Practice Insight explores incidents reported to the College that present learning opportunities for pharmacists and pharmacy technicians. This close up on a complaint highlighted below encourages registrants and the broader pharmacy system to reflect on how they provide care to transgender patients.
A PROBLEMATIC ENCOUNTER AT THE PHARMACY
A patient, who is a transgender male, attended a pharmacy for a prescription for Vagifem®. The patient (who uses the pronoun "they") reported that the pharmacist, who was not a regular pharmacist at the pharmacy, stated that he could not dispense the medication as the patient’s insurance company would not approve the claim, or would somehow hold him accountable for dispensing the prescription when he should not have, because the patient had a typically male name and the medication was for intravaginal use. The pharmacist also indicated that he wanted to ensure that the medication was appropriate for the patient and preferred to double check if there is any uncertainty. The patient asked whether the pharmacist could just speak to their prescriber instead; but the pharmacist refused and instead gave them the choice of either paying out of pocket for now or waiting for the pharmacist to call the insurance company in three days (as it was a long weekend). The patient chose to wait.
When the patient was notified that the prescription was ready three days later, they spoke to the Designated Manager, who said that she did not know what the problem was and that the insurance company did not need to be contacted. The patient was confused about why they were denied the prescription in the first place and felt that the pharmacist was inappropriate in making a determination about whether the medication was appropriate for them based on their name or gender. The patient was upset that they had to disclose that they are transgender, when they had previously received intravaginal prescriptions without incident. They felt that their dignity and access to medication was compromised.
OUTCOME FROM THE INQUIRIES, COMPLAINTS AND REPORTS COMMITTEE
Upon reviewing the complaint, a panel of the College’s Inquiries, Complaints and Reports Committee noted that pharmacists have a professional responsibility to ensure that a prescription is correct and therapeutically appropriate. Therefore, the panel felt it was appropriate for the pharmacist to use his professional judgment by asking the patient about the suitability of the medication for their needs.
However, while the panel noted the patient’s comments that they believed the pharmacist intended to be respectful in his communications with the patient, there was a missed opportunity for the pharmacist to ensure that the patient fully understood why he was asking these questions and to be clearer about the course of action he was taking. Ultimately, this resulted in the patient feeling uncomfortable and vulnerable, as well as having access to their medication delayed.
The panel did recognize that systemic discrimination may have played a role in this incident, particularly in the limitations or conditions imposed by insurance companies on access to intravaginal medications for male patients. They noted that one option for the pharmacist was to dispense the prescription as written and ensure he documented his decision-making process in case there were any issues in the future.
In this case, the pharmacist, upon his own initiative after the incident, sought out additional education regarding caring for transgender patients and apologized to the patient. The panel also reminded the pharmacist of his obligations under the Standards of Practice related to communication and ethics.
The panel felt that the complaint was an opportunity to remind the profession as a whole of the importance of having appropriate education and knowledge to provide care to transgender patients and the importance of effective communication that speaks to potential patient concerns.
LEARNINGS FOR PHARMACY PROFESSIONALS
The Code of Ethics requires pharmacy professionals to embody the principle of respect for persons/justice, actively and positively serve and benefit patients and society, and prevent harm. In reflecting on the scenario above, pharmacists and pharmacy technicians can consider how they work to respect patients, how to improve their own knowledge and when to seek more information, and how to ensure they are communicating clearly and listening thoughtfully.
Pharmacy professionals must practise patient-centred care and treat patients with sensitivity, caring, consideration and respect. They should look for, and be aware of, their own potential biases that may impact how they communicate or care for patients. The Code of Ethics requires pharmacists and pharmacy technicians to ensure that their views about a patient’s gender, identity, sexual orientation, personal life, religious beliefs or other morally irrelevant factors do not prejudice their opinion of the patient and affect the quality of service they provide.
Pharmacists must apply their cognitive skills to ensure that the patient receives the correct and appropriate prescription – this can include asking questions to clarify the purpose of the prescription and its appropriateness for the patient. However, pharmacists must also be aware that the purpose or need for these questions may not be obvious to the patient. Careful communication must be used to ensure that the patient understands the purpose of these inquiries and how they impact the care provided.
Pharmacy professionals should also be aware of potential sensitivities and vulnerabilities for patients when discussing issues related to sexuality and identity, and ensure that these conversations are happening in a confidential, private manner, with appropriate language. The focus should be on seeking only information that is considered reasonably necessary for making informed decisions about the patient’s health and treatment.
When providing care to transgender patients, healthcare providers are encouraged to follow the patient’s lead on terminology and to ask open ended questions (see the University of Toronto Faculty of Medicine – Infographic on providing care to LGBTQ+ patients for examples). Pharmacy professionals may need to engage in further professional development and education to provide care that is reflective of the concerns and needs of the diverse patient population.
While individual pharmacists and pharmacy technicians may apply these learnings to their own practice, they can also look for opportunities to advocate for the fair treatment of their patients on a broader level, such as working with all members of the pharmacy team to ensure that the pharmacy as a whole is welcoming to transgender patients.
When possible, pharmacy professionals can also work collaboratively (with other healthcare providers, insurance providers etc.) to address incidents of systemic discrimination that affect their patient’s access to appropriate care.
Ultimately, pharmacists and pharmacy technicians are expected to demonstrate professionalism and apply ethical principles in their daily practice, maintaining the patient’s best interest as the core of all activities.
SELECTED RESOURCES ON PROVIDING CARE TO TRANSGENDER PATIENTS
- Ontario Pharmacists Association – An Introduction to Caring for Trans Patients in the Pharmacy
- Canadian Pharmacists Association – Smashing Stigma: Practice Tools and More to Help Your LGBT2SQ Patients
- University of Toronto Faculty of Medicine – Infographic on providing care to LGBTQ+ patients
- Ontario Human Rights Commission: Policy on Preventing Discrimination because of gender identity and gender expression
- Rainbow Health Ontario:
- The 519’s Glossary of Terms
- Human Rights Campaign – Providing LGBTQ-Inclusive Care and Services at Your Pharmacy
- World Professional Association for Transgender Health – Standards of Care