Advocating for LGBTQ+ Education


Student pharmacists have the empathy and desire to help LGBTQ+ patients. Many schools are examining their curricula to find ways to broaden their scope.

By Athena Ponushis

LGBTQ+ people face an array of health disparities. They are at higher risk of having anxiety, depression, mental illness and substance use disorder. They are more likely to struggle with poverty and isolation. They are more likely to contemplate and attempt suicide. These challenges are consistent across the LGBTQ+ population, yet pharmacy school curricula are inconsistent, and the approaches to educating future pharmacists on LGBTQ+ issues differ drastically among institutions.

cross-sectional survey recently published in Currents in Pharmacy Teaching and Learning shows how transgender-related care is taught to variable degrees in Pharm.D. programs: A little more than half the schools surveyed reported transgender-related care was currently addressed somewhere within the curriculum, yet only half the respondents felt confident that their graduating pharmacists would be competent in providing care to transgender patients. Most responding schools teach only one or two hours of transgender-related care in their entire curriculum, and the schools that do not presently teach it have no plans to incorporate additional courses.

Dr. Cheyenne Newsome, coauthor of the research paper and assistant professor of pharmacotherapy at Washington State University College of Pharmacy and Pharmaceutical Sciences, expected that some schools would not include this content at all. But when she saw the results—nearly 50 percent of schools do not teach transgender-related care and have no interest in doing so even after taking the survey and thinking on the matter—she was disappointed. “That’s creating so many graduates who have no exposure to learning about how to care for trans people, so even if they have the best of intentions, they are not equipped with the knowledge and skills to provide good care,” Newsome said.

LGBTQ+ content may not yet be required in the Pharm.D. curriculum and some schools may decide not to include it, but students are keen to learn how to care for lesbian, gay, bisexual, transgender and questioning/queer individuals. Faculty who have introduced LGBTQ+ content into their courses report that students welcome the topic, are active and engaged in discussions and eager to learn more. Additional research papers, all as candid and compelling as the cross-sectional survey, have sounded a call to action for LGBTQ+ content to be required and customary so future pharmacists can help improve health outcomes for individuals who, having been repeatedly mistreated when seeking care, do not seek medical attention when they need it most.

Fulfilling an Oath

How can pharmacists best serve LGBTQ+ people? A recent American Journal of Pharmaceutical Education article title sums it up: “The Pharmacist as an LGBTQ Ally.” The article defines an ally as one whose purpose is to help, to provide support and assistance in an ongoing effort or struggle. The commentary argues that most colleges of pharmacy are not well equipped to teach future pharmacists how to counsel LGBTQ+ individuals, while it reiterates the oath of a pharmacist, to “consider the welfare of humanity and relief of suffering my primary concerns.”

When students hear from an individual who has had a bad experience or a good experience, they begin to understand the impact they can make by being a trans-competent provider. It helps them see why it’s important to learn this material and it helps them feel more comfortable and confident stepping up to be a good provider.

Dr. Cheyenne Newsome

Dr. Oliver Grundmann, lead author of the article and clinical associate professor at the University of Florida College of Pharmacy, sees a deeper meaning in educating future pharmacists to serve LGBTQ+ people beyond that oath. The LGBTQ+ community, like many other minority communities, needs allies in healthcare who can understand their specific needs and give them credence.

“We see a pattern that kind of projects out in life, if LGBTQ folks experience rejection early on, or they are not supported by their family, by their friends, not accepted for being as they are,” Grundmann said, “they tend to have higher rates of depression and anxiety, homelessness, especially with LGBTQ+ youth, mental health problems and substance use disorders that may start early in life, and subsequent consequences related to stress or obesity accompanied by an eating disorder. This is a particular area where pharmacists can provide advice to caregivers or to youth as they struggle with such disorders. And it’s important to be mindful when counseling older LGBTQ folks that, throughout their life span, they may have suffered and continue to suffer discrimination based on sexual orientation and gender expression.”

