get started. Well, I was going to say in a couple of minutes, but yeah, yeah, let me see how many people are usually like, all right, well, I'm going to start with the introduction. Welcome to back to the McLean ethics lecture series, gender equity and ethics. I'm just going to remind you where we are in our seminar series. We are nearing the end of the winter quarter. This week, of course, I'll be introducing Dr. Sonali Paul. And next week we are ending the winter quarter with Yana Gallin, who's in the Harris School of Public Policy. We did have to cancel last week because of a conflict, but we will try to reschedule Dr. Kim somewhere else. And then we're going to start take a little break and then start back in March on March 22 with our spring quarter, and then we'll finish out in May. So, but today I'm really excited to introduce Dr. Sonali Paul. She's an assistant professor of medicine and a transplant hepatologist at the University of Chicago Medicine. She also serves an associate program director for the internal medicine residency specifically for diversity, equity and inclusion, vitality, climate and community engagement. Dr. Paul received her medical degree from Tufts Medical School and completed her internal medicine residency and transplant hepatology fellowship at Mass General Hospital. Her clinical niche is within non-alcoholic fatty liver disease from an obesity medicine perspective. Dr. Paul is also passionate about health equity specifically for sexual and gender minorities. She is a founder and executive council member for Rainbows and Gastro, a collaborative group for gastroenterologists and hepatologists rooted in the mission of charm, community, healing, advocacy, research and mentorship. Her mission is to educate the medical community on how to provide inclusive and safe spaces for LGBTQ identifying trainees, patients and colleagues. And as an educator, I have really benefited from her expertise and I'm excited to welcome her today. So welcome Dr. Paul. Thanks so much Dr. Euler and for having me and the invitation. So I'm super excited to be talking about, oops, sorry. My passion really so it's my talk is called overcoming the challenges and mitigating the disparities in our LGBTQI plus patients and I'll talk about it a little bit from an equity gender ethics perspective. These are my disclosures but not relevant to today's talk. So in terms of objectives, I'll talk a little bit about my journey towards LGBTQI plus health equity. I started at USC about seven years ago and even before then never did I think this would be kind of my life's work. So things definitely change in career paths. We'll talk a little bit about history language and current affairs about the LGBT community. We'll talk about disparities and as a transplant hepatologist I did do GI as well so we'll talk about digestive diseases and transplant. And then steps as to how to move beyond the binary and create inclusive spaces not only for our trainees, but for our patients. So just a little bit about myself so I'm actually from New York. I was born on Long Island I was actually born in Brooklyn we moved to Long Island that's actually our house it's amazing what you can find on Google Maps it's kind of scary. Okay, thank you. I thought I was taller than I was. This is a picture of actually from my white coat ceremony a long time ago. Those are my parents my dad is a retired primary care doctor, my mom is a nurse. My brother is actually 10 years older and a cardiothoracic surgeon. I live in a house that very much had a South Asian immigrant mentality. My parents came with $26 in their pocket to the US in the 1970s and kind of built their lives from that. And so my mentality was all about hard work and education. But there were kind of, you know, normative gender roles, even though my parents wanted it were expecting me to be a professional specifically in medicine, it enforced me but they wanted to be very highly encouraged.  And it was very heteronormative there was never any question that I would marry a man, and not a woman. And so being gay was not a thing, kind of growing up. So then I moved to Boston and stayed there for a significant portion of my time there, 16 years so I went to college at Tufts and then med school at Tufts as well. And college was actually the first time I'd come out, probably to like five people in my junior year. But it was the first time I actually felt like it was an inclusive space and a safe space to do so where I wouldn't be judged or medical school I promptly went back into the closet, because I didn't know I didn't know what the, and even though I was in Boston. At the time I just didn't know there weren't many out LGBTQ faculty, certainly not any of my residency classmates were out and so I didn't know what the climate was going to be like, I was probably out to maybe one or two people and that was it. Residency was much of the same towards the end of residency, maybe a few more people knew that I was gay. And then in GI fellowship actually, my program director who was actually one of my best friends now outed me to the entire section. And so, looking back that was not a good thing I mean then it was like not a good thing but you know we talked about it kind of an extensively and I think I taught her never to do that again but also I mean I got her perspective of like you know I don't understand why this is such a big deal because for her it was such a non big deal that she didn't realize why was such a big deal for me because it is so because the environment was so accepting. I get where she's coming from but again never, I would never encourage doing that. But that actually did help me kind of own my identity and be able to be out more openly. Two amazing things happened during my time in Boston. I found my wife Kathy got married, then we had our son, Raj in 2014 he's actually eight years old now and pretty much as tall as I, which isn't hard I realize. And then I finished up my transplant hospitality fellowship at Mass General and here I was out pretty much throughout and and really had no qualms about being out with my life. On the interview trail I was very deliberate in bringing up my wife and my son, as I talked about the job and the community that I'd be in. Not every place was very. I didn't get warm fuzzy feelings everywhere, but you see I did. And it was one of the main reason not one of the main reasons but one of the reasons I wanted to come here, because not only is my section but the department of medicine and I think the whole institution just very welcoming and I feel very comfortable being an out physician here. And I bring up these experiences and so this is a picture of me and my wife and my son with our mayor, current mayor I guess, Lori life foot. And I bring this up, because I've interfaced with healthcare, and so many facets right as a med student as a trainee. Now as an attending physician, but also as a patient wife and mom and a much kind of more personal level. And I think when you go through the grind of training or at least for me when I went through the grind of training, you know I'd see doctors and I would be a doctor, you know, interact with doctors. And I never fully realized the disparities that were in front of me, because I probably didn't stop to look. And it only became when I became a mom that I realized how much the heteronormity of medicine was affecting our lives and it was going to affect my son's life in particular.   And so very kind of not great not great interactions. And so really, this was kind of what made me want to look more into what we can do as a community to make our to make medicine more inclusive for everybody. So with that, I'm going to talk about history, language, and current affairs. So just to orient everyone so that we're all kind of on the same page when we talk about definitions. So sexual orientation is a person's emotional and or physical attraction to people of the same gender, different gender or both. One can be lesbian or gay, bisexual, straight, bisexual or something else. What's really important though in terms of terminology, sexual preference and homosexuality are really outdated terms and should not be used anymore. And then just kind of the alphabet so LGBTQI plus so a lesbian woman who's attracted to other women.  