So thank you for coming to our session on the very last day of the conference at 8 a.m. It's very moving to see you all here. So the title of our talk is called, and can you hear me okay? Okay, is this better? Okay, thank you. So thank you again for coming on this last morning at 8 a.m. The title of our presentation is Beyond Race, Sex, and Gender Intersectionality, Intersex, and Non-Binary Identities. And we actually just got notification that, so we submitted this as a paper as well to the Child and Adolescent Psychiatric Clinics of North America, and a special edition that's focused on transgender and gender diverse youth. And just got word that it was accepted and is in the printing process. So if you wanted to read more about it, it will be coming out shortly. And then if you can, go to this Poll Everywhere website, pollf.com slash ningjo136. We'll have a few Poll Everywhere questions coming up. All right, we'll start with introductions. So my name is Ning Zhou. I use he, him pronouns. I am a child and adolescent and adult psychiatrist at the San Francisco Department of Public Health. I'm also a voluntary clinical faculty at UCSF. I identify as a Chinese American gay, queer, cisgender man. And I think my intersecting identities have really informed me in why I want to do this work and why I feel it's important to be talking about topics of race, sex, and gender. So I'll have Terrence introduce herself. Sure. Thanks again for coming. My name is Dr. Terrence Howard. I use he, him pronouns. I'm a current second-year psychiatry resident here at UCSF in the city. And I identify as a cisgender, black, gay man. And I too think these intersecting identities have made me so much more invested in public psychiatry and working with marginalized communities or those communities that have been historically marginalized. And I look forward to working with those that are part of my community in my future work. Talk close to the microphone. Sure. Hi, everyone. My name is Kai Huang. I use they, them, he, him, and she pronouns. Please use all of them. I'm a first-year medical student at UCSF. I'm trans, non-binary, queer, and Chinese American. And I'm really interested in transgender health. I am obviously very early in my medical career, so I have not yet decided exactly where I want to go. But I am very strongly interested in child and adolescent psychiatry. I'm not so subtly trying to recoup, Kai. We have no financial disclosures to report. Here are our learning objectives. So I'd like to describe a framework for conceptualizing intersectionality and ethnic racial identity. Discuss challenges, disparities, strengths, and resilience of black, Latinx, and Asian American Pacific Islander trans and non-binary youth. Identify common challenges for NSX youth and how to support these youth. And also describe non-binary youth and how to best affirm these youth with individually tailored interventions. So our outline for today, we already did our introductions. We're going to start with the intersectionality of trans youth of color. I'll begin with an overview of intersectionality and ethnic racial identity. Then we'll talk about specific populations. You know, black trans and non-binary youth, Latinx trans and non-binary youth, Asian American Pacific Islander trans and non-binary youth. And then some clinical pearls for working with this population. Then we'll have sections on intersex youth and also non-binary youth. So starting with intersectionality. So if you can get out your devices and put into the word cloud, you know, what words come to mind when you hear the term intersectionality? Oh, wow. Already have started. Great. So discrimination is the biggest word kind of front and center. I also see, let's see, disability, sexuality, social understanding, gender, together, coming, multiple, common, understanding, LGBTQIA. Okay, it keeps changing so it's hard to read. But diversity, multiple, feminism, together, xenophobia, disability, fundamental, belonging. Okay, so there's many more words that you can see up here. Or can you see it? I can see it. Can you see it? I don't think so. Technology. Yeah. All right, I just switched my screen so that you can just see all these great words that are up here. Yeah, just so you can take a look. All right, so intersectionality. So Audre Lorde has this quote, there is no such thing as a single issue struggle because we do not live single issue lives. And intersectionality was really first created, the term first kind of discussed by Kimberly Crenshaw, who was a legal scholar, and then talked about by many other scholars. But what the core is how our multiple social identities intersect within systems of power and oppression that then lead to privilege versus marginalization. I've put a few of the social identities here, so race, ethnicity, class, gender identity, sex assigned at birth, sexual orientation, religion, ability, age, body size, nationality. This is not all of the identities that are out there, but to give you an example of some of the identities that people can have. And that these different identities can intersect in different ways and also in different contexts that then might lead to differing marginalization and or privilege. So some of the core principles of intersectionality, the first is that individuals have multiple simultaneous social identities that interact. So for example, let's say a Latinx trans female who is of upper class will have a very different experience from an Asian American non-binary person of lower class. Even though you might superficially see, oh, they have, you know, similar identities, but they can have very different experiences because of how those identities intersect. These identities are not static and can evolve with youth depending on their setting and circumstances. One example of this is when we think about puberty and as youth are starting to, as their bodies are changing and developing secondary sexual characteristics, that they can have a better understanding of their identity and there can be some changes in how they identify. Holding a particular social identity does not equate to having the same experience. There's a large intergroup variation. So one example would be the non-binary community, right? Very, very diverse. Some want no medical intervention, some want surgery, some want hormones, some want a combination of all of that, or always some and not others. So just to know that there can be huge intergroup variation. And then various social identities offer privilege or oppression dependent on the context. So I can give my, you know, an example of, let's say, like a black trans male youth might experience support for their racial identity at home, but not their gender identity, versus at school maybe they get more support for their gender identity rather than their racial identity. So the context is very important and can have differing effects. And then, you know, so during the gender affirmation process, there can be changes in social identities, which then might lead to additional oppression and or privilege. So for example, a black trans male might have more negative encounters with law enforcement after, you know, affirming themselves as a black man compared to before. And that changes in appearance may push some individuals to appear more racialized or more white passing, especially with facial features, and that further influences social position. So I want to bring up the concept of ethnic racial identity, which is especially salient in ethnically conscious societies such as the U.S. It's a multidimensional construct, and there are content components. So these are affirmation, which is the positive affect that individuals have toward their ethnic racial group. Centrality is kind of how important ethnicity and race are to the individual's self-concept, like how large of a role that plays. And public regard, which is how individuals feel that others are viewing their ethnic racial group, whether positively or not. And then there are some process components. So these are exploration, so really learning about the traditions and history of one's ethnic racial group and really exploring. And resolution, or achieving a clear sense of meaning of ethnicity in an individual's life. So we know that with higher ethnic affirmation, there can be decreased anxiety and depressive symptoms among African American, Latinx, and Asian American college students, and that those associations were even greater for those who had higher levels of ethnic centrality. We know that ethnic minority high school students with increased levels of exploration also had higher levels of resolution and affirmation. So kind of having more opportunities and experiences of exploring their ethnic racial identity led to feeling more positively about their identities. And context matters. So for those ethnic minority youth attending predominantly white schools, they had even greater ethnic identity affirmation, which I thought was very interesting that they didn't find the same kind of result in youth who were in majority non-white schools. And I think there might be an assumption there that these people were able to find maybe a group of people who shared their identity. I can say for myself growing up in Salt Lake City, Utah, as a gay Asian boy with not many people around, I think it was not so easy to have this sense of ethnic identity affirmation. And then for sexual and gender minority individuals, the sexual and gender identities have high centrality, so are highly important to their concept of self, and they intersect with ethnic racial identity. All right. I'd like to invite Terrence, Dr. Howard. Great. So although I do identify as a black queer man, I do recognize that I don't identify as trans or non-binary, and I'm really appreciative of the chance to be able to speak on this topic and hope that having the sponsorship to do so will inspire all of us in this room to increase our allyship for those who have those identities and increase the work in academia and psychiatry. Alrighty. So it's kind of first important to note when we're talking about black trans non-binary youth that black individuals in America are not a monolith, and even within the trans non-binary community for black individuals, you know, there are differences that are important. But of course there is a shared history and cultural bond across the diaspora that allows us to have commonalities that make our experiences more similar than similar in a lot of different ways. Some of that includes there being a decreased representation of trans identity in our media, and unfortunately that leads many to kind of not have that validation or affirmation as they're developing as youths. And even though there's been so much increase in the coming years in terms of who we see as