 So welcome everyone to the McLean lecture series. We're so excited that you joined us. We had a wonderful session with Dr. Street just prior to this with the students and residents and some faculty. And the ethics fellows are going to join us at the end. But we are at the beginning of our spring quarter for the gender equity lecture series and we have a number of upcoming talks, including Dr. Pringle Miller, who's also an alumni of the university works here in the city on justice and she'll be speaking next week then week following that is the panel of our women surgeons who will be talking about the state of gender equity and surgery. And then a number of other presentations on Wednesdays following that so I encourage those of you who might be interested to join us but I'm really excited to have Dr. Carl Street joining us today I'm going to introduce him and then let him get started on his talk. Dr. Street is an assistant professor in the Boston University School of Medicine. And he wrote this not me but after being a nerd at the University of Chicago and attending med school and residency in internal medicine at Johns Hopkins he completed fellowship in general internal medicine at Brigham and women's nationally he has chaired the American American Medical Association's advisory committee on LGBTQ issues served on the board of glamour health professionals advancing LGBTQ equity equality and currently serves as the president elect of the US professional Association for Transgender Health. Carl's efforts to improve the health and well being of sexual and gender minority individuals and communities have earned him several awards, notably from the University of Chicago and Johns Hopkins University alumni associations, and also the American Medical Association Foundation, the World Professional Association for Transgender Health and recognition from the Obama White House. As the research lead for the Center for Transgender Medicine and surgery at the Boston Medical Center. He collaborates with researchers clinicians and staff to assess and address health and well being of transgender and divert and gender diverse individuals so welcome Dr. Street. Thank you everybody for that warm welcome and we'll come ahead and jump right in some things about me that we shared earlier I'm an introvert so giving talks for me as a unique form of stress. So that means I will be talking quickly I'll probably be gesticulating gesticulating wildly with my hands and such. The goal is to make sure there's plenty of time for questions at the end as well. As you heard, where a number of hats within Boston universities to Benion, and of a decent school of medicine. We actually recently renamed our Center for Trans Medicine and surgery to the gender care center to provide a more holistic view. Again, we're not just about medicine and surgery we're really trying to care for the whole person, and the number of other roles. In the closures you heard about a number of things I do carry is still a number of leadership positions within organizations that are dedicated to broadly LGBTQ health and particularly trans and gender non binary health as well. Grants that helped me do research around these health issues as well and then fortunate to have some consulting roles, none of which are directly related to this material. I really like to start with a land acknowledgement normally I'd be coming to you from Boston land of the city land of the Massachusetts tribe. We are now in Chicago, which is actually part of Potawatomi and Peoria tribes as well as additional tribes. Unfortunately, I do not have my notes to remember off the top of my head but there are six concurrent tribes that actually this land is originally theirs. I bring this up because a lot of the work that I do is around social justice and equity and I think some of the first steps we really have to do is acknowledge past bronze to really begin to redress them. And has harmed not only indigenous populations but has continued to actually harm broadly everybody. Particularly LGBTQ individuals and particularly people as it relates to gender sense our binary focus around gender is actually a Western and colonial concept. I'm not going to go too much in the history of that there are extensive books and work around this. And biased by work for Dr. Jen Manion out of Amherst who has written about female husbands the existence of additional categories in the late 1800s and early 1900s and big fan of Jules Peterson from Hopkins who has talked about the existence and documentation of trans identified youth across cultures and history so again, I want to highlight that recognizing colonization is a really big first step in addressing a lot of wrongs in the world, particularly here. So this, I saw Dr. Snowy Paul's great lecture I wanted to share a little bit about my own background since there are a few trainees here. I'm from around Chicago. If I wasn't here in Chicago I would say I'm from Chicago but I'm actually from Zion which is a small, very conservative religious town just north of here. I chose to then fortunately come to the University of Chicago where I was in fact a nerd I was very focused on a PhD career I was thinking about doing proteomics I was really focusing on Alzheimer's research. And once I did some of that work during the summer I realized that is not what I wanted to do. I was fortunate to be part of at that time the the course still exists always changing every year it seems. But I got, I had a social professor Dr. Holly Swires who I always joke rude in my science career. She was the one who really kind of helped me think about a more holistic view of patient community community well being. Eventually I started volunteering at a number of organizations notably the hard brown health center, they have the Broadway use center and I actually started volunteering, while an undergrad and afterwards to do STI testing and counseling and so forth and I got to see firsthand how people could actually be very engaged in community work and providing direct clinical care so that really kind of got my got me excited about thinking about a career in medicine. It took two years between med school and undergrad I also while working at our Brown also worked at sidetrack. Those for those who are familiar sidetrack is the largest gay bar in Chicago, one of the oldest gay bars in Chicago. I had a great time there, because, not only because fun being a young gay man working at a gay bar, but having to see the ways in which business could actually change politics. The owners of sidetrack are very involved in the political landscape in Illinois and Chicago in particular. They are the founders of equality Illinois, one of their main focuses was naturally civil unions marriage equality early on but they've expanded beyond that thankfully. And they made sure that any company that wanted to work with them had to be supportive in some way so any alcohol company that wanted to be featured within their bar had to actually donate to LWQ initiatives as well. So there's a unique experience to see how as troubling as capitalism is capitalism can actually be used to try and help community as well. Yep, so that's me as a bouncer way back when the gentleman next to me is john finolio who is now actually a news anchor in California, so sidetrack has been a unique launching pad for a lot of folks. I eventually got back into school chose to go to Johns Hopkins on the East Coast was hard to leave Chicago but Johns Hopkins was an awesome opportunity. But there I learned that, like, I think many folks have experienced that LGBTQ health is not often part of the curriculum. And I really started getting involved in more national organizations including the American Medical Association, as well as historically known as the gay and lesbian medical association but is so much more than gay lesbian or medical at this point it is multidisciplinary it is all identities, and really focused on trying to improve the experience of healthcare professionals and trainees across the board, as well as the, the care needs of our patients. I stayed at Johns Hopkins for my internal medicine residency training at Johns Hopkins Bayview we always joke it's the kind of gentler Hopkins it's not the poster program. But so they have a primary care track, which was an awesome way for me to actually engage in more long term care, as well as having a program that was essentially said Carl Sloan's it's not illegal you can do whatever you want. And they essentially allowed me to get a certificate program at George at George Washington University in LGBTQ health policy. So a lot of opportunities during training when I asked for it which was really helpful. And then essentially chose to go on to get additional training in research methods went to bring them women's as part of the general internal medicine fellowship. I was very much paid for my master's in public health I always encourage you to have somebody else pay for your education at some point. I eventually decided I cannot take on any more debt, and I was very fortunate to be able to have them do this, so that I could get additional research skills to use research to inform policy which is through a theme through a lot of my training. You'll