 Dr. Elizabeth Eamon graduated from University of Michigan Medical School and came to Washington to complete her family medicine residency. After residency, she worked for Health Point, traveling all over King County, covering where needed at their community health centers. She then spent six years with the University of Washington neighborhood clinics in Kent. After more than a decade in the field, she decided to start her own practice, Udall Family Medicine, where she could be the kind of family doctor she envisioned in medical school. She enjoys practicing the direct primary care model because her partnership with her patients is free from the burdens of the corporate medical business model and profit-minded, instead of patient-minded, insurance agencies of modern American medical culture. In addition to caring for patients of all ages and walks of life, Dr. Eamon has specialized in primary care of transgender, non-binary, and LGBT patients. Since 2003, she has worked with various organizations and educational institutions to improve LGBT plus patient care and continues to work with the University of Washington and other Washington schools to further LGBT health education. We are so grateful to have the opportunity to learn from you today and please join me in welcoming Dr. Elizabeth Eamon. Thank you, Sarah. So I'm Dr. Eamon, Liz to my friends and to you guys if you'd like as well. This is casual. I will not be doing any exams, so you do not have to address me as doctor. Let me get my clicker. So I'm really honored to be here. I love talking about LGBT and queer health. It was it's always really hard for me to find a focus because I have taught and done so much research on this topic. It's really hard to focus on something. So I find most interesting is kind of putting a face with the issues. So I created some patients to talk about today. So we're going to do case studies regarding trans and non-binary patients. I want to give you a little foundation. This is this is my dog Oliver. He's just really cute, so I put him on the first real slide. So Before we really get started, I want to make sure that we're all on the same page in terms of nomenclature and some terminology. I'm not sure if you guys are going to get other lectures on some of these topics. This is more sociological issues as well, but they do reflect into the medical world. So there's a difference between sex and gender. There's many many years where they use them interchangeably, but those are not the same thing. And then gender is more of a societal construct and sex is more of a biological aspect like x, y, x chromosomes. Gender identity versus gender expression, that's going to be really important, and that'll be on my next slide a little bit more. And then sexuality, I'm actually really not talking about sexuality today. It's not super relevant when we're talking about transgender health in the ways that I will be talking about it. Obviously sexuality is an important issue, especially when we're talking about sexual minorities, gay, asexual, bisexual, lesbian, and other identities, but that's not today's talk. So here's the, some people may have seen the transgender umbrella. This is a double umbrella, and it's it's, the reference isn't below, but the woman who made it, her name and signature is on the right side there. So it's useful to know the difference between the identity and the expression of an individual. Both can be medically supported. Transgender really is somebody whose gender identity doesn't match what they were assigned at birth. So let's say you were born with a penis, they called you a male, and you actually are female. So that's transgender gender non-conforming is say, let's say you were born with a penis, they called you male, you actually identify as female, but you love to wear suits and ties, right? So that's your gender expression. And there is just a variety of gender expressions. I think they're beautiful, and we'll talk a little bit about that today as well. I'm gonna kind of go through this pretty quickly, but basic medical terminology. We talk about gender affirming care now in the medical world, and then I do like to clarify at the bottom here that we don't use gender identity disorder anymore. We do not, it's not pathological to be transgender. Sometimes we do need to bill insurance companies and insurance companies like codes, and codes are associated with diagnoses. So that's kind of a hassle sometimes when we're talking about identity, but we do not use that term anymore, so make sure you erase that from your memory. dysphoria, something we will talk about, that's where you have discomfort with something, that's really what that word means. In general, people who have dysphoria related to their gender will often have problems inside and out. So internal issues, internal struggles, sometimes as extreme as suicidality, and external struggles are hard time coping with their social integration, for example. Dysmorphia, some people confuse it two words, so that's why I really have that on here. We're not really talking much about dysmorphia. Dysmorphia actually means deformity in medical terminology, and so there's body dysmorphic disorder, which I think some of you may have heard of, like anorexia, where people see in the mirror something that's