Abstract

Introduction

The transgender community has recently been brought to the forefront of the mainstream media, and this has served as a springboard for starting long-overdue conversations about the societal stigmatization of transgender persons, including by that of the US health care system. The Department of Health and Human Services has listed improving the health and overall well-being of the lesbian, gay, bisexual, and transgender (LGBT) community as a goal of the Healthy People 2020 Initiative.¹ Some initiatives encompassed within this directive include appropriate inquiry by health care providers about a patient's sexual orientation and gender identity as a means of improving patient-provider interactions and regular use of care, providing adequate social services to reduce suicide and homelessness among LGBT youth, and also providing medical students with adequate training in order to provide competent care.¹ Transgender individuals, that is, people whose gender identity differs from that of their biological sex,² are highly underrepresented and underserved within modern health care settings even when compared to bisexual, lesbian, and gay individuals.³ For example, the 2015 US Transgender Survey, published in 2016 by the National Center for Transgender Equality,⁴ surveyed 27 715 transgender people and found that nearly one fourth of respondents did not see a physician when needed due to fear of being mistreated and endorsed problematic issues with insurance coverage due to their transgender identity. Further, one third of participants who had seen a health care professional within the previous 12 months endorsed having at least 1 negative experience, including such things as refusal of treatment, verbal harassment, or having to educate the provider about how to provide care to a transgender person.⁴ Given these findings and an ever-evolving LGBTQ (Q denotes queer) community, incorporation of LGBTQ education into allied health programs is of great importance.

There is a lack of research regarding the means by which LGBTQ topics should be integrated into pharmacy school curricula, especially transgender health care topics. In the Accreditation Council for Pharmacy Education (ACPE) 2016 Standards and Key Elements for the Doctor of Pharmacy Degree, Standard 3 discusses graduates' approach to patient care.⁵ Within this standard, ACPE defines that “The graduate [should be] able to recognize social determinants of health to diminish disparities and inequalities in access to quality care.”⁵ Further, a recent survey study of community pharmacy residents conducted by Leach and Layson-Wolf⁶ reported that this cohort of pharmacists (1) identified discrimination and a lack of provider education as major barriers to transgender healthcare, (2) overwhelmingly believed (82.7%) that community pharmacists play an important role in transgender health management, and (3) supported integrating transgender health into pharmacy education.⁶ Given the role of cross-sex hormones and other medications in transgender health care, pharmacists are uniquely positioned to provide critical education on both medication and overall health maintenance in a community-based setting.^3,7 Positive interactions with appropriately educated pharmacists may also serve as opportunities to repair health care relationships and establish rapport with transgender persons. The following aims to describe the current status of transgender health education in North American pharmacy schools as well as a discussion on areas for future study.

Methods

A PubMed Central literature search on November 28, 2016, using the MeSH terms transgender persons or transsexualism and pharmacy education was conducted. This search revealed 1 article published by Parkhill and colleagues³ in the American Journal of Pharmacy Education in 2014. A Google search of the phrase “transgender education in pharmacy school” was conducted, and results were reviewed for relevance. The Google search produced 1 additional published article as well as an online transgender education program launched in November 2016. Opinion pieces and calls for action were not included in this commentary.

Results

A study conducted by Mandap and colleagues⁸ aimed to describe the extent to which LGBT topics are covered in pharmacy school curricula. From November 2011 to January 2012, curriculum deans (or equivalent) from US schools of pharmacy were invited to report the amount of LGBT health content taught in their respective schools using a 14-item questionnaire.⁸ Out of 125 invited schools, 28 responded to the survey, and only 14% of respondents claimed good or very good coverage of LGBT content. Fifty-four percent of participants reported no coverage of LGBT health content in required didactic courses, and 68% reported no coverage in experiential courses.⁸ When LGBT health content was present, the preponderance of topics covered were human immunodeficiency virus (71%) and/or sexually transmitted infections (non-human immunodeficiency virus; 46%) in LGBT people. Overall, resources for faculty development for teaching LGBT health content were very low (18%).⁸ Respondents believed that incorporating material that highlighted LGBT health care disparities and having faculty who were willing and able to teach such content would be the optimal strategies for improving coverage in their curriculum.⁸ Overall, this study⁸ was limited by a small sample size and likely selection bias given the lack of randomization of pharmacy school locations. However, results of this study⁸ highlight the significant lack of LGBT content in pharmacy school curricula, especially as it relates to health care disparities, barriers to care, and unique health risks.

