Good morning. We're going to go ahead and get started. I've got quite a bit of material to get through. So my name is David Cochran. I identify he, him, his. The employment note at the bottom is only half true. I don't start that job until May 1st. I'm technically unemployed right now. So I have no financial interests or conflicts. I want to emphasize that nothing I'm presenting represents current or currently proposed ACOM policy procedure. I will acknowledge inherent bias. I'm a gay man who identifies as male with pronouns he, him, and his. You're going to hear me use an abbreviation that I got from the NIH, sexual and gender minority or SGM. I'm using that simply because it's easier to communicate than the letters LGBTQIA+, which we'll talk about in a second. This is not a defense or advocacy for SGM. We will not be talking about political or religious based opinions. I just want to familiarize the professionals, the OEM professionals with terminology and issues related to the SGM community, especially as they relate to employment and healthcare. I'm going to touch a little bit on primary care and preventive care and transgender transition care, but only for a basic understanding. My impetus for doing this talk, my previous job to the current one was in Norfolk, Nebraska, which is northeast Nebraska, fairly rural area, socially quite traditional, and yet I was surprised by the number of transgenders I saw in my OEM clinic. Most of them were for pre-placement. I saw a couple of CDMEs there as well. The second impetus was last year at the TED Talks here at AOHC, I heard Dr. Jill Rosenthal talk about her transgender son. I was like, wow, that's the first time I've heard those words uttered at ACOM. I said, you know what, we need to talk a little bit more about that. I just found out there was a proposal a couple of years ago on this topic, but unfortunately that AOHC got canceled because of COVID. So these are the objectives. I wrote these objectives back in about December, January, because they were required to be turned in. What I've put together is a little, it's not perfectly consistent with these objectives, but this is kind of the basic idea of where I want to go. So after meeting Dr. Rosenthal after last year, she appointed me to the new Justice, Equity, Diversity, and Inclusion Committee, or JEDI Committee, which was tasked, she was tasked by the board to run. She's the chair. We've had several meetings since, I believe we started in October was our first meeting. I'm sad to say I have not been issued a lightsaber yet. I will acknowledge that the SGM issues are a very small part of what JEDI does. It's a much broader charge than just that. If you want to read more about it, there's an article in the ACOM quarterly winter edition, Dr. Rosenthal discusses the committee and its charges, and I urge you to seek out members of the JEDI committee as well as our ACOM support staff, Aaron Ransford and Charlie Peckman. Most of the committee has grabbed these little green tags for our pronouns to kind of identify that that's where we're coming from. So when I started looking for research articles and science on this, first place I went was J-O-M-E, and I did a search on LGBT, and this is what I got in JOME. I did eventually find an article in there that I found through my PubMed research. What I found was most of the articles are from sociology or from legal perspectives. There was a good bit of research in the first decade of this century, but because there's been so many social changes, changes in perspective over the last ten years, that research doesn't have as much applicability anymore. So we're going to talk about terminology so we can be kind of familiar with these patients as they come in. As I alluded to, there's kind of this alphabet soup that has been used, L-G-B-T-Q-I-A plus. The LGBT is lesbian, gay, bisexual, and transgender, as we know. Q, some people use that for queer. Some people use it to represent questioning. It just depends on your perspective or where you're coming from. The I and A is intersex and asexual, and then the plus is a simple term of inclusion for others who may not identify specifically with one of those letters, but is still part of the big umbrella. The term sex refers to the sex assigned at birth. Using the traditional terms, male or female, the issue that people in the community have is that those terms provide no individual sense of self or self-identity. Then the word gender, in its traditional use, refers to the characteristics and roles displayed by members of the two sexes assigned at birth, the feminine and the masculine, whereas gender identity is how an individual perceives themselves and how they label their gender-related representation, and of course gender identity may or may not be the same as sex assigned at birth. Sexual orientation is preference of partner, and that can be partner of sex assigned at birth or partner of a gender identity. Sexual orientation is usually manifested by behavior or it can be purely internalized. The term is usually not applied for the rare or occasional sexual event, but rather enduring patterns of experience and behavior. For example, in 2006, there was a survey of New York City men, 9.4% of the men who self-identified as straight also reported having sexed with multiple men and no females within the previous 12 months, but they still identified themselves as heterosexual. Gay and lesbian we know is gender-based terms for homosexual. Traditionally, we've considered those to be attracted to the same sex, but as I alluded to, they can also be attracted to the same gender regardless of the sex. And then bisexual and pansexual are often confused with each other. I've confused myself on it a few times in the past. Bisexual really refers to attraction to someone of either of the sexes, male or female, so a bisexual can be attracted to either one of those, whereas a pansexual is someone who's attracted to any gender or gender identity. So they're really just attracted to the person regardless of the underlying gender. Gender binary is a term that refers to the traditional social construct with two genders as defined by our societal norms and expectations, and it aligns with the gender, aligns with the sex assigned at birth, so it's that masculine and feminine. You'll also hear the term heteronormative, which is kind of the same thing. There can be subtleties and difference, but really it's heteronormative refers to that gender binary mindset of there's only one or the other. Cisgender is when one's gender identity aligns with sex assigned at birth, and a good example of that is myself. I'm a gay male, but I am cisgender. I perceive and display myself, display my gender in a manner that's consistent with my sex assigned at birth. Gender diverse is for those who fall outside that binary structure. There's a lot of synonyms, and there can be subtle differences from people within the community, but generally you'll hear non-binary, genderqueer, genderfluid, pangender, and gender nonconforming all kind of referring to the same thing. You'll hear me use an abbreviation, TGD or TGE, which stands for transgender and gender diverse or transgender and gender expansive to kind of focus on that particular subset of the SGM community, but it's also important to remember that the TGD is a subset of that bigger SGM community that I'm talking about. Gender affirmation or expression is how an individual expresses their gender identity. It can be through