Good morning everyone. Welcome to the American Psychiatric Association's roundtable discussion titled Combating the Nationwide LGBTQIA plus Youth of Color and the Mental Health Crisis. My name is Dr. Regina James and I serve as the Deputy Medical Director and Chief for the Division of Diversity and Health Equity here at the American Psychiatric Association. I'd also like to bring you greetings from our CEO and Medical Director, Dr. Marquita Wills, who could not join us today, but brings us all warm well wishes and a great success today. We'll start this event with remarks by APA's 2024 Grand Marshal for the More Equity and Mental Health Initiative, Dr. Jay Barnett. And let me introduce a little bit about Dr. Barnett. Dr. Barnett is a former professional football player, marriage and family therapist, speaker and author of bestselling books, including Finding Our Lost King and Queens, Letters to a Young King, and he's on board to release his highly anticipated book, Identity Crisis, a discussion around social media impact on personality identity. Dr. Jay Barnett. Good morning, everyone. Good morning, everyone. It's Friday. Happy morning. Happy Friday. All right. Tough crowd. Thank you, Dr. James. I'm excited to be the Grand Marshal for the 2024 More Equity Initiative. Once again, it's always a great opportunity to work with the APA and also just a great opportunity to work with them on all the many initiatives that they are bringing to the community and to the nation about mental health and about mental wellness. And so it is my sincerest pleasure to be here as the 2024 Grand Marshal to officially kick off the 2024 programming of the APA More Equity and Mental Health Initiative. Today is the first of our many events being hosted throughout the summer focused on mental health equity for young people of color through education, outreach and advocacy. In addition, through our collective efforts, we honor B.B. Moore-Campbell, a staunch mental health advocate and award winning author who worked tirelessly to shine, sorry, tirelessly to shine light on the mental health needs of communities of color. In 2008, the U.S. House of Representatives announced July as B.B. Moore-Campbell National Minority Mental Health Awareness Month. And without further delay, I yield the microphone back to Dr. James to begin this much needed discussion that I'm excited to hear about today, combating the nationwide LGBTQI plus youth of mental health crisis. Thank you. So thank you, Jay. So we're now going to get started. I just wanted to provide a little background information before we do get started to provide some context about the conversation. So I think we all are aware and can agree that we are in a youth mental health crisis. The Center for Disease Control and Prevention shows that there's a 40% increase over the last decade in the number of high school students responding and reporting persistent feelings of sadness and hopelessness. And suicide rate among teens and young adults have gone up by 57% since 2007. In addition, data from the Youth Risk Behavioral Surveillance Survey supports that 1 in 10 children and youth in the U.S. identify as being in a sexual or gender minority group, lesbian, gay, bisexual, transgender, queer. And based on review of population-based studies, LGBTQ youth have a three times higher prevalence rate of depression and anxiety compared to their heterosexual or cisgender youth comrades. So when you now step back and examine the trifecta of being a young person, being a person of color, and being LGBTQIA+, there's nuanced challenges, I think, that they face as young people. And we must be aware of these challenges so that we can meet the needs, not only through services, but through family support, friend support, et cetera. My last statistic I wanted to share with you is really highlighting this issue in terms of youth of color who identify as LGBTQIA+, with mental health issues. The Trevor Project, which is a leading suicide prevention and crisis intervention nonprofit organization for LGBTQ+, young people, conducted a national survey in 2024. It highlighted the experience of about 18,000 young people from 13 to 24 of age across the U.S. And for those who identified as a person of color, LGBTQIA+, the survey noted that nearly all of the young people of color reported higher rates of attempting suicide compared to their white peers in the past year. And black, transgender, and non-binary young people report disproportionate rates of suicide risk, with 58% seriously considering suicide and about 25% attempting suicide in the past year. So this morning, our esteemed panel will discuss this growing crisis and issues around education, outreach, advocacy, and how can we truly, truly address this public health crisis. So before I get started with our panelists, I'd like to introduce you to them. To my right is Dr. Tammy Benton. Dr. Tammy Benton is a board-certified child and adolescent psychiatrist. She is the newly elected president of the American Academy of Child and Adolescent Psychiatry, a distinguished fellow of the American Academy of Child and Adolescent Psychiatry, chair of the Department of Psychiatry at Children's Hospital of Philadelphia, also known as CHOP, Professor of Psychiatry and Pediatrics at the Perlman School of Medicine at U of Penn, and she directs the Child and Adolescent Mood Program and the Youth Suicide Prevention Center at CHOP. Let's