Transgender Care Is Patient Care

Put away assumptions about sex and gender and learn to communicate with patients.


Cheyenne Frazier and Karen Gunning
Cheyenne Frazier and Karen Gunning

In today’s era of patient-centered care, pharmacists have boundless opportunities to create a welcoming environment for transgender patients and help them reach their personal health goals.

“I think there is a lot of opportunity to get creative and identify ways that you can be a gender-affirming provider, identify any barriers in your practice that your patients express to you or that you identify as gaps, and work to correct them,” said Cheyenne Frazier, clinical assistant professor of pharmacy at  Washington State University in Spokane and lead speaker at the Dec. 9 Midyear session Caring for Transgender People: Insights and Points of Controversy in Medication Therapy.

Frazier shared how she rethought her assumptions about sex and gender and learned to communicate in ways that better respect patients’ wishes and put them at ease.

“We all develop implicit biases based on our upbringing, the culture we’re around, the media that we’re exposed to,” Frazier said. Her own biases included generalizations that people with long hair are women and that speakers with deep voices are men.

But she cautioned that there’s no sure way to determine a person’s gender identity — the internal sense of whether one is a man, woman, both, or neither — without asking the person.

So that’s what she does.

“I ... introduce myself with my pronouns and then ask the patient to introduce themselves to me,” Frazier said. “I ask them to share what first name they would like to use. And this was really helpful not only for my gender-diverse patients but also for patients who went by a nickname or their middle name.”

Unfounded assumptions can also get in the way of clinical care for gender-diverse patients, said co-presenter Karen M. Gunning, clinical professor and associate dean of community engagement at the University of Utah College of Pharmacy and family medicine clinical pharmacist for University of Utah Health in Salt Lake City.

“It’s very important for you to listen to your patient’s goals for care. Make no assumptions about what their wishes may be,” Gunning said. “A patient who identifies as female may want gender-affirming hormonal therapy, may want a little bit of gender-affirming hormonal therapy, or may be completely uninterested in receiving hormones. So just because a patient is transgender does not mean that they require, have to be, or want to be on gender-affirming hormone therapy.”

Gunning said that despite the existence of recommendations and protocols from various sources, gender-affirming therapy is an emerging science without a solid evidence base.

“There are lots of very divergent opinions out there,” Gunning said. “I’ve found really going back to pharmacology and pharmacokinetics very helpful to me in answering questions from both providers and patients.”

Gunning said pharmacists can help patients who opt for hormonal treatment understand what to expect and when to expect it.

For example, she said, patients who take estradiol and antiandrogens often require 3–6 months of therapy before the onset of breast growth, body fat redistribution, and decreased muscle mass. And testosterone therapy typically requires 6–12 months to produce certain masculinizing effects, such as facial and body hair growth, deepening of the voice, and increased muscle mass.

“We need to ensure that their expectations are aligned with what the medications can do,” Gunning noted. “As hard as we try with drug therapy, we can’t always guarantee the outcome.”

She also pointed out that transgender patients need primary care services for the management of diabetes, hypertension, and other common conditions unrelated to gender-affirming care.

“So providing the inclusive environment ... is an important first step even if there’s not support for providing gender-affirming hormone therapy in your clinic,” Gunning said.

AJHP’s collection of resources on transgender care includes Transgender/Gender Nonconforming Adults’ Worries and Coping Actions Related to Discrimination: Relevance to Pharmacist Care, Pharmacists’ Role in Provision of Transgender Healthcare, and the AJHP Voices episode Providing Healthcare to Transgender Persons.