Incorporating LGBT Instruction into Pharmacy Curricula

by Elizabeth Hearn, Pharm.D., PGY-1 Community Pharmacy Resident, University of Mississippi School of Pharmacy, Jackson, Mississippi

While only 4.5% of adults in the United States identify themselves as lesbian, gay, bisexual, or transgender (LGBT), this population faces some significant health problems.¹ HealthyPeople2020 reports that LGBT youth are more likely to be homeless and are up to 3 times more likely to attempt suicide when compared to heterosexual, cis-gendered youth. They also have significantly higher rates of illicit drug, tobacco, and alcohol use.² Transgender individuals are more likely to suffer from mental health disorders such as depression, post-traumatic stress disorder, and suicidality as well as HIV/AIDS and other sexually transmitted infections.^2,3 Perhaps one of the most shocking data for healthcare providers to digest is that LGBT individuals report feeling isolated and a lack of social support due to culturally incompetent healthcare providers.²

HealthyPeople2020 set nationwide goals for improving the health, safety, and well-being of the LGBT community. One of the metrics is to provide, “medical students with training to increase provision of culturally competent care.”² However, healthcare providers across multiple healthcare disciplines – not just physicians – have reported limited knowledge and confidence in treating transgender patients.³ Are we doing enough to equip pharmacy students with the knowledge and confidence needed to address the healthcare disparities experienced by the LGBT community? Or are we leaving them ill-prepared?

A recent cross-sectional survey of 142 schools of pharmacy in the United States found a wide variety of transgender-related instructional activities. However, only 53% (35, n=66) of surveyed schools reported purposely implementing instruction regarding transgender care in their curriculum. Of those schools who have transgender-related care coursework, only 14 of 35 provided 2 hours or less of student experience with this patient population. Moreover, only 15 schools had plans to further develop or implement transgender-related care in their curricula within the next 3 years. When schools were asked to rate graduating pharmacy students’ confidence level for providing competent care to transgender patients, only 2 schools felt students would have a high level of confidence.³ With these data in mind, there is room for improvement with regard to transgender-related care in American pharmacy schools.

Instruction regarding LGBT health-related issues can be taught in several ways. In a 2017 study, didactic instruction about transgender-related care improved pharmacy students’ scores on knowledge-based assessments and self-reported confidence in decision making. Third-year Doctor of Pharmacy students received a 2-hour lecture about transgender-related care. When compared to 4th-year students who did not receive the lecture, 3rd-year students scored significantly higher on both a knowledge-based assessment (63.4% vs. 72.5%) and a self-confidence assessment (60.6% vs. 76.8%).⁴

In another study, lecture-based instruction about LGBT healthcare was shown to improve students’ understanding of the role of a pharmacist in transgender care. Pre- and post-lecture surveys showed a marked increase in student pharmacists’ understanding of their role in caring for transgender patients (30.6% vs. 96.5%).⁵ Amongst the schools of pharmacy who have already incorporated instruction about transgender-related care into their curricula, didactic lectures and discussions are by far the most prevalent instructional methods.³

Some schools of pharmacy report offering Introductory and Advanced Pharmacy Practice Experience (IPPE and APPE) opportunities for students to interact with LGBT patients. Utilizing IPPEs and APPEs for this purpose may seem ideal, as educators have reported they perceive that there is not enough time in the didactic curricula to include additional lectures, discussions, or care-based activities. Designated IPPE and APPE sites could be LGBT-specific clinics or locations that have a higher-than-average percent of their patient population who identifies as LGBT (such as an HIV clinic). However, these IPPE and APPE experiences are uncommon, with only 12 (out of 63) schools providing an experience where students can interact with LGBT patients. Due to limited availability and potential site-to-site variability, these types of IPPEs and APPEs may be best suited as elective experiences.³

Researchers at two schools of pharmacy in Washington and New Mexico took a creative approach to their instructional methods. Students were exposed to 3 hours of content about cultural, empathetic, and medical considerations for patients with diverse gender identities. Interestingly, the educators used a variety of mediums, namely: a pre-recorded video lecture; a list of frequently-asked-questions and answers; a game-show-style game; a patient video; a gender identity exploration exercise; role-playing scenarios; and a panel discussion with gender-diverse patients. The gender-exploration activity, which was adapted from Lavender Health’s Gender Role Socialization activity, was rated least helpful by students in the post-class surveys. However, more than half of the students found the remaining exercises to be very informative — the panel discussion with gender-diverse patients was considered by students to be most helpful. A panel session with individuals who identify as LGBT appears to be an effective way to include LGBT instruction in pharmacy curricula.⁶

We should use these examples to establish or update curricula at schools of pharmacy. When developing LGBT-related care education, consider the following learning opportunities for student pharmacists:

1. Understanding sexual and gender development
2. Discussing gender identity and how to document sexual preferences and gender identity in medical records⁴
3. Identifying barriers to access to care by LGBT people
4. Outlining drug and health-related resources for LGBT patients who are uninsured or underinsured
5. Motivational interviewing for smoking, alcohol, or drug cessation in the LGBT community⁷
6. Managing pharmacotherapy in LGBT people experiencing:
1. Mental health disorders
2. HIV and AIDS
3. Sexually transmitted infections
4. Chronic diseases
5. Gender transition ^4,7

Student pharmacists have expressed the desire to learn about this topic.⁵ Multiple exposures to LGBT-care-related issues would result in greater sensitivity, confidence, and competence.⁵ Given that health disparities for the LGBT community clearly exists and pharmacy students are willing to learn how to minimize them, it is our responsibility to step up and provide the opportunity. Incorporating LGBT instruction in our classrooms can transform a pharmacy student from a culturally incompetent healthcare provider to a well-informed, self-confident practitioner.

References

1. Williams Institute: Adult LGBT Population in the U.S. March 2019. Accessed 15 August 2019. Available from: https://bit.ly/2W2AxHB
2. HealthyPeople2020: Lesbian, Gay, Bisexual, and Transgender Health. Accessed 15 August 2019. Available from: https://bit.ly/2H939tF
3. Eckstein MA, Newsome CC, Borrego ME, et al. A Cross-sectional Survey Evaluating Transgender-Related Care Education in United States Pharmacy School Curricula. Currents in Pharmacy Teaching and Learning. 2019; 11(2019): 782-792. DOI: 10.1016/j.cptl.2019.04.005
4. Ostroff JL, Ostroff ML, Billings S, Nemec EC. Integration of Transgender Care into a Pharmacy Therapeutics Curriculum. Currents in Pharmacy Teaching and Learning. 2018; 10(2018): 463-468. DOI:10.1016/j.cptl.2017.12.016
5. Knockel LE, Ray ME, Miller ML. Incorporating LGBTQ Health Into the Curriculum: Assessment of Student Pharmacists’ Knowledge and Comfort Level in Caring for Transgender Patients. Currents in Pharmacy Teaching and Learning. 2019; DOI:10.1016/j.cptl.2019.07.001
6. Newsome C, Chen LW, Conklin J. Addition of Care for Transgender-Related Patient Care into Doctorate of Pharmacy Curriculum Implementation and Preliminary Evaluation. Pharmacy. 2018; 6(4): 107. DOI: 10.3390/pharmacy6040107
7. Mandap M, Carillo S, Youmans SL. An Evaluation of Lesbian, Gay, Bisexual, and Transgender (LGBT) Health Education in Pharmacy School Curricula. Currents in Pharmacy Teaching and Learning. 2014; 6(2014): 752-758.  DOI:10.1016/j.cptl.2014.08.001