In celebration of Pride Month in June, we are sharing the voices of our AJHP authors and their perspectives and experiences. In this episode, Carolanne C. Wartman and Carol A. Ott explore the mental health disparities faced by SGMs individuals and discuss strategies to promote better mental health outcomes for this population.
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This year, in celebration of pride, ASHP is interviewing selected authors from the AJHP theme issue on health care considerations and sexual and gender minorities. This series highlights reflections from contributing authors and key takeaways from their articles. Sexual and gender minorities often face unique challenges that can affect their mental well-being, including increased rates of anxiety, depression, and suicidal ideation. Joining me today to talk about their recent AJHP article on the diverse experiences and identities of SGM individuals and factors that may contribute to health disparities and poorer health outcomes for doctors Carol Ann Wartman, clinical assistant professor of pharmacy practice at the University of Mississippi School of Pharmacy, and Dr. Carol Ott, clinical professor of pharmacy practice, and clinical pharmacy specialist at Purdue University College of Pharmacy. CC and Carol, thank you so much for joining me today. Thank you for having us. Thanks for having us. Happy to be here. So before we get started, as we talk about the article, which I'm really fascinated by, I'd like to talk a bit about your personal journeys, and maybe Carol, I could start with you about what really drives your passion for providing care to LGBTQIA+ people. Sure. I think that to start out with, I'd like to recognize my own intersections because this is something that's become very important to me and my practice in gender health at Esenazi Health and Indianapolis. So I identify as a cisgender straight white woman, I use shear pronouns, and my practice is really focused in on gender health kind of by accident. My practice to Esenazi Health for almost 20 years now, and I've had the opportunity to practice with very diverse populations of people. And so LGBTQIA+ folks have been a part of my practice for quite some time. In 2016, our gender health program was initiated as a center of excellence at Esenazi Health, and is the only one in Indianapolis, far as you've been trying to gain traction there for quite some time. And I kind of fell into it actually during COVID, because I sit on some echo programs for IU Indianapolis, primarily with high school medicine around opioid use disorders and substance use disorder treatment, but also for the public health echo that started around COVID. And there were some folks there who also were on the LGBTQ+ echo. And so I joined that expert panel really not being an expert in gender health at all. And so I was able to provide mental health care services. My passion for this is that these are very unrecognized and untreated conditions in the LGBTQIA+ population. And when you get into transgender, non-binary, gender diverse folks, there are a lot of other intersections that are involved in that. My passion for it is that these conditions are already treatable for these folks, not just with mental health care, but also gender referring care as well. And so being able to provide kind of that all around treatment is something that I'm really passionate about. Sisi, what about you? You trained with Carol, but what started you on this path? Yeah, I mean, I do have Carol to thanks for a lot of this. You know, she trained me in the gender health clinic. And we did my research project as a PUI2 psychiatric pharmacy, right, on her clinic. And so that really just sparked the love for taking care of this population. But I think also the personal side of it, like similar to Carol, I identify as a cisgender white female. I use she/her pronouns straight as well. And so it's reminding these patients that although maybe my identity differs from them, I still want the same thing as them. I want them to live a healthy life. I want them to be happy and I want them to, I want to help minimize their mental health concern. And so I have people in my life that I've seen deal with this and who do identify differently. I have friends, family members, and just being them struggle has really wanted and that desire there for me to help get rid of some of that for others. Got it. Both inspiring stories in terms of your commitment to the community. In your article, you discuss how SGM individuals and I'm going to go back and forth the times I have to admit in our conversation between the use of SGM and LGBTQIA plus. But you discuss how SGM individuals experience a higher incidence of mental health disorders. Carol, why is that? And what are the implications? Sure. I think the evidence base is growing and has been really clear up until now. Through large population based studies looking back at diagnosis codes and hospitalization rates that the rate of mental health disorders and LGBTQIA plus folks is vastly higher in almost every area than the general population. And I think a lot of this goes back to things like not being accepted, not being able to come out to people around them, not being able to find a support system, being fearful for their own safety, being discriminated against kind of these daily things that go on. In my clinic, I see gender dysphoria is clearly a diagnosis that we need to make in our populations. SGM folks who come into our gender health program. I mean, that's not a difficult diagnosis to make. Many folks are experiencing mood symptoms related to those things that they go through. Identifying as trans, identifying as non-binary, any other gender diversity or LGBTQIA plus identification is not a mental health disorder. And so I think the American Psychiatric Association and mental health providers in general have come along to understanding this. We still have the diagnosis of gender dysphoria in the DSM-5 that's still not perfect because it still identifies ways that people identify themselves as a mental health disorder. What we really need to think about is the fact that they don't have support or they feel fearful or discriminated against contributes to that dysphoria, as well as perhaps not feeling like they fit in the body that they were born with. And so I think it's multi-factorial, but relates