J Am Pharm Assoc (2003). 2026 Jul 24:103491. doi: 10.1016/j.japh.2026.103491. Online ahead of print.
ABSTRACT
BACKGROUND: Transgender and gender-diverse (TGD) individuals may experience physiologic changes from gender-affirming hormone therapy (GAHT) that complicate clinical calculations with binary sex variables. Common tools such as the Cockcroft-Gault creatinine clearance (CrCl) equation and the American College of Cardiology/American Heart Association Atherosclerotic Cardiovascular Disease pooled cohort equations (ACC/AHA ASCVD PCE) require binary sex inputs; however, no national or international guidelines specify whether sex assigned at birth or gender identity should be used when completing these clinical calculations that have binary sex inputs.
OBJECTIVES: To evaluate (1) pharmacists' practices and confidence in using sex assigned at birth versus gender identity when calculating CrCl with the Cockcroft-Gault equation and ASCVD risk with the ACC/AHA ASCVD PCE in TGD patients and (2) the effects of GAHT on these decisions.
METHODS: This IRB-approved, cross-sectional survey of licensed pharmacists (October 2024-February 2025) assessed clinical decision-making in transfeminine and transmasculine patients with and without long-established GAHT, as well as confidence and prior training. Paired comparisons were analyzed using McNemar's test to test for the effects of GAHT on these decisions.
RESULTS: A total of 190 pharmacists completed the survey. Most respondents selected sex assigned at birth for calculating CrCl using the Cockcroft-Gault equation and ACC/AHA ASCVD PCE in patients not receiving GAHT (85.2-85.4%). In patients with long-established GAHT, there was a consistent and statistically significant shift away from using sex assigned at birth (p < 0.001) when compared to patients not on long-established GAHT. Confidence was low overall (median 1-2 [IQR 1-3]), and 90% reported no prior training. Training was associated with higher confidence (p < 0.05), but not with consistent decision-making.
CONCLUSIONS: Pharmacists demonstrate inconsistent approaches and low confidence in deciding binary sex inputs in clinical calculations for TGD patients. Decision-making shifts with long-established GAHT and training improves confidence.
PMID:42498131 | DOI:10.1016/j.japh.2026.103491