pronouns or through a preferred name. It can be clothing and hairstyle, very visible external evidence. It can be through evidence that you see, but you don't see how they got there, so I'm talking about things such as binding or tucking in order to get the presentation that they want. Gender affirming treatment is also a form of gender expression, whether that's through hormone therapy or surgical procedures. The term transsexual has had various uses in the past. Most modern users refer to it, use it for someone who has undergone gender affirmation treatment and now presents with the gender identity, with a preferred gender identity. However, within the transgender community, that term has generally fallen out of favor because of the past misuse of it. And of course, transitioning is the process of undergoing the affirming treatment. The word queer is used to express the spectrum of identities and orientations across the SGM community. I personally don't use the term queer because when I was a kid, queer had strong negative connotations. Today's youth, though, use that term queer as an affirmation of being different from the traditional societal norms, so that a lot of the younger people have embraced the term queer. The term two-spirit is an American Indian Alaskan native term, referring to a member of the tribal community who embodies both masculine and feminine spirits. I'm not going to go any further with that because I don't have any expertise in Native American issues. That would be a great talk in and of itself. Intersex is the more common term now for what we used to call hermaphrodite. The clinical term now used is differences in sex development, or DSD. And then agender refers to someone who does not experience a primary identity component related to gender or sex. Asexual is someone with no sexual attraction. And bigender, less commonly used, but it's someone who combines both traditional gender roles within their own gender identity. These are some terms that have a bit more negative connotation. Misgender is when a gender-related word not consistent with the individual's gender identity or expression is used. Outing is the involuntary or unwanted disclosure of another person's sexual orientation or gender identity. Certainly individuals can out themselves at their own needs to whoever they choose, but when you out someone without the permission, it's actually a form of harassment or bullying. And then homophobia and transphobia are prejudicial terms describing attitudes that result in discrimination and marginalization of the SGM community. These phobias, especially gender identity prejudice or transphobia, can manifest at an individual level, but they can also be manifested in communities, institutions, family systems, as well as in written policy. I'll talk for a moment just about the pronouns I already mentioned. When you state your pronouns, such as on a name tag as I've done here, it's a way to help avoid the misgendering, and it can also be a way to show acceptance of somebody who may not be a traditional gender identity. If you want one of these green ribbons, they're at the ribbon counter up at the front desk. I found them last night, didn't know they were there, and so they're available if you want them. The TGD community will often apply pronouns of their gender identity before they even start taking transition. So their appearance may be incongruous with the sex assigned at birth, and it can create a potential for misgendering without clarification. What I found and what is recommended is simply ask directly. Ask the individual what is your preferred pronoun. If you present yourself in clinic with a name tag that says Dr. Cochran, he, him, his, that's also a cue to that person that you're open to their personal pronouns. I mentioned here the neo pronouns. I don't know much about them. They're not used terribly commonly, but they're simply an expression of the non-binary community to indicate that they live outside that heteronormative construct. This is an example of an online resource targeted towards school kids to help them assess, kind of see all the aspects of their own identity with relation to gender and expression and sex. One term I have failed to include up to this point, I forgot to put on the slides, is an ally. This is most often a cisgender person of heterosexual orientation, but not strictly, doesn't have to be strictly that. Someone who expressly supports the SGM at either the community or individual level might be a parent, family member, friend, co-worker, or really anyone who openly expresses acceptance and support for the SGM community. And as I've already alluded to, an expression of allyship is simply presenting yourself with pronouns saying that I'm open to that mindset. So I'll talk a little bit more about gender identity and the TGD community. It's important to remember that everyone has a gender identity, even if it aligns with a heteronormative construct. We all have a gender identity. And there's some sociological research that shows that gender identity tends to develop at a very early age, around two, maybe three years old. But at the same time, there's some evidence that the gender identity could be subject to change throughout a person's, throughout an individual's personal development over time. In the August 2021 JOAM article, the JOAM article I finally found, Dr. Wayne Burton and his team published an article titled, Demographics, Preventive Services Compliance, Health, and Healthcare Experiences of Lesbian, Gay, and Bisexual Employed Adults. This was a survey, it was pre-COVID, so it's not influenced by the pandemic, of employees from seven different employers. The participants in the survey were members of those employers' pride or LGBTQ employee research groups. There were over 1,500 participants that responded to 50 questions regarding sexuality orientation, gender identity, and related topics. And we do have to recognize, though, this survey sample is not truly representative of the entire American workforce, it is of the community, the SGM or ally type community specifically. And I'm going to touch, I'm going to kind of reference Dr. Burton's article a couple of different times through the talk. One of the questions they asked was a self-report of gender identity, and you can see on this slide kind of the range of identities that were reported on the survey, which reflects a wide range of identities that's going to exist in the workforce that we're taking care of as OEM docs. And just a few more terms to be aware of. Gender dysphoria is the distress that the individual may experience when gender identity does not correspond to the sex assigned at birth. It is experienced by some in the non-binary community, but is not a defining part of being gender diverse. The DSM-5 describes distress of gender dysphoria as impairing at a clinically significant way in social and occupational functioning. But it's important for us that we avoid the tendency to pathologize all members of the TGG community as having gender dysphoria, because they don't. Sadly, this diagnosis is required by some insurance companies for an individual to be authorized to undergo treatment, which presents a challenge for someone who actually is not experiencing gender dysphoria. So I'm going to focus now on the term transgender and those who identify as transgender for just a moment. Once again, I'm not advocating. I'm just trying to help us understand this unique group of patients. So