Pharmacists Should Prioritize Inclusivity, Provide Gender-Affirming Care

In an interview with Pharmacy Times, Jay Holloway, PharmD, AAHIVP, a pharmacist with the AIDS Healthcare Foundation, discussed their presentation at the 2024 American Pharmacists Association (APhA) Annual Meeting and Exposition. Holloway will be discussing gender-affirming care, the challenging current legal landscape, and in particular how pharmacists can best serve their patients who are transgender or gender diverse.

Q: What does gender-affirming care mean, particularly in the pharmacy setting?

Jay Holloway, PharmD, AAHIVP: So, more broadly, gender affirming care refers to the range of interventions—both social, legal, medical—that a person may partake in, in order to live as their more affirmed identity. In the setting of pharmacists, specifically, gender affirming care is going to be the medical component. Very specifically, the gender affirming hormone therapy component of it. So, in the pharmacy setting, we're going to be focusing mostly on gender affirming hormone therapy and related medicines that a patient may be taking.

Q: Why is this so crucial?

Jay Holloway, PharmD, AAHIVP: So, gender affirming care and access to gender affirming care is crucial because it's an important topic. It's a component of medicine that we have a well-established knowledge base now, that we find that it leads to better health outcomes and better life outcomes for transgender and nonbinary individuals, or transgender and gender diverse individuals. It is the best practices of pretty much every major medical association that gender affirming care is life saving and important. There have been studies that it greatly reduces the risk of suicide for trans and gender diverse patients, and it's just good care. It always baffles me how we give this double standard regarding veracity of gender affirming care when gender affirming care itself has been practiced since the 1930s. It goes all the way back to Magnus Hirschfeld in Germany, before his care was shut down and burnt by the Nazi party, and it's been approved by every major medical association. We have this long history. So, imagine, for example, if all of a sudden, blood pressure became a politically popular topic to regulate. It's kind of like that.

Q: What barriers to gender affirming care do patients commonly encounter?

Jay Holloway, PharmD, AAHIVP: There are a lot of barriers that patients encounter to gender affirming care. If you're going from the individual and interpersonal levels, it could be a non-affirming provider, it could be a non-affirming pharmacy. For example, a provider might not be aware of gender affirming care and may turn away a patient due to their personal beliefs; they may turn away a patient or be hostile. In a pharmacy setting, a pharmacist may not believe in gender affirming care and its benefits, and may turn a patient aways, oftentimes to the distress of the patient. In the more systemic and higher-level barriers, we see a general lack of knowledge amongst pharmacists. This is a topic that needs to be more frequently discussed in our curriculums and in our day-to-day practice.

In terms of education, there is also legal barriers. That is a huge topic right now, in that there are many states—I believe 22 states at the time of this recording—which have banned gender affirming care for children and adolescents. Gender affirming care for children and adolescents often utilizes the exact same medications that cisgender children use for precocious puberty. And in addition to seeing outright restrictions, you're also starting to see other laws that are similar to what is called “trap laws” in abortion practice, which are targeted restrictions, that while not outright banning care make it more and more difficult to access and practice. An example of this would be bans on Medicaid covering gender affirming care. You see this in several states, bans on what practitioners are allowed to provide gender affirming care. For example, in Florida, only physicians are allowed to provide gender affirming care. Prior to this, the majority of this was practiced by nurse practitioners. [Laws] may also include additional waiting times or additional paperwork that people need to sign, basically things to discourage people from pursuing care.

Q: The current legal landscape is quite challenging for gender affirming care. How does this impact pharmacists?

Jay Holloway, PharmD, AAHIVP: This impacts pharmacists, because especially if you're working in an institutional setting, you may start seeing institutions or pharmacy chains or others starting to get weary about providing care. You may see things starting to come down the line of, “Hey, our new policy is to not provide care,” to refer patients out, to say we don't have this in stock. Maybe not to outright deny care but go hands off and say we don't want any involvement. And I professionally disagree with that approach because oftentimes, it results in patients waking up and finding out that they're no longer receiving care, and then patients having to scramble. And additionally, it kind of preemptively capitulates to the motives behind these laws. The motives behind these laws are to make gender affirming care impossible in that area. And before clear enforcement mechanisms of these laws, sometimes before these laws even really get instated, I have seen institutions basically go, “We're going to drop gender affirming care,” or “We're going to drop gender affirming care for children, adolescents.” And I really think that is a great disservice to trans and gender diverse patients who already face difficulty accessing care in general due to discrimination, not just gender affirming care, and then having to scramble to find care. There is a recent report that 43% of transgender people who live in a state where care is being restricted are considering moving out of their state, and I believe in that same study 8% of the people already did. These bans on care are creating a domestic crisis of health care access, and I really do think that before people are quick to withdraw their support, I think it is part of our duty as pharmacists that, regardless of gender affirming care being a political target at the moment, we still need to provide care, even if that is not comfortable at the time. And institutions need to think about, not how can we preemptively be safe from these lawsuits, but how can we work best within these to provide care?

