Caring for transgender and gender diverse patients

Advocacy by transgender and gender diverse people (TGDP) and communities has resulted in a shift towards greater societal acceptance of gender diversity. A growing need exists for healthcare professionals, including pharmacists, to have the ability to provide safer and gender-affirming care for TGDP. Pathologization of TGDP by the western medical community was introduced in the Diagnostic and Statistical Manual of Mental Disorder-III (DSM-III) in 1980 and subsequently included in the DSM-III-R and DSM-IV.1 Consequently, TGDP in many parts of the world must seek a psychiatric assessment and diagnosis in order to access gender-affirming care. While advancements towards depathologization of gender identity have occurred in diagnostic classification, as seen in the DSM-V, pathologizing practices have entrenched years of institutional transphobia, discrimination and violence into healthcare systems, ultimately creating access barriers for many TGDP.1,2 Pharmacists thus have an important role in repairing decades of discriminatory and unsafe care. A literature review using PubMed, Embase, Google Scholar and grey literature revealed minimal primary literature regarding strategies for pharmacists to provide gender-affirming care within pharmacy settings for TGDP, though some grey literature exists. The search, rather, revealed topics composed of attitudes and readiness of pharmacists in providing gender-affirming care. Overall, the lack of formal education and training on this topic has generally left pharmacists unprepared to provide such care.3-10 This article seeks to describe strategies pharmacists can use to provide gender-affirming care and create safer spaces for TGDP. The suggestions put forward are not absolute, but can be preliminary considerations. Setting the foundation Colonialism and Gender Colonial ideologies and institutions introduced the view that only two distinct categories of gender (male and female) exist and are nonchanging.11 This is regarded as the gender binary, with sex often incorrectly used synonymously with gender. However, having more than two genders in many non-European cultures, including Indigenous cultures, has historically been the norm—not the exception. Imposition of the gender binary and European gender roles upon Indigenous Peoples is one result of colonization. Indigenous Peoples have always resisted such efforts of colonization and Two-Spirit Peoples and their gifts, roles and identities are experiencing a resurgence.12 Two-Spirit is an English term that refers to Indigenous people on Turtle Island (what is colonially called North America) with diverse gender identities, sexualities, roles and expressions. The term Two-Spirit is not a specific identity and instead a way for Indigenous Peoples to describe oneself and reconnect to their traditional languages and cultures.13 When exploring topics related to Two-Spirit health, wellness and social determinants of health, it is important to consider the impact of colonialism on Indigenous Peoples, and that culturally safe care for Two-Spirit people may also involve services falling outside Eurocentric views of gender and sexuality. Definitions Pharmacists should be able to differentiate between sex and gender, and apply this in their practice. Sex is defined as the biological attributes that classify people as male, female or intersex (Table 1).14 A person’s legal sex is usually determined based on examination of external genitalia at birth.14 Gender is a social construct that contains both individual and societal dimensions of gender identity and expression. Societal constructions of these roles, behaviours and attributes are known as gender norms.14 Language is constantly evolving. Tables 1 and 2 outline some commonly used terms.14 Gender affirmation Gender affirmation for TGDP involves expressing one’s gender or taking on a gender role to better reflect their gender identity. Transitioning is a word used by some to describe the process of gender affirmation. Transitioning may not have an endpoint and does not have to adhere to the gender binary.14 Nonmedical ways of gender-affirmation (i.e., social transition) can include:15 Using a different name or pronoun Changing legal documents Making one’s gender expression more comfortable. This can involve: Changing how one dresses, speaks (voice training) or expresses body language Chest binding: compressing one’s chest to appear more masculine or androgynous Packing: wearing padding or a nonflesh penis in one’s lower garment Tucking: concealing the penis and testicles by modifying its position with or without padding to create a smooth outer appearance Padding: Using breast forms and other garments to enlarge one’s breasts, hips and/or gluteal region. Medically-related ways of gender affirmation include:15 Hormone therapy and/or puberty-blocking medication Chest reconstruction Genital reconstruction (e.g., phalloplasty, metoidioplasty, vaginoplasty) Hair removal from face, body or genital areas Facial surgery or body contouring. The pharmacist’s role in creating safe spaces Inclusive communication Part of providing gender-affirming care is ensuring that appropriate language is used when interacting with others. Using gender-inclusive language can help promote gender equality. Pharmacists can introduce themselves with their name and pronouns, or include this on their nametag when building rapport. This suggests that the pharmacist acknowledges the importance of using the correct pronouns and that the pharmacy strives to be a safe space for all. Table 3 provides examples of gender inclusive terms that can be used to replace gendered terms.16 Workflow Adjusting electronic systems, intake forms and prescription labels can make the pharmacy more inclusive. Adding the patient’s preferred name separate from the patient’s legal name within the same profile can avoid identity mismatch, billing errors and deadnaming (i.e., calling someone by their birth name when they have changed their name). If the electronic system currently being used at the pharmacy does not allow separate documentation of legal and preferred name, or does not have space to indicate a patient’s pronouns, a reminder notification can be considered. When possible, the prescription label should contain the patient’s preferred name including a reminder for staff to use the patient’s correct name and pronouns at pick-up.17 Similar to making changes to the pharmacy’s electronic system, intake forms can also be made more inclusive by adding sections for preferred name, pronouns and expanded and/or self-described options for gender.18 Physical spaces Visible signs of support for TGDP are another way to make the pharmacy an inclusive space. This can include trans and/or pride flags, pronoun pins and rainbow safe zone signs. Patient education and health promotion materials can be chosen to include people of diverse gender identities, abilities, ethnicities and family structures.17 Signs on single-stall washrooms can be changed to all gender signage. For those involved in the design of pharmacies, consider building gender-neutral washrooms. Information about a patient’s gender, sexual health and physical anatomy should be treated as confidential information and discussed in a private space. Only ask about this information if necessary. Pharmacist’s role in clinical care Estrogen-Based Hormone Therapy (HT) Estrogen-based HT is used to reduce testosterone-related secondary sex characteristics and induce estrogen-related secondary sex characteristics. Regimens typically consist of estrogen and a testosterone blocker. Dosing for oral or sublingual estrogen (sublingual is an off-label administration route)19 typically starts at 1–2 mg daily of 17β-estradiol with maintenance doses ranging from 4–8 mg daily.20 Estrogen patches, gel or compounded estradiol valerate injections may also be used.20 Spironolactone is the most common testosterone blocker used. Dosing starts at 25–50 mg daily and may be titrated to a maintenance dose of 200–300 mg daily. Oral cyproterone is a second-line option. Some TGDP undergoing estrogen-based therapy may choose to use progesterone for breast growth, although evidence on the effectiveness of progesterone is limited.20 Testosterone-Based Hormone Therapy (HT) Testosterone-based HT is used to reduce estrogen-related secondary sex characteristics and induce testosterone-related secondary sex characteristics. Testosterone can be administered subcutaneously, topically or intramuscularly, with the most common routes of administration being topical and subcutaneous (an off-label administration route).21 Dosing of testosterone (cypionate or enanthate) starts at 25 mg intramuscularly or subcutaneously weekly and is titrated to 50–100 mg weekly, while dosing of testosterone gel 1% starts at 2.5 g daily and is titrated to 5–10 g daily. 20 Dose Adjustments The rate of titration for estrogen or testosterone therapy is individualized based on factors including patient goals, age, health conditions, response, other medications and side effects.19 About four to six weeks is the suggested interval between dose adjustments, though not a definitive rule.20 Clinical Pearls: Titration of doses to meet patient goals can take months to years. For example, the maintenance dose for adults can be achieved at around six months, while younger adolescents may reach maintenance doses after 18 months or longer.19 If a patient decides to receive a gonadectomy, doses of hormones may be lowered post-surgery if levels are out of range for their affirmed gender.20 Participate in informed consent discussions regarding dosing changes as patients age or their health status changes. Management of common issues related to gender affirmation Suggested strategies for the management of common issues that may arise during nonmedical gender affirmation and gender-affirming HT are listed in Table 4. Drug coverage Many medications used for gender affirmation are used off-label and may not be covered by government-funded drug plans. Pharmacists can facilitate requests for medication coverage. Medications requiring special access requests differ in each jurisdiction, but may include leuprolide acetate, micronized progesterone, transdermal estrogen and testosterone. Patients who decide to receive gender-affirming surgery may be on temporary disability as their ability to work is impacted during the recovery process. Pharmacists can support patients in having continued access to medications during these times. Counselling and patient education TGDP may seek support from pharmacists when it comes to injection training or medication counselling. Appropriate counselling may require “unlearning” gendered norms and patient-specific considerations. For example, TGDP may wonder whether medications or supplements that are labelled “male” or “female” are suitable for them. Pharmacists may need to reframe what is considered a side effect versus a sign of drug efficacy. For example, spironolactone causing gynecomastia could be considered a desired effect. Pharmacists can also add counselling points unique to TGDP. For instance, emphasizing that medications such as estrogen-containing contraceptives may cause temporary changes to chest or breast tissue. TGDP who have undergone top surgery or experience discomfort or distress related to their chest region may wish to avoid or stop these medications in this case. The paucity of literature and barriers to accessing gender-affirming care may defer TGDP to practices shared within the TGDP community or others’ personal experiences. Each interaction should be approached with an open mind and patients should feel empowered to make informed decisions. Table 5 offers additional resources for pharmacists to learn more about gender-affirming care. Summary Supporting the gender-affirming needs of TGDP requires a focus on specific goals of therapy with regards to the patient’s gender expression as opposed to focusing on gender identity. Pharmacists can create safe spaces for gender-affirming care by using affirming language and creating a workflow and physical space that meet the needs of TGDP. Clinically, pharmacists are part of the healthcare team when it comes to managing TGDPs’ health conditions and use of medications to affirm their gender, by communicating evidence, managing side effects and preventing serious harm. Accessible healthcare is a right for all. Education and awareness around gender-affirming care is therefore a positive step towards better, safer and more accessible care for TGDP. Timothy Lim (he/him), BScPharm, ACPR, is a lecturer and clinical pharmacist at the University of British Columbia, Faculty of Pharmaceutical Sciences. Mel Tsai (they/them), RTR, is a PharmD student at the University of British Columbia, Faculty of Pharmaceutical Sciences. The authors thank Tristan Lai, Alex Tang and Drs. Kelly Mattheis, Marria Townsend and Jaris Swidrovich for peer reviewing this article. 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Pharmacists can be accessible, trusted providers for transgender patients. Pharm Today 2016;22(3):57. Redfern JS, Jann MW. The evolving role of pharmacists in transgender health care. Transgender Health 2019;4(1):118. Hernández-Agosto J, Melin K, Rosa-Vega J, et al. The development of a knowledge test on transgender patients’ care. Int J Environ Res Public Health 2020;17(19):7192. Lugones M. The coloniality of gender. In: The Palgrave handbook of gender and development London: Palgrave Macmillan; 2016. pp. 13-33. Robinson M. Two-spirit identity in a time of gender fluidity. J Homosex 2019;67(12):1675-90. Wilson A. How we find ourselves: identity development and two spirit people. Harv Educ Rev 1996;66(2):303-18. Trans Care BC. Glossary [Internet]. Provincial Health Services Authority. (accessed January 6, 2023). Coleman E, Radix AE, Bouman WP, et al. Standards of care for the health of transgender and gender diverse people, Version 8. Int J Transgend Health 2022;23(S1), S1-S260. United Nations. United Nations Gender-inclusive language. (accessed January 6, 2023). Human Rights Campaign Foundation, American Pharmacists Association. Transgender pharmacy resource guide. 2021. (accessed January 6, 2023). Rainbow Health Ontario. Breaking down barriers: a tool to address inequalities in LGBT2-SQ healthcare in Sudbury, Ontario. (accessed January 6, 2023). Townsend M, Mattheis K. Personal communication during article peer review. December 2022. Trans Care BC. Gender-affirming care for trans, two-spirit, and gender diverse patients in BC: a primary care toolkit. 2021. (accessed January 6, 2023). Sandoz Canada Inc. Testosterone cypionate injection [package insert]. Boucherville (QC); 2018.

Caring for transgender and gender diverse patients

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