- Email: [email protected]
Examining community-based pharmacist perceptions on the care of transgender patients
SCIENCE AND PRACTICE Journal of the American Pharmacists Association 59 (2019) S62eS66
Contents lists available at ScienceDirect
Journal of the American Pharmacists Association journal homepage: www.japha.org
RESEARCH NOTES
Examining community-based pharmacist perceptions on the care of transgender patients Kelsea Gallegos Aragon, Jessica Conklin, Amy Lenell, Laura A. Rhodes, Macary Weck Marciniak* a r t i c l e i n f o
a b s t r a c t
Article history: Received 15 September 2018 Accepted 26 March 2019 Available online 13 June 2019
Objective: The objective of this study was to determine whether community-based pharmacists in North Carolina have the personal confidence, comfort level, and resources needed to care appropriately for and interact with transgender patients. Methods: Using the North Carolina Board of Pharmacy database, a link to a 25-item questionnaire was e-mailed to all actively licensed community pharmacists in North Carolina. Survey items included pharmacist demographics, prior or current education on transgender health care, comfort regarding care provision for transgender patients, and the ability to care for transgender patients at the practice site. Questionnaire items were developed in collaboration with a pharmacist who actively participates in the care of transgender patients. The questionnaire was pilot-tested among a convenience sample of student pharmacists and pharmacists for feedback on validity and question structure. The survey was open for 30 days with a reminder sent on day 15. Upon survey completion, participants had the option to be entered into a drawing to receive a gift card incentive. Results: In total, 342 surveys were completed of 4784 surveys distributed, yielding a 7.1% response rate. Three percent of survey respondents reported receiving education on treating transgender patients during their respective pharmacy school curricula, and 12% of respondents sought other forms of transgender education (i.e., continuing education). Seventyone percent of respondents viewed the role of the pharmacist as important in the care of transgender patients. Sixty-six percent of respondents were comfortable welcoming transgender patients into their practice sites, and 36% were comfortable asking for pronouns. Conclusion: Survey participants reported a lack of formal or postgraduate education, which describes a need for accessible education on transgender care. North Carolina communitybased pharmacists believe that it is within their role as pharmacists to provide genderaffirming care, but they may need additional training to feel comfortable in providing this care. © 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
Disclosure: Macary Marciniak declares that her spouse is employed by the American Pharmacists Association. The remaining authors declare no conflicts of interest or financial interests in any product or service mentioned in this article. Contributions: Conceptualization (all), data curation (K.G.A.), formal analysis (K.G.A., L.A.R.), funding acquisition (all), investigation (K.G.A., A.L.), methodology (all), project administration (all), resources (K.G.A., A.L.), supervision (all), validation (all), visualization (all), writing of original draft (K.G.A.), review and editing (all). Previous presentations: American Pharmacists Association Annual Meeting and Exposition, Nashville, TN, March 2018; Sex and Gender Health Education Summit, Salt Lake City, UT, April 2018; Research in Education and Practice Symposium, Chapel Hill, NC, May 2018. * Correspondence: Macary Weck Marciniak, PharmD, BCACP, BCPS, FAPhA, Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 115G Beard Hall, Campus Box 7574, Chapel Hill, NC 27599-7574. E-mail address: [email protected] (M.W. Marciniak).
In 2016, it was estimated that 1.4 million adult Americans (0.6% of the population)1 and 150,000 adolescents identified as transgender.2 There is increased visibility and recognition of transgender individuals in recent years,1,3 leading to increased insurance coverage of health care services related to transgender health. For the first time, the U.S. Department of Health and Human Service’s Healthy People 2020 initiative has objectives related to collecting data on (or for) transgender populations and standardizing data to identify transgender populations. Included in the data collection portion of Healthy People 2020 is for health care professionals to inquire about a patient’s gender and sexual identity to improve patienteprovider relationships in the lesbian, gay, bisexual, and transgender (LGBT) community.3 The gender identity of transgender individuals does not align with their sex assigned at birth. The Diagnostic and
https://doi.org/10.1016/j.japh.2019.03.014 1544-3191/© 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
SCIENCE AND PRACTICE Pharmacist perceptions on transgender care
Statistical Manual of Mental Disorders (DSM-V) provides a diagnosis of “gender dysphoria,” which is defined as the distress or discomfort individuals might feel when their assigned sex and gender identity do not align. According to the National Center for Transgender Equality, 50% of transgender patients have to teach their medical providers regarding their unique care needs, and almost 25% of respondents did not seek health care because they feared being mistreated.4 This finding reinforces the importance of recognizing that transgender patient care should be affirmed and individualized. Not all transgender patients choose to pursue pharmacologic interventions, but those who do will require additional medication monitoring and are exposed to the potential risks and adverse effects of the medication. There are distinct clinical factors to consider when providing care to a transgender individual compared with a non-transgender person (also known as cisgender). For example, transwomen (designated male at birth) receiving estrogen therapy should be monitored for deep venous thrombosis.5 In addition, depression, suicidality, and