celebrities and who has come out as public folk, unfortunately black trans non-binary individuals still face a lot of various disproportionate negative experiences throughout their lifetimes. Notably higher rates of incarceration or engagement with the police and higher rates of medical comorbidities, including those with psychiatric ideologies. So as I was alluding to, in American society there's a sort of what I like to think of as equal loyalty that kind of springs for those who identify as people of color, but I think especially for those with a black identity. I feel that early on there are many who have their, like Dr. Zhao was alluding to, have their black identity affirmed, whether it's through music, whether it's through other forms of media, or even just how they talk in their homes. But for those who identify as queer, especially for those as trans, that validation of their sexual or gender identity is not similarly validated. And so there was a nationwide survey by the HRC, and unfortunately they found that about two-thirds of black trans non-binary youth found that they were shamed by their families for their gender or sexual identity. And similarly, a third felt unsafe to be their true total selves in their community. And you can just imagine what that has on someone as they're developing into an adult. For those who are black and trans non-binary, unfortunately they do encounter more forms of violence, and it doesn't surprise us that systemic violence becomes actual violence. And you can see here that there are higher reports of verbal violence, but of course they experience physical and sexual forms of trauma, and the reports of numbers that we see here probably are lower than what are actual due to fears of retaliation or just not feeling like their voices will be heard. And kind of to punctuate this point about violence in the community, in 2021 it was the deadliest year for trans individuals, and in particular for black trans women. They made up almost, if not half, of the list that we only know about in terms of fatal forms of violence in that year. I am reassured that in 2022 that number did decrease in terms of total numbers of known killed trans individuals, but unfortunately still black trans non-binary individuals still made up about half of that list. And so again, kind of talking about the socialized and interracialized means of what it means to be a person in America. So how does this matter? It's clear to say that there's a lot of trauma and a lot of negative adverse life events that trans non-binary youth do interface, and not surprisingly this would lead to higher instances of mood, anxiety, disorders, and use of substances. And I thought it was interesting that this difference is not just between trans black non-binary individuals or their white counterparts, but also between cisgender black queer individuals. They reported less percentage of depressive or anxiety symptoms compared to their trans non-binary brothers and sisters. Such that for cisgender black queer folks, 66% had anxiety symptoms, and for trans individuals it was about 70%. So even still staggering. And I think that's even more salient and even more harrowing to point out is that because of all of these negative adverse events that are more likely to occur for our trans non-binary individuals, they have a higher unfortunate rate of suicidal ideation and then also suicide attempts. Especially there's been a growing number of black youth who've been having or have been reported to have suicidal thoughts, and I don't have the data to say that this is proportionately more so in trans, but I think it's important to not discount those of trans non-binary experiences when we're talking about the increased number of youth who are black who are thinking about suicide. And so considering what are some barriers, even though there are higher rates of suicidality or suicidal ideation, unfortunately not many trans non-binary youth who are black have access to care. As you can see here, probably one of the most unifying reasons is for distress of the medical system. Because imagine going through all your life being disvalidated and having your experiences not deemed as worthy. Why would you run or go to care? But the Trevor Project does have a great list of resources and kind of infographic that I thought was really helpful about trans non-binary youth. And some of the top five reasons out of ten for why black trans non-binary youth could not get care really relates to structural racism relating to not being able to afford care or not even having simple access to transportation that would allow them to reach your services. So really just thinking about how we as providers and as clinicians can further ease access to those who most need it in our communities. Okay. And so kind of relatedly, unfortunately there are about 4.2 million young people in America who are houseless every day or every year. And again, unfortunately, about a third of those individuals identify as black, trans, and non-binary. And that kind of would make sense to see how they could have higher instances of negative interactions with those in their communities, those who are supposed to be there to help and save them. But luckily for many, they do and are able to find refuge amongst those who do look like and identify as themselves. As we've seen in media, you know, there's been increased representation of these communities of chosen families that are uniquely black. Whether it's drag or whether it's ballroom, these offer black, trans, and non-binary individuals a space to foster their identities amongst people who do look like them and also just develop into the adults they should and deserve to become. And kind of relatedly, it's important for us as providers and clinicians and psychiatrists and therapists to reach out and be able to be comfortable to rework with these individuals. As we know, there's a dearth of black psychiatrists in America. And so there's not going to be everyone around in their state to have an ethnic concordance with them. And so how can you further your knowledge and further your skills to be able to help this population that needs it most? And something that I didn't put on the slide, but I think it's important to recognize, especially for black individuals, is the importance of religion for some, not many, and the importance of the black church and their identity as a black individual. And I think it's important to highlight that black Christians or those of faith are not more transphobic than their white or Asian or Latinx counterparts. But obviously, again, through the history of America, we see there's a socialization against those who are trans. And of course, that would have an internalized hatred within the black community as well. And so with that, I'll pass it on to Dr. Jung again. Thank you, Dr. Howard. And so these slides are courtesy of Aza Frias, who unfortunately couldn't be here this morning, but gave me permission to present these slides. So to give you a little bit of background about the Latinx community, it's about 20% of the U.S. population. And by the way, I'll be using the term Latinx, but also acknowledge that Latine may be used, and there are other ways to be describing the population. It's a very heterogeneous population that has, you know, there's European, there's black, there's indigenous racial backgrounds within these communities. About a third are immigrants coming from another country in Latin America. Multiple languages are spoken, for example, Spanish, Zapotec, Nahua, and more. There are high rates of poverty among these communities. And then to share a little bit about the cultural background, so the concept of familismo is that, you know, that family is one of the most important things in one's life. And also, it's very important to be respecting the authority of one's parents and elders. So the concept of family is highly important. There is the concept of Marianismo, which is kind of thinking about like the Virgin Mary, but so that, you know, women are supposed to be pure and obedient, submissive, and domestic. And then kind of on the other side, machismo, for men kind of needing to show more aggression and dominance and independence. So fairly strong, you know, gender role behaviors among the community. And that high rates of Latinx individuals are religious, you know, with a high number of Christian and Catholic people. And so many Christians still believe that being trans is a sin. And so this influences how Latinx trans and non-binary individuals might view themselves. So we do need more research and literature on this, you know, among this population and community. We know that about 45% have been taunted or mocked by their family and have experienced rejection. And that there are high rates of harassment and victimization in school, being bullied, being targeted, and that there are high rates of depression, almost 80%, anxiety, over 80%, insomnia, you know, 95%, and also racial discrimination, 80%. Some common themes that show up in therapy might be surviving multiple forms of oppression, including, you know, racial, gender, classism, et cetera, developing healthy masculinity in the context of machismo, internalized trans misogyny, and then also racism within LGBTQ plus spaces that are predominantly white. It's important to recognize, though, despite all of these challenges and adversity, that there is a lot of resilience among the community, and that being in communities where folks can be fully authentically queer and trans and Latinx can be very, very protective. Finding LGBTQ plus community in schools with specific groups, kind of like the Gender Sexuality Alliance, GSA, having a strong connection to family, and potentially using family therapy to strengthen the bonds of family, having more visibility and representation in the media. So, for example, in the show, I have it in the notes, The Flag. In Our Flag Means Death, it's a show on HBO Max. It's a very queer show. It's about pirates. It's very funny, but there's an actor, Vico Ortiz, who is a non-binary Latine person, and they play a non-binary character in the show. I would just recommend the show in general, but it's a really good form of representation, especially for young folks. Yes, thank you. And then there's another show, The Owls. Yeah, there's another show called The Owl House. It's probably more suited for younger folks. It's on Cartoon Network, I believe. And the main character, Luz, is a queer, gender non-conforming youth. While Luz does not explicitly identify as non-binary, there's a lot of really great exploration of being a young Latine person in the context of a very fantastical world. Thank you. And then connection to indigenous history. So there are strong traditions of gender diversity among, for