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All right. Hello again, everyone. This is Nina Clark. I'm the surgical education fellow with Behind the Knife, and I am very excited to be back with our friends from the Association of Out Surgeons and Allies for our third episode, focusing on LGBTQIA plus healthcare providers and their patients. We are once again, joined by Dr.

Andrew Schlessel, who's going to help us introduce our guests for today. Well, good evening. Thank you, Nina and the behind the knife team for inviting us back tonight for a very exciting episode. We have three guests tonight. We have Dr. James Taylor. He's an assistant professor of colon and rectal surgery at Montefiore Medical Center in Bronx, New York, and his pronouns are he and him.

We have Dr. Alex Bonte. He's a general surgery PGY 4 resident at Hackensack University Medical Center in Hackensack, New Jersey, and his pronouns are he and they. And we have Dr. Paige Tanhauser. She's a general surgery PGY 3 at Allegheny

General Hospital in Pittsburgh, Pennsylvania, and currently she is finishing up a postdoctoral research fellowship at University of Virginia, and her pronouns are she and her.

Thank you So tonight I'm very excited about this episode because we're going to take a deep dive into LGBTQ plus health care. Our guests tonight have provided us with some very essential information that I think will help providers at all levels create a more inclusive environment for our patients. I do think as surgeons, I feel that we have a very unique interaction with our patients.

They often see us when they're in severe amount of pain with new cancers or any variable amount of vulnerable times in their lives. So I really think we owe it to them to provide a very welcoming, trusting and caring environment for them. So, with that said, I want to turn it over to our guests to discuss some of the background and important concepts about LGBTQ health care.

Great. Thank you so much Andrew, for that introduction. I think a lot of the

historical aspects of the sort of LGBTQ healthcare really stemmed back to sort of the 1980s when the DSMV being a homosexual was still designed as being a mental health disorder. And when you add sort of the, the stigma that was associated with that and then all of the tragedy and all the loss that was suffered during the HIV and AIDS epidemic, really that sort of as a starting position for the LGBT community made it a very difficult place.

There was a lot of associated stigma and a lot of associated difficulty with healthcare. A lot of getting started on how to make sure we get away from all that is really understanding our patients better. So I think as we learn more about the community and how to provide this care for them, there's a lot of terms that we use for our patients to help them feel like they're included in our.

Clinic and hospital. So I was hoping you can discuss a few of the terms and what people out there should know about our patients going into

these conversations. Yeah. Hi, this is Alex. I am very happy to talk about terminology. I think it's one of these like basic things. And I think as Dr Taylor was talking about, like health care is the Classically and still currently a place, I think, in which many LGBTQIA people, me included, many, you know, of my, like, friends, family members still feel, like, pretty excluded, especially when we're talking about, I don't know, it's a, you know, healthcare as a field, sort of, Sometimes we'll move slower on social issues like this.

And when you encounter a healthcare provider who knows it, or is at least familiar with these sorts of like basics, it can really make a big difference in kind of your experience of healthcare. And oftentimes like your likelihood to seek healthcare, which can be a big barrier. A lot of the time, my, my like earliest clinical experience or one of my earliest clinical experiences with the, you know, the Gay men's health collective at the Berkeley free clinic, which was started during the AIDS crisis when, men would be turned away from their doctor's offices just, you know, for being gay.

And so, that history is pretty

recent and I think even small things like this can make a big difference. So, I'll start. Has anyone ever heard of the genderbred person? Yes, I have. Yeah? Okay. Yes, I have. Yes, I do love that diagram very much. I think it's extremely helpful. It sounds delightful. It is.

The genderbred, it's gone through several versions. And actually the most recent version is a unicorn. But the idea basically is it gives you this picture. person and in various parts of the sort of like the physical representation of the gender bred person. They talk about the differences between gender identity, gender expression, your sex assigned at birth, and then the differences between romantic and emotional attraction.

And the idea that all of those things are on their own spectrums and don't always have to align in the ways that I think, they traditionally align. popular culture or the ways that we like have been taught to think about them. So I'll start with sex assigned at birth. It's the first definition I have on my list.

And this is sort of the male female or intersex definition that is assigned at birth based primarily

on, external anatomy or your chromosomal analysis or basically what the baby looks like at birth. Of course, that sex assigned at birth can be different than your gender identity, which is my next term.

I think I also heard a statistic that like the incidence of an intersex personhood is like 1. 7%, which is roughly equivalent to the number of redheads in the world, just for perspective. But so gender identity different than sex assigned at birth is an individual's Personal and internal understanding or sense of being male, female, neither, both or another gender, or like a man, a woman, neither, both or another gender.