anxiety might be higher in transgender individuals. The National Transgender Discrimination Survey reports a suicide attempt rate of 4.6% in the general U.S. population compared with 41% in the transgender population.6 Transgender youth have higher rates of depression (50.6% vs. 20.6%) and anxiety (26.7% vs 10.0%) when compared with cisgender youth.7 The pharmacist’s role within transgender care has been described within interprofessional teams; however, more information is needed within the community pharmacy setting.8 As medication experts, pharmacists should have knowledge regarding transgender pharmacotherapy and care of individuals. However, minimal literature is available describing formal education on the care of transgender patients in the curricula of schools and colleges of pharmacy. In a survey of postgraduate year 1 (PGY-1), community-based pharmacy residents, more than 80% of respondents believed that community pharmacists are integral in providing care for transgender patients, but more than 70% of these respondents were not formally educated about treating transgender patients in pharmacy school.9 In addition, less than 37% of respondents believed that they had sufficient knowledge or confidence in treating transgender patients.9 Additional literature supports the claim that student pharmacists who had access to and attended a lecture on transgender health were more likely to have greater knowledge and confidence when treating this patient population.10 Objective The primary objective of this study was to determine whether community-based pharmacists in North Carolina have the personal confidence, comfort level, and resources needed to care appropriately for and interact with transgender patients. Methods This cross-sectional survey was conducted online using Qualtrics and was exempted from review by the Institutional Review Board at the University of North Carolina at Chapel Hill. Using the North Carolina Board of Pharmacy’s (NCBOP) database, a link to a 25-item questionnaire (Likert scale, multiple
choice, and 1 free text response) was e-mailed to all actively licensed community pharmacists. The authors defined actively licensed as an individual who has earned and maintained an active, nonexpired pharmacist license in the state of North Carolina. The e-mail was distributed by the NCBOP to the email address on the registrant’s record, which could have been a personal or work e-mail address depending on the preference of the pharmacist. Those included in the survey were those who were actively licensed, community-based pharmacists registered with the NCBOP. Pharmacists with invalid e-mail addresses or who were not practicing in the community setting were excluded from the survey. Survey items included pharmacist demographics, prior or current education for transgender health care, comfort regarding care provision for transgender patients, and the ability to care for transgender patients at their practice site. Questionnaire items were based on current literature, past surveys, and in collaboration with a pharmacist who actively participates in the care of transgender patients. The survey instrument is in Appendix 1, available on JAPhA.org as supplemental content. The questionnaire was pilot-tested among a convenience sample of 27 individuals for feedback on validity and question structure. These individuals included student pharmacists, pharmacist practitioners, and pharmacists whose primary job function is academia. The survey was open for 30 days from January to February 2018 with a reminder sent on day 15. As an incentive to participate in the survey, participants had the option to be entered into a drawing to receive a gift card upon survey completion. Survey responses were excluded if the participant did not complete the survey in its entirety. Descriptive statistics were used to analyze data.
Results In total, 342 surveys were completed of 4784 surveys distributed, yielding a 7.1% response rate. Table 1 demonstrates demographic information collected from the responding pharmacists, including their pronouns for which 3 respondents use the gender-neutral pronouns “ze/zir.” Three percent (11/342) of survey respondents reported receiving education about caring for transgender patients during their respective pharmacy school curricula, and 12% (40/342) reported seeking other forms of transgender education (i.e., continuing education) after their pharmacy degree was conferred. Seventy-one percent (243/342) of respondents reported that they viewed the role of the pharmacist as important in the care of transgender patients. Sixty-six percent (226/342) of respondents were comfortable welcoming transgender patients into their practice sites. When asking a patient for their pronoun, pharmacist comfort levels varied: 36% (122/342) were comfortable, 33% were uncomfortable (114/342), and 31% (106/342) were indifferent. Table 2 depicts the pharmacist comfort levels when interacting with this patient population. Pharmacists who reported receiving education on providing health care to transgender persons, whether through a home-study or live continuing education (CE) program or other formal education curriculum, described increased levels of comfort with counseling transgender persons receiving hormone therapy. For example, the percentage of pharmacists who reported being uncomfortable counseling S63
SCIENCE AND PRACTICE K.G. Aragon et al. / Journal of the American Pharmacists Association 59 (2019) S62eS66
Table 1 Demographics, education, and resources of survey participants (N ¼ 342) Demographics Age (years) 20-29 30-39 40-49 50-59 60-69 70 Years in practice 0-5 6-10 11-20 > 20 Primary practice site Academia Ambulatory care Grocery store chain Independent pharmacy (multiple locations under the same ownership) Independent pharmacy (single location) National chain Other Postgraduate training PGY-1 community-based pharmacy residency PGY-1 pharmacy practice PGY-2 (any) Fellowship Response not provided Affirmed gender Female Male Other Pronoun She/her He/him Ze/Zir
n (%) 78 110 62 62 21 9
