How To Provide Equitable Care For LGBTQIA+ Patients

Good afternoon my name is Katie Schultz I'm super excited to be here with everyone today and talking about how we can provide Equitable care for our lgbtq patients we'll talk a little bit about why that acronym is a little different on my slide versus what I say I want to start off by mentioning that the duration of this talk is meant to be an intent safe space in a moment I'm going to ask you to provide some Fe some terms you've heard when as it relates to the queer Community I ask that you be mindful I recognize some terms you may or may not realize or slur I invite you to share those so we can talk about them but I ask if your intention is to be harmful if your intention is to offend that that a you not share that and if you're not here to grow with us to learn I'm going to kindly invite you to leave because this is not the space or the talk for you so starting off why me why am I giving this why should you listen to me professionally I've been a clinician for over 10 years now I've cared for many patients in the queer community and I also have a master's degree in medical education so fair amount of training behind teaching and educating and techniques and theories on how to do those things personally I myself am non-binary or gender fluid I kind of float between the two terms we'll talk about what that means I am married to a woman and my wife is Bulgarian and so the Bulgarian word for dad is Tati so I am a proud dog tati a little overview of where we're going we're going to talk about terminology like I said kind of start at Basics because you may know no terms or you may know every term but I want to meet everyone where they're at we're going to talk about some statistics and what our patients are facing on a day-to-day basis and then we're going to end up with what can we do how can we support our patients so let's start off with terminology there's all sorts of terms I imagine you've heard and we're going to have you go to this link you can QR code it I believe it's going to be put in the chat and so what you should be seeing is what terms related to the lgbqt space Have you heard and you should be able to vote as Anonymous I will just enter so we can see it come up wonderful so lots of terms already coming up queer is a very popular one gay lesbian sapphic belonging someone put several terms that's wonderful transexual bisexual yeah and you might know if you've done word clouds before the bigger the word the more the more someone has put that word in so looks like gay lesbian and queer are definitely the things people have heard most demisexual asexual AC acceptability equality Spectrum would like that rainbow yes often the community is represented with a rainbow so that's a wonderful one questioning a romantic sapiosexual female male assigned at Birth wonderful so we're going to go back to the PowerPoint proud oh that you guys that was a wonderful set wonderful set of words you probably noticed a lot of words and a lot of words that are in our community that aren't even that weren't even in that word cloud and so I wanted to kind of hit what I call The Big Three I think a lot of resources will call the big two sexual attraction and gender identity and what those mean but I also wanted to bring in this idea of romantic attraction because many individuals will mention that as well as their sexual attraction or gender identity so let's start with sexual attraction this is going to be who you are sexually interested who you're sexually attracted to this is going to be true for all the terms I talk about it is not an exhaustive list there are many more terms out there than I have the space to share and probably in the terms I'm not aware of for those who are aware gay means attracted to the same gender and we commonly use it to refer to men who love men that's the MLM you sometimes see it referred to lesbian is also attracted to the same gender but we tend to apply it to women who love women bisexual you're usually attracted to your own and other genders pansexual you're attracted to all genders and asexual you have little to no sexual attraction these individuals will sometimes refer to themselves as Ace we contrast that to romantic attraction which is really the feelings of romance towards another person so you can be sexually attracted to someone but not romantically attracted or vice versa again just a couple examples biromantic you feel romantic towards your gender and the gender of someone else polyamorous these are individuals who may have several romantic relationships a romantic like asexual they're going to be individuals who experience little to no romantic feelings towards others and just a fun fact if anyone likes those squish mallows an a romantic when they have a crush on someone a very platonic feeling they call it a Squish and then the final thing to talk about gender identity so I think what I grew up knowing was you could be man or woman and I think many individuals understand that prescribe to that in the community and many scientists now are finding actually the opposite that that gender is a spectrum as some people say or an infinite amount there's no set number of genders to be and so we get to terms like these transgender I think someone had put or trans for short these are individuals whose gender identity does not match their sex at Birth so if they were assigned female at Birth they may identify as man we can counter that with cisgender or CIS individuals these are the individuals who do identify with their sex at Birth so if you're born a woman you identify as a woman nonbinary which is what I identify as you don't necessarily combine you're not confined to the gender binary you don't really feel man or woman and I mentioned I would mention this I also identify as gender fluid which is for me flexing between wanting to appear more masculine and more feminine depending on the day and then like we talked about before a gender does not have a gender you'll see a lot of