example, the Mujes and Zapoteca, who are a third gender and really recognized and celebrated by society. And that historically and traditionally, trans and gender-variant people were often spiritual leaders and shamans. All right, pass it to Mike. All right, so I'll be talking about Asian American and Pacific Islander youth, or AAPI youth. So Asian American and Pacific Islanders were a very heterogeneous population. There are over 40 ethnicities and languages represented across the U.S., about 7% of the U.S. population. And we come from many places, from Asia, East Asia, South Asia, Southeast Asia, and the Pacific Islands. Asian Americans and Pacific Islanders are the fastest-growing population in the U.S., with an increase in population, 88%, in just the last two decades. And we're projected to become the largest immigrant group by the middle of the century. So the six largest ethnicities make up 85% of all Asian Americans, which are Chinese, Indian, Filipinx, Vietnamese, Korean, and Japanese people. And in the context of intersectionality, when we talk about Asian American and Pacific Islander trans and non-binary youth, it's very important to acknowledge that recently there's been an increase in anti-trans legislature and sentiment, and as well, also in the past several years, a very large increase in anti-Asian racism. So 85% of AAPI LGBTQ people have experienced discrimination and or harassment based on their ethnicity or race. And 78% have experienced racism within predominantly white LGBTQ communities. So we see that within some of the spaces that we would hope to be safe for us, we are still experiencing marginalization and oppression. 69% of AAPI transgender people experience discrimination due to their gender identity. So again, even in spaces for AAPI people, we may experience transphobia. And additionally, stigma within the LGBTQ community sometimes looks like being devalued or fetishized based on our race or ethnicity. There are some phrases, for example, within queer male spaces such as no fats, no femmes, no Asians, right? And this is something that people will openly state that these are their preferences and they won't talk to or they're not interested in Asian people, which is just a very explicit form of racism. So some of the barriers for trans youth in coming out and being able to be fully their authentic selves can clash with some Asian cultural values. These are not universal, but these are some common ones that we have seen. So collectivism, right? This idea that the collective is kind of the center and more important than necessarily individualism, which is a bit more of a Western kind of way of approaching, you know, just navigating society. So this often looks like a strong emphasis on family as well. So the concept of filial piety is also very similar to some of what Ning discussed in our slides on Latinx youth, right? This emphasis on respecting one's elders, one's family. Adherence to traditional gender roles can also be very emphasized within culture and family and other forms of family recognition through achievement. So high pressure on youth to perform academically or otherwise, as well as these emphases on emotional self-control. So sort of limiting the external expression of one's emotions may make it harder for folks to talk about their mental health or express themselves, as well as the concept of humility. So we see actually an increase in adherence to Asian cultural values is associated with a decrease in disclosure of sexual orientation. And this is mediated by internalized heterosexism, so stigma related to being a queer person. And though this data is around sexual orientation, we believe that this may be similar for folks who are trans and non-binary and have a difficult time disclosing their gender identity. So again, API trans and non-binary youth may find it difficult to express themselves. So they may emphasize their gender identity over their ethnicity, right? Despite holding both of these identities and these are not just like separate parts. These are integrated parts of oneself. They may not feel comfortable emphasizing their ethnicity in certain spaces. Again, they may feel less comfortable expressing their gender in Asian contexts due to stigma, due to homophobia or transphobia that they see or experience. They're less likely to share their gender identity with parents compared to non-AAPI LGBTQ youth. And when they do share their identities with their parents, Asian parents are more resistant to prescribing medicine and surgical procedures, right? So when youth are doing this incredibly brave thing of telling their parents like, hey, I am not the person that, or I'm not the gender that you originally thought I was. I'm still your kid, but I need this access to this life-saving medical care, right? They may experience rejection. They may experience sort of these barriers to receiving this care and that can be really detrimental to their mental health. So within the context of AAPI spaces, right? How are people perceiving folks part of the LGBTQ community? So gender can be a very salient characteristic on how Asian American and Pacific Islander people view others. So gender non-conformity may be something that folks who are unfamiliar haven't really been exposed to before or feel uncomfortable with. And this may translate into being more uncomfortable with LGBTQ people. We see increased rates of heterosexism, anti-LGBTQ bias and adherence to traditional gender roles in Asian American spaces compared to a sort of broader American spaces. And we also see AAPI sexual and gender minorities have increased rates of internalized oppression than other groups. And this is often due to that external oppression that is then internalized. So among our trans and non-binary youth, we see that they are three times more likely to report a past year suicide attempt compared to cisgender AAPI LGBTQ youth. And this rate is already increased compared to non-AAPI LGBTQ youth and non-LGBTQ youth. They experience increased rates of discrimination, racism, being verbally insulted or physically threatened and feeling unsafe or unprotected at school. And on the flip side, outside of school, at home they may experience increased rates of physical abuse compared to LGBTQ youth from other ethnic identities. So it may be difficult for people if they're not experiencing a safe home environment and they're not experiencing a safe school environment, where are they going to find these spaces for themselves where they can be true to themselves? Despite all of these difficulties, AAPI trans and non-binary youth are incredibly resilient. So when they are able to express themselves authentically in the face of all of these pressures to conform to traditional gender roles, they really do thrive. So fostering authenticity protects against depression, anxiety and school isolation. And they may do this by actively creating their own communities. So this can be online, which a lot of young people have a lot of access to online spaces. It's very expansive. You can connect with people across the world really, right? And this may help for folks who are living in spaces where they don't see others who look and identify similarly in the spaces where they do live. And a study of AAPI sexual minority individuals describes that they're building resilience by drawing strength and meaning from one's Asian culture and values. And AAPI trans and non-binary adults are able to negotiate their various identities towards integration and achieve a sense of authenticity. So we see as our AAPI queer and trans people are growing up, we are able to integrate our identities and find a sense of authenticity in all aspects of ourselves. I'll pass it on to Ning. So clinical pearls, how can you use all this data to be helpful in your patient encounters? I think that the hallmark of all of this is really just getting to know and really understand the values of your patients. Don't make assumptions about what they would like in terms of their care or how they want their experience to be. Especially in regards to family, how much do your patients want to disclose or how much of themselves, you know, do they want to be with their family? It might be a journey for them. And it's important for us as providers and clinicians and psychiatrists to really take the time to not force someone's journey and be on the ride with them and validate and affirm them as they do so. And thereby that means if they want to use different pronouns when they're with different people in their sessions or when you're kind of talking with collateral, that's important to not just recognize but also respect. And then also just being aware to make sure to not put the extra burden on the patient. Doing things like this, getting to get more information and be more educated on trans and non-binary issues outside of the APA conference would be helpful. So that your patients are not, don't have to have the burden of just being a patient but also being a learner, sorry, a teacher for you. Because that can create more stress for them when they're already in a vulnerable state. And again, just being, even though we've mentioned a lot about how, as especially young people develop, there might be a lot of conflict between their ethnic identity and their sexual gender identity and how that can sometimes become, can stem from family values. But it's important for you not to push away the family or kind of create an antagonistic view of them and really welcome them into the sphere of the patient and how they want to proceed moving forward. I think relatedly, the school place and social settings is really pertinent, especially for youth development, but even for us as adults. It's hard making friends as adults. So it's really helpful for us to help foster and also support acts where individuals want to make spaces that are catered specifically for people of color and then beyond that for specific ethnic or racial groups. Especially in predominantly white spaces, having this sort of home can really be validating but also just a place where you can kind of relax and not have to code switch or feel as if anything that you do will be judged. And kind of relatedly, I think it's also on the onus of us as psychiatrists and as therapists and mental health providers to reach out to these really vulnerable individuals. Go out to your local LGBT center or go out to a drag show and kind of see what the community is like, see what their needs are and collaborate with stakeholders within those spaces to see how we can help promote and increase access for these individuals. And then of course, again, use translators. Please do not make your patients or their family members be a translator because again, things can get lost in that translation but also things might be misconstrued