Clinical pearls: Clinical considerations and creating safe spaces for 2SLGBTQ+ patients

June 15, 2022
By Jessica Sheard

This article was written and researched by a CSHP student member for Interactions, our biweekly newsletter. Crafting these pieces not only helps students gain in-depth knowledge of specific conditions, treatments, and resources, it also helps them hone their skills in research, critical appraisal, evaluation, synthesis, and writing – all of which will serve them well in clinical practice. The Professional Practice Team works with the student to select topics that are of interest and utility to both the student and to you, the reader. We hope you enjoy this piece by one of our future colleagues! Let us know what you think: If you would like to provide any comments or constructive feedback for our students, please email us at practice@cshp.ca.

Background

The 2SLGBTQ+ community represents a significant portion of the Canadian population.  The most recent data reported from Statistics Canada estimates the Canadian 2SLGBTQ+ population 15 years of age or older to be over 1 million as of 20181. A more recent statistic provided by Statistics Canada reports that in May 2021, 1 in 300 people over the age of 15 identify as being transgender or non-binary2. Although self-disclosure of belonging to the 2SLGBTQ+ community is increasing due to more inclusivity, 2SLGBTQ+ patients still face significant healthcare disparities. Healthcare disparities experienced by 2SLGBTQ+ people are not inherent to their identities, but rather from societal rejection, stigma, prejudice, and discrimination3,4. When accessing healthcare, 2SLGBTQ+ people have reported experiencing discrimination, including healthcare providers using harsh or abusive language, asking inappropriate questions not pertaining to care, providers refusing to touch them or using excessive precautions, or refusing to provide care completely5.  Transgender people who have received healthcare also report overhearing jokes, slurs, and mockery from staff in health care settings5. While receiving care, 2SLGBTQ+ patients report their healthcare provider admitting to their lack of knowledge in providing 2SLGBTQ+ healthcare and having to teach their provider about their own care4,6. An Ontario study found that 54% of transgender patients had to teach their provider “some” or “a lot” about trans issues, with 52% of transgender patients having a negative experience when presenting to the emergency department or their provider not knowing enough to provide care7. Similarly, another Canadian study from Vancouver Island found that 63% of transgender patients had to teach their provider about trans issues8. Negative experiences such as these can have a long-lasting impact on 2SLGBTQ+ patients. Even small, honest mistakes can be triggering for patients who have had previous negative experiences with the healthcare system and may create an emotional response4 and cause some 2SLGBTQ+ patients to delay care or avoid services all together9.

How Hospital Pharmacists Can Help Create Inclusive, Safe Spaces for 2SLGBTQ+ Patients

Pharmacists are in a unique position to help 2SLGBTQ+ patients feel comfortable and safe during their interactions in hospital. Several communication strategies can be incorporated into pharmacists’ clinical practice to enhance relationships with 2SLGBTQ+ patients and create a more inclusive space10:

  • Asking every patient their pronouns or how they would like to be addressed, and offering their own pronouns
  • Using the patient’s pronouns when charting, documenting, or speaking of the patient; referring to the patient by first name only; and/or not using pronouns at all
  • Refraining from using gendered terms when addressing patients, such as sir or ma’am
  • Offering sincere apologies when mistakes to names and pronouns are made
  • Asking questions only relevant to providing care
Pharmacists can be leaders in the hospital and pharmacy departments by creating an environment of accountability by politely correcting colleagues if mistakes are made to names or pronouns, and if insensitive comments are made by staff or others4. 

Pharmacy departments can advocate for transgender patients by ensuring access to hormone therapies while in hospital to allow for continuity of care5. Many transgender patients require gender affirming personal items such as makeup or clothing to feel comfortable. Pharmacists may also advocate for the allowance of these items for easy access while transgender patients are in hospital5.

Training surrounding 2SLGBTQ+ experiences and healthcare needs has been largely lacking in medical training6,11. To provide a safe and inclusive healthcare environment for these patients, all staff must receive training in 2SLGBTQ+ health disparities and inclusive communication12. 2SLGBTQ+ affirmative training should be provided during onboarding and at regular intervals, and educational resources should be made available to staff at all times13. Training and cultural competency for 2SLGBTQ+ health increases knowledge, attitudes, self-efficacy, and intentions of providers11. Although each individual pharmacist and staff member can be responsible for their own knowledge and learning regarding 2SLGBTQ+ health, leadership should be engaged to create an inclusive environment for all patients. Senior management should be actively engaged to set the tone for creating an inclusive space and scheduling training on 2SLGBTQ+ health12

