Through cultural humility, shared-decision making, and appropriate implementation of masculinizing and feminizing therapy, providers can reduce health disparities and ensure gender-affirming care for transgender and non-binary individuals, said a speaker at AMCP Nexus 2022.

The session for student pharmacists began with a discussion of sex vs gender by Tam Phan, PharmD, AAHIVP, assistant professor of clinical pharmacy, USC School of Pharmacy, Los Angeles LGBT Center. Sex is assigned at birth and determined by genitalia, and gender identity is an individual’s sense of self. Dr Phan emphasized gender affirmation as a tenet of care.

“Gender affirmation is the way we interact with someone, in a way that supports their gender goals,” Dr Phan.

Approximately 13 million adults in the United States identify as LGBTQ+. Of these, 1.3 million adults and 300,000 people aged 13 to 17 years are transgender.

“The prevalence of transgender and gender non-binary individuals in the United States is about the same as individuals with type 1 diabetes who are currently going on treatment,” Dr Phan said. “Yet, in the curriculum today, we don’t see gender health being discussed at all.”

Contributors to Health Disparities

There is a general lack of data on the health of LGBTQ+ individuals, Dr Phan said, which contributes to ongoing health disparities.

Overall, LGBTQ+ individuals are less likely than cisgender, heterosexual individuals to seek preventive services for cancer and have higher rates of smoking, alcohol use, depression, and anxiety. Among all male individuals, gay and bisexual men comprise 83% of new HIV cases.

LGBTQ+ people under the age of 18 are more likely to attempt suicide, have mental illnesses, and be physically or sexually abused than cisgender heterosexual individuals. Likewise, older adults who are LGBTQ+ may experience social isolation and a lack of culturally competent care, as well as ageism.

In the 2015 US Transgender Survey, respondents said they did not see a doctor due to fear of being mistreated (23%) or inability to afford care (33%). One-third (33%) of respondents who saw a health care provider reported at least 1 negative experience related to being transgender, and this number was higher for people of color and those with disabilities.

Dr Phan noted other barriers to care for LGBTQ+ individuals, which may include a lack of health insurance, stigma and prejudices, lack of knowledge among providers and office staff, and minority stress derived from being a member of a group that experiences discrimination.

Practice and Medications

Previously, transitioning entailed a psychological assessment, hormone therapy, and then surgery, Dr Phan said, noting this model positioned providers as gatekeepers to gender-affirming care.

By contrast, current care models have expanded to include speech therapy, facial hair removal, surgery, hormone therapy, cognitive behavioral therapy, and more. Patients can choose which procedures they would like in accordance with their preferences, Dr Phan said.

“This is very individualized and collaborative. There are so many aspects of a person’s transitioning process beyond the medical or surgical procedures,” Dr Phan said.

Medications are used to induce feminizing or masculinizing changes and may be administered through an informed consent model, Dr Phan said.

Masculinizing therapy is intended to help patients develop male secondary sex characteristics and suppress female secondary sex characteristics. Testosterone is contraindicated for pregnancy, hormone-sensitive cancer, coronary artery disease, and polycythemia.

“Coronary artery disease and polycythemia are…potential adverse effects, but really, these are not absolute contraindications. There are other risk factors that can contribute to someone’s coronary artery disease risk, such as smoking,” Dr Phan said, adding that gender affirming therapy may encourage patients to pursue smoking cessation and take other actions to reduce their risk.

Testosterone is formulated as an injection, transdermal patch, and topical. Considerations for monitoring patients on testosterone include the following parameters:

• Serum testosterone—measured every 3 months
• Virilization, adverse reactions, and undesired menses—monitored every 3 months in the first year, and 1-2 times annually thereafter
• Hematocrit and hemoglobin—measured at baseline, every 3 months in the first year, and 1-2 times annually thereafter
• Weight and blood pressure lipids—recorded at routine health maintenance intervals

Feminizing therapy suppresses male secondary sex characteristics and aids patients with developing female secondary sex characteristics. Estrogen and antiandrogens can be used as feminizing therapy, with a serum estradiol goal of 100 to 200 pg/mL and serum testosterone goal of < 50 ng/dL.

Considerations for monitoring patients on feminizing therapy include:

• Serum estradiol—measured every 3 months
• Spironolactone—electrolytes measured every 3 months in the first year, and once annually thereafter
• Tissue-appropriate screening
• Bone marrow density screening for patients at least 60 years of age who are at low risk of osteoporosis and noncompliant with hormone therapy

“Taking more than what is prescribed is not always going to lead to a sooner development of their secondary characteristics. It’s going to actually increase their risk. We should be counseling our patients that they should be patient with the medications they are prescribed,” Dr Phan said.

Improving Cultural Competency

Dr Phan offered several strategies for health care providers to create a welcoming, affirmative environment for transgender patients.

He recommended providers practice cultural humility, introduce themselves with pronouns, advocate for patients with other staff and care teams, and educate themselves rather than depending on the patient to educate them.

“Regardless of someone’s gender identity, whether they identify as transgender or not, introducing yourself with your pronouns doesn’t really hurt. It lets your patient know that you are aware and that you care for these individuals,” Dr Phan said.

Dr Phan warned against using patients’ deadnames and encouraged providers to document and refer to sexual orientation and gender identity data when treating patients. Being mindful of slang can help ensure patients feel respected during their visit, he said.

“Terminology, today, continues to change, so we want to be keeping updated with terminology and respecting patients’ gender identity,” Dr Phan said.

Shared decision-making with the patient can also ensure care is affirmative and inclusive, he said.

“We have to really appreciate what our patient has to say and let them be the voice vs having our voice dominate and conducting a paternalistic type of visit,” Dr Phan concluded.