welcome Dr. Benton. Next to her, Dr. Shemeika Dixon. Dr. Dixon is board-certified in both pediatrics and adolescent medicine. She is the director of adolescent medicine at Atrium Health Levine Children's Center for Gender Health and Teen Health Connection. Dr. Dixon specializes in transgender health, and as an outside activity, I have to note because she included it in her CV, she loves spending time with her husband and children. Please welcome Dr. Dixon. And rounding out our panelists, Dr. Roberta Laguerre-Frederick. Dr. Laguerre-Frederick is board-certified in pediatrics. She's a clinical director of immunology at the Dorothy Mann Center for Pediatric and Adolescent HIV at St. Christopher's Hospitals for Children. She's an assistant professor of pediatrics at Drexel University College of Medicine, and she has received numerous awards for her contributions to understanding HIV and AIDS. Please welcome Dr. Laguerre-Frederick. So I'll now join my panelists. We'll go through a few questions, and then we'll also take questions from those who are here in the room as well as those who are in the virtual room. All right. Good morning. Good morning. You were all like antsy, like, what's the question, what's the question? So I'm going to start actually with an open-ended question. Given the expertise that each of you bring to the table and the family and the patients that you serve, why is this topic that we're discussing today, this conversation so important now? So I'll start with you, Dr. So, well, thank you for hosting this event and inviting us here to have this important discussion. I think the issues that we all see is that things do not appear to be heading in the right direction for young people in our country. And so what we're seeing is increasing rates, as you mentioned, of anxiety and depression, increasing rates of suicide for most populations, increasing at a more rapid rate among minoritized populations. And this has been happening for more than 20 years and we're really not seeing a lot of changes. And there are populations that are at risk. We know that social determinants of health drive a lot of mental health presentations and outcomes. We know that there are marginalized populations and those who are more than one minority, you know, whether it's gender, sexuality, or race are at increased risk. And unfortunately, the political environment, I think, has made that much more challenging for those at-risk populations. We also know that young people with chronic medical conditions are at higher risk for mental health conditions. And so I think what all of us are experiencing, and we spent some time talking this morning about how we're all treating mental health because it's the responsibility of all of us, but all of us work with the most vulnerable population. So I think that all the indicators suggest that we need to be doing something different and that's why I believe we need to have this conversation right now. And I think that's really highlighted the significance of the issues. This generation of young people are our future. We have an opportunity to secure the future well-being of aging people. This is a generation. And if we can't do it right now when we've had as much national attention and collaboration as we have, we're never going to be able to do it. So this is our moment to take this on. Thank you. Thank you, Dr. Benton. Dr. Dixon, you'd like to add some comments to that? Well, I think Dr. Benton said it all, right? Like part of it is addressing the mental health crisis that we're seeing for all of our young people throughout the nation, but then looking at marginalized youth and then understanding the importance of intersectionality, right? So I think this is highlighting some of that crisis and the need for us to continue to intervene and encourage our colleagues and all the people we work with to understand the importance of intervention and how we can go about doing that. And so I agree with both of my colleagues. I just feel that we're at this really pivotal moment right now. I think the COVID pandemic for the nation kind of helped us all to focus, unfortunately, because of the crisis on mental health in a way that maybe we didn't focus on it before the pandemic. And I think we shouldn't squander the opportunity that we have that people are focusing and paying attention to mental health. And as a provider taking care of young people with HIV and mostly of color, you know, we've studied this problem. None of this data about LGBT youth of color and the dire vulnerabilities they face in terms of mental health and medical outcomes. We've known this for a long time, and I think we can't waste any more time studying the problem or assessing the problem. We have to move to action. And, you know, there's so much that we can do, and particularly for me as a physician and, you know, having these amazing tools at our disposal right now to prevent some of the really severe health outcomes like HIV infection, to know that for so many, they are not linked to that kind of care. They are not. And even when they're linked to the care, they can't fully utilize it because we're not addressing mental health issues. And I think, you know, because it's just so obvious and, you know, we have this data, we need to really do everything we can, seize this moment, and move towards action. I love that. Seize the moment and move towards action. My next