transgender is someone whose gender identity does not conform to the societal expectations resulting from the sex assigned at birth. It's a little more specific than just saying gender diverse, because you're talking about someone who's transitioning over. It's preferred and appropriate to use the gender term that that person currently identifies, regardless of where they are in the process of transition. So, example, if it's a someone who was female, sex at birth, but they now identify as male, we'll call that a transgender man instead of a transgender woman. So it's whatever they're identifying now is the terminology we use. The ICD-11 uses gender incongruence to clinically describe the discrepancy between gender identity and the sex assigned at birth. This is to replace the older term, such as gender identity disorder. The incongruence is used without reference to any existing dysphoria or preference for treatment. The ICD-11 also has moved this code from the mental health section to the sexual health section to emphasize that it's not related to the mental health issue. In the 2019 article in Annals of Internal Medicine, the article is called Care of the Transgender Patient. It discusses the natural history of the transgender development. The exact mechanisms are not well known, but there is data pointing to a biological underpinnings to gender identity present at birth. At the same time, some researchers have reported an inability to manipulate gender identity by external means, which reinforces that biological underpinning. There's some clinical evidence that suggests that in some people with congenital adrenal hyperplasia, the excess androgen exposure in utero is associated with increased rates of male gender identity, and inversely, those with complete androgen insensitivity syndrome may be more likely to express female gender identity. Despite a young age of gender identity awareness that I've mentioned, most TGD individuals present to their clinicians as adolescents or adults. The authors of this article note that it's unclear if this delayed presentation is related to a delayed recognition, to an inability to articulate gender identity, or due to pressure to conform to familial or societal expectations. Now, we as OEM providers are probably not going to provide specific treatment for transitioning, but it's important for us to understand some basic concepts of that care in case they come into our clinic for some reason. When providing care, it's important to clearly establish the transgender identity prior to initiating treatment. The guidelines require or indicate that there should be a persistence of the gender incongruence over years if there are brief periods that may suggest a need for further investigation of what's going on. The transgender individual needs to have the capacity to make medical decisions. There should be a basic mental health evaluation to assure that potentially confounding mental health conditions are addressed. One article I read said that if a primary care physician, for an adult, a primary care physician can basically do this simple mental health evaluation, the Endocrine Society guidelines suggest mental health evaluation in adults wishing transition, but they strongly recommend a multidisciplinary team for pediatrics that includes mental health as part of it. This slide very briefly just summarizes basic concepts of the hormonal transgender medical treatment. Again, I'm not going to try and teach you how to do it, because that's not the point here. I think what's most important as OEM physicians is when we see a transitioning patient to understand their medication list, side effects, interactions, as well as some of the manifestations of taking the hormones that are not consistent with their sex assigned at birth. Now, I want to switch focus a little bit and talk a little bit more about employment related to the SGM community. There's numerous reports of how much of our population is part of the SGM community, but the key takeaway for us as OEM is that there's at least 7 million, probably well over 7 million, employed adults in the U.S. who are part of the SGM community. That survey by Dr. Burton I mentioned also asked about sexual orientation, and this is the breakdown of the self-reported sexual orientation. And similar to the gender identity, it reflects a diversity of sexual orientation within the workplace that we should be aware of. It's important when you talk about employment of the SGM community to understand there are no federal laws that protect an SGM worker against discrimination in the workplace or by the employers. The Employment Non-Discrimination Act, or ENDA, has been repeatedly introduced in Congress since 1994, though it has never passed both houses and been signed. More recently, there's been the Equality Act introduced, which would provide government protections across a much wider array of government services. No action has been taken on that yet. There are some very important legal decisions, however, that have impacted the SGM community, and I'm going to talk about three from the Supreme Court. In 2015 was King v. Burrell, which interpreted numerous provisions of the Affordable Care Act, and one of the findings of that decision was that coverage based on sexual or gender identity is included in the ACA. We've all heard of the 2015 momentous Obergefell v. Hodges that determined the right to same-sex marriage. Where this impacts the employment perspective is it opened up to same-sex spouses being eligible for workplace-based insurance or employer-based insurance. And in 2020, Bostock v. Clayton County, the Supreme Court found that discrimination against LGBT is a form of sex discrimination and is therefore illegal under the Civil Rights Act. Despite these legal actions that have provided some protections, there are still a lot of discrimination experienced by members of the SGM community. This article, an article in 2019 Health Services Research, describes the prevalence of interpersonal discrimination. Over half of the survey respondents, as you note, reported slurs, microaggressions, sexual harassment, and violence, and many reported harassment regarding bathroom use. Gender diverse report an even higher level of these kinds of discrimination. And from a socioeconomic perspective, gender diverse are found to be much more likely to be homeless, unemployed, and low-income, which certainly impacts their ability to access care. The UCLA School of Law published a report in September of 2021 on workplace discrimination experienced by SGM workers. This is a graph I borrowed from their article that reinforces that the discrimination can be manifested both through firing or refusing to hire. And I'll touch a little more on that in a second. And also kind of notice there's harassment of verbal, physical, or even a sexual nature. There's an article that talks about sexual harassment, stalking, and sexual assault in the military among SGM as compared to non-SGM members. I'm not going to go too really into the numbers specifically, and we do have to recognize that the military is a highly unique employment group. Nonetheless, the report shows a tangible risk of sexual victimization for members of the SGM community. The UCLA report I mentioned also notes that as much as 40% of SGM workers have experienced some form of workplace abuse or harassment. The risk of being fired or not hired is estimated to be five times greater for those who are open about their