or it might be awkward to kind of navigate that space for a patient. So again, please use your allied health professionals. I think something that's come through a lot and something that's being really pinpointed a lot in medicine is resilience. And I personally like us to broaden us outside the scope of resilience. I personally feel like it's kind of like, yay, pat on the back for enduring trauma. But I know, I think that the hallmark of this idea is acknowledging and again, validating and affirming someone's strengths. How have you been able to endure? What has made you persevere so far in really being able to not only just respect that but then help the patient identify and see that within themselves so that they can nurture that further and then therefore succeed further within all aspects of their lives. And again, for many people, especially in predominantly white spaces, sometimes their ethnic identity can be devalued. And so it's important for us as clinicians and providers to really sort of remember to keep that as a focus for them. Again, you don't want to dictate for the patient how they should feel or how they should behave. But especially for those who are of non-white experience, it is something that should not be ignored and should be kind of approached as the patient feels comfortable to see how they can feel comfortable with both forms and all forms of their intersectional identities. And of course, we've talked a lot about how trans and binary people of color have endured lots of negative adverse events. So it's important even in your general screens to screen for trauma, criterion A events that might kind of be normal to them but actually should be significant and should be told is important to talk about. And then thereby incorporating trauma-informed care. I know not everyone has a specialty in that. And so maybe it's important to refer out to those that you know within your network who could be able to either better provide trauma-informed care or somehow integrate that within your practice. And then of course, if there are conflicts in how culture and their sexual gender identity comes across just making sure that at the hallmark you wanna be true to the patient and see how they can be their most authentic self. What is important to them that will make them feel safe in the world, feel less like they need to or consider suicide, and how can we as a greater community be there to support them? Whether it's combating congressional acts against their rights to just be a person or just being an ear to listen to, giving them that space to just be them is I think a really highlight that I wanna underscore for today. And I'll pass it back on to Kai. Okay, so we'll be talking about intersex youth and then non-binary youth and then wrapping up with clinical pearls. So what words come to mind when you hear the term intersex? So this is the same link FERPA everywhere. I see rare. Okay, y'all see this too, right? Okay. Okay. Okay, so I also see marginalized, non-conformity, struggle, misunderstood, diverse. Expressing. Common red hair. Someone knows this. Okay. I see confusion. I see a term that we no longer use. So, thank you everyone for participating in that. I hope you had a chance to read some of the terms coming up. So, sex. This is a term that is highly controversial these days. I feel like it's important to define before we talk about the rest of this. So, sex is often portrayed as a binary of male and female, and more accurately, it's a bimodal distribution spanning variations in multiple sex characteristics. So, we've listed some of these characteristics here, right? Chromosomes, external genitalia, internal reproductive organs, gonads, hormone secretion, hormone response, and then secondary sex characteristics. And these, you know, commonly will sort of align for people who do fit into those large peaks in the bimodal distribution, but they do not necessarily always match in the way that we expect them to. And this is natural variation. So, the concept of assigned sex at birth, usually a sex marker is assigned to an infant when they're born, and this is typically based on their external genitalia, right? This does not, you know, when a baby is born, we don't typically go and find out what their chromosomes are. Most people walk around not knowing what their chromosomes are, right? So, for infants who do have a variation, especially in their external genitalia, this may result in them undergoing a diagnostic process, in which case a physician is typically going to determine what binary sex category to assign them to, and we'll talk a little bit more about what is done after that, but there is a really great diversity of intersex traits, and this is the preferred terminology, intersex, intersex traits. And these factors, like why this is the case, is not always identified, especially at birth, and sometimes these only become apparent at puberty, and sometimes people go their entire lives without knowing that they're intersex, or they find out later in adulthood. So, some of the terminology used. We have DSD. It used to be called disorders of sex development. Now, intersex activists have pushed for this to be moved to differences of sex development, to emphasize that this is not a disorder, it is just natural variation in human development. Intersex community organizations, such as InterACT, have put out some guidelines. So, intersex or intersex traits are preferred terms. We don't use other terms, such as intersexual, intersexed. DSD is preferred, it's very clinical, preferred not to use. And then, I did see one person use the term, or write in that term that they thought of, hermaphrodite, which is not used to describe humans. This is sometimes a phenomenon that occurs within other animals, but is not something documented in humans, and is considered a slur. So, do not use that term. So, epidemiology, right? Someone said in the word cloud, red hair. One common statistic is that there's an estimate that intersex people are 1.7% of the population, about 2%, and that is about the amount of people who have red hair. So, intersex people are a lot more common than most people think, they just are not always disclosing to others, or they are not always aware of it themselves. And this may be due to stigma, and lack of awareness and knowledge. So, about 69% of people who are intersex endorsed a multi-sexual identity. So, bisexual, meaning people who are attracted to people of two or more genders, or pansexual, people who are attracted to people of any or all genders. 58% identified as transgender, non-binary, or questioning their gender identity. So, we see a very large overlap here with intersex and trans and non-binary people. I want to make the note that this is not the exact same community, but there is a large overlap and intersections here, and a lot of the fights that intersex and non-binary people really go hand in hand. A lot of intersex people fight for the right to have bodily autonomy and not have medical procedures performed on them without their consent, and a lot of trans and non-binary people were fighting for the rights to be able to access medical care that we do want. So, intersex stigma, this is a structural, institutional, interpersonal, experienced, anticipated, and internalized phenomenon. People don't typically talk about intersex people in a positive way in media. There's very little out there that's normalized about being intersex. And as mentioned before, when a baby is born, if they are determined to be intersex, and a physician or the family decides or is pressured to have this baby conform to binary notions of sex, they may perform surgery on the child as an infant or in childhood to conform their genital appearance to what we would expect of this assigned sex. And oftentimes, this is cosmetic. It's not medically necessary for a function, and this can cause irreversible physical damage. It can also cause psychological harm. This is a very highly controversial thing. A lot of intersex advocates are asking for hospitals and medical institutions to stop performing these surgeries unless they are medically necessary. So, an intersex variation in which a baby has a slightly larger clitoris but otherwise has no other differences, intersex advocates are asking, do not perform surgery on this child until they are older and only if they want to with informed consent, whereas an intersex variation in which a child is born with no urethra, there would be a medical reason in which to do a surgery to create a urethra. So, as I mentioned, these surgeries are often done without a child's informed consent, and they can violate this child's human rights autonomy, self-determination, and an open future. There's an intersex advocate, Pidgeon, who talks openly about their experience of going through a surgery when they were an infant that removed their clitoris, so they do not have one anymore. And then again, as an 11-year-old, they were subjected to another surgery to deepen their vaginal canal with the expectation that they would grow up to be a cisgender heterosexual woman and this surgery would be better for their future husband. Rather than thinking about this child's happiness and what they want, this surgery was performed without their full knowledge of what was really going on, with this expectation that this would better serve a man in their future, that we don't even know if this person wants to have a marriage like that or if that's something that they desire. This may feel really violating for people who later identify with a gender that is different from the one that is assigned. If someone is born intersex and they are forcibly or coercively assigned to one binary sex and they later identify as trans or non-binary, it can be very damaging to know that their body has been changed in ways that they had no control over that may be irreversible and that are conforming to an expectation of bodies that doesn't match who they really are. We also see intersex children and youth have a high rate of gender expansive behavior. We really emphasize it's important to let intersex kids just be kids. It's something that is really important for their mental health. We see increased rates of mental illness, including high rates of depression and suicidality in intersex youth. 