deformed, but really that's not their reality. That is not relevant to the patients I'm talking about today. Cross-sex hormones, we'll talk about that. Those are hormones, and generally hormones that somebody's organs that they were born with weren't there, and then blockers, we talk about that as well. I'll skim through this, definitely faster than the last slide, even though it's a really busy slide. It talks about kind of some of the things we're going to get into. So we're going to talk about medical transition. We're going to talk about maintenance. We're going to talk about supportive gender expression without actual continuing transition. So how to support that, and we can go back and kind of go through some more details later if we want to. One of the first and most important things when we talk about treating somebody who wants to transition or to support a gender expression is consent. Now we used to always make people sign these really long forms, and these are some sample forms actually that are from Fenway Health, which is in Boston. They can be really useful, because they do lists, like these are the reversible issues, and these are the non-reversible aspects of starting this, and I understand the risks, and I understand this, and this, and this. So kind of cover your but, excuse me. So sometimes we do still use these. I tend to use them sometimes when I have a parent consenting for a child, just so that there's something in writing that everybody kind of understands, they can file away. So in most trans care, we talk about the ICATH model. So I see informed consent, so that means that somebody has autonomy over their own body, and if they're able to make decisions, they can decide what their gender identity is. We use informed consent for just about everything in the medical world. If I'm going to be washing out your ears, sometimes I'll get informed consent. If I'm going to lop off a mole, I'm going to make sure we get informed consent. But the ICATH specifically, the AFT part, is to make trans health care more accessible, so that we're not really gatekeepers, that we're not preventing people from getting the care they need, because they need to jump through all these really unrealistic hoops. We used to do that back in the day. I'm really not going to go into that. It's important history, but it's not what I'm focusing on today. Surgery, it's not going to be the topic for right now. I do talk about that sometimes. If you have questions about it, I'm happy to address them. As much as I can, I'm not a surgeon, but I do help patients access that care. It can be life-saving. It's not right for everybody. That's the main point I want to get across there. There's my dog at the dog park. We're going to go ahead and get into some cases. Case one is Ava. I just want to make a comment that this is a trans woman who was murdered a few years ago. I just wanted to memorialize her by making her our case. Unfortunately, she did not live to be 25 years old, but in this presentation, she gets to be older. Ava, she's now 25. She was assigned male at birth, so that means she was born with a penis and testes, and her birth certificate initially says male. She does identify as a transgender woman, and she has feminine expression, and she's been expressing her feminine gender expression for the last six years. But she hasn't been on hormones, and she's talked to some friends, and she'd like to start hormones. She's not sure about surgery yet. It's expensive. She doesn't really know a lot about it, but maybe. She does have some support. She moved out of her parents' house because they were not accepting, but she lives with her sister, who's very accepting. She has lots of friends in the queer community. She does have depression and anxiety, and she's a counselor. When I first see her, I'm going to get a full medical history. I'm going to get a release of information to get old records. I'm going to really want to clarify her mental health history. She says she has depression and anxiety, so that's a really common trend in people who are minority stress receivers. This is not a talk of minority stress, but minority stress is something that hopefully somebody else will be getting into a little bit. But being transgender can really wreak havoc through childhood, school age, post-adolescence, and we'll talk a little bit more about that. Unfortunately, it's very common. Even though being transgender is not a mental illness, sometimes we do see an increased incidence of mental illness in people who are transgender because of society. I want to clarify, has she had any suicidality? What kind of support do we need as her primary care doctor? It's not going to inhibit her transition. She'll still be able to get whatever help she needs to transition. I really want to clarify with her what she's expecting from this treatment and transition. What does she think is important? What does she think is going to happen? There are a lot of myths out there. We review medication options. I briefly reviewed some of the medications. We do blockers, which is spurnolactone that blocks testosterone, and estradiol, which is the bioavailable form of estrogen. It comes in multiple ways. Then we get some baseline labs because these medications can affect the organs and electrolyte levels. This