set of questions I'm going to do directly to each of you. And I'll start with you, Dr. Benton. Social media can play Thank you. Because you're right next to me. Social media can both play negative and positive roles in the lives of our young people. Can you provide your perspective on both sides, positive and negative, the impact of social media on the mental health of LGBTQIA plus youth of color? So, you know, as you know, the whole social media question has been really tricky. And I anticipate you guys will have comments about that because you deal with this as well. You know, so there's the upside and the downside of social media. But the reality, there's one thing we can all agree on is here to stay. It's not going away. And so the question for us is really harm reduction and management. And how do we identify the things that are going to be useful? Because it's not going away for certain populations. Social media has been a lifeline. And that was pretty clear for vulnerable populations during the pandemic. This was especially true for LGBTQIA youth who were able to maintain networks that you couldn't maintain otherwise. And so that is actually true for most young people. You know, during the pandemic, when we made the rapid transition to telehealth and other modalities, you know, the world virtually went to remote learning, although about 90% of the population actually had challenges, particularly girls and international girls. But for the most part, here within the United States, for LGBTQIA populations, it was positive. There's a tremendous amount of data that really supports the potential harms for vulnerable populations. So we know that for youth of color and other youth who actually are struggling with things like anxiety and depression, they are more vulnerable to the impacts of social media when there's bullying and inappropriate use. And then, of course, all the other stuff that was happening with algorithms targeting people who are too young. We provide a lot of guidelines. I think the American Academy of Pediatrics has done a nice job at establishing guidelines. The problem is that when my patients come and talk to me and they tell me these things, I have to go look them up after the appointment because I don't know what they are. And I think many of us, you know, I'm a parent, but I'm also a provider. We just don't know social media in the way that young people do. So we're not going to be able to count on parents to do all the monitoring. And once they're adolescents, parents can't do that anyway. So I think that the potential harms are when youth are bullied and exposed and traumatized by predatory online behavior that we're not familiar with or aware of and that there's not adults to monitor like at schools and other places. And that is more true for vulnerable populations. We also know that even for young people who are struggling with mental health conditions, who feel good about themselves, have more pride. This is especially true for minoritized populations. We know that racial socialization, pride messaging, feeling good about yourself is protective of online activities. So the other piece of this is that social media can't have a lot of positive benefits. We're just actually starting to look at that. And, you know, so I don't think, I mean, unfortunately it's not a simple solution if we shut it down. One, we're not going to be able to shut it down. The second piece is young people don't want it shut down. It's a way of connecting for them. But there are also ways that we can use it in positive ways to reach people who otherwise wouldn't be reached. So there are things we know about the use of technology and mental health for young people. One of them is that young people like to have some access to control of their own mental health. They want to talk about it when they want to talk about it. They want text, not a lot. They don't want to have to talk to somebody on the phone sometimes. And, you know, technology allows them to do that. Social media allows them to connect with peers who may be struggling with similar issues. And we know that peer support and, you know, peer interventions can be very positive for young people. So, you know, I think that, you know, we know some bad things. I think we know some positive things. There's a major investment right now in research. American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry are currently engaged in a large grant that SAMHSA's been supporting looking at social media use in adolescence. So there's a lot of focus in that area. Great. Great. Dr. Dixon, you were shaking your head. I think you wanted to add a few comments there. You're relating to adolescence. I have this conversation every day, all day with parents, with youth. And I'd say the one thing I always encourage parents, you're right, you can't stop the train. The train is out. But parents do need to continue to acquire new knowledge about social media and different apps and platforms that are out there. There are so many articles that will talk to parents on ways that you can guide your young person in Snapchat and Instagram and know all of it can't be policed the same. But there are definitely regulations, limitations and rules you can put in place to support your child during their journey. Right. And so I strongly encourage all parents to get that information and knowledge. Right. Because kids are far more technologically