48% seriously considered suicide in the past 12 months. It's almost half. 19% attempted suicide in the past 12 months and two-thirds reported symptoms of major depressive disorder in the past two weeks. These are kids. They should just be kids, but a lot of the time stigma and discrimination can make it very difficult for them to have an authentic and kind, happy experience. Despite all of these challenges, intersex youth are very resilient. We see that positive parental experiences, having a confidant in childhood, having a best friend, this leads to improved adult well-being, more body satisfaction, and fewer suicidal thoughts. These are just normal childhood things, nothing especially pertinent to them being intersex, just having a nice childhood. Having access to affirming spaces, either at home, at school, or online, also leads to decreased rates of suicide attempts, as well as peer support groups that provide emotional support, increase social well-being, and facilitate exchanges of information. Again, we see a lot of access to the internet these days allows for people to talk about their own experiences, share about them, learn about others, connect with people where they maybe don't live. If they live in a small town and they don't know any other intersex people, they may be able to find community online and meet others who have similar experiences to them, and that will foster greater connection and authenticity. Having a parent, at least one parent that is accepting of their sexual orientation, leads to a 55% lower odds of attempting suicide, and having at least one parent accepting of their gender identity leads to a 46% lower odds of attempting suicide in the past year. Again, it's very important that people are having supportive environments. This is very protective of mental health outcomes. Intersex youth who have supportive friends also have lower rates of attempting in the past year, and trans and non-binary intersex youth whose pronouns were respected by all the people they live with have a 64% lower odds of reporting a suicide attempt. And note that none of these are medical interventions, they're just being accepting, which is a very simple intervention. So in terms of psychosocial management for clinicians, clinical management is best handled by a multidisciplinary team whose members are trained and experienced in intersex-related issues, and all of you being here today, you're learning more about this, and I hope you continue to do a lot of learning and engaging with intersex activists especially, who are doing a lot of education. Care needs need to focus on bodily autonomy and mental health. Again, a lot of these youth have autonomy taken away from them at birth or at a young age, so being able to give them that autonomy back, give them that space to be themselves, make their own decisions in an informed way is really important. There's an organization for intersex that has many, many helpful resources with brochures that intersex youth wish their doctors, friends and teachers knew. I would really recommend checking out their website, it's a really great user-friendly resource. So in terms of clinical pearls, again, center intersex youth's bodily autonomy, voices and mental health. Ask them what terms they use to describe themselves. Let them take the lead on that. They may have preferred terminology, and so let them use those terms. Connect intersex youth with appropriate counseling and mental health services when needed. Link intersex youth when old enough, and their parents to appropriate support groups of other youth or parents who have children with the same or similar intersex conditions. Assist the intersex youth and their parents in handling disclosure of selected aspects of the medical condition to people outside the family, as indicated. Some people may choose to never disclose, and you should respect that and allow them to have space to know this for themselves. Some people may want to disclose to everyone, and some people may be forced to disclose in certain settings. They may not want to, but for medical reasons or other reasons, they may have to. So support them in navigating these situations, especially if they are not necessarily safe spaces for them to disclose. And then, of course, helping parents accept the youth's intersex traits, gender identity, gender expression, and sexual orientation if that is needed. Sometimes people have a difficult time in which their parents wanted the best for them, and maybe listen to doctors or others who said it's best for this child if you raise them in this binary way, if you perform these surgeries to quote-unquote correct their bodies, and parents often don't know better. There often is not a lot of information, and they feel pressured to do these things because they're told by medical professionals or health professionals that this is the best for their child, but that may not always be the case, and there may be some conflict or guilt associated with that, and so it's important to acknowledge and work through that as well. And then, of course, help intersex youth get access to gender-affirming care if that is needed, especially for trans and non-binary intersex youth. They may have more complex medical cases, or they may face a lot of discrimination as they are trying to access gender-affirming care, so advocate for them so they do not have to fight for these things for themselves. And moving on to non-binary youth. What words come to mind when you hear the term non-binary? I see genderqueer, spectrum, nonconforming, expansive, fluid, between, anti-colonial, queer, neither, diverse, sex, non-dual, shades, gray, spectrum is becoming very big on here. Alright, thank you everyone for sharing so far. Okay, I'm going to move to the next slide here. So, in a national survey of LGBTQ youth, what percentage identified as non-binary? Take your best guess here. We have a little bit of everything. All right. So I see 12% and 26% are leaving here, and then a bit for 2% and 56%. So actually, we have 26% of LGBTQ youth identified as non-binary in a Trevor Project survey from 2020, and an additional 20% of LGBTQ youth reported questioning if they were non-binary. So almost half of LGBTQ youth are either non-binary or questioning if they are. So there's a lot of diversity within the non-binary umbrella. So I saw the term genderqueer on the word cloud earlier. There are also other identities that people may hold, such as genderfluid, agender, and many, many others. Non-binary refers to people who do not exclusively identify as men or women or as a binary gender. And this may mean very personal things to each and every single person, right? Anti-colonial was on there. I think that's a very important thing to acknowledge, that non-binary identities have existed throughout history. These are not new. This term, for example, this word non-binary may be new, but this concept is absolutely not new. And this is something that is important to acknowledge, especially in the context of trans and non-binary youth of color. Non-binary people may use many, many sets of pronouns, any combination of such. So for example, right, I use they, them, he, him, and these are pronouns. Some people may use just one set of pronouns. Some people may use multiple sets of pronouns. Some people's experiences may shift and change over time, and they may use different pronouns in different contexts, and that's also totally okay. There's no one way to be non-binary, which kind of is in the definition there. And in terms of non-binary youth's access to care, right, the gender binary is kind of everywhere in society, right? If, you know, I may go to go get some coffee, and someone may be like, what can I get for you, sir? I'm getting coffee. We really do not need to be addressing me by my gender, but this is a very ingrained thing in society. Oftentimes, right, when you're selecting gender marker on a form, there's usually, like, male or female, right? There's not often an option for non-binary people to disclose, even if they want to, right? Or when people are choosing to go to the bathroom, for example, right, most of the time we have gendered restrooms, and people, you know, trans and non-binary people, we often just want to go to the bathroom. Mind our own business, you know? Go wash our hands, leave. But non-binary people may face this dilemma of, like, which bathroom can I go into that is safest for me, where I will experience the least violence, where people will not stare at me, where I can just go and mind my own business? And this is something that a lot of people maybe don't have to think about in the day-to-day, right? So, I really challenge everyone here to think about all the instances today, like just today, in which you see the gender binary, or where you see gender being used or expressed or addressed, or where you need to think about gender to navigate a space as you move through the day. People often make assumptions about others based on their appearance, right? I've been called kind of everything under the sun based on my expression. I used to have longer hair. People used to call me Miss all the time and then be very surprised when I would speak, right? Because they're assuming things based on my appearance or the way that I speak, right? Based on my hair, they would think, oh, this is a woman, right? And then I would speak, and they'd be like, oh, this is a man. And actually, neither of those things are true. But nobody asked me, and they would make these assumptions about me, and it would be very awkward for everyone, so not making assumptions can really ameliorate that. Lack of awareness or dismissal may lead to non-binary youth feeling invalidated and invisible, right? We live in a very, very binary society, and so when people don't see others who look like themselves, when they don't hear about themselves being included, when there are literally no spaces for them, they may feel like they are not seen, they are not valid, people don't respect them. And also gatekeeping medical models, right? When people are trying to access care, if they feel like their non-binary identity is not going to be respected, they may feel a pressure to conform to a gender binary, right? So people may choose not to disclose their non-binary identity, or they may choose to present as binary trans people in order to access care, right? So perhaps a non-binary person is interested in receiving hormone therapy, right? But they maybe express themselves in a way that is not necessarily associated with the other sex assigned at birth, and they feel a pressure to present as a binary trans person in order to get that care, because otherwise physicians may not believe them or not support them in their transition. So non-binary people experience significantly higher stress levels compared to binary trans youth. They're less likely to have already accessed gender-affirming medical care compared to binary trans youth, even if they wanted to have access to this care. Trans and non-binary youth who are unable to access gender-affirming care have higher rates of depression, self-harm, and suicidal thoughts compared to peers who did receive gender-affirming care. And when a non-binary youth's pronouns are not respected, they have a 2.5 times higher suicide attempt rate than