So, I am Ken Ashley. I am an associate professor at the Icahn School of Medicine. I work in the Department of Consultation and Leadership on Psychiatry, doing inpatient and outpatient work. And let's get started. And so I am going to be talking a little bit about, you know, trying to get our voices heard. Also, Dr. Behakar mentioned HLP. For those who don't know, HLP is the Association of Gay and Lesbian, the Association of LGBTQ plus Psychiatrists. And so, as I said, I'm talking about trying to get our voices heard. And I will be talking mostly about working in the APA and in the WPA. No disclosures. So, hopefully by now people kind of recognize this picture. It's a picture of John Fryer at the 1972 APA, which I'll be talking about shortly. But he was part of the work towards changing the DSM and changing the way LGBT folks are treated and dealt with in the APA and the society at large. So, back in the 1960s there was something called the Gay PA, which was an informal association of LGBTQ psychiatrists within the organization that would meet at the big meetings, at the annual meeting. But, you know, they'd pick some bar and they would all kind of go there. If people were at the lecture yesterday, at the John Fryer Award yesterday, there was some discussion of what that was like early on, that people wouldn't use their last names, it would be basically on a first name basis because people didn't want to be known that openly just because of concerns about legal ramifications of being out. In 1971, an association of folks both within the profession and outside of the profession got together. They crashed APA meetings. They kind of did zaps at the meetings and they kind of demanded to have a dialogue with members of APA around the status of homosexuality as being a mental illness. So, in 1972, there was a presentation, a panel called Psychiatry, Friend or Foe to the Homosexual. And that was a presentation in which John Fryer was wearing a mask. Supposedly it's President Nixon. He had a voice modulator. He had a very large suit on just to be sure that he was not recognized. Dr. Fryer had had issues with being out previously in his career, lost positions. And so at that time, since homosexuality was still a mental illness, you could lose your job as a psychiatrist, probably reportable to a variety of agencies, and you could lose your job. So, in 1973, APA removed egocentronic homosexuality from DSM. In the mid-1970s, the APA caucus of gay, lesbian, and bisexual members of the APA was formed. At a certain point in time, the caucuses became a committee. Right now, committees have been sunsetted, but we do have the caucus of LGBTQ psychiatrists for all APA members if you're interested in joining the caucus. All you need to do is go to your profile on your membership page, and you can click on the caucus membership if you join the caucus. You can join as many caucuses as you'd like. You can only join one to vote in just because it does include some representation in the assembly. But once again, joining the caucus will open up a host of resources to you, emails about events and things that are happening. So, in 1978, they formed the task force. Typically, APA task forces come first, then maybe committees come afterwards. And then there was, as I said, the Committee on GLB Issues in 1981, which resulted in a host of action items, position statements being written and passed by the APA around LGBTQ issues. Around that same time, a lot of the district branches formed LGBTQ committees, and there was some networking amongst the committees at the district branches, as well as the national committee, just getting more work done around position statements, action items, and things like that to help move forward the gay agenda within the organization. In 1985, HLP was formed. It was initially the Association of Gay and Lesbian Psychiatrists. Now, it's HLP. As I mentioned earlier, the Association of LGBTQ Psychiatrists. Dr. Behikhar is our current president-elect. I was president years and years and years ago. So, and I will just add that, you know, years ago, I think, where I was talking with a friend earlier, how very many of the LGBTQ-focused sessions were off in the APA, the LGBTQ hospitality suite of HLP. However, now, I think we have been integrated so well within the organization with presentations and sessions that we have maybe a half day of planning in the hospitality suite for HLP, which, you know, sometimes you miss that, but I think the advantage that we are much more fully integrated within the organization, I think, is a much better place to be. I will also say that we now have the first openly gay president of the APA, Petros Livonis. We have had gay psychiatrists as presidents in the past, but they were not out during their terms. I'm going to quickly switch to the WPA, the World Psychiatric Association, which is the kind of global organization of organized psychiatry. So, if you're a member of APA, you're officially a member of WPA. The WPA hosts an annual meeting similar to our annual meeting that used to be every three years. They become annually, but once again, it's a very large psychiatric organization, and similarly, we were trying to get a voice within the WPA. So, in 1992, the APA Board of Trustees passed the resolution, which was later passed by the General Assembly of the WPA in 1993, talking to the fact that homosexuality causes no decrease in function, and it does not really qualify as a mental illness. And then the WPA should also call on its member organizations to do all that's possible to decrease stigma related to homosexuality wherever and whenever it may occur. The passage of that within the WPA was more challenging than we thought it should be, but ultimately it was passed. One of the sessions went very, very late into the night, couldn't get passed. It was revisited at a subsequent WPA and was ultimately passed, but it was a challenge because there are members of the WPA, member organizations that did not particularly specifically agree with the statement. So, 1996, the WPA, the 10th annual WPA meeting, there was a symposium on gay affirmative psychiatry that was in, the meeting was in either Barcelona or Madrid. Actually, the fact that there was such a presentation made the news, made the newspapers in Spain, and so for some of the, I think it was the first symposium on LGBTQ issues at the WPA, and for some of the attendees, it was their first symposium on the topic that they'd ever seen. So, we were able to obtain meeting space at that meeting for a meeting of LGBTQ psychiatrists, and at that first networking meeting, there were over 40 psychiatrists from 20 different countries, and it kind of became the beginnings of what we were trying to do similarly within the WPA at the WPA in terms of organizing. Then there was a depathologization of homosexuality submitted to the WPA by the APA. There was a lot of discussion back and forth, as I mentioned earlier. It was finally passed at Yokohama meeting in 2002. They couldn't pass it at the initial meeting in 1999 in Hamburg, but later it was passed. Very late night session, people were tired and wanted to go home, which we felt was probably part of the reason they just passed it, because it was like people were tired of kind of arguing back and forth, or at least that's the story I heard. I wasn't there, but that's kind of like the discussion around it. In 1997, we sent a request for the creation of a section on LGB issues. It was denied. They recommended that we become members of the newly formed section on human sexuality. We met with the leader of that section. We