(23) (32) (18) (18) (6) (3)
122 51 58 111
(36) (15) (17) (32)
2 2 40 50
(0.5) (0.5) (12) (15)
73 (21) 165 (48) 10 (3) 28 5 3 2 304
(8) (1) (1) (1) (89)
209 (61) 130 (38) 3 (1) 211 (61) 129 (38) 2 (1)
Education Formal transgender education No Yes Other transgender education None Yes, home study or on-demand continuing education module Yes, live continuing education module Yes, formal curriculum Other
331 (97) 11 (3) 302 (88) 20 (6) 12 (3) 1 (1) 7 (2)
Resources Known resources for transgender health I am not aware of any resources for transgender health Endocrine Treatment of Transsexual Persons: An Endocrine Society of Clinical Practice Guideline Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People World Professional Association for Transgender Health (WPATH) Other
Comfort levels Welcoming transgender patients Very uncomfortable Uncomfortable Indifferent Comfortable Very comfortable Counseling on hormone replacement therapy Very uncomfortable Uncomfortable Indifferent Comfortable Very comfortable Asking for preferred pronouns Very uncomfortable Uncomfortable Indifferent Comfortable Very comfortable Asking for affirmed name Very uncomfortable Uncomfortable Indifferent Comfortable Very comfortable
n (%) 32 12 72 89 137
(9) (4) (21) (26) (40)
25 60 86 131 40
(7) (18) (25) (38) (12)
32 81 107 86 36
(9) (24) (31) (25) (11)
13 29 86 144 70
(4) (9) (25) (42) (20)
19 13 67 137 106
(5) (4) (20) (40) (31)
Current practice Importance of pharmacist role in transgender care Very unimportant Unimportant Indifferent Important Very important Professional responsibility of pharmacists No Yes Prefer not to answer Currently providing transgender care No Yes Response not provided Electronic medical record allows documentation of affirmed name and pronoun No Yes I’m not sure Ever declined to fill hormone prescription for transgender person No Yes Prefer not to answer
3 (1) 333 (97) 6 (2) 88 (26) 178 (52) 76 (22)
164 (48) 91 (27) 87 (25)
337 (98) 3 (1) 2 (1)
304 (89) 25 (7)
6 (2)
3 (1) 4 (1)
Abbreviations used: PGY-1, postgraduate year 1; PGY-2, postgraduate year 2.
a transgender patient was 20% in those without versus less than 1% in those with formal education on transgender health care. Regardless of whether any formal education on health care provision to transgender persons was completed, 71% of S64
Table 2 Comfort level and practice related responses of survey participants (N ¼ 342)
respondents believed that pharmacists play an important role in transgender health. When asked whether the survey responders were currently aware of any resources regarding transgender health, 89% (304/342) of respondents were not aware of any resources. Of the few (11% of respondents [38/342]) who were aware of resources, more than half indicated knowledge of the Endocrine Treatment of Transsexual Persons: An Endocrine Society of Clinical Practice Guideline. The majority of respondents preferred home-study or on-demand CE modules regarding transgender health. Respondents had the option to add a voluntary free response comment (of any kind) at the end of the survey;
SCIENCE AND PRACTICE Pharmacist perceptions on transgender care
almost 25% (85/342) of respondents provided a comment. Comments expressed a range of opinions on the provision of health care to transgender persons. A sample of 4 responses, 2 expressing positive views and 2 expressing negative views, follows: 1. “All persons are created in the image of God and deserve to be treated with respect and dignity! That principle applies no matter what their self-image is or what struggles they have.” 2. “Should only be treated with psych meds like other mental disorders.” 3. “We should stop making up diseases to treat so we can treat legitimate diseases.” 4. “We are all humans, we are all born equal, no one is better than anyone else.”
Discussion This survey indicated that the majority of communitybased pharmacists in North Carolina lack formal education regarding gender-affirming care. Only 3% of respondents indicated that they received formal training related to transgender care in their pharmacy school curriculum. In our study, approximately 88% of survey respondents reported that they have not received any formal education after completing pharmacy school regarding the care of transgender persons, whether through live CE modules, homestudy CE modules, workshops, meetings, or other mechanisms. Previous literature that surveyed schools and colleges of pharmacy found that there is limited coverage of gender dysphoria within curricula, which showed that only 14% of respondents reported good coverage of LGBT health content.11 This survey by Mandap et al.11 contained survey items in relation to the entire LGBT community; the content of survey items was not transgender specific. Despite the differences in these survey items, the percentage of respondents indicating a lack of educational coverage on LGBT or transgender health care is similar. The responses of this survey indicate that 71% of pharmacists believe that they play an important role in providing care to transgender patients, despite a lack of formal or information education on the topic. This disproportionate finding from the study is interesting because it identifies a gap between the perceived importance of the pharmacists’ role and the reported level of education on the topic of transgender health care. If the profession of pharmacy plays an important role in the health care of transgender persons, it would be reasonable to assume that pharmacists should be provided opportunities to complete education regarding how to care appropriately for this patient population. Many pharmacists indicated that they were uncomfortable counseling transgender persons on hormone therapy because they had not completed training on the topic. However, they also reported that once they had the received training, they would be very comfortable. Subanalyses support this claim; 99% of respondents who reported completing a CE module on how to care for transgender patients felt comfortable or very comfortable counseling transgender patients on hormone therapy.