see some of that as we go forward. This is the easy trajectory of my life. Of course, none of this was at all what I planned when I came when I first came to Chicago, even when I was in medical school I had no idea that I was going to be doing a career focused in LGBTQ health it's just something I kind of fell into I feel, because nobody, I didn't really see a whole lot of folks in my training experience doing it or doing it well, or in fact being harmful, and maybe doing a Q&A when there's no recording we can talk about different history of different institutions and their role in being helpful or harmful to LGBTQ health issues. So I was fortunate to join Boston University. They had already established at that time their Center for Transgender Medicine and Surgery now their gender care center. And the current director had moved down to Mount Sinai in New York to start the same center Dr. Josh Safer, and Dr. Jenny Siegel took over as the medical side of it and they wanted somebody to come in and do research so for me this was like a win-win, was able to just move right across the streets and got to work with some amazing have continued to work with amazing folks. I'm going to put this all up here just to spare us the ridiculous animations. This is kind of how I view a lot of the work that I do in terms of addressing data gaps in population surveys around sexual orientation gender identity, looking particularly at trans and gender non-binary individuals but also looking at community resilience factors that really strengthen and protect us from some of the harms in society, and then really trying to incorporate more intersectional methods to understand the experiences of multiple marginalized individuals. Policy, big part of that is really trying to get more data collection that includes sexual orientation gender identity. We've been talking about it earlier in terms of how it relates to trainee data collection as well. We talked about how faculty earlier on do not know as much about these topics as we'd like so I'm a big fan of actually seeing if we can get continuing medical education requirements for certification for existing faculty and clinicians moving forward, and then of course non-exclusion issues within insurance. I do a lot of different education initiatives, both of course in the didactic realm of writing textbooks and doing lectures and so forth, but also making sure trainees rotate through clinic with me. And then my particular interests are around primary care outcomes including cardiovascular disease which we'll focus on today, but also trying to understand how we can better prevent cancers and be again, one of the training you mentioned this very recently in terms of we are too gendered in the ways we approach a lot of issues, particularly around cancer so that's another area we're working on. And then as an academic, we always have to turn out a lot of different papers so naturally I do write a lot of different opinion pieces with other colleagues to really try and make sure people are talking about LGBTQ health very broadly, and recognizing that this is not something unique to primary care or internal medicine that it is something that can be addressed across multiple capacities from multiple perspectives. Oh, and I included some fun slides in terms of this is not all just work that I do in clinic not all just work in the office. I have had a lot of fun getting to meet other like minded folks within the American Medical Association the AMA has a sorted history, both good and bad around a variety of issues, particularly around race ethnicity particularly around LGBTQ issues. In the last few years we've been able to pass a number of policies and they've done a really good job of trying to address again they're wrongs in the past by calling them out, and moving forward so this is me working with our ambassador steering committee, which is really trying to help with messaging around LGBTQ issues. This is again us taking over sidetrack where if you if you mentioned my name you might still get a free drink. This is us passing out an award within our state society so Massachusetts Medical Society is part of the AMA to standalone state society you have your Illinois State Medical Association as well. And we have an LGBTQ focused committee within our state society, and this is us providing a wonderful award to Dr event. Yvonne Gomez carry on who is a gynecologist who has been instrumental in providing gender affirming surgical care for trans masculine individuals. Oddly enough, some of the strange stuff as a fellow is getting invited to Baku Azerbaijan to talk about gender issues. So again, recognizing that this work can be highlighted. This is the point foundation which is I encourage medical students or other if there's any undergrads who are listening or watching to look at this foundation which provides scholarship trainees who are LGBTQ or do work in LGBTQ issues and provides a wonderful source of mentorship that's been a wonderful joy for me to be part of this. And then naturally making sure that you speak up whenever you can. This was at an Atlantic event where one of the speakers was talking about how trans issues are in vogue, and that trans identities are a new feature of modern society and I naturally had to speak up after having read a few books and doing the work that I do, which is always And then also having fun with friends doing charity work so this is a charity bike ride originally in Maryland, still in Maryland I had done the ride for AIDS here in Illinois as well which starts in Chicago goes all the way up to Wisconsin and back so I encourage you to find ways to be have fun enjoying this work. And then naturally they may giving us opportunities to highlight amazing folks such as Admiral Rachel Levine. And then working at ABC News, which was a weird experience, something you as residents have the opportunity to look into, where there is a month long rotation at ABC, ABC News, where you are essentially their medical voice. And you are the ones vetting research providing stories and such. When I was there we made sure that we talked about trans youth issues as part of Dr, then Richard Besserts Twitter chat essentially so. And then lastly this was when I was honored from the Obama White House so Vice President Biden. And as I mentioned the American Medical Association is trying to redress its wrongs it has created a new health equity center they have a new fellowship focus around anti racism in particular this is something that I'm part of and these are some more other fellows, all of whom are dedicated to the intersectional issues around LGBTQ health as well. And then lastly just personal. This is my husband, and this was coming up on four years ago when it snowed in April here on campus we got married here you Chicago. So again, I didn't do this by myself. I don't think anybody does this kind of work by themselves. The chat has been very, very understanding, and I have many amazing mentors who've helped me along the way. So, but let's talk about non binary issues getting beyond binaries and so forth. I'm a big fan of using some cartoons. I think this is always fun where we always are told men are from Mars women from Venus and yet we're on earth. We are not as binary I talked a little bit briefly about the historical context, but I want to focus specifically as it relates to cardiovascular health and some other issues and internal medicine about how binaries have really missed the mark for us. The CME related objectives. Briefly I'll talk about terminology won't be any testing after this. These are just key concepts. We'll talk about some unique disparities and cardiovascular health for trans and gender non binary folks, and then we'll talk about some opportunities to improve research and clinical care. I'm a wonder. I'm a big fan of the NIH is sexual and gender minority research office definition of sexual and gender minority populations. It can be boiled down this paragraph can be boiled down to anybody who is not sys hat, who is not cisgender who is not heterosexual. Because it works very well to make sure that we are not only focusing on strictly lesbian gay by trans individuals that we are really trying to have a more expansive definition. It really calls out specifically the inclusion of intersex and people born with differences in sex development. It also acknowledges the different additional identities that have historically been erased again from colonization to spirit and other additional indigenous identities as it relates to sex and gender. Love again different graphics that move beyond binaries this is a form of the gender unicorn that I like using because it doesn't have masculine versus feminine it doesn't have male versus female and so forth it really tries to acknowledge that you can be on these different spectrum concurrently you can have significant components of masculinity and femininity and so forth as well as additional categories that are moving beyond our western concepts. We're going to focus mainly around gender identity and gender expression. So gender identity I don't think anybody in the crowd doesn't know this but just for those who are listening in gender identities your internal sense of self as