A person's gender identity it's important to note is self determined and doesn't always match with their gender expression or their sex assigned at birth. And gender identities are most often described as male or man, female or woman or non binary, but these terms are necessarily limiting and are sort of always changing based on who you're talking to.

The next one I have is gender expression. So we have sex assigned at birth, gender identity, gender expression. Gender

expression is how an individual chooses to express their gender identity on an outward manner and generally determines how a patient is treated in society or clinical interactions is often dependent on their gender expression.

But again, it's important to remember that a patient's gender expression and their identity may not always align and that pronouns are determined. And we'll talk about pronouns a little more later, I'm sure, but pronouns are determined by the individual and are a form of gender expression. So I think also there's a one of the earlier popular ways to talk about gender or about pronouns was your preferred pronouns.

And I think for those of us who have. pronouns that are maybe don't fit with the way that we express our gender. That idea that it's just a preference can be a little, what's the word, like patronizing, I guess. And so, you know, when you're asking someone what their preferred pronouns, and it's, we're really just asking, what are your pronouns?

Cause they are what they are. And it's not like a matter of choice. It's like, it's just your identity. I'm sorry. I wanted to make that plug. against preferred pronouns. Next one, I have it. So now we're talking about, we have sex

assigned at birth, the cell is gender identity, gender expression, and the, now we can talk about sort of cis and trans, which are terms that people hear a lot of the time.

And if we remember from organic chemistry, cis is when, the two branches are on the same side and trans is when they're on opposite sides. I'm trying to ground it in something that we're all traumatically familiar with and so a a cis person is someone whose gender expression and gender identity aligns with their sex assigned at birth.

So if your sex assigned at birth was male and you identify as a man, you are a cisgender man. I, so a transgender person is a person whose gender identity is not the same as the sex that they were assigned at birth. So for example, a transgender man is a person whose gender identity is male and their sex assigned at birth is female.

Transgender people do not always identify as male or female. And it's important to remember that like anyone else, transgender people may identify anywhere along the spectrum of gender. And so, the idea that a transgender person is either a man or a woman is like still sort of working within this

binary that has caused a lot of.

A lot of binaries cause a lot of problems in history and society, and this is one of them. And then also, I'd like to. And I wrote this in the list just so we know the term transvestite, which is a very old term, is definitely, is considered offensive and really would not be appropriate in any clinical setting.

Unless, of course, that's what the patient has asked you to address them as. The next section is sexual orientation. So sexual orientation describes the type of attraction an individual feels towards other individuals. And that can also be any mix of. all these things that we're talking about.

Orientation includes individuals who do not feel sexual attractions. That's asexual people, that's the A in LGBTQIA, and sexual orientation is not the same as gender identity or gender expression, and to assume that they align in some way is probably, is not always accurate. And then the last one I have, deadname.

You've maybe heard this in popular culture or around before as well. A person's deadname refers to a transgender's

person's name that was assigned at birth that they no longer use to refer to themselves. And the verb dead naming is the act of referring to a transgender or non binary person by their dead name, which can be very traumatic to that person and which may be unintentional.

And I think You know we encountered this a lot of electronic health records really sort of, a lot of times will point us in the direction of the person's sex assigned at birth or will have, the name that they were assigned at birth. And sometimes that is not always the identity or name that the patient still uses.

And so while it can be unintentional, it is also used, you know, sometimes in less friendly context deliberately to mock or negate a person's identity. And I think, that's part of why that can be Even if you, the clinician are thinking, oh, this was, you know, an honest mistake, it's not the information I had, it can still be really painful for the patient that you're talking to because of experiences they've had.

This is Paige. I think Alex did a great job at going over all of the terminology. I think one thing to add to is the

term non binary because there are, yeah, there are many people who may not necessarily identify whether they're female or a male gender identity, which I think can kind of segue into you know, different pronouns that people may prefer to go by.

For what it's worth, you may have noticed my pronouns are he, they I'm coming out on this podcast, I suppose, to my whole residency, but I identify as non binary. I don't think anyone's gonna be super surprised, but I forgot myself and my definition. So that's cute. I love it. That was a super helpful overview.

I think of a lot of this terminology, much of it, I think is really new to a lot of probably older. Physicians who maybe haven't gone through the steps of educating themselves and Alex, you specifically mentioned that this was actually from a score module, which I think is actually really important to highlight that this is now being expected of us as surgical trainees to learn as part of becoming trained and board certified surgeons, which I think is hopefully indicative of a step in the right direction as a

surgical culture.

One thing that I'm from a very small town that has a lot of people who haven't gone out of their way to educate themselves on how to refer to their patients or other people in general. One thing I think a lot of folks have anxiety about when they're referring to patients or interacting with patients from different backgrounds.

