Good afternoon, everyone on the East Coast. On behalf of our team, our speakers, and ASLD, we'd like to wish you all a happy Pride Month. Today is the honor of myself, Arpan Patel, and my colleague, Elizabeth Gocher, to moderate this session entitled Approaching and Supporting LGBTQ Patients, Practical Tips for Clinicians. My pronouns are he, him, his. Today we have a wonderful lineup of speakers for you today whose topics will be centering on ways we can all do better in taking care of our LGBTQ community. I'd like to, if you'd like to ask a question to one or more of our speakers, just a reminder, feel free to drop your question in the Q&A tab. We will try to address those questions at the end, and with that, I think we'll go ahead and get started. All right. Thanks, Arpan. I'm going to introduce our first speaker. Our first speaker is Dr. Allie Strauss, who is a transplant hepatologist and assistant professor at Johns Hopkins University School of Medicine. Dr. Strauss is an active health services researcher whose lab is focused on using systems engineering and data science to improve health equity for patients with liver disease. She also serves as an active member as a AASLD LGTBQ plus task force. Dr. Strauss. I can't share while you're sharing, Howie. Okay. Well, I'll be kicking us off today with my talk called Understanding the Terms and Definitions of the LGBTQ Plus Community. And again, my name is Allie Strauss. My pronouns are she, her. So I think that it's not unreasonable that a lot of us may feel like there's a little bit of an alphabet soup floating around us when it comes to all the terms related to the LGBTQ plus community. So my goal today is to hopefully make all of these terms a lot less confusing. And so that way you all can feel more comfortable when you're taking care of your patients. So first, why does this matter? And I think that the core to understanding the language involved with talking with our patients is that good communication builds trust. And as providers, we all want to be trusted because we know that that's the key to best taking care of our patients and getting them the optimal health that they can achieve. So that's why hopefully throughout this lecture, you'll be able to pick up on some terms that will make you able to converse more freely and easily with your patients. And that way you can build on that trust. There's a power to language. And for one, that involves that language shapes how we perceive and interact with the world. So terms and different labels and words that we use, they can really influence people on a societal level regarding their attitudes and what's considered normal and how people interact with each other. So that's one key aspect is the idea of shaping perceptions. Secondly, is this concept of the correct terminology validating the identities and experiences of marginalized groups. And if you're able to talk about things easily, it makes them feel a lot more visible in society. So another concept is empowerment. And this is really important when it comes to language because language can empower individuals by providing a means to articulate their identities to you as their provider and their experiences. So language can be just critical on many levels. It can help with self-acceptance of the patient in front of you. And it also helps to build a community among your patients and among the patients with their providers. So hopefully that gives a little background on why this is important. So what we're going to do moving forward, the outline for the talk, I'll give a little bit of historical context. I'll go through some definitions of terms and words, and then I'll also try to end with some terms to avoid that you might be nervous, like, is this the right term or not? So there's an evolution of terminology over time. Words are not static in any sense. And in the LGBTQ plus population, things have definitely evolved. So starting back in the late 19th century and early 20th century, the word homosexual is said to have been introduced to the English language, at least. These began being used around this time more for medical and psychological contexts to describe things like sexual orientation. And then in the 1940s to 60s, the terms gay and lesbian became more popular among the LGBTQ plus community themselves as they were able to self-identify themselves. And gay was initially used more broadly to describe men, but later it's become more inclusive of women as well. The term transsexual was first introduced in the English language in the same time period, too, of the 1940s to 60s by, it's kind of debated between David Caldwell or Harry Benjamin, but around that time period, this word was introduced in English. It was previously already being used in Europe. Next in the 1970s, the acronym that we know today began taking shape. So initially it started as GLB, and this sort of introduced the idea of bisexuality alongside gay and lesbian identities. And then in the 1980s, LGB took form and started to change the acronym that we know. So during the 1980s, the AIDS epidemic was at the forefront. And because AIDS was a deadly disease and affecting predominantly gay men, many of these men were actually alone in the hospitals having been essentially outed by the disease and abandoned by their families and loved ones around them were also dying from the disease as well. So many providers were even scared to care for them. And during this time, lesbians stepped up and were caring for these men in the hospitals. So during this time, gay men wanted to show an appreciation as well as support for the feminist movement that was sort of also happening right around that time. And they made a small but meaningful gesture to move the L to the front of the acronym. Also around this time, the word queer, which was historically before the 80s used more as a derogatory term, it was being reclaimed by the activists and academics of the 1980s and sort of started forming this umbrella term for just non-normative sexual and gender identities. Moving into the 1990s to 2000s, the word transgender, while it had already certainly been used previously, it was kind of throughout the 1900s, it was really popularized in the 1990s, used more freely in media and being embraced by the community. So this timeline, lastly, non-binary and cisgender, which is probably the most recent change that we've seen in our generation is, and we'll go more into these terms later. But this timeline represents a very general and organic shift over time. And I will point out, it's a very Western world perspective. There's certainly a lot more history that goes back further and can encompass a more worldview. Also, this may not represent every individual's understanding or experience throughout these times, but I wanted to just give a sense for how things have evolved in the words that we're choosing to