all agreed that it probably was not the appropriate place because they're two very separate issues. One of the other issues was for the meeting, for the 1999 meeting in Hamburg, we had organized after the meeting in Madrid to submit a lot of symposiums on LGBTQ issues. There was some concern that there was a gay agenda being proposed, and so all of the submissions were pulled for separate consideration. Ultimately, I think they accepted three of them with some back and forth, but there was a lot of concern that there was some formant, primarily by American psychiatrists, trying to kind of take things over. They continued to recommend that we join the Human Sexuality Committee, but our second request was denied, but we did collaborate with the leadership of the section on human sexuality to get some things like meeting space and things, because WPA, you can't get meeting space if you're not a section. We worked with them, and they helped us get meeting space. We did form an international committee at AGLP in place of having something with WPA, which helped organize events for meetings with WPA. There were LGBT groups in several other countries. There's one in the UK, one in Germany, one in the Netherlands. Those are the ones that we had most contact with and were fairly engaged with around organizing events. Gradually, things changed with WPA. I would say there's a new current statement on sexual orientation and gender identity. I'm not going to read the whole statement, but it does move forward the idea that same-sex orientation is not a mental illness. It moved in a way that there's much more decreased stigma. It's depathologized. Trying to get all the member states to move these into their ways of practicing locally has been something that we have been trying to see accomplished. The WPA did have an openly gay president, Dinesh Bhugra. He was president maybe three years ago, but that was a, you know, once again an example of the change within the organization. We still don't have a section, but we are kind of tossing around the idea of trying to move forward with that. It just, we kind of lost some steam around that, and we're trying to engage with some other people internationally to kind of make that happen just because of the requirements of WPA around forming sections of the representation that's required for these things to happen. This is the rest of the statement, if folks want to read that quickly, but once again, it's talking about LGBTQ rights within, from a mental health perspective, and that is my talk. I don't know if anyone has any questions now or can hold them until later. I just wanted to give a broad overview. Once again, there are a lot of things happening in a lot of other organizations. The American Academy of Child and Adolescent Psychiatry has a group, the group on sexual orientation and gender identity, the group for the advancement of psychiatry, which some of us on the panel are members of, has a LGBTQ committee. So there are a variety of spaces where we are engaging. We have sections and representations, so we are kind of getting a seat at the table, having our voices amplified, which I think is a great thing. Thank you. Thank you. Hi, everyone. Thank you so much for coming at 8 in the morning. I wondered what I could add to this talk as someone who came out at 40 in 1995 and is a shy person, or at least was, but then I suspect that most of us psychiatrists are shy or introverted, so I thought maybe it would be of interest. I am a psychiatrist in general private practice in Manhattan, and my other main area of devotion is working with asylum seekers. I'm an expert on the psychological consequences of torture, and I teach and train this around the country and around the world. And that's, I guess, where some of my leadership work started. I was the founding medical director of the Weill Cornell Center for Human Rights, which is the very first medical school asylum clinic in the country. And since we opened in 2010, now 25 medical schools around the country have asylum clinics based on our model. We've evaluated hundreds and hundreds of asylum seekers, providing pro bono mental health medical GYN evaluations, and for the first five years, we had a 100% success rate of the people we evaluated being granted asylum or some other form of humanitarian relief, working in concert with law school clinics, legal representatives, pro bono attorneys. And it is also, by the way, a wonderful recruiting tool for the very best of medical students to find their way to psychiatry, because they get to sit with us as we work, which is not so easy to come by. So I was the founding medical director there. I'm also a member of AGLP. I was, very briefly, one of the editors of the newsletter. I'm now the new co-chair of the LGBTQ Plus Committee of GAP. So I found that as the years accumulate, and as I was willing to volunteer, jump in, try something new, that leadership sort of comes to you. And I also think that all of us here are leaders. We wouldn't be what we are if we weren't naturally leaders, and you wouldn't be sitting here if it weren't something that's important to you. Also, as I thought about today, I wanted to point out that we really want to hear your thoughts and experiences. I talked to these people as I prepared for today, and their thoughts, Jack, Jose, Gabrielle, Margie, Stuart, all of these are LGBTQ leaders, and got their thoughts, and they're incorporated here. So a few questions Margie Sved told me to think about. When did you come out? Has it changed your career trajectory, for the better, for the worse? How? Have you been involved in LGBTQ advocacy groups? Has that helped your career? Have you felt local support, national support from the APA? And are there some of us in the LGBTQ Plus community more affected by homophobia, transphobia, bi-phobia, inter-phobia than others? So a summary of my experience. I was the oldest of four. I think that primed me for leadership. I was also the editor of my elementary school newspaper in Quincy, Massachusetts. The Adams School was right up the street from where the presidents were born, and so this will date me. And I named the newspaper the Adams Atomic. I've been in solo private practice for 37 years, came out pretty late, and I've mentored, I've supervised, I've been volunteer faculty, I've been a trainer. I think that also was a big help to me, was just needing to train people around the country how to do the asylum work that I do. And going to court to speak as an expert witness. Necessity. I mean, and when I started to do volunteer asylum evaluations in the early 2000s, I would occasionally get a call from someone asking me if I would take on an asylum case. And then I would hear the catch in the voice, the silence a second too long, the apologetic tone, and they'd say, but he's gay, or she's gay. And then I would say, that's okay, I am too. Send them. Send me more. And so because I did that, they did send me more, and I found that because I was taking on those cases and doing them, I became the expert in how to do them. With a colleague here in San Francisco, Arielle Shidlow, we created the first scale for assessing sexual orientation and gender identity in forced migrants, asylum seekers. We updated that, we took advantage of COVID time, and worked with a medical student doing an elective and brought that up to date in terms of gender identity issues. Happy to email that to anyone who'd like to see it. And then I got to be a co-author on the main UN document called, for short, the Istanbul Protocol on Working with Asylum Seekers. They found as they were close