isn't a pharmacy talk. I can do that as well if people have questions about after. Before starting hormones, we like to do with every patient and every treatment plan. We always do a risk assessment. Is this safe? Are you going to do okay on this? Are we going to do harm? First, do no harm is our way. We do a mental health assessment. Usually mental health doesn't improve once you start gender-affirming treatment. Clotting risks. Estrogen and blood clots. Some people may have heard about that. I know one of the Williams sisters, a tennis player, had a blood clot when she was on birth control and flew on an airplane. Clotting can be something to discuss. We're going to talk about that in a minute, a little bit more. Risk factors for clotting include smoking, and if there's a family history of that kind of thing, and then a personal history if they've had one in the past. We just make sure we get all that out in the open before we start the estrogen. We review the labs and then we really document the consent. One of the things that we really want to clarify, like I mentioned before, is what's reversible and what's irreversible. One of the things that's irreversible, especially when we're talking about estradiol treatment and testosterone blockers, is fertility. Sometimes we offer people options for fertility preservation, like sperm banking. That's definitely something to think about for your transgender patients. What do we expect? Ava starts estradiol. What are her expectations? In the first few months we'll start seeing some softening of the skin and hair may change a little bit. We'll see sex drive might go down a bit. There are a lot of changes to the gonads that happen. Breast growth takes some time, and a lot of people are impatient about that because they want to present as the gender they identify as. That's definitely a defining factor, but patience is really important. Puberty is a slow process, and so you think about this as a second puberty. Things that estradiol will not do, we really clarify that with Ava so that she has some realistic expectations. As you can see on the slide, there are options for these things that estradiol does not do. Down the road. We need to talk about long-term treatment. I'm a primary care doctor. I'm a family doctor. My goal is to take care of patients, prevent illness, and do it through the lifespan. You want to make sure that you're treating the patient specifically and the organs that that patient has. Ava, even if she did have vaginoplasty surgery, she'd still likely have her prostate and then no cervix, so we wouldn't need to do pap smears and so forth. The United States Preventative Service Task Force, the USPSTF up there, they're the ones who make the recommendations for us, for most health care providers about how frequently to do that kind of screening. What if she gets a blood clot? Let's say she's been on estradiol for 10 years and she gets a blood clot. The basic answer to that is we can continue estrogen. We just have to figure out why did she get the blood clot? Does she need ongoing treatment for that issue as well? You don't have to stop somebody's life-saving medication for an incident like a blood clot. That's why you have informed consent. I have seen patients who've had clotting disorders and you put them on blood thinners as well as estrogen and they live happy lives. Will she have a satisfying sex life? This is a question a lot of people have. Yes, absolutely. Number one, there's lots of ways to have sex. Number two, you can have sex with various different organs. I can answer more questions about that, but that's something to always keep in mind as sexual health in terms of happiness and satisfaction. Safety. I picked AVA because trans women of color are most frequently victims of violent death when it comes to violence against trans folks. I think this year so far there's been over 25 murders that we know of and those are people who are appropriately identified in the media. A lot of people are misgendered in the media, so it's really hard to track those. Case two, and I have three cases. We're almost halfway. Corey is 38, so they are approaching 40 because they use they, them pronouns, but assigned female at birth. Corey identifies as genderqueer and their gender expression is masculine and they have a real big issue with their chest and their menses. It really is disturbing for them. And then other health issues, there's weight issues and asthma. So Corey uses a binder. Does anybody here know what a binder is? Yes. Does anybody here not know what a binder is? So a binder is a kind of tight elastic device you put around your chest to compress your breasts. It allows people born with extra breast tissue or breasts, depending on whatever the individual would like to call their breast tissue, to be flat enough to pass, hopefully, for safety reasons. And it's really restrictive. So Corey wants to get the binder off and no longer have any breast tissue. Periods are really distressing. Corey has a panic attack just about every month when the period comes along. Asthma is doing okay. Corey is not sure if they want to do cross-sex hormones, but really considering it. Supportive partner, not currently in counseling, but has it in the past. And to make it simple, I just didn't know family history. Some