it relates to your gender. So these are a lot of socially and culturally derived categories. So again recognizing that this can change depending on where your patient or where your community is actually hailing from. And then gender expression more broadly is the social and cultural cues that people physically used to essentially signal their gender identity, and again making sure that people recognize you don't make assumptions about somebody's gender identity based on their gender expression. And I'm always, I like using the example from the daily show with Trevor Noah actually a few years ago, Trevor Noah had on Jacob to buy is a non binary activist author actor, who essentially wanted to try and help Trevor Noah, acquire his gender essentially provided Trevor Noah with an airing saying you can try this on want you to be a little bit more feminine Trevor Noah puts clips on the airing says he doesn't like clip on earrings but he'll do it for for his guests. And he says this is wonderful my grant my grandmother will be so proud because where I come from in South Africa from my grandmother's tribe this is actually masculine. And my grandma would be very happy to see that I'm wearing this so again recognizing that there are different cultural cues as relates to gender expression. So again, overall, don't make assumptions about your patients or the community you're caring for just based on where you're coming from so it's always worth asking people about this. So basic demographics in terms of where we're going. I get a kick out of the Gallup survey they haven't done this question in a while but essentially just your best guess what percent of Americans today would you say are gay or lesbian. Last time they had a check in 2015 essentially nearly people thought on average a quarter of the US population adult population was lesbian or gay by itself. I always get a kick out of that I wonder which neighborhood they live in I'd like to move there be a lot of fun. The reality is still optimistic. In terms of the increasing trend and people feeling comfortable identifying as lesbian gay by trans or an additional identity beyond heterosexual or cisgender. So we're at 7.2% of the adult population feeling comfortable answering a phone survey saying that yes they are one of these identities. I always encourage remind people that this is probably an underestimate because somebody's calling you asking you are you gay or lesbian straight like and so on so forth. I feel comfortable answering that question depending on who's calling. There's a lot of national surveys that do this. I honestly think there's fluctuations year by year depending on who's in the administration or which state is actually calling and asking these questions. So I do like Gallup because Gallup typically has a little bit more brand recognition is a little bit more nationally trusted. So 7.2% we're talking about overall 20 million adults who identify broadly as a sexual or gender minority individual. So we're talking about gender by generation. Again, this is where a lot of not helpful people. I would say think there is a trend or contagion, but I would argue that there's been great research from the Williams Institute their generation study which had a few publications about five six years ago now at this point. And what they had done is look at different generations and when people actually came out when did they feel comfortable coming out. So three generations starting 1825 all this being 52 to 59 that they surveyed, and you can see that for around sexual orientation, people tended to group around the same age for when they recognize that they had same sex attraction. So understanding that internal sense of self, but it's when you start incorporating that identity start coming out with that identity is where you start seeing a spread across generations. So having sexual debut already an age difference there between youngest generation being at 16 on average older generation being closer to essentially early adulthood at 19 self identifying incorporating that identity into who you are young, a younger generation on average 14 so still more than likely living at home up to 18 so already on the way out for the older generation and then coming out to a family member still living at home with the youngest generation typically all the way up to established young adult at 26. So, I always point to this information when people say oh it's just a trend and so forth I'm like yes it's a trend in terms of how people feel comfortable coming out, and how they actually have connection to community and how they actually have family support and families are recognizing this more and more. There is research, ideally coming out soon from the trend from their trans focused survey called trans pop, which will also be able to look at this generation question, moving forward. This is the fast and dirty of some of the terminology some of the key concepts and some of the epidemiology. Let's talk about cardiovascular health. So why focus on cardiovascular health, I feel like for a lot of our internal medicine colleagues and pretty much for everyone. You recognize that cardiovascular disease is still one of the leading causes morbidity mortality in the US and in the worldwide. It has a number of factors that we can intervene upon which is always exciting that we as doctors can actually do something to help somebody feel better and live longer so cardiovascular health for me has been a major interest, as long as I've been interested in medicine. I would say a key turning point was during residency. So, I, during what second year, going into third year residency I was on my cardiology rotation, when my attending is Dr Monica Mukherjee, who was amazing who was an awesome ally. So she said Carl, I have this patient I have no idea what to expect I don't know what the research shows. They are 70 year old individual assigned male birth. They're a long standing patient of mine they have diastolic heart failure. And they are beginning estrogen therapy as part of their gender firming care as part of essentially being a trans woman. What can we expect for this patient. She is an expert in diastolic heart failure she's an expert in terms of different effects as it relates to cardiac function and output and so forth but there were differences based on the literature around sex. But what does it mean for for trans individual who may be beginning hormone therapy are the hormones a key factor of this. And that kind of led us to ask a number of questions what do we know about cardiovascular health for trans folks and what we do know at that time was very little. So some of the unique factors that are that trans folks face and we've actually expanded this broadly to all LGBTQ folks. And then what can we do to provide better preventive healthcare. And this actually really launched my current career was this one interaction with an early mentor, mentor about trying to understand what's happening for a patient in front of me and this is a lot of my research is making sure that there's a patient story that actually grounds it because I'm not a fan of research for the sake of doing research it needs to actually make sense and has to come from a patient perspective. And ideally a patient, we've gotten better about this actually patients telling us this is what I want to know, how can I help you as a researcher figure it out. The CDC has started to recognize unique factors that affect cardiovascular health. They have used this circular model which I'm not the biggest fan of and will critique as we go forward talking about recognizing how stress and anxiety actually affect cardiovascular health and various factors affecting cardiovascular health, leading to heart attack and stroke and so forth and that some of that can actually feedback and cause depression anxiety and can be particularly not helpful. And this research was focused in veterans, and as well as cisgender women and additional racial ethnic minor marginalized populations, but nothing looking at other marginalized populations such as LGBTQ or particularly trans folks. In the ability series, and I expanded the existing minority stress model. As part of our American Heart Association statement to get out of this cycle of saying it's always just stress and anxiety and it moves forward to cause and cardiovascular disease. What is upstream that causes stress and anxiety what's further upstream that may be causing a number of factors that lead to poor coping mechanisms as it relates to cardiovascular disease so kind of pause here to focus around the minority stress model posits that your internalized identity can be protective you can have access to community factors you can recognize that you have strength as an individual, but that society will interact with you based on that identity or even on that perceived identity. And it will cause a number of unique stressors particularly as it relates to discrimination, violence, and so forth in terms of rejection, and that can start as early as childhood because the family can often be the first place. The people experience discrimination as it relates to sexual orientation gender identity, and that a lot of this can get internalized and lead to