 Okay, my name is Donna Messer Smith, and I'm at NHGRI, the National Human Genome Research Institute, within the education community involvement branch. And welcome everyone to our presentations of our 2021 to 2023. This is the ISCC pegs scholar group. We're really proud to have this. This project going especially in the sense that this gives an opportunity for people early in their careers to connect through the ISCC peg with people more senior in their genomics related careers. So this is our presentation or clinicians or educators themselves, creating resources, and connecting with other clinicians. So, this is our second class. And today we have presentations from Aviv Bola Olodeo and Sarah Roth, and we're happy to say that the mentor for Aviv Bola is present. And we're going to have an introduction I believe from because I saw you on the call. Dr. Brody is that correct, Dr. Brody. I was going to introduce Sarah. Sarah, right. So Sarah will have an introduction from Dr. Brody. And I think we can jump in and begin with the introduction from Dr. Wilkins Hogg of Aviv Bola, and then I'll share this. You can share, let's see, you need to be able to share the screen. All right, so. Great, so I can go ahead and introduce Amid Bola. As you see here, she's currently at the University of Iowa. Her training is in dentistry and her particular interests are in the genetics of oral facial complications and oral facial developmental changes. She reached out as a mentee and we were looking at her interest in wanting to educate providers, but also my interest within educating providers with an OBGYN. So we were trying to marry the two of those to develop a project. So I will let her take it away. Thank you for the introduction, Dr. Louise, and I'll just ask and everybody see my screen without a comment. Perfect. So good day, everyone. I am Abin Bola that I has introduced and I'm a member of the 2021 to 2023 class of scholars and I'm also 1890 fellow at the College of Dentistry University of Iowa. The opportunity to be mentored by Dr. Louise Wu just introduced me in the OBGYN work group and I'd like to thank all for giving me the opportunity to share my presentation today. To give a brief overview of our project, our project goal was to improve access to genetics and genomics education resources, by creating a central resource point for assisting of up to date information. This is because a lot of efforts have gone into and it's still going into curating resources and tools to foster genomics literacy of providers. However, a lot more could be done to ensure that the audience benefits from this resources optimally and has a value of my involvement in the OBGYN work group. Our target audience would be OBGYN providers. And we know that the advances in our understanding of the molecular basis of inherited disorders have led to the increased adoption of genomic technologies at different point of care. And this would include diagnosis, prognosis treatment and preventive intervention. And as advances in the science of genomics continue, it is essential for providers to have access to evidence based information to guide their management options for their patients. And genetics and genomics testing are increasingly becoming a more integral part of routine medical practice, including OBGYN practice. And as such, a thorough knowledge or lack of these advances may impact treatment and prevention approach to fetal and maternal care. And this further speaks to the needs to improve OBGYN providers understanding of basic principles of genetic screening and interpretation. Although the importance of genomic literacy in healthcare providers have been emphasized, lower level of literacy, genomics literacy in non-genetic healthcare providers, including OBGYN professionals still persist. Clinicians should understand the basic genomics principles and how they apply to their chosen specialty, because having this basic understanding allows an appropriate response to queries that can arise from either patients or their families, and also the knowledge to seek for the expertise or help if required. And research has shown OBGYN professionals are limited due to limited literacy to manifest in different ways, and this include limited knowledge regarding testing options, low confidence about using genetic tests results in patient care, limited knowledge about when and how to make a referral to a specialist or not knowing I'm out of conduct risk assessment using various information in care decisions. And again, because of the shortage of genetic counselors, OBGYN providers who would be called upon to be involved in genetic testing and its outcomes. All of this would impact the delivery and incorporation of genomics into care. So what are the barriers to provide a genomic education that has been identified. This includes time requirements for elective education, having commercial or for-profit entities being major sources of information. The pace of advancement of genomic technology is not matching the pace at which the available resources are being updated and providers awareness of educational resources that currently exists and how easy it is to navigate these resources. And for example, we will see that on the ACOG's website, even after having these educational resources, you have the statements that these resources are for informational purposes only, or they reflect emerging clinical and scientific advances as of the date issues and they are subject to change. These can be very frustrating for providers that are already very busy and would need a short point of information to assess or help that patient quickly adding to the workload that they already have to deal with. And again, for the ACOG or members of Specialty Society, they may be able to assess this information by going to their organization. But what about care providers that are not part