Although the question to provide additional comments regarding transgender care was optional, almost one quarter of respondents provided their thoughts, which might indicate the (positive or negative) passion respondents have about this topic. These free text comments at the conclusion of the survey generated a wide array of responses. Many reflected positive views that indicated a desire for additional education on transgender care, indicating a desire to better care for transgender persons. Other responses reflected negative views with this patient population and a lack of comfort with interacting with gender nonconforming patients. With this growing patient population, it is essential that specific transgender education be incorporated into curricula and available for practicing pharmacists. Surveying only a single state and practicing pharmacists in the community setting are limitations of this study. A low response rate of 7.1% could limit generalizability of this study to other populations. While the exact reason is unknown, the authors speculate that reasons for a low response rate could include (1) only 1 reminder e-mail sent on day 15 being sent to eligible persons and (2) the sensitive nature of the topic. A nonresponse bias analysis was not performed by the authors. The authors cannot make substantial claims on the finding of comfortability on counseling because of the low response rate; however, this might add strength to the claim that CE on treatment of gender dysphoria should become more prominently available for pharmacists. To increase generalizability, the authors believe that additional research is needed that examines pharmacist perceptions in other practice settings and states. Conclusion The lack of formal education embedded within pharmacy school curricula, limited educational opportunities after pharmacy school, and the desire for pharmacist knowledge on transgender care indicate a need for accessible education on transgender care. North Carolina community-based pharmacists believe that it is a professional responsibility to provide gender-affirming care, but they might need additional training to feel comfortable when providing this care. The majority of respondents were not aware of any current guidelines or available practice resources. The creation of on-demand or live CE modules, as well as increasing access to this information, could be one mechanism to increase pharmacists’ knowledge and comfort with providing health care services to transgender individuals. Supplementary Data Supplementary data related to this article can be found at https://doi.org/10.1016/j.japh.2019.03.014. References 1. Flores AR, Herman JL, Gates GJ, Brown TNT. How many adults identify as transgender in the United States?. Available at: http://williamsinstitute. law.ucla.edu/wp-content/uploads/How-Many-Adults-Identify-as-Trans gender-in-the-United-States.pdf. Accessed September 15, 2018. 2. Herman JL, Flores AR, Brown TNT, Wilson BDM, Conron KJ. Age of individuals who identify as transgender in the United States. Available at: http:// williamsinstitute.law.ucla.edu/wp-content/uploads/TransAgeReport.pdf. Accessed September 15, 2018.
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3. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People; 2020. Available at: https://www.healthypeople.gov/2020/topics-objectives/topic/lesbiangay-bisexual-and-transgender-health/objectives. Accessed September 15, 2018. 4. Grant JM, Mottet LA, Tanis J, Harrison J, Herman CL, Keisling M. Injustice at every turn: a report of the national transgender discrimination survey. National Center for Transgender Equality and Lesbian Task Force. Available at: http://www.transequality.org/sites/default/files/docs/resources/ NTDS_Report.pdf. Accessed September 15, 2018. 5. Daniel H, Butkus R. Lesbian, gay, bisexual, and transgender health disparities. Ann Intern Med. 2015;163:135e137. 6. Haas A, Rodgers P, Herman J. Suicide attempts among transgender and gender non-conforming adults: findings of the national transgender discrimination survey. American Foundation for Suicide Prevention. Available at: https://williamsinstitute.law.ucla.edu/wp-content/uploads/ AFSP-Williams-Suicide-Report-Final.pdf. Accessed January 10, 2019. 7. Reisner SL, Vetters R, Leclerc M, et al. Mental health of transgender youth in care at an adolescent urban community health center: a matched retrospective cohort study. J Adolesc Health. 2015;56: 274e279. 8. Newsome C, Colip L, Sharon N, et al. Incorporating a pharmacist into an interprofessional team providing transgender care under a medical home model. Am J Health Syst Pharm. 2017;74:135e139. 9. Leach C, Layson-Wolf C. Survey of community pharmacy residents’ perceptions on transgender health management. J Am Pharm Assoc. 2016;56: 441e445.