In another study by Parkhill and colleagues³ at the Wegmans School of Pharmacy, the authors evaluated the utility of a patient panel discussion in 2014. As a part of a required first year pharmacy student (P1) course, students attended a 1-hour lecture on LGBT terminology as well as a 2-hour panel discussion composed of 4 transgender individuals who described their health care experiences. Students completed preintervention and postintervention surveys as well as a self-reflective paper on the experience. The authors³ reported that following the panel discussion, 91% of students could describe methods for showing respect to transgender patients and felt that the learning experience was very good or excellent. Additionally, qualitative analysis of self-reflective papers demonstrated themes of “optimizing interactions with transgender patients in the pharmacy” as well as “understanding the transgender population.”³ Importantly, student self-awareness was significantly improved following completion of this academic activity given that zero students reported “none” or “little knowledge” about LGBT issues in the post survey and 86% of students self-reported that they knew “a lot” after completing this course. One potential limitation of the project was that the class and reflections were mandatory, which may have led to student responses that were not genuine. However, negative feedback on the self-reflective survey was reported, suggesting that students were presented an opportunity to give feedback candidly.³ Overall, the authors³ concluded that the panel discussion served as an effective tool for improving student self-reported awareness and education about transgender patients.

An innovative project, termed TransEd, was released in November 2016 by both the Department of Family Medicine and the Michael G. DeGroote School of Medicine of McMaster University and the University of Waterloo School of Pharmacy. TransEd provides postsecondary health care students with an online transgender health learning experience and is advertised as “freely available to interested health care programs.”⁹ The program itself comprises 8 sections, including Introduction, The Healthcare Landscape, Clinical Best Practices, Assessment, Psychosocial Health, Medication, and Surgical & Resources. The online nature of the program allows students to review any and all of the 8 sections, learn at their own pace, and complete online learning assessments in an environment of their choosing. Recorded interviews with trans men, trans women, and health care providers specialized in trans health care are available for viewing as well as discussions on best practices. Additionally, TransEd has included a facilitators' guide, which affords educators the opportunity to learn about transgender health and suggestions on how to integrate these topics into their existing curricula. Interested individuals may request access to the TransEd module by completion of a short Google form at http://www.transeducation.ca.

Discussion

In November 2014, the Association of American Medical Colleges¹⁰ published its first set of guideline recommendations for training physicians to care for gender nonconforming, differences of sex development (DSD), and LGBT individuals. This guideline aims to provide medical schools with education about the health needs of DSD, LGBT, and gender nonconforming people; a discussion on how to integrate this content into the curriculum; a framework for facilitation; and a list of national resources.¹⁰ As a result, many medical schools now include a median of 5 hours of LGBT health topics in their curriculum although covered content and perceived quality varies by institution.¹¹ Unfortunately, no such guideline yet exists for pharmacy schools. In a publication referenced earlier, Leach and Layson-Wolf⁶ found that more than 70% of community pharmacy resident participants were not educated about transgender health care in school and were overwhelmingly unconfident in their ability to competently provide care for this demographic. Historically, undereducation of pharmacy and other allied health students on transgender health care issues may, in part, be due to an unintentional lack of perceived need. Current prevalence studies indicate that roughly 0.3% of the US population is transgender¹²; however, this figure likely disproportionally represents only individuals who are seeking treatment for gender dysphoria or who are pursuing surgical correction of primary sex traits.¹³

Prior research¹⁴ has shown that educational programs, such as experiential rotations or elective courses, can positively influence student attitudes and future encounters with stigmatized populations. Similarly, use of discussion panels, standardized patients (ie, patient actors), and virtual patient technology have all been investigated as means of evaluating trainee communication and interaction with unique patient populations, all with encouraging results.^3,15-17 Given the current state of transgender health education in pharmacy schools, coverage of even basic information using any combination of these tools presents a significant learning opportunity, for example, the use of appropriate terminology and importance of asking patients for their preferences. Similarly, students should understand that being transgender is not a psychiatric illness; rather, gender dysphoria, or the marked discomfort associated with the incongruence of one's gender biology and gender identity, is a psychiatric disorder according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition.¹⁸ Ultimately, students should know that language and attitude can have significant impacts on patient-provider interactions, irrespective of the professional's background in formal training on the subject.

Research on integrating transgender health education into pharmacy schools should occur with the Association of American Medical Colleges “Integrating LGBT and DSD content into medical school curricula” guidelines in mind. Information on faculty development, curricular integration, student-based outcomes (ie, attitude and knowledge gaps), and minimum competency standards are all needed. Comparisons of didactic-based learning against more interactive forms of pedagogy are certainly indicated with particular emphasis in assessing the impact of these educational interventions on direct patient care. Investigations of PharmD student communication and interaction with transgender patients at different times in the curriculum would also be useful in understanding if students' intrinsic biases change throughout the course of training. For example, the study by Parkhill and colleagues³ was effective in presenting P1 students to this diverse patient population but included students who were neither trained in the health care settings nor introduced to pharmacotherapeutics courses; thus, the scope of questions asked was limited. Additionally, assessments of experiential-based learning with the transgender community would be useful in determining what role this type of experience has on patient care. For example, a previous survey study by Gable and colleagues¹⁹ demonstrated that use of mental health experiential-based electives had positive impacts on student perception, social distance, and stigmatized views. Ultimately, pharmacy educators and practitioners should collaborate together to solve problems leading to transgender health care barriers rather than contributing to them by stagnating in our educational endeavors.

Conclusion

Guidelines for training pharmacists in transgender health are needed in order to keep the profession relevant with the changing dynamics of the US population and to promote research-based education and care for this underserved demographic.