savvy than we are. But this is going to stay. Right. And it has many great positive things. Just requires like everything else with adolescence boundaries, limits, rules. Right. But where do you get this? I'm sorry. Where do you get this information? Well, I'd say if you Google like even Snapchat ways to like monitor Snapchat or Instagram, you find that some platforms do a better job than others. But there are definitely certain things you can do, like having your child turn off their location. Right. Not having your child share their information or contact with people they do not know. As a parent, having rules in place. So my own teenager understands at any point in time, if I pick up your cell phone, I should be able to open it. Do I open her cell phone? Not very often. But I should be able to open it because I pay this bill. Right. I should be able to know who you're friends with on Instagram and on Snapchat. I am not reading her stuff, but I have that ability to if ever I need to and I'm worried about it. Okay. She understands that there are rules in place. You want that privilege. You want that phone. Mama pays the bill. Right. And so there are just certain things that you must continue to have in place. As you know, I'm trying not to laugh, too. Do I open it? I thought she was going to say no. No, she says not very often. I'm honest. I'm honest. I try to give her privacy and that's her business. But, you know, with limits. Any additional comments? Well, I agree with all these comments. I definitely am concerned about it. And I think that parents really need to understand how much that sort of use of these devices can really impact mood. I think parents don't really appreciate it until something has happened that it can have such a deleterious outcome for their young people in terms of mood. So I think we need to do a better job at educating parents about what we know now. We don't have as much information as we would like, but we do have a lot of good data so far about how much mood is altered and, you know, worsened with the increasing use of these devices and particularly for young women. And I think, you know, we use it a lot for good. Right. But there's so many ways it makes kids particularly vulnerable and particularly young people, LGBT youth of color. I'm thinking of young men who have sex with men who are African-American. They face a tremendous amount of stigma in other communities, schools, churches. When they come out, they're losing a lot of the previous sources of support and particularly amongst the adults that used to be very close to them. And social media is right there to step into that void. And it could make them, you know, they can have opportunities where they get support from peers and good information, but there are a lot of opportunities. And when they are cut off from all their previous sources of support, it makes those interactions they have online all the more important, whether or not that person means them well. And so I think we need to do a much better job with parents. I agree with contracts. I encourage our patients. There's a couple of contracts online that parents use with kids that they must abide by to keep their cell phone. And we do need to check things. We don't want it to be that after something happens, then we figure out that there needed to be some limits. Great, great. Thank you very much. Okay, I'm going to direct the next question to Dr. Dixon. See, I didn't direct it to you. Thank you. So Dr. Dixon, based on your service to the transgender community... Oh, sorry. I thought it was another question. Based on your service to the transgender community, particularly young people, what factors do you see that contribute to this higher rate in your practice? So I take care of LGBT youth in a primary care setting, a specialty setting. I have a gender health program. And we see teens, young adults, and children. And I would say, and our program has been around for some years now, and what I definitely see would be one of my biggest impacts that I see to the mental health of youth of color who identify as transgender or gender diverse is support. And so I think that's definitely a difficulty for all trans and gender diverse youth, being able to come out to people that are supportive of you, one, coming to terms with your identity, and then telling someone about it. But definitely for youth of color, that can be of greater difficulty. Whether it's because of religious beliefs or cultural immigration things, right? Your parents worked hard to get you here, and now things are different here. And so that is a big barrier to care. And so I have, over the years, seen more and more gender diverse youth of color come out, and their parents take the time and eventually accept and do the work that they need to do to get where they need to be. But that can be a detriment. So I have lots of kids that I see not in my gender health program, but I see for primary care who identify as LGBTQ+, and their parents aren't aware, they're not ready to tell, they're worried about being homeless and being rejected if they come out, right? And so clearly I'm not divulging that information on their behalf, but I'm creating a safe place for them to share that in my medical practice. But I see what it looks like when you're worried about not being supported or when you are not supported. And so it makes a significant difference. And