use. So these are important shifts over time and the language has been shown to be important for two main reasons, really legal recognition and policy. So inclusive language and laws and policies, and just knowing what words that people want to be called and then using them in the rules that we're making can ensure recognition and protection of these marginalized groups. For example, things like sexual orientation and gender identity actually being used in anti-discrimination laws, as opposed to offensive terms. For public policy, language can shape debates and actually outcomes of patients based on how that has downstream effect, how these policies can have downstream effects. Terms like marriage equality and gender neutral in, you know, gender neutral bathrooms, these can change public opinions and legislative decisions. So just another example of the importance of language. So now we have a little bit of history under our belts. Let's move into the nuts and bolts of definitions of some of these terms. So I'll start with sex at birth or assigned sex at birth. In the liver space, you know, this has been made more prominent recently because of the MELD 3.0, where now centers are able to put in sex at birth and also the sex is relevant to the center. So that's sort of why this has come to the forefront, but backstepping as to what it actually means. So essentially when people are born, they're assigned a sex by a midwife or a provider, and it's binary, male or female, based off their external anatomy that can be seen. So we might say also assigned male at birth or AMAB. You'll see that acronym or assigned female at birth or AFAB. And so you can imagine that you might have a male sex assigned to you at birth, and then it was incorrect. And that can happen because of this other category called intersex. So people that are intersex are born with a variety of differences in their sex traits and reproductive anatomy. So the genitalia might be misinterpreted as to what their chromosomes or their internal sex hormones or hormone production or hormone response and other later secondary sex traits. So there's a wide variety, and this is what is important to be aware of and how it's important to differentiate what someone's sex at birth is from what we'll talk about in a few minutes about gender. And this isn't a trivial point. It's estimated that one in a hundred Americans is intersex and around up to 2% of the population worldwide. So we can think of a lot of things that we talk about in medicine all the time that have that kind of prevalence. And we don't talk, but we tend to overlook this concept of sex at birth or assigned sex at birth. So next acronym is SOGI. So you might see this, and this stands for sexual orientation and gender identity. So sexual orientation is broadly the emotional, romantic, or sexual attraction to someone else. Whereas gender identity is a person's internal, deeply held knowledge of what their own gender is. So that can be man, woman, both, neither, somewhere on a spectrum, it can change. And the difference, an important thing to acknowledge here is that gender identity as opposed to a gender behavior expression, which we'll also talk about later. So let's dive into what these two concepts are. I'm actually going to start with the G part of the SOGI, because I think that'll make the sexual orientation part be easier to understand. So for gender identity, we have cisgender. So these are individuals whose gender identity matches their assigned sex at birth. So it's going to be a large part of the population. Transgender is an umbrella term for people whose gender identity is different from cultural expectations based on the sex that they were assigned at birth. And non-binary is another broad term for gender identities that are not exclusively man or woman. And then gender queer, and sometimes non-binary and gender queer can be confused, but gender queer is essentially people that typically are rejecting the notion of static categories of gender, and they embrace more of a fluidity to their gender identity. So they may see themselves as man, woman, or neither, and that can change. So that's gender identity. Now taking those into sexual orientation, which as I mentioned, was more about your attraction to others. So straight is described as those attracted to the opposite gender. And this is how cisgender and transgender people may identify. Next is lesbian. So these are women with emotionally, romantically, or sexually attracted feelings towards other women. And women and non-binary women may use this term to describe themselves. The term gay is a person who's attracted to members of the same gender, romantically, emotionally, or sexually. And this may actually be men, women, and non-binary people may use this term to describe themselves. Because like I said, it used to be that was more for men, but now it's a more generalized term that can be used. Asexual is a complete or partial lack of sexual attraction or lack of interest in sexual activity with others. And it can exist on a spectrum that they might experience no little or conditional sexual attraction towards others. Bisexual and pansexual can also sometimes be used by some people and it means very similar, they mean very similar things. So typically we might think that bisexual is only referring to someone attracted to emotionally or romantically or sexually to men or women and or women. But you actually, it's meant to mean the bi part is actually meant to refer to someone that's attracted to someone that's the same or just different gender than oneself. So that's why that can be used as well as with pansexual because those are people that they have the same idea of sexual attraction to people of any gender. It's not always set and it can change and they can also be simultaneously that they're interested in any other gender. So I hope that makes sense sort of sussing out gender identity and sexual orientation because this is very important for what we talk about with our patients and being able to really understand people's and their preferences, their attractions, their behaviors, and being comfortable to talk about all those things. So another acronym breakdown. So this is the LGBTQIA+. So we've covered a lot of these already so I won't belabor them but I wanted to touch on queer. We already mentioned too that that was sort of a term that's now embraced by the LGBTQ plus community. It's sort of just an umbrella term for non-heterosexual and non-cisgender identities. Questioning is sometimes used for the Q as well. These are individuals that are exploring their sexual identity, sorry their sexual orientation and gender identity and they maybe not have not yet defined it. And then we talked about the other ally is sometimes also the A with asexual and those just meant to be inclusive of people that are supportive of the LGBTQ plus