Transgender is an umbrella term for people whose gender identity and or expression is different from the cultural expectations based on the sex they were assigned at birth. But what's really important here is that it doesn't specify a specific sexual orientation and transgender people can be and can identify a straight gay lesbian or bisexual. We are used to be used as a slur, but it has really been reclaimed by members of the community much more like the younger community. And it's used to express the spectrum of identities and orientations including non binary folks, and those were gender expansive identities. Intersex folks are born with different people that are born with differences in their biological sex traits including hormones, chromosomes, and anatomy. And plus again is a to identify other sexual identities not listed, but not including but not limited to a sexual non binary gender fluid and pansexual, in addition to many others. And then just gender identity so there's kind of two facets of gender identity there's sex assigned at birth or kind of what the medical community labels you, and then gender identity which is more of a social construct and how you identify gender identity is a gender identity that you can use to see yourself. There's gender expression. How you want to display your gender and then gender attribution or how others are perceived, how your gender is perceived by others. Other terms that we talked about so cis gender is one one sex assigned at birth corresponds to their gender identity and expression. And as we talked about transgender being an umbrella term where once gender identity doesn't match their assigned birth gender. It's a gender identity email, but again is another umbrella term for different identities outside of the gender binary. So just want to kind of bring up kind of trends that we have noticed across the years about the number of people that identify as lesbian gay or bisexual in the United States. So you can look here in 2012 there's about 3.5% of the population. And then you can see in 2021 and went up to 7.1% that identified as LGBT. I don't necessarily think there are all of a sudden more like a doubling of gay people I think it just has become more culturally accepted and safer to come out and identify as LGBT. If you look at the breakdown, greater than 50% identifies bisexual, about 20% identifies gay and 14% is lesbian. But what's really interesting when we look at it through generations of us adults, you can look at Generation X here in the red. Between 1965 and 1980, about 4.2% identifies LGBT. We go up to the millennials 1981 to 1996, about 10.5%, but then Generation Z it's doubled. So those born between 1997 and 2003, about 21% identify as LGBT. So this is huge not only for a patient populations that we're going to be seeing as adults and obviously in our pediatric populations, but also for our colleagues I mean they're going to be more and more trainees coming through the pipeline, as a residency they're going to identify as LGBT and so really the onus is on us to make this space much more inclusive than it is. So just thinking about kind of discrimination and medicine, I think this is kind of set the tone for a lot of the mistrust that the community has against medicine. You know, back in the day, there were theory that medicine actually claimed this right that homosexuality could be cured, that it was seen as a deviation as a physical problem there was conversion that were touted for a little bit. And so this really set the tone for kind of the deep mistrust that a lot of members of the community have for medicine and provide and seeking health care. So Joanne Mayerowitz is actually an American historian he actually got her bachelor's degree at University of Chicago. She writes in one of her books so in traditional medical histories doctors often stand as pioneers in science. In the history of sexual and gender minorities doctors with few exceptions lag behind reluctant pioneers at best pushed and pulled by patients who came to them determined to change their bodies and their lives. And I really like this quote because it really is I mean if I think about kind of my life and I mean I'm a physician right I knew I was gay since I was seven and came out as a physician and still didn't really, even though it affected me didn't really realize it until much later on. And so that's just kind of one example of how kind of deep rooted these things are. So, I just want to go through kind of the history because really to improve health care, I really do think we need to recognize lived experiences and not just of the LGBT community really everyone's lived experience. But I'm going to talk a little bit about lived experiences of the LGBT community and kind of go through the timeline. In 1952 the DSM actually considered homosexuality and mental disorder. And again this kind of set the stage for a lot of mistrust and not wanting to seek care. It was thankfully I mean it took 21 years but it was repealed in 1973. And a lot of folks actually think that Dr johnny fryer was responsible for repealing it. And he is actually is actually a psychiatrist.  And I think people think that that was why a year later the, the everything was changed and no longer was homosexuality considered mental disorder. Kind of shifting to government in the 1950s there was something called the lavender scare this was in the era of McCarthyism. And this was when when, if you were a government official and identified openly as LGBT, you were actually fired because you were considered a spy and you work for the communists. And a lot of government officials around that time either went back in the closet. Not many were out but if there was any question of whether they identified within the community they were fired. 1969 is when the Stonewall riots happened. So Stonewall is a bar that's still there in Greenwich Village in the 60s, police could actually go in and raid bars and reverse patrons. And just one night in June, the patrons stood back and rather fought back in the community fought back, and that really started the rights movement that LGBTQ rights movement that we kind of know now. Going back to medicine so in 1983 the FDA kind of in the height of the AIDS epidemic had a blood band so men who had sex with men were no longer allowed to donate blood. And this was revised a few times, once in 2015 and most recently during COVID in 2020. Now there's actually a requirement for three months of celibacy which I mean is kind of, and people could lie people cannot but think most a lot of men who have sex with men consider this kind of a lifetime ban, regardless. In 1993 don't ask don't tell happened, which was a government ordinance that said if you were going to serve openly if you wanted to serve in the military and you identified as LGBTQ, you cannot serve openly. This was repealed in 2011. It took a little bit longer for a transgender service people to get the same rights and in 2021 they were able to serve openly as transgender. In the 90s, again, 1996, the Defense of Marriage Act pass. This was kind of writing into law on a federal level that marriage was defined by one, but was for one woman and one man so basically outlying same sex marriage on a federal level. But there were many states that allow takes are had past same sex marriage. I was in Massachusetts at the time where we were one of the first states. And I still remember going with my college professors and the deans who, you know, had waited for this and they were getting married on the court steps on the courthouse steps. And I still remember that being a very powerful kind of image. In 2015, the Supreme Court made same sex marriage legal. This was a huge day. I still remember where I was. I was with my parents and family. And I remember feeling really proud and I actually have this picture hanging up in our living room because it was such a momentous day for the community. And that eventually became codified into law just in December of last year. 2016 pulse happened. This was a pretty monumental event. So Paul says a predominantly gay nightclub in Orlando, Florida, and a gunman went in one night. It was during pride month and killed over 50 people injured countless others. And it was considered a hate crime. And kind of adding insult to injury. Gay men tried to donate blood to help their community and they returned away because of the blood ban. In 2015 to January 2021, there was just a lot of anti LGBTQ rhetoric and a lot of anti LGBTQ legislation, specifically targeting