to all of those separate issues. CC, what about young people? What about youth who identify as LGBTQIA plus? Yeah, youth in general just have a higher likelihood of or higher risk factors of having poor mental health outcomes like depression and anxiety due to multiple facets. So if you think about middle school, what isn't always the best time for people? I can think back to my own experience of a lot of bullying and you're growing and you're still learning about yourself in that time, but this is a great organization, The Trevor Project, and they have come out with 2024. They're really good almost every year. They have some new data focusing on mental health and young people. And we see this just anecdotally in the care that we provide and seeing young people who have higher likelihood of experiencing depression and anxiety, but this survey highlights that even further. One of the things that they looked at and one of the results that they published is that 66% of LGBTQ+ youth people reported experiencing recent symptoms of anxiety. 66%. I mean, that's more than half. They also found that 53% had symptoms of depression. So it's very prevalent. And I think there's a lot of outside factors that contribute to that in addition to, you know, there's that legislative piece that we have to keep in mind. Maybe they don't have access to the care that they need. Maybe they're scared. They also looked at why they didn't get the care that they needed. And some of that was because they were fearful. They didn't want to be outed. They didn't want their parents to know. So a lot of those factors go into their overall mental health as well. CC, you just mentioned the Trevor Project and you and Carol referenced the Trevor Project in your article as well. Can you talk about them a bit? I imagine that there may be some listeners who are not familiar with the Trevor Project. Yeah. So the Trevor Project is a nonprofit organization and their effort really focuses on suicide prevention for LGBTQ+ youth. And I mentioned some of the findings that they already had. But for example, another one was that more than one in 10 attempted suicide in the past year suicide is a huge issue. And so they're focusing on they have a bunch of efforts in addition to the published data that they have, the survey that they complete. They also have tips and resources for the general public, for healthcare professionals. So for example, you know, we actually used one of their activities that they published in the classroom. And so it's the star activity that tries to relate what that coming out process is for those who have never experienced it. And so we use some of their activities in the classroom. I use their data to underscore a lot of the issues that we see and just highlight, you know, this is something that we should continue to talk about. So it's a great resource for, I think, patients, providers, and really the general public. Cece, we've talked a bit about the unique epidemiology in youth and the concerns there. But what about transgender people? Because I believe that, again, if you look at the prevalence, it's striking in this population as well. Can you talk about the prevalence of mental health disorders and people who are transgender? Yeah. And so going back to the Trevor Project for a second, they also found that like seven and 10 transgender non-binary youth experience anxiety, three and five experienced depression. In addition to the Trevor Project, there's also the 2022 United States Transgender Survey. They have early insights, so it's not fully published quite yet. But they found that 44% of respondents experience serious psychological distress in the past 30 days. And I think a lot of that comes into some of the things that Carol was already mentioning early on with stigma, discrimination, feeling fearful, especially, you know, there can be a lot of hostility surrounding people who identify as transgender. And so they just don't feel safe to come to us and to seek care. There's, you know, a lot of stress that comes with trying to fit to that identity that they feel that they should represent. And so I think transgender people do have a high degree of depression, anxiety, suicide because of all of these external factors weighing in on them in addition to not feel uncomfortable in their own body and not being able to get the care that they need to feel comfortable. And also potentially an increased risk of violence in that population as well. That was a thousand percent. Yeah. Carol, it's in my conversation with Kyle Wilby talking about his article that was included in the theme issue and we're doing a podcast with him as well. We talked a lot about the minority stress model. And you also raised the minority stress model here. And I'm wondering if you can really talk about that connection between disparities and this model. Sure. I think NCC mentioned discrimination, victimization through bullying, whether it is in the school setting. When we think about adults, I've had clients who have experienced not just microaggressions, but violence and attacks while doing things like writing the bus to get to their healthcare appointment, to get to the pharmacies, to get to places kind of out in the world. And so the minority stress model really looks at that discrimination, victimization, microaggressions, violence and rejection. That is a part of the stress that is experienced. And when we add in an LGBTQIA plus identification, you're adding in another intersection that adds to the risk for these folks. And there's a paper that was published recently that talks about multiply marginalized people. And so it's looking at LGBTQIA plus identifying people who also may have intersections as persons of color and other different identifications and really how the racial ethnic identification intersects with their LGBTQIA plus identification in terms of where they even find safety in their own spaces. In the LGBTQIA plus space, the person of color may not find the same safety that a white person might experience. And so there are some findings in that study that really showed that identifying intersections in addition to LGBTQIA plus identification is important to helping people find community because they're in we find resilience. And that can impact the minority stress that they may feel and their mental health outcomes. CC threaded