sexual or gender identity compared to those who are not out. There was one research article I referenced where they basically sent identical resumes into open job positions except that one resume identified college activities related to SGM pride groups or whatever. And there was a one-third reduction in follow-up hiring actions such as callbacks for those who identified basically were out despite the resumes being matched otherwise. The 2015 U.S. Transgender Survey suggests transgender people are three times more likely to be unemployed as I already alluded to. There are certainly effects on employee engagement when workplace discrimination is there. This data is from the Human Rights Campaign Foundation 2018 Workplace Equity Program survey data. I will certainly acknowledge this is not nice, clean, unbiased research because they're not a true research organization and it doesn't represent the general workforce, but it still has some interesting data for us to look at. There's a broad range of impacts, as I said, on employee engagement. From our perspective at OEM, my concern would be that some of these issues could lead an employee to not report work injury or work illness as well as impact our clinical management when they do get into our clinics for a work-related issue. There are actions that employers can take to address SGM discrimination in the workplace. Most of these are kind of outside the scope of what we do as OEM. I put them up here just for your awareness. I do acknowledge having come from a somewhat more traditional location recently, there's some political ramifications for employers that can impact their willingness to fully engage on some of these things. In the most recent AECOM quarterly, Dr. Zahra Chowdhury, who is a member of the AECOM JEDI committee, quoted an article or reviewed an article called the Surgeon General's Framework for Workplace Mental Health and Well-Being, a Call for Advocacy in OEM. I pulled out this one quote from her that struck me, OEM physicians are uniquely qualified and positioned to serve as both advocates and leaders when it comes to workplace mental health and well-being. Dr. Chowdhury discusses workplace mental health and well-being in fairly broad general terms in his article, but when I kind of dove into the Surgeon General's website that she referenced, they were very clearly including the SGM community in their addressing of workplace wellness. This figure I borrowed from their website succinctly points out several aspects of the employment experience I've touched on that would include the SGM community. I think, you know, I referenced you to Dr. Chowdhury's article, but take a look at that as well as if you have more interest to go into the Surgeon General's website for a lot more detail. I'm going to very briefly mention hate crimes against the SGM community only to highlight the ongoing pervasiveness of the negative attitudes. There was an article in 2022 in Clause 1 that reported on the 2017 to 2019 National Crime Victimization Survey. Despite hate crime legislation at the federal level and in several states, victimization of SGM individuals has persisted, with SGM individuals 10 times more likely to be victims of hate crimes than non-SGM. Additionally, SGM victims of hate crimes, when you compare them to SGM victims of hate of crimes that are not hate-related, are much more likely to experience social and emotional problems, physical symptoms of distress, and problems at work, which could be relevant to our work with the employers. I'm going to shift gears here a little bit and talk about healthcare for the SGM community. It's estimated that as much as a fifth of the SGM community will avoid healthcare altogether due to fear of anticipated discrimination. That's a slightly higher proportion for the gender diverse. When healthcare is sought out, more than one-sixth of these individuals report actual discrimination during healthcare encounters. There's reports of routine preventive care being refused due to the incongruence between the gender identity and sex reported in the insurance policy. For example, and I've heard this example more than once, a transgender man whose demographics have aligned with his gender identity of male, but he is denied a pap smear despite the persistence of the vaginal cuff. And that denial can be by the medical providers, or it can be by the insurance company, the coverage entity, who will not pay for that care because of that discrepancy. There's also been challenges in finding therapists or mental health clinicians willing to provide care. Dr. Burton's article notes that between 30 and 41 percent of SGM individuals have difficulty accessing mental health care. From an OEM perspective, I see a concern here with the EAPs and their effectiveness. In the summer of 2022 ACON quarterly, Dr. Craig Thorne discussed stigma as it related to the monkeypox outbreak and the vaccine at that time. These are some quotes of his from that article. What jumped out to me was this concept of stigma, and so I kind of did a little more deep dive. And I found actually a book published by Institute of Medicine in 2011. It's available online called The Health of Lesbian, Gay, Bisexual, and Transgender People, Building a Foundation for Better Understanding. Extraordinary depth and detail. Unfortunately, I didn't find it until very late in getting all my information together, so I didn't do a whole lot of deep dive. But there was a section on accessing barriers to care where the OEM further goes into the discussion of stigma. They talk about personal barriers due to stigma called enacted stigma, felt stigma, and internalized stigma. I'm not going to go into definitions or detailed discussion. They do acknowledge there can be other personal barriers that could be at play as well. And they discuss structural barriers to care. The structural stigma can encompass policies and practices of a health care system or organization or even our society at large. And those barriers include the provider training and knowledge as well as the availability of health insurance. To kind of display or understand structural stigma, the 2015 U.S. Transgender Survey reported almost one-third of transgender individuals who showed an ID document with a name or gender marker that conflicted with their gender identity were verbally harassed, denied services, or even assaulted. Other sources have suggested as much as 40 percent of gender diverse have been denied care. I'm going to talk a little bit more in a minute on the training part. And as we know, health insurance in this country is closely tied to employment status, where much of our insurance is employer-based. Gender diverse, as I've alluded to, the unemployment rate is as high as 29 or 30 percent, despite 80 percent of these individuals having advanced degrees. The 2011 National Transgender Discrimination Survey provided some additional data regarding health care and the gender diverse community. As you can see, a substantial proportion of gender diverse reported discrimination in the health care. It's notable that about 50 percent of gender diverse individuals report having to educate their health care professionals on the basic tenets of their care for the gender diverse. There are also impacts on specific health outcomes. In a research letter in JAMA Internal Medicine in 2023, SGM adults were reported to have higher levels of all of the following, poor or fair health status, functional limitations, psychological