Clinical Considerations for 2SLGBTQ+ Patients:

Hospital pharmacists may need to consider factors for laboratory monitoring and risk assessment in 2SLGBTQ+ patients while they are in hospital, particularly for transgender patients. It is important that pharmacists be familiar with clinical guidelines and laboratory monitoring for transgender patients on hormone therapies14. However, gender-specific “normal” values can be challenging to interpret in transgender patients on hormone therapy14,15. A small study compared laboratory values of transgender women to both cis women and cis men. This study found that the trans women’s reference ranges for hemoglobin, hematocrit, and LDL more closely resembled that of cis women, while the reference ranges for ALP, potassium, and creatinine more closely resembled that of cis men14,15.

Kidney function of transgender patients is another complex area in which pharmacists may need to navigate for dosing considerations. A review of four studies assessing transgender patients’ serum laboratory values demonstrated that these more closely reflected the patients’ gender identity, rather than their gender assigned at birth16. The authors recommend assessing renal function by using creatinine clearance and ideal body weight for the patient’s gender identity16. However, creatinine clearance may not be a reliable measure in transgender patients because this value is dependent on age, race, muscle mass, diet, and drugs16. A 24-hour urine creatinine collection may be used to assess renal function with a value independent of sex or muscle mass16.

A metanalysis and an Endocrine Society review found significant elevations in TG and LDL and decreases in HDL in trans men on testosterone17. However, the clinical outcomes of these findings have been debatable, and overall evidence of CV outcomes was insufficient to allow for conclusion17. A transient increase in liver enzymes can occur occasionally in trans men on testosterone17. However, the elevations spontaneously resolve, unless another cause is present17.

Risk of VTE has been a concern for trans women on estrogen therapy, especially in the first year of initiation. However, many of the studies on trans women using estrogen therapy were using ethinyl estradiol, known to carry a higher risk of thrombogenic events than estadiol17. Age over 40, sedentary lifestyle or obesity, smoking, or underlying thermophilic disorders can increase risk17. A meta-analysis and meta-regression study found the overall prevalence of VTE in trans women to be 2%, with large heterogeneity18. Prevalence of VTE increased to 3% in patients who were 37.5 years of age or older, while risk was reduced to 0% in patients younger than 37.5 years of age18. Duration of therapy more than 53 months was found to have VTE prevalence of 1%, whereas prevalence was found to be 0% in less than 53 month duration of therapy18. Management of VTE risk in hospitalized transgender women remains controversial. In the perioperative period, some surgeons advocate for estrogen therapy discontinuation 2-6 weeks prior to surgery, with resumption of therapy when ambulation is reliable19,20. However, discontinuation of hormone therapy may result in emotional and physiological effects in these patients, including exacerbation of gender dysphoria19,20. Current Endocrine Society clinical practice guidelines recommend collaboration between the prescribing physician and surgeon surrounding perioperative hormone management, including informed consent discussions with the patient20. VTE prophylaxis should still be considered in transgender women where indicated, particularly in patients in their first year of estrogen therapy or with risk factors such as smoking21. In patients undergoing surgery under general anesthesia with operation times over 60 minutes and Caprini Score between 3-6, postoperative use of low-molecular-weight heparin or unfractionated heparin should be considered21.

