Resource spotlight: Clinical resources and creating safe spaces for 2SLGBTQ+ patients

July 27, 2022

 

Written 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

It is estimated that there are at least 1 million 2SLGBTQ+ people over the age of 15 living in Canada as of 20181, with 1 in 300 people over 15 identifying as either transgender or non-binary2. Although there has been progress for 2SLGBTQ+ inclusivity, patients in this community still face significant healthcare disparities due to societal rejection, stigma, prejudice, and discrimination3. Many 2SLGBTQ+ patients report having negative experiences with the healthcare system and with healthcare providers. Some patients report inappropriate questions or lack of knowledge from their healthcare providers, while other patients report outright refusal of care and discrimination4,5. Negative or discriminatory experiences can result in long-lasting affects for 2SLGBTQ+ patients. Small, honest mistakes can be triggering for patients who have had previous negative experiences, and can lead to emotional responses, or delaying and avoiding receiving future care. In this “Resource Spotlight” pharmacists can learn more about the 2SLGBTQ+ community, how to integrate inclusive strategies into their practice to create safe and welcoming spaces for 2SLGBTQ+ patients, and access clinical guidelines important for transgender patient care. 

Cultural Competency, Inclusivity, and Safe Space Guidelines

Health Professionals Advancing LGBTQ Equality (previously known as the Gay & Lesbian Medical Association (GLMA) is the world's largest and oldest association of lesbian, gay, bisexual, transgender, and queer (LGBTQ) healthcare professionals. GLMA was founded in 1981, as the American Association of Physicians for Human Rights, with the mission of ensuring equality in healthcare for 2SLGBTQ+ individuals and healthcare professionals. GLMA has created a three-part webinar series titled “Quality Healthcare for Lesbian, Gay, Bisexual & Transgender People” (GLMA - Cultural Competence) free for anyone to access. The webinar series covers topics to understand healthcare needs of 2SLGBTQ+ people, creating a welcoming and safe environment, and clinical skills for the care of transgender patients. 

Rainbow Health Ontario (RHO) has created a new online learning platform for healthcare providers called LGBT2SQ Health Connect.  On this platform pharmacists can access the LGBT2SQ Foundations Course, to heighten comfort and competency when providing high quality and inclusive, affirming, welcoming, culturally sensitive care. The course is available for free for healthcare professionals in Ontario, and $50 for those outside of Ontario. Many other courses are available through LGBT2SQ Health Connect, including another useful course called Removing the Barriers: Making your Organization LGBT2SQ friendly, which is offered at scheduled intervals bimonthly. This course explores various strategies for programs and services, policies, and inclusive language, intake forms and signage. The LGBT2SQ Foundations course is a prerequisite for this course, and all others on LGBT2SQ Connect. Course descriptions can be found here (Education & Training | Rainbow Health Ontario). Pharmacists can sign up for an account to access these courses here (Rainbow Health Ontario).

The University of Toronto Faculty of Medicine has created this (LGBT Infographic Page 1 – Aug 9, 2016 (utoronto.ca)) condensed infographic for healthcare providers. The infographic, through useful information, tips, and creative drawing, is a tool for healthcare professionals to learn about 2SLGBTQ+ terminology and providing inclusive healthcare. 

This article (LGBTQ cultural competence for pharmacists (pharmacytoday.org)) published by Pharmacy Today and developed by American Pharmacists Association (APhA) as a continuing education home-study, aims to increase 2SLGBTQ+ cultural competence for pharmacists. The activity contains a brief pre-assessment questionnaire, learning material, and 20 question assessment following the readings. Learners will cover topics including foundational concepts about the 2SLGBTQ+ community, 2SLGBTQ+ health disparities relating to physical and mental health, the pharmacist’s role in 2SLGBTQ+ patient care, and creating a welcoming pharmacy environment.

Mount Sinai Hospital has developed this gender identity policy (General Manual Master Form - Microsoft Word (rainbowhealthontario.ca)) to provide guidelines for the care of trans, intersex, and Two Spirit individuals in the hospital. This policy covers the rights of members of the hospital community, including patients and staff, responsibilities of members of the hospital community, and guidance on policies for managers and employees. Policies surrounding education, bed assignments, washroom access, and intake forms can be found in this document. Although specific to one hospital, this policy manual can be used as an example for hospitals and departments in creating and implementing policy to protect patients of various gender identities. 

Trans Care BC Resources

Trans Care BC provides free educational courses on gender diversity for healthcare providers that introduce key terms and concepts as well as basic strategies for creating welcoming and gender-affirming services in both a basic, 30-minute course, and expanded 60-minute course for professionals regularly interacting with gender-diverse individuals. The basic course can be accessed here (Intro to Gender Diversity - LearningHub (phsa.ca)) and expanded course here (Intro to Gender Diversity - Expanded - LearningHub (phsa.ca)), and learners can receive a certificate of completion after signing up for a free account. To bypass the account sign up and complete the courses without receiving a completion certificate, access the basic course here (Intro to Gender Diversity - Overview | Rise 360 (articulate.com)) and expanded course here (Intro to Gender Diversity - Expanded - Overview | Rise 360 (articulate.com)).