the ones that have a something as we see in medicine means does not or lacking or something to that extent and so the point of all that is to talk about when we talk about the LGBT community you've also heard me use queer which used to be a slur and the community has reclaimed that there's tons of ways the community will refer to itself here's a slew of other terms you may hear or may have heard some of them people put such as demisexual gender non-conforming to Spirit a queer person of color they slang like twink which refers to kind of a small a smaller gay male versus a bear which is a bigger buffer gay male we talked about gender fluid trans or trans masculine, trans feminine again by no means are these exhaustive and the point of introducing all of these terms and the point of talking about it is each individual identifies in their own way and even the same words do not mean the same thing between individuals so my definition of non-binary and or gender fluid may not match another person's definition of non-binary and what I encourage you to do is approach your relationships with openness and curiosity and ask your patients what do you identify as how do you want to be known how can I refer to you that way we don't make assumptions all right so we're going to take a sharp turn and actually come out of talking about terminology and talk about the some of the things that our patients are facing out the gate talking about lgbqt youth these individuals are two to three times more likely to attempt suicide than their cohorts and scarily enough among homeless youth nearly half of them are queer so very high rate of individuals who are queer being homeless throughout life but especially when they're young up to a quarter of patients who identify as queer have had abusive language used at them to them towards them from healthcare providers and again just over a quarter have been refused care because they were queer and I want to stress these this data and this statistic actually comes from the US which is a country where being queer is not illegal gay marriage is illegal it's you're not supposed to discriminate based on gender identity sexual identity so we're still despite it being legal we're still seeing quite a bit of discrimination and because of that it probably won't surprise you that a good chunk of our patients won't disclose their Identity or orientation to us about a third of adults and almost three quarters of children or adolescents won't share with us and this is really important because we can't give the best care possible if we don't know and understand what our patients need individuals who are clear are less likely to get preventative cancer Services some of which for the reasons I mentioned but also if you're unaware that your patient is a trans male you may not follow through with breast screening or cervical screening similarly if you're unaware that your patient is a trans female you may not think about prostate exams or the difference in again the breast screening and then I want to touch on the older community I feel like a lot of attention especially in this talk has been given towards Youth and adults and so often the geriatric community in medicine in general but also in the geriatric community kind of gets left out they don't get included in the conversation and this is really important because these individuals are often really isolated and lack support a lot of people who are queer for whatever reason do not have the support of their biological family and so they have chosen and found family as things have gone along a lot of the current generation who are elderly a lot of their support has died either through the AIDS epidemic or other events a lot of them as they've gone into assisted living or communal living have faced discrimination so this is I think a particularly vulnerable population within the queer space so a little bleed a little scary and it brings us around to well what can we do as providers how can we support our patients and as daunting as it may seem the answer is change really does start with each of us a single drop causes Ripple effects and two affect change at an organizational level at a societal level it really starts with changing ourselves so the first thing is using inclusive language correct pronouns how a person wishes to be addressed and also correct names never ask someone what their real name is the name they've given you is their real name there's also preferred terms and you can if you're doing an exam or discussing a topic that could be sensitive you can ask your patient what terms they prefer for example some patients may prefer chest instead of breast the other thing you can think about doing is being mindful of your gendered language or your use of gendered language for example instead of saying wife or husband you can say spouse or partner instead of brother or sister you can say sibling this one I think is a little less intuitive but instead of saying born female born male you can say assigned female at Birth assigned male at birth which someone put in the word cloud that was wonderful I always think about language being a really powerful tool of expression and when we to explain why born female born male is not the preferred term when we use the language that way we're implying well was born male we still we still look at her as male as opposed to saying oh she was assigned male at Birth that doesn't necessarily mean that's what she is today and then a final example drawing from our Latinx community for those of you who do speak Spanish oftentimes you'll add an a at the end of a word to indicate feminine or an O to indicate masculine so Latina Latino and you can say Latin X and instead to be gender neutral I think this is a really good question too before I recognized I was queer I was always very nervous what if I mess up what if I say something wrong or offend someone and I think the thing to remember is no one is perfect and if your intention is that openness that Curiosity that