internalize homophobia transphobia hyper vigilance always being on guard. And that those factors lead to a number of issues that affect cardiovascular health. We already talked briefly about anxiety and stress and depression experiences of discrimination and unique stressors has already been very well tied to that, and that those have been tied to a variety of factors as it relates to cardiovascular health. What has been more expand further explored of late is trying to understand how experiences of discrimination maybe tie into poor coping mechanisms. So why do we smoke more why do we drink more. But then what we're trying to really piece apart some of these issues is what actually happens with discrimination when it gets internalized is there a physiologic response and is that physiologic response sustained. So trying to see early research that looks at the experience of marginalized populations, particularly racial and ethnic marginalized populations, and how this essentially is causing increased, not only cortisol but cortisol over the long term which is affecting issues around heart rate reactivity affecting issues around hypertension, insulin resistance and so forth. This research is now being redone looking specifically at LGBTQ folks. And this is the model I want people to think about when you're seeing a patient in front of you. Yes, they may be somebody who is smoking. Why are they smoking. Yes, they may be somebody who has high blood pressure, why do they have high blood pressure. You really have to explore some of the additional factors upstream for them, and ideally connect them to additional resources that may be beneficial having community support saying you have community support is actually protective as it relates to hypertension. Key factors that we like to intervene upon. I think folks are very familiar with course we can treat blood pressure we can treat diabetes we can get people on preventive medications such as aspirin and statins. We can encourage people to work out and so forth but how does this actually play out for our trans patients and wisely of late, which I always get a kick out of telling trainees that sleep is important. I can't I think I sat through at least three lectures as a resident and morning report half asleep like, Oh sleep quality is really important and just like that's not happening right now. But sleep quality is a critical new addition to the American Heart Association's view of ideal cardiovascular health. So naturally a healthy diet physical activity glycemic control. They focus on BMI I say excess weight. We're looking at lipids looking at blood pressure smoking cessation and better sleep. So we'll look at each of these factors as it relates to trans individuals. I think there's always been a lot of good research and a great campaign to really remind us that broadly LGBTQ folks do smoke more than the general population. I think I always have to remind I always have to remind people again the history of this where could we find community where it could be be safe. They were in bars. In the late side track it was still smoking bar and like that was awful, but you're around folks and you're in, you're essentially getting these triggers to maybe engage in smoking smoking behavior. You're stressed society, you had a bad experience at work that experience and any parts of what was going on at the time. And the tobacco industry knew this the tobacco industry has been we have evidence of this has targeted marginalized populations. This is the case as it relates to racial ethnic marginalized populations, particularly around menthol. We know that menthol has also been used to target LGBTQ youth overall. So again, this is why we may in fact be smoking a little bit more. What's interesting here is again there's more research. Some of this done by Dr Phoenix Matthews based here in Chicago that shows that experiences of discrimination for trans individuals has been tied to a higher likelihood of reporting smoking, and that more discrimination is actually associated with dual smoking so actually smoking and using e-cigarettes. What it is is that some research has shown that when people engage in gender affirming care, they actually smoke less. They feel a little bit more comfortable about themselves and they actually qualitative research has shown that they actually want to take care of their bodies now, now that their bodies are more in alignment with what they want, what they want to what they feel it should be. They actually, they actually feel like, Oh, this is my body I need to take care of it it's finally where I needed to be. Physical activity. There's this is an area that is ripe for more research as it relates to adults we have a lot of research for trans youth and adolescents, particularly from the youth risk behavior surveillance system which is a survey of high school age youth and a number of states and a number of large school districts including Chicago school district. What I found was that the experience and recall discrimination discrimination for youth led to less physical activity for particularly trans individuals. But what we found in subsequent surveys is that, again, engaging in gender affirming care led to people wanting to actually work out more or engage in some sort of sport. I think this is particularly prescient as it relates to issues with how state legislatures are banning access to sports and community opportunities through sports for trans youth as well. Physical activity, not great for trans individuals overall. BMI. I'm not a big fan of BMI as a metric of health there's a lot of issues that we won't go into here but I always again point out excess weight is your weight in any way, getting in the way of what you want to do physically or any other parts of your life. What I found for trans individuals overall is that there is a higher likelihood of them reporting excess weight essentially this is based on the behavioral respect or surveillance system, which is the largest and older surveillance system of its kind in the US. It's a survey of all states through their state health departments as well as the turret are offshore territories. What we found is that trans individuals essentially on overall have a BMI my apologies BMI over 25, about three quarters of the time versus the general system population being two thirds of the time. There's also been some research looking at what are the effects of hormone therapy as it relates to excess weight. We found that testosterone actually affects lean weight, we don't know what that means in terms of actual BMI for for transmasculine individuals receiving testosterone, and the obverse has been seen for for folks who are receiving estrogen therapy where lean mass will decrease, but there BMI may stay the same diet. Again, opportunities for more research here. A lot of the work that we have a lot of the data we have at this point is focused on youth and adolescents. We're essentially not having a healthy nutrition being engaging in essentially unhealthy eating behavior as well in terms of trying to manage their body shape and body conformity. So we're seeing more binging binging behavior more eating disorders among trans and gender non binary adolescents and youth based on the survey data so far. And lastly, one of the last ones glycemic control so this is where more research has been done focused around hormone therapy so the effects of testosterone have been tied to possible increases in insulin resistance, but it has never been followed long enough to say do those people have been diabetes as a result. I'm not a big fan of saying that's actually what we're probably going to find more than likely will actually just see that they have insulin resistance that there's no effect in their actual overall cardiometabolic health as it relates to insulin, but a few other factors I'll talk about that testosterone seems to have a stronger effect on that I'm worried about for estrogen we're not seeing a whole lot of change in terms of insulin resistance or not so testosterone is not the most helpful for this. So lipids are where we have the most data for trans individuals, especially as it relates to hormone therapy testosterone does not help lipid profiles in general we've seen this particularly in cisgender men who are hypogonadal. This eventually leads to is lower HDL higher LDL higher triglycerides, but again, nobody has ever tied that to long term outcomes what's actually happening as a result of testosterone for cardiovascular health in the long term. As a primary care doctor. Great we'll continue testosterone because this is actually helping you with regards to a number of other factors as it relates to your gender information, and if and when you need a statin we will provide you a statin that's the only thing that I would recommend at this point. So we are seeing the opposite now so estrogen's actually are improving HDL actually lowering LDL so we're, but nobody again has tied that to better outcomes for trans individuals receiving estrogen therapy just yeah. And then last one main traditional factors, hypertension, a lot of mixed data out there, estrogen's particularly progestin seem to show lower blood pressure so actually reduce the rate at