distress, difficulties with health care affordability. And these findings were found to be relatively consistent from 2013 to 2018. Other reports note that sexual orientation, other than heterosexual, is associated with negative outcomes, as well as challenges in accessing care. And it's interesting to note that several professional organizations, including the AAFP, refer to sexual identity and gender expression as a social determinant of health. In a 2016 article in JAMA Internal Medicine, there was a comparison of various health outcomes of lesbian, gay, and bisexual adults as compared to heterosexuals. The data was from the 2013 to 14 National Health Interview Survey. You can see some of the findings summarized in this slide. The authors found a statistically increased odds ratio for psychological stress, heavy drinking, moderate to heavy smoking, poor or fair health, and multiple chronic conditions. So what do we do about the health care inequity, or the inequities within the health care system? There was a report from the National LGBTQI Plus Health Education Center. The title of the report was called Focus on Forms and Policy, Creating an Inclusive Environment for LGBT Patients. They have a few recommendations, such as paying attention to the definition of family, so that partners, children, and even friends without legal status can be included according to the patient's wishes. To include terminology in written policy that addresses the SGM community specifically. To appropriately document sexual orientation and gender identity in the medical record data points, such as demographics. Take a sexual history that is clinically appropriate, unbiased, and unassuming. Train the frontline staff, I'm going to touch on that here in just a second, and apply these process changes to all customers, all people coming in, not just to those who appear to be a little bit different. I talk about the frontline staff because that's where our patient interface starts. There are paperwork and processes that can be revised, so the frontline staff can utilize respectful terminology during the patient check-in. Patients can be asked directly about their pronouns and preferred names, as I've previously mentioned. There should be, we should avoid sex or gender-assuming language until the desires of the patient are confirmed, and I kind of give some examples there of how you can use more gender-neutral language until you're given direction by the patient on what they prefer. The table on this slide shows how language can be revised on the forms to allow the patient to affirm their own demographics and their personal information that's consistent with their gender identity, and I found this gender-neutral drawing that I was intrigued by allows a patient to indicate an area of clinical concern without assumptions about genitalia. For example, a transgender male who may be experiencing vaginal symptoms can indicate that without having to use a female drawing versus a male or whatever. I think the key message is that we show respect to all of our patients at all touch points of care. We all know that, and that's regardless of the reason that they're in our clinic. These are, I think, some fairly common-sense concepts of how we show respect for our patients. We had to be careful not to assume that mental health issues are directly related to the individual's status in the SGM community, as I've previously alluded to. We should employ what's called a trauma-informed approach due to the prevalence of emotional or personal trauma experienced by so many in the SGM community. I added this last bullet, revise it from a source I found. It's just a simple statement of how a provider who's not experienced in dealing with his community can address the patient, especially with a gender-diverse, simply saying, I had no experience, I'm willing to be taught, basically. I think the key takeaway here is that we need to make every effort to provide all patients with the best care possible in an environment in which they feel safe. I'm not going to talk in detail about physical exams. I think it's fairly straightforward. The one thing that jumped out to me that I had not considered before was ask the patient's preference for a chaperone when it's needed, both for sex as well as gender identity of the chaperone. Allow the patient to kind of direct who you ask in to chaperone. Even with our best intentions, misgendering and other mistakes can happen. Some of the individuals will have learned defensive postures from their past experiences, but acknowledging the mistake and requesting their correction of your action can go a long way towards relieving that, the negative emotions, and it's important to use the patient's preferred name when addressing them as part of that engagement with their reality. The education I've talked about should be not only for providers, but for the frontline and other clinical staff as well. Interestingly, there was an article in the journal Medical Education in 2019 that reported that the only factor found to impact provider knowledge about transgender issues was transphobia. The amount of education did not appear to be associated with the overall provider knowledge. So educational efforts need to find ways of addressing the systematically socialized phobias surrounding the LGBTQ culture in order to help reduce the stigma that I've been talking about. We're all familiar with the term cultural competency. It's been one of the requirements in the mock system that's now being called something else. So it's all about the cultural competency as it relates to the SGM community. Even from the organized medicine perspective, virtually every national professional medical society endorses provision of high quality care, and that's not specifically talking about providing transition care, just high quality care when you see these patients. The National LGBTQI Health Education Center published a pamphlet in 2021 called the 10 Strategies for Creating Inclusive Healthcare Environments for LGBTQIA plus People. This is just a quick overview of the strategies. I don't have time to go into a lot of detail on them. First, there must be an active engagement from the organizational leadership. I've alluded to previously that policies should specifically address the SGM both as patients and as employees. The work or healthcare environment needs to be tangibly welcoming to all patients. We talked about revising the forms to be gender neutral, not only in the healthcare setting but in HR and other levels of the organization. The organization should develop partnerships with the SGM community, both those employed within the system as well as in the local community. I've already talked about all staff, not just physicians and providers should receive training on using affirming communication. De-identified data on sex and gender can be used, collected and used to assess and improve health outcomes or treatment plans. Individual histories should be appropriate for the individual and collected without judgment, as I've previously mentioned. While not necessarily in the realm of typical OEM practice, ensuring the SGM patients have preventative needs met is very important. Members of the SGM community should be actively recruited and retained as employees. I can tell you from previous employment experiences, there are plenty of employers out there that do not engage on any of these 10 steps, unfortunately. The National Institute of Health's Sexual and Gender