non-binary youth whose pronouns are respected. And again, this is already higher than for cisgender youth. So again, despite all of these things, non-binary youth are absolutely incredible, very resilient. To already be able to tell yourself and tell the world that, hey, I don't fit into this gender binary that is so deeply ingrained in society is a really incredible thing, to be able to question something that is so embedded. And so when they have in-person support, family support, and online resources, this can mitigate negative mental health outcomes. And having these other things here, like the ability to self-define one's gender, having agency and access to supportive educational systems, connection to trans and non-binary affirming a community, reframing of mental health challenges, and navigation of relationships with family and friends, these are also protective factors. So what can you do, right? For clinicians, it's important to affirm folks in their gender, to allow them to have an informed consent model, advocate for that if gatekeeping models of care are currently in place where you practice. And if there are gatekeeping models of care in which people are required to go through an evaluation or get a letter of support from a mental health care or medical health care professional, just write these letters. There's a lot of templates out there. Having one step less that people have to push and fight for can be really helpful in this long, long journey where people have to take so many steps to get necessary care. Creating a safe space for gender exploration, right? And this goes beyond just, like, your office or, like, your meetings with the youth, right? As amazing as a clinician can be in the one-on-one space with a client, right, if the client goes to a center and they have no access to a gender-inclusive restroom, other staff are misgendering them, and the language used in the health care system, the intake forms, the educational materials are all binary. They may feel really discouraged from coming back or feeling uncomfortable and unsafe in that environment. So it's important to think about all aspects of the environment of care. Supporting youth in navigating society, institutions, and interpersonal relationships. So again, as we've mentioned, society is very binary. And so this is going to be a lifelong thing for people to navigate. And as young people, it's very difficult to kind of come out and be out as someone who doesn't fit into this, especially in today's sort of political climate. And of course, let clients take the lead on how much they want to focus on their gender, right? If someone's like, I have a ton of anxiety related to school and presentations, and I just am really struggling with history, maybe they don't need to or want to talk about their gender in that moment or in that context, and they really just need to talk about how to do time management, right? And so avoid this trans broken arm syndrome, which is the phenomenon of attributing their issues to their gender when it's not related, right? So if someone fell off a ladder and broke their arm, they probably broke their arm because they fell off a ladder, not because they're trans or non-binary, right? I'll pass it back to you. All right, so we're coming toward the end. So in summary, race, sex, and gender are better thought of as being on a continuum rather than fitting neatly in binary categories, as we've seen from our presentations today. Trans youth of color, intersex youth, and non-binary youth have multiple social identities that intersect within systems of power and oppression that might lead to increased marginalization and increased societal and structural barriers to receiving the care that they need. And mental health providers should support these youth to build their strengths, cultivate authenticity, and increase resilience. So here's our contact info. Thank you. And we're open for questions. And please come to the microphone if you have a question. I see there is one on mine. Please define the difference between trans-binary and trans-non-binary. Sure. So a binary trans person is someone who is transgender, meaning they do not identify with the gender that they were assigned at birth, and this is a large umbrella that can also include non-binary people. So a binary trans person is someone who, for example, is assigned female at birth, identifies as a man, and so that would be a transgender man, or a person who is assigned male at birth and identifies as a woman. So for example, a transgender woman, and then non-binary people would be anyone who does not exclusively identify as a man or a woman, and that falls under the broader transgender umbrella. I hope that helps. Thanks for that. I had a question about the pronouns. So this is the first time I've heard of zee and zur, and then this idea that you kind of described it like a cloud. Is it context-specific? Like, can you change your pronouns based on the context? Yeah, absolutely. So, I mean, if we think about it, all words are made up, right? Language evolves over time, right? We don't speak old English anymore, right? And every language is different, right? So pronouns in one language are not going to correspond exactly to pronouns in another language. And so, you know, for example, the singular they has come into sort of popularity and it's well-known now, but 10 years ago it wasn't super well-known. A lot of people would be like, are you talking about multiple people, right? And so as people kind of explore things, they may find that other terms feel more right to them, right? So zee, zur, and you can look this up, Spivak pronouns, they've been around for decades, actually. And they were actually invented as a singular gender-neutral pronoun before they then became sort of common and used for singular purposes, because, again, it used to be for multiple people. And so, you know, anyone can use any pronouns and it really is just based on the comfort of someone. And in terms of context, it absolutely can change in context, right? I use they, them, he, him, and zee, zur pronouns in spaces where I feel affirmed, where I feel safe, but I understand that a lot of people aren't familiar with zee, zur pronouns, right? They might be like, they don't, you know, if someone is like, oh, that's Kai, zee is my friend, and this is our first year at UCSF, people might be a little confused. And so sometimes I choose to use just they, them, and he, him pronouns, because that's more familiar for people. Or I choose in very, very few spaces to use just he, him pronouns, because I know that I'm not going to be respected as a non-binary person, and it is going to be safer for me if I do not disclose that. And similarly, right, for some people, they may choose, like, at school, they may be like, I'm using they, them pronouns, this is the most comfortable for me, but at home, my parents are not affirming, I'm choosing to go by he, him pronouns, right? So being respectful and mindful of that, especially if you're working with a youth, right? If they, within your session, are like, I want to use this name, this set of pronouns, I want to be referred to in this way, but my parents don't know, or my parents are not affirming, when you speak to them, please use this name, this set of pronouns, and refer to me in this way, being very mindful of that, so we allow them to feel safe and comfortable with you or where, you know, where they do want to be out, whereas if they're not safe somewhere else, then we need to make sure that we provide the safest thing for them, which may unfortunately be to misgender them, but with their consent. And even pronouns carries across languages, so not just in English, I think you see, like, Dr. Joe has his pronouns in characters, and then there are many people who identify as she, her, in Spanish, they might say their are, their pronoun is Ella, so it can also depend on that context, too. Cool. Thank you very much. That was helpful. I think there's a question from the individual with the light here in the back. Thanks. Teddy Getz, they, them, I'm from Penn. I thank you for this talk, wonderful. I think something that, oh, one note on the previous question, too, if you see someone has multiple pronouns listed, I would generally ask them how you want them to be using them. So someone who, for example, has they, he, might wish that you alternate, or they might wish that you, if you're willing to use they, exclusively use they, and it's kind of he is like the begrudging backup, or like safety in certain spaces, et cetera. So if, when in doubt, ask, or just, you know, if you use the one that's listed first, you're probably not going to be wrong, but I think people really appreciate when you ask if you see multiple things and you're not sure what to do. Thanks, Teddy. Sure. So something that I have run into in my own life, and then also in my clinical and research work in this topic, is the multilingual issue, because certain, I mean, English, though more gendered than I would like, is more gender neutral than Spanish, which I, in most of my family, speaks, and also I've, like, had friends and also research assistants talk about Cantonese and not having a word for, like, child that's not, like, baby that's gender neutral, and, like, having that be a real issue. So I think, again, that's been, I mean, I do the, like, O, or, like, the more, like, I guess, masculine endings in Spanish or in Hebrew, because that's just kind of easier. I mean, I'll, might, I might use the, like, A-J, myself, or A-A, but that's just, it's too difficult, kind of, and it's, like, the bandwidth, but I guess I was curious if you have any preferred resources that you can recommend to everyone for offering to patients and clients who are trying to explain these things to their parents or have alternatives in other languages, because it can be so difficult. Yeah, thank you so much for that question. So we actually are working on developing a resource for Chinese, specifically. Cool. We, Kai and I have been doing a study on how to ask about sexual orientation and gender identity in Chinese, in Mandarin Chinese, because I was noticing in the clinics that I work at that our clinicians are not asking about sexual orientation and gender identity, and when I ask them, you know, why not, they're like, well, we don't know how to ask, we don't know what words to use, and also, sex and gender are kind of taboo topics in Chinese culture, and so there's a lot of silence around these topics. And so it's been really interesting that in, that a lot of terms for, let's say, non-binary and genderqueer have actually been directly translated from English into Chinese, and so the general Chinese population is not going to know these terms, only if you're, like, a member of the community, and then