the trans population. And I have friends who are trans in other states that are not as friendly and I remember them thinking of moving to more friendly states or just moving out of the country completely. In January 2021, there was an executive order that was signed looking to prevent so G so sexual orientation and gender identity discrimination from all facets so housing, employment, health care. And that was thought to be a big win for the community. Similarly, March 2021 so Rachel Levine was actually the first transgender woman confirmed by this Senate. She's assistant health secretary and she's actually used her platform I follow on Twitter. She's used her platform as an amazing thing to really represent the trans community in healthcare and I think that's just been a really great thing to see, especially now. And just looking at 2023 just in the last two months. The ACLU has actually tracking. So the American Civil Liberties Union is tracking the number of anti LGBT bills that are being proposed in the US mainly on a state level. And right now there's around 336 about a third of those are related to health care specifically for trans youth getting gender and care, which we'll talk about. So, even though we've had a lot of success there's a lot of work to be done. Just kind of shifting to medical education. When we think about LGBTQ content. This was one of kind of the landmark surveys I don't, I don't, I haven't seen anything that's come out for at least undergraduate medical education that's updated this, but they surveyed 132 medical schools. And what they found was about five hours taught for LGBTQ content. Nine schools actually had zero hours taught during the pre clinical years and 44 schools had zero hours taught during the clinical years, and only 11 out of the 132 had everything that was supposed to be taught in the topics.  And so really, when we think about this it really puts the burden, not just on the health care system but on magic medical educators like we have to start right at undergraduate medical education I think things are changing slowly. But in order to do this and this is how we're going to be able to reduce and eliminate or help reduce and eliminate health disparities. So at graduate medical education level. There are very few studies that look at LGBT content, just specifically for residency programs. There is a meta analysis that looked at this and they only found about seven specialties. If you look at some of them, I think this is important across all specialties but specifically specifically if you look at endocrinology or OBGYN. So, you can 60% of fellows actually reported only 60% reported transgender related education and their training. And these are folks that are dealing with gender forming hormone therapies. And so that's certainly alarming, not to mention just a huge gap where we need to go. And even more alarming probably is that some program directors actually did not want to include LGBT education they wouldn't do it, unless they're mandated by the ACG me. Which the ACG miss come out, not so much as a mandate but someone. So not surprisingly there are fears and concerns about healthcare. This was a survey that went out to folks that identifies LGBT and folks living with HIV. Just looking at their healthcare experiences and their fears and concerns across the board across all communities but he specifically look at the transgender community. They thought they would be refused medical service because they were trans 73% thought that they would be treated differently because they're trans. And 90% thought there weren't enough health professionals that are adequately trained to take care of them which is probably true. I mean, but again, I think things are changing but very slowly. And it's just going back to discrimination and legislation which we kind of touched on. So this actually is the bigger map so if you go to the website you can actually see state by state. What's what's been happening. Just looking at schools and again this is how much it affects every facet of society so in March of 2022 don't say gay was passed in Florida.  And it's unclear kind of now teachers don't entirely know what to do, there's a lot of confusion because if they're gay, do they not disclose that they're gay do not talk about their own personal lives if a family if a student has gay parents, is that student not supposed to talk about their gay parents so there's a lot of confusion that this is created. And even probably even worse schools actually have to disclose so g information to the parents so if a student is has different sexual orientation or gender identity. They have to tell the parents as long as it's not going to result in abuse and abandonment or neglect. I don't entirely know how you assess that as a teacher, but some of the quotes that have been supported that are supporting this law so, and these are coming from kind of state officials and senators. So there's a concern there's a big uptick in the number of children who are coming out as gay. So that's one of the reasons why we need this law and restricting discussions are justified because LGBT is not a permanent thing. So a lot of just kind of rhetoric that's that's in deeply deeply entrenched. There's a lot of confusion as I mentioned and there's laws right now that can actually revoke the license of any teacher who violates the law. And not only is this in Florida but there are 14 other states that are looking into passing similar legislation. So, folks can also just thinking about the dying healthcare on moral grounds. So Ohio is one of the states that can do this this was back in 2021, South Carolina just passed it last year. And the law says that health care providers to decline to serve if they feel like doing so would violate the religious beliefs. Although it's interesting because none of the laws specifically say LGBTQ people, but a lot of folks think that this is going to report disproportionately affect LGBTQ populations specifically trans populations. And the law in in South Carolina is called the Medical Ethics and Diversity Act. And the proponents say this is America where you should have the freedom to say no to something you don't believe in. And so I remember when this came out there was a huge I mean it was very very upsetting not only for the population but also physicians that identifies LGBTQ and physicians in general that support the community. So just looking at the number of anti transgender legislation that has gone through state legislators so in 2018 to 2020, there was about 19 bills got up to 60 bills in 2020. 2021 had 131 and last year there are 155 and there's probably even more that that are going to come out this year. And usually bills that deny sports teams that align with one's gender identity and limit the ability of youth to access gender affirming care. So, many of you may remember last year Texas was one of the first states that actually banned surgeries and hormone treatments for minors. I have to say not a lot of minors are getting these surgeries or hormone treatments but they banned them. There are newer laws that they're trying to get passed that actually make it child abuse to even give gender affirming treatment to trans youth, it's and they're trying to make it a second degree felony. And they're mandatory reporting requirements for not only healthcare professionals but teachers and the general public. 