So to speak, is what do you do if you mess up? And what's the best way to ask and do this right? And if you guys have experienced that or if you have thoughts on best practices for learning what your patient's pronouns might be, learning how they prefer to be addressed in, in clinic, and what to do if you mess it up even if it is inadvertent.

I think the thing to appreciate is we're all human and we all make mistakes. So if you do use the wrong pronoun or the wrong name then apologize and ask them which names and pronouns they prefer, and then continue to use those going forwards, if they're documented in the charts inappropriately or incorrectly, then also make sure that they're changed on the charts as well.

I think at the core of it is really like a genuine respect and curiosity for your patient and how they identify. But like I

mentioned, you know, when I was talking about this, all these definitions are, they're moving targets is not quite the right term, but like there anybody can be anything.

Yeah. We're human beings, you and your patients. And I think that ultimately the best advice is that, you just ask your patient. And I think a lot of the best practices around sort of incorporating pronouns into clinical practice talks a lot about, you can just introduce yourself, including your pronouns and ask the patient how they would like to be addressed.

Yeah, I think all of this is really about, you know, respecting the patient and who they are and meeting them where they are. And I do think it is going to be a cultural change. Even myself, I have intake nurses sometimes doing the exam and they don't understand sexual identity versus sexual orientation and they're very confused when I say that I'm a male but I'm married to a man and it's it's difficult and I'm not insulted and I just want people to feel comfortable being comfortable asking and being comfortable if they don't know how to ask too and it's kind of fun to educate them a little bit.

But with that, I do want to get into men who have sex with men, and I wanted to touch on that a little bit with all of you, too, because in colorectal and in any area of surgery, you may have some of these patients come in, and you may be really happy that you're making forward progress by asking if they're gay, straight, bisexual, and we often miss this really important patient population, and I was hoping you could touch on that a little bit as well.

Thank you. a little bit more of understanding that these men may not identify as being gay or bisexual, but they may participate in anal receptor intercourse, so they may be at risk for some of the same STIs, anal dysplasia, and we oftentimes may miss that, those appropriate screening modalities for some of these patients.

It can be a very difficult you know, embarrassing thing for the patients to, to discuss and it's all about setting the scene and using appropriate screening questions when you are taking a good history. The CDC has a really good screening system

called the five P's where you talk about you ask about the partners that the patients would have, the practices that they do if they engage in oral or anal intercourse, or they use toys.

Whether they use protection any past history of sexually transmitted infections and then if appropriate talking about plans for pregnancy as well. And that can be something that can help to gather that information and elucidate some, some extra information from the patients. I will also take that and make a plug for CDC with everything that we talk about tonight.

No, we're not here to provide specific recommendations for health care, but anyone can download the CDC STI guidelines, all their data is extremely well put together for those who want to go back and look. And we can certainly provide that in the show notes. I think tuning a really great resource for providers and patients.

Absolutely. So let's move a little forward and talk about you've all alluded to it, I think, in various ways, but there are some documented and

some undocumented, probably, disparities in health care access and utilization from LGBTQIA plus patients. I think one of the key things to appreciate is that the amount of evidence related to sexual orientation and gender is really lacking.

It's starting to come through now and there's now dedicated centers of NCI, for example, for cancer research that are looking at sexual orientation and gender identity. But compared to the heteronormative heterosexual population, the data is simply not there. You know, up until recently, you weren't asked about your sexual orientation at all, so it was hard to make any inferences from the data about risks.

But we do know that members of the LGBTQ population have different risk factors. There's higher rates of behaviors such as smoking. Yeah, I mean, I, yeah, I was going to make the same point to begin with is that like, you know, our, we

as a like community and as a demographic are underrepresented in like historical Data and current data.

So it's tough to actually speak to, you know, the disparities that we experience that aren't disparities that sort of fit into a popular narrative about what it is to be an LGBT person. And I think that's why sometimes it's hard to talk about, you know, there's evidence to show that maybe there are higher rates of, sexually transmitted diseases and in people who identify as a man who has sex with a man.

But I think it's, I don't know. Maybe this is what you were running into, Dr. Taylor, but like, I sometimes have trouble figuring out how to talk about that in a way that doesn't reinforce, you know, the stereotypes that are there that put us into certain boxes of like, thought, you get a question stem that has like a gay man that starts the question stem and like, this is going to be an STD question, you know, and like that, That kind of sucks in a, in a sense.

So it's tough to, I don't know. I also have trouble talking about this. I have trouble talking

about the disparities that we experienced that are not, that, that don't put us into boxes, I guess. And I think that's sort of what we're part of what we're talking about here. Right. It's like to sort of appreciate that our identities are not just what we've like learned about in medical school or the way that we fit into certain epidemiological brackets, but at the same time, we're on this episode talking Healthcare in particular.

