Editor’s note: Maeleigh Tidd returns with another contribution to the Pharmaceutical Inequalities feature, this time co-authored with a graduate student colleague, Lucy Abrams. Mae and Lucy discuss the history of LGBTQ+ health in the USA, and situate existing LGBTQ+ rights within the international context. They subsequently discuss how pharmacists play a key role in providing gender-affirming care, and how this can be improved upon. The Pharmaceutical Inequalities series is funded by the Holtz Center and the Evjue Foundation.
History of treatment of LGBTQ+ in healthcare
Prior to the declassification of homosexuality as a mental illness in the United States in 1973 , individuals with same-sex attractions were used for medical experiments in the search for a “cure” to homosexuality. ‘Treatments’ for homosexuality date back to the late 19th century, when a German psychiatrist believed hypnosis therapy “turned a gay man straight”, an early practice that antecedents conversion therapy.
Unfortunately, the ‘curing’ of homosexual desires did not stop with hypnotic interventions. The overarching attitude of the 1900s towards homosexuality was that it was deviant, sinful, and even criminal behavior, which led to various medically unethical experiments that aimed to alter sexual orientation. Some gay men were subjected to castration and the transplantation of “heterosexual” testicles, due to a theory that homosexual desires in men were rooted in their testicles. Gay men and lesbian women were also subject to lobotomies – another invasive experiment performed in the mid-1900s. Other experiments include electroconvulsive therapy and aversion therapy, involving various techniques of electrical stimulation in response to same-sex sexual stimuli.
These outrageous medical practices (among other societal and social practices) towards the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community lead to the Gay Rights Movement within the United States. The movement, and those a part of it, have overcome many barriers to their right to freedom and equality (in society and the medical sphere). Since the movement began in the US, homosexuality has since been decriminalized (1962), declassified as a mental illness (1973) and then completely removed from the Diagnostic and Statistical Manual for Mental Disorders (1987), gay marriage has been legalized (2015), and transgender individuals are protected (2019).
Nonetheless, barriers remain. Conversion therapy persists and transgender rights are up for debate. The future of LGBTQ+ rights is hazy, despite the newest executive order signed by President Biden on anti-trans laws and conversion therapy.
LGBTQ+ Rights outside of the States
Let us not forget about the ongoing global inequalities in the LGBTQ+ community, where many places globally are still restricting and criminalizing legal, social, and economic rights to this community which in turn impacts their access to healthcare and medicine.
The International Lesbian, Gay, Bisexual, Transgender, and Intersex Association (ILGA) produces an annual report on the United Nations, state-sponsored homophobia, an overview on global legislation on same-sex relations. As of 2020,
- Same-sex sexual acts between adults in private is criminalized in 59% of Africa, 27% of Latin America and the Caribbean (LAC), 52% of Asia, and 43% of Oceania (about 70 countries)
- Those caught in the engagement of same-sex acts are still subject to the death penalty in 11 countries
- There are legal barriers to freedom of expression on sexual and gender diversity in 37% of Africa, 3% of LAC, 40% of Asia, and 8% of Europe
- There are legal barriers to the registration or operation of civil society organizations working on sexual and gender diversity issues in 50% of Africa, 50% of Asia, 4% of Europe, and 7% of Oceania
- There are only 11 countries that mention sexual orientation in their constitutional nondiscrimination clauses
- In about 60% of the UN states, individuals can be discriminated again in their play of employment for their sexual orientation
- In only about 25% of the UN has criminal liability for offences on hate crimes towards sexual orientation.
- As for incitement of hatred, violence, or discrimination of sexual orientation, only 23% of the UN prohibits it
- Conversion therapy is only banned in 4 countries (2 in LAC and 2 Europe)
- Marriage equality is only recognized in 29 countries
Among these statistics, the United States is most progressive in recognizing and protecting LGBTQ+ rights as human rights. With that, there is a surge of LGBTQ+ individuals seeking asylum in the U.S. All the more reason to acknowledge and put forth action towards the on-going health disparities this community faces.
Ongoing health disparities & inequalities the LGBTQ+ community faces in the U.S.
Perhaps this history of unethical scientific experimentations, traumatic healthcare experiences, and discrimination among the LGBTQ+ community can explain the medical mistrust that many LGBTQ+ individuals have.