desire to support you can come into it make a mistake and tell your patient I'm sorry and continue the visit on so if you use she instead of they correct yourself excuse me they move on the thing not to do is to make it about you is to put an emotional load on your patient by over apologizing or catastrophizing what you've said or done another thing that's really important is to work on providing a safe space and again this is something that can be done individually it can be done organizationally it can be done societally when we think about providing a safe space one of the first things that lets someone know the space is safe is to see representation so is there literature in the waiting room or in the exam room that shows individual Square queer do you have something like a badge on that says you're safe with me or has a room though now I will say that one and also the next one depends on your location and how receptive your surroundings are where you feel safe hold accountability if you hear someone misuse a pronoun help them recognize oh this person's pronouns are they not she or excuse me she not he I know many of you were in training and with training comes a hierarchal expectation in medicine and it may be uncomfortable or hard to offer that feedback to a resident a fellow an attending a practicing nurse and so while in a perfect world I would say hold accountability let's all be inclusive I know that's not the world we live in and I just encourage you if you don't feel psychologically safe doing this don't feel guilty for not following through I mentioned this earlier don't assume when we are working with patients I always think broad questions are great way to go so when I was in medical school I was taught to say GF with men women are both sounds pretty inclusive but you're leaving out an entire group who don't identify as man or woman instead what could be useful is to say something like who are your sexual partners who are you sexually active with and then have the person use their language which helps you know what they how they want to refer to it but also helps you know what interventions if any are needed for example screening or pregnancy test etc. I can also give you an example of don't assume earlier this week I was talking to a colleague who had just moved and said you know we just moved and I asked that person you know who is involved in the Wii and they shared with me that it was another woman as well and so just a very simple change of Who's involved with the Wei instead of like oh you and your husband moved or and what that did was open the space for the individual to share as much are as little as they wanted to about the state of the being and then the last thing that I think is so easy to fall into as a trap is only ask what's relevant it's easy to be curious and I also think when you're a trainee you're taught to ask everything and as you go along in your training you learn to refine that you learn to narrow in but if a patient comes in and they're queer and being queer has no relation to why they have come in don't ask about it you know if they come in for a cut on their forearm it's probably not really relevant if they're a trans man or a trans woman or if they have sex with men are also man okay the next thing you can do is educate yourself lots of ways to do this I've mentioned being curious several times ask your patients queer individuals are not teachers they're not meant to educate you but many of us if you ask us for example what are your pronouns or how can this how can I do better at this many of us are happy to offer that sort of feed especially helpful is keeping abreast of news and societal expectations knowing what policies are being enacted both within your hospital within your city your state etc. this one I think's pretty important just to being a doctor at all and that's to remain non-judgmental it's not our place to put Val value or judgment on a person their experience their identity our role as Physicians is to be healers we're there to support them in their health Journey so they can be the healthiest they want to be and can be and then the final thing that is also going to vary based on the level of training you're in the location you're in but where possible Advocate right you can advocate which we talked about earlier at a very small level of you know holding colleagues accountable or stepping up to say this is what the patient asks for or what the patient need you can Advocate at a at a more physician level professional level by doing prior Ross by noting you know my patient needs this treatment needs this medicine you can Advocate at the societal level there's different things policies are very obvious one but there's also a need for support for homeless shelters Mental Health Services etc. so lots of ways you can Advocate if you're interested and I we're kind of coming up to the end and so I will say of all the advice I've given I want to be mindful and I want to recognize how important it is to be aware wherever you are what the rules and laws are there are some spaces is where it is not legal to be queer or you are a mandatory report if someone reports their clear and so in those cases I encourage you to let your patients know when you start the conversation hey I'm a mandatory reporter if you're queer I must notify XYZ because then again they might not share with you but that's safer for your patient perfect I think at this point we can do some questions if that's okay and I'll pop out I'm GNA stop screen sharing for a moment we'll look at questions wonderful so I see the first one respectfully gender modality would be a more accurate framework for Trans and Cy for this of us in academic and research settings I don't disagree I'm wondering if you're one if you're meaning that instead of spectrum Diane I would love for you to clarify I don't I don't disagree there are many individuals in the community who don't agree with using the word spectrum let's see might add one is Ashley okay I'm less