So it's tough. I don't think I answered your question. I just talked more about how it was tough. Well, I mean, even just listening to y'all talk about it. I I'm doing big database research right now. And that's not even a field in my data, right? This is a national database that's frequently used for specifically disparities research because it collects things about income, race, ethnicity, payer type, yada yada, you name it.

But there is no sexual orientation. There is no, you know, I think about these like five Ps, right? All of those have accordant risks, probably from an epidemiologic standpoint, and they probably differ. As you say, anyone can be kind of anything. And so it's, you know,

Both complicated in that you have to document that stuff to be able to know the risks associated with those things and to be able to track them and track improvements hopefully in them over time, but we haven't been doing it for very long.

And then sometimes it's like difficult to disclose as well like from the patient side, like, sometimes you don't really want to tell your doctor or your researcher or whatever that like you're LGBT because you're afraid of like how it's going to affect you. Like how it's going to change the entire way that they think about you in your life, you know, and that's hard.

And like, that's like, you know, that that's all the social stuff that's coming into the, you know, our clinical practice, but that all that stuff is real. And, we have to think about it and I don't know how to solve it on this podcast, but I hope it helps. I think too, something that goes along with all of this is, you know, mental health disparities and challenges.

I think especially in the pediatric population, you know, there's now it's, we're fortunate enough that there's a little bit more visibility in the

LGBTQ community for the current youth to kind of look up to, but still, I think there are. Many who don't really have those role models or are in difficult family situations or are living in less, you know, accepting, environments and to get mental health care for them.

You know, who do they talk to, especially if they're their kid? You know, the person who you would talk to, to get that next step of help, would be your parent, but sometimes that is the challenge that, they're facing, you know, they may not be accepting. So I think that's a big thing where there's, there's not a lot of visibility.

Ability on youth facing mental health disparities because of this. Yeah. And I think it was a great points page. And I think that segues nicely into sort of the barriers and facilitators that members of the LGBTQ community face. And they, you know, as we like to do in surgery, they can be broken down into subcategories.

And I think of a good way to think of it is individual factors. So barriers are sort of lack of knowledge, a fear of results, a fear of discrimination. Maybe a lack of social support as well. Like you touched upon Paige with with the mental health in the adolescent groups. And then the provider and team based barriers.

So not having a provider who is familiar with the LGBTQ knowledge and risk factors and doesn't know how to use the appropriate terminology or pronouns to address you and makes you not want to disclose the information that might be crucial to your healthcare. And then there are, there are system based barriers.

Insurance might not be accepted. Documentation is saying, you know, having, asking questions, I do identify as male or female rather than asking about your sexual orientation and your gender identity. All those sorts of things can be huge barriers. And I think as we're seeing in today's. Political climate.

There are lots of states and national barriers that are making it very difficult for

certain members of the community to get the help that they need. Yes. And one of the background pieces you all provided us, you spoke about the term organ inventory, which I thought was a really interesting concept.

If you could speak a little bit more to that and how that can help direct you to give the appropriate care for these patients. Yeah, of course. So it's something that's been around since about 2013 and it was put forward as a way of recording in the electronic medical records the organs that the patient has or does not have.

So, it includes things such as having a penis, having testicles, prostate, breast, vagina. Uterus and cervix and ovaries, I believe, and using those that enables you to talk about risk factors and screening for cancer and sexually transmitted infections and really allows not only the patient to feel you know, seen and to, for them to know that the provider knows what the, what they have and do not have, but then to guide their

care appropriately.

For example, a trans man may have had top surgery and may not have. breast. I mean, I think that they have breast tissue, but not all of the breast tissue is completely removed. So it's important to be aware for breast cancer screening. Do you think a lot of those patients are educated preoperatively to know that they need to focus on the screening?

During their life postoperatively. I imagine it's not perfect. You know, I deal a lot with inflammatory bowel disease, for example. And you know, I know a lot of patients who come back to see me, you've had part of their, they may be, they've had your ulcerative colitis and they've had their colon removed and they've still got their rectum and they weren't aware that they needed to have the rectum surveilled and that we, you know, 50, 60 years later, and they come back with a rectal cancer.

So. Obviously education from the patient side and also from the provider side is not perfect, I believe. You guys have highlighted a couple of ways how we can better support

and demonstrate inclusivity of the LGBTQIA community in our individual patient interactions by asking you know, how they prefer to be addressed and asking about things like their practices and their anatomy.

What are other ways that we can ensure that our practices, our surgical practices are friendly and opening and inviting to people in the community? I think something simple really to start with is if you have, a, a rainbow badge or pin on your white coat. I know a lot of medical schools, And healthcare organizations go through a safe zone training where they kind of discuss proper pronouns and terminology, and they'll give you a little pin after that.