to finishing the update of this beautiful document that they were very weak on LGBTI issues and on kids. And these were two areas that they wanted to add to this document, which guides all medical and legal work with asylum seekers in all 40 countries that offer asylum. And so I was brought in to review what they'd done and to pump it up. So as I thought about what were the steps that I took and talked to other people about the steps they took to leadership, the first one is showing up. Simply showing up. Join the groups that Ken mentioned. We welcome you to join, if you're not members already, HLP, the GAP LGBTQ committee, your local committees if you've got them. Walk the path that other people have created before us. I knew when I came out late in 1995, and I felt that so many people had sacrificed to make this way before me, that I felt a moral obligation to come out, to be out everywhere. My dentist, very traditional. I was most scared of coming out to him. The day he told me I had just come out to him for the third time, I knew I was, I had completed my circuit. And to volunteer to do my part on this road. So volunteer for stuff. There's really, in terms of community building, there's no step too insignificant. Collegiality. None of us can fix things alone, and we've got big things to fix right now. And you'll also make lifelong friends and find lifelong support for the work that you do. What to do once you get there, once you show up. Find a mentor. Find a lot of mentors. Be a mentor. Personal therapy almost goes without saying. There's a book in the 1980s, I remember studying the 80s, I think maybe the 90s, that said LGBTQ people, as we get older, we increasingly seek out personal therapists who are also in the family. And that we find that therapy more helpful. I've wondered, I don't think that kind of study has ever been redone. Is that still true? Take on work and issues you're passionate about. I'm passionate about giving people who've been persecuted a chance at a new life. And when I think about the reasons of the head and the heart that bring me to that volunteer work, as well as to psychiatry, I think, I had a chance at a new life. And that's a big part of why I'm passionate about doing that for other people. And why that means so much. When you do what you're passionate about, other things come. Your ability to be that role model, to be that mentor, to be that teacher. Be involved in all of our spaces. And say yes, as they say in the 12-step groups. Say yes if you possibly can. So several people I spoke to said, please say, stand up for the equality of all people. For human rights for all people. Fight for parity for our patients. Mental health is medical health. I've worked with legislatures, with the public and media and social media. Work intersectionally. A glass closet for some has been a concrete closet for others. When will the day come when we have an APA president who's openly lesbian? Who's openly trans or gender expansive or non-binary? And the other things people shared with me were the importance of being patient. Progress comes slowly. The necessity for a thick skin. You'll be criticized and attacked, as we saw with the history that Ken gave us. Be strategic about when you say yes and when you say no, so that you prevent burnout. Balance your life. Take time out. And that's it. Thank you so much. I don't know which one is mine. Hi everyone. My name is Sarah Noble. I am a psychiatrist in Philadelphia. I'm the medical director of our outpatient program and I have a practice right now that is probably, I don't know, 30% trans, non-binary, gender expansive folks. And so I think my presentation is really more of a call to action for you, whereas my lovely friends and colleagues I think have talked a little bit more about their own experiences. I'm going to talk about the political landscape and how angry I am and how angry we all should be. So I don't have any financial relationships to disclose. I just want to read a land acknowledgement. This is actually from Area 5. Dr. Margie Sped was gracious enough to share this with me. So we recognize that our country has a complex legacy. For 246 years, our states engaged in the abhorrent practice of enslavement of African Americans, followed by decades of terrorism and Jim Crow laws, which cynically legalized voter suppression and segregation. These scars have yet to heal. In addition, American Indians, Catholics, Jews, Asians, Muslims, and other groups were often targeted for persecution. Economically disadvantaged whites in rural populations have often been ignored or exploited. We acknowledge that some of us have gained advantage through centuries of white supremacy and hegemony, while others among us have struggled against them. Although none of us chose benefit or struggle, and many of us have membership in many different groups simultaneously because of the intersectionality of our respective heritages, we must all acknowledge the existence of injustice, strive to correct the wrongs of the past, and be vigilant in order to not perpetuate them. So objectives. So we need to identify, we'll identify the need for LGBTQ in the current political climate, and develop some tools to increase LGBTQ leadership. So gender trouble. So currently this is as of, is it too loud? Sorry, I was using my big girl voice. So this is as of yesterday. There were 549 bills of anti-trans legislation across 49 states. 71 of them have passed, and 376 are currently actively in debate. So here's an example of some of the ones that are currently up for debate. I want to point out in Oklahoma, felony charges for physicians providing gender care, gender affirming care. In Wyoming, a person is guilty of child abuse, a felony punishable by no more than 10 years imprisonment if they know knowingly inflict any procedure or drug to intentionally change the sex of a child. And you're going to see this trend, felony, is an ongoing trend. And then the rest of these are all bills that have passed. So in Florida, the state will take custody of any child that has been threatened with being subjected to sex reassignment, this is their wording, prescription or surgery, will immediately suspend the license of a healthcare practitioner who is arrested for committing or attempting to commit violations related to sex reassignment prescriptions or procedures for a patient that's younger than 18 years old. Iowa, again, again, licensee discipline for gender transition of a minor. In Indiana, as of June 30th, providers can no longer treat patients under 18 for gender-related concerns. In Missouri, sorry, Mississippi, I always get those two confused. Mississippi, prohibiting Medicaid from covering gender transition services and any physician who provides gender affirming care will have their license revoked. Missouri, it's called the Save Adolescents from Experimentation Act, and any physician who provides gender affirming care will have their license revoked. Seeing a trend here. Montana, this one I think is particularly dark. So healthcare institution and insurance companies are not required to participate in healthcare services that violate the institution's conscience. So this kind of covers everything. Covers gender care. They don't have to pay if they think being gay is a problem. They don't have to pay for abortion services. I mean, this is very vague. If they just don't think your lifestyle agrees with their conscience, they don't have to pay for your care. And then also, anyone who's under the legal custody of a county detention center or incarcerated cannot file a complaint against a medical practitioner. So