familiar with that individual I apologize but again I have no objection to using gender modality let's see okay the next question I see do statistics apply equally because I remember reading trans people tend to be more affected I appreciate we don't mean to belittle anyone struggles and yes part of the reason the statistics ranged so widely is it was inclusive of different subsets of individuals and you're absolutely correct if I go back to for example individuals who refused care 8% of individuals who identify as lesbian by or gay were refused care because they identified that way versus 27% of individuals who identified as trans were refused care oh this is an excellent question and I definitely invite others to offer as English as my native tongue how can you use gender neutral language in gender languages like French Spanish would be another example since adjective nouns etc. are either female or male regardless of if it's plural or single this is a great question I don't know that I have the answer which I apologize because English is my native language I'm totally happy if someone in the chat or someone in the group has an answer Spanish uses e to be gender neutral okay so what I would advise and yes please add to the chat if there are other answers like the French example one of the things I would advise then is looking I'm going to share some resources and Stephanie might have already done that but looking at local resources in your native language that might know here's a way to be gender neutral these are such great questions everyone I'm just going top to bottom so if you've just asked a question I've seen it I promise I'll get to you to it and to you all right okay is it common to figure out another sexual orientation of yourself after reaching adult age even though you are already familiar with the career context and involved in their communities and activities and trying to be aware shortening the question for an already informed person can changing in sexual orientation happen at adulthood for example transferring from CIS to bisexual I don't know the statistics on how that happens but I can tell you it happens anecdotally I would say the majority of my queer friends recognize their different identities in adulthood I myself figured out I was bisexual when I turned 30 and then figured out that I was non-binary when I turned 33 I'm now 35 so I'm still fairly new to being part of the community but I have been and considered myself an ally a person who supports the community and tries to be mindful of the community I've considered myself an ally for as long as I've been aware that the community exists I also think it's common for many individuals to fluctuate or change throughout time and change their perspective I gave the example of some days I feel non-binary I don't really feel male or female and some days I feel gender fluid I feel a little bit masculine I feel a little bit fluid so how you identify is valid and that can change and still be valid if I woke up tomorrow and decided and real not decided realized because I don't I don't think it's choice you can't just turn off being queer but if I woke up tomorrow and realize oh I'm not bisexual I'm pansexual or I'm a lesbian that would still be a validated oh there's the ranks of wonderful question what is queer thank you so queer is a broad term to refer to the community it was I believe in the 70s and 80s considered a derogatory term for the community and for at least the last decade a lot of individuals have been working to reclaim it and so generationally I think if you talk to older individuals queer may be offensive still to them I think a lot of the millennial generation and younger have embraced queer and use it kind of inter interchangeably with lgbqt I think if you're in a professional setting if you're seeing a patient and you want to refer to the queer community a safer way is to say lgbqt if you're unsure if there're okay with the term oh this is a great question and I thought about this as I was talking I did come in with a bias thinking medical student medical residents interns etc. and realized as I was saying that there may be nursing students there may be Pa students so I apologize for using U medicine as the example I recognize and appreciate your support and this question is reminding me of this as well accreditation standards require all credit accredited PA programs to prepare graduates to care for patients with consideration I know SGI but of course I'm going to struggle to remember what it stands for give me one second sexual orientation and gender identity lots so PA programs are required to care for patients with consideration for sexual orientation and gender identity and the national certifying exam includes gender dysphoria have medical schools caught up yet So my answer is going to be very related to the US because it's where I trained and what I know best I can't speak to other countries in the US to my understanding it is an expectation that students learn and understand how to provide care for individuals who are lgbqt plus and exams should include issues like gender dysphoria Let?s back up a step and say what is gender dysphoria for those who are unaware this is a feeling or experience an individual has when their outward appearance or feeling of their body does not match what they view their body as so I think most commonly people think of it as individuals who are trans a trans man may experience gender dysphoria when forced to wear a dress for example I think perfect the next question before we do it since we're talking about the gender dysphoria also important to note as you're thinking about working with these patients a lot of the stigma that comes around some of the issues especially with transgender individuals we set up in medicine so the DSM five is the first time gender dysphoria was removed as a mental illness okay do you have a gender do have a suggestion for gender neutral term of respect such as what I might use introducing adults or