The average community pharmacy is a reflection of the population it serves, and pharmacists shine when dealing with people from all walks of life.
Transgender issues are forcing their way into the nation’s consciousness – and community pharmacy is no exception. In April, C+D blogger The Information Sage wrote about improving the transgender experience in pharmacy. In response, locum pharmacist Margaret Allen commented: “I recall the look of sheer joy on the face of one of my patients when the great day came when the prescription was presented with a new name and I could say ‘Miss’.”
This shows the value that a good experience between a pharmacist and a transgender patient can bring. But unfortunately, these interactions may be all too rare. In 2015, the charity Stonewall commissioned research on the treatment of lesbian, gay, bisexual and transgender (LGBT) people within health and social care services. It found that a quarter of health and social care staff admitted they are not confident in their ability to respond to the specific care needs of transgender patients.
As research by the Gender Identity Research and Education Society (GIRES) estimates that 1% of the population could identify with a different gender to some extent, pharmacy must build up its clinical and communication skills to treat these patients fairly and sensitively.
The needs of every transgender person are different. Transgender identity does not depend on undergoing medical treatment. Some transgender people choose not to live as their chosen gender identity, whereas others want to be permanently accepted as theirs – and so will pursue gender reassignment treatment.
This includes, but is not limited to medical treatment – such as prescribed hormones. Surgery may also be used as a way of expressing gender identity. GIRES estimates that 12,500 transgender adults in the UK had sought treatment by 2010 – but since then, there has been an average rise in referrals to NHS gender identity clinics of 11% a year.
Transgender people who do not pursue medical treatment may still have significant health needs. According to charity Rethink Mental Illness, LGBT individuals are more likely to suffer from mental health issues and substance abuse, which can make them regular visitors to a community pharmacy. And many transgender people who undergo gender reassignment will require lifelong treatment, meaning pharmacy staff must have an understanding of their specific health and medication needs, as well as the more general requirements shared by all patients. So with all this to consider, how can you make these interactions run as smoothly as possible?
Creating a welcoming environment is essential to providing good community pharmacy services – and supporting those going through the transitioning process requires a sensitive approach. In partnership with transgender youth support company Gendered Intelligence, the Government Equalities Office published Providing Services for Transgender Customers in 2015, which gives good-practice guidance for businesses on providing services that are inclusive of transgender people.
It advises avoiding phrases such as “one of the men who uses our services is turning into a woman” or “we have a female client who wants to be a man”.
Caroline Dada, lead pharmacist and non-medical prescriber for gender identity services at Leeds and York Partnership NHS Foundation Trust, says pharmacists must use the correct terms during conversations with transgender patients.
“Pharmacists should always refer to the patient in their chosen gender – simply using the correct pronoun could make a huge difference in developing a respectful relationship with the individual,” she says.Patient confidentiality is also essential, according to Alex White, service coordinator at sexual health charity Brook. “If someone is asking for a particular medication relating to transitioning, the pharmacist needs to be mindful that this might be sensitive for the client – by, for example, not calling out medication names across a busy counter.
“It’s also important to be aware that the transgender person might not be ‘out’, so always offer the option of a private space to discuss their needs – this is especially a concern for young people,” says Ms White.
If you set the tone by treating the inclusion of transgender people as ‘business as usual’, it will help the rest of your staff to follow. However, situations may come up where you have to ask some delicate questions.
“Just as you wouldn’t say to someone, ‘You’re fat, what can I do to help you?’ you shouldn’t ask someone going through a gender change what you can help them with,” says Royal Pharmaceutical Society (RPS) president Ash Soni. “Asking them, ‘Is everything going OK?’ opens up a question they can answer any way they want to. Your approach should be more about noticing what questions they are asking you and then dealing with their queries as sensitively as possible.”
Ms Dada says some people may want to talk, whereas others may just want to collect their medications and leave, so trying to gauge an appropriate level of interaction can be a challenge. “Getting to know the individual is essential, and pharmacists should have an understanding of the treatments available, their side effect profiles and withdrawal symptoms – so they can engage effectively,” she says.
“For example, a transgender woman presents with hot flushes, which could indicate insufficient estradiol. Therefore the advice would be for her to have her estradiol level checked to assess if any dose changes are required,” she says.
RPS English pharmacy board member Deborah Evans says training is vital for pharmacists and their staff to effectively and sensitively engage with transgender patients. For example, transgender people may describe themselves by using one or more of a wide variety of terms – including transsexual. Others do not identify as transsexual and prefer the word transgender. So it is best to ask which term a person prefers.
“This requires educating the pharmacy team and colleagues regarding transgender issues and respecting the individual’s wishes regarding any potentially sensitive questions,” Ms Evans says. “For example, if taking data – in a medicines use review or the new medicine service – the patient intake forms should reflect diversity and ask questions such as: What is your gender? What was your sex at birth? Do you identify as transgender or transsexual? How would you describe yourself, eg female, male, transgender, or do not identify as female, male or transgender?
“Also be aware that transgender people will have health issues relating to their birth gender and so related questions may need to be asked. For example, an individual identifying as a male may require access to emergency hormonal contraception,” she adds.
It can be helpful to appoint a member of staff responsible for providing guidance, offering referrals and fielding complaints, and ensuring that there is ongoing training for staff. Sue Burchill, head of nursing at Brook, suggests all clinicians work through the e-learning resource from the NHS and GIRES on caring for gender non-conforming young people, which can be found at bit.ly/trans-pharmacy.
It’s worth considering whether to contact a patient’s GP, in order to give them the best support. Mr Soni recommends this because: “With [the patient’s] medical and health situation apt to change, we find it useful to have GP contact.”
Ms Dada agrees, saying: “The confidence of GPs in dealing with transgender individuals varies so, as with all patients, pharmacists should address any concerns they may have with the GP. For example, it could be that the brand of HRT patches are not sticking and the pharmacist can suggest an alternative.”
It’s not just transgender patients that you may encounter. You may also have staff who are transgender or transitioning and need your support as an employer or colleague.
Because only a small proportion of the population is transgender, there is sometimes a lack of awareness in the workplace in relation to gender identity, which can result in employers failing to support staff effectively.
Another Government Equalities Office report, in partnership with the organisation Inclusive Employers, advises that managers should listen, show support, discuss levels of confidentiality, agree to seek advice, and agree an approach that meets the needs of transgender employees.
The employee may not be ready to tell anyone else at the early stages of transitioning and this should be respected. But when they are ready, their colleagues need to be able to ask questions. Managers must therefore “set a tone of absolute inclusion and respect” without breaching confidentiality, the report’s authors said.
Ms White stresses no one should “out people without their permission”. “Ask them how ‘out’ they are and how they’d like to be referred to privately, and in public.”
She adds: “Be sensitive but don’t over-worry; accept that you’ll get things wrong, but be honest with your colleague. And don’t ask personal questions about bodies or sex lives – some topics are best left out of workplace discussion altogether.”
Ms Dada says that pharmacy is still, in some ways, learning how to support transgender people. “This can be attributed to not having the relevant exposure to such patients and therefore believing they need to be treated differently, which simply isn’t the case.”
She believes that as wider society comes to recognise transgender rights and becomes more familiar with the issues, the profession will also become more confident and accommodating.
“Currently there is a lot of media attention around transgender issues, which is good. But I think it may take society, including pharmacists, some time to feel confident dealing with transgender patients,” she says. “It’s really about raising awareness.”