21 other states actually have similar bills that are brought that they're being brought forth at a state level. In Indiana our neighbors, six days ago, this actually this law actually passed into the house and it's going up to the Senate. So, in addition to don't say gay. It's going to actually force teachers to out transgender students at the school level. So, I, I mean, I don't know why that's necessary but the amount of bullying and the amounts of kind of psychiatric illness that's going to come from this for our trans youth is just unconscionable. And it's a shame because we know that gender affirming care is life saving so if you look at youth that have gotten access to gender affirming hormone therapy, there's decreased rates of depression thoughts of suicide and attempted suicide. And now pediatricians who kind of serve these trans youth are facing harassment they're getting death threats. This has happened at Lori's Children's it's also happened at Boston Children's and across clinics across the country. And what's really interesting because like I'm a transplant hepatologist right like I don't prescribe hormones for gender affirming hormone therapy. I don't do surgeries, but affirming care is so much more than hormones and surgery. We can all provide affirming care it's affirming the person for who they are recognizing their name recognizing their pronouns recognizing the way they dress and just kind of being with them as the person that they want to be. And that is all really gender affirming care is yes it is also hormones and surgery, but at a lot of these states at a state level, even this is not allowed to be just be able to affirm the person that's standing in front of you. So again, there's a lot of work to be done. So I talked a little bit about, I talked a lot about rather LGBTQ equity kind of in the whole society. There's also kind of a different lens when we look at equity within the LGBTQ plus community and so when we look at within. And there's not a ton of research within this realm there's a lot of sociologists that are looking into this. There are lots of theories kind of floating around so some actually some folks believe that lesbians are more accepted in society than gay men. gay men are more likely to be targets of violence one study actually found 40% of violent encounters with gay men and only 13% with not only but 13% of lesbians. There's also this kind of thought that maybe society is more comfortable with lesbians parenting children. For many of you that have seen the show modern family.  Are we laughing because it's funny or are we laughing because they're so inept at kind of parenting and so a lot of the jokes, and I never really thought about a lot of the jokes are kind of the dad's aptitude of parenting. And so it's just kind of something to interesting to think about that I never really thought about. But this is something that definitely has come out so there's a lot more high profile lesbian athletes that have come out much more often so ones that come to mind Megan Rapinoe and US women soccer, and then Brittany Griner and basketball was actually the number one draft pick they both came out at pivotal moments in their in their careers. But in 2021. It's been a long but Carl NASA was the first active NFL player to come out as a gay man, and the NFL for better or for worse they actually were incredibly supportive of this as were his teammates at the teammates across. And so the NFL tweeted, you can be that person who saves a life. And so I think this is so so important. And the more folks I think that do come out is, you know, more helpful for the lonely folks and states that are trying are And within the community, as much as we as a community are trying to get equity. There's a lot of invite, but not a lot there is some inviting that happens within the community as well. Specifically against trans, the trans population and then also bisexuals, which can be kind of another lecture onto itself. Okay, so a little bit about kind of the history so I'm going to switch to kind of talking about disparities disparities specifically and digestive diseases and transplant. So just kind of defining health disparities so actually in 2016, the National Institute on Minority Health designated the LGBTQ community as a health disparity population. So health disparities are really differences in health health outcomes and access to care. Health inequities are a bit different though these are when differences are a result of systems of oppression and structural factors that disproportionately affect and harm certain groups. And so when we think about health disparities we really have to talk about social, we have to frame that into social determinants of health. So social determinants of health are kind of six domains we think about economic stability, neighborhood and physical environment, education access to food, community and social contact and of course healthcare. And all of these interplay and affect our health outcomes for any given patient population and kind of compounding that we have to think about intersectionality the LGBTQ population is such a heterogeneous group there are many and intersecting social identities, not only not only my gay and also a woman and also South Asian. And so all of these kind of come together also to contribute to oppression and discrimination, and then all of that kind of compounds health disparities as well. And so when we think about how are these health disparities created the minority stress theory comes up a lot as a framework of thinking about this. In this theory, there's life and environmental circumstances that kind of happened for everybody there are general stressors, but when you're part of a descent disadvantage status of a minority so in this case sexual orientation gender identity but can be across to the gamut of any kind of disadvantage status. There's a minority identity that emerges and there's proximal minority stress that kind of is the internal process of like concealment constantly having to come out not knowing what it's okay to be yourself expectations of rejection if you do come out and then also internalized homophobia there's a lot of internalized homophobia that can happen specifically when you're first starting to come out, and even after. And then there's more distal stress processes that include prejudice events, the social context that we just kind of reviewed, and then interpersonal stigma that can happen as well. And all of these, in addition to coping and social supports, which we know are decreased in the sexual and gender minority communities can affect health outcomes whether they be positive or negative. So, when we think about that, just identifying health disparities in this population is incredibly difficult for lots of reasons so there's a consistent lack of data collection on sexual orientation and gender identity. So, a lot of the large public records to identify community members just doesn't exist. I think things are changing now but at least back you know 10 years ago you couldn't find that traditional research methods and study designs study designs may not be applicable. It's somewhat hard to do randomized control trials and think about data like that. A lot of this work is qualitative work which in at least in GI and hepatology is incredibly difficult to get published in our kind of mainstream journal so if you are doing this work, a qualitative work goes into either sociology journals or more journals related to LGBTQ health specifically. It's very difficult also to recruit LGBTQ patients there's fear and stigma, discriminate fear of discrimination also stigma, and then still in some parts of the world it's a crime and depending on where you live in the US there can be societal fears. And a lot of the fluid of the terminology is very fluid and changing and so it's very difficult to operationalize the terms I used in the beginning, maybe obsolete in one to two years from now. The studies that we do have are incredibly small and non representative. And there's just a lack of grants and research awards specifically for LGBTQ health and when I talk about this I specifically think about kind of in digestive diseases, which is my home. I'm thinking about LGBTQ health disparities so the top ones that we think about so violence is huge. There's a lot of trauma, both physical emotional and sexual transgender populations actually have the highest rates especially especially trans folks of color. There's a lot of substance abuse tobacco and alcohol and again because of minority stresses. And there's increased alcohol rates of two to three times more than heterosexuals mental health concerns are very big so depression anxiety suicidal ideation. Anxiety is more common and lesbian and bisexual women, eating disorders like anorexia are much more common and gay and bisexual men. There's increased rates of breast and cervical cancers, partly because of increased substance use but also partly because of decreased cancer screenings. There's increased rates of heart disease with increased smoking obesity insulin resistance, and then STI so sexually transmitted infections, like HIV, Chlamydia, syphilis and gonorrhea.  