children or what my children could use when speaking to adults other than Mr. or Mrs. ma'am or sir this is a great question I think a lot of the community uses MX which different people pronounce differently depending on the person you can use things like doctor or Professor if they have a title to their name I think that would be the big ones I know again I invite other individuals in the chat if they would like to offer terms they've heard ah yes this is a great question okay I am worried about the debate when it comes to trans kids can you give advice yes and that is a very big oh wonderful we thank you can you give advice that's a very big and Broad question if whoever entered it wants to direct it in any way if the advice is how do you interact with these families and the children if the advice is ?Music? you know how medically what do we do for them or maybe the advice is just simply when the debate comes up what do we do if you'd like to clarify that I'm G to take it well I will come back to this one if you can clarify what about the debate you would like advice on otherwise I'll come back to it at the end and give kind of a broader answer wonderful yes sexual orientation is fluid it can change over time adulthood childhood or anytime in between and someone gave the example so instead of n in Spanish which would be child boy girl you could say n great example oh okay this is a great question how would you go around treating a patient in a non-friendly hostile environment at the hospital so the way I interpret this question is treating a patient in the hospital where the hospital policies don't support being lgbqt Plus or for example if you're aware of the debate around trans children being in a state where they don't support gender affirming care pin in that we'll talk about what gender affirming care is when you are young it starts with puberty blockers to prevent development of secondary sexual characteristics as you progress you have option of taking hormones of you want it if you're a trans man you would take testosterone if you're a trans female you take estrogen that's super simplified there's so much more to it so how would you treat a patient in a non-friendly hospital environment I'm going to take the example of let's say we are in a state where puberty blockers you're not allowed to get puberty blockers to a trans child I think this question is really hard and it's what a lot of Physicians are facing right now because we know giving care to these individuals the care they want and the care they need literally saves lives there are a couple ways to go about it one if it's a hostile environment I definitely encourage you to be mindful of what you put in the chart do not unless the patient specifically requests it do not put their pronouns in the chart use their pronouns with them do not identify them in the chart because that may flag them and put them unfortunately put them in danger I encourage you to be mindful of anything else you write in the chart I know some Physicians will get around certain things by finding a commonality so I'm not suggesting you lie to get a child on a puberty blocker but if there's another reason the child may qualify convenience that helps your case let me know if that didn't fully answer your question I'm happy to delve more all right we answered this one and I believe W added some wonderful information about medical schools and accreditation okay question are asexuals and demisexuals considered ask we when they are stripped I'm a little I I'm a little confused by the question I think I think because I consider them queer is the answer there is within the lgbqt community a lack of inclusiveness among some individuals and so this question will depend a little on who you ask I am someone who believes that if you identify as lgbqt then you are lgbqt if that is asexual if that is trans I think what this question is saying is if you're asexual or demisexual are you still considered queer even if for example you are romantically interested in the opposite gender in which case the answer is also still yes you are considered you are considered queer or part of the community oh this is a great question in the case of trans people what happens if they've not yet gone through gender change process but have legally changed their gender how this could be important for clinical in order to treat them at that time and how to put it in the medical record which we touched on a little bit earlier so if they legally changed their gender this opens up a door of what to report right they've legally now they identify as let's say for example a man you can put in the chart he him what's put in the medical record again is going to depend right is it safe to acknowledge he is a trans man if so and he's comfortable with you putting that in his chart you can put that in that chart as far as treatment goes again that's also going to be dependent on your location we talked a little bit about Youth and how that affects it as of now I won't say most I'll say several States again very us Centric because that's what I know I apologize I definitely invite other individuals who may know for other countries to share in the chat but as of now what I know is there are still several states that support gender affirming care for adults and so you don't have to have your gender or name legally changed to receive that care it might just or I had another thought but it might just help in terms of insurance and the other thought I had for example was let's say you're a trans man and you need a mammogram if you've legally changed your gender to mail it may require a little more work as the physician to convince Insurance to pay for a mammogram as a screening tool without other risk factors I love this I ref friend to a non-binary teacher and their teachers call them teacher so thank you when okay so I think they're asking about puberty blockers and gender affirming surgery as a minor I'm just going to scroll down make sure miss little okay I believe