population. And the pluses there you'll see that is to recognize that there's a limitless sexual orientation and gender identities used by members of the community that we want to be inclusive and not exclusive because there is actually a lot of history behind the LGBT acronym and excluding certain groups. I sort of touched on that with bisexual and transgender has a long history with that as well. So meant to be plus for inclusive. Next is TGNC. So this is transgender and gender non-conforming. And then lastly is sex and gender minority. You'll see that acronym as well sometimes in papers more recently. So quickly going through two myths. So one myth is that non-binary and genderqueer identities are new and trendy. So that can sort of be a vibe that people give off or conversations you overhear. And this just isn't true, right? These have existed across cultures and history and there's examples. The hijra is centuries old and it's a term used in the Indian subcontinent. And then two-spirit people is used in many indigenous cultures. So sometimes you actually will also see that in the LGBTQ plus acronym as a number two S. Second myth is that bisexual people are just confused or going through a phase. So this is a valid sexual orientation. There's a concept of bi erasure which is meant that many people that are bisexual feel that their identity is invalidated by both communities and they are kind of like invisible. So it's important that we recognize that this is not a phase and that people in this group might face unique mental health challenges. So it's important that we recognize it for our patients. So going through next on pronouns. These are important because they represent gender expression which is external manifestations that people might give to the outside world on what their gender identity is. And sometimes it aligns and sometimes it doesn't. It can depend on the people around you. And generally it represents masculine and femininity that's defined by society but that also changes over time and across cultures. But this is where pronouns can play a role and they're largely important because they're a sign of showing respect. You can't always tell by looking. So trying to just show be respectful of someone's pronouns can really prevent them from feeling invalidated or dismissed. And some people use the wrong pronouns intentionally. So you have to be aware that this might not feel important to you but it's very important to your patients based off their prior experiences with people. And also it's important when we're talking with our patients because they might use their pronouns of their partners too. So it's important for you to be able to pick up with that and move with them on the fly when they're having conversations and not be all tripped up on it. So these are some examples of the pronouns that people use. There's masculine and feminine ones. The neutral ones are they, them, theirs. And also ze, zeer, and zeers. And zee, here, and here's. So an example would be zee ate here food because zee was hungry. And that zee can be spelled in two different ways as well. The z-i-e or the x-e you might see as well. You just sub those in for wherever it says z-e. If you misgender someone, don't like stay on on it. Just apologize and move on with the correct pronouns. If you're ever in doubt, use neutral pronouns or just use names because people always will go by their names. Briefly, some terms to avoid is biological sex. We talked about that earlier on. It's assigned sex at birth. Biological can be very confusing and not actually what people mean. Transsexual, transvestite are all, I would avoid those words. You should be using transgender and homosexual. We're also using gay, lesbian, a lot of the other words that I mentioned. It's just less stigmatizing. And then FTM or MTF, so male to female or female to male, just using terms like transgender woman, transgender man gets the point across. So continuous learning, it's okay to make mistakes, educate yourself and ask questions about people's experiences. We're going to talk more about that in the future lectures. Key takeaways are three points. There's a historical context to language and it's important to understand that and things will change. This slide deck will be outdated hopefully in five years because we're going to keep evolving. So just keep learning. Two, show respect and use the proper pronouns. And three, avoid outdated and inoffensive terms. So I hope that through this talk, you're a little less like this with words swirling around you and that things have sort of found a place in your brain and you'll be able to be more confident when talking to your patients. I had some citations in here and great references for if you need definitions of the terms that I mentioned today, you can scan this QR code and it'll take you to the list of the references that I put. There's great ones by HRC, which just literally you can search any term that you want. And please contact me if you have any questions. Thank you. Thank you, Dr. Strauss for that wonderful talk. We're going to go ahead and move on to our next speaker who is Dr. Jason Latsky. Dr. Latsky is a family medicine and pediatric trained primary care physician, as well as a certified HIV specialist practicing at Fenway Health in Boston, Massachusetts. His work has been centered on improving visibility of LGBTQIA individuals and has worked with multiple organizations to accomplish this, including the American Academy of Family Physicians and the Building the Next Generation of Academic Physicians program. So we're delighted to have you join us here today, Dr. Latsky. And just a reminder for everyone to feel free to drop any questions you have in the Q&A tab. Thank you. Sorry, just readjusting my camera because screens are different for me. Can everyone see me? Yes, I hope so. All right. So hi, everyone. My name is Dr. Jason Latsky, originally born in Canada. I do work at Fenway Health here in Boston. It's an absolute pleasure to be talking to you guys today. I'm going to keep it brief. I love to lecture for like two hours. So please, if you have any questions, let me know. Sorry, just checking this chat. Yes. Awesome. So my job today is to demystify asking the right questions in about 20 minutes. I'm going to try my best. But I do have a couple of what I want to do is I want to leave you guys with some key takeaway points and some key frameworks to really help you guys in your practice and really make sure that we're doing the right things for our patients. So. Why is this important? I do believe that Ali made some really, really great points, and I just wanted to focus on two really cute cartoons here that you guys should keep in mind. Number one is the difference between equality versus equity, realizing that the LGBTQ community has had a very difficult past in the medical community. That means