References

  1. A statistical portrait of Canada’s LGBTQ2+ communities. Statistics Canada; 2021 June 15 [cited 2022 June 2] Available from: https://www150.statcan.gc.ca/n1/en/daily-quotidien/210615/dq210615a-eng.pdf?st=LSJc4Y2w
  2. Canada is the first country to provide census data on transgender and non-binary people. Statistics Canada; 2022 Apr 27 [cited 2022 June 2] Available from: https://www150.statcan.gc.ca/n1/en/daily-quotidien/220427/dq220427b-eng.pdf?st=CgjeOryJ
  3. LGBTQ2 Health in Canada: Study brief for the Standing Committee on Health [Internet]. Rainbow Health Ontario. 2019. Available from: https://www.ourcommons.ca/Content/Committee/421/HESA/Brief/BR10445304/br-external/RainbowHealthOntario-revised-e.pdf
  4. Providing Inclusive Services and Care for LGBT People [Internet]. National LGBT Health Education Center. 2016. Available from: https://www.lgbtqiahealtheducation.org/wp-content/uploads/Providing-Inclusive-Services-and-Care-for-LGBT-People.pdf
  5. Transgender-Affirming Hospital Policies [Internet]. Human Rights Campaign Foundation. 2016. Available from: https://assets2.hrc.org/files/assets/resources/TransAffirming-HospitalPolicies-2016.pdf?_ga=2.13740471.1667924262.1652800445-840857854.1652800445
  6. Literature Review to Support Health Service Planning for Transgender People [Internet]. The Canadian Professional Association for Transgender Health. 2015. Available from: https://cpath.ca/wp-content/uploads/2015/10/Trans-lit-review-supporting-service-planning-final.pdf
  7. Bauer GR, Scheim AI, Deutsch MB, Massarella C. Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: Results from a respondent-driven sampling survey. Annals of Emergency Medicine. 2014;63(6):713-720.  https://doi.org/10.1016/j.annemergmed.2013.09.027.
  8. Heinz M, MacFarlane D. Island lives: a trans community needs assessment for Vancouver Island. SAGE Open. 2013 Sep 16;3(3):2158244013503836.
  9. Mitra S, Globerman J. Rapid response: Facilitators and barriers to health care for lesbian, gay and bisexual (LGB) people [Internet]. Rapid Response Service. 2014. Available from: https://www.ohtn.on.ca/Pages/Knowledge-Exchange/Rapid-Responses/Documents/RR79.pdf
  10. Schwindt, R. LGBTQ cultural competence for pharmacists. Pharmacy Today. 2020. Available from: https://www.pharmacytoday.org/action/showPdf?pii=S1042-0991%2820%2930876-8
  11. Bhoten B, Burkhalter JE, Joo R, Mujawar I, Bruner D, Scout NFN, et al. Impact of an LGBTQ cultural competence training program for providers on knowledge, attitudes, self-efficacy and intensions. Journal of Homosexuality. 2022;69(6):1030-1041. https://doi.org/10.1080/00918369.2021.1901505
  12. Ten Strategies for Creating Inclusive Health Care Environments for LGBTQIA+ People [Internet]. National LGBT Health Education Center. 2021. Available from: https://www.lgbtqiahealtheducation.org/wp-content/uploads/2021/05/Ten-Strategies-for-Creating-Inclusive-Health-Care-Environments-for-LGBTQIA-People-Brief.pdf
  13. Providing Inclusive Care and Services for the Transgender and Gender Diverse Community: A Pharmacy Resource Guide [Internet]. Human Rights Campaign Foundation. 2021. Available from: https://hrc-prod-requests.s3-us-west-2.amazonaws.com/Transgender-Pharmacy-Resource-Guide.pdf
  14. Roberts TK, Kraft CS, French D, Ji W, Wu AHB, Tangpricha V, et al. Interpreting laboratory results in transgender patients on hormone therapy. The American Journal of Medicine. 2014;127(2):159-162. https://doi.org/10.1016/j.amjmed.2013.10.009
  15. Redfern JS, Jann MW. The evolving role of pharmacists in transgender health care. Transgender Health. 2019;4(1):118-130. DOI: 10.1089/trgh.2018.0038
  16. Jue JS, Alameddine M. Assessment of renal function in transgender patients. American Journal of Health-System Pharmacy. 2020 Sep 15;77(18):1460-1.
  17. Bourns A. Guidelines for gender-affirming primary care with trans and non-binary patients [Internet]. Rainbow Health Ontario. 2019. Available from: https://www.rainbowhealthontario.ca/wp-content/uploads/2021/06/Guidelines-FINAL-4TH-EDITION-c.pdf
  18. Totaro M, Palazzi S, Castellini C, Parisi A, D;Amato F, Tienforti D et al. Risk of venous thromboembolism in transgender people undergoing hormone feminizing therapy: a prevalence meta-analysis and meta-regression study. Frontiers in Endocrinology. 2021. https://doi.org/10.3389/fendo.2021.741866
  19. Tollinche LE, Walters CB, Radix A, Long M, Galante L, Garner Z, et al. The perioperative care of the transgender patient. Anesth Analg. 2018; 127(2);359-366. doi:10.1213/ANE.0000000000003371.
  20. Honstscharuk R, Alba B, Manno C, Pine E, Deutsch MB, Coon D, et al. Perioperative transgender hormone management: Avoiding venous thromboembolism and other complications. Plastic and Reconstructive Surgery. 2021;147(4):1008-1017. doi: 10.1097/PRS.0000000000007786
  21. Lennie Y, Leareng K, Evered L. Perioperative considerations for transgender women undergoing routine surgery: a narrative review. British Journal of Anaesthesia. 2020;124(6);702-711. https://doi.org/10.1016/j.bja.2020.01.024
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