that floats us back to that question around advice around trans kids which we've touched on a little bit and the answer I'm so sorry to say is just so complicated and so dependent on where you are medically gender affirming care is life-saving and is indicated if you can walk away with knowing that gender affirming care looks different based on a person's age there are Scare Tactics talking about mutilating children and that's not happening puberty blockers don't mutilate a child they prevent secondary sex characteristics and Studies have shown when you stop them the child enter puberty and the biggest adverse effect would be delayed growth they catch up that growth they would have obtained otherwise so there's not loss in height there's not loss of bone need there's really not Health adverse effects for taking puberty blockers the advantage for a child whose trans is it prevents development of the secondary sex characteristics so that when they reach adulthood if they want to do gender affirming surgery for example or hormonal treatment it's very different to be a trans man and start testosterone having never grown breast than it is for be a transman and start testosterone having grown breast yes as far as gender affirming surer as a minor I am unaware of anyone who does gender affirming surgery I'm I that's not a thing that happens again that's a scare tactic that's part of that mutilation tactic I a snarky comment but I will keep it for a FES you okay I love this question how can we work towards gaining trust for my better care especially if the community has been ostracized outside of effect of literature as pronouns wearing inclusive symbols I think this is a great question I think the biggest thing is and how I approached it when I was CIS and straight the biggest thing is to be respectful have good intentions be open and curious and you can even tell your patients if you feel like your patient is uncomfortable sharing or uninterested you can share with them this is a safe space I'm not here to judge you I just want to give you the best care possible how can we make that happen I also think because I've had this happen being prepared for the individual to bring up some of the situations and acknowledging their grief and their pain over the situations that have happened such as the AIDS epidemic I think that goes a long way towards earning trust too that's another question where I see individuals who are responding we're in the queer Community please feel free to add in more I love your input recommended encourage not required I'm not sure which that's referring to when I'm so sorry oh I meant from a medical perspective I've read conflicting things about hormone therapy how do you navigate care for them and so we did kind of touch on this I'm just going to loop back a little more I think the biggest thing is you have to know you have to know what the laws in your state and rules in your hospital are you have to know what the relationship of the child is to their caregivers and then you have to know what you're comfortable doing I appreciate that there's conflicting evidence out there what I know and understand is that puberty blockers are safe and hormonal therapy and gender affirming surgery is not recommended or done on miners in terms of knowing what your patient needs not all kids are out to their caregivers or their families and so that's another thing to navigate when I talk to the child alone I always ask them what are you comfortable sharing what does your family know and I offer but don't demand helping the child disclose if it's their interest to let the know okay yes the A and lgbtqia which is another acronym asexual aromantic resources all right in Reproductive Medicine is there a different approach to be taken in same sex part of the spectrum parents in the US I think this question is asking about fertility perhaps in individuals who are same sex or non-binary if not just let me know to my knowledge I don't know that that affects the approach to be taken Whoever has the uterus can receive the sperm and whoever produces sperm can give the sperm I think maybe the big difference would be if you have two individuals who have uterus and don't have someone who can produce sperm then you have to find sperm and similarly if you don't have someone with a uterus you do a surrogate or find a way to okay oh thank you can a minor consent to any procedure this is going to be a really great question that depends on where you are so even in the US it's dependent on State broadly speaking no some states will Define a age of consent or age of the ability to know private medical information about themselves and keep it like hide their chart from their parents or caregivers in New Mexico that's age 14 for example so at that point there are certain procedures that yes the child can consent to that the parents don't need to know about for example being tested for STI younger kids that that's not in place so technically it depends on their age and it depends on the state whether or not they can consent to any procedure or certain procedures Google G Integrity project if you're confused by Miss or disinformation I absolutely will I have not heard of the Y Integrity project and so that is a great space for me to learn more okay how can we protect and support queer group as those who have been abandoned neglected or stigmatized in terms of care schooling shelter other organizations to support them and connect me I'm a nurse and have come in contact several times this is a fantastic question there's great support I Tred to be mindful there's so many more support groups and websites than what I hold but I tried to be mindful of including both us and international and I tried to be mindful of including different groups including youth adults geriatric trans lgbqt Ace etc. yes we have pins in our badges rainbow and states that you safe with me I also have that pin I wear it when is provided a wonderful link on safety of puberty blockers both short and long term