throughout our conversation so far. If we talk about incidents of mental health disorders, if we talk about the interplay with the minority stress model and mental health disorders, threaded throughout those are really the barriers to care in this population. But can you talk about that a bit more in terms of what are the barriers that an SGM individual is confronting when they go into the system and are looking for mental health care? Yeah, when thinking about mental health care, you can even say in general, I think it's so difficult to find mental health care. There are a lot of barriers. Then you add on that identity where you don't feel safe going to a mental health provider. That just makes it so much harder. I have patients here in Mississippi where you don't really have a lot of locations for these individuals to go to and I've had them call my office phone looking for someone who can provide care and I'm not in that space anymore where I can provide direct patient care for them. So I have to find those resources really hard. So even just the resources and lack there of makes that difficult in itself. Having the fear of going in and talking to someone and not knowing if there's going to be repercussions for sharing my identity. I think that's a large piece. I talk a lot about my anecdotal experience but I do think it's really important to also highlight what the data shows because numbers don't lie. So in the United States Trims Gender Survey in their 2022 report, they found that 48% of the individuals who did see a provider in the past year reported having at least one negative experience and those negative experiences to me were shocking because it could be anywhere from refusal of care, being misgender, having harsh abusive language or be physically abusive and rough. And that's shocking to me but it's still really important that we talk about that because this is happening and as much as we want to pretend like it's not, people have their own loved experience and these are reasons that they're not going to come see us and seek the care that they need. Shocking as we are supposed to be caregivers. Harold, what would you add to CC's comments on the barriers? I think in addition to just kind of a CC mentioned, generally we find mental health care providers to be lacking in several areas, often concentrated in urban areas and even then on per capita population basis, we still don't have enough mental health care providers to get out into rural areas where LGBTQIA+ folks may not feel safe to come out in that environment and during COVID we figured out how telehealth works but now we are lacking in paying it for those services since that expired and so telehealth has been a really great measure to be able to provide this kind of healthcare to folks in all kinds of communities and I think that's one thing I've discovered at Eskenazi Health is that I mentioned my own personal intersections before and one of the things that is really important is that am I an LGBTQ+ inclusive healthcare provider and what does that mean? Have I done the work? Have I gotten education credits? Have I gone to different trainings to learn about how to be an inclusive provider? We know that there are some settings like outcare health for example is a place where healthcare providers can go and register themselves as a LGBTQ+ inclusive healthcare provider. Pharmacists can be on there too. It's a nationwide type of website where people can register, they provide trainings and kind of just basic pronouns 101, how to be inclusive, how to really center the patient and in pharmacy you talk about patient center care all the time but what does that mean? And it means for me as a healthcare provider when I see my clients in mental health I need to center them and so the things that they talk with me about I need to not talk right? I need to ask the questions get the information that I need but at the same time find ways to connect with them that kind of transcend my intersections because we all have so many different intersections. We all have a sexual orientation, we all have a gender identity when we think about it in those terms it becomes easier to recognize that we are very diverse as human beings and so when I think of ways that I try and connect with my clients one example comes to mind I got my bachelor's degree in pharmacy at Purdue in 1989 which dates me a whole lot and I had a client one time a couple years ago in her early 20s who was way into 80s alternative music and she started telling me about this and I'm like sister I love that in real time. I mean I saw the blow monkeys in concert when they were actually my age so there's not much you can tell me about 80s alternative music and I gave her some bands some groups you need to listen to and so you find these connections. I mean I started getting my chart messages through epic from her about how she picked out one particular album and listened to these particular songs and so I think being an inclusive provider means centering who that person is and trying to get to know that person and everything they bring to the table well at the same time confronting our own implicit bias so what comes into my mind when I'm seeing a patient I know if I close my eyes and I'm listening to a patient perhaps a trans woman if I don't pay attention to her pronouns and how she identifies if I'm only going by her voice I'm at risk of misgendering her so it is on me as a health care provider to not be a barrier for that patient. I think ways to really impact these barriers are to get this training. I mean the LGBTQ health education center through Fenway Health has a lot of basic health care provider education to learn about how to engage with folks. I think health care providers part of the barrier is that they worry a lot about misgendering someone or dead naming someone calling them by the name they used to go by accidentally not really knowing how to apologize for that so there's spending a lot of time in worrying about how they interact with patients as a health care provider so kind of overcoming those things would help to eliminate or at least reduce some of the barriers that we find. You know Carol you have talked a lot about at the system level and health care providers and you've made reference to how pharmacists really can fit right in there with the larger health care provider