of these patients have been simplified to make this a little shorter. So one of the things that's really important for Corey now is stopping their menses. And there's a couple of options. We can do testosterone or we can do depo. Depo is usually used as a birth control and it's every three months, but it can cause weight gain and Corey is really concerned about that. We can do testosterone, but we're going to have some masculinizing factors to that. But Corey is kind of okay with that. Stopping menses is really important. Some people talk about starting testosterone causing cardiovascular risk problems, and that is actually not true based on all the research that's been done so far. So we can kind of check that off the list. The other drawback to testosterone is injections are more often as it puts every three months like the depo. Corey is like, I'm ready. Let's do this. They want to start the testosterone. So we do the ICATH, the consent. Corey does not need to see a counselor to confirm to me their gender expression and their gender identity. I trust Corey and so I'm going to go ahead and document that Corey understands what we're doing with medication and we will go ahead and get started. We do need to provide a letter of support for any top surgery that Corey would like to have or breast removal or bilateral mastectomy. That's a surgical requirement, but I'd be happy to provide that for Corey. And then we titrate the testosterone until MENSI stops. Later on, after menopause, no periods, so you could stop testosterone or if Corey really finds a lot of benefit from the masculinizing factors, we can continue it. Still needs routine screening like everybody else. No mammograms needed if there's no more breast tissue. But what if they didn't have the top surgery? What if Corey was binding? Corey has asthma and asthma is a respiratory illness. Binding actually restricts the lungs. And so what can happen is, let's say Corey gets a cold and Corey is not taking a deep enough breath, the lungs won't open up in the bases and it can be a nightest for infection. And so you actually can get increased pneumonia and other infections and people who bind. All right, my last case, Eden. All right, I love Eden. So Eden is eight. She was assigned male at birth and she uses her pronouns. Since she was four, she has been very adamant that she is a girl. But when asked, you know, so, you know, how do you describe yourself, right? She'd say tomboy, but she's a girl. She was bullied a little bit in early grade school. Mom took her out of school and is homeschooling now. And it's a single mom. She's super supportive, but has a lot of questions. Eden's pretty healthy. There's not a lot of health issues. Mom is really worried about puberty. So that's going to happen in a few years. And that's a really fair thing to be worried about. And sometimes we see in kiddos, we'll see some self-harm as early as this age, some self-mutilation if they see a body part that they don't think belongs there. Thankfully, Eden does not have a history of this. So puberty blockers. This is an exciting topic. We've been doing this for a while. So you can actually stop puberty from what we call endogenous puberty. So endogenous means that it's from the organs with which you were born. So if you were born with testicles, those testicles will produce testosterone and you will go through male puberty. So we can stop that by using this medication. This medication has been out for quite some time. It's used for other indications, issues with growth in children and so forth. What's so exciting about it is that... So we talked a little bit about dysphoria, right? So Corey had chest dysphoria. So we can prevent that. That'll be a billing nightmare, maybe, because you don't really have a diagnosis code. You're a perfectly happy, healthy person. But boy, how wonderful is that to be able to actually prevent the gender dysphoria that we see in trans individuals? We need to consider bone density because the sex hormones are the ones that cause that. It causes the bone growth. But when you start the cross-sex hormones, which would be, in Eden's case, estrogen, right, then the bones will grow nice and strong. So the question is, when do you start? So if you're going to block puberty, when do you start puberty? Like the new puberty, right? And we'll talk about that in just a second. The biggest drawback to puberty blockers is that they are expensive. $30,000 a year. Actually, that's for histrulin, which is pretty similar. Lupron is often used. It can be used daily, weekly, every couple months. Kind of depends on the formulation. But it adds up to be about the same as the histrulin. And this is actually with a coupon. So it can cost much more than that. Some insurance companies will cover it. Some will not. If the diagnosis code is mental health, some insurance companies don't cover mental health at the same rate that they cover other health issues. And so it can be kind of a nightmare. But boy, when kids can get it, it can really save lives. So what do we do for Eden? So we definitely do a lot of education for Eden and her mom. We talk about integrating possibly Eden to a new school. If they want to continue homeschooling, that's great. The reason why they're being homeschooled is they were concerned about