So just looking at the digestive disease lens and LGBTQ population so when we think about increased rates of alcohol and smoking from from my standpoint, you know, does that mean that there are increased rates of colon cancer or their increased rates of cirrhosis in the population. Again, and everything on the slide is not studied. Increased rates of trauma so for me, when I talk about this for a GI audience I talk a lot about the physical exam and how important it is getting that history when you're doing a colonoscopy and just for general patient provider relationships. Increased rates of obesity and lesbians and bisexual women does that mean there are increased rates of non alcoholic fatty liver disease again no one's really studied this. And just knowing how important a sexual history is because a lot of sexually transmitted GI diseases or syndromes can be very, very similar in symptom apology as inflammatory bowel disease so if you have practice from gonorrhea it can look a lot like ulcerative colitis practice but if you don't get that history you can give them a salamine all you want but that gonorrhea it's not going to get fixed. There are increased rates of depression and stress that we know so does that mean that there's an increased risk of disordered gut brain interaction diseases things that we think about typically as functional dyspepsia or irritable bowel syndrome. When we think about our transgender and gender diverse populations, these populations have very much unique needs. We have no idea, and this isn't just in digestive diseases but just thinking about gender affirming hormone therapies and surgical therapies are so many unknowns. They affect natural disease courses, I think about the big ones and GI is IBD and cirrhosis, but also the liver is exquisitely sensitive to hormones so does how does that affect fatty liver disease and the incidence of paddock adenomas. And then we know that a lot of the hormones can increase the risk of thromboembolism so how does that affect our patient population. And then we'll talk about considerations and organ transplant as well. I'm going to wrap this up because I never really thought about this until I started doing some of this work and I certainly didn't learn about it in GI fellowship. So, in transgender and gender non binary patients, if folks get surgical therapies they can get a neovagina and how they do that is they take intestinal segments from the small or large bowel, they actually create a neovagina. And then there are post operative complications that not only GI physicians should be aware about, but surgeons need to be aware about things like small bowel obstruction peritonitis, fish lids that conforms to no system prolapse. And so if you don't know that the patient has had this procedure if you haven't asked, and you don't know the complications that can arise it can, I mean, it could be kind of your, you'd be treating the wrong thing. And then also the question arises of kind of the incidence of colorectal cancer screening in these segments and how often we should be screening. And again there's no data to kind of guide any of this. There are case reports though of adenocarcinoma. This is not they're not they're not in trans patients but this is a case of a 76 year old who had congenital vaginal, a vaginal, sorry congenital vaginal a genesis. And she came in with vaginal bleeding and had a vaginal endoscopy but they knew about that history and she actually ended up having cancer and got it treated but again, if you don't know that history you would think maybe GI doesn't have to be involved because it's a GYN problem. Kind of switching a little bit to organ and tissue donation so we talk a lot about when we consent to our patients. We talk a lot about the type of recipients that they can get their different types of recipients. And one of those recipient categories is recipients who are at high risk. They're kind of CDC high risk for infections and those infections are HIV hepatitis B and hepatitis C. All the recipients gets get nucleic acid testing right at the time of donation. So they're all negative but they have quote unquote engaged in behaviors that can potentially make them high risk, potentially they're in the window period where they don't get caught. And the DNA hasn't come up yet. And so men who have sex with men is actually considered to be a high risk or folks that men who have yet they're considered to be high risk donors. And while men who have sex with men can actually don't they can donate solid organs so livers kidneys hearts lungs. And in the designation of high risk, they actually can't donate tissue. So, vein graphs corneas things like that and corneas are huge. There's a huge push from the ophthalmology society to let to get rid of the span. But again, same thing with the FDA, you have to be 12 months celibate in order to donate tissue. And if you look at the data behind it like does it really, really make sense and so men who have sex with men are greater risk for HIV, but this is decreased dramatically and the advent of prep and 89% of men who have sex with men are actually HIV negative. And when the FDA actually looked at the data their own data in 2015, when they replaced the lifetime blood band to 12 months of celibacy, they actually found no increased risk to the blood supply. And subsequently the band was actually lifted in Canada and so the band here is still here and I think the FDA just wants more data so there are centers like Emory and I think there's another one. I can't remember where on they're actually looking, giving prospective data and hopefully will bring this to the FDA soon. But you know it doesn't make sense is it equitable is it ethical or does it just perpetuate systemic discrimination and prejudice. 16 year old AJ Bratz of Iowa in 2013 he actually committed suicide after homophobic billing bullying. And in his note, he actually wrote that his final wish to was to be an organ and tissue donor. He was able to be an organ donor designated as high risk, but he couldn't donate his corneas and so his mom says I couldn't understand why my 16 year old son's eyes can be donated just because he's gay. And so, some of you may know the melt score so it's the model for end stage liver disease. Basically, it is a reliable indicator of short term survival and patients with end stage liver disease, and allows basically to determine who the sickest patients are that can get allocated organs. The current version of our melt score looks at it's a melt sodium so it looks at the INR the serum failure have been creatinine and sodium, it can go anywhere between six to 46 is a healthy organ, healthy liver 40 is someone who's in our ICU. Incredibly ill if they don't get an organ within a week they're probably going to die. But there's been concerns that women actually in the system are being disadvantaged and mainly because of the creatinine so there's the serum creatinine. It's found to overestimate renal function in women so it can actually underestimate their risk of mortality. And so, some researchers on the West Coast at Stanford looked at this and they came up with something called the melt 3.0. And in addition to all of those factors they actually are advocating including female sex. And they in their models they actually found that this can actually address the existing sex disparity on the liver transplant list. I'm actually proud of the liver transplant community because a lot of editorials came out kind of subsequent to that to ask about what's going to happen to our transgender patients, because we really don't know the ones that have transitioned we don't know how those therapies affect renal function measurements and so we're just going to add more controversy more disparities and kind of more confusion to something that's already kind of wrought with disparities. And so that's just kind of something that's, I mean, I don't, it hasn't been opted yet as our new meld allocation system but if it does I know this is going to be coming up as an issue. There's actually only one kind of series of case reports that I found in kidney transplants, looking at transplant and transgender folks. There's a series coming out of U Penn. And basically there were four recipients that the recipients were transgender and then there were four donors that were transgender. And I think the article actually did a pretty good job of kind of sharing their experiences of what the issues that came up the anatomic considerations the hormone considerations and then also the psychiatric considerations that they have to go through for these patients. In terms of anatomy, I think, just