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10. Ostroff J, Ostroff M, Billings S, et al. Integration of transgender care into a pharmacy therapeutics curriculum. Curr Pharm Teach Learn. 2018;10: 463e468. 11. Mandap M, Carrillo S, Youmans SL. An evaluation of lesbian, gay, bisexual, and transgender (LGBT) health education in pharmacy school curricula. Curr Pharm Teach Learn. 2014;6:752e758. Kelsea Gallegos Aragon, PharmD, Postgraduate Year 2 (PGY2) Ambulatory Care Pharmacy Resident, University of New Mexico College of Pharmacy, Albuquerque, NM; at time of study, PGY1 Community-based Pharmacy Resident, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, and Walgreens Pharmacy, Asheville, NC Jessica Conklin, PharmD, PhC, BCACP, CDE, AAHIVP, Assistant Professor, University of New Mexico College of Pharmacy, Albuquerque, NM Amy Lenell, PharmD, CLC, Pharmacist and Residency Site Coordinator, Walgreens Pharmacy, Asheville, NC Laura A. Rhodes, PharmD, BCACP, Assistant Professor of Pharmacy Practice, Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, FL; at time of study completion, Community Practice Engagement Fellow, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC Macary Weck Marciniak, PharmD, BCACP, BCPS, FAPhA, Clinical Associate Professor and Director, PGY1 Community-based Pharmacy Residency Program, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
Contents lists available at ScienceDirect
Journal of the American Pharmacists Association journal homepage: www.japha.org
RESEARCH NOTES
Examining community-based pharmacist perceptions on the care of transgender patients Kelsea Gallegos Aragon, Jessica Conklin, Amy Lenell, Laura A. Rhodes, Macary Weck Marciniak* a r t i c l e i n f o
a b s t r a c t
Article history: Received 15 September 2018 Accepted 26 March 2019 Available online 13 June 2019
Objective: The objective of this study was to determine whether community-based pharmacists in North Carolina have the personal confidence, comfort level, and resources needed to care appropriately for and interact with transgender patients. Methods: Using the North Carolina Board of Pharmacy database, a link to a 25-item questionnaire was e-mailed to all actively licensed community pharmacists in North Carolina. Survey items included pharmacist demographics, prior or current education on transgender health care, comfort regarding care provision for transgender patients, and the ability to care for transgender patients at the practice site. Questionnaire items were developed in collaboration with a pharmacist who actively participates in the care of transgender patients. The questionnaire was pilot-tested among a convenience sample of student pharmacists and pharmacists for feedback on validity and question structure. The survey was open for 30 days with a reminder sent on day 15. Upon survey completion, participants had the option to be entered into a drawing to receive a gift card incentive. Results: In total, 342 surveys were completed of 4784 surveys distributed, yielding a 7.1% response rate. Three percent of survey respondents reported receiving education on treating transgender patients during their respective pharmacy school curricula, and 12% of respondents sought other forms of transgender education (i.e., continuing education). Seventyone percent of respondents viewed the role of the pharmacist as important in the care of transgender patients. Sixty-six percent of respondents were comfortable welcoming transgender patients into their practice sites, and 36% were comfortable asking for pronouns. Conclusion: Survey participants reported a lack of formal or postgraduate education, which describes a need for accessible education on transgender care. North Carolina communitybased pharmacists believe that it is within their role as pharmacists to provide genderaffirming care, but they may need additional training to feel comfortable in providing this care. © 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
Disclosure: Macary Marciniak declares that her spouse is employed by the American Pharmacists Association. The remaining authors declare no conflicts of interest or financial interests in any product or service mentioned in this article. Contributions: Conceptualization (all), data curation (K.G.A.), formal analysis (K.G.A., L.A.R.), funding acquisition (all), investigation (K.G.A., A.L.), methodology (all), project administration (all), resources (K.G.A., A.L.), supervision (all), validation (all), visualization (all), writing of original draft (K.G.A.), review and editing (all). Previous presentations: American Pharmacists Association Annual Meeting and Exposition, Nashville, TN, March 2018; Sex and Gender Health Education Summit, Salt Lake City, UT, April 2018; Research in Education and Practice Symposium, Chapel Hill, NC, May 2018. * Correspondence: Macary Weck Marciniak, PharmD, BCACP, BCPS, FAPhA, Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 115G Beard Hall, Campus Box 7574, Chapel Hill, NC 27599-7574. E-mail address: [email protected] (M.W. Marciniak).
In 2016, it was estimated that 1.4 million adult Americans (0.6% of the population)1 and 150,000 adolescents identified as transgender.2 There is increased visibility and recognition of transgender individuals in recent years,1,3 leading to increased insurance coverage of health care services related to transgender health. For the first time, the U.S. Department of Health and Human Service’s Healthy People 2020 initiative has objectives related to collecting data on (or for) transgender populations and standardizing data to identify transgender populations. Included in the data collection portion of Healthy People 2020 is for health care professionals to inquire about a patient’s gender and sexual identity to improve patienteprovider relationships in the lesbian, gay, bisexual, and transgender (LGBT) community.3 The gender identity of transgender individuals does not align with their sex assigned at birth. The Diagnostic and
https://doi.org/10.1016/j.japh.2019.03.014 1544-3191/© 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
SCIENCE AND PRACTICE Pharmacist perceptions on transgender care