So wearing that, I know I at least feel, a little bit more, you know, safe and open to speak to my provider if I see that they have a pin, or as far as like decoration goes in the office, if they have, something that's Signifies, you know, accepting

the LGBT community, whether it's just a rainbow or says something on there.

But, you know, that's something simple, I think you can start with that, you don't have to even say anything to begin with. So I think when you do start speaking to your patient, and inquiring about pronouns and all of those details that they may not feel as open to sharing, I think that that will kind of set the stage for them and make them feel a little bit better.

more comfortable to share that information with you. I agree about the badge pins. I feel like it's like such a small thing, but I, multiple times, like, I've had patients who are like, just thank you so much for, like, wearing the pin, like, it's made me feel at ease and to your point about pediatric patients, I, like, it's actually been, Pretty common with like adolescent patients who are still sort of figuring out their gender identity.

They're like, ask me about the pin and, you know, talk to me about something that normally they wouldn't talk to their surgical consult resident about, I guess. And I think from a resident's perspective it's like also nice sometimes to see an attending who is wearing

like a pride pin or like a pronoun pin or something like, as a trainee, I know relatively few out attendings that I can like talk to about Well, what this whole thing is like, and I really think those little indicators surprisingly go a long way.

And so, yeah, I'm in huge support of the pins and pronoun pins are nice too, because, you know, I think I agree with you that I think in sometimes in many clinical contexts, it can be, this is difficult to say, while I am very, supportive of integrating pronoun disclosure in all of my clinical interactions.

Sometimes it can be a barrier or like it feels like a barrier to incorporate that into my introduction to a patient. And I feel guilty about that. And I'm still figuring that out, but like a pin with the pronouns on it really sort of introduces it in a way that is there for people who are looking for it or like who, who can recognize that this is a sign of a safe place, but not in the way that if you, I don't know, you know, sometimes you have a patient, if you introduce yourself with your.

pronouns, they're going to be like, Oh, Oh, what are you talking about? Oh, we're doing pronouns now. You know, like I've,

you know, you can sometimes have like attendings who are going to do that with you. And so, you know, the pins can really help. That's all. I think you're really voicing a lot of the internalized fears that I mean, frankly, like probably all of us have, right.

About any question that we ask a patient is by default. intrusive and a little scary to ask. And whether it's me asking when their last mammogram was or what their pronouns are, like you're introducing a topic that is not normal human conversation. Right. And so I think it's it's refreshing honestly to hear you express that it's hard to work into conversation because we don't talk like this normally.

We don't, you know, interact with people the way that we do when we're, I'm seeing, you know, patients in the emergency department as a consultant, especially. I'm, and of course I would make the argument that I, I wish it wasn't, you know, something that was abnormal from daily practice. But, you know, when you're talking to a patient, you sort of put yourself aside to, to be there for the patient in the way that they need.

And sometimes that can mean being, you know, Very upfront and

open about pronouns. Like, I had a young trans patient who was coming in for an elective procedure and I made it, you know, first opportunity I had as like a chief to really sort of like be, we're going to, we're going to respect this patient's pronouns and we're, there aren't going to be any questions asked about it.

And in that context, it. really made a lot of sense, right? And that, that was something that I could do to obviously make that patient feel like more welcome and affirmed and in this situation that is already very stressful for them, they're having surgery, you know, but in, in other contexts, like it may not feel that it's something that is like a conduit for the patient provider relationship.

So sometimes these, like these passive indicators can be a way into those conversations when it is the, a way to connect and. You know, provide better care to those patients. Well, and exactly like you said it's simple stuff, right? It's having a pin on your lapel. It's having a, you know, a pronoun pin on your badge or something like that.

It's not difficult to implement, right. But it affirms people clearly, right. When they see it.

And so that's, it's nice that there are options for like, I don't know, entry level ways to make yourself a more welcoming provider and a more open provider for patients. And having pronouns all over people will make it much like more regular to talk about pronouns.

If you normalize the conversation and you, it feels normal to you, it'll feel normal to them. And it's really even important in an emergency situation, even though someone may have perforated something and need something urgent, but they really perceive that initial interaction with the provider and they will remember the fact that they've Felt like they were really seen by that provider even in their worst situation.

The other thing is I've noticed some institutions on their intake forms, things like that, will have their pronouns and however, and gender orientation identity, and not only that might make it help more helpful for a provider that may not feel as comfortable right away, but it also makes the patient feel that the whole system is inclusive on their healthcare, which I think is really interesting.

I think forms are huge

surprisingly like I think the first time I went to somewhere that had a forum that had like multiple sexual out as listed I was like oh I didn't realize I was feeling Excluded in this way for a long time because I now feel included, you know Yeah, I think that's huge. I think when we typically think about intake forms, they usually ask, you know, either What's your gender or you know, what's your sex and the two options are male or female?

