Are we woefully unprepared to care for the LGBTQ population?

By Rachel Priddy Ramsey, PharmD

I recently graduated from a top ten college of pharmacy and completed an accredited PGY1 residency; however, it wasn’t until PGY2 residency training in ambulatory care that I first learned about providing healthcare for LGBTQ patients. How is it that I completed an advanced pharmacy curriculum and postgraduate training with no didactic or experiential education on this vulnerable patient population? I not only was unfamiliar with cultural competency of care, but I was also unaware of where to find answers to therapeutic questions. For example, infectious disease may not be my strongest area, but I know to lean on my trusty Sanford Guide and the Infectious Disease Society of America guidelines if needed. Until I began this year of residency training, I couldn’t name a single reference for transgender health care.

Kenneth Mayer, the medical research director at the Fenway Institute, whose mission is to enhance the wellbeing of the LGBTQ community stated, “The biggest challenge is that the health care system is woefully unprepared to take appropriate care of LGBTQ people.” My personal experience validates this state of unpreparedness in pharmacy practice. In my early training as a student intern in community practice, I remember filling a testosterone prescription for a patient undergoing gender transition. Always curious about therapeutics, I asked the pharmacist I was working with how she knew it was the right dose. Her frank answer, “I don’t. I trust that the doc knows what he’s doing.” Woefully unprepared, indeed!

In a mixed method systematic review published by Sekoni and colleagues in 2017, it was found that while trainings geared towards culturally competent LGBTQ care improved short-term knowledge and attitudes of healthcare professionals that a conceptual model for training methodology was lacking.¹ Further studies have shown that even though professional students generally have positive personal attitudes towards the LGBTQ population, their therapeutic knowledge is lacking, particularly in the care of the transgender population.² These studies illustrate that training is advancing, but as a recent graduate, it seems these changes are moving too slow.

I recognized this as a gap in my therapeutic arsenal. I learned from a seasoned LGBTQ practitioner on site, and then self taught from trusted resources. I received no formalized training, but don’t you think I should have? This is not a specialty care issue, all healthcare providers need to be able to care for LGBTQ patients. Yes, I saw these patients in a clinic, but we care for them throughout the healthcare system. Our community colleagues verify high dose hormones for transitions. Our hospital colleagues have patients admitted every day who identify as LGBTQ. Do we know how to counsel these patients on their healthcare, verify their prescriptions, and provide culturally competent care overall?

In my alma mater, a new curriculum has been implemented with coursework aimed at providing culturally competent care to the LGBTQ population. Standards 16³ has Key Elements aimed at both patient-centered care and cultural sensitivity, which should result in future pharmacists receiving more direct resources and education in LGBTQ care. No longer should a pharmacy graduate enter the workforce with little to no knowledge of caring for the LGBTQ population, according to Standards 16 students should, at minimum, be equipped with the knowledge of cultural competency.

Faculty, what would your graduating class say they learned in pharmacy school about LGBTQ health? Does your curriculum have a single case study that involves culturally competent care for an LGBTQ patient? Preceptors, what conversations do you have with your students about diverse patient populations in your practice and how to address their specific needs? What training does your worksite have to lead the transition from education to practice in culturally competent care? At this time we’re lacking pharmacy education models in this arena. However, I believe training of LGBTQ care would be best spread longitudinally throughout the curriculum. Start with learning about culturally competent care (i.e. communication, proper use of pronouns, etc) and disparities of health care of the LGBTQ population during core curriculum lectures. Follow with brief training in endocrinology regarding therapeutics. This therapeutic discussion doesn’t have to take up an entire lecture, but could simply help lead the student to the right resources.

While I am by no means an expert, I now know which resources to consult to provide culturally competent care and to answer therapeutic questions. I’ve included resources and guidelines that I have found helpful below. Whether your role is teaching, precepting, practicing pharmacy, or a combination of the three – we must do our part to ensure that all patients can count on culturally and therapeutically competent care from their pharmacist. This is our duty to our patients and to our profession.

Acknowledgements
Holly Divine, PharmD, BCACP, BCGP, CDE, FAPhA

General Resources

• National LGBT Health Education Center
• UCSF Center of Excellence Transgender Health

Guideline Resources

• Center of Excellence for Transgender Health, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 17, 2016.
• Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. World Professional Association for Transgender Health. Version 7. 2012.
• The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Institute of Medicine Consensus Report. March 2011.
• Healthy People 2020: Lesbian, Gay, Bisexual, and Transgender Health. Overview, objectives and data, and evidence-based resources from this important U.S. public health initiative.

References

1. Sekoni AO, Gale NK, Manga-Atangana B, Bhadhuri A, Jolly K. The effects of educational curricula and training on LGBT-specific health issues for healthcare students and professionals: a mixed-method systematic review. J Int AIDS Soc. 2017 Jul 19;20(1):21624.

2. Lapinski J, Sexton P, Baker L. Acceptance of lesbian, gay, bisexual, and transgender patients, attitudes about their treatment, and related medical knowledge among osteopathic medical students. J Am Osteopath Assoc. 2014 Oct;114(10):788-96.

3. Accreditation Standards And Key Elements For The Professional Program In Pharmacy Leading To The Doctor Of Pharmacy Degree. (2015). [PDF] Chicago, Illinois: Accreditation Council for Pharmacy Education. [Accessed 24 Apr. 2019].

Rachel Priddy Ramsey is a PGY2 Resident in Ambulatory Care at the University of Kentucky College of Pharmacy and Bluegrass Community Health Center. She will be starting as a clinical pharmacist at Hardin Memorial Hospital upon completion of residency, and aspires to create pharmacy driven outpatient services. Her current academic interest includes preceptorship and pharmacy practice readiness. In her free time, Rachel enjoys spoiling her sweet pups and spending time with her family.

Pulses is a scholarly blog supported by Currents in Pharmacy Teaching and Learning