Statistical Manual of Mental Disorders (DSM-V) provides a diagnosis of “gender dysphoria,” which is defined as the distress or discomfort individuals might feel when their assigned sex and gender identity do not align. According to the National Center for Transgender Equality, 50% of transgender patients have to teach their medical providers regarding their unique care needs, and almost 25% of respondents did not seek health care because they feared being mistreated.4 This finding reinforces the importance of recognizing that transgender patient care should be affirmed and individualized. Not all transgender patients choose to pursue pharmacologic interventions, but those who do will require additional medication monitoring and are exposed to the potential risks and adverse effects of the medication. There are distinct clinical factors to consider when providing care to a transgender individual compared with a non-transgender person (also known as cisgender). For example, transwomen (designated male at birth) receiving estrogen therapy should be monitored for deep venous thrombosis.5 In addition, depression, suicidality, and anxiety might be higher in transgender individuals. The National Transgender Discrimination Survey reports a suicide attempt rate of 4.6% in the general U.S. population compared with 41% in the transgender population.6 Transgender youth have higher rates of depression (50.6% vs. 20.6%) and anxiety (26.7% vs 10.0%) when compared with cisgender youth.7 The pharmacist’s role within transgender care has been described within interprofessional teams; however, more information is needed within the community pharmacy setting.8 As medication experts, pharmacists should have knowledge regarding transgender pharmacotherapy and care of individuals. However, minimal literature is available describing formal education on the care of transgender patients in the curricula of schools and colleges of pharmacy. In a survey of postgraduate year 1 (PGY-1), community-based pharmacy residents, more than 80% of respondents believed that community pharmacists are integral in providing care for transgender patients, but more than 70% of these respondents were not formally educated about treating transgender patients in pharmacy school.9 In addition, less than 37% of respondents believed that they had sufficient knowledge or confidence in treating transgender patients.9 Additional literature supports the claim that student pharmacists who had access to and attended a lecture on transgender health were more likely to have greater knowledge and confidence when treating this patient population.10 Objective The primary objective of this study was to determine whether community-based pharmacists in North Carolina have the personal confidence, comfort level, and resources needed to care appropriately for and interact with transgender patients. Methods This cross-sectional survey was conducted online using Qualtrics and was exempted from review by the Institutional Review Board at the University of North Carolina at Chapel Hill. Using the North Carolina Board of Pharmacy’s (NCBOP) database, a link to a 25-item questionnaire (Likert scale, multiple
choice, and 1 free text response) was e-mailed to all actively licensed community pharmacists. The authors defined actively licensed as an individual who has earned and maintained an active, nonexpired pharmacist license in the state of North Carolina. The e-mail was distributed by the NCBOP to the email address on the registrant’s record, which could have been a personal or work e-mail address depending on the preference of the pharmacist. Those included in the survey were those who were actively licensed, community-based pharmacists registered with the NCBOP. Pharmacists with invalid e-mail addresses or who were not practicing in the community setting were excluded from the survey. Survey items included pharmacist demographics, prior or current education for transgender health care, comfort regarding care provision for transgender patients, and the ability to care for transgender patients at their practice site. Questionnaire items were based on current literature, past surveys, and in collaboration with a pharmacist who actively participates in the care of transgender patients. The survey instrument is in Appendix 1, available on JAPhA.org as supplemental content. The questionnaire was pilot-tested among a convenience sample of 27 individuals for feedback on validity and question structure. These individuals included student pharmacists, pharmacist practitioners, and pharmacists whose primary job function is academia. The survey was open for 30 days from January to February 2018 with a reminder sent on day 15. As an incentive to participate in the survey, participants had the option to be entered into a drawing to receive a gift card upon survey completion. Survey responses were excluded if the participant did not complete the survey in its entirety. Descriptive statistics were used to analyze data.
Results In total, 342 surveys were completed of 4784 surveys distributed, yielding a 7.1% response rate. Table 1 demonstrates demographic information collected from the responding pharmacists, including their pronouns for which 3 respondents use the gender-neutral pronouns “ze/zir.” Three percent (11/342) of survey respondents reported receiving education about caring for transgender patients during their respective pharmacy school curricula, and 12% (40/342) reported seeking other forms of transgender education (i.e., continuing education) after their pharmacy degree was conferred. Seventy-one percent (243/342) of respondents reported that they viewed the role of the pharmacist as important in the care of transgender patients. Sixty-six percent (226/342) of respondents were comfortable welcoming transgender patients into their practice sites. When asking a patient for their pronoun, pharmacist comfort levels varied: 36% (122/342) were comfortable, 33% were uncomfortable (114/342), and 31% (106/342) were indifferent. Table 2 depicts the pharmacist comfort levels when interacting with this patient population. Pharmacists who reported receiving education on providing health care to transgender persons, whether through a home-study or live continuing education (CE) program or other formal education curriculum, described increased levels of comfort with counseling transgender persons receiving hormone therapy. For example, the percentage of pharmacists who reported being uncomfortable counseling S63
SCIENCE AND PRACTICE K.G. Aragon et al. / Journal of the American Pharmacists Association 59 (2019) S62eS66