there's also the issue of political oppression and internet censorship, so certain terms for, let's say, transgender are censored on the internet in China, and so then, you know, people there who are of these communities are having to find creative ways to even talk about themselves because, without hitting the censor, right? So if one example is the term, like, so we're moving away from using this term here in the U.S., like, FTM, or female-to-male, but in China, they might say, like, feitianmao, which translates to flying cat, but it uses the first letter of each of that, so as a way to, you know, to kind of signal, oh, this is our community, right? When it comes to pronouns, so the pronoun ta in Mandarin was traditionally gender-neutral, so the radical was the radical for the person, right, and it was only a hundred years ago after, you know, exposure to the West and then translation of Western texts that they developed a pronoun with the female radical to be, like, she, her, and then by default, the other one became he, him, but historically, it was always gender-neutral, right? And so that was a very interesting topic for us to discover is how are, you know, non-binary pronouns being used, and there's a huge diversity. Some people are using the radical for the divine, so for, like, Jesus, for God. Some people are using the radical for animals and pets, so, like, it. Some people are using the plural form, like, would be equivalent to our they, them, and some are even adopting a new one with an X as the radical, and we see that in more, like, Anglo areas, not so much in mainland China, but people who are in other areas. So it's, I think it's really interesting, and so we are actively working on developing resource for Chinese because we just found there aren't, we could not find any resources on this topic, so when we have that developed, we're happy to share. Yeah, please send it to me. That would be awesome. Yeah, yeah, yeah. And then I know Azza, who was, who helped, who was not able to be here, actually has a YouTube presentation that's on, I think it's called Working with Trans Latinx. It's on YouTube, and so she actually, what's that? They. They. Or sorry, they, apologies. Yeah, so they actually developed a great training and actually talk about how to use non-binary Spanish and how to use like the a rather than a or o. And so happy to share that resource. But I feel like there aren't so many developed resources out there. We are working on it. If people know of other people also developing resources, it'd be really great to connect. But I will say, I think we've referenced them a lot. I was very impressed when like researching this topic, you know, the Trevor Project and the HRC Human Rights Campaign. They have great kind of like basic info kind of ways into talking about and learning about trans identities and non-binary identities. So that can be a good first pass too. Oh yeah, absolutely. And then also, sorry, thought of another thing with medical trans, like translation in the hospital is so atrocious and they don't know the terms for these things. So how do you generally, I mean, obviously working with a translator rather than having a family member translate or your patient translate is always standard of care. But I mean, sometimes, I mean, I'm fluent in Spanish, but if someone else isn't and you know, we're using a translator, they get basic things wrong that aren't even involving words that they aren't familiar with. So do you have a way that you generally try to improve the quality of that translation? Yeah, that's such a good question and so tough. So we, like at the clinic I work at, we have like a translator that we know, like that we've worked with. And so that we really try to get if, you know, if that translator is available, because we know she actually has familiar, experience and familiarity, you know, because it can be very tricky to be talking about these sensitive topics in a nuanced way. And I have had, I've had experiences where, like when she wasn't available and I had to use whoever was available that I actually, I wasn't sure if that translator was interpreting accurately, just based on how the questions that they were asking were reflecting back. I had lots of questions like, are they getting my message across and what are they saying? So it's really tough. I don't know of a way right now to kind of like, like, like, like sort of, not certify, but like check how good they are, right? And so for us, it's been experience and working with, trying to work with the same interpreter as much as we can, once we know that they are, that they are more competent and more, more kind of skilled in this area. I will say that the research that Ning and I are doing includes like example phrases or a kind of glossary for how to use these terms in Chinese. And so we're hoping, or at least I'm hoping that in the future we will be able to release a sort of PDF or guide or something, in which case, even if you don't know a translator and this is your first time working with them, you can email them the PDF and say like, when I'm talking about these topics, please use these phrases or words. And that way they can interface with the patient in a way that you know is researched, accurate, respectful, especially, because sometimes terminology used is outdated. Amazing, I really look forward to that resource, thanks. Yeah. Yes, hi, well thank you, it was very informative for me, basically, to come here. I have an issue that I wanted to bring up. I, several years ago I was treating an individual who is non-binary and used the pronoun they. The issue for me, I was doing medication follow-up, it wasn't therapy, psychotherapy actually, but the issue was is that this individual was also in a relationship with somebody else. And it became confusing to me when they was used, whether it was interfering, it was referring to the singular they or the plural they. And I brought it up with this individual, but I could not get it resolved in a way for me that it felt like it wasn't interfering with what I was doing. In other words, I had to stop and okay, what are we talking about here? So do you have any suggestions in regards to this? Yeah, I would say the number one thing in this case would probably just be practice and getting used to hearing it. If you're able to find like podcasts, YouTube videos, et cetera, media in which that is used and you can just kind of listen and get used to it, that may be one way. I know some people who practice, right? And that may be something where before you go to speak to the client, you just kind of practice and run through a few phrases in your mind. I mean, this is just a me thing, but I'm like maybe you can, and some people do this, where you like name a plant in your office and you maybe like practice and talk about your plant or something in a way that's very safe. You're not gonna be like harming someone if you're talking about a plant, right? And that's one way to get used to that kind of phrasing. Another may be to clarify and ask, right? You may just need to clarify and ask. You may refer to this person by their name and kind of use that in each sentence. So you're like being very clear, like might be like, okay, Kai is starting a new medication. They have been experiencing this side effect, right? And just each time. But it's not clear to be, are you, I mean, I can understand that part of its context. So in other words, I can get better at using the context. Okay, it sounds like, but the other one is also working it out with the patient so that it becomes, you have this sort of an agreement in terms of making it more clear so that we can proceed and do the work that needs to be done. I'm not sure where you're going with this in terms of both or one or the other. What do you suggest? I would say if you can, I mean, ideally we don't want our clients and our patients to be educating us on issues related to who they are as a person. Right, right, yeah. So, you know, if, it's, I'm sure it's like challenging. And I think I, you know, I want to commend you first and foremost for like bringing up the issue to the patients. I think a lot of times we'll have this in our minds and kind of just toy with it and not bring it up. And so I think owning that and kind of like respecting that challenge maybe also gives you insight to what the patient goes through in their daily life too. Well, yeah, of course. As well, the challenges they have to navigate with talking with people. But I think just kind of, I don't know if you're talking about within like your own notes, like how to differentiate it or just. No, it's just that it's when, because the patient brought up not just themselves, they also brought up this other person. I think it's fair. And it went both ways. And at least, and so it was like, I mean, we eventually kind of knew, but it just kind of like, it was like this extra thing that had to be resolved or somehow, you know what I mean? And it just felt to me like, well, is there a better way? Because I feel like I'm just kind of like, you know what I mean? And I didn't want to be disrespectful. Yeah, of course. I think it's always fair. And so forth, but it also, I mean, honestly, I felt a little frustrated. Yeah, of course. And why aren't you helping me out a little bit more was honestly what I felt. And I kind of had to deal with that and at the same time, put that aside. You know what I mean? So, I mean, I wanted to feel like, how do I, what suggestions you would have so that we could work this out in a way that's good for everybody? Yeah, and I think it's always fair to ask. It might be cumbersome to have to always ask, but I think it's always fair to earn the side of just asking instead of presuming. And then if they're talking about them and their partner or whatever, we can maybe have a suggestion of like, hey, when you're referencing they as in yourself, you can use they. If you're using they as in me and someone else, you can be like, I and Joe or whatever, to make it super really clear. Not a contract, but an agreement about like. Well, that would be the best thing. Yeah, I would think so. Yeah, anyway. Okay, all right. Well, anyway, thank you. Yeah, I think as you get used, you just hear it more and more, you probably will become more fluent in using this newer terminology for yourself, right? You know, all of us, we're learning new words all the time, right? And so, as you hear things more, you'll probably just get more used to it. But for now, just clarifying and asking is probably a little bit awkward, but it is going to be the most respectful and most accurate way for you to get to know what is my patient talking about? Thank you for asking. Yeah, good morning. I am wondering and would love to hear your thoughts, strategies on what to do with