bullying. So there's a lot of kind of social factors we'll do. We'll talk to a school and make sure everybody understands. And then we definitely recommend counseling for kids. And now Eden has no issues. And Eden has no dysphoria. Eden's just a happy little girl. Just totally happy eight-year-old, you know. But we want to prevent any changes to that, if possible. And so what we need to do is we need to have mom and Eden learn about what's happening and what's going on, what transgender is, and how to answer questions about it in a comfortable way and how to address things that are uncomfortable. And that's a challenge. And as a physician, I do that somewhat, but I really do rely on the mental health providers for that aspect. So if you're here looking at maybe getting a degree to go do some mental health counseling, maybe focusing on trans youth would be really, really beneficial. So Eden's not anywhere, like, not quite near puberty yet. So we don't do any meds right now. It's all of this kind of preparatory work. But we make a plan. So the first sign of puberty is usually when we start it. And in Eden's case, that would be some testicular enlargement. And, you know, we would just make a plan, you know, mom or Eden just let me know right away and we'll get you started. We wouldn't do a bone density baseline. Some people, if you do research on this topic, it's a commonly discussed, the whole bone density issue. But we don't really need to do that. There's no family history. So it makes things a little easier. And then there's some research that talks about when we do start puberty, do we start how old? So a lot of people say 16 because that's kind of an age of consent. But going through puberty at the end of high school and beginning of college, not so fun socially. So we do tend to start more when their peers are going through it. So that was my last case. So just some importance. I want to give a lot of time to questions and answers. So important points from today's talk, I think, is that people have autonomy over their identities. Like you don't, medical community should not be a gatekeeper. If somebody wants to seek care for gender affirming treatment and they're getting asked to do all these letters or other things, that's not ICATH. That's not the informed consent model. It's restricting access and that's not appropriate. Gender, nonconformity transgender identity is not pathological. But dysphoria, which is the discomfort or issues with mostly societal pressures, is a treatable condition. But you don't need to be dysphoric to get treatment, which again, insurance can have some struggles with. And then early treatment is ideal, but it's not always accessible and hopefully someday it will be, but I'm not holding my breath. So for those of you who are extra interested in the topic, the Center for Excellence for Transgender Health at UCSF has an amazing resource online. You can Google that. It was on one of my slides as well. It's fabulous. It's very clinical, but it breaks down everything about transgender health. GLAD is an advocacy organization. They do try to keep track of violence against trans folk and do a lot of good advocacy around that. The Gay and Lesbian Medical Association is a multi-disciplinary medical association, so you do not need to be an MD to join. You could be a physical therapist, social worker, anybody who kind of works in the health industry. And they're great. They have conferences every fall. I think theirs is next weekend, actually. And then locally there's a few gender... There's two gender centers. There's kind of the north one and the south one. So there's IngerSoul, which is in Seattle, and then there's a gender alliance with the SouthSoul, which is out of Tacoma. And then Gender Odyssey is a conference that happens every year in Seattle. It started out as a conference for trans kids to get to know each other and for the parents to get to know each other. And then it really expanded. And so now it's lots of events. They have stuff for healthcare providers. They have a special conference for that. And it's kind of amazing that Seattle gets to be the host for that. There's my dog when he was a puppy with my cat. Isn't that cute? So this is my information. And I really focused on trans health and trans patients. But I do talk about a lot of the other topics. I can talk about medications. I can talk about surgery. I picked this because, like I said, faces with the names is really helpful. And there's a chance that probably 15 to 20 percent of you know somebody trans or somebody who's about to come out as trans. So feel free to contact me on any of those methods by phone. I guess people don't really fax much anymore. By phone, by email, you can visit my website. You can even stop by my office. And I'd be happy to talk to you about these things. I'd love to take time to answer questions. Any specific, do you want to talk about any of my patients that we talked about? They're not real, by the way. They're just kind of loosely based on real patients. Oh, come on. Is there any specific, like, health insurance companies that you've noticed are a lot more trans-friendly? That's a great question. So if like you're looking at the market, you know, where do you go? The big corporate insurance companies tend to cover a little bit better. They