Table 1 Demographics, education, and resources of survey participants (N ¼ 342) Demographics Age (years) 20-29 30-39 40-49 50-59 60-69 70 Years in practice 0-5 6-10 11-20 > 20 Primary practice site Academia Ambulatory care Grocery store chain Independent pharmacy (multiple locations under the same ownership) Independent pharmacy (single location) National chain Other Postgraduate training PGY-1 community-based pharmacy residency PGY-1 pharmacy practice PGY-2 (any) Fellowship Response not provided Affirmed gender Female Male Other Pronoun She/her He/him Ze/Zir
n (%) 78 110 62 62 21 9
(23) (32) (18) (18) (6) (3)
122 51 58 111
(36) (15) (17) (32)
2 2 40 50
(0.5) (0.5) (12) (15)
73 (21) 165 (48) 10 (3) 28 5 3 2 304
(8) (1) (1) (1) (89)
209 (61) 130 (38) 3 (1) 211 (61) 129 (38) 2 (1)
Education Formal transgender education No Yes Other transgender education None Yes, home study or on-demand continuing education module Yes, live continuing education module Yes, formal curriculum Other
331 (97) 11 (3) 302 (88) 20 (6) 12 (3) 1 (1) 7 (2)
Resources Known resources for transgender health I am not aware of any resources for transgender health Endocrine Treatment of Transsexual Persons: An Endocrine Society of Clinical Practice Guideline Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People World Professional Association for Transgender Health (WPATH) Other
Comfort levels Welcoming transgender patients Very uncomfortable Uncomfortable Indifferent Comfortable Very comfortable Counseling on hormone replacement therapy Very uncomfortable Uncomfortable Indifferent Comfortable Very comfortable Asking for preferred pronouns Very uncomfortable Uncomfortable Indifferent Comfortable Very comfortable Asking for affirmed name Very uncomfortable Uncomfortable Indifferent Comfortable Very comfortable
n (%) 32 12 72 89 137
(9) (4) (21) (26) (40)
25 60 86 131 40
(7) (18) (25) (38) (12)
32 81 107 86 36
(9) (24) (31) (25) (11)
13 29 86 144 70
(4) (9) (25) (42) (20)
19 13 67 137 106
(5) (4) (20) (40) (31)
Current practice Importance of pharmacist role in transgender care Very unimportant Unimportant Indifferent Important Very important Professional responsibility of pharmacists No Yes Prefer not to answer Currently providing transgender care No Yes Response not provided Electronic medical record allows documentation of affirmed name and pronoun No Yes I’m not sure Ever declined to fill hormone prescription for transgender person No Yes Prefer not to answer
3 (1) 333 (97) 6 (2) 88 (26) 178 (52) 76 (22)
164 (48) 91 (27) 87 (25)
337 (98) 3 (1) 2 (1)
304 (89) 25 (7)
6 (2)
3 (1) 4 (1)
Abbreviations used: PGY-1, postgraduate year 1; PGY-2, postgraduate year 2.
a transgender patient was 20% in those without versus less than 1% in those with formal education on transgender health care. Regardless of whether any formal education on health care provision to transgender persons was completed, 71% of S64
Table 2 Comfort level and practice related responses of survey participants (N ¼ 342)
respondents believed that pharmacists play an important role in transgender health. When asked whether the survey responders were currently aware of any resources regarding transgender health, 89% (304/342) of respondents were not aware of any resources. Of the few (11% of respondents [38/342]) who were aware of resources, more than half indicated knowledge of the Endocrine Treatment of Transsexual Persons: An Endocrine Society of Clinical Practice Guideline. The majority of respondents preferred home-study or on-demand CE modules regarding transgender health. Respondents had the option to add a voluntary free response comment (of any kind) at the end of the survey;
SCIENCE AND PRACTICE Pharmacist perceptions on transgender care
almost 25% (85/342) of respondents provided a comment. Comments expressed a range of opinions on the provision of health care to transgender persons. A sample of 4 responses, 2 expressing positive views and 2 expressing negative views, follows: 1. “All persons are created in the image of God and deserve to be treated with respect and dignity! That principle applies no matter what their self-image is or what struggles they have.” 2. “Should only be treated with psych meds like other mental disorders.” 3. “We should stop making up diseases to treat so we can treat legitimate diseases.” 4. “We are all humans, we are all born equal, no one is better than anyone else.”
Discussion This survey indicated that the majority of communitybased pharmacists in North Carolina lack formal education regarding gender-affirming care. Only 3% of respondents indicated that they received formal training related to transgender care in their pharmacy school curriculum. In our study, approximately 88% of survey respondents reported that they have not received any formal education after completing pharmacy school regarding the care of transgender persons, whether through live CE modules, homestudy CE modules, workshops, meetings, or other mechanisms. Previous literature that surveyed schools and colleges of pharmacy found that there is limited coverage of gender dysphoria within curricula, which showed that only 14% of respondents reported good coverage of LGBT health content.11 This survey by Mandap et al.11 contained survey items in relation to the entire LGBT community; the content of survey items was not transgender specific. Despite the differences in these survey items, the percentage of respondents indicating a lack of educational coverage on LGBT or transgender health care is similar. The responses of this survey indicate that 71% of pharmacists believe that they play an important role in providing care to transgender patients, despite a lack of formal or information education on the topic. This disproportionate finding from the study is interesting because it identifies a gap between the perceived importance of the pharmacists’ role and the reported level of education on the topic of transgender health care. If the profession of pharmacy plays an important role in the health care of transgender persons, it would be reasonable to assume that pharmacists should be provided opportunities to complete education regarding how to care appropriately for this patient population. Many pharmacists indicated that they were uncomfortable counseling transgender persons on hormone therapy because they had not completed training on the topic. However, they also reported that once they had the received training, they would be very comfortable. Subanalyses support this claim; 99% of respondents who reported completing a CE module on how to care for transgender patients felt comfortable or very comfortable counseling transgender patients on hormone therapy.