And so you're not quite sure what exactly are they asking? Are they asking what you identify? Identify with or you know what your sex assigned at birth was But something on at least Epic, I know not everybody uses epic. There is the sexual orientation and gender identity section so really allows you to kind of elaborate and expand the discussion with your patient on gender identity and expression.

But it is, important to ask your patient

if they feel comfortable putting that information in their chart, because it's something maybe they feel comfortable discussing with you specifically. But once it's in, you know, their EMR, that's something that, you know, all their providers that have access.

I do think sometimes it can be like little things, you know, where. Someone has, pronouns that don't match what they are in the chart, and you're, like, running the list and someone has to, like, remind themselves to correct the pronouns or they'll just use the wrong pronouns, and, like, blow past them, and just, you know, not address it, or, like, when they change it, they, like, have a sigh, or something, and I think little things like that, just for all of us, can, you know, that, that's, That could be very exhausting.

Getting at like micro aggressions or, yeah, yeah. Stuff like that, that just builds up over time. I think there are many, many groups beyond this one that would say that that stuff happens all the time and exhausting is a perfect term for it, right? But I think that it highlights this idea of. Just trying to be a kind person when you're in the hospital, right?

And except when

you've said something wrong and say you're sorry and move on and try not to do it again. And I think even just coming at this whole topic with that kind of mindset of, I just want to be the best provider for my patients and the kindest person I can in the hospital. Yeah. Colleagues to write it, it applies across the board is a good starting spot.

You know, it's not going to be perfect. None of us are, but I think it's, if you come at it with that kind of mindset it seems to be a theme that being able to accept when you've made a mistake and learn from it, hopefully the next time around and try to make it preventable in the future, right?

Whether that's by updating the Epic chart or what have you, all of that makes a huge difference. I'm going to transition to some rapid fire questions to you all about LGBTQ health care. So, let's talk a little bit about STI screening and treatment. What is the new up to date guidelines for our patients?

Even though it's not surgery, I promise you, every surgeon is going to see patients that have an STI, and we should

know what these patients need for screening, and peer treatment, and treatment. So I will turn it over to you for STI treatment. So a lot of this depends on a patient's sexual practices using the screening questions that we mentioned previously talking about number of partners and their practices.

But if you've got somebody who's has multiple partners and isn't using protection, then they should be getting screened at least every three to six months for common STIs, including. Chlamydia, gonorrhea they should be getting screened for HIV and also for syphilis as well. Also, I just want to say like, you know, those screenings are, as we're talking about, are based on sort of your sexual practices and behavior and like the way that you have sex and who you have sex with and all those things.

And it's not actually specific to, you know, being LGBT. It's really about, you know, what, what's happening, like taking an adequate sexual history. Yes, and to that point too, CDC does recommend that depending on what your sexual practices are, it should be screening

for urine, anal, and oropharyngeal gonorrhea chlamydia.

You can do swabs of all the locations as well. And then HIV is very important. How about anal dysplasia screening? I think it's often a Common concepts. Sometimes we forget that HPV is the one of the most, actually is the most common STI worldwide. So what, even though there's no formal guidelines yet, hopefully one day there will be to make it a little easier for us, but what do you do for anal dysplasia screening, who do you recommend screening and how do you go about treating that?

Yeah, you make an excellent point. There are no formal guidelines, but as you mentioned with with the results of the anchor trial that came out last year, I think we're going to see some new guidelines in the near future. But really for it's identifying patients who are at high risk. So, MSM patients who have HIV, patients who are immunocompromised, so may have had a transplant and maybe on immunosuppressive medications.

for your questions. And females who've got a history of cervical or vaginal neoplasia

or interstitial neoplasia they are patients who are at higher risk, so they should be screened at least with cytology or checking for high risk HPV usually with a swap but you should be including as well a digital exam and then depending on what you find on those results, potentially needing to go to do a high resolution anoscopy.

You guys mind telling us a little bit about PrEP the medications we might see and perioperative management of PrEP medications? My general understanding is that they do not need to be held, stopped, started, you know, at all perioperatively. They can just continue taking the medications. You're absolutely correct.

Yes. But I think understanding the PrEP medication, there's two oral medications, Trevodin Descovy, and that's for, PrEP is pre exposure prophylaxis, and I think it's really important, I have had trainees and colleagues who have, And other staff providers in family medicine, internal medicine, assume these patients had

HIV, which they assume that without asking the patient and then it makes for such an untrustworthy environment for that patient.

Also, it. It puts them in this a whole nother version of treatment and screening that maybe they wouldn't need to be. And so I think it's important to understand what medications they are, they have, and also correct me if I'm wrong, I believe the FDA has now approved the injection prep, believe it, every month you have to go to CDC to confirm.