from a kidney standpoint, like feminizing vaginoplasties and valloplasties can increase the risk for anatomic issues. They saw this in one of the donors they had urethral strictures recurrent UTIs and fish that formed. And then in terms of the folks that were on hormone therapy. You know there's a lot of right there's no guidelines for this really at all and so the question of what to do with kind of feminizing drug therapy so things like estrogen. There's a risk of venous thromboembolism, especially with PO formats and so the question is kind of, do you stop them do not stop them, and kind of the time duration and the perioperative period and beyond. Masculizing drug therapy testosterone and their study they actually didn't stop testosterone supplements. And the question is really, you know, discontinuing versus holding therapy and kind of when, when the guy when should we restart them. And we have no idea what the effects are going to be long term on graft and patient survival. And so the article I think again did a really nice job and I think I highlight the psychosocial because we know because of minority stress and the systems of oppression that the trans folks have increased rates of psychiatric disease and depression. And for transplants psychosocial is such a huge aspect of having someone be deemed as an appropriate transplant candidate. And so I think working really really closely and not just seeing their history of, you know, psychiatric illness and automatically saying that they're not a candidate, but really kind of delving down into into that much more thoroughly than I think we would for someone else is really important. It was a case that not at our institution but there was a high male patient that had cirrhosis. She was 35 transgender woman she was currently on estrogen she had been on it for the last few years as she was transitioning. She had new alcohol related cirrhosis had to compensated her meld was 30 basically meaning 50% survival in three months, or 50% mortality I guess the way you look at it. The transplant center said she was an appropriate candidate for liver transplant, but the requirement was that she stop her estrogen, and they really couldn't tell her when she could restart it. If she could restart it at all, and definitely not in the first year like they definitely said not in the first year you can't restart it maybe after that depending on how things go you could. Again, we have no guidelines to help us with this. And it really becomes really a matter of life and death and not only from a liver transplant perspective.  But also I mean if she gets the transplant and she can't be her true self and that's also a matter of life and death for a lot of these patients. And so again there's so much that needs to so much work that we need to do just in the little realm of transplant hepatology. There are also just thinking about urine transplants and so for those of you have seen Danish girl. This is actually based on a true story of Lily Elb. She was actually one of the first people that got a uterine transplant. Unfortunately she died of rejection infection three months later but this was in the 1930s in Germany. And we actually do transplant for absolute uterine factor infertility. So basically these are women with no uterus or a malfunctioning uterus and cisgender women. In the US and kind of globally we've had 100 transplants and cisgender women with 23 live births so relatively successful. But when you look at the criteria so the revised Montreal criteria for the ethical feasibility of urine transplant. The first thing that they say is that the recipient has to be a genetic female. And so you've already kind of considered you've already ruled out trans folks to be even considered in this model. Okay, I also like that super depressings we're going to talk about ways to move beyond the binary. There are really there are a lot of things that we can do that are very tangible things. So I think education is kind of one of the big things and we talked about this so amc has guidelines for under undergraduate medical education. So we're focusing on integration of LGBTQ health related topics so how do we do this through didactics case based learning clinical rotations, and then also patient exposure and experiences. I really thought this was interesting interesting so at Vanderbilt, there's a first year course that is called brain behavior and movement, they actually think and talk about the neurobiological basis of sexual orientation and gender identity right off the bat, kind of in like And then Pritzker I'm very proud to say has the health equity advocacy and anti racism. They're here curriculum course. And it spans kind of not just LGBTQ health but across all of health equities. It's a really great course. And so myself on a house and Scott cook actually talk about LGBT communities and the health and well being of those communities and in a three part lecture series. And then for graduate medical education there are requirements which I won't get into but there's a requirement kind of for diverse population requirement that's kind of vague. And I don't entirely know if it's as enforced. But at the end of the day we want our field to be inclusive and safe, especially with 20% of Gen Z coming up to the pipeline. A lot of these. A lot of that generation is going to come into healthcare. But there's a study that looked at in 2015 that 30% of medical students actually concealed their sexual orientation, because of fear and discrimination and 2015 wasn't that long ago is what eight years ago. And if you look at just medical students in general, comparing folks that students that identify as lesbian gain bisexual. They had much more increased rates of burnout disengagement and exhaustion compared to their heterosexual counterparts. So there's a lot of work to be done just kind of on a safety and inclusion standpoint just from a medical school standpoint. And there's been, you know, it's really hardest for trans hardest for transgender and non binary trainees transphobia and biases are very common I think medicine, not only are we very heteronormative we're very gender rigid and so there's, you know, male females so that the non binary is not really accepted as much. And this can lead to burnout sun professional development and really decreased representation in our field. And it becomes kind of how many sexual and gender minority physicians are there. We really don't know the amc just started collecting this data in 2017. And they found that maybe about 5.4% of current graduating medical students identified as sexual and gender minorities. This is likely an under representation given what we just talked about the fear and stigma of coming out. And really from a kind of a trainee and practicing physician point of view there's really no large scale data collection. So we don't know sexual and gender minorities in terms of how many there are and what specialty and where they're practicing. And we know that there's a need for underrepresented minority and female physicians that the question kind of in the LGBT communities, is that the same for LGBTQ plus physicians. And I don't advocate for guests, but I think it's, you know, there are unique challenges because it's really difficult to convey this identity rather than kind of race or gender. And there's a balance between respecting individual physician privacy and safety. First the need to develop the LGBTQ physician workforce. And so I think really there's there needs to be an increase in leadership, because representation matters and I've had conversations at least within the FBI with kind of two very prominent people that are in very high leadership positions that identify as gay or lesbian. And when we talked about them coming out, they said they couldn't. And they were very, very afraid that one of them was afraid of their NIH study sections, which I found so heartbreaking. And I get where they're coming from they're older than I am. And they have seen much. I mean, I think when they were growing up and coming through the ranks it was much, much different. I think I have had the privilege of kind of coming up behind them and having a lot more visibility. I mean, there's a lot more work to be done. But I think that's been kind of, I mean, if I had known that there were gay people in GI and hepatology, I would have been so much, I would have felt more proud to