Grundmann believes pharmacists may be uniquely positioned to connect with LGBTQ+ people and inspire the patient engagement needed to attain optimal health. “In order to see a pharmacist, you do not need to make an appointment, you do not need to present health insurance, you do not need a prescription, you just need to go to a pharmacy, go to the counter and say, ‘I would like to talk with a pharmacist,’” he pointed out. “I realize that currently pharmacies are not compensated appropriately for offering this service, but I think there is a model where we can say it is a compassionate, human service, as the oath of pharmacy states, we serve humanity and all of humanity, to make sure everyone is cared for and to ensure the health of all human beings.”

Passionate about LGBTQ+ issues for professional and personal reasons, Grundmann came out as a gay male at the age of 17. After graduating from pharmacy school, he moved to the United States from Germany in 2004 to start his graduate studies at UF where he met his partner. The two were married in 2015 and are now raising two daughters. Grundmann has seen his students share his passion for LGBTQ+ issues. When he first held an active learning session on how to be more inclusive in a pharmacy environment and more welcoming of LGBTQ+ community members, the conversations he had with his second-year Pharm.D. students were lively.

“They showed their interest not only from a professional perspective, but they showed that they truly cared. They wanted to know more about this topic, and that was encouraging. I saw this passion that I personally had reflected in the passion my students have for this topic. It was already there, it just needed to be kindled or tended to,” Grundmann said. “We did not have enough time during the active learning session and quite a few students came to me afterward to say it was a great session and they wanted to continue the discussion.”

This is a particular area where pharmacists can provide advice to caregivers or to youth as they struggle with [substance use or eating] disorders. And it’s important to be mindful when counseling older LGBTQ folks that, throughout their life span, they may have suffered and continue to suffer discrimination based on sexual orientation and gender expression.

Dr. Oliver Grundmann

A Critical Takeaway

When Newsome joined the faculty at WSU a few years ago, she began teaching three hours of transgender care in a required course. She taught the terminology and pharmacotherapy of transgender care, elaborating on patient interaction and pronoun etiquette. Other faculty members took notice and followed suit, creatively weaving LGBTQ+ content into their courses.

Last year Newsome added a case study on masculine hormone therapy for trans masculine individuals to the men’s health session in the P3 year. It serves as a refresher for students and gives them the opportunity to ask more questions. In the fall she expanded on cancer screening discussions in the oncology block, describing how easily cancer screenings can be missed in trans people, how a person who presents as male may have a cervix and need a Pap smear. Her fellow faculty members added a two-hour lab session to the first-year communications course on gender minorities, focusing on women and trans people. They plan to add a transgender case to the applied patient care lab in the spring, where students will identify pharmacotherapy-related concerns as they work through the patient case.

But what has had the greatest impact on students has been facilitating opportunities for them to see how pharmacists can make a difference. Newsome’s students rank discussion with a guest speaker as the thing that has helped them the most. Newsome noted that when schools bring in a respectable community member who is transgender, students are able to hear a personal story and make a connection that opens their eyes and inspires them to care for LGBTQ+ individuals. That’s what Newsome believes students need to know most: the impact they can make.

“My guest speaker has had good experiences with pharmacy and bad experiences with pharmacy. He shares the experiences his trans friends have had with healthcare professionals, too,” she said. “When students hear from an individual who has had a bad experience or a good experience, they begin to understand the impact they can make by being a trans-competent provider. It helps them see why it’s important to learn this material and it helps them feel more comfortable and confident stepping up to be a good provider. Obviously, the medications are important, but they are not complicated and that information is readily available. Pharmacists are good at looking things up, so I think the key piece is helping students build that empathy and desire to help trans people.”

UF has also modernized its Pharm.D. curriculum, increasing the number of diverse case studies, including LGBTQ-specific cases, during active learning sessions. “When we talk about hormone therapy, we talk about transgender patients. When we talk about the different stages of aging, we include either a lesbian woman or gay male, maybe in a case relating to prostate cancer, but we don’t want to stereotype here, we don’t want to bring out a gay male case when it comes to HIV/AIDS. We want to be diverse in that as well,” Grundmann said.

He would like to see a more holistic approach to the pharmacy curriculum that underscores that a person’s sexual orientation or gender expression—while only one element that defines someone’s identity—may impact daily life and well-being. And when it comes to LGBTQ+ issues, he would like programs to look at the social, economic and medical disparities that jeopardize the long-term health of this population. “What I want to see is that LGBTQ+ issues are consistent throughout the curriculum, that we do not only look at it in one course and then make a checkmark, because it really stretches from medication care to health insurance coverage to inequities in disadvantaged areas, depending on where you live,” Grundmann emphasized. “There are many different factors that impact a person. We need to be aware of that and think about how we as pharmacists can provide overall care to patients.”