But I believe that's out now that was pending FDA approval a couple months ago. So I think that that's even wonderful. And I will tell you, I have had multiple patients come to me for various anorectal issues who are identified as gay or bisexual or MSM and on their first provider, they even be able to talk to them about PrEP.

They had no idea it existed. So I think it's really important, especially as surgeons who are going to treat anorectal disorders, that you understand these things because you may be the first line of defense for these patients. Are there specific

mental health screening recommendations specifically for members of this community or overall that you tend to apply more often when you're thinking about the LGBTQIA patients that you treat?

The underlying factors that contribute to those higher rates are probably, Related to the difficulties that are inherent to being an LGBTQ person in a heteronormative world. So I guess I would like, I'm sort of advocating for approaching these scenarios. Similar to what we've been talking about with this general theme of like, you know, really just like pursuing an understanding of the fact that the lived experience of the world is different for LGBTQ people than it is for straight people.

And like cisgender and. And people who are not LGBTQ, and that those differences can contribute, can manifest in these ways that are like epidemiologically significant. And I would hope that yes, like we should think about these things that are more common in this demographic in our demographic.

But I would hope that we're

thinking about it in a way that is understanding that it's like, there's nothing wrong with you for being LGBT. being LGBT and living in a society that like tells you that there's something wrong with you can make you depressed because then you think something's wrong with you.

Right. And I don't know, that's, that, that is the balance that I feel like I'm trying to walk when trying to answer these questions about like, should we be treating LGBT people different in clinical context than other people? And I think. Harmony wants to say like, no, you know, like you should, we should treat everybody the same.

But at the same time, of course, what really, what I'm trying to say is like, I would hope that you would approach this patient with the same, again, sort of like respecting curiosity about how the way that they interact with society and the world affects their health. And it's like, I think that's what we try to do for everyone.

Yeah, that's a great point, Alex. Because I think also it's important to remember that this is a huge spectrum of community. And we're not all the same. We're not just a, an LGBTQ person.

And so the health problems and health risks that we have are going to differ. Vastly amongst the amongst the community.

So as a health care provider, it's just important to be mindful of that and to be asked open ended questions and to try and gather as much information and as appropriate and have a good team on board. Know your community too. There's a lot of outreach in various communities, a lot of academic and even private hospitals are out there at Pride, out there with their booths.

They are there doing STI and HIV testing on the street. And so you, you may know what's in the community. Also remember that there's public health offices in every city too. And all of these STIs, HIV, I mean, it doesn't have to be public health. For someone who identifies as LGBTQ is just for anybody.

So you may don't feel the pressure in the trauma Bay or in the hospital, or necessarily in the clinic that you have to do all of this all at once. There, there's a system that our states have developed to help you

with this as well. I think I have to say one thing that I've noticed over the past few years is that the education of medical students is definitely improving towards the LGBTQ community.

You know, when I trained and I'm sure when you trained Andrew, we were told to address patients either as Mr. or Miss and then use their last name. Whereas now I think medical students are encouraged to ask the patients what they want to be called and what, how to be, how to address them appropriately.

And I think that sort of leads me to say that that with education. Now we sit on a point where we can really start to not just help medical students to improve their education, but also providers and within the hospital setting. Education regarding LGBTQ health should be really mandated on a yearly basis, should be part of licensing, and it really should be something that we strive and push to, to incorporate more into our education and lives.

Alright, we're going to jump into some rapid fire pre app site questions for all you trainees out there.

So, you have a 34 year old transgender woman with no significant medical or surgical history presents the office for evaluation of a genetic test result. She has recently learned that she is a carrier for her hereditary breast cancer mutation.

She is considering initiating gender affirming hormonal therapy. But is concerned about how that might affect her risk of future breast cancer. What is the patient's most likely genetic mutation and their associated estimated risk of breast cancer? So A, BRCA1, 45 70%. B, BRCA1, 1 2%. C-B-R-C-A two 7%, or D-B-R-C-A 2 45 to 70%, or EP 53, 50%.

So this is a 34-year-old. It's a transgender woman. So we have to think about, you know. what is their likely sex assigned at birth if we're going to be thinking about their

genetic risk, right? So a transgender woman with no surgical medical history who has not initiated a hormonal therapy, it is a like safe clinical assumption that their sex assigned at birth is male, which means their most likely BRCA mutation is BRCA2.

And because they've had no hormonal therapy, this is basically just a BRCA2 question. And the, At least what the score module says about BRCA2 is that for patients who are assigned male at birth, the BRCA2 mutation carries an approximately 7 percent risk of breast cancer. So the answer is 7%. That is correct.

