the Role of the Pharmacist in Transgender Pharmaceutical Care

  • Presented by: Caroline Dada

  • Position: Lead Pharmacist for Gender Identity

  • Affiliations: Leeds GIS, Leeds and York Partnership NHS, Harrogate and District NHS

Presenter Background

  • Experience: Over 10 years in the field, started as the only pharmacist in the UK specialized in transgender pharmaceutical care.

  • Qualifications: Independent Prescriber (IP), Advanced Clinical Practitioner.

Introductory Quiz on Gender Identity

  • Question 1: At birth, people are categorised as male or female based on their physical appearance/characteristics. This is known as their Sex.

  • Question 2: The term to describe someone whose biological gender matches the gender they identify as is Cisgender.

  • Question 3: Our inner sense of our gender, usually the feelings of being a man or a woman, is our Gender Identity.

  • Question 4: The umbrella term for people who feel that their sex does not match their gender identity is Transgender.

  • Question 5: Individuals who do not identify exclusively as male or female are Non-Binary.

  • Question 6: Some people do not regard themselves as having a gender identity and may describe themselves as Gender Neutral.

  • Question 8: A person experiencing psychological discomfort due to conflict between their gender identity and their sex and/or expected gender role is experiencing Gender Dysphoria.

Common Terminology in Gender Identity

  • Transgender: An umbrella term for individuals whose gender identity differs from the sex they were assigned at birth.

  • Trans Man: A person assigned female at birth who identifies as male.

  • Trans Woman: A person assigned male at birth who identifies as female.

  • Cisgender: Individuals whose gender identity matches their biological sex.

  • Intersex: A term for individuals born with a mix of male and female biological characteristics.

  • Non-Binary: A gender identity that doesn't fit within the traditional binary of male and female.

Historical Context and Mental Health Implications

  • Historically, gender clinics were aligned with mental health services, often considering transsexualism a mental disorder.

  • The narrative has shifted to recognize gender diversity as a matter of individuality and identity, not a disease; social stigma and discrimination can lead to psychological distress.

  • A study published in The Lancet notes that many transgender individuals experience mental distress primarily due to societal rejection and violence rather than as an inherent aspect of being transgender.

Mental Health Risks Associated with Gender Dysphoria

  • Compromised Well-being: Increased risks include:

    • Depression and social anxiety

    • Substance misuse

    • Suicidality and deliberate self-harm

    • Disordered eating

    • Neurodiversity issues

Myths and Misconceptions About Gender Identity

  • Common misconceptions include:

    • “This is just a fad.”

    • “You are just confused.”

    • “You are a new concept.”

    • “Gender identity is on a spectrum.”

    • “You are either male or female.”

    • “Your pronouns are ridiculous.”

    • “You are making a political statement.”

    • “You can only transition medically.”

  • Important perspective comes from voices like Jack Monroe, emphasizing the importance of recognition as a person beyond gender labels.

Barriers to Healthcare Access for Trans Individuals

  • Barriers may stem from:

    • Lack of understanding among healthcare providers (e.g., GPs, clinics)

    • Prejudiced beliefs and biases

    • Inadequate healthcare identification practices and physical examinations

Guidelines and Professional Organizations

  • World Professional Association for Transgender Health (WPATH): Provides guidelines for the assessment and treatment of individuals with Gender Dysphoria.

  • Royal College of Psychiatrists: Offers good practice guidelines and specialty service provisions for managing gender identity issues.

Pharmaceutical Care in Gender Identity

Prescribing Practices

  • Key Points:

    1. Prescribing unlicensed medications is permissible under specific guidelines.

    2. Risks and benefits of treatments must be thoroughly discussed with patients.

    3. Communication regarding patient care with gender specialists is critical.

  • Informed Consent: Patients should be provided clear and accurate information about treatment options, including side effects and complications.

  • Reproductive Considerations: Patients should consider options for preserving fertility prior to hormone therapy initiation.

Self-Medication Risks

  • Trans individuals may resort to self-medication due to urgency and lack of immediate medical support, often using unregulated online sources.

  • Recommendations for Healthcare Providers:

    • Discuss risks associated with self-medication.

    • Understand patient perspectives and concerns regarding adverse outcomes.

