Gender-Affirming Care: Fostering Inclusive Pharmacy Practices

By James Morrison, BScH, BScPhm, RPh

There is growing evidence that people who identify as a member of the 2SLGBTQ+ (Two-Spirit, lesbian, gay, bisexual, transgender and queer) community are facing inequities when it comes to accessing health care.

According to a national transgender discrimination survey, 28 per cent of individuals in this group have postponed or avoided medical care due to discrimination, 19 per cent have been refused care due to their gender identity, and 50 per cent have found health providers lack knowledge in their care. 

In British Columbia, 11 per cent of 2SLGBTQ+ individuals reported avoided emergency rooms and more than half rated their mental health as fair or poor. One in four considered suicide in the past year.

In an attempt to understand what the experiences were in pharmacy for 2SLGBTQ+ individuals, Molly Yang and myself at Wholehealth Pharmacy Partners decided to conduct a survey among patients accessing pharmacy services at Canadian pharmacies in 2023. The survey yielded 55 responses, which give an indication of what it is like to be 2SLGBTQ+ while interacting with pharmacies.

In the survey, more than half of the respondents said they were uncomfortable or very comfortable discussing their gender identity with a pharmacist they did not know. And more than three in four said they avoided going to a pharmacy because of their gender identity. We found almost one in four patients encountered a pharmacist who refused to address them by their lived name or use their preferred pronouns while communicating. Alarmingly, more than 15 per cent of respondents said their pharmacist used hurtful or insulting language about their identity or experience. 

When patients have a negative experience, it can lead to them avoiding health care altogether. 

The reality is that there is a list of current barriers that 2SLGBTQ+ patients face when accessing all sorts of health care, not just in pharmacies. These barriers include a lack of knowledge from health providers on 2SLGBTQ+ needs, or having negative attitudes towards people who are 2SLGBTQ+, in addition to potentially having less access to health care due to their ethnicity, or education and income level, immigration status, or other factors.

These barriers can result in reduced health-care outcomes. While data is scarce due to a lack of tracking of 2SLGBTQ+ health outcomes in the prior decades, there is evidence that shows trans people, for example, are less likely to be screened for cancer and have cancer detected later when compared with cis individuals. 

When a 2SLGBTQ+ person attends your pharmacy, be aware that they may be guarded patients, not because of something you did, but because of previous negative experiences within the health care system. This can mean that they are reluctant to disclose their sexual orientation, or gender identity, and they may hold a perception that you and your pharmacy team are not welcoming towards 2SLGBTQ+ people until they see otherwise.

But there are also positive experiences that we heard in the survey. 

One patient reported how a pharmacist began immediately using the patient’s chosen name after a conversation with their doctor about a refill, and expressed how affirming the experience was.

Another patient described telling their pharmacist that they would like to pursue hormone replacement therapy, how the pharmacist said they would be happy to help in any way they can. 

A third patient described how the two pharmacies they visit have at least one trans, non-binary and lesbian or gay person on their staff team.
 

For community pharmacists, there are steps you can take to help provide affirming care to 2SLGBTQ+ patients. 

These steps can start from something as simple as using the patient’s own words in your communication with them. The words your patients choose can cover anything from the patient’s name, their gender identity, or to the word they use to refer to their partner. If you as their pharmacist also choose to say the same words used by the patient, this can be a form of gender-affirming care. 

The language you choose is crucial, and it often starts with pronouns. Pronouns are something we use when we are talking about another person. Something I have adopted is to wear a pronoun pin and a rainbow pin on my uniform. It’s not because I am trying to communicate my pronouns, or that I am a queer person, I am wearing these items to help communicate to my patients that they are safe with me. Once a patient has communicated their pronouns to you, document them for future visits and so other team members in your pharmacy will use them too.

And if you are uncertain about a patient’s pronouns, or if a patient seems reluctant to communicate their pronouns, a good idea may be to avoid pronouns altogether by referring to the patient by their name. If you don’t know a person’s pronouns, a good default is they/them.