population in terms of being listed on websites going through specific training but are there other ways that pharmacists really can step up and address disparities and there are there things about pharmacy settings for example that we could do differently to address disparity? Sure I think one of the things to really think about is I mean I practice in a gender health program so I'm a clinical specialist in mental health and gender health in a gender health program so it's required me to learn a lot about gender for me care hormone therapy different types of things that are caused by hormone therapies and side effects those are ways from a clinical perspective that I under my collaborative practice can manage gender for me hormone therapy I do mental health assessments and write for mental health medications and so I do a lot of independent management that way also working on treating side effects whether it be acne, weight gain if somebody is looking at gender-forming surgeries there are steps to go through but we also know that LGBTQIA+ folks need primary care and so it is any a pharmacist in an ambulatory care practice setting in any kind of specialty setting in community pharmacies is going to take care of folks who identify as LGBTQIA+ and so it's really how do we think about that how do we provide care to them I think sometimes we have pharmacists who and other health care providers who focus in on maybe somebody who identifies as transgender and is more curious about what process they've gone through for medical care for that as opposed to the upper respiratory tract infection they came in to actually have treated so how do we learn how to build our communication style so that it centers what that person is actually coming to us for and so it can be a primary care setting we have primary care pharmacists at Eskenazi Health who work in our primary care setting with those providers for medication management for all kinds of folks and so we do a lot of LGBTQ+ inclusive training for our pharmacists our pharmacists identify themselves with pronouns on their main badges and in treatment settings I mean when I introduce myself hi my name is Carol my pronouns are she/her this is what we're here to do today what are you here for today and I mean obviously if I get to know somebody really well I don't do that because they look at me like I know you're pronouns already but being inclusive in that way having a pride flag out on a shelf in a community pharmacy site it doesn't have to be the big three by five flag it can be just a flag sitting out on a counter or wearing the progress pride flag pen or pronoun pins on your white coat if you wear one those kinds of things I think are really important we had a guest speaker in one of our courses one time at per day who is transgender and comes and talks to our students about in a professional education setting about her experiences and she says when I'm driving in my car I can see a pride flag on somebody's bumper from a mile away then she laughs and she says I'm in my mid 50s I literally can't see that well but the point of this is their eyes are drawn to these things and when they see them that says to them these people are here are going to be inclusive maybe they'll make mistakes everybody does we're all humans but at least I know in this space when I walk up to the pharmacy counter or I walk into my clinic to an appointment I'm going to be working with somebody who sees me Cecee what would you add? Yeah I just want to highlight the directory that Carol talked about I mentioned how I have patients who call me looking for help and it's because of those directories like I'm on that directory and they feel like they can just call me I've never met these patients I don't know who they are but they're looking for help and I can serve as that although I can't provide the care for them right now I can find someone who can so outcare has a great directory also LGBTQ+ health care directory I'm also on that and I get a lot of calls from them from there and then I just want to also highlight you know it's easy to just put up a pride flag or put on I have my pronouns on my badge because like Carol mentioned they spot this and they feel comfortable to come to me and talk to me about these things and then the last thing I just want to highlight you know Carol touched on implicit biases but we are human we all have them and it's important to remember that I think as health care providers we kind of put ourselves on a pedestal like I don't have any biases but that's not true we all have them it's just a matter of how are you going to ensure that your biases are not coming out in your appointments in your conversations as a health care provider because we all took an oath to help our patients and it's important to always remember that and when you do experience those biases challenge them when you can because it's really important to provide comprehensive care for all people. CC we talked before about the fact that you did your PGY2 with Carol and if you had a young person a pharmacy student or maybe a PGY1 resident approach you today and say I really want to do something different I want to make a difference in the care of LGBTQIA+ people how do I go about taking that path in my career what would you recommend to them? Yeah I think Carol mentioned it earlier but listen like don't talk just listen because there's a lot that I learned from my patients that I have no idea about and so any interaction that they have I highly recommend to stop and to listen you know I think we are doing a little bit better of a job trying to incorporate this education into the pharmacy school and so utilizing that time to ask more questions you don't have to do a PGY2 psych residency with Carol to be able to do this although it helped me it's the same with luck but look for maybe go on the directory and look for other healthcare providers to pick their brain but doesn't have to be just a pharmacist who's providing education to you you can ask other disciplines all of the other healthcare disciplines that I've worked with in these clinics have been nothing but open and wanting to provide more knowledge you know so try to find locations you know it really does depend on where you are located but if you can find locations that are providing LGBTQ+ care go shadow go check it out go listen to patients this