of or do not have a relationship with a specialist society. And furthering awareness about the availability of educational resources would be somewhat difficult for them. And as such, education needs to be maintained consistently for these clinicians to be able to keep pace with rapid advances in genetics and genomic technology and its application. This is an imperative for health systems to develop scalable strategies to engage, educate, and empower non-genetic health care providers in large numbers to be able to use genetic information. And thus, they need to curate resources providing up to that information on basic genetic concepts of and diagnostic techniques for OBGYN providers and by extension other providers becomes very important. And another abstract by the ACOG that was released earlier in the year looked at a survey of prenatal care providers including OBGYN providers and they looked at professionals knowledge, barriers, and confidence in prenatal genetic counseling. And they found that providers spent too little time on genetic counseling. More than half of the participants could not correctly identify ACOG's recommendations and they listed barriers such as time constraints, health literacy, lack of a visual aid, and language barriers as things that have affected their knowledge and confidence. And the future direction from this abstract pointed to the need to develop and assess prenatal genetic education tools to supplement counseling. So what we did was to conduct a review of available information through Google Scholar, PubMed, and websites of scientific, clinical, and professional organizations to see what resources were existing. And from professional organization, the top obviously was the American College of Obstetricians and Gynecologists. We also had information from the American Medical Association, the ACMG and European Society of Human Genetics. Looking at public data bases, we had a list of his data base that provided information on, or ranging from the clinical relevance of genes and variants, points of care resources for clinicians, and an archive of information about genomic variations and phenotypes and the impact of variation on drug response. We also looked at a list of government-supported programs that either had gotten a grant from the government to develop these resources and on the top of the list was NGRI with healthcare provider resources for genomics education and this might be a little tiny to read, I'll just read it out. We also looked at the genomics education resource center, that's Genome Ed, Global Genetics and Genomics Community, TRIG, healthcare provider and genomics education, also on genome.gov and the OBG projects. And we also have information for providers and also patients from the CDC, State Health Departments and the National Coordinating Center for the original genetics network. So for educational portals we had information from non-profits, MOCs and also the Genome Ed program, which is not in the United States but I'm out of the country. And earlier in the year, one of the educational portals that existed, by the time I had a meeting with Donna some weeks ago, it no longer exists and this is what you would see when you go to that website which again points to the very fluid nature of the availability of resources and how this can make it difficult for providers who clearly don't know where to go to to find information. So going through all of this, is there any evidence that web-based genome education approaches are effective? Well, this study described the content and impact of a mandatory system-wide program that was implemented on Southport Health. It's called the Image Genetics Initiative and they developed a two-year genetics education program with quarterly web-based models and this was made mandatory for physicians and advanced practice providers. And they reported that web-based genome ed programs or this program was highly effective in increasing health care providers' confidence about using genetics. So based on what we found, the first thing that we would recommend is that for the existing resources, it would be helpful for providers to find if they were organized based on keywords or common categories. And going through genome ed quickly, you can type OBGYN or GYN resources and see what the output of the search would be. The second recommendation was also to find a way to improve providers' awareness about education resources and a clear plan for dissemination. For example, the way that G2C2 became non-existent and the website is also something unrelated to genomics education and also a review of the available education resources, which is thankfully ongoing from my discussions with Donna. And again, extending that to the understanding and supporting of patients following testing. So how do we educate our providers to make better reference to genetic counselors and also familiarity with practical and ethical issues. For example, patient identity protection, not withholding information from patients regarding their health, including test results, and managing secondary findings which could raise complex or ethical and legal issues. And also propose an alliance consisting of multiple organizations to develop a standard and central education approach. And ICCPEG could be able to take a lead on this or reach out to organizations that will be able to take the lead on this. I would like to acknowledge my mentor for taking a time in the past two years to offer expertise and guidance and also the OBGYN genetic curriculum co-chair Barbara, the ICCPEG co-chairs Rich and Donna, I'm very grateful for your support. The NDRI for putting this program together and my mentor at the University of Iowa and NIH for providing my training grant. These are my references. Thank you for listening and I'll take questions now. Thank you, Abinbola, and that I've