that they have some traumas and some associated experiences that might make it harder for them to trust their providers and really get involved in medical care. So it's important to boost them up using an equity and trauma informed care approach, meaning that we assume that a trauma has already taken place and that we are exceptionally making a little bit more of an effort to provide a little bit more culturally competent care because these people have suffered some injustices in the past. So using the equity based approach is really, really important. And another really cute cartoon that really states how I do things. And one of the main focuses of my framework is this one on the bottom left called the curb cutting effect, which essentially if you use it in the in the setting of a handicap is if you design a sidewalk to be accessible to someone with a wheelchair, you may have the inadvertent consequence of helping all the other people you see highlighted in yellow, people with bikes, people with dollies, people with children in carriages, people with rolly suitcases, people with mobility reduction. So when we design things for certain people, in this case people with disabilities or in this case people with undue medical trauma, we make things better for everyone. So if you can just take this approach and apply it to everything, I think it'll be very helpful. And I'm really happy that Ali brought up the point about pronouns. I've heard this quote way too many times from people over the age of a certain age or just anyone in general is pronouns are silly. I'm too old to care about this. And I think that's absolutely ridiculous. And I just want to show this slide very briefly. It's a really, really beautiful illustration and very complex that talks about the injustices that the LGBTQ community faces, which is barriers that we create as a society and as individuals that lead to inadequate access to care. And when people have inadequate access to care, they develop issues that become uncontrolled, whether that be increased burden of mental disorders like anxiety, depression, PTSD, as an example, or having preventative care that's not being done. So lesbians having a higher incidence of cervical cancer because they don't want to go see their doctor. And insurance not insuring someone because their pronouns are wrong. So I do think I don't want to spend too much time on this slide, but just understand that this justifies why we have a trauma-based trauma-based care and why we give our LGBTQ patients just a little bit of extra attention. Okay. I love this slide because I do want you to see here that 80% of trans people who access gender identity services still say that access have been difficult and still 38% of people are having negative experiences. What's really important here I wanted to show up was this inappropriate curiosity part. So 18% felt like their providers were unduly talking about their transness when it wasn't relevant. So just really be cognizant of that when we're providing medical care to people. If someone's here for a concussion or something, then we really shouldn't be questioning them about their sexuality unless we need to. So how do we get a good history? The framework that I use is a really old one, one that we've all went through in med school, which is the biopsychosocial. And I'll try to keep the pink, green, and blue notes. So that way we can see where I'm getting each piece. And I've sort of developed in conjunction with a couple of my other colleagues here at Fenway Health and throughout America, just a really good framework on how to collect a good history. This is based on WPATH guidelines. And what I really want you to take away is if you can follow this biopsychosocial model and understand that it's a lot about compassion and there's really not that much medicine involved, it's less scary. So here is my general framework. So the first thing I do is I always address social history first. So the first thing I talk about, of course, I've met my patient. I'll give you some verbiage in just a minute. Please don't worry about it. But it's really important to find out two things with time, which is when they started feeling gender incongruent and when they actually came out. That time lapse can give you a lot of insight as to has this patient had an easy life, had a harder life? Oh, you know, this patient's 40 years old. They felt gender incongruent when they were three, but they came out three years ago. Oh my goodness, they've been living a life for 35 years. Imagine the trauma that that produces. So just asking these two really simple, supportive questions of when did you start feeling gender incongruent? I'll give you some verbiage for that in just a minute. And when did you socially come out? That is the word that we use. That is really, really good information. You also want to follow up right away screening with support. So, oh, I understand that you socially came out last year. Do you feel well supported at home? Can you name me a few of your supports? And they'll usually say, oh, yes, my coworkers are great. My family's great. My friends are great. Or, oh, they're not great. And then again, this is increased insight as to the risks that these patients might have for substance use disorder, mental disorders, mental illnesses, excuse me, or any other issues that might come up. So the support is very, very important. Of course, you do want to spend a small minute just reviewing their medical history. I do not unduly force them to say, like, do you have depression or anxiety? I just go through their medical history and I say things like, do you have any medical issues I should be aware of or any other mental illness issues that I should be aware of? And then I let the patient let me know because as you guys hopefully are familiar with the WPATH Society Standards Version 8, there are not very many conditions that stop someone from accessing hormone replacement therapy or transgender services, even if they do have mental illness or medical issues. So the next question that I ask them is, are you currently engaged in therapy? And I always couch this question carefully because, again, the transgender community is used to being over-medicalized and over-stigmatized for mental illness. And I always say, I just want to know if you're engaged in therapy because as a medical professional, I might have to support you with getting letters for any of your therapy and for your treatment. And if that's the case, I just need to know who to contact. So it's really, as I say, it's a checkbox for insurance for a surgery. I don't actually care about their therapy. I do always ask them, is your therapist comfortable gender-affirming care if they have one? But I always couch that question very carefully. And I say, this is mainly a checkbox question just to make sure that I have some good information