essentially, that person's rights have been taken away. Again, in North Dakota, a physician who treats a minor for gender reassignment is guilty of a felony. Oklahoma, guilty of a felony. Until the child reaches the age of 45 years. So at any point, they can come back and charge you. South Dakota, you get your license revoked. Again, until the patient reaches 25. Texas, Medicaid can't cover gender-affirming care. The attorney general can bring an action against you and the medical board will revoke your license. Utah, they're going to create a specific certification for providing transgender treatments. They have to review, sorry, I said the literature, even though there's an entire organization that's already done this. There's scientific literature out there. But somehow, the legislature of Utah thinks they can do a better job. And it allows an individual to bring medical malpractice provided to the individual as a minor who later disaffirms consent. And West Virginia, at least they allow gender-affirming care if two physicians agree that it's required to prevent or limit self-harm. So what I think is really important, the takeaway here, is that you've got states who have decided they can take away our medical licenses and they can charge us with felonies for doing scientifically-backed medical treatment. We should be very angry and we should be very scared because this is the tip of the iceberg. And we should be very angry and we should be very scared because this is the tip of the iceberg. They're currently writing laws for people under 18, but again, they're starting to write, they're starting to put forward laws for adults. And this is just, you know, this is just the tip of the iceberg. Here's an article from JAMA, May 18th, because this is all happening really quickly. Currently 15 states ban gender-affirming care and they are explicitly redefining the practice of medicine. These are states' legislatures that are redefining the practice of medicine. And as I said, we're facing medical license disciplinary action. They're allowing the private legal action against physicians, which can include extensions on our malpractice statutes, civil legal action, and felony provisions. And this is really, the future is very uncertain because trans care has been traditionally covered by Section 1557 of the Patient Protection and Affordable Care Act, but that's been challenged and we don't know what the courts are going to say about that. So currently, we're sort of up in the air. Are we going to be protected? It's hard to say. So what do we do? Well, as I said, we need to get angry. I have a quick little video. Let's see if I can make this work. Oh, it's actually showing. Okay, that's exciting. Well, we're going to be just as effective as they need to be. We're not even spitting back on this. We have six extremist justices on the United States Supreme Court who have decided that their moral and religious views should be imposed on West America. So she's talking about Roe versus Wade, but if you recall, Clarence Thomas said that wasn't the end, right? So we need to be angry and we need to take action. Let's see if I can figure this out. All right, yes, technology. So what to do? Reach out to your legislative representatives. Let them know that you do not want these legislatures making decisions about scientific and medically-backed decisions. Reach out to your medical boards to say similar things. Reach out to the Senate and tell them that you want the Equality Act passed. All of these things are tools to help fight these laws. Donate. There are many projects, many organizations that are fighting this fight. The first few, the National Center for Transgender Equality, the ACLU, Lambda Legal, Human Rights Campaign, National Center for Lesbian Rights. These are all organizations that are fighting this fight on the legal side. The Trans Lifeline, Trevor Project, Trans Women of Color Collective, the OCRA Project. These are fighting it more on the ground with helping folks in terms of mental health and actual collective financial aspects. And then any kind of local organization in your area. Right now, like I said, as of May 18th also, a press release, the Lambda Legal, American Civil Liberties Union and the ACLU of Texas and the Transgender Law Center are filing a lawsuit against the Texas legislature for the Texas law that was passed stating that it's banning the only evidence-based care for gender dysphoria for transgender people under 18 and it aims to strip doctors of the medical licenses for providing patients the care that they need. So there is action that's happening on the legal level. It's yet another reason to support these organizations because they are doing the work. And I'll just leave this with this. As Angela Davis said, if they come for me in the morning, they'll come for you at night. Thank you. Thank you, Dr. Noble, for your passionate talk and this is exactly why allies and LGBTQ individuals should take up leadership roles. But when you're trying to take a leadership role, especially for somebody like me, who is an early career psychiatrist, there, you know, opportunities to network for other LGBTQ individuals or who are passionate about this are limited. It's difficult to find a mentor. If anybody is willing, then there are so many people who want to be mentored from the same person because, you know, the availability is so scarce. So I would encourage allies or whoever was willing to mentor should have an open mind and accept LGBTQ mentors. And mentor-mentorship relationship is two-way street. So sometimes the issues faced by LGBTQ individuals are somewhat unique than most individuals. There is issues about microaggression. There's issue about being discriminatory policies at various organizations. And there are other daily struggles that sometimes any LGBTQ individual has to go through. So what other important, what are the important things that an LGBTQ individual being at a leadership position can achieve, right? So they can bring in more diversity. So diversity itself is a blessing. I'm gonna get some, I'm gonna rely some data from McKinsey Institute Research Think Tank. What they have found that organization who have diversity in their workforce tend to be more financially successful. They tend to be more creative and innovative. Because when you have diverse opinion altogether, you learn more things. You have a more in-depth knowledge about the world and how things work in general. So you are more prone to incorporate all of that and come up with a solution that tends to be creative. And of course, it brings in with a better problem-solving skills. Now, LGBT individuals, when they are at the leadership position, which could be a governmental institute, public or private, it could be clinical, hospital, outpatient, or it could be non-clinical, such as insurance agencies, such as pharmaceutical or consulting work. So when you have somebody who understand the issues, they can bring in some inclusive policy and that can lead to engagement of more individuals in the workflows as well as leadership places. So I think it's important to encourage diversity and bring in more success to an organization. Well, I wanna thank everybody for listening to us and we've been talking for almost an hour. So I would want everybody to take a minute and maybe ask us a few questions and generate some interesting conversation. Sure, Dr. Forenstein. Yeah, yeah. Well, as you can see, I've been around a while. And before, most of the gay positive legislation took place. Now, I do live in Massachusetts, which is a separate country, except