be a gay hepatologist and a gastroenterologist until I found other people that also were gay in the field. And so how do we do this so addressing implicit bias, and not just for LGBTQ populations so implicit bias so they're unconscious on acknowledged preferences that affects one's outlook or behavior. They're very much automatic or triggered without intention. And these are biases based on cultural stereotypes so it's really kind of what we don't think we we think and they're embedded from kind of a young age. So systematic review, looking at 42 studies, looking at implicit bias and healthcare professionals, none of them really looked at sexual orientation or gender identity, but they found that physicians manifest implicit bias like the general population I mean that's not a surprise we're definitely human, but our implicit biases impact our clinical decisions and so knowing what our implicit biases are, and kind of checking them at the door so to speak is so important when we take care of patients and just when we interview trainees and medical physicians. So how do we create these supportive spaces so again collecting sexual orientation and gender identity data across both clinical education realms, using gender neutral language so so important so saying patient instead of he she partner a spouse not husband or wife, you're getting a family history saying parent or guardian mother or father. And then, you know if you're pulling someone out from the waiting room, not saying like, or if you're, if you want to help someone, can I help you not saying can I help you man or sir.  This is changing annually. This is changing informal diversity equity and inclusion programs. And then really I think this is really really important so recognizing the LGBT community so seeing the room through their eyes. We know that LGBTQ folks and they walk into an unknown space they're scanning the room to see if there's anything that symbolizes that they might be in a safe space. I do this and I didn't realize I did it until I read kind of that that's what LGBT folks do. And so I look for the rainbows I look for the HRQ some HRC symbol that equals sign, or even if it's something as simple as just a sign that says all are welcome here I mean it's not necessarily gay related. But that's like, for me, empowering enough, displaying non discrimination policies including sexual orientation and gender identity, and then acknowledging events that are important to the community so when you see MC kind of puts out their newsletter newsletter about pride that's that's, you know, honoring the community and the members of the community that are at the hospital, and then also trans transgender day of remembrance which I don't think we do as good of a job as acknowledging. So epic, I mean we have our epic storyboards and now we can actually capture someone's gender identity, their legal name their preferred name, their pronouns, and their sex assigned at birth. And there's also, I mean, epic says organ inventory we've been trying, we've been trying to have them change it to anatomical inventory, think organ inventory just sounds odd. But having this and kind of knowing again, knowing what has happened to your patients is so important, especially in the situations that we talked about. So pronouns again a very simple thing that we can do so pronouns and email social zoom and social media. I mean it seems like such a small thing but it really goes beyond that beyond trans or non binary quality. I mean yes it absolutely represents that, but it really normalizes discussions around gender. There's no assumptions there's no misgendering. It demonstrates inclusivity and create safe spaces. The most common pronouns are listed here so they're she her hers and he him is, and then the more gender neutral ones, they them there and see the years. These are the most common there are many many others and many many other combinations. So pronoun badges department medicine got pronoun badges. And this actually happened because the pronoun badges at least from the medicine standpoint started with our graduate medical education so the trainees wanted these badges. They got them and then the some of the attending saw them and they wanted them and so again this is kind of how younger generations are educating older ones and so now there's opportunities to get pronoun badges. I think this is also really important, especially for the smaller specialties so Lauren West of her is a physician she's an emergency medicine physician at Bay State up in Maine. And she does a lot of research looking at this and so one of the things she says is to wait to post match trainees and new hires on social media, because they actually looked at this and they found that many trans folks actually use match as a natural point to transition. So if you post them with their kind of eros picture or pronouns, you might actually be outing them because they might be using that point to transition. And so not only have you added them but it's really really hard for folks to unlearn names and pronouns. And so it's, you know, the, the practice that we should be doing is actually when you can call to congratulate them or email them actually ask them, you know how they want to be if they if they want to be identified on social media and if they do how do they want to be addressed and what pictures should they use. So other steps just having inclusive benefits packages, different family structures and policies that cover gender affirming care. So having out trainees and faculty so having mentorship programs again there are very few openly LGBTQ identifying leaders in medicine and helping find community. Again, not all family systems were supportive and mine wasn't certainly when I was going through training my parents has owned me for five years so I have a lot of chosen family in Boston. And, you know, my residency has actually helped me and fellowship actually helped me kind of get through that really difficult time. And there's family building and unique needs in the community and again not one one size doesn't fit all so like this isn't going to apply to everyone obviously but for it might make a may apply to some and you can actually do a lot for that one person that it's going to apply to. And I think lastly just be an ally. And again such a simple thing but where pin. I can't even tell you how you have no idea how much it's going to help. It can help a trainee can help a medical student, it can help a patient. Just feel a little bit more comfortable in the space. And I'm going to just end with talking about cultural humility so we talk a lot about cultural competency and medicine, you know, knowing everything about every culture that's not going to be possible and not going to be, I'm not going to be able to do that. So I think more about cultural humility. So it's the ability to maintain an interpersonal stance that is other oriented or open to the other in relationship to aspects of cultural identity that are most important to the person. So this is again very different from cultural competency it really focuses focuses on self humility, and rather than just knowing everything. We're always going to make and we're not going to know everything we're going to make mistakes we all make mistakes I think just owning them, acknowledge acknowledging them and apologizing. It's such a powerful thing, especially when there's a dynamic between patient and physician, especially when the patient is an marginalized community. And with that, I can take any questions. So we'll take questions from the audience if you have any I'm going to start off with one I think, being in the GME space, both of us, and seeing kind of the ACG me and their lack of clarity around it and also, I think, for me feeling like we don't do the greatest job I mean I know that's you're not going to ever do better for us but, but like how could we do better, not only an internal medicine but like across the institution for, and then kind of influence ACG new policy. It's not a tough question at all. You know, I think it becomes advocacy right I think a lot of these things start at position advocacy levels and not only physician but I think medical at the medical school level where we have to advocate for changes. The meta analysis that I mentioned, because I think a lot of people are like well I'm in dermatology I don't know why this affects me. And I mean I