which we see hypertension and trans individuals. This is based on a lot of electronic health record data from a number of pooled cohorts. We're seeing mixed results for testosterone where testosterone may increase the style blood pressure by on average three to five millimeters of mercury. What does that mean for somebody actually having hypertension, we're not exactly sure in terms of the clinical significance of that but we are seeing it consistently across the board. And then lastly sleep. So this is one of the newer areas of research that the American Heart Association Association wants us to focus on some of the earliest studies around the experience of sleep quality for trans individuals is done by Dr. Billy Kiseris out of Columbia who was given one of the leads on the AHA's statement on broadly LGBTQ cardiovascular health, and what his group found is that poor sleep quality was associated with recalled experiences of discrimination, particularly as a related to trans individuals and that accessing gender affirming care particularly over the long term led to people actually reporting better sleep quality. So again, gender affirming care reductions in discrimination are a way to actually help people's health. So it's not just strictly what we can do in the clinic but what can we do within a community setting as well. So in terms of factors I've covered all the essential eight that the American Heart Association Association wants us to focus on, but there's other factors that we agreed upon as a group of cardiologists and neurologists that really should be talked about as it relates to potentially hormone hormone effects. So testosterone effects endothelial function, particularly as it relates to decreasing essentially the ability of arteries to dilate so leading to arterial stiffness potentially at an earlier age. This has not been tied to any kind of heart attack or stroke but it is a factor that essentially are described more of our bench research scientists are trying to better characterize and understand. Is there, is there additional intervention we should think about in the future to protect our arterial stiffness or relax the ability to relax. Estrogens have the opposite effect actually improving elasticity and reducing arterial stiffness for trans feminine individuals receiving estrogens. I talked about tobacco alcohol. I honestly think this is more of a political thing in terms of alcohol not being wrapped into the American Heart Association's guidelines because alcohol has not really helped a lot as it relates to cardiovascular health. I think this will be something that comes up in the next few years and being a focus of what we need to do we already do that in primary care in terms of talking about excess alcohol use. And again, all the research has shown that access to gender affirming care leads to reductions in alcohol consumption. People again are within qualitative studies saying, I want to take care of my body now. And so this is why people are reducing alcohol, but also again community connectivity has also led to reduce reductions in alcohol. But again, the bigger problem is how are we targeted as a community. You can always see during pride parades I remember all of the different alcohol companies being out front supporting us and making sure that we had a good quote unquote good time. So just be mindful of the community effects of this. And lastly, HIV by itself is a cardiovascular risk issue. A lot of the earlier medications have been an issue. Our trans populations have an undue excess burden of HIV so another factor to keep in mind moving forward. So, but this is where I want us to think about really beyond some binary issues. These are the tools that we use as primary care doctors as cardiologists to try and prevent any kind of a heart attack or stroke. But we know that these categories suck. We know that the race ethnicity category has been awful. And thankfully work from for example like the multi ethnic study of atherosclerosis the Mesa study and Jackson heart study have really tried to expand these categories and say it's helpful when we're really trying to predict who's at risk, we may be under or over estimating people's risk for cardiovascular disease, and therefore either providing them an intervention they don't need, potentially exposing them to harms of statin, or withholding a medication that they would actually benefit from what is actually happening for our trans individuals when we are using only a binary category around sex male and female. I will argue that what would be helpful here is actually really trying to expand. If we think there's an effect difference around hormones we should maybe include some sort of measure of hormones or some sort of hormone status. Because we know for example for cisgender women who go through menopause at an earlier age they have earlier cardiovascular disease we know that for cisgender men who have some form of andro, andropause or hypogonadism they also have cardiovascular disease issues. And the calculator doesn't take that into account at all for cisgender individuals as well. So it's for I always like to say that when we focus on marginalized populations, particularly the work that I do around trans health, we actually learn ways we can do better for everyone. So, this is where we need to get beyond binaries because cardiovascular health research, and I even joked about this when I was in residency because every time I was in the cardiac critically care unit. I had to know five studies off the top of my head at all times for any kind of intervention because they collect so much data cardiology is one of those very evidence based which I appreciate kind of specialties, but they're collecting data and binary categories and you're missing opportunities to really expand on this. We've highlighted this actually just this literally just got published a few days ago with work from Dr Tonya petite who is now based at moving from UNC to Duke. I'm covered up here I'm the senior author here oddly enough, where we really wanted to highlight what's going on for trans individuals when we use these risk calculations. So this, these are just the basic demographics of the light plus study which is a study of a prospective longitudinal study of transgender women, trans feminine individuals who are Latina or black, and who live with HIV, really trying to identify a number of health issues we were focusing on this for this paper on cardiovascular disease. This is the basic demographic characteristics of our population, who's ever received hormone therapy as a gender from hormone therapy who's receiving treatment for HIV. A number of the key traditional risk factors as part of the risk estimation scores including blood pressure, cholesterol, the profile diabetes and so on and so forth, and who's getting treatment for some of these characteristics as well. It's a very simple table that we really are trying to drive home the message. If we use their sex assigned a birth which is all male. We should be providing statins to over a third of this population. If we do it strictly based on their gender identity it drops down to 18%. And if we do it based on who's receiving feminizing hormone therapy it's 22%. Who should be getting to stop, who should be getting statins at this point and we do not have enough evidence to say what should change in clinical practice but I feel there's enough evidence to say there is a very large gray area for our trans patients. I, as a result of these kind of, of these kind of studies and even when I'm with a patient who is at an age or we really need to be thinking about cardiovascular prevention. There are two risk factors we have a very much as best we can informed decision discussion where I'm waving my hand saying this is what the evidence kind of shows and this is what I think we could do. And this should really be a discussion about, do you have a family history are they are there any other risk factors that are not taking into consideration in the risk estimation tool that may tip you over to maybe needing a statin, or no are you you just happen to have high blood pressure and of an age and your lipids are just right on the edge, but you're, you're getting back into a workout where you're really engaged and not smoking and drinking anymore moving forward, maybe we'll hold back on stand so there's a lot of nuance around this, and this is just the beginning data that we want to show that for. So let's talk about what can we do better. So, Dr. Lauren Beach who's at Northwestern is also amazing cardiovascular researcher epidemiologist, particularly focused on broadly LGBTQ health issues and the experiences of marginalization and how that relates to that. We're very close in our one trying to look at the experience of marginalization within the framing and heart study but sometimes you just don't get there. But we're trying so we were invited to write a commentary for circulation looking at the ways in which cardiology can do better trying to move beyond this binary category. Overall, and we, one of the, one of the reviewer comments was was concerned that we were picking cardiology. And we were, that was like that was like the language and I was like I get it I