All right. Question number two. A 47 year old transgender man presents to the office for evaluation of a small breast mass detected on self exam. The patient has no medical history or surgical history. On examination, the mass is approximately 2 centimeters, rubbery, well circumscribed, and easily mobile.

He does not have a family history of breast cancer. He undergoes diagnostic mammography with the result of BI RADS 2. He is planning to

initiate gender affirming hormonal therapy this year. When would you recommend this patient undergo their next screening mammogram? A. No screening mammograms are necessary in this patient.

B. Beginning at age 50. C. In two years. D. One year after the initiation of hormonal therapy. Or E, recommend bilateral mastectomy as gender affirming surgery has been shown to improve quality of life in transgender patients and will reduce his future breast cancer risk. All right, I'll take a stab at this one, because I have not started studying for my ABSA yet.

So a 47 year old transgender man, so that would mean that they identify as a man, but their sex assigned at birth was, Not that that was on the other side of the molecule as we learned so they would have been female sex assigned at birth, correct? Yeah. Okay, great. So, so this is then a BI RADS 2

finding in a 47 year old.

So, so this would be returned to routine screening, I think as a result. So this would be start mammograms, routine mammograms starting at age 50, but no extra screening or other treatment at this point. Okay. That is correct. Can you guys talk a little bit about the specifically the gender affirming hormonal therapy and if that carries any risk and specifically how you can contextualize that?

Yeah so again, this is another one that is mostly a terminology question. And you worked through it perfectly. And so this is a transgender man. So if they are going to be undergoing gender affirming hormonal therapy, they're likely going to be taking androgens and not estrogens which means that it does not have any effect on their risk of future breast cancer.

I also, I included E as an answer choice because it's pretty seductive, I think, you know, like to, it feels very, you know, gender affirming surgery. Great. And if they have a lump, you know, maybe it's cancer. And okay, just to get the bilateral mastectomy is going to be a great for everyone. But the point to make in the explanation is that not,

not every transgender individual desires gender affirming surgery.

And that's, you know, important to remember for, everyone that you talk to, but specific to this patient, not all transgender men desire top surgery. And to recommend this without discussing with the patient, you know, what their goals are and what, what they want is presumptuous. And so that's why I included that answer choices, the intentional red herring.

Well, this next one, I think is very important because we all ask questions about what to do about medication. So here is a 43 year old transgender man. presenting to the office and is found to have asymptomatic inguinal hernia. He is scheduled for elective laparoscopic inguinal hernia repair. He has been on gender affirming hormonal therapy for the past one year.

He has not taken any other medications and has no surgical history. What should you recommend for this patient perioperatively for his pharmacologic management? I would say continue all of his medications preoperatively with no changes. I believe his hormonal

therapy would involve androgens specifically primarily testosterone.

And I do not believe that these suppress the HPA axis, so there would be no reason to hold it in the preoperative period. You know, no need for stress dose steroids preoperatively for this. Well, I think we're coming to close to a close. I want to give you guys an opportunity to say anything else that you might want to to close out or final thoughts for our audience.

If any other recommendations for resources that are out there for folks, Alex is a million. I'm sorry. I, I think my close, my first closing thought was I did, I, I have a friend who they're, they work for a company that does gender inclusive, like they're a trainer for Gender inclusive trainings for corporations and schools and hospitals and stuff like this.

And so I reached out to them today to just be like, Oh, I'm doing this podcast. Like, can you tell me things to send people? And so, yeah, that you can Google the gender unicorn. That is a pretty helpful diagram to just sort of like,

you know, again, appreciate that all these things are on a spectrum and that people's identities are very complex.

And then I have a, like several Instagram handles of really Nice resources of, you know, LGBTQ creators who are out there, you know, giving out good resources, which I think is surprisingly, you know, not surprisingly, I mean, we tend to go to journals, but there's a lot of really good information on this on Instagram.

And so I will send some, that's great. We can put those in the show notes for the episode too. So folks can find them. Cool. The company's name is gender wise, I think a good resource is the LGBTQ health care directory, where you can go on and type for what you look for, search for whatever you're looking for.

So colorectal doctor or primary care physician. Or you're simply searching for someone to prescribe you PrEP and you enter your zip code and that links you to somebody who has registered for that site. There are also several hospitals that have directories of out

surgeons as well. And I think that those can be very helpful for patients in the LGBTQ community.

Specifically for transgender youth patients WPATH, the World Professional Association for Transgender Health I believe they're on standards of care version eight. So that is a useful resource for healthcare providers. That's incredible. Well, thank you all three of you for joining us and Andrew, of course for hosting again and wrangling everyone into this.

I really appreciate it. I've learned a lot from listening and asking you guys questions. I know our listeners will as well. So I very much appreciate it. Andrew, do you want to bring us home? But thank you again very much and dominate the day.