it's attached to the other countries. Other than that, we'd be a floating island. So I'm gonna propose something. I want you to imagine, you know, I'm angry too, but I'm old enough to know that anger doesn't do anything except can sometimes paralyze us. I'm a kid of the 60s, and when the war in Vietnam was overwhelming, we organized. And at 15, I showed up at Sheep's Meadow in New York City. And my father, who was a World War II vet, drove me there, in spite of the fact that he didn't understand why we were protesting the Vietnam War as a veteran of World War II. But he reminded me that the reason that they went to war was to preserve our rights. And it stuck with me for the rest of my life. He eventually came around and became as rabid as I was about the war. I mention that because it taught me that action is the only thing that matters. So I'm gonna ask you to imagine something. Imagine if all the doctors in the United States unionized. Imagine if we told our patients, who were not against us, our patients, by and large, support gay rights and support gay marriage and all that. We have the evidence that over 65% of US citizens don't care whether we get married or not. But imagine if we told them that we were being persecuted because we were also supporting the healthcare of minorities who happen to be GLBTQ+. And imagine if all the doctors unionized, which is hard because we're taught to take care of patients even when we take care of a patient who would put us in a dangerous position. As a Jewish man, can I take care of somebody who supports Nazism? And what's the moral prerogative that I have to separate myself from that position? But imagine if all the doctors unionized and we said clearly to the states, you can't practice medicine without a license, so we're not going to take care of you. We're not gonna take care. We have a list of all the legislators at the state level, local level, and federal level. We will not take care of you medically. And maybe a few of us would violate that and take care of them, but there aren't enough of them. And I think the union would provide a kind of fiscal safety net. Now, it's risky. It was risky for me when I came out as a medical student in 1976, and it was risky for me at Mass General as the first openly gay resident, but I didn't have any choice except to follow my conscience. And I knew the risks. I knew that they might kick me out of the program, and there was an incident I'm not gonna spend time on that came close to that. But imagine if we took those risks to live an authentic life, and we said to people, you're violating and practicing medicine without a license, and that violates my conscience more than my conscience says I have to take care of you. Imagine what would happen at the local level if people couldn't get to their doctors. And what we would do is mobilize them as part of that allied group that would go to their legislators and vote them out, make a protest, and say, you can't do this to our doctors. You have no right to sit in as judges of medical care. It's unconscionable that they don't read and understand and obey the scientific data. But imagine if we actually mobilized, not just got angry. Because- The anger is the fuel. Absolutely. We need to mobilize the anger into action, and the only way that's gonna happen is if we, as individuals, band together and take some risks and say, you can't do this. Because if you continue to persecute us, we have to pull out of your healthcare. Now, I know what that sounds like, and I think it's a frightening perspective. And I'm fully aware that it asks us to do things that go against our do no harm oath. But they're doing harm. They're practicing medicine without a license, which is against our oath. You know, as a psychiatrist, I won't do surgery on a patient, even though license-wise, I'm allowed to. It's against my conscience to do something I'm not legally, ethically, morally prepared to do. So, you know, the call to action for us now is taking that anger, and Sarah, I appreciate where it's coming from, and, you know, I've been there. I was part of the movement. The war in Vietnam was changed, and Lyndon Johnson didn't run again because he heard that the population wouldn't elect somebody who supported the war. And frankly, Americans were tired of the war. Well, we have to make Americans tired of this nonsense that's coming out of state and federal legislators. I don't have answers, but I think the work that you're all doing up there as leadership, you know, I'm on the down slope of that, but it's not too late for any of us, you know? And that's, when we talk about the glass ceiling, we're also talking about those of us who have been in positions, you know? I acted, I was an acting chair of the Department of Psychiatry, and the first openly gay chair at Harvard Medical School. Now, I know there were other chairs that were gay, but they were scared. It turns out they have no reason to be scared. The demons we have are often imagined. We have to take issue with that. Anyway, I'll stop. Well, thank you so much for sharing those remarks. And that brings up the interesting point that sometimes being a minority within an institution, it's a moral dilemma, because in a way, do we feel pressured to be the face of discrimination so that others can follow after you? Or is there any pressure to become, not a mascot, but a representative? I know, I don't want to put anybody in a spot, but maybe Dr. Ashley, if you can answer. Because, you know, being a minority within a minority is a challenging thing, as most of us know. Do you feel that, are there any lessons for us to learn from your experience, whether, you know, you get asked for so many things to do, like sign up for this committee, do that, do this. It's exhausting sometimes. So what advice do you have for all of us? I mean, so it's been written about, you know, people have often, I hope people have heard of what they call a minority tax. And so, I mean, the question is, do you want to be in the room, or do you want someone else representing you? And so sometimes it's like, I don't really have time for this, but I don't know who they're gonna put in the room instead of me. I mean, I'm trying to let go of some of that in a lot of places, in a lot of spaces, as more people step up and are engaged and involved in a variety of activities around, and mostly it's around DEI-related topics. And I think, you know, after the murder of George Floyd, and, you know, the idea of the, and after COVID and the acknowledgement of, health inequities, which you knew about for decades, but, you know, COVID, George Floyd, all these things kind of came together and kind of pushed forward the DEI movement. So lots of institutions now have DEI committees and work groups and trying to address policies and procedures and things like that, which are all good. I mean, the question is how those things get executed, who's in the room, and if there are not representatives of a variety of identities in the room, who makes the decisions? Because sometimes you'll see statements like, clearly there was no one in the room from the group they're trying to talk about, because they would not have let this get through. Or maybe there was, and that person was so junior that they didn't feel empowered to say anything, which is the other issue. Or people that have been kind of tokenized, like, we want you to sit in the room so your face can be put in the picture, but we really don't want you to say anything. So you need to be bold, you need to be, take the risk, or just say, no, I'm not gonna be involved or engaged in