have more funding. They're richer, right? So Blue Cross Blue Shield at the Boeing Health Plan. The Boeing Health Plan is actually quite good. They cover just about everything, as far as my patients are concerned. But people pick different options, right, so from their employers. The state plans do cover, and even Medicare has been known to cover some surgery as well. But it's kind of a crapshoot, because insurance companies, their job is to make a lot of money, not to actually provide health care, right? There is to be kind of the fallback. So it's tough. I do advise my patients to kind of shop around and ask when they're looking to get coverage, especially for kids, because as you see, Lupron is really expensive. And often, if they do have insurance plans that aren't covering it, if it's a private insurance, we can often write letters to convince them, including attachments. I can say attached is an article that will, you know, explain to you that this patient could die if you don't approve this medication. And sometimes if you really push hard, they'll say yes. But yeah, I don't think very highly of insurance companies. And I don't really care if they know that. Which is why I have a direct primary care practice, by the way. I don't actually work with insurance to see my patients, so I just see them. Come on, I talked so fast so that we could have time for questions. Do you have any questions? No? Was it signed mail at birth? Correct. Okay, yeah. I was so confused for a while. Yeah, that's fair. And, you know, in my head, Eden is a very happy little girl and has no dysphoria at all. You know, Eden knows that she has a penis and she was born with it. But she's a little girl and she's really happy with who she is. If you know little kids, you know that's a little child. And how great would it be to prevent that from becoming a problem, right? From her being, you know, told that she wasn't right in some way or another. And her starting to integrate that and starting to cause some problems. Like maybe Ava was dealing with later on in life. So, yes, you have a question. First and foremost, thank you for being here. I was thinking in terms of Eden's case as like an eight-year-old, right? How do you consult with parents that are struggling? You know, like know that that's probably the best decision for their child. But maybe, you know, based on like the way they grew up and their own, like, you know, own background, social implications, they may be concerned. And also with the money, because when you showed us that it was like over $30,000 with a coupon. You know, just really thinking in terms of that. Like how do you, as a physician, support the parents in their decision-making? So, that's a great question. Thank you. So, you know, I do, so I'll just start by saying I do send them to a licensed counselor who can do family counseling. But you really appeal to the parents' desire to have a happy child and really kind of focus on what makes, you know, what makes your child happy. And parents are incredibly motivated to keep their kids happy and keep them safe. Like Eden's mom in this case, you know, took Eden out of school. For Senate bullying, you're out. We're homeschooling, you know. You can, there's a lot of resources. There's books. There's articles. There's gender odyssey where parents can meet other parents of trans and non-conforming kids. And by kids, I mean kids like Eden, even younger. Some kids, there's some reports from kids as young as 18 months old expressing their gender, yeah. So, I think there's a lot of resources out there. The problem is that a lot of parents don't know where to look. And so, my job is to just point them in that direction. And they're able to really become more comfortable with their new life and their new child. Same child, but the new gender of their child. Because a lot of parents, and I counsel parents on this, especially adolescents and older kids who are post pubertal, parents project their wishes on the child. I see, I dad see walking my daughter down the aisle one day. Well, now your daughter is your son, you know, you need to reevaluate that. And that's dad's baggage, right? And so, there's something called ambiguous loss, which is kind of loss of something that's not really gone. And a lot of parents have to grieve the loss of the gendered child that they initially had. And some parents even will have like a memorial and a birthday party, you know. So grieve the loss of this one child and have a birthday party for this gendered child, right? So, yeah, it's hard because we put a lot onto our youth, a lot onto our kids. So, yeah, it's mostly the parents, the kids are great. The kids are perfectly happy. It's the parents that have the issues, yeah. Any other questions? Come on, I love questions. What got you interested in trans health, like studying more about it? Good question, thanks. That's a personal question. Those are fun. So, when I was in medical school, I was a part of a group of LGB students who wanted to improve the environment in med school, which wasn't super awesome when I was there, but was really great by the time I left, so victory. But everything was really focused on the L, the G, and the B, mostly the L and the G. So do you guys know what LGBT stands for? Has that been