families where you can't come to common ground, where there isn't that family acceptance, let alone affirmation. Yeah. Yeah, that's a great question, and it's a challenging one, right? Because we know how important the family is. So, the Family Acceptance Project did a project with TFCBT, so Trauma-Focused Cognitive Behavioral Therapy, and they have a manual, actually, where they actually talk about different techniques. In terms of aligning, so we're not gonna change the family's beliefs, but we might be able to help them get clarity in their values, right, and work with them in their values, their value of loving their child, their value of wanting their child to be happy, their value of wanting their child to succeed, right? And so, getting clarity that, okay, these are values that are important when there might be tension with belief systems, let's say religious beliefs. I think bringing that into clarity, that, okay, there might be tension here, and we can really help you get clarity in what your values are, and we know how important family support is for these youth, and so I think even psychoeducation about the importance of acceptance, and also, like, the really terrible consequences of rejection and not accepting the youth. I find that really letting the parent, like, really giving them the experience of feeling heard and feeling listened to is really important, right? Otherwise, it's hard to move forward. And also, I come from the perspective that every parent really, at their core, wants what's best for their child and really loves their child. They might be kind of misinformed in terms of how to carry that out, but that's kind of how I remind myself to have patience and empathy for the parents, even when they may be very rejecting. And I would, I mean, you know, maybe go on to say that if there can't be some form of alliance you can make with the family, at least in your office, in your space, that can be somewhere where the patient or client feels their most free self, and try to find other outlets outside the family where they can find that, not just affirming, but validating space to be themselves, too. Yeah, and I would say, yeah, similar to what Ning said, right, emphasizing, like, love for the child. And, you know, you don't necessarily have to understand something to respect it. And so, sometimes parents may be like, I don't understand this. And, you know, we can remind them, right, you don't necessarily have to fully understand exactly how your child feels, what is necessarily, like, the nuances of, like, how they came to this exact, this is how I feel. But to know that this is who they are, and this is important to respect. It may shift and change over time, and that's okay, but right now this is the most important thing. And, you know, respecting someone's name and pronouns is a very safe intervention, right? There's not really going to be, like, a negative consequence of, like, oh, if you do this now, later down the road they're gonna have this side effect or something. And so, being able to emphasize that this is such a simple and effective intervention. And also, yeah, I think, right, supporting the youth, right, if their parents are not supportive. Like, don't make the youth stand there and be subjected to this while you're working it out with their parents. Like, maybe meet with the parents separately so the youth doesn't have to be, like, experiencing the harm of their parents maybe saying negative things about their identity. Yeah, like, if possible, kind of keep that separate so that you can keep affirming the youth and can support the parent in the ways that you can try to, yeah. And obviously with minors, remember your role as a mandated reporter if you have serious concerns for physical or sexual violence in the home. I want to acknowledge that we are over time, but we will take one more question. But if people need to leave, we don't want to keep you here if you need to go. But yeah, go ahead. Thank you. So, my question is along the same line. I'm a Latinx physician, and last year we tried to do research about the gender affirmation barriers that Latinx transgender people encounter where they want to, like, I don't know, go to get hormone therapy, or they want to go to a surgeon, or start the process of, yeah, getting gender affirmation something, right? But what we found is that they don't want to talk to us, like, to the healthcare system. So, I understand all of the advice that you just gave to the doctor about how to manage the family and all of that, but that's when you already got to the point that the person is already in healthcare, right? So, what would be your advice for me that I'm a junior physician that I want to continue helping my community, and, like, to be able to get there to my community and let them know that it's safe to go to my practice, right? That it's safe for them to at least ask questions, because what we found is that they are doing the transitions by themselves because there is so much judgment in the Latinx community that they want to do it, of course, but they don't feel safe going to a physician. So, what would be your advice to approach those kind of judgment in cultural settings? Great question. What kind of physician are you? Sorry? What kind of physician or what kind of setting do you work? Sorry, so I'm an international medical graduate. I'm from Colombia. In Colombia, we get to practice before going to residency, but since I'm going to apply for residency this year, I've been working along psychiatrists here in the US. This specifically was in a community in Chicago. Okay. Yeah, so I think that's a really great question, and I think part of why, you know, Latinx people and other people of color don't want to get healthcare is because they've had negative healthcare experiences in the past where they've been really harmed, right? And so, that can be tricky. I see that also in the Asian American community. I think if there can be ways to, like, advertise that your clinic is accepting, so having maybe like a rainbow trans pride flag, you know, on clinic, like materials about your clinic, for example. I, you know, I always introduce myself with my pronouns to kind of indicate that it's okay to talk about pronouns. I think thinking about community partnerships, right? So, if they're not wanting to come to your clinic to see you for care, you know, could you go out into the community and maybe meet them in the community and just address maybe some questions that they may have and let them know, hey, it's actually safe to come to our clinic for care. And so, I think community partnerships are really key. And having, you know, kind of allies within the community that can then really say, hey, this is a place that's actually safe to go. I think it's also helpful for all of our medical systems to engage in, like, you know, local community pride parades, setting up booths or other sort of, like, informational materials at those places where they can see, like, hey, you're an ally and you're a resource to go to for medical care that is, like, safe. And simple things like Dr. Joe was talking about with in terms of, like, flags or pins or just any little thing that can show that you know about queer life and culture might give someone more liberty and freedom to kind of put their fears aside and think that you're trustworthy. Thank you so much. I really appreciate the answer. And I have a question. When you want to identify as an ally, I use she, her pronouns. I'm heterosexual, I'm cisgender, I'm heteronormative, literally, like the definition of it. And I know there's a privilege on that, but I do want to acknowledge the people that I interact with, that I'm an ally. So is it disrespectful, for example, to use, like, the rainbow flag because I'm not part of the community, right? But I do, I want to be an ally, so I don't want to take something that's not mine, but I want to let people know that it's safe to talk with me, right? Yeah, and this is something that varies individual to individual, right? So there's no universally right answer. I think the fact that you're here asking, thinking about this is already incredible and amazing. I do find, right, like, a small rainbow pin or something, I think often indicates, like, this is someone who is at least familiar or, like, can talk about this. Some people might interpret it as you're part of the community, but a lot of the times people will understand that this is just, like, I'm showing support, right? And so I think a rainbow pin or having a little rainbow sticker or something in your office, like, things like that are totally appropriate. That's just my personal opinion. And, you know, having other, like, small supportive rainbow or other similar, like, trans flag, especially, materials can be, like, a little, like, someone sees it and if they know, they know, you know, right? Like, some people might be, like, I don't know what that flag is for the trans flag especially, but someone who is part of the community might see it and be, like, oh, my God. And I'll say lastly, you know, please embrace social media as you or your department or clinic is able to, whether it's TikTok or Twitter or Instagram, these are spaces especially that youth and younger people are using and so that can be another avenue for you to advertise yourself and show that you are there for them and their community. Thank you. Yeah, and very lastly, I would say people often, like, especially in trans community, in my experience, like, we refer our friends, like, word of mouth, right? It'll be, like, I had a good experience with this provider. I'm gonna recommend this person to you for, like, literally any kind of care. It might be, like, I saw this asthma specialist and they were really affirming of my gender. I would recommend this person, right? And so go at, like, Terrence mentioned, like, and Ning mentioned, like, going to community spaces, right? Like, the community's not gonna come to, like, some random clinic if they don't know that you're affirming, but if you can go to places where community is already gathering, such as pride parades, LGBTQ centers, things like that, and you can set up a little booth and talk about the services you offer, right? You might be, like, hi, my name is so-and-so. I use she, her pronouns. We offer gender-affirming hormone therapy. I can write letters of support for gender-affirming surgery, you know, things like that. People may be more likely to be, like, oh, I'll take a look. I'll make an appointment, right? Or I'll send this to my friend who's been looking for an affirming doctor. Thank you. I really appreciate it.

intersectionality

non-binary

intersex

transgender

gender-diverse

mental health

healthcare

inclusivity

AAPI

Black

Latinx

youth

privilege

marginalization