Minority Research Coordinating Committee published a strategic plan to advance research in the area of SGM health and well-being through 2020. You can see the goals that they outlined on this slide. As previously noted, there's a need for OEM physicians and providers to serve as leaders of the healthcare team in addressing this unique segment of our population. In the slides that you can download, I've got resources from the Department of Labor as well as several websites that have extensive information related to the SGM community or transgender more specifically. This time I think we have some time to take questions or comments. Okay, over here. Hello. Can you hear me? Yeah, you can. Hi. My name is Matt. I'm from the University of Texas Health Science Center, Houston. I'm a PGY3 resident. My first two years of medical school were in Australia. My last two years were in Louisiana. I found something interesting in Australia at the Princess Alexandria Hospital in Brisbane. They have a whole section dedicated to other cultures and they try to welcome people like, for example, the aboriginal community that may not be as acclimated to the hospital environments and to Western cultures because they have a lot of beliefs specific to their culture. So there's a whole section that is dedicated to being culturally sensitive and to trying to meet their cultural needs, making them feel included. I was thinking that might help with LGBTQI communities or, sorry, SGM communities, but I'm afraid that they may feel segregated by them having a separate section. I just want to find a way to capture them so that these individuals with such high odds ratios can present when they need to the hospital. So I was wondering what you thought about that system and if it would work or if you feel like it would be of benefit. I agree that I think having a separate access or a separate clinic or a separate process for the SGM community may not be as fully beneficial. I think even if you're a physician who doesn't fully engage the community, a simple little rainbow flag, you know, the most current rainbow flag on the front window of your office simply tells people that you're a safe space. You may not understand it, but you're willing to see them and take care of them. And then it incorporates everybody into the same care system. I alluded about using the, changing the processes to apply to all patients that come in, and I think that's part of that, because as you allude to, when we segment populations, then we start creating those divisions. So I think it's important to find ways to, for the SGM community as well as for those of different races, different religions, different backgrounds, to say everybody's welcome and we'll try our best to honor and respect who you are, whatever your background is. Thank you. Great. Thank you very much for this presentation. I've been waiting for over 30 years to hear this. I'm going to do a case report, and the case report is on myself. In 1984, my older brother's roommate in med school died of AIDS. In 1985, as a senior med student from Kansas, I went back and worked for two weeks at J.P. Gaiman's Health Crisis and learned about the AIDS crisis and the center of it. I went back as an intern in the Air Force. We started testing for the virus. That fall, within a month, we had over 40 Air Force people who were positive. They had no one to talk to, myself and a nurse. Created the first Air Force AIDS education support group. I then set up, was the co-founder of the San Antonio AIDS Foundation, so they could talk off-base. I then, after internship, set up some programs in Colorado and then I applied for something called the White House Fellowship, which is a year-long internship with a cabinet secretary because of this work. I was turned down, I didn't know. In the next eight years, I was turned down, applied, and interviewed three more times for a total of four. I probably hold the record for the most people interviewing for a White House Fellow and not getting accepted. In one of the interviews, somebody asked me, so you're single, over 30, and work with AIDS patients. Is there anything you want to tell me? I did not say anything. I then finished in the Air Force. I did a residency at Harvard. Thank you, Air Force, and your tax dollars. I was a consultant in the Air Force. The Surgeon General of the Air Force called me as a major and offered me a position to be the consultant in the Air Force for the whole Air Force. Don't ask, don't tell. They just come on. I turned the Surgeon General down and killed my brilliant career in the Air Force because I could not go through ten more years of fearing that I would lose my job every day. I could not do it. I then took a position as a residency director. I'm not going to talk much about it, but it was a shared with the University and a not-for-profit. I was hired for the not-for-profit. Within two months after starting the University, the chairman of the School of Public Health and the Chief Occ Med Nurse in the program wrote a letter to the Residency Advisory Committee and the CEO of the company saying that Dr. O'Neill is not an appropriate role model for residents. I sued them for libel. I did not want money. I wanted to keep my job. I wanted to keep my respect. It took nine months, but they retracted it. I stayed there for three years and built the program. At the end of the three years, I won an award for Outstanding Educator out of the 700 providers in that group. First time an Occ Med doc had gotten that. At my thank you, I said, if I had a partner, I'd thank him. And I publicly did that. I then, don't ask, don't tell, was repealed. I then joined the Kansas Air National Guard. Yay military for doing this. I took a position in Kansas at a hospital there. Only resi-trained doc west of Topeka. Within two months of me taking the position, the firefighters stopped saying, we do not want you to do perny exams. I asked my nurse practitioner and she put her head down and said, the fire chiefs have decided that you're too feminine to do these exams. This is six years ago. And then, I'm sorry. And then the other people in my medical group did not return my phone calls. They did not take my consults. I had to send my consults to another hospital 45 miles away. And then companies started, stopped sending patients to me. I talked and found out that someone at the Chamber of Commerce was telling companies that Dr. O'Neill did unnecessary rectal exams. I could not do anything about it because I could at the time get fired if I said I was gay. I would lose the other stuff. I let that go. That's the back story. Now I want to talk about ACOM. I have for 20 years been involved, or actually over 30 years been involved with this. For 20 years of those, the last 20 years, people said, why do you not run for president of ACOM? Within the context of everything else that happened to me, in this conservative group where I had never felt encouraged and I was concerned about being on a ballot where I'm now a single man, over 40 and over 50, I withdrew from my activities in ACOM. I come to meetings because I have friends, but I stopped being involved with the health of delegates and other stuff. And I use that as an example that this organization needs to start addressing these issues. And I thank you for doing this. I tried to put together something two years ago. Long story short, I knew three people in ACOM in 30 years who were gay men. Didn't find out through ACOM. I found out