to go off of. I'm going to skip the goals one for now because that's a whole little quote that I do. But that is a really, really, that's probably the most important question that we can ask a trans person when we're helping them with their care in terms of their trans person care. And then we'll obviously talk about how that can change over time. And I will show you an example of an organ inventory. So it's really important that we go through it in this systematic fashion and that this become routine for you guys, because that is the only way that you're going to gain trust and be able to ask for commitment from your patients and retain them in your care. Otherwise, we'll have no shows, we'll have inconsistent care, and we're just going to further the disparities that these individuals face. So HRT requires follow-up. All medical care requires follow-up. And I really encourage you to widen this net of providers that are being very inclusive to the trans and LGBTQ and in general. I do want to say, I apologize for making this very trans-focused, but I do want to really, really spend a lot of time talking about that because I feel like that demographic is the one that is the most often overlooked and most often stigmatized. And I do feel like the rest of the LGBTQ spectrum gets a little bit better care in medicine. So approaching gay, lesbian, bisexual, other individuals in the LGBTQ is generally more comfortable. It's more the transgender patients that seem to cause a problem. If anyone wants me to expand on gay and lesbian stuff, I'm happy to do so in the Q&A. So here's a little bit of my verbiage and my framework that I use. So the first thing I want to do is, again, remind you, be conscientious that during your history, trans people are used to and will think that you are over-medicalizing them. So I really encourage you, that's why I started off right with that social aspect, and don't be afraid to explain in simple terms. So, you know, I said, when did you start to feel gender incongruent? If you feel like that's too sterile for your patient, you can say things like, hey, when did you first feel like you were different? Like your body did not match up with your gender. And really just being very honest, getting to that patient level, and you're really just starting off being like, hey, I'm your doctor. I want to make an appointment with you. You know, I want to do a trans history. I think this is very important for our medicine. And just to start off, when did you first feel like you were different? Like your body did not match up with your gender. Or if you have a data scientist, trans person, say gender incongruent. So again, I'm giving you a couple of different verbiage you can use to establish that social link. Explain clearly why you're asking these personal questions. Like I said, you know, this is really, really important when we do the organ inventory. So I do want to say, I would like, you know, so when did you first feel different? Like your body did not match up with your gender, blah, blah, blah. I go through a bunch of social stuff. And then I go, okay, as part of my trans history, I do something called an organ inventory. I would like to go through this because it helps me keep track of, oh, sorry, there's a typo there, helps me keep track of and take care of all of your different parts. And I'm just doing this as your doctor so that I can keep track. You're explaining to them, showing them the EMR and telling them the reason why I am obsessed with their organs and their genitalia. Because again, unfortunately, trans people will have been objectified and or over-medicalized or made to be curious when, you know, I'm doing this organ inventory because it's important. If it's not important for your practice, don't do it. Next, when we start getting into more SOGI or the sexuality and the gender, make sure that your questions remain open. I love that Allie put in that plus. There are a lot of new words every day that I don't even know to describe what is going on and it's being developed daily. So when I'm asking about sexuality, I don't say, are you sexually active with other men or something? I say, are you sexually active? If so, can you tell me about the number and different types of partners you are active with? And then I always follow it up with, are you single or not? And the reason, because if they say yes, they're active, I say, are you single or not? This is really important to include for STI screening. Obviously, if they're not single, they might say I'm partnered, but this reminds me also that polyamory and open relationships are a real thing. So we have to be really cautious. So just because someone is sexually active doesn't mean it's just with one person. So they'll come in and you'll say, are you sexually active? Yes, I'm sexually active with my partner. Wonderful. Is this a monogamous relationship? And they go, oh no, we're part of a throuple and we have an open relationship with five new sexual partners every day. So that's completely different than what we were taught to expect in medical school. So try to keep these questions open and just have this discussion with your patient. I put here people with a penis. I like to say that if you notice your patient is struggling or feeling uncomfortable with how open-ended your question is, they start saying things like, what does that mean? Oh, what do you want to know? Because it can sound a little probing. So I would just say things like, oh, I'm just trying to understand the different types of people that you have sex with and what parts they have so that I can best take care of you. So do you have sex with people with a penis, people born with a penis, people born with a vagina? So we're again, using words like AFAB and AMAB to help tell our patient, like, we're just here to support you. And I'm not using societal words like man or woman, and I'm not implying that you're monogamous. I just want to know what body parts are touching what body part so that I know what I'm doing. And then we do want to admit that we have a lack of knowledge. A lot of our research on some of the HRT and the therapies that we go is still ongoing. Trans care is currently under-researched and very underrepresented in the medical literature. So it's so important to build a shared decision-making bridge with your patient. I've come up with a quote that I really hope you guys can keep. I've had a couple of trans patients even cry when I tell them this, so please, it's very valuable. This is exactly what I say. I say, I would like to learn about your current goals. Trans care is an art. You are an artist and I am a paintbrush and your body is a canvas. Help me see how we can best work together on this canvas that is your body and gender expression. So that way you really give them the power and help understand that we're not over-medicalizing them and we're