By Andrew Sommerville, Specialist Hepatitis C pharmacist, NHS Greater Glasgow and Clyde
Transgender patients are known to have worse health outcomes and a higher burden of disease than cisgender patients. (1,2) They commonly report negative experiences with the healthcare system, ranging from long waits to access gender identity clinics, discrimination from healthcare professionals and lack of understanding of their healthcare needs.(3) We all have a duty to educate ourselves to help minimise these health inequalities.
Language used and terminology
Transgender (often shortened to trans) refers to people whose gender identity does not match with the sex they were assigned at birth, whereas cisgender refers to people whose gender identity does match with their sex assigned at birth.
A trans man is someone who was assigned female at birth however identifies as a man, and a trans woman is someone who was assigned male at birth however identifies as a woman. Some people identify as non binary, which means they don’t identify as either male or female. In general transgender has replaced transsexual, as gender identity is distinct from sexuality. Some trans people will choose to go on to have gender affirming surgery, however not all do.
In some healthcare settings it may be appropriate to use gender neutral or inclusive language to avoid discrimination. For example some trans men will have a cervix and some trans women will have a prostate; both should be included in the relevant cancer screening.
Pronouns
Using the correct pronouns for trans patients is essential for treating them with dignity and respect. While most patients will want to be referred to by “he” or “she”, some will prefer the gender neutral “they”. If in doubt, ask the patient how they wish to be referred. To make patients feel more comfortable consider sharing your own pronouns when introducing yourself or make them visible on your name badge. If you accidentally use the wrong pronoun, apologise, correct yourself, and move on with the consultation.
Pharmaceutical care issues
Trans patients face long waiting lists before they are seen at gender identity clinics. The long wait times can cause some to resort to buying hormones online, which has obvious associated risks, as the content, quality and safety is unknown. These risks should be discussed with patients when identified during medication histories.
There is limited data available on the impact of long term hormone therapy and gender affirming surgery on how transgender people handle medication. These change the composition of fat and muscle in patients, which will impact on the distribution of drugs.
The change in muscle mass will alter creatinine levels and thus estimation of patients’ renal function and how drugs are cleared. One review suggested that after six months of hormone therapy or any gender affirming surgery, estimated creatinine clearance should be calculated based on the patient’s gender identity rather than their biological sex.(4) Another suggested using clinical judgement based on both male and female results when calculating an estimated renal function.(5) Patients who have not undergone hormone therapy or affirming surgery should have renal function based on their biological sex.
There will always be variation with how patients handle drugs and calculations can only provide an estimation. It is an important role for pharmacists to consider how the stage of a patient’s transition may affect doses. Consider adding guidance on the application to transgender patients when creating dosage calculators that factor in sex/gender.
Ultimately, we should endeavour to provide the most individualised patient-centred care possible to all patients, but we must pay particular attention to marginalised groups such as trans patients to help minimise associated health inequalities.
We want to encourage voices that express the diversity of lived experiences in the profession as part of our inclusion and diversity work. If you’d like to share your story, contact [email protected] or get involved through our ABCD group.
(1) Townsend M, Jaffer H, Goldman L. Adverse health outcomes in transgender people. Canadian Medical Association Journal. 2017;189(32):E1046-E1046.
(2) Dragon C, Guerino P, Ewald E, Laffan A. Transgender Medicare Beneficiaries and Chronic Conditions: Exploring Fee-for-Service Claims Data. LGBT Health. 2017;4(6):404-411.
(3) Stonewall and YouGov. LGBT in Britain: Health Report [Internet]. 2018. Available from: https://www.stonewall.org.uk/system/files/lgbt_in_britain_health.pdf
(4) Webb A, McManus D, Rouse G, Vonderheyde R, Topal J. Implications for medication dosing for transgender patients: A review of the literature and recommendations for pharmacists. American Journal of Health-System Pharmacy. 2020;77(6):427-433.
(5) Collister D, Saad N, Christie E, Ahmed S. Providing Care for Transgender Persons With Kidney Disease: A Narrative Review. Canadian Journal of Kidney Health and Disease. 2021;8:205435812098537.