Despite the progression of LGBTQ+ rights in the United States, the community is faced with many ongoing health disparities and inequities that stem from the historical discrimination and homophobia in the healthcare system. The community’s health disparities range from behavioral to physical and involve many access barriers. Some astonishing disparities include:
- The rate of suicide amongst LGBTQ+ youth is 3x higher than non-LGBTQ+ youth
- 20-30% of the LGBTQ+ community has[CD5] been diagnosed with an alcohol and substance use disorder at some point in their lives, compared to 9% of the population as a whole
- LGBTQ+ people are more likely to be diagnosed with an eating disorder, and/or mood and anxiety disorders
- Gay and bisexual men, and transgender women, are at greatest risk for HIV/AIDS infection – making up about 70% of new HIV infections in 2019
- Lesbian and bisexual women have higher rates of breast cancer, and transgender men and women are at greater risk than non-LGBTQ+ individuals
- Transgender individuals have higher prevalence of victimization, mental health issues, and are less likely to have health insurance than LGB and non-LGBTQ individuals
- LGBTQ+ individuals have higher rates of HPV infection and related cervical or anal cancers
Many of these disparities stem from the community having less access to the health care they need. LGBTQ+ individuals are (1) less likely to have health insurance, (2) more likely to delay getting care, and (3) more likely to report poor quality of care and unfair treatment by healthcare providers due to a lack of cultural competence.
The breadth of literature on LGBTQ+ disparities and inequities in healthcare are primarily focused on the communities’ experiences in primary health care. However, there are inequities and inequalities that the community faces at the pharmacy as well, specifically among transgender individuals. Aside from the concern of being denied coverage for their gender-affirming care, transgender individuals may be faced with the additional concern of discrimination at the pharmacy counter. There have been instances where pharmacists/pharmacy staff have violated transgender individuals’ privacy by outing them in the pharmacy as trans, by using only their dead name and/or consulting openly and loudly with them about their gender-affirming care. Another inequality the trans community is faced with at the pharmacy is the possibility of their pharmacists refusing to fill their hormone prescription, or the act of ignorance for assuming a prescription error for an individual – this leads to patients, who may otherwise feel confident about their desire to transition, to become anxious about interacting with a pharmacist to receive their medication.
Many of these pharmacy-related inequities involve a lack of cultural competence and the ability to provide a safe and inclusive environment. However, there is a growing awareness of the role and potential impact that pharmacists have in providing inclusive gender-affirming care, and steps are being taken to improve LGBTQ+ health care disparities within the pharmacy profession and within the pharmacy environment.
Pharmacists’ role in gender-affirming care
Pharmacists have the opportunity to play an important role in the health care received by individuals who identify as lesbian, gay, bisexual, transgender, nonbinary, or queer (LGBTQ+). This may be especially true when it comes to counselling transgender and gender-diverse (TGD) individuals who are considering taking or already using hormone replacement therapy (HRT).
Expanding the training that Pharm.D. students receive during their schooling is important for reducing pharmacists’ stigma and bias towards LGBTQ+ patients. This also provides future pharmacists with the confidence and knowledge to counsel patients who may be going through the process of transitioning using HRT. The American Association of Colleges of Pharmacy (AACP) is in favor of including the discussion of diverse gender identities as part of diversity training within pharmacy school curriculum. However, it is up to each school to figure out how to incorporate such teaching material.
Schools may feel as though time constraints surrounding their current curriculum do not allow for the addition of LGBTQ+ health topics. Fortunately, there are small ways that schools can incorporate this topic into the current curriculum. For example, TGD-relevant pharmacotherapy information could be added to existing lectures and active learning experiences, such as interprofessional education (IPE) activities, could include LGBTQ+ standardized patients. Solutions such as these may improve students’ ability to work with the LGBTQ+ population without making any major structural changes to schools’ curriculums.
Pharmacists are accessible health care providers who should be trained to act as allies to LGBTQ+ folk looking for health and medication guidance. One of the best ways to empower pharmacists to be compassionate providers who understand the health challenges faced by LGBTQ+ individuals is to give them plenty of information and time early on in their pharmacy career.
In our next post we’ll further explore this topic through an interview with Dolyn Salm, a transgender pharmacy student at the University of Wisconsin Madison School of Pharmacy.
Feature image: Robert Clay, Alamy Stock Photo