Q: How can pharmacists provide the best possible care for their patients?

Jay Holloway, PharmD, AAHIVP: I think there's a couple of ways that pharmacists can help. One of the important things is to be aware of your state laws, know if your state has a shield law—which, in states that have shield laws, they protect individuals seeking gender affirming care. You see patients who are going out of state, like from Texas to Seattle, to Washington, to get gender affirming care. And there have been attorney generals like in Texas who have asked out of state providers to turn over information on individuals from that state seeking care. Know your laws, know your HIPAA rights. If a person comes in asking for gender affirming care, you should have a policy in place. And specifically, I think all institutions and pharmacists should be creating, in addition to their HIPAA policies and procedures, HIPAA policies and procedures for marginalized and politically persecuted patients. If we're going to be in a situation where there are patients fleeing other states in order to get care, we need to have policies in place that best protect them.

On the less systemic, less institutional, more interpersonal level, what pharmacists should be doing is educating themselves on gender affirming care and educating themselves in frequent communication with trans and gender diverse communities local to them. Pharmacists could provide a huge amount of information and resources to trans and gender diverse people within their community. And because of how prevalent medical discrimination is in health care against trans and gender diverse people, I think it is our duty to step up and show that we are a safe and affirming place, not just by low effort things such as pride flags or showing your pronouns. I think you need to be directly involved, volunteering your time and resources for these communities.

Q: Are there any resources you can recommend for pharmacists looking to educate themselves or get involved?

Jay Holloway, PharmD, AAHIVP: Yes, so APhA has something called the APhA HRC—in collaboration with the Human Rights Campaign—Transgender Pharmacy Resource Guide. I really love that guide, I've been recommending it for years as a really good primer on basic terminology regarding trans and gender diverse people, basic concepts, and specifically in the context of pharmacy practices in which we need more pharmacy-specific educational resources. It also provides triaging tips for issues that trans and gender diverse people may face within the pharmacy, such as for injectable, gender affirming hormone therapy, the importance of providing a draw up needle and an administration needle, ways to get around insurance barriers so that you are having affirmed identities on your patients’ prescription bottles, stuff like that, if they have a different legal name than their affirmed name. Additionally, if you want to get into standards of care and practice guidelines, there is also the WPATH, World Professional Association of Trans Health. They have as their standards of care 8 guidelines. UCSF also has guidelines that are pending revision right now; they used to have a 2016 version, and now have a 2024 version.

And I really think it's important that that pharmacy professionals also look into surveys on the experiences that trans and gender diverse people face. The US Trans Survey just released their early insights for the 2022 edition, and that's going to be coming out this year. So, once the full survey is released, I highly recommend pharmacists checking that out because the 2015 survey was a really good comprehensive look into trans and gender diverse people within the US.

Q: Is there anything you’d like to add?

Jay Holloway, PharmD, AAHIVP: So, I would say as some closing remarks that one of the ways that we can really make pharmacy more inclusive to trans and gender diverse people is in updating our electronic health records. For years, people have been trying to advocate for electronic health records that are inclusive for trans and gender diverse people. A big hurdle at pharmacies that make trans people not want to go to their pharmacies, is that we don't have separate data fields for affirmed name versus legal name. I would really love to see electronic health records for pharmacy have affirmed name that goes on the bottle, goes on goes patient-facing [materials], and then have that administrative name or legal name if it's separate when billing. It's deeply frustrating. If I may be personal, it's deeply frustrating as a transgender professional to advocate for better pharmacy systems like electronic health records and being told, “Well, this is a second priority. This is expensive to implement,”etc. I really think that if we want to actually be allies and be supportive of trans and gender diverse people, instead of having inclusive electronic health records as an afterthought, we need to be prioritizing it. So, I would like to say that that's my personal challenge to electronic health record developers, that they that they speak with transgender people to see what they need to change in their systems in order to make things more inclusive. And what benefits trans and gender diverse people benefits all patients because it gives us more flexibility and really allows for the diversity of humankind.