Seattle’s LGBTQ+ Center and Kelley-Ross Pharmacy have developed a new informed-consent gender-affirming hormone therapy program for adult patients that may be one of the few in the country led by clinical pharmacists.

Medical Director Janna Cuneo said the program allows trained pharmacists to operate at the top of their license in Washington, which she hopes can help expand health care access to people medically transitioning in the Seattle area. With only a handful of providers participating in the early stages of this small program, capacity is still limited, but its creators see it as a novel solution designed for the community that could address a problem with bridge care.

Cuneo, a nurse practitioner and HIV clinical specialist who has provided gender-affirming care since 2015, said they noticed people losing access to hormones when they lost jobs, lost insurance coverage, or moved from states with less access. They wanted to help create a program that filled that gap.

“You can’t suddenly stop taking hormones,” Cuneo said. “They’re super important to having any kind of homeostasis in your body, emotionally.”

Cuneo took inspiration for the gender-affirming hormone therapy program from the pharmacy’s successful PrEP distribution program, which it runs out of the LGBTQ+ Center building at 400 E. Pine Street. PrEP is a daily medication that reduces a person’s chance of contracting HIV. 

In that program, pharmacists interview the patients, conduct testing, manage STI treatment, help people decide which PrEP drugs to use, and refer them for higher-level care when necessary. Cuneo thought a similar approach could work for gender-affirming care medications.

Recent research shows an improvement in HIV outcomes for trans people if they could receive gender care and PrEP in the same place. And because transgender people are more likely to have a mental health diagnosis such as depression or anxiety, in part due to stigma and discrimination, pharmacists can anticipate any interactions between psychiatric and gender-affirming care drugs.

Using pharmacists instead of doctors addresses another issue: the relative scarcity of MDs trained to administer gender-affirming care.

There’s limited data on what doctors learn about transgender health while in medical school, but one 2018 literature review published in the journal Advances in Medical Education and Practice found most training was composed of one-time awareness and attitude-based interventions. The researchers concluded that the training helped in the short-term but that trans patients still suffered health inequities.

Even if a trans person finds a doctor who fits the bill, not everyone has insurance, a consistent job, or can legally access care in their state. 

Cuneo said when designing the program she kept in mind people fleeing red-state laws restricting their access to hormones who may not know where to resume care when they land in Seattle. Adding those services to the LGBTQ+ Center, where people can be connected with an Apple Health coordinator and other resources for queer people, could curb that potential problem. Seattle’s LGBTQ+ Center is very Googleable.

The program’s new patients begin care with a one-hour consultation, where providers explain what can be expected from HRT and ask patients about the changes they’re seeking. After that, patients will see the same clinical pharmacist every six weeks while still adjusting the medication dosage early on. They’ll eventually see their provider twice a year once they’ve settled on a consistent dose. Cuneo said the program will function like a primary care relationship for the gender-care component of their care, with the goal of patients developing a relationship with a provider who knows them.

Early on in the program’s development, Cuneo and their team conducted focus groups asking trans people what they did and did not like about their gender care in the past, and what has led them to trust and distrust medical institutions. They’re planning for additional focus groups at the one-year mark to ask patients what they could improve.

“The thing I really want to avoid is doing poor health care for poor people,” Cuneo said. “It’s kind of a trope that something’s better than nothing.”

Once Seattle’s LGBTQ+ Center has collected enough community feedback from visitors to its wellness center and to the pharmacy’s gender-affirming clinic, it will provide social and community support to patients.

“We recognize that there are not enough resources, or not enough community spaces for LGBTQ folks seeking gender-affirming care or community,” said Elle Brooks, director of health services at Seattle’s LGBTQ+ Center. “... It’s really our hope that when folks come in, they feel cared for, from the moment they come in until the moment they leave.”

Cuneo said the unprecedented popularity of the program, which the LGBTQ+ Center announced in February, has led Kelley-Ross to increase its number of pharmacists and rework its schedule to guarantee access for new intakes and follow-up appointments.

The Center, which started in 1995 as the Gay Men’s Health Project and was later known as Gay City: Seattle’s LGBTQ+ Center, ditched the “Gay City” part of its name in 2022 when it moved to its new home on Pine Street. In a statement, a spokesperson said the center’s services had not always been inclusive, and the new name reflected changes they’d made.

Nakita Venus, executive director of Seattle’s LGBTQ+ Center, said partnering with Kelley-Ross for the gender-affirming program leans into that new identity to meet the needs of the entire queer community. 

“The name was only a symbol,” they said. “It means nothing if we don’t put effort and action behind it.”