Inclusive language goes beyond pronouns. Recently, I was travelling and saw at the airport a “lactation pod” and I thought this was a great example of inclusive language. The word “breast” or “breastfeeding” is gendered and can cause gender dysphoria for individuals. So instead of breast, try “upper body”. Instead of “penis”, try “genitals” or “external genitals”, and “internal genitals” instead of “vagina”. For reproductive organs, try “external” or “internal” reproductive organs. 

Avoid assumptions. You can’t assume a person’s gender identity by looking at them or from hearing their voice. Do not assume their gender identity, their sexual orientation or their family structure. If you are unsure and the answer is relevant to the patient’s care, the best thing to do is to respectfully ask. 

Privacy is also extremely important. Someone’s gender can be deeply personal and depending on who else is in the room, you could potentially “out” someone by accident, for example by calling across the counter about their prescription, or communicating about their gender-affirming prescription with a family member who doesn’t know. Have safeguards in place to protect your patients and their privacy, and only discuss their medications with others if you have the patient’s consent.

As we have covered, many 2SLGBTQ+ patients have had negative experiences accessing care. Identifying yourself as a pharmacy that offers inclusive care can be a way to help 2SLGBTQ+ patients rebuild their confidence in our health-care system.

At my two pharmacies, I have created posters that identify my stores as positive spaces where lesbian, gay, bisexual, trans, Two-Spirit and queer people, along with their friends and allies, are welcomed and supported.

Many pharmacies will have posters describing various clinical services often featuring images of families. Ask yourself whether 2SLGBTQ+ people are represented in these materials. Having 2SLGBTQ+ representation in visuals around your store help communicate, without words, that your pharmacy is in an inclusive space.
With the introduction of minor ailments, I know many pharmacies are using intake forms to fill out patient details prior to an assessment. Consider including inclusive options beyond just “male” and “female” in the intake form when inquiring about a patient’s gender, and include an additional question asking for the patient’s sex at birth. 

Other considerations can include gender-neutral washrooms, placing your pronouns on nametags, and placing inclusive messaging on your pharmacy website. Everything helps.

Not every trans person wants to take hormones, and not every trans person wants gender-affirming surgeries, but many do. It’s important not to assume.

The most common therapy for a person undergoing transmasculine transition are testosterone intramuscular injections, which are taken to help the patient develop male secondary sex characteristics, and suppress or minimize typically-female secondary sex characteristics. Transmasculine individuals may also be treated with progestins to help with contraception and to suppress their monthly bleeding. 

For transmasculine individuals taking testosterone, common side effects include acne, scalp hair loss, and internal genital dryness. If monthly bleeding continues past six months for patients receiving testosterone, the pharmacist can recommend the addition of a progestin.

Individuals undergoing a transfeminine transition will typically take oral estrogen, such as 17-beta estradiol, to develop female secondary sex characteristics and suppress or minimize typically male secondary sex characteristics. Often these individuals will also take an anti-androgen to block the effects of testosterone. Side effects can include dizziness, low libido and difficulty maintaining physical arousal.

Most changes related to hormone replacement therapy occur within the first year, with maximal effects over two to five years. 

Even if you do everything right, health care is a team effort. An important part of this is helping educate your fellow colleagues so your pharmacy is offering an inclusive space even when you are absent. Many of our profession have been doing things a certain way for many years. Our patients know it is not easy to change the words we use and the way we think, but they also recognize when you take the small steps to make changes in your pharmacy to help accommodate people of diverse backgrounds. 

The style I take is to make it as welcoming as possible for the learners themselves, by inviting them to see things from another perspective. It will not be easy. You can’t make people want to address social inequities or inequities in health care. 

Yes, there will be resistance. But as health care workers, we are not in the profession for ourselves. We’re here for our patients, and the reality is that 2SLGBTQ+ patients have always been here. 

The question is whether we as a profession recognize that this is a group of patients who face health care inequities, and whether we take steps to help this group of patients access the same level of care that everyone has a right to receive. 

James Morrison is the Director of Pharmacy Excellence with Wholehealth Pharmacy Partners where he oversees pharmacy operations for more than 200 Wholehealth pharmacies across Canada.