through other stuff. There are now more people, three in this room, that I know are gay than I knew for the first 30 years. I tried to find someone to be on a panel that was an ACOM member that was lesbian. I asked all my friends. They did not know any. So I thank you for doing this. I want you to understand there is bias and other stuff. I'm a strong personality. I have the unconditional love of my parents, but we have no idea how many people do not apply for jobs, do not get the jobs, resign from jobs, fire for jobs, or God forbid, kill themselves because of job related issues in this. So I thank you for doing that. I am sad that I withdrew. It was my own choice to withdraw from leadership and other activities in ACOM, but this group needs to sit and say it needs to be a welcoming environment. And I thank you very much. I didn't do a resume review, but I did 20 years in the Air Force as well. I joined in 1997 and retired in 2017. And in 2014, it changed significantly. That's when the Don't Ask, Don't Tell was dropped. I remember that day. Yeah, I'm not going to go into detail, but I've experienced what you're talking about of having to hide for most of my career. And it was rough. It was very tiring. And part of the reason I'm doing this today is because I'm tired of hiding. And I don't anymore. I'm married to a wonderful man, and we're very open about who we are. But you reach a point where you say, I just can't. I just can't duck under the covers anymore. Yes, ma'am. I'm Dr. Karen Linick. I'm currently a Corporate Occupant Physician at 3M. This man was my residency director and the best educator and the best role model that I have ever had. So I just have to say that, Dr. Linick. I try to be a good ally. I think one thing we could provide to you, I know it's a small thing, but we could have rainbow lanyards at the conference, I think would be really great. It's a thing 3M started doing. They were so popular, they ran out of them. So I'm waiting for my rainbow lanyard to come in the mail. So trying to be a good partner. One of the things I've been trying to figure out how to word is asking people for their biological sex. So when we're doing spirometry, we're comparing people to the right NHANES tables. Or if we are to take on the NHANES audiometric data, same thing. We would need to look at male, female. So what I did, and I don't know if this was right or wrong, when I was at my other position, I had three transgender patients. And I just politely let them know to be able to look at the reference values and have them be accurate. If it's okay, I would like to put into the system, you know, male, we can identify as female or female if you identify as male. Is that okay with you? Is that a way to approach it? And what's the best way in a survey question to ask that? Like, what is your biological sex at birth? Is that too long? When you ask what is sex, though, it gets really confusing. So please help me. Well, and that's why I use the term sex assigned at birth. Sorry, again? Sex assigned at birth. Yeah. Yeah. So it's a little easier to say. Sex assigned at birth. Love it. Sex assigned at birth. Yeah. So that's what the community uses to say, you know, this is where you started. You know, there's some very early data that shows that transgenders who are undergoing hormonal therapy, their numbers change. Now, this gets into the whole complex political decision about the sports and stuff, and I'm not going to even go there, but you're talking about something that's very clinical, and you're right. I don't have any answer, but there's some early data that suggests maybe the male assigned at birth who's been on hormones shouldn't be compared to other males. I don't know. So it's an interesting dilemma. So I don't know there's a right answer there, but sex assigned at birth is the easiest way to get that portion of the information. Great. I will use that, and then I think what we'll have to do is, depending on when people transition, is maybe we'll just look at both tables and make the best decision we can in terms of where their lung function is. It sounds like there's a little bit of discrepancy on whether you would go with assigned sex or sex when you transitioned. Yeah, and it depends on the stage of transition, because if they've started transitioning but have not been on hormonal treatment for very long, there's not going to be that much physiological change. So I think doing the baseline of sex assigned at birth, but then talk to them and say, okay, I know you're transitioning or have transitioned. How long have you been on hormones? Has it changed other aspects of your physiology? So let's also look at the other sex and make sure if they're fine on both of them, then they're probably okay. Thank you. Hi. My name is Dan Samo, and actually there are some good news for you. The good news is that if you search ACOM, you'll find that the ACOM's Guide to the Evaluation of Law Enforcement Officers has just created a chapter, which took us two years. We did an association with TCOPS, the Transgender Community of Police and Sheriffs, and it is about transgender gender diverse police officers. But for all of us who really, what this impacts is our need to be able to do fitness for duty evaluations on transgender gender diverse patients. What we say for law enforcement officers applies to everybody. And there's extent, there's a chapter, the beginning of the chapter says how you do a fitness for duty for a transgender gender TGDP people. But then, and that's just medicine, and that's not very short. But then there are very several appendices, which are extensive. One is about medical issues. One is a huge one about psychological issues. One's about definitions. And then two, which I find, which I found personally the most educational, we ask the TCOPS members to send us in their experiences with the medical, their interactions with the medical community. And when you read these things, it's frightening and educational, and I think everybody should read it. Unfortunately, you have to subscribe to the document, but hey, that's good for my group. And then the last one is actually what I lovingly call stupid shit that people say to transgender people. And we have a whole, just unexpurgated, this is what was sent in to us and we published it. And also so educational to read all this stuff. So good news is, yes, we are addressing it. And I think it's very important. And thank you for a great presentation. Thank you. So I was actually aware of the new chapter, but I don't have a subscription to the LAO guide. And so I actually emailed somebody at staff and said, can I get a draft copy? I'm not going to share it. I just want to use it. But I was not able to get that because of the subscription issue with that. So yes, ma'am. Thank you for an excellent presentation and long overdue. I was looking for your, I have two short questions. One is, can you, will your slides be available to us because you have great terminology? Yeah. Yeah. The slides are in the swap card system so you can download them. Thank you. My other question is, do you have any recommendations for physicians who do occupational medicine and primary care so that we can better serve our LGBTQ community in terms of their health needs as a means of being able to support our community that has that, whether it be through the occupational medicine realm or primary care both? Could you provide any resources in addition to the WPATH, like any CME courses or anything