    • Encourage transparency about use of alternative remedies and medications.

Bridging Prescriptions

  • If patients are self-medicating, a bridging prescription may be justified to prevent withdrawal and support mental health until formal evaluation occurs.

  • Guidelines for Bridging Prescriptions: A GP may prescribe hormones if all of the following criteria are met:

    • The patient is self-prescribing from an unregulated source.

    • The prescription is intended to mitigate self-harm risk.

    • The doctor consults with a gender specialist.

Hormone Treatment

Principles of Hormone Treatment

  • Administer sex hormones according to the patient's desired gender while reducing endogenous hormone exposure via:

    • Antagonists

    • Gonadal Down-regulation

Trans Male Hormone Treatment

  • Testosterone Treatment:

    • Types of administration include:

    • Injectable: Sustanon/Enantate 250 mg IM every 4-6 weeks; monitoring testosterone levels pre-injection.

    • Nebido: 1000 mg IM every 10-12 weeks; monitoring steady-state testosterone levels.

    • Gel: Testavan/Tostran/Testogel: 10-80 mg daily application; monitoring steady-state testosterone levels.

Expected Effects from Testosterone Treatment

  • TABLE 1A: Effects and Timeframes

    • Skin oiliness/acne: 1-6 months onset, 1-2 years max effect.

    • Facial/body hair growth: 3-6 months onset, 3-5 years max effect.

    • Clitoral enlargement: N/A onset, 1-2 years max effect.

    • Deepened voice: 1-2 years onset, varies in effectiveness based on age and genetics.

Risks of Testosterone Treatment

  • Likely Increased Risks:

    • Polycythaemia

    • Weight gain

    • Acne

    • Androgenic alopecia

    • Sleep apnea

    • Venous thromboembolism (first 6 months)

  • Possibly Increased Risks:

    • Elevated liver enzymes

    • Hyperlipidaemia

    • Psychiatric disorder destabilization

    • Cardiovascular disease

    • Hypertension

    • Type 2 diabetes

  • No Increased Risk or Inconclusive:

    • Bone density loss

    • Breast cancer

    • Cervical cancer

    • Ovarian cancer

    • Endometrial cancer

Trans Female Hormone Treatment

  • Estrogen Treatment: Includes formulations like:

    • Transdermal patches (100-200 micrograms twice weekly)

    • Gel applications (1.5-4 mg daily)

    • Oral estradiol (2-6 mg daily, mean of 6 mg) aiming for serum E2 levels between 350-650 pmol/L.

Expected Effects from Estrogen Treatment

  • Timeframes for Effects on Trans Females

    • Body fat redistribution: 3-6 months onset, maximum effect in 2-5 years.

    • Breast growth: 3-6 months onset, maximum effect in 2-3 years.

Risks of Estrogen Treatment

  • Likely Increased Risks:

    • Venous thromboembolic disease

    • Gallstones

    • Elevated liver enzymes

    • Weight gain

    • Hypertriglyceridaemia

  • Possibly Increased Risks:

    • Cardiovascular disease

    • Hypertension

    • Hyperprolactinaemia

  • No Increased Risk or Inconclusive:

    • Breast cancer

Monitoring and Long-Term Care

  • Key Monitoring Parameters:

    • For both trans males and females include: lipid profiles, liver function tests, hemoglobin A1c, weight, and blood pressure.

    • Recommended cancer screenings (e.g., breast, colorectal, prostate) based on patient history and anatomical considerations.

Cautions in Treatment

  • Expectations should be managed:

    • Understand hereditary limits and tissue responsiveness to hormone therapies.

    • Higher doses are not always better; complications can arise

Clinical Reflections

  • Case Studies:

    • Case 1: Trans man, 22 years old, from Nigerian descent, balancing cultural fears with healthcare needs.

    • Case 2: Trans man, 42 years old, Pakistani descent, navigating family and faith.

    • Case 3: Trans woman, 50+, from British descent, facing stigma and readiness to transition.

Resources and Internal Support

  • Video Resource: Link to lived experiences of gender dysphoria, aimed at enhancing understanding.

  • Final Consideration: Emphasis on how professionals can genuinely contribute to improving transgender healthcare.