been incredibly positive and highly motivated. They are really helping to push the profession forward,” Melin noted. “That’s why I like working with students—they have not resigned to things being the way they are and they have this sense of, ‘We can make things better,’ and they inspire us to do that.”
Melin’s research and work with students led to a study assessing readiness to provide pharmaceutical care to transgender patients, gleaning perspectives from pharmacists and transgender individuals, that was published in the Journal of the American Pharmacists Association. The study found that pharmacists were aware of their knowledge deficits when it comes to providing care for transgender patients and that they were open to receiving training and education. He and his students worked on providing a continuing education program, published in Pharmacy Practice, and once again found that pharmacists were eager to improve.
Melin also found that despite what pharmacists did not know, transgender patients still believed pharmacists could play an important role in their healthcare. “In conversations with transgender individuals there was this sense that, pharmacists know about medications and I am taking different medications and they can help me, even if they don’t know about pronouns or don’t understand my identity or understand how I would prefer to be spoken to, they can help me,” Melin said.
One distinction that Melin and Newsome point out: Within the LGBTQ community, individuals have different needs. “We say LGBT all the time, but the T is kind of this add-on, like they’re included in this catch-all umbrella of LGBT, but it’s a subpopulation that’s really been neglected or overlooked even within the lens of LGBT work,” Melin said. “There’s so much more we have to do as a society and as a profession as well to prepare our pharmacists to understand the unique needs and disparities faced by transgender and gender nonbinary individuals.”
The American College of Clinical Pharmacy updated its pharmacotherapy didactic curriculum toolkit in 2019, categorizing what topics should be covered into three tiers. (Tier 1: Students must be taught this in therapeutics courses. Tier 2: If there’s time, it would be good to include. Tier 3: Students are responsible for learning this on their own.) Gender affirming care was added to the toolkit in 2019 as a Tier 3, listed as not necessary to include in therapeutics courses. Newsome sees that as a step in the right direction, that transgender-related care is starting to appear on the radar, but fears people still do not understand its importance.
“If you’re not teaching it, I guess one of the assumptions I make is you don’t think it’s important enough to teach, so I always try to emphasize the risks of graduating pharmacists who are not competent to care for the LGBTQ community,” Newsome explained. “What are the risks of those microaggressions that patients continually face? What does that add up to? The suicide attempt rate for people who are transgender is nine times higher than the general population. Part of what I think leads to that is the mistreatment from medical providers and the lack of trust there, so I try to emphasize the importance of this education and the risks of putting providers out there who are not equipped to help care for this vulnerable population. They can do harm, and that’s not what we want to do.”
Athena Ponushis is a freelance writer based in Ft. Lauderdale, Florida.