not just saying like, oh, you are trans man, therefore testosterone. It's way more broad than this, way more varied in terms of the different types of expressions that we really need to create that partnership with our patient. And using an art analogy really gets them invested, I found in my experience. So building on that, it's really important because given the lack of information, how do we make educated evidence-based decisions? So let's say we have some sort of trans feminine person whose estrogen level came back at 76 and the literature goal is 120 to 200. How do you interpret that in context? So I like to use verbiage like this. I see that your estrogen level came back at 76. Do you know what the target ranges are? Oh, I remember you define yourself as non-binary. So those ranges do not necessarily apply to you. That's great. And let's explore how does this currently make you feel? And are you getting the results that you want? Maybe this is a good level for you. Really, really important verbiage. Also making sure that patients understand when stuff is taken is really, really important and trying to keep patient accountability. Don't want to go into the details of HRT too much, but in endocrinology, we need to get a mid-cycle level to prevent peaks in the concentration. That's where we get the danger of clotting and polycythemia with testosterone. So I always ask my patient, wow, you got the estrogen of 76. Did you get your labs drawn mid-cycle? This is really important because remember my main goal is to keep you safe and make sure your levels don't get too high. That's why it's so important that we get those values at the mid-cycle time. So again, educating the patient, getting them involved, and not just telling them, yeah, go mid-cycle. Tell them why. Why do they go mid-cycle? This is really important to get them involved in their care and invested. Otherwise they won't comply with your therapy, which can be a problem. So here is a quick little screenshot of my Epic here at work at Fenway Health. Obviously patient is protected, but this is a nice trans woman that I work with here at Fenway. So you can see here we have legal sex assigned as a male, gender identity female. You'll see that Epic only shows female, which is great. Everything will go through as female on their labels. And to access this area of Epic, all you have to do is click on the person's name, which is blacked out here, obviously for reasons. But if you hit that, the area where the patient's name, this will bring up this demographic basics thing, and that will show you all the information about your patient. Here on the storyboard on the left, if you just hover over their name, you'll get a quick overview of this. And that will help you, sorry, if you hover over the gender identity, you'll get a quick legal sex, aka sex assigned at birth. I'm not really using the right words, both of them. And then you'll also get the gender identity in like a quick story view. So that way you can see right away, oh, this is a trans woman versus like a cis woman. The next thing I wanted to say is if you click on that female button or the gender identity marker, this beautiful window will pop up if your version of Epic has it. And this is our SOGI information collection smart form. It's really, really cute. I highly recommend that you use it. Fenway's is obviously quite extensive, but your own organization can tweak it as necessary. It contains all of the sexuality, gender identity and documentation areas that you can put. And most importantly here for us as primary care doctors, the organ inventory to make sure we're doing the correct cancer screenings for that patient. So you can see here, my patient was assigned male at birth. So I completed an assigned male at birth. Currently, mostly assigned male at birth parts, but have some breasts that were not surgically enhanced. It did cut off a small area here that says they were hormonally enhanced. So this is a very complete organ inventory and this actually informs Epic so that Epic knows, even though this patient identifies as female, not to ask me for a pap smear. It's very, very clever how this was built into Epic. So I highly recommend completing the SOGI information if you do have it available at your institution. And if you don't have it at your institution, I do encourage you to get it covered. The last thing I wanted to share with, before I had times for questions, this is literally the summary of what I just told you, my framework, and this is my SmartFrames that I use. So as you can see, patient has felt incongruent, support network, how long have they been on a certain hormone, what their history is with it, have they had any surgeries, are they in therapy, what are their current goals, the art thing, did I update the inventory? And then I have a SmartFrames here that just brings in their testosterone, estrogen, CMP labs. So easy peasy to put that into Epic. I'm happy to share this if anybody wants, and that gives a very, very thorough gender affirming care example. So on that same patient that I showed you, this is what it looks like in their chart actually. So I do believe that is my last slide. I'll leave that up just for a couple of minutes if anyone wants to observe. So you guys can see patient has been taking estrogen for six years, started blah, blah, blah, patient uses this blockade, stopped Spiro, has had bottom surgery, updated the organ inventory, that's their estradiol, which is within range, which is great. And then this overview will not change every time I bring in their plan, but every time I see them, I can update my assessment and plan and say things like FFS appointment has been booked, which is great. So the overview is a great function in Epic you can use. That is everything I have. I will thank you so much for your attention. You can feel free to email me, that QR code is my contact information if you want that in your phone. I have not been active on Twitter in many years, but that is my Instagram if any of you wanna follow along. I don't really use it that often. I'm really bad at social media, but I just wanted to wrap this up and say thank you so much for your attention. And if you need anything, I'm here for you. Thank you so much. Thanks, Dr. Lasky. I really appreciate that. It's great to have that perspective from primary care. Thanks for pulling down your slides. While Dr. Lee is putting his and sharing, I just wanna introduce him. Dr. Lee is a transplant hepatologist and assistant professor at Baylor College of Medicine in Houston. His academic and clinical interests include viral hepatitis, liver transplant, and health disparities with a special focus in the LGBTQ plus population. Dr. Lee is our chair of our LGBTQ task force of WSOB and an executive board member of Rainbows and Gastro and the diversity community of AST. And so I will let Dr. Lee take it