understand we are being very focused on cardiology it's circulation that's what we're supposed to do. But again it's, as I mentioned earlier cardiology is just one of those very data rich specialties and I were picking on it because you're that you had actually have the opportunity to do the most good moving forward because you have all these mechanisms mechanisms in place. It's not just cardiology, we've already talked about this, but, for example, it's kidney, it's nephrologist, they use, they use gender male female when they're trying to calculate the EGFR. They have thankfully updated as it relates to race ethnicity in terms of removing that and updating the calculations, but when we still have a binary category around male female, what are we doing here. And we know that this is not going to be great because it's really trying to understand, how should they be accounting for creatinine and essentially blood urea nitrogen and so forth. How should they be accounting for that, based on assumptions for body composition for male and female. But we know that that actually changes for trans individuals as it relates to hormone therapy over the long term so what's actually happening with their lean mass. And this calculator then actually feeds into the meld score in terms of actually what else is going on so, and we have, you'll see there's a few papers coming out as it relates to what can nephrology do in the future. A number of hepatologists actually based here at University of Chicago are trying to update the meld score to ensure that not only cisgender women actually benefit from it because they've often actually been lower categorizations in terms of liver transplants, but actually people are actually explicitly included in the calculations moving forward. So we picked on cardiology a lot, but it's not strictly cardiology. And then again, talking about alcohol, the audit C is still men versus women, what's actually going on here. Why do we think there is a difference between here when we know that alcohol there's a big issue in terms of it's actually being water soluble and like which body composition actually has more water so should we be using body composition rather than making assumptions based on somebody's sex and so forth. There are so many other tools I'm not going to go through all of them but they have binary categories categorizations that lead to clinical decisions that may benefit or harm people. So, we've currently fortunate to have an administration that's really on board with trying to improve broadly LGBTQ health, particularly trans health. This is just addressing a number of issues as it relates to discrimination around sexual orientation gender identity. We also had the wonderful national academies of science engineering and medicine, including guidance on how to collect better data around sexual orientation gender identity, how to get beyond binary categories and so forth. We can later date we can definitely critique how this recommend these recommendations can be operationalized at minimum they are start and they are a national message that everybody should be doing this moving forward. And there are many, many, many publications that Dr beach has kindly consolidated this is just a small sampling that really get at the messaging around collecting sexual orientation gender identity. As clinicians, and as somebody who goes around giving these talks and trying to convince people to do this better data collection and I'm sure there was issues here in terms of trying to get so G included it with an epic was that oh people are going to patients are going to be offended by us asking that question we're going to scare away people. This is early data from Family Health Institute, which is like Howard Brown in Boston, in terms of what is the experience of outpatient patients across the country they looked at for geographic different outpatient settings. And what they found was that the vast majority essentially above 85 to 90% and this was back in the early 2010s, everybody essentially understood why these questions need to be asked, they understood that when the clinical was like oh yeah absolutely you should have that information to inform some of these decisions. And they had no issues with regards to sharing that information with the clinician when it was appropriate. This is outpatient work done at Hopkins and bring women's looked at this in the emergency room setting. So again across a number of demographic categorizations you see the number of people choosing not to refuse to answer the question around sexual orientation is much higher than those who refuse across any number of factors, even highlighting across age naturally you see younger generation more comfortable answering questions around sexual orientation gender identity, talking in at around 93.5% saying they would not refuse. But it's still above 85 for those over 80 so people are comfortable answering these questions. So basically, what this group had done from their study had actually then done surveys with the clinicians at these centers clinicians were overwhelmingly way more uncomfortable asking the question than the patients were answering them so we have to get over our own discomfort and some of that could be a factor or reflection of how we're trained like this oh it's very sensitive like this is just you only have to do it only certain sexual situations and so forth. So assuming you're trained to ask the questions with broad categories, so I think we need to do better about our training and our own internal issues around sexual sexuality and gender identity. So, and then in national surveys so this is old data at this point but it's we've seen similar trends moving forward. This is just looking at Washington states behavioral respect or surveillance data this is wonderful work by Dr Fredrickson Goldson who's one of the researchers in older LGBTQ adult research, and she essentially looked at based on different age categories the rate of refusing to answer sexual orientation question you see dropping down to like 1% less than 2% for older generations. And what's unique is that people are more likely to not tell you their income they will refuse to tell you their income, rather than they will refuse to tell you their sexual orientation. There are much higher odds here of refusing to answer how much money somebody makes, which goes to show how a capitalist society doesn't want doesn't want us to share our incomes so. But there's a lot of great guidance out there at this point in terms of how to incorporate sexual orientation gender identity questions into electronic health records. And it is no longer something that you can choose to do it's something you have to do moving forward. There's essentially guidance from the United States core data for interoperability as well as our meaningful uses. Essentially, electronic health records have to have the tools and they all do at this point, we now have to use them we have to flip the switch from saying it's just there in the background to actually collect that information. There's a lot of different ways of doing it this is gratuitous that's one of my publications, but there are there's a lot of guidance in terms of how to make sure you roll this out not just to turn on the sexual orientation gender identity data fields but how to prepare your health care system to respectfully ask those questions to make sure patients can volunteer that information when they want to, they can control over who sees that information. And I think this is especially important for adolescent individuals who may, for good reason want to share that information with their clinician, but their parent may be somebody who's actually on there, for example their epic my chart, who can see that data so how do you make sure there's a safeguard between guard between essentially patient who is getting increasing autonomy is protected by law to have that autonomy to make sure that something doesn't happen with with the parent or guardian. A lot of other guidance out there for how we can do this better in research. But also I want to make sure that we do this better with community led work so this is the 2015 us trans survey. They just got done doing the 2022 and they're cleaning the data right now this is one of the largest studies of trans health in the US with over 1,000 respondents. They have not shared the number for what the 2022 year cohort is they said it is larger, which is amazing. And this is all trans led and this is how a lot of research community research should be done it should be we should be providing the tools, and really supporting folks who are living the experience to understand what's going on what's meaningful research questions for them. And I'm a big fan of the all of us study which has broad categories around sexual orientation and gender identity they've been very exposed about that. And that's because they actually directly partnered with the all of us study, which is a PCORI, not all of us sorry, I just said that, as part of the part of the pride study which is the largest longitudinal study of LGBTQ health, it's part of funded by the patient centered outcomes Research Institute housed at Stanford now. And they are essentially the