this, because I don't know that your goals really align with what I would like to see happen. So, I mean, that's a decision, first decision one has to make. But once again, trying to decide, I mean, and I've talked to a variety of people who are in that situation, it's like, you've got to decide how much you want to give, is this where you really want to spend your energy and time, or would you rather let someone else manage it? Because they're often allies you can call on, people who you know that are going to represent the issues that you feel are important as well, but you need to kind of know who the players are. So, and that sometimes is a challenge to figure out who they are, but if you're at an institution long enough where you start talking to people, you'll find out who is going to be in the room and feeling if they're going to be able to, you know, represent your interests adequately. So I don't have any, there's no easy answer, and everyone's got to decide how much time and energy they want to give to these activities. But it's important that the activities happen and that there is some way to, and once again, it's always a process, so they may get, the committee may get it wrong the first time, but then they're, you know, you can always kind of check in and say, gee, I don't know that that was done properly, and we can, let's revisit it. But yeah, I mean, I am currently, you know, involved in a lot of committees, a lot of work groups around DEI issues, just because it's what I like. I mean, and interestingly, I was doing it before it was in vogue. And once again, the institution I am at actually was doing a lot of this work, has been doing the work probably for 10 to 15 years, so we were kind of ahead of the curve, and so we've got policies and procedures in place, and I know a lot of the people who were doing the work, and they're supportive and good, so that makes my day-to-day a lot easier. Well, as you said, there are no easy answers, but thank you for sharing your experience and your thoughts on the matter. I invite you, everybody, to chime in, but while we do that, I wanted to share another experience that I had. I gave my CV for some particular purpose to a person, and he looked at my CV, and my CV has a lot of LGBTQ-related stuff, like committees and papers and whatnot. So he looked at my CV and told me, oh, okay, you're very good at advocacy, but what exactly your interests are? And that was an interesting moment for me when I had to kind of take a pause back and tell them, like, this is exactly what my interests are. But that just speaks to the level of advocacy that's needed, ironically. Having said that, I know Istanbul Protocol was a very big deal, but my understanding is you were asked to join last minute. And did it feel like an afterthought to you? Did you feel that they should have invited you early? It would have, except for one interesting thing. The first Istanbul Protocol was created primarily by people from 15 countries in the global north. And so with the update, they were asking people to be authors who lived in the global south. And so that influenced, I think, that outcome. I was very sorry I didn't get to be in on it from the very beginning. And I think, as with many documents, we wrote pages and pages, and the LGBT chapter, which is very good, is very brief. So there's definitely more work to be done. And in the 20 years from now, hopefully it will go differently. I just have a question. I mean, who here is kind of engaged in any kind of advocacy around whatever issue? And what have those experiences been like for folks? If anyone wants to share what that's been like. How do you decide to get engaged in it? Do you, are you asked? Do you kind of ask? Are you invited to be engaged? Or do you invite yourself to the table? I mean, do you know who to talk to? Do you know how to, I mean, do things come out and you're like, where did this come from? Who made this up? And I mean, what are people's experiences like? I mean, because I think almost every institution around has got a DEI committee probably, or DEI, or a JEDI committee, or whatever. So to direct, that's actually a good proposal like that, because there's so many things going around in my head with everything that's been brought up today. I did want to say, before I answer that question, I appreciate that this was a topic and that you guys are willing to talk openly about this. When I came to APA last year in New Orleans, there was a panel and it was mostly therapists and there was a psychiatrist and they were talking about transgender youth. And I was like, okay, I don't know about you guys, but I don't know about you guys. But they were talking about transgender youth. And the main topic was really kind of very, for me, activating, because they were basically saying that as gender-affirming therapists or psychiatrists, we just let people be transgender, that we are influencing people to allow them to be transgender. But I was really proud that there were a lot of other psychiatrists in the room that kind of spoke up and were able to be, like I am right now, and say, no, this is wrong what you are saying. So that actually does go back to your question. After that happened, I knew that I had to go back to my institution to become involved. So I'm a medical director for a national telepsychiatry company, but I hadn't really been involved in any of the DEI efforts. So that got me very interested and the way that I've become involved with it has kind of been a little bit more informally at this point. Well, it was informal, a little bit more formal now, being like the co-chair of the DEI committee. And we have a charter. I think that that's something that's really important to actually put it down so that your employees know. Whenever I'm interviewing applicants, we ask the DEI question and it's been interesting. Some people will say, like they screen themselves out if they're not willing to talk about DEI. But even though we have DEI committee, we still struggle with being able to just teach our psychiatrists and therapists about how to be LGBTQ plus affirming. But we're just very open about it. You know, whenever I do have clinicians that I meet with one-on-one, I'll have the discussion about how do they feel about that? Where can we help them build those skills? And I think that that's where I see my role right now, like within my own organization, being able to help the clinicians gain skills and with that population in general. So thank you for this. I thank you for your work. I mean, when you said you're informal, like being co-chair of the DEI committee is not so informal. Yeah. Yeah. And I mean, I think the other thing is sometimes being on a DEI committee, trying to make sure that LGBTQI issues are included because often people think it's just race, ethnicity and making sure that, you know, the LGBT plus piece is included as, well, you know, the rest of other, a variety of other kind of inequities, so kind of rolled into the social determinants about, you know, educational background, immigration status, and all of those things always need to be included as well, so. I was just going to ask, in looking at the app that lists the different sessions, a lot of them include downloadable copies of the information, and I don't think this session did, and there's some really good information in there that it would be good to make more widely available, if that, I don't know if that's possible at this point or not. Sure. Well, after the session, I'll come to you and get your email so we can send you the slides. Well, thank you for asking that, and