also had the pleasure of working with Abinbola particularly on that last point about how web resources are rather fluid. Thanks Donna. We're happy to entertain other questions. So I have a question, and do you think there is a role for trying to centralize them? For me or for Donna? For Abinbola. Abinbola, yeah. Oh yes, obviously, because having to go to several points to look for resources can be exhausting. So if we have a central point, we're, you know, reducing that search time and also we're able to, you know, point to a resource that it is going to die to this coming from an organization that obviously not for profit and all of that. So you're having some form of confidence that the resources that you're getting is a good quality. So I think yes, there's a role for that centralization. Great. Donna? One question that we consider is NHGRI the central place to do so. I mean, obviously I'm staffier so I'm biased. But what are your thoughts on that? Obviously, I would say that, yes, that's that would be the logical way to, you know, go about that, but how do we ensure that providers know that NHGRI is ready to be the one stop shop for all of their genome admins? Happy to hear other people's thoughts, including yours, Louise. Yeah, and I think several people have beaten to it in the chat already saying that NHGRI would be a good place. Because I think many of the other sites are challenged with how fluid they are with support and such so that they disappear. And then, you know, as I said, physicians become very frustrated and patients become very frustrated and they often then go to more commercial sites. But I think the other key aspect to this is that under an umbrella like NHGRI, there's also a commitment to keeping these items updated, which I think is very important as the whole area changes very rapidly. There has to be like a yearly review, you know, a process of commitment to continue to update. I believe we have folks on the call who are in project groups within ISCCPEG who've been very dedicated to keeping resources updated. It's a challenge as we all know. So it's something that we have to keep at. Yeah, and someone just suggested in a partnership with ACOG, which I think is a great, a great idea as well. Yeah, and the ISCCPEG of course is began as a core component of ISCCPEG was the professional societies. Yeah, those partnerships are key. Yeah, no, I think that's great. I would love to see that move forward. I think Lawrence Brody has his hand up. You mentioned commercial parts and this maybe is for the clinicians in the audience as to what is the threshold to have this tip over so now up to date or some of the other commercial providers actually take it on. I believe that they do a reasonably good job at keeping the material up to date. I know they employ a bunch of professional experts to make sure it's accurate. Not that I'm trying to shirk the genome's responsibility here, but they reach a large audience, and it's really a viable business model. And so, is there, does anyone know what the threshold is on when they actually would say, oh, we're going to create modules on this. So, I can comment and then also with a disclosure that I'm one of the editors for up to date. And I think that they are commercial but the difference is that they're not driven by the sale of a product that, except for the knowledge that they're putting forward they're not producing the test that you're ordering. I think that that's also another good idea because a lot of a lot of clinicians either independently or now or now through epic are tied to up to date modules. Thank you. I see a hand from Dr. Tracy Weiler. So just regarding up to date in the, we've created an FAQ that is hosted on genome.gov and our approach was to go talk to the up to date editor and say hey, can you put a link to our stuff on the up to date site because you're right. It's really, really important to get to where the people are, the people aren't going to come from it, you know, from their, you know, OBGYN office to an HDRI, they're just not. So we've got to get them where they're going to go and, you know, shepherd them to where the information is. So that's one point. As a site and disclosure, my wife has done now up to date stuff and everybody gets a check. So it is an opportunity for some of the genetics education people to monetize their knowledge. Thank you everyone. Evan Bola, did you want to have any wrap up comments. So I think, please, I had a question on how G2C2 fits into the idea of a central repository. And as I said, my last question we've done at G2C2 is no more. And at the content, I'm a bit more to many JRI. So it looks like any JRI is consolidating resources from external resources or from representatives that used to be. So G2C2 might be no more, but you can also access the resources on genome.gov. Even correct, Donna. That's correct, right. Genome Ed is where we're centralizing the repository that was G2C2, which served an important role, but needed to be updated. Yeah, so this is Kathy Blazer. I'm the one who posted that question. So I did go to it. I see that it is. And so would this be what a place we would build from if we were to try to take Amagola's idea and make a more robust central resource, and then taking Tracy's idea and then disseminating access to that resource or links to that resource for different groups. Would that be something that would be the way we look at this because we already, there already is a repository, right? It's not like it doesn't exist. I agree it's a staffing and, you know, question of how we can manage that. Yeah, so it's, I mean, it's not starting from, it's not cutting it from whole cloth. There already is this wonderful, robust and very attractive resource that is Tracy mentions is underutilized and perhaps many people don't recognize it and are not going to go out searching for