from there. Hi, everyone. And also reminding people to put the chat. Sorry, Dr. Lee, don't forget to put your questions in Q&A so that we can address them at the end of our talk. Hi, everyone. Thank you for a nice introduction, Elizabeth. I'm Howard Lee, a transplant hepatologist in Baylor. My pronouns are he, him, his. Today, I'm gonna talk about the last part of our seminar today. How can you really do it in your daily practice and even your daily life to support our LGBTQ patients? And I'm gonna talk about why is this important? The study has been shown, there's actually more and more people identify as LGBTQ plus. The number has been doubled in the last decade. In 2012, according to this Gallup survey published a couple of years ago, in 2012, there's 3.5% of people in the US identify as LGBT. And now it's up to 7 to 8%. So the number has been increasing. And more so, if you look at the generation, the generation Z, who are the people born in 97 to 2003, there are up to 20% of the generation Z identify as LGBTQ, which has significant increase from the previous generation, such as millennials, which has 10% or baby boomers, which only 2.6%. So this is going to be a trend that we'll see more and more people, especially younger generation identify as LGBTQ plus. So, and now this is a prime month that we all know that there's a lot of parties and events going on. And, but we need to remind ourselves that pride is start as a riot in the Stonewall Hotel in New York City, which is leading to a lot of protests and consider the beginning of the LGBTQ civil right movements. And for, and even in the United States that the same sex marriage was not legalized national wide until as less than 10 years ago. So a lot of our rights that seems intuitive for our non-LGBTQ population, that it's not, as a part of LGBT community, we don't get it as spontaneously. And then we, I think it's important to have allies and people that's not in the LGBTQ community give us a support to push all this changes. So what can we do, or what can you do in your daily life to support your LGBTQ patients and colleague? This is some recommendation from the HRC. When you, and you can, this, I like the small tips that you can, really do in daily life. For example, when you socializing with non-LGBTQ friends and family, you can talk openly about your LGBTQ plus friends and family and the issues they face. You can occasionally mention a new items about LGBTQ plus issues in a possible way and mention other LGBTQ plus friends or family you might have in an open conversation. When you socializing with LGBTQ friends or families, you should include the partners of your LGBTQ friends in events and activities, just as you or any other friends, spouse or significant other. I'll encourage everyone to attend prize celebrations and other LGBTQ plus community events. And you can also suggest a get together to watch a movie or show with LGBTQ plus topics or characters. How about at work? I'm going to divide this to different levels. From our individual levels, I think it's important to know the terms and definitions of LGBTQ plus population, such as the one that the first part of a presentation by Dr. Strauss today. And as a hepatology provider, I think all of us should understand the gender affirming hormone therapy and the potential impact. And the most importantly, understand the benefit of it as well. I think it's important to use language as Dr. Strauss mentioned earlier, as to pronounce and names, add pronounce to your signature and ask questions without assumption or judgments in clinic and our daily life. We also should aware of the biases. There are implicit bias and explicit biases. So implicit biases are the one that's also called unconscious bias. It's something that sometimes we heard during our, you know, when we growing up. So, but it's really important, I think, to understand what are those and what's the impact for our decision-making. How does that change we treat or see our patients or our colleagues? So there's some conscious sensitivity and implicit bias training tests or modules that you can do. Here are some resources that from different organizations about how to deliver better care. And there are from WPATH or Glamour. There's some from AFP, American Academy of Family Physicians or Enterprise Societies. So there's, and this is a list that if you're interested, there's more resources out there. From an institutional level, I also think it's important to talk, to have several, several stuff I want to talk today. From an environmental standpoint, I think it's, it will, for a lot of us in the LGBTQ community, when we go to a new environment, we scan the environment and find, is there any signs that tell me this is a friendly and safe place? So I think it's important to have welcome signs in gender-neutral bathrooms. Well, and Dr. Lasky talked about the, how to collect SOGI data. I think it's important that we have intake forms or other providers from that should be trained how to put that in our system. For the educations, I think every institution should provide or even mandate culturally sensitive training to understand the needs for LGBTQ patients. I also think it's important to have a diverse team for staff, employees, and it's important to have a multidisciplinary approach. You know, most of us work in the liberal world, but I think it's important to work with your patient's primary care provider, endocrinologist and other specialty taking care of the patient as well. Lastly, I think all institutions should be partner, collaborate with the local LGBTQ communities and other organization to understand the need locally and to better serve this population. Lastly, I'm going to talk about systemic level. A lot of challenging we are now in the LGBTQ health disparity is the SOGI data was not really well collected. I think that's important that we need to think about from a systemic level, how are we going to overcome this barriers. And I also think it's important to encourage LGBTQ research and project or initiatives as well. Lastly, I do want to mention that, you know, a lot of us in our community, we have, we've been, there's a lot of discrimination, discriminatization, not just in the healthcare setting. There's also, we also face a lot of those in our daily life. For example, this is a graph from the ACLU. They're checking, there's actually 491 anti-LGBTQ bills in the US, which is pretty sad to look at this, to, you know, to see. And then as you can see, a lot of the states that the more purple state, meaning they have more anti-LGBTQ bills, they're in certain part of country, such as the South part of the country. So, you know, as a person that live and work in Texas now, you know, I did get, you know, a lot of times I did get this, people will ask, how are you doing? You know, because people are aware of the concern of living in a certain