I always tell parents, support does not mean you are ready at this moment to put your kid on blockers or hormones. That is not what it means, okay? Every parent is different, every family is different, and they're at different stages of acceptance. My job as your physician is not to push you in any one of those directions. It's to help get you the education, the support you need so you can support your child. My kids who are supported and loved fare so much better than my kids that are not, okay? And support and acceptance can be you calling them the name and the pronouns that they told you they want to be called. I always tell parents that is free, that is without side effects, and that in and of itself helps to mitigate some of the suicidal ideation, some of the mental health risks that we are seeing. And so I see improvements. Just repeat that line, the free and without side effects. I like that. Calling your child their preferred name using their pronouns is free and without any side effects. And that is a great deal of support that mitigates suicidal ideation and depression and anxiety and all of the risks that we worry about with LGBT youth. Absolutely, thank you. Any other comments on Dr. Dixon's? No, I absolutely agree. I think that youth of color especially in this group, I sort of touched on it before, when they come out, their rejection can be so incredibly intense. It just, for a lot of them, even watching it, it's kind of a brutal thing to see, especially when folks are very close, they have very close relationships with their families, their aunties, and they're the youth, sort of a music minister at their church. And when they come out, slowly, one by one, losing all of those things. It's just, it's incredibly isolating, and it really breeds sort of internalized homophobia as well as the homophobia they're feeling. And those, that sort of horrible toxic mix really makes that kid incredibly vulnerable to so many negative health outcomes. And so, it's incumbent upon all of us to really identify that. All the patients that we see in our program, we are always taking that into context, right? Taking that context into every clinical encounter, right? We had lots of folks for a long time in HIV medicine sort of lamenting that African Americans are the least likely to know about PrEP, least likely to be counseled about PrEP, even when they're offered PrEP, they're the least likely to stay on it. And I think a lot of those conversations just kind of dumping on this population. And I think it's important that we're finally starting to say, well, what would it mean to be a young person of color, an African American young man who has sex with men? And from the moment you're sentient, you're getting messages that your life doesn't have the same value as others. And that when you are sort of surrounded by that even before you come out, right? And now you come out and you're further marginalized, right? And now we want them to show up to clinic and get their blood drawn and take this medication to prevent, you know, I've worked with folks in other groups and you can see that they're not ambivalent about their self-worth. But I think, you know, once we start to take that, you know, look at that and step back and look at the big picture and say, if you were in this position, right? Would you feel fully confident about your self-worth, right? I think the more we try to do that and to really think about it in those terms, the more we sort of create policies that will hopefully be supportive. We have a completely open access policy for a lot of our prep services because we know we have to strike while the iron is hot because there's that ambivalence, right? Because we, you know, make it our business to understand that context. And we then sort of have policy and procedures created in response to that so that we can respond, yeah. Any comments on that? Just with a comment, you know, I so appreciate that the two of you talked about the family and community context. Yes. Because I think so many times, particularly with adolescents, that's lost. And there's this sense that you as the clinician are the community for that child. Right. And that can't be the case. I mean, the family, when you can engage the family, sometimes that's not possible. Having other communities makes a huge difference and really supports mental health. And one of the things that's been, I think, really very interesting and really important is that a lot of the faith-based communities have started to become much more open about embracing all of their members. And we typically don't think of, well, maybe you guys do, but a lot of people typically don't think about those communities as partners in mental health. We know that suicide prevention is a community activity. So it will not be that the healthcare profession and mental health professionals will solve that problem. That's not going to happen. It's not how it works. What we're gonna have to take is a public health approach. And a public health approach requires that we have other partners. And that we think about that, when we think about adolescents, somehow it has occurred, at least I see it in mental health often, that the patient is, the child is my patient, the adolescent is my patient. And then the parents are just the people that drive the kid to the appointment and pay the co-pay. And the reality is that it is that family system you