have a slide on it but actually maybe I can show it. These are all kind of clinical considerations so if you look through kind of all of the sub specialties, they go through why this is important why it's important to know about LGBTQ health and so, like in colon rectal cancer so thinking about gender affirming vaginoplasties and phalloplasty that I talked about. And so I think if you think about this from a lens of this and if we were bring these. And pathology like if we were to bring this to our graduate medical and maybe we could make a dent and having more inclusive and more education doesn't answer your question. That's an inspiring list. That's awesome. Yeah, Dr Rora. Okay, for the people on zoom, Dr Rora was reflecting on our medical school students and saying that there is a kind of a question of like should all faculty get trained, just like we are today, you know, increasing our education around this area. I have questions. It's a great question. So I think a few things so I think it's not just I think from what I've heard it's not just within the queer community I think a lot of communities feel this way, especially first and second year of Pritzker I think is very, I think Pritzker does it well right Pritzker is a very different environment and then when folks go to the wards with attendings and residents that are very different kind of generations and weren't trained right. Yes, exactly. Yeah. Yeah, exactly. So, I mean I think, and it goes back to I think training a lot of times, I don't think they're being just on purpose or exclusionary I don't think they realize what's happening and so, again I think getting more education from the attendings, because I think the students have it and they know what they're doing they have the terminology, they have the education it's translating that education to the older generation that didn't it's not their fault like they didn't have the education but that's not an excuse anymore we can educate the attendings and the community the greater medicine and medical community academic community so I think that's where it has to go but there has to be buy in from the leadership. Yeah, I mean I think, you know, I don't know. I guess my question would be like, are those comments shared to leadership from like the hospital side. Yeah. Yeah. So I don't think web modules are the answer. I think, you know, one idea that I had had was to have, it's a lot I mean, have a quarter of physicians that can go to section meetings and do like a 10 minute talk on why this is important, and record it and not make but kind of make people listen to it, because it doesn't take it's not you don't need an hour lecture, right like it 10 minutes I think 1015 minutes I think is enough to kind of get the point across, and then do that every year because again it does change right, and I think also underscoring why it's important because I'm pretty sure if a lot because I don't think the leadership may know but I don't know how much of the faculty know that that's how the students and residents are being are perceived our environment, and I think if more faculty knew that I think there'd be a bigger push to change. I'm going to read this question from the zoom okay and what can we be doing in selecting residents, fellows and new faculty coming from states where LGBTQ care is minimized or discouraged. And making sure that there is the expectation that those patients will be cared for appropriately are their ways as an institution we can place pressures on states that don't adequately train their medical trainees. That's a lot of, that's a lot of questions. You know, like, how do we deal with like, getting to a new some state like should we be accepting the whole mind of the in their communities and knowing that. Yeah, I mean, yeah, absolutely so I think, I think, interview, and I think this is why the interview process is so important and I think I don't know how much on zoom where we miss out on this is when you visit an institution and you actually walk around and you see what you see, I have to say our institution as much as I love it when you walk down the hall is you don't see a ton of inclusivity that reflects our, not only your students or trainees but also our faculty. And so I think there are things that need to be done kind of just to change that on a broader level, but absolutely I mean I think if you, if you, if we get and we're going to get trainees that weren't trained and states that had a lot or that went to have this curriculum. And that's why the GME training is so much more important right. It has to come from every layer. And if you just do it kind of from one, if you just think from a medical student perspective you're just going to treat. Educate the medical students. I don't think that's going to permit up you have to do it on every level. And that's how you're going to create that inclusive environment. Any questions in the audience. Yeah, I'm just going to repeat it because I had the same question, you know, March 17. The question is match day coming up for general surgery internal medicine all the specialties. Many of us post the pictures without asking and so as we reach out should we be asking for permission about posting pictures and maybe pronouns, you know, how does that work. I mean, I personally think we should. And because the less and even though it's not it's not going to be traveling and affect what one to 2% of your match list or the class that's going to come in. It's just so important because I also think it sets the tone for the residency program and the environment that you're coming into right. We care about about you we care about your identity, and we don't want to. We're just looking for. Oh my gosh. We don't want to. Yes. Sorry. You know, I think it sets the tone so even though it's an extra step and it might delay you matching names and and I think it's so, so important, especially, I mean, if you imagine being that trainee that finish finishes medical school in like May uses that time to transition and then all of a sudden their picture is out on social media with like their dead name and their old pronouns so I can't know what that training would feel like. So I'm going to try to repeat that eloquent question. So basically the question is where in the hospital to LGBTQ patients feel the most discrimination and then kind of a general experience of maybe coming less from surgery or trainees that have had training versus like our staff that might not have the same training, but that'd be a good summary. That's a great question so I think one thing is that I don't think there's any one part of the hospital that has increased discrimination against LGBT folks. I feel like, you know, LGBT, the hospitals get one chance right. There's one thing that happens that makes patients feel not safe LGBT folks not feel safe or feel targeted. I think that's it. And for the patients that have the opportunities and privilege to be able to find another institution to go to think it's great for them to go to the hospital. I think just have to kind of muddle through and kind of accept these things right. And so a great example I mean I went to an institution and I had to fill out. I think it was like 12 pages of paperwork and every single line had something about a husband, right it was wife husband wife husband, and I finally just gave up I was like I'm not going to do this and I didn't see care there. But again I have that privilege to be able to do that and that's like I hadn't even met anyone in the hospital yet. And so I think it could happen really anywhere and I don't and I think that speaks to your point it's not just physicians that need to be trained. It is anyone that interfaces like the valet folks the nurses that want the cafeteria folks. Everyone needs that training and it's obviously different training on different levels and the things that you talk about are going to be different. But I don't think if you again if you train all the physicians but then you know my endoscopy texts don't know pronouns and I haven't mean that patient still going to feel marginalized. All right, I think just there's a couple more questions that I'll show you but I think for time will wrap up. So thank you all for participating and we'll stop the recording as the ethics fellows to come down to the front and continue our more personal discussion up here so thank you Dr Paul one more round of applause.