it. But I think to your point, Tracy, a lot of the work is going down into making people aware of it and making it easy for them to access. Yeah, absolutely. I think that was one of the motivations also that Emma Boll and I spoke about is like, at least to get this out into an article that Obigine's read so that they have the links there, you know. But up to date, it's a good idea as well. Right, the partnerships I think are going to be key in getting this out. All right, I think we're to time. Thank you everyone and we really appreciate the contributions on the chat and the discussion that we've had. Thank you. And I have to put a shout out to our mentor. In this case, Louise Wilkins hard and certainly to our mentee. This might be the time for me to say we're looking for mentors for our new class. Certainly it was my pleasure it was it was great fun and she did a wonderful job. Thank you. I think this is the point in our agenda where I believe. Dr Brody put your camera on and introduce our next scholar, which is on over here. And so it's my pleasure to introduce Sarah Roth either her mentor or advisor. I would say I'm an acquaintance and someone who's had opportunities to discuss lots of different topics with Sarah over over the years. Actually, it's now many years since we first met. She's also, I think still a neighbor so she lives a couple hundred yards from where I'm sitting and probably where she's sitting relatively close. So she gives me good restaurant advice as well. But Sarah is takes the approach that is sometimes a difficult road to follow in the academic world where you're interested broadly and a lot of different things. And you want to bring them all together. It is just for those of you that are trainees that kind of career path, it can be greatly rewarding it's a little bit tougher because it's easier if what you do is study one organelle. Then people know how to define you so I have a hard time defining what Sarah does she's interested in history interested in humanities interested in the sciences is a genetic counselor having been through our joint genetic counselor and is currently a PhD candidate in anthropology at Hopkins. As I said she's interested in the broad use of biomedical stuff from the humanities that the personal view the community view and as well as having seen her and invited her to present at a meeting that I helped run in Montreal is an excellent presenter as well her mentors who I guess are not here and we'll see them. Otherwise they would be doing a better job at introducing Sarah than I am our archery squire. Seattle Children's Hospital and Daniel McKenna at Penn University of Pennsylvania School of Medicine, and they should take credit for anything nice that the Sarah present because I cannot take credit for it and Sarah obviously will take deserves most credit. So take it away Sarah. Thank you Dr Brody I did want to mention that Dr Larry Brody is our division director of genomics and society. Thank you. Thanks Dr Brody for that introduction and I will share my PowerPoint. Are you all able to see just just the PowerPoint. Yes. Okay, great. Well, hello everybody. My name is Sarah. I've been a ISCC pig scholar cohort from the last two years. I think maybe think it's possible that someone need to mute themselves here. Yes, ISCC pig scholar cohort from the last couple years. I recently graduated from the Hopkins NIH genetic counseling program and I'm currently wrapping up a PhD in medical anthropology at Hopkins. I am a sort of lead stage PhD student and bringing together these two things as Larry just shared to. So my project as an ISCC pig scholar has been a qualitative study designed to explore the lived experiences of trans and gender diverse folks with hereditary cancer risk. My mentors as Dr Brody mentioned are Daniel McKenna and Audrey Squire at Penn and Washington. But also Leila Jamal and Kellen Baker who have also been involved with ISCC pig. They were both on my committee for the project at Hopkins so also both quite involved with the project development and Leila has been my advisor for the project as well. So before I dive into talking about the project I just wanted to note that language is important in this field. And here I'll be talking about sex as assigned at birth, gender as lived and expressed, and transgender or trans folks as having a gender identity that's different from sex assigned at birth. And here I use gender diverse as an umbrella term that more broadly encompasses folks whose gender identities differ from sex assigned at birth, but that also includes non binary gender non conforming and gender queer identities. So at the beginning of this project and I went into a greater detail about this in my initial scholars talk. But I thought I would I would highlight the background a little bit because then and kind of iteratively as I write up analysis I've turned to the medical literature to see what it says about trans experiences of cancer risk. I think trans folks are sort of vastly underrepresented in medical and epidemiological studies of cancer risk, which then creates these exclusions from data sets as well as standards of care used to care for these populations as I'm sure many of you are very aware if you're this is especially notable in cancer care where risk figures are inscribed with the presumed gender of these big population data sets. And so in my thesis as well as in my ICC pick scholars project, I held space for this work to address these gaps and needs through interviews. So last year for this project, I interviewed 19 gender diverse folks the majority of whom had BRCA one or two pathogenic variants were in their 20s or 30s, and were non binary or gender queer. And also importantly mostly white. Because this is generally what the participants in patient advocacy groups look like and that is where I met and recruited folks. This wasn't