I agree, I mean, especially Dr. Noble, you had very good information, and it clearly takes a lot of effort. I have to admit that I just did my presentation yesterday, which is why it's so up to date. Well, I wonder if, you know, if you guys remember COVID, oh my goodness, you know, that time, that was a good example where how the diversity, not diversity, but how socioeconomic factors, how it affected care, and it was so obvious at the time, right? So LGBTQ individuals at the time, I wonder, like, they had more instances of domestic violence, more instances of receiving less care in all sorts of settings. So I wonder if that could be a good example where having a seat at the table helps the population that is in need and underserved. I don't know if anybody has any experience about having a seat at the table and how it changed things for people they serve. Yeah, yeah. A little shy, so I'm Raul. I'm from Florida. Yeah, yeah. I've been living there since 1997, when I moved from New York City. So it was like a little change in terms of the dynamics and then I will say non-academic environment that I found in Jacksonville, Florida. That's like North Florida. And I'm an inpatient psychiatrist. I've seen, like, through the years, you know, through years, a change in the field of medicine in general, like how they've been isolating doctors more and more and more, and bringing administrators to, like, run the units. And they have meetings and they don't involve the doctors, but they have, like, you know, they have decisions that involve our, you know, our job. And then at the end of the day, we all know that that's, the liability is ours. It's not the administrator. So I've been lucky enough until now to be on a unit in which the administrator, who is a nurse that I've known for many years, and she happens to be a lesbian and she happens to have a wife. So she has been a very good source of making change happen for everybody. Unfortunately, she was promoted. And now the new person on Facebook is a very loving, ultra-Catholic, conservative, DeSantis lover. Loving person. Well, lover, because I was like, so she just started, like, two weeks ago, so I don't know how things are going to change. But the fact that the unit itself is very welcoming to and has, like, things in place for patients who come, like, you know, we have in place all these things, even when the law doesn't, we are adults, so those laws that DeSantis is trying to implement, like, they have been, like, I guess, like, trying to do for years. This is not something new. They have been planning this for years. We all know that. So it has been, like, a good experience for many of our patients. We also have a residency training program. And I am, like, the last token, I would say, token of three minorities in one. I'm gay, I'm Latino, but I'm also from a U.S. territory, because many times I've said I'm from Puerto Rico, and I don't know if you've seen the news recently, they, like, even, like, think that they were, like, we need to have our own passport, blah, blah, blah. And I even noticed on the thing for the American Psychiatric Association that they named Puerto Rico as international, like, whatever. And I'm, like, what the hell? I don't know why they named, like, okay, blah, blah, blah, and territories and blah, blah, blah. But that's, like, how bad it is even here, the American Psychiatric Association. So being that, we do take into account, like, for the residents, I make sure that they have experience with people who come from all, you know, it's not just, like, you know, but all types of, like, walks of life. And we do have in Jacksonville, for whatever reason, a big gay community, which includes transgenders, gays, lesbians, people who are, like, questioning what they are, this or that or whatever. So they do have a lot of experience. We expose our, I make sure that our residents are exposed. And the other attending on the unit, she, you know, they all know that I'm gay, so they're, like, friendly. I take my boyfriend to all our meetings and whatever, so they all know. But I don't know how it's going to change now. But that's, like, the experience that I have had, even in Jacksonville, Florida, with that, the Santis and all those politicians that I keep telling the residents, you need to, like, you know, I'm on the way out. You're going to be there, and you're going to, you have to push back, because at the end of the day, again, they put the liability on us. They don't go, oh, you are responsible, you are responsible. And we're letting all these politicians make, which is, like, weird for me, make rules for the practice of medicine, which is just political. But we know that that's an effort that they have been doing. So that's been my experience. But, like, after this, I want to say what other results. I used to be a member of the AGLP whatever, and I would find that when I would go to those meetings and all those things, it was very clicky, clicks here and clicks there, and I would always feel that, okay, I'll go to, like, social events, and I would be, okay, like, with my friend, and, like, okay, nobody's talking. It's, like, they're all talking among themselves. Nobody socializes. I also was not very fond of going to those meetings. I stopped, like, years ago. So I don't know how that is going to be, like, because that's part of, obviously, what happens is that even within our, you know, groups, like, there are, like, divisions, and we're not cohesive, and that doesn't help, you know, to be, like, speaking for things for us. We're not even, like, cohesive. Even, like, the little fact of, like, my last name is Soto Acosta, and people insisted on calling me Acosta, and I would have to explain, Soto Acosta, you know, you're, like, from, like, whatever, for God's sake. That's, like, basic learning Spanish. Like, Soto is my father's last name. Acosta is my mother's last name, blah, blah, blah. So Soto would be, like, if you want to call me something, Soto, but not Acosta. Oh, yeah, yeah, and then later on again, hey, Dr. Acosta. So I got tired of all those little, I would say, microaggressions, you would call them, even within our groups here. That's what I wanted to say, but, like, I would like to see what other resources we can, that we can, like, go, okay, we can belong to this group, and we can share ideas among us. Thanks. Thank you. Thank you. Yeah. Thank you. Go ahead. We only have a few minutes left, and it's, you know, we finally have, like, really lively dialogue going, and I encourage everybody to kind of share their thoughts. I wonder if, you know, like you said, and Dr. Noble said, organizational psychiatry can, in this context, can play a, you know, important role, and traditionally, AGLP has done that, and Dr. Noble is also secretary of AGLP. Traditionally, AGLP has done, especially in the 90s, a lot of advocacy work, and I think we are going to have to go back to doing more advocacy work, given the political climate. Again, Dr. Noble, if you have any thoughts about, yeah, go ahead. One thought I had based on the taking action and the idea of unionizing is we have colleagues in family practice, OBGYN, internal medicine, who are spending weeks of their months and years in border states providing medical abortion care. I have one colleague my age who just retired in order to do that full time. So, if we could do that in our world, and for those of us on the down slope of our careers, we have less to lose. You know, if there are legal consequences, financial consequences, we should be the ones out there taking the heat, because we can more easily afford to