population they're so once they feel comfortable with you they're so open about their experience and want you to learn more we also have someone at Mississippi who comes in and provides their experience and I think that is just so insightful for our students and really important for them to hear. Carol what would you add in terms of your recommendations for that student who's thinking about how to get started? I think about it in terms of academia in the college of pharmacy at Purdue we have added an hour of gender affirming care into our required curriculum plus revised our sex gender reproductive health lab that's required along with that to require practicing taking a sexual health history and gathering sexual orientation and gender identity information from a patient because we know that this can be uncomfortable for healthcare providers it's taking a sexual health history it should be part of healthcare and I won't diverge into that because we don't have time for that but we set it up so that we gave them a script it said you can read the script I just want you to say the words and we partnered with our black cultural center so we had a patient mock patient of color that was actually represented in who the patient was that came in and then we did the soji or sexual orientation gender identity apartment with our LGBTQ center and had trans and non-binary students come in as mock patients and honestly I mean it's been the most celebrated lab we just redid it this year because the students that came in from our LGBTQ center spent extra time with our students to say okay let's let's just make mistakes let's just make mistakes and talking with each other right now and then let's get comfortable and apologizing for it and what that means that it's okay we all make mistakes we're all on this journey of life together and so those students took a lot of time to really interact with the pharmacy students in that all of the first year pharmacy students got to do this so I think I would tell that student to think about what's happening in their own college are they being trained in this area and is there an opportunity to advocate at some level for that to be added to their curriculum and we have a new student organization in the College of Pharmacy at Purdue that started last fall called QueerRx and it's one of the few in the country I'm not sure there is another one right now it started University of Washington which I'm not sure that it's still active but this is within the College of Pharmacy and supported by the University for LGBTQIA plus identifying students and allies which ally isn't a word that we've used yet I don't think in this session but I think is important for all of us as healthcare providers to become and so this starts our students at Purdue off on the right foot in learning how to do that well and the editors of the theme issue actually challenged us to move from allies to accomplices actually Harold there's a you mentioned something earlier about your time as a BS pharmacy student and I was in my BS program at about the same time and I'm curious as to whether your experiences having lived through the 1980s the decade where the HIV epidemic the decade where we first saw the reported cases and it exploded as well as a very different cultural and political environment in that time wondering if those experiences have shaped the way you look at your interactions with LGBTQIA plus people today absolutely and one of the things I think and from a personal perspective I had a very close friend who came out to me in college my best friend and I was the first person that they told and the only person for a while and I remember that conversation I do to this day I remember it because they waited until I was stuck in a car on a road trip with them because I couldn't escape me it was very stressful for them because we were really close friends and to lose that potentially lose that friendship that was the thing I was going through in my mind is how is she going to react to this and so I guess when I you asked the question at the beginning about why I'm so passionate about this I guess it does go back to all of those years ago when then I got to walk beside him for through college and after and what that looked like I mean you know I do remember in class learning about the early medications for HIV and the challenges that were associated with them I spent time at Boys Town in Chicago as a college student so my students are going to listen to this ago I am so not surprised so so I do I mean I think my college my early you know like bachelor's program fits at the stage for a lot of how I practice today well Boys Town is one of the most vibrant neighborhoods in Chicago so this is part of the Pride podcast series so I'm wondering about how each of you are celebrating Pride this year CC what's it going to look like in Mississippi? It was funny I'm actually leaving Mississippi during Pride Month and heading to Arizona for a new position so I will be moving during Pride Month and figuring out how to integrate myself into Arizona and those patients there. Carol what about you? So Pride, Indy Pride is always this huge parade. Eskenazi health is always walking in the Pride parade and so that's something that we do we have the Eskenazi health booth at the fair that happens after the Pride parade and now we are actually breaking out the gender health program so we will have a booth there at Indy Pride and it's always the most fun thing too maybe I'll come it sounds fun it sounds fun well that's all the time we have today I'd like to thank both CC Wartman and Carol Ott for joining me and sharing insights on improving mental health care for sexual and gender minorities if you'd like to read this article please visit hhp.org and look for our theme issue on health care considerations in sexual and gender minorities again CC Carol thanks so much for joining me today thank you for having us thanks for having us thank you for listening to ASHP official the voice of pharmacists advancing health care be sure to visit ashp.org forward slash podcast to discover more great episodes access show notes and download the episode transcript if you loved the episode and want to hear more be sure to subscribe rate or leave a review join us next time on ashp official music playing. 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