a terrible surprise, but it definitely points to very necessary future directions in working with other underrepresented groups in after looking, looking over transcripts and recordings from interviews as well as reflexive field notes that I took as I was conducting the projects. I really moved between interviews and the literature to articulate three main themes that I'll focus on to highlight. These are also the themes that I outline in the first public publication on the project that I'm working on, which is it's currently under review for the Journal of Genetic Counseling and hopefully will will be forthcoming soon. So firstly, interviewees described experiences of discrimination and dysphoria as they navigated care experiences as well as care environments. They also shared narratives of gender identity and genetic diagnosis intertwining in terms of access to interventions, shifting relationships to gender identity and expression, and navigating multivalent forms of medical uncertainty in their care. Throughout interviews participants also shared their aspirations for what hereditary cancer care could or should look like for other gender diverse folks navigating it. So as highlighted in my last talk, interviewees really pointed to what anthropologist Lachlan Jane has called the redoubling of femininity in cancer care, marking experiences of dis-ease they had navigating interactions and care environments. These three participants reflected this remark by Ben, sorry, the second quote, a trans BRCA2 carrier that the worst thing that the worst space to navigate for them was the waiting rooms. They also pointed to screening appointments and interactions with admins and texts as especially difficult as these were the most common places that they were misgendered. So interviewees explored the social and emotional ways that they responded to these experiences, in particular describing how they would brace for misgendering in advance of appointments. This really supports lit documenting trans experiences of anticipatory anxiety around genetic counseling encounters that role a describes in a recent article in the Journal of Genetic Counseling, and also suggests that cancer genetic counselors who are working in oncology can anticipate anxiety from their patients stemming from previous experiences of mistreatment of mistreatment or anticipating future experiences of mistreatment. And this really calls for specialized compassionate care, which I will circle back to after I dive into a couple more sets of quotes. So in interviews, participants explored the complex ways that their care journeys intertwined, and this theme from interviews is really at the heart of our article manuscript. And it's also dear to me as a queer BRCA1 carrier myself because it's really up for folks in the community as they navigate these intertwining fields. And as Fern described in their interview, there were care from these experiences were tied up or interleaced together for many cancer risk on the one hand presented a crossroads in gender expression, how to respond to the embodied risk prophylactic conditions or disease. For some also the risk or genetic diagnosis presented a different kind of turning point when that enabled them to overcome barriers to gender affirming care through insurance coverage for surgeries in particular. At the same time, though, an alert to elevated risk and recommended screenings introduced new forms of medical uncertainty. And hopefully you can read more about this soon in our article manuscript. And in the meantime, if you're interested in reading more about these kind of intertwining journeys, it suggests taking a look at the article cancer butch by Lachlan Jane in the cultural anthropology journal. And these are two sub themes that I that I just highlighted and should have clicked click through as I was talking. So as they navigated largely unwelcoming environments and these complex care experiences, interviewees also shared about experiences that were affirming or give them insight on a future that they'd like to see for hereditary cancer care. Jason, a non-binary BRCE2 carrier reflected on how it felt when a clinician honored the identity that they had shared on an intake form. I feel like my identity is included in the room they said rather than just my biology. So reflecting on these experiences and needs and barriers that they encountered navigating care participants shared that they appreciated when providers communicated a sense of allyship so implicitly or explicitly through cues, pins or lanyards were attentive to gendered language partnered around difficult and complex care decisions and validated and normalized their preferences. They also expressed importantly a real longing for providers to work to hold space for the emotional complexity of pre-viborship. So living with cancer risk over time and through many different kinds of difficult and complex care junctures. As I conclude, I thought I'd spend my last couple minutes discussing some ways that providers can use these insights to work more inclusively with patients and communities since the majority of folks present are likely providers working in these intersecting or allied spaces. And I'll also note that the experience of working on this project has helped me to develop some of these practice implications modules and I've used them to help give guest lectures for trainings in the Hopkins NIH program. So that's something that I should note and highlight because it's an education piece. So, okay. So in the context of use complex care journeys for gender diverse folks navigating hereditary cancer care, and also keeping in mind mounting attempts to censor trans existence within the US and around the world through anti trans legislation. It's really important to consider how we can build trust with queer and trans clients. And here are some