The First Step

Before pharmacists can provide holistic care, they must create an environment where LGBTQ+ patients feel comfortable, safe, welcome and affirmed. “Sexual gender minorities face health disparities in every arena of life, whether it’s related to substance use disorders or just access to care. Those disparities are real and prevalent,” said Dr. Kyle Melin, associate professor at the University of Puerto Rico School of Pharmacy. “Until we as a profession learn how to create an environment where LGBTQ individuals feel safe and welcome in our healthcare settings, we are not going to be able to address their healthcare needs and those disparities which come out of those needs. Until we undo that barrier and create an environment where they feel safe and respected, we are not going to be able to help people the way we want to.”

At the University of Puerto Rico, the majority of LGBTQ+ education has centered on cultivating such cultural competency. Melin is working on ways to incorporate LGBTQ+ issues into the therapeutics curriculum, particularly concerning transgender and gender nonbinary patient care, improving instruction relating to hormone therapy and gender affirming therapy to better build the capacity of pharmacists. While Melin has not seen much movement at any official level to accredit LGBTQ+ content as a national standard, he has seen movement among students. Students are seeking out this content and training and have identified it as an area that they want to work on to be better prepared as pharmacists to provide care for all patients. “The students have been incredibly positive and highly motivated. They are really helping to push the profession forward,” Melin noted. “That’s why I like working with students—they have not resigned to things being the way they are and they have this sense of, ‘We can make things better,’ and they inspire us to do that.”

Melin’s research and work with students led to a study assessing readiness to provide pharmaceutical care to transgender patients, gleaning perspectives from pharmacists and transgender individuals, that was published in the Journal of the American Pharmacists Association. The study found that pharmacists were aware of their knowledge deficits when it comes to providing care for transgender patients and that they were open to receiving training and education. He and his students worked on providing a continuing education program, published in Pharmacy Practice, and once again found that pharmacists were eager to improve.

Melin also found that despite what pharmacists did not know, transgender patients still believed pharmacists could play an important role in their healthcare. “In conversations with transgender individuals there was this sense that, pharmacists know about medications and I am taking different medications and they can help me, even if they don’t know about pronouns or don’t understand my identity or understand how I would prefer to be spoken to, they can help me,” Melin said.

One distinction that Melin and Newsome point out: Within the LGBTQ community, individuals have different needs. “We say LGBT all the time, but the T is kind of this add-on, like they’re included in this catch-all umbrella of LGBT, but it’s a subpopulation that’s really been neglected or overlooked even within the lens of LGBT work,” Melin said. “There’s so much more we have to do as a society and as a profession as well to prepare our pharmacists to understand the unique needs and disparities faced by transgender and gender nonbinary individuals.”

The American College of Clinical Pharmacy updated its pharmacotherapy didactic curriculum toolkit in 2019, categorizing what topics should be covered into three tiers. (Tier 1: Students must be taught this in therapeutics courses. Tier 2: If there’s time, it would be good to include. Tier 3: Students are responsible for learning this on their own.) Gender affirming care was added to the toolkit in 2019 as a Tier 3, listed as not necessary to include in therapeutics courses. Newsome sees that as a step in the right direction, that transgender-related care is starting to appear on the radar, but fears people still do not understand its importance.

“If you’re not teaching it, I guess one of the assumptions I make is you don’t think it’s important enough to teach, so I always try to emphasize the risks of graduating pharmacists who are not competent to care for the LGBTQ community,” Newsome explained. “What are the risks of those microaggressions that patients continually face? What does that add up to? The suicide attempt rate for people who are transgender is nine times higher than the general population. Part of what I think leads to that is the mistreatment from medical providers and the lack of trust there, so I try to emphasize the importance of this education and the risks of putting providers out there who are not equipped to help care for this vulnerable population. They can do harm, and that’s not what we want to do.”

Athena Ponushis is a freelance writer based in Ft. Lauderdale, Florida.