LGBTQ experts for the all of us study and that's how it should be community folks should be the ones informing this data collection. And that means we need to understand what does our community want to know with regards to how to ask these questions what do they want to know in terms of their credit to their health and health issues. A lot of great research again community members, essentially doing qualitative work to understand what's the best way to do this. And then for those who are thinking about doing any kind of research projects. And I may have scared you off saying there's not a whole lot of great research sources out there, there are there are dozens of national surveys out there that collect some component of sexual orientation or gender identity there's only a handful that collect both and probably one or two that do fairly well, but I'm a big fan of using the CMS clearinghouse where if you want to just think about projects look at this have to talk about it more. This is one of my go to places where I have a question I wonder which data second try and answer that and really go at go at what needs to be done for patients. So, broad recommendations naturally I want to make sure that we are including such orientation gender identity and any research moving forward, making sure that it makes sense for the research question at hand, and that if you are for any reason saying collecting sex, why are you collecting sex and why are you only using binary categories. I really tried to push on a lot of different research studies I co chair and institutional review board in Boston as well and I've been really trying to push for folks like your research question has no reason to note need this information. And if you feel like there is something a priority that's going on why are you using only binary categories, and that's often how we try to get a little bit of expansion on the research projects. We should be including more measures around behavioral health and experiences of discrimination that's something we have not been typically trained to do in clinical research or clinical care, and we should be partnering with our community to actually measure these factors over time. And in terms of more research that's coming forward. Just this week, the National Institutes of Health sexual and gender minority research or office essentially put together a workshop, and we've reported out. I was one of the members of their older adults workshop to really try and understand what is going to be needed. What do we need to know for trans folks moving forward. The biggest one that we, I think we was able to plug for is that we have to get beyond binary categories and we have to find ways of using the tools we have now. How do we shoehorn them to better serve trans folks and then how do we make sure that all tools moving forward, do not have binary categorization that leaves people out. And that if we have a question that we think is some sort of assumption around sex assigned to birth, what factor of sex assigned to birth, are we really questioning here and then we should maybe be measuring that. There's guidance out there. This is led by the WCG IRB, one of the largest national IRBs in the US. They've been wonderful partners in terms of making sure that LGBTQI plus folks are incorporated into a lot of the research studies moving forward. So again, we need our oversight committees to be doing this. I and Dr McNair also then publish this within the Society for General Internal Medicine's publication the forum to provide guidance for how to do this for researchers. Again, lots of great resources out there. I'm not going to belabor the point we'll make sure we have time for q amp a, but then in terms of clinical practice I've been alluding to this overall. Yes, I want to make sure we have the data collected up front. I think the sooner you can allow patients to do that themselves the better they're always more comfortable doing it from their home if they feel comfortable in terms of being tech savvy or at least having some sort of privacy around it but also again are still comfortable answering those questions when the clinician will ask it as part of a standard intake. I'm not sure that we're incorporating this into your training. It's been great to meet a lot of the trainees here present here in the room and then also a few folks over the years that are making sure this is part of your experience but I know it is not necessarily standardized and I know that sometimes what standardized is also negative so trying to find ways to make sure that we are incorporating this in a positive way. And that again requires that we as faculty have to go to some trainings we have to really try and be a little bit more upfront about how can we do better and be prepared to train folks. I, as I mentioned, I cannot do it alone I don't do it alone and a lot of us have to really partner and essentially share resources. There's more guidance on how to do this in academia. I'm going to leave this for you can check out later but all the different modalities by which we can improve training as relates to LGBTQ issues across undergraduate graduate medical education and continuing medical education for faculty. You'll have access to these slides as well. And this is also in a publication. So don't worry. And that's it. So again, it's all about community. And a lot of this work has come out of our American Heart Association statement on trans cardiovascular health. This is the working group that Dr Beach and I pulled together again a lot of the folks I've mentioned before with experiencing cardiovascular health and was transgender and gender diverse health. So you can see a lot of folks from across the country, it's been great. So, leave it there. Any questions in the audience. Dr Paul, and I'll repeat the question so the people on zoom and then zoom people if you'd like to type it in the q amp a I'll read out your questions. Thank you. Let me just repeat. So the questions is two fold that has to do with when Dr street gives us talk around the country and people ask questions about the politicization of this topic, how do you deal with it and then also how do you. Manage kind of the current political state. Good questions, difficult questions in terms of. So I actually have an old slide that I've taken up because the data has not been updated that shows that it's based on the census data it looks at same sex households and they are in every county in the US there are different sex households everywhere in the count in the US and one that their issues with that data doesn't tell us about trans folks. It doesn't tell us about by folks who may be an opposite sex relationships for the census. But it does show us that typically we are, we are everywhere. And when I've given this talk in different parts of the country that stereotypically maybe seen as more conservative. And I may be here from the audience. Oh, this is great so glad you did this I don't have any patients like that I'm like, patients are either coming to you and you don't know it or they know not to come to you. And as clinicians, we, we kind of are one of our main ulcers we are supposed to care for everyone. And that's at minimum you are supposed to put aside any judgment and care for everyone. On the more political side of it which it is getting, I think, more toxic is that I really try to appeal to sense, which doesn't exist, but I really just point out that they are coming at this from political ideology I'm like. So, if you think this is all things that are in vogue, please provide the evidence that supports your opinion, or tell me what kind of evidence you would need to change your mind. Because if you're being honest about saying that you're open minded and you're just asking questions and are trying to make sure you understand things. Tell me what kind of information do you need to actually change your mind. And honestly, I normally get people fumbling over that because like oh they can't because anything that they ask for I can provide because there's always there's all the research already out there saying we've been around forever. Gender Firm and Care is not a new thing. And that the increase in the number of folks who self identify as an increase in the people who self identify not the number of people who actually are that over the years. So I always try to push back and say tell me what you want to know to potentially change your mind. And if you can't change your mind. That is where political ideology is really is really rooted unfortunately. And this has come up even in some reviews of articles that I published with with colleagues and such where we are lacking objectivity because we are part of some of the communities we're writing about. There is no way to to disengage from that and the the expectation that you are not part of the population you're studying somehow lens of objectivity is, is, is, is just like in my mind a form of white supremacy it is form of colonization. This expectation that just because you're not part of it you are somehow more objective, doesn't make sense to me, and has never borne out in a lot of the sciences at this point. One question, what do I do. So I wanted the one of the translators in Boston shared a quote from a book and I always forget the book I wish I could remember the book where she says, the way a choir holds a note indefinitely is that you have a group of people singing the note and everybody takes a breath when they need to take a breath and everybody else is carrying the note when the other person's taking a breath. That's kind of what I have to do at this point. I've never gone into this thinking it's only me alone and I that would be very egocentric and I, and I there are people in our movement unfortunately who are a little egocentric who need to maybe take a step back and take a breath. But on days when I need to I take a breath, even when I still have to give a lecture I will tell people like trainees and such, you need to break take a break. This is being recorded, you can watch this later. I don't, I don't force that too much. But I'm also extremely privileged at this point I am economically comfortable, which is such a cheesy way of saying I have enough money. My husband and I are married we are in a state that protects protects that and has provided additional protections around that we are we are cisgender I'm white. Like we have a lot of privilege already in that so it's one of those things we have to acknowledge. I, which means that when I do take a break, or if I'm able to carry, or what actually what I'm able to carry the load of that I check in on my friends, more. Any other questions yes darker or. So just repeat it quickly and that is that we talked about this in our earlier group too and sometimes our students or trainees are more educated than our faculty and how do we educate not only faculty who are allies and interested but also faculty who are you know off doing other things but also need to be educated. If I had the answer to that I'd be reset. So one there, there's an undue burden on trainees to do this work. I really enjoyed doing it as a student and as as a resident and such but I did recognize that I was not getting as much as I could as a learner because I was the one doing a lot of teaching. Which, but again gives builds confidence gets you become quote unquote a leader what what have you there are benefits still, but the flip side being. I am a big proponent of trying to change requirements because I used to joke I was raised Catholic I believe in having a like you need to like you need to do this. In terms of, I would like licensures for new and renewals to have some sort of training run LGBTQ health issues. I feel I'm being no specialty society, no state society will support that organized medicine as a guild, a guild doesn't like to be regulated. I totally get that as somebody who's part of these organizations I see that that tendency to want to push back. I would argue that it's going to happen anyways. DC is one of the first jurisdictions to require that anybody with the DC licensure has some sort of training on LGBTQ health issues. They are a model and their city council past it and made the board do it. We've had similar situations in Massachusetts where the state has actually mandated that all clinicians and folks getting licensure and renewals have to get training on Alzheimer's disease and care. That makes sense for me as an internal medicine doctor but because our state society wouldn't engage and was fighting them are pediatric colleagues now have to learn about Alzheimer's disease and how it relates to the patient population. So there are unintended consequences if you don't play along. So I, that's one way I think is going to get the broadest reach. Institutions need to incentivize this work in some way. I do a lot of this work for free essentially a lot of its trainees are doing it for free a lot of our faculty are doing it for free. I think it's going to be some sort of carve out potentially for broadly equity work because I'm not a fan of necessarily picking apart each identity group saying equity and we include all this in the umbrella when we talk about equity and that's what it should be. And ideally, we should be focusing on multiple marginalized populations a lot of this research even LGBTQ health still has an overwhelming race racism issue in terms of being overwhelmingly white. And only recently is that really being called out. So I'll just repeat quickly one of our pediatricians was talking about capturing sex assigned at birth and then sexual identity gender identity and how do we do it better. Yeah, within so not a pediatrician I always want to defer to the AP and additional organizations that are thinking about this more explicitly and are being very, I think, cognizant of a number of factors in terms of how to safely collect this information about what does it mean at young ages and so forth. There's always questions even around sexual orientation for adolescents how that should be documented for younger for younger individuals and particularly in clinical trials it's still important to collect sex assigned to birth I think we just make sure we have enough categories, particularly if there are individuals born with differences in sex development, and what those specifically are the gender identity component I think is a question for how is it related to the research or the particular outcomes for the for the child and for the family. Again, we know that variety of stressors unique stressors and general stresses that people face affect their outcomes and it may be important, I think it's important to be able to collect that information and look at differences over time. And other thing to keep in mind, which is a little bit harder sometimes to to get researchers on board with is that recognize that your data will be used at some point in a meta analysis, and it is helpful to include additional demographic characteristics to think about potential and thinking about in the future, so long as that data can be protected and potentially updated if there's any ways in which a youth may want to be able to update their gender identity over time as well. I think one thing to recognize is, as I mentioned, early in the presentation, the differences in generations in terms of pretty much everybody at the same time recognizes they are lesbian they are by, but how they come out changes over generations. The trans pop study from the Williams Institute has the data be able to look at nobody's looked at that yet. They're the 2015 US Trans Survey has a publication recently led by Dr. Jack Turbin out of UCSF one leaders and trans youth research, showing that again there is not a big difference in terms of the age at which people recognize that identity, but the age of which people come out still is what's changing across generations. The paper, the graphic wasn't as pretty as the one that the Williams Institute did which is why I didn't include it because it was not as intuitive, but we're essentially seeing that very similar trends that we are seeing more trans youth because it's something that they can have words for and talk about. But for the research side of things collect the data that is most pertinent for the research question, and then anticipate potential additional questions down the road. Thank you. Yeah, so just the quick for repeating is like how often do you encounter barriers to paying for gender-perving care every day. I mean, literally this morning I was like trying to address a prior authorization for a testosterone patch, because I personally believe that patients should have preference for how they obtain their medications. Whereas a lot of insurers are like oh everybody should be started on injectable testosterone just like that is not what everybody wants that is not how it should work. Every day is, is me battling and that's, and that's not just for my trans patients, but it is particularly for my trans patients. In terms of what we try and do in Massachusetts is that we are engaged with a number of the payers. We, they have advisor group for our blue crossing shield, our own healthcare system is a very large a co as well so we've been trying to make sure that that insurance plan is up to date. And I think as you saw on the news, there are plenty of insurance plans that just outright deny claims without even looking at the claim itself. So this for me is a larger, much larger system issue where I would like to think that single payer is an option although I'm always worried about who's in charge with that single payer system, since we've seen fluctuations in how Medicare and Medicaid provide coverage, depending on who's in charge as well. But we are also trying to push and get CMS to have a new. Why am I totally forgetting on their declaration of coverage or their specific terminology for providing coverage for gender affirming surgeries so that's hopefully going to get updated soon by every, every day, but it is not unique to gender for me care. So I think with that we will, these are comments, we can read these comments but I don't think they're quite not questions for you. And so we will stop the recording thank you to run on it for recording it and and we will give Dr one last round of applause for a street. And then, and then we'll ask our ethics fellows to come down and join us in the front for the final kind of conversation. So thank you again. Yeah.