blah blah to give resources you can recommend to give patients I have many patients who are to receive vaccines due to lack of inclusive care and I think maybe the idea is your queer patients especially are hesitant to receive vaccines I'm a pediatrician so oftentimes I get the hesitancy for vaccines unrelated to being queer and so I think some of the resources I've pointed you to are really helpful I don't know off the top of my head a specific resource that deals with vaccines targeting individuals who are que I will invite my fellows who've been doing a great job supporting me so far to offer that establish programs again I'm going to point to those resources this is not a silly question you led with that but I want you to know no question is silly if you come in intentional and with the desire to help it's not silly to have not been EXP exposed to the answer if someone is nonbinary and the hospital only has female male bathrooms or etc. how do you handle that so that's a great question it's really hard ?Music? I think there's lots of ways to handle it if you as the individual are non-binary it's a little trickier if you are someone who's supporting someone who is non-binary the things you can do right we can't change the system Sy quickly like that but we can try to make those in the system mindful so for example if you're on the ward making sure the providers use the pronouns that individual prefers or if they if they are uncomfortable you know they they're transwoman but they're in the male Ward and they're uncomfortable seeing if you can get them to the woman Ward I know you mentioned nonbinary sorry about that okay our standards quality management with the Institute of medicine this is a great question I am actually less because I'm not in Internal Medicine I'm less familiar although so I'm not sure if there's standards for Quality Management I would suspect yes but we're not doing great on them oh wonderful CDC provides vaccine information I love that oh I think that's all the questions which is great because we're almost out of time any last minute questions or anything I also want to invite anyone to share if there is you know in the last few minutes something you want me to know or you want to share I'm happy to hear it there's one more question that I just posted yes thank you what should you do if other Superior Healthcare team members are intolerant of patient sexuality and advocacy of care and Hospital settings so the thing to do is to go to human resources or HR assuming you're practicing in a setting where they are a culture of Tolerance and are a culture of inclusivity most places will have a human resources department excuse me for the staff for the residents for the fellows for the attendings and those there should not be retaliation who reports that someone is being intolerant should be remain con confidential and there should not be retaliation meaning it shouldn't impact your performance your grade how you're treated on the team it's not foolproof and guaranteed but that would be my recommendation if you're seeing that and you don't feel safe going to the team member and noting that it's you know hey you're not using the right pronouns or the other thing you could try to do is find someone to Advocate who's higher up in the chain for a one yes thank you when quality management the healthcare equality index by the oh the Human Rights Campaign which is one of the links we provided yes oh this is great Diane how do you recommend we navigate saith based exclusion from career inclusion and healthcare this is a this is a really hard question ?Music? I this is a really hard question for me because I have a personal belief that being a doctor is a job you choose and to be a doctor means to heal others and you don't get to pick and choose whom you help heal and so if you have beliefs that mean you can't heal someone you shouldn't be a doctor that is my personal belief that's not on that's not osmosis is St that's not that's just my personal belief how to navigate for example faith-based institutions and hospitals that that don't believe been providing those that care one is understanding then that if it's possible and there are other resources for your patients send them to those places instead of the institution that will deny recognizing their Identity or deny them care at a systemic level the best I can think of is policy and fighting for equality and Equity do you have suggestions on improving medical schools professional schools education on providing care such as certain topics they should introduce I think this might be our last question because we're right at one o'clock so anyone who needs to hop off totally understand I am going to answer this question I think there's a few things we can do to improve the education we provide to Learners on how to provide care one I always think patient involvement is so important no one is going to explain their experience better than the person living it and so having individuals come and talk to students or Learners I think is profound when I was in medical school I to this day remember sitting and listening to a panel of individuals who are trans and a trans man discussing how his doctor laughed in his face because he' had a period so I think having access and learning from the individuals themselves is really important I think being inclusive a lot of schools do things like patient encounter stimulated patient encounters and making sure those encounters include individuals who are non-binary trans gay etc. not for the sake of the encounter right not this is a trans patient coming in for gender affirming therapy but this is an individual coming in for a cough and they happen to be trans oh Jenna thank you yeah so for anyone who's still on thank you so much for your time I really appreciate it this was for me an amazing experience I appreciate how thoughtful your questions were and I appreciate your time so thank you everyone helping current and future clinicians Focus learn retain and Thrive