ways that we can do it in this space specifically. So in addition to listening well, asking for pronouns and conveying a sense of implicit or explicit allyship. We can also ask for input on a family tree as we document it so if you're working in person you can kind of like share the document as you're mocking it up, ask them how does this look asked for input about how you represent the gender of family members. We can also partner through counseling skills around experiences of dysphoria as they come up as cancer related experiences are narrated. And importantly, you can use gender neutral or patient first language to describe parts of the body, as well as care experiences. So we can also especially in cancer genetic counseling explore gender identity and expression in the clinic. We can do this again by using these counseling skills that we developed through our specialized training to compassionately explore gender as a hemoventrist. So asking open ended questions, following the patient's lead on language around labels and exploring what their vision for gender affirmation looks like or could look like. That said, especially in the context of clinical environments and the sort of like transphobic political milieu especially in in specific regions of the states. People aren't always going to come into a genetic counseling or oncology session expecting to get vulnerable, and they may be primed by difficult passage points before meeting with us and so it's also okay. We can feel safe getting vulnerable and exploring this in a clinical setting. Finally, as clinicians and as genetic counselors in particular we can refer clients to support, and there's no reason not to refer folks to queer friendly support settings with affinity group offerings. So we can share information about forces LGBTQ support group which full disclosure I'm now a co-leader for and I'm happy to provide information about. And we can also share information about the breasties LGBTQ support group. These are both monthly virtual and they're accessible from anywhere. And these groups are not perfect, but they do provide a kind of support and affinity that is hard to find elsewhere, and that folks report feeling really sort of disconnected from when navigating oncology settings. And with that, thank you so much to ICT peg for the whole thing space to work on this project to my mentors and committee to the HBO C advocacy groups and to our study participants. If any of you would like to get in touch my contact info is under the bird in the lower right hand corner of this slide. I'm an open book and happy to talk about this work, discuss collaborations, or come to your class or program to talk about queer health or qualitative research. Thanks so much. And with that, I will turn to questions. Thank you, Sarah. This was terrific presentation and we really appreciate your work as well as the dedication to your team. And the email was blocked briefly so. Yeah, there we go. S a r a h r o t h at jhu.edu. Yes, please questions. I have a nerdy question Sarah so your data set is, you know is probably the largest data set of interviews of folks out there who are in this situation. You have any idea how many what the total number of people in the US might be. I guess we could probably calculate the intersection between trans and your state carriers and cancer susceptibility but you thought about that. Yeah, that's a good question and not. I'm afraid it's not one that I can answer with the knowledge that I have. I think, you know, the going number going around the literature I think is that like 1.2% of the population is trans or maybe it's 1.4 it's depending on what what data set you look at. In terms of how many people are gender diverse and living with hereditary cancer risk. I honestly I have no idea, but it, whatever it is it's more than you think. I think that's why I was asking because I bet it is more than I think. Yeah, I I'm honestly I feel like even just going about my day to day life, not in a research setting I feel like I'm constantly meeting people who are gender diverse and affected by hereditary cancer risk and that's just in Baltimore just you know, navigating life as a graduate student in Baltimore. And so I think it's it's more than his thought, but I don't know how many. So I just did the rough calculation based on your top estimates that if you just do breast ovarian cancer it's probably 5000 people in the US and if you throw in colon cancer susceptibility and double that. That was more complicated implications than the other. Right. Yeah, I mean, that's not that sounds. That sounds appropriate to me. Those are little kids so it's not I mean the whole population US right. Oh, and actually. Yeah, no, it's an estimate. So Andrew has a question. Thank you for this great presentation and this really interesting qualitative work. I'm interested to hear you meant talked about gender dysphoria I'm wondering if you heard had any emergent themes from these interviews that identified maybe a gender affirming philosophy or behaviors or attitudes of clinicians created a sense of gender euphoria in any of your interviews. Yeah, that's that's a really lovely question. So, so like the easy answers is yes. In interviews, there are discussions both of dysphoria and euphoria emergent from care experiences. Generally speaking, I think clinical environments, especially for for people with diagnosis navigating surveillance and just really complicated tough decisions. They're stressful encounters that there's just a baseline stress to them and so I think it's a lot easier for a care experience to trigger dysphoria than to bring up gender euphoria even in the most affirming and supportive of interactions. And so mostly when people were talking about clinical interactions specifically, mostly, you know, I would say the spectrum range from like a lot of dysphoria