Although the question to provide additional comments regarding transgender care was optional, almost one quarter of respondents provided their thoughts, which might indicate the (positive or negative) passion respondents have about this topic. These free text comments at the conclusion of the survey generated a wide array of responses. Many reflected positive views that indicated a desire for additional education on transgender care, indicating a desire to better care for transgender persons. Other responses reflected negative views with this patient population and a lack of comfort with interacting with gender nonconforming patients. With this growing patient population, it is essential that specific transgender education be incorporated into curricula and available for practicing pharmacists. Surveying only a single state and practicing pharmacists in the community setting are limitations of this study. A low response rate of 7.1% could limit generalizability of this study to other populations. While the exact reason is unknown, the authors speculate that reasons for a low response rate could include (1) only 1 reminder e-mail sent on day 15 being sent to eligible persons and (2) the sensitive nature of the topic. A nonresponse bias analysis was not performed by the authors. The authors cannot make substantial claims on the finding of comfortability on counseling because of the low response rate; however, this might add strength to the claim that CE on treatment of gender dysphoria should become more prominently available for pharmacists. To increase generalizability, the authors believe that additional research is needed that examines pharmacist perceptions in other practice settings and states. Conclusion The lack of formal education embedded within pharmacy school curricula, limited educational opportunities after pharmacy school, and the desire for pharmacist knowledge on transgender care indicate a need for accessible education on transgender care. North Carolina community-based pharmacists believe that it is a professional responsibility to provide gender-affirming care, but they might need additional training to feel comfortable when providing this care. The majority of respondents were not aware of any current guidelines or available practice resources. The creation of on-demand or live CE modules, as well as increasing access to this information, could be one mechanism to increase pharmacists’ knowledge and comfort with providing health care services to transgender individuals. Supplementary Data Supplementary data related to this article can be found at https://doi.org/10.1016/j.japh.2019.03.014. References 1. Flores AR, Herman JL, Gates GJ, Brown TNT. How many adults identify as transgender in the United States?. Available at: http://williamsinstitute. law.ucla.edu/wp-content/uploads/How-Many-Adults-Identify-as-Trans gender-in-the-United-States.pdf. Accessed September 15, 2018. 2. Herman JL, Flores AR, Brown TNT, Wilson BDM, Conron KJ. Age of individuals who identify as transgender in the United States. Available at: http:// williamsinstitute.law.ucla.edu/wp-content/uploads/TransAgeReport.pdf. Accessed September 15, 2018.
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3. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People; 2020. Available at: https://www.healthypeople.gov/2020/topics-objectives/topic/lesbiangay-bisexual-and-transgender-health/objectives. Accessed September 15, 2018. 4. Grant JM, Mottet LA, Tanis J, Harrison J, Herman CL, Keisling M. Injustice at every turn: a report of the national transgender discrimination survey. National Center for Transgender Equality and Lesbian Task Force. Available at: http://www.transequality.org/sites/default/files/docs/resources/ NTDS_Report.pdf. Accessed September 15, 2018. 5. Daniel H, Butkus R. Lesbian, gay, bisexual, and transgender health disparities. Ann Intern Med. 2015;163:135e137. 6. Haas A, Rodgers P, Herman J. Suicide attempts among transgender and gender non-conforming adults: findings of the national transgender discrimination survey. American Foundation for Suicide Prevention. Available at: https://williamsinstitute.law.ucla.edu/wp-content/uploads/ AFSP-Williams-Suicide-Report-Final.pdf. Accessed January 10, 2019. 7. Reisner SL, Vetters R, Leclerc M, et al. Mental health of transgender youth in care at an adolescent urban community health center: a matched retrospective cohort study. J Adolesc Health. 2015;56: 274e279. 8. Newsome C, Colip L, Sharon N, et al. Incorporating a pharmacist into an interprofessional team providing transgender care under a medical home model. Am J Health Syst Pharm. 2017;74:135e139. 9. Leach C, Layson-Wolf C. Survey of community pharmacy residents’ perceptions on transgender health management. J Am Pharm Assoc. 2016;56: 441e445.
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10. Ostroff J, Ostroff M, Billings S, et al. Integration of transgender care into a pharmacy therapeutics curriculum. Curr Pharm Teach Learn. 2018;10: 463e468. 11. Mandap M, Carrillo S, Youmans SL. An evaluation of lesbian, gay, bisexual, and transgender (LGBT) health education in pharmacy school curricula. Curr Pharm Teach Learn. 2014;6:752e758. Kelsea Gallegos Aragon, PharmD, Postgraduate Year 2 (PGY2) Ambulatory Care Pharmacy Resident, University of New Mexico College of Pharmacy, Albuquerque, NM; at time of study, PGY1 Community-based Pharmacy Resident, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, and Walgreens Pharmacy, Asheville, NC Jessica Conklin, PharmD, PhC, BCACP, CDE, AAHIVP, Assistant Professor, University of New Mexico College of Pharmacy, Albuquerque, NM Amy Lenell, PharmD, CLC, Pharmacist and Residency Site Coordinator, Walgreens Pharmacy, Asheville, NC Laura A. Rhodes, PharmD, BCACP, Assistant Professor of Pharmacy Practice, Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, FL; at time of study completion, Community Practice Engagement Fellow, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC Macary Weck Marciniak, PharmD, BCACP, BCPS, FAPhA, Clinical Associate Professor and Director, PGY1 Community-based Pharmacy Residency Program, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC