Expert: Women’s Health Is Part of Gender-Affirming Care

In an interview with Pharmacy Times, Alex Mills, PharmD, BCACP, AAHIVP, assistant professor of pharmacy practice at the University of Mississippi School of Pharmacy, discussed his presentation at the American Society of Health-System Pharmacists 2023 Summer Meeting. Mills’ session focuses on women’s health and gender-affirming care, and pharmacists’ roles in both.

A: Your session links women’s health and gender affirming care. Can you discuss how they’re related?

Alex Mills, PharmD, BCACP, AAHIVP: Yeah, I mean, they're certainly connected and related. I mean, many of the health issues that are logged under women's health—so things like safe and effective contraception, sexual function activity, or concerns about menstruation and reproductive health—are definitely in a central area of health for those assigned female at birth. Yet sometimes, you know, discussing those concerns and goals to the clinician or another health care professional, like a pharmacist, they're impacted by stigma, right? And things seem like a taboo topic, especially sexual health. So, these needs help affirm one's identity. You know, someone who identifies as female, that portion of their identity absolutely parallels other aspects of gender affirming care, like the health needs of trans and gender diverse folks.

A: Why is gender-affirming care so crucial and what is included under this umbrella?

Alex Mills, PharmD, BCACP, AAHIVP: It really helps individuals feel like they belong in society, presenting as their authentic selves. Many have been either suppressed or oppressed, either internally by family, friends or loved ones, and sometimes externally. So, thinking, you know, from a societal standpoint, legislation definitely can be [an example]. When they have this gender affirming care, for some folks, it is lifesaving, particularly for youth and young adults. So, when I think about, you know, my expertise in gender affirming care and transgender diverse individuals, mental health disparities are huge. You'll see anywhere from up to 10 times higher suicidality and depression rates for those experiencing gender dysphoria, and that comes from, again, that lack of support that these individuals are needing.

So, gender affirming care really kind of falls in this continuum. There are several different components to what is gender affirming care. So, that could start off being more of your social affirmation, so perhaps using, you know, a person's chosen name and pronouns, being able to express yourself outwardly with your gender identity. So, it would be, you know, particularly the clothes that you wear, the mannerisms that you may have, and being comfortable to express that. [Gender affirming care] can be legal, as well. So, document changes are the easiest choice that I can think of when it comes to that legal affirmation. And, of course, medical. So, that could be anything from using hormones, there are choices that are non-hormonal in nature, and then non-pharmacologic, non-drug options to help that person feel more affirmed in their gender.

A: How are state restrictions on gender affirming care and women’s health affecting pharmacists in this space?

Alex Mills, PharmD, BCACP, AAHIVP: Yeah, I mean, so starting with thinking about transgender individuals, I mean, this year alone, we've had over 200 bills that specifically target trans and gender diverse folks in their health care. And we've actually had more bills introduced this year in this arena than the past 5 years of legislative sessions combined. So, I think that's pretty alarming as well. And the challenges that we're seeing with the landscape is many of these bills are very wide reaching and since they are rather new in the landscape, it's difficult to determine for a health care professional, like a pharmacist, where's that line when it comes to that liability? And where does the buck stop for some of those things? So, you know, a lot of these, or most I'd say, if not all of the bills that really have been introduced are unfortunately surrounding disinformation from groups that are uncomfortable with something that, frankly, they don't want to understand. And then unfortunately, their avenue of doing that comes through legislation.

When we think about reproductive rights, you know, being in a post Roe v Wade world, that makes things like reproductive rights incredibly restrictive. And again, this is not only just for cisgender women, but for people with reproductive potential who have uteruses. You know, it significantly impacts their reproductive rights and what their reproductive health may look like. So, for the pharmacist in particular, you know, I think it puts pharmacists and pharmacies at liability—either civil or sometimes criminal. It can be a concern if you're knowingly facilitating gender affirming medical services like gender affirming care and therapy or dispensing agents that can facilitate an abortion.

Additionally, transgender-diverse patients are going to find ways to continue affirming their gender, which sometimes leads to unsafe and poor outcomes. So, I'll tell you, a patient in my previous practice used to see someone for black-market injections of what they thought were hormones and silicone fillers in someone's back office at someone's house who's not trained. And who knows if that's actually the drug or substance they're getting actually injected with? So, not having access to safe medication, not knowing what a patient's taking, from a pharmacist perspective, that puts the pharmacist in a dangerous situation that, can that pharmacist or that patient legally even talk about it? I'll give you an example here in Mississippi, too. I mean, we have in our bill, which is incredibly punitive for those under the age of 18, there's an aiding and abetting clause. What does that mean? You know, many of us here are even asking legal counsel, we're not sure what aiding and abetting related to gender affirming care services, what that really means. So, it really does kind of force people to pump the brakes, just out of fear of losing their license, being sued, whatever that may be. And I think unfortunately, that's probably the purpose behind some of the wording that's used in bills like this.