to like a feeling of support, and maybe affirmation that felt, you know, like someone was helping to shepherd them through a really tough decision or through a complex, complex decision, but people did did talk about gender euphoria as emergent from their experiences of navigating intersecting care journeys. And that mostly came from experiences of community support and like queer community connection through, especially for, and this this is a big theme and it comes out in the manuscript a lot, a lot of folks feel felt very affirmed by the experience of having the preventative mastectomy. And even if they hadn't been thinking they would have top surgery prior to the genetic diagnosis, some people found that through the experience of having a preventative mastectomy they felt very affirmed and very comfortable and euphoric in their body, though it still carried the trace of the trauma of the genetic diagnosis and all of the, you know, familial and, you know, ontological orbits of illness and risk. There were lots of discussions of a feeling of coming into oneself and one's gender expression in a way that felt really really good. It was very it was just rarely like a key, a key interaction with a provider that got someone there. It was like just the long term journey of coming into a body and expression that felt good and feeling a sense of legibility and support and affirmation in that new bodily expression, which like the medical piece helped, you know, was a was a piece of the journey that got there but yeah sadly there were there were very few clinical interactions cited that like brought up up gender euphoria, but other stuff did. So Tracy really, really lovely question. Weiler had a somewhat of a related questions that you restricted your study to the clinical interactions around cancer, what other clinical actions are also particularly complex for trans folks which, I guess is a lot. Yeah, yeah, that's that's a good question and in interviews and an observation I talked with folks and observed conversations beyond just cancer I just, I just talked about cancer here and and in the manuscript I'm generally focused on cancer but people talked about, there are a couple of people who had, who had had carried pregnancies and had given birth and so they reflected on their experiences of navigating prenatal care as as gender diverse, and people also talked about navigating broader social barriers that people use and not just their clinical cancer care environments. Something that I have been reflecting on. Even if I am like connecting cancer care to other clinical interactions is that, and I think I just mentioned this but people. There's a lot about waiting rooms and imaging appointments as particularly stressful and and triggering of dysphoria and also like sites of misgendering. And I know in the clinical literature on prenatal and repro care there's a lot of of that precedent as well in particular there was a 21 2021 study from Ruderman. That cited waiting rooms and imaging appointments as particularly stressful and gendered like overtly gendered spaces. And so I feel like there is a sense of resonance between cancer care and prenatal care in the in those specific in the context of those specific sites being stressful or triggering. Yeah, so something that emerged from people's discussions of cancer care, but is also applicable to other sites is that a lot of people cited being misgendered in their clinical notes. Of course people have access to their clinical notes after encounters now, and when people see that they've been misgendered in their notes after the fact, even if everything went well in the clinical interaction there's a sense of like being let down. That is definitely applicable across settings and not just unique to cancer care and something that's a takeaway for anyone working clinically is to have a sense of consistency between, you know, the intake form, the interaction and the notes because people are people are watching and they're not when they experience inconsistency there. Okay. I think we're getting up to the time we predicted for our presentations thank you. And any other questions or comments before rich provides some concluding remarks, I think I still see which I know his time was here. You're here. Great. Now so I was just adjusting my camera which is a little out of whack, but oops. There we go. Hi everybody. But yeah, like Kathy just said, thank you very much. I mean the scholar program was an idea that came out from one of our annual meetings and has just been incredible and I hope that both of our scholars got a lot of the program because we got a lot of working with both of you and learned about a lot from your discussion so as you go out. Hopefully you'll remain associated with us, but if you can also help spread the word about the scholars program that would also be great. And I CC pick but, and thanks to Donna, and the others that in each year I would really made you know it's one thing to come up with an idea it's another thing to actually make it happen so very much thanks to them as well but. Yeah so we hope we'll see you around. So, thanks a lot. Thanks a lot to the mentees, the mentors, and you will be getting some certificates. You'll see us a little bit more with those communications and like Rich says, we're certainly not ending our relationships we're hoping you all will stay with us and continue to contribute. Let me just add sorry, definitely thank the mentors as well, we know it's a significant time commitment so, but I hope you found it rewarding as well but thank you so much for doing that, but. All right. Any other comments or are we wrapped up. I think we're good. Thanks, Donna. I think we're good. All right, thank you so much everyone and this is recorded and we will post it on genome.gov eventually. Thank you all so much as well. Good to see y'all.