area of our country. For example, this is a study done by Trevor Project. So actually one third of LGBTQ youth live in the South of the United States. And their study did show that those people, that's LGBTQ youth live in the South, have less access to affirming space. And actually the same study also showed LGBTQ youth will last slightly to attempt suicide when they report failing affirm in their sexual orientation and gender identity. So again, even, you know, there's a lot to be done, especially in certain part of our country. And I'm going to provide you, if you are happen to live in the area, I think it's even more important for you to show your support. So a couple of things, I'm going to show you some tips here, such as some of them I mentioned earlier, adding pronouns on your email signature, wearing rainbows or pronoun badges, register yourself on the LGBTQ health directly. There's one from Glamour that will recommend everyone register using correct languages in your daily conversation, integrating inclusive language into your regular conversation and professional interactions. And if you're hearing any anti-LGBTQ comments and joke, you speak up and explain why such common jokes are harmful and offensive. Please also help spread the message in support of LGBTQ issues on social media and get to know involved with the pro-LGBTQ groups locally. I think those are really good tips. I want to share some personal story as well. Like the feedback I got from our patients in the past three years that moved down to Texas, you know, I have a patient tell me, oh, I'm really glad that I found you who can really understand my situation. And I have a transgender patient. His mother told me that, oh, my son only want to see you because you're the only one that he felt like he understand his situation. Also have colleague that come to, a senior colleague come to me and say, oh, why are you putting pronouns in the signature of your email? What does that mean? And turn out after I explained to her why about importance pronoun, she become such a strong ally and she's helping me now setting a better, more friendly environment for our patients in our clinic. And lastly, one of my, the other of my senior partner that come to me and he want to share story with me, he told me, oh, one of my patient told me she was having a hard time giving her husband who she had married for 30 years, just came out to her as gay and asked for a divorce. And my patient is now in deep depression and it really had a hard time with it. I was a little bit nervous initially. I didn't know which this conversation will go. And then he just opened that up to say, oh, and then what I told the patient is, I told her it must be very difficult for your ex-husband too. So, you know, like, I think even you were at a certain part of country, if you keep doing the right thing, I think you will eventually change the microenvironment and hopefully we'll change the bigger environment one day. And thank you. That's a part of our talk. Just to remind everyone, we have a prior reception going on this year and a little different meeting as well. We'll have a couple of talks around LGBTQ issue as well. And I will encourage everyone to join us. Lastly, I would like to invite Martha, who's a nurse practitioner at UNC to share a little bit about her life story about supporting a son through the process of transition and live in the state of North Carolina. Martha. Thank you so much, Dr. Lee. My name's Martha Sheher. I'm in North Carolina. My son, Dylan, came out to my husband and I as transgender when he was 15. At the time, we've lived in the same house, in the same community ever since he's been born. And we had to go around and let our neighbors know, let his teachers know, let all his doctors, healthcare providers, dentists know that he was now Dylan. All these people had known him as Kate, as she, her. And every time we would call someone, when I had to make his first dentist appointment after he transitioned socially, before he legally changed his name, I had to call and let the receptionist know, hey, Catherine is now Dylan, he, him. And every time you have to do that, there's this anxiety and fear that you're going to get rejected, that someone's going to try and shame you, that someone will tell you that this is wrong. And so when people ask me, well, why is it so important to ask about pronouns? I'm not going to be referring to this person when I'm talking to them in the third person, I'm going to call them their name. Or why do we need these signs of welcome and support, these visible signs? Like, I don't want to bring politics into it. And it's, for me, it's just so important to have a visible sign that this is a safe place for my son, that this is a supportive place for my son. And it's so good for him too. And just a real quick story. The first time I got Dylan's prescription for testosterone filled, this was before he legally changed his name. And I remember the pharmacist, when I went to go get it filled, I was very, very nervous being in North Carolina, never quite sure what you're going to encounter. And the pharmacist pulled me aside and just said, I see the name Catherine, is that your child's preferred name? And I said, no, it's Dylan. And then he asked, well, what are his preferred pronouns? And I explained that. And he went through the process of changing the name on the label and said, Dylan should not have to see his dead name on the label for this prescription. And referred to him as he, him, put a note in his chart. And ever since, whenever we go to that pharmacist to get prescriptions filled, it's under Dylan's name. This was so meaningful, and it was so meaningful to my son. And really and truly just very simple things like asking about pronouns, having visible signs that you are going to be a supportive environment can be so incredibly meaningful and really, really appreciated. So, you know, please keep supporting just the fact that you're here shows that you're supportive and please keep supporting as much as you can. And it's so appreciated. Thank you, Martha, so much for that really wonderful tribute to your son, Dylan, and being such an amazing advocate, ally, and voice for him and the entire community. We actually do not have any Q&As, but I think I wanted to, on behalf of everyone, just share what a wonderful group of speakers we had who probably answered most of the questions we needed to answer anyways. And with that, I really want to thank the organizers. Me and Elizabeth are just really overwhelmed and joyed that we had this opportunity to co-lead this session with them. And with that, we wish you a happy Pride and a good rest of your month. Please be well.

LGBTQ patients

clinicians

good communication

terminology

correct language

SOGI data

cultural competence

allies

inclusive environment

supporting LGBTQ individuals