do so. So, I don't know how we do that exactly, but I think that they set a good role model for us. I think, you know, as marshals, I mean, we've got to be creative in how we address this, and we're probably going to have to address it in a host of ways. Once again, I'm thinking, why don't the doctors just do some big action and just kind of push back in some way? That's not what, for general, that's not what doctors do. That's not our way of being in the world, for the most part. We're like cats. We don't go into groups easily. We do, but I think it's something that we need to do and think about. I mean, the downside is, are we, in the long run, probably beneficial for our patients. The short one, are there going to be some issues that we feel really uncomfortable not doing, and maybe we need to be able to feel uncomfortable. I mean, it's just amazing that it has gotten to this place. I mean, and once again, we talked about the science, but clearly, these legislations, it's political, it's not scientific. They had the scientific literature put in front of them. They've had the reports from every major medical organization telling them that the data you have is not good. The reality is, these are the treatments that are best for people. The mental health outcomes are much better. The data is there. But they are choosing to make this a political issue. It's not about medicine. It's not about what's best for the patients. It's really about what is going to rally their base. So, we have to get creative as well. They've gotten creative. We need to get creative. I don't know what that's going to look like. It's going to take someone who's able to think outside the box and come up with strategies to address this. I think one thing that is important is that states that do support these medical interventions, medical treatments, need to pass legislation to protect physicians in their state. They're saying, if you provide treatment to our patients, even if they come to your state, we're going to extradite you back to our state and try you. I don't know if that's legal, but I know that there are states that are passing laws to make sure that physicians practicing in their state, doing what they are licensed to do, cannot get extradited to some other state to face charges against something that's illegal there. So, we can call on our states, the states that are supportive, to support their physicians and their other health care clinicians doing the work that is appropriate. You raise a good point, and I've noticed over the last year or two, before the end of the public health emergency, states have cracked down, right? To the point where we're all running scared and trying to gather up licenses in other states. And I really think, and we've talked about this, that it's a movement to prepare, to block us from providing trans care and abortion care across state lines. And Raul, I want to speak to your point about looking at the microaggressions and the unwelcomingness in our own spaces, right? For many years, I think I felt that way about AGLP, too. I would go, and it seemed like everyone knew everyone and didn't know me, and I would tiptoe away. And I think that one of the sweet things about COVID was that AGLP has grown enormously. We've done Zoom meetings. It's now a much bigger, more diverse, younger organization, friendlier, I hope. And for me, I was given a big nudge to be the editor of the newsletter for a couple of years. And that put me in a position where I met a lot of people. And then it started to feel different. But I do think we have to be mindful as we go forward to be the friendly face at the welcoming door. And if you feel like giving us a chance again. Again. Yeah. But if you do go to aglp.org, there's a list of activities and there is a dinner. So there's a BIPOC dinner tonight. If you're around and are available to come. And everyone else is welcome as well. But yeah. The problem with getting old is that you think you don't have enough time and you have to talk everything. Anyway, I have two things. One is, I go to those meetings and having in the past known everybody at the meeting, I now know 10%. Usually people in my peer group. And the younger people are afraid to come up to us in some ways. Because they have all sorts of fantasies about why we were there and why we would talk to them and all that. So I go up to them. And I introduce myself and we talk about where they are in their careers. And I make it clear that I'm interested in their life in psychiatry. And if I can be helpful, call me. It takes some courage to go into a group we're not familiar with. And say, I'm here. Pay attention to me. I try to go up to as many people at the parties and the people I don't know and introduce myself. But I can't get around that way. So I would encourage you to go up to people that you see talking and introducing yourself. I think it takes some courage to do that. We've had to do that as gay people all the time. To make ourselves visible. I can share, as an older person walking in New York City, I feel invisible sometimes with people rushing by me. And people have actually bumped into me. And I feel like, okay, stop and say, what are you doing? You know, take your hands out of your phones and look around. I do think that I really hope that you'll let us know when you're being ignored. Because that's not what we want to do. Because we've all felt that. And the second thing, I think to make a place at the table, one has to be good at something. I got really good advice from my training director who said, you have to become really expert as a psychiatrist in any way that you want to work. And then you have a platform in which you can talk about your minority status. And I think that's really important to not just be focused only on the population you're most comfortable with. So being an expert in any part of prison psychiatry, asylum psychiatry, whatever, gives you a kind of credibility in the field. And I'm also gay, I'm also lesbian, I'm also trans, whatever. I think that gives us a kind of credibility that we can then use slowly to introduce these other ideas. I want to be clear, I don't think change happens with revolution. We're not going to see, well, I don't think we're going to see a revolution. But I do think evolution occurs even in our clinical site. I've had patients who have said to me, oh my god, these legislations down in Florida must be scary. And I said, well, how are you feeling about them? And what could you do about that? So it changes how we work even in psychotherapy with patients if we are willing to stretch the boundaries a little bit to include talking about things that my patients are concerned about. And so I ask them, when they ask me, what are you doing about it? I turn it back and say, what are you doing about it? And I think all of us have to pay attention to that over time. I still think, as the residents have taught me, where I was training director, they were unionized. It made a tremendous difference about them getting what they needed in ways that even as acting chair of the department, I couldn't get. So that's why I'm going back to my roots in the 60s when unions were much more powerful. Thanks for this presentation. It really opened up some thoughts in my head. Thank you, everybody, for coming. We are almost out of time. And we are able to talk offline after the session as well. Again, thank you. And have a great conference. Thank you.

LGBTQ

psychiatry

advocacy

representation

transgender rights

gender-affirming care

DEI initiatives

discriminatory policies

APA

WPA

mentorship

activism