that you would recommend? AAFP has a health toolkit as well. Yeah. I didn't dive too deep into that, but AAFP and the ACP both have stuff on how to do clinical management, clinical care, whether you're doing transition treatment or just caring for them in general. So I think those will both be really good resources. Okay. Thank you so much. And I was going to mention to the lady who talked about the rainbow lanyards, most of the professional organizations that I'm aware of actually have whatever they call it, sections or interest groups or whatever within the organization for the LGBTQ community. ACOM doesn't. We're a much smaller organization. Maybe there's a little more conservatism, but that could be something we could investigate as some kind of connection within the organization. Yes, sir. Hi, I'm Steve. I'm from the UK. I just wanted to make a couple of points about the UK experience of this. I'm the current president of the UK Faculty of Occupational Medicine, which is the UK equivalent of ACOM. I'm a cis gay man. I'm the second openly gay president of the faculty within the last six or seven years. And my experience is very different to what I'm hearing from you. I think part of the reason for that is the UK Equality Act 2010, which defines sex and gender and sexual orientations, protective characteristics and discrimination in the workplace is illegal. I'm not saying it doesn't happen, but it's a rarity. It's something I very rarely come across. And I very rarely come across homophobia or any kind of discrimination in the under 25s in the UK. It's pretty much confined to older people. My passion outside medicine is I coach an LGBT plus rugby team. 80% of the players are LGBT. I've got male to female trans players. I've got lots of gay men. I've got pansexual players. My experience is it's a very high incidence of economic inactivity and being out of work, which means that people like you and I don't get access to them and a much higher prevalence of mental health problems. So we're certainly not perfect in the UK, but I think within the workplace we're a bit further ahead than you are at the moment. I'll tell you what I like. One of the things I like what you said is 80% of your team are LGBTQ. That means there's 20% in there that are nothing but allies and they're out there playing rugby with them. I love people like that who just, they don't care. They just want to be around and be with their friends. One of the things that surprised me is this is a brand new team development site that's been going for a year. We just came third in the International Gay Rugby League in the UK, which put it into a cup final and we came away with the plate. We won silverware our first ever year. Congratulations. And most of the players have cried. We're the straight ones. It wasn't the gay ones. Thank you. I want to thank you for your presentation. I want to thank you for really opening everyone's eyes to this issue. I wanted to also commend you on the one slide that said it's okay to make mistakes. You know, having a gay transgender male son, I make mistakes. I still make mistakes, but to be an ally, just recognizing that it's okay to make the mistakes if you're really trying and just reject that guilt that you have when you make those mistakes. I'm trying. As far as the lanyards, great idea. I know I have one for work that I got at the Civil Rights Museum that is rainbow and also has Martin Luther King quotes all over it that is awesome. Highly recommend that. And then please, please return to leadership. Please return. I hope that the Jedi committee, we're trying, we're just getting off the ground, but beyond that, if you have a passion for leadership, if you have a passion to make change, please consider starting that path to the leadership or continuing the path that you're already on. Thank you. So we're just a couple minutes over time, but I think we can do one more question. If anybody needs to leave, that's fine. Good morning. I'm Renee Williams from Park View Occupational Health Clinics in Fort Wayne, Indiana. And from an occupational health standpoint, in cases where sex assigned at birth matters, how do you approach that, for example, DOT direct drug screens? How do you approach that with compassion and care for those who haven't fully transitioned? That's a good question. I think you got to approach it carefully. You know, I would have to go back and look at the DOT rules. I don't know that they define the sex marker on the forms as sex assigned at birth. I'm not sure about that. I would have to go back and look at that, because if they don't, then you have the flexibility to assign the sex that the individual prefers. When you examine them, you need to examine them appropriate to your comfort level if they are qualified. And if you need to do an unclothed exam, as I talked about talk to them about why, that you're trying to make sure of public safety and do the exam with respect. And it's not an easy area to consider. This first came to light in my practice. My staff said, oh, there's a guy in there for his CDME. And I walked in, and it was facial hair, clearly male structure, but wearing a dress with some breast appearance. And so the first thing is I'm sorry if my staff didn't know what to say to you. I assume you go by she, her, and she said yes. I can't remember her name, but it was not the male name that she had taken on the female name. That's fine. I did the exam as I was supposed to. I chose not to do an unclothed exam on her, because I don't do that on women who come in for a DOT, for a CDME. And so I just decided to respect the identified identity and moved on from there. I think in her case, the driver's license still said male. And so I said I'm going to have to mark on the form male, so it's consistent with your driver's license. And she said that's perfectly fine. She understood that. Did you do the hernia check with her? No. No, I didn't do anything exposure-wise. That was a personal choice, and I know Dr. Harden-Balmer probably slapped me for that, but that was my choice at that time. Then afterwards, I called my staff together and did some training with them, not out of anger, but none of them had dealt, since it's Nebraska, none had really dealt with transgender before. And that's what kind of drove me to realize, heck, it can't be just the providers who are trained, the frontline staff, the nurses. And they were all very receptive. They were very willing to listen and understand. And it made a difference when we had transgenders come in in the future. Thank you. You bet. Yes, Dr. Thorne. My name is Craig Thorne. I'm just tracking online questions for the session. And this was more of a comment that came in, but I think important. Just a comment about sharing of information with the employers and questionnaires. I think we all know that in certain circumstances, employers do have access to answers that come forth or full copies of questionnaires. Obviously, it's not something that we want to do, but in certain contexts. So just a warning, particularly with DOT exams, et cetera, from this particular listener, that we should always work in the context of protecting information from being shared with employers and the government. Just wanted to share that. Great presentation. Thank you very much. Thanks, Craig. Thank you very much. Thank you.

SGM community

employment

healthcare

David Cochran

terminology

discrimination

inclusive environments

training and education

progress

awareness