addressed? Lesbian, gay, bisexual, transgender? Okay. So, trans was really left out of the picture. And I had a friend from high school who was trans, and I just, I kept seeing the absence. In fact, we did, our first year, we even did a research study on how to improve the curriculum in our own med school to educate medical students on, you know, LGBT issues. And our research advisor took out the T. It was like, you just, you can't include that. That's just too much. It's a whole nother thing, right? I got really upset about all of that. So then I started, I joined the transgender group in Michigan where I was, so I went to University of Michigan, and started teaching my peers. And I was like, well, I'll just do this. So I had panels of people who were trans come and talk, and people would just ask them all their uncomfortable questions and get things out in the open. And people would recognize that trans people were people too and had really fulfilling lives and start kind of like my initial talk demystifying, right? The transgender person. So that's how it really got started. And then I kind of became the local expert. And then I went to lots of conferences and met a lot of other people who were passionate about it like me. And we all just kind of, you know, helped raise each other up. And now I'm currently a member of the World Professional Association of Transgender Health, as well as the Gay and Lesbian Medical Association, and a few other groups that provide that kind of education and training and stuff. Oh, yeah. How do I feel about gender reveal parties for babies? I do not like them. I get it. I mean, it's, you know, it's society, right? I mean, we've done it for so long and we've done it this way for so long. And it's so fun. And, you know, my older sister had one. I want to have one too. So it's going to be a really hard thing to get rid of down the road. But it's, yeah, it's, it makes me uncomfortable. I think it, and you know, and it's always pink and blue too, right? You know, like why? Why is it always pink and blue? Like we just keep perpetuating this. I guess that's all I'll say on that. I mean, this isn't really a political talk, but I'm not a huge fan. And hopefully next time you see like a Facebook video of a bunch of balloons flying out of a cake or whatever they do these days. A bunch of pink sheep running across the living room or something. I hope you get a little uncomfortable too and realize that like, you know, gender is a social construct. And here we are perpetuating it as, as something almost oppressive. Like how do you get out of that? What if the kid is born and it's trans and, you know, you just, you just don't give any room when you do that. When you just start assigning pink in the womb or blue. Yeah, great question. Right. Purple. It's pretty neutral, right? Or yellow or green or every color of the rainbow, right? You don't have to assign colors for genders. That's silly. That's like when, when, you know, a guy cooks and they're like, oh yeah, you'd be a good wife. No, he's just cooking. You know, that's not like a gender thing, right? Right. So, oh, you have so many questions. Yeah. So yeah, and actually, so the question was any resources for homeless trans individuals or gender nonconforming individuals. So, so I Ingersoll is actually a good resource. There are some clinics, most of the trans clinic or trans friendly clinics are in Seattle, but there's some free clinics. Oops. So, but Ingersoll will have a list of all the ones that are nearby. I do see patients who don't have insurance or patients who are transitioning and have their parents insurance, but don't want to bill that because their parents are not supportive. So they pay out of pocket and my costs are generally lower than going to your usual like corporate medical center. So yeah, and there's, there is an epidemic of trans, homeless trans youth, which, you know, and because of gender odyssey, sometimes we do see more in the Seattle area, but there are resources for that. Thankfully, we're kind of in a safer place. I wouldn't necessarily say safe place because for trans people of color, it's still pretty darn scary. Any other questions? I'm supposed to be ending now ish, but I we're going to be at 10 o'clock. I think we're going to open up for more if there are any. I just wanted to say thank you because I, there was just so much there that I didn't even know. And I was just around so many LGBT, QIA folks for such a long time. And even though like by passing, they would say if you mentioned a few things of this, but like this kind of from your, from your, like your medical point of view, it was really helpful to understand more. So thank you. Sure. Thank you. Yeah, I love talking about this stuff. And when I was coming up with the talk, I, you know, I do lesbian, gay and bisexual stuff as well as transgender stuff when I, when I talk or teach, and I really did want to focus on trans health today. And it's a pretty clinical talk, but like I said, my email is up there or was up there. And, you know, I also teach nursing students, nurse practitioner students, medical students. So if you're ever getting clinical education and need a rotation site, don't hesitate to contact me either. So I guess we're going to take a break for about five to seven minutes, seven minutes. Thank you.