Trans Care BC has very useful practice tools that can be used by pharmacists and pharmacy departments to assess their current practices and implement strategies to improve patient care for gender-diverse patients. This short reference (Gender-Affirming_Patient_Care_In_a_Hospital_Setting.pdf (phsa.ca)) provides tips for healthcare workers in hospitals to ensure they are providing gender-affirming care to their patients. The reference provides guidance on pronouns, referring to patients, and name verification with example scripts, and guidance on transferring care, washroom access for patients, and times of greater vulnerability for this population. Pharmacists can reflect on their knowledge, approach to gender diverse patients, personal comfort, and patient engagement using this personal reflection tool (Service_Provider_Reflection_Tool.pdf (phsa.ca)). Pharmacists can also use this tool to reflect on their approach to advocacy and allyship for their gender-diverse patients, their organizational supports, and to create time-based goals to improve their patient care. 

This tool (20_Care_Strategies.pdf (phsa.ca)) can be used by pharmacists and pharmacy departments to find strategies that will increase and improve access to care for gender-diverse patients. The practice tool includes 20 strategies, 10 which are organizational and program specific, and 10 that are service provider and staff specific. Strategies can be marked based on relevance to the organization, a level can be given based on current practices, and targeted goals can be created to meet the strategy guidelines. This organizational assessment tool (Organizational_Assessment_Tool.pdf (phsa.ca)) can also be used by pharmacy departments and hospitals to help develop an approach to offering more inclusive and gender-affirming care. It can be used on its own, or in combination with the Service Provider Reflection Tool. Sections for assessment include education, visibility and outreach materials, programming, forms and charts, waiting rooms, referral services, rooming, and hospital policies for providing gender-affirming care and protecting gender-diverse patients from discrimination. 

Clinical Guidelines

Sherbourne Health and Rainbow Health Ontario developed clinical guidelines for gender-affirming primary care for trans and non-binary patients. This Canadian guideline (Guidelines for Gender-Affirming Primary Care with Trans and Non-Binary Patients (rainbowhealthontario.ca)) provides a brief framework for providing gender-affirming care to trans and non-binary patients, a useful list of other transgender health guidelines, and clinical guidance surrounding hormone therapies in transgender patients. Within the clinical guidelines for hormone therapies, pharmacists can find convenient tables for formulations and dosing, and monitoring parameters, including bloodwork and time to onset of expected effects from hormone therapy. Pharmacists can also find tables outlining precautions for both feminizing and masculinizing medications, with guidance to minimize associated risks. 

This Standards of Care (SOC) clinical guideline (SOC V7_English.pdf (wpath.org)) was created by the World Association for Transgender Health (WPATH). This organization has been creating Standards of Care for transgender and gender diverse patients since 1979. The SOC document is intended to provide clinical guidance for healthcare professionals to maximize the overall health, psychological well-being, and self-fulfillment of transgender and gender diverse patients. Guidelines on primary care, gynecologic and urologic care, reproductive options such as sperm and oocyte preservation, voice and communication therapy, mental health services, and hormonal and surgical treatments can be found within the SOC. It is important to note that most of the research that has guided this document comes from a North American and Western European perspective. 

Research Surrounding Hormone Therapy in Transgender Patients

Many transgender patients will choose to initiate hormone therapy to achieve characteristics of their gender, which may result in clinical considerations for healthcare providers while they are in hospital. This meta-analysis and meta-regression study (Frontiers | Risk of Venous Thromboembolism in Transgender People Undergoing Hormone Feminizing Therapy: A Prevalence Meta-Analysis and Meta-Regression Study | Endocrinology (frontiersin.org)) identifies the prevalence of VTE in transgender patients on feminizing hormone therapy. This review (Perioperative Transgender Hormone Management: Avoiding Venou... : Plastic and Reconstructive Surgery (lww.com)) discusses the evidence and recommendations surrounding the management of feminizing hormones for patients in the perioperative period. 

Two Spirit Resources

The National Collaborating Centre for Indigenous Health is an organization established by the Government of Canada, funded by the Public Health Agency of Canada (PHAC), and hosted by the University of Northern BC. The organization was established to support Indigenous health equity. This webinar (NCCIH - National Collaborating Centre for Indigenous Health > Home > NCCIH PUBLICATIONS) is an introduction to Two-Spirit people and their health. An accompanying document, and suggested pre-reading for the webinar, on Two-Spirit health can be accessed here: An Introduction to the Health of Two-Spirit People: Historical, contemporary and emergent issues (ccnsa-nccah.ca).

This (Indigenous gender diversity: creating culturally relevant and gender-affirming services - LearningHub (phsa.ca)) free, three-hour course was created by Trans Care BC in collaboration with gender diverse Indigenous and Two-Spirit community members. It is intended to increase awareness, knowledge, and skills for people working in healthcare settings to ensure culturally relevant and gender-affirming services for gender diverse Indigenous people. 

There is an Inclusive Healthcare Community (QID - Community Page)) that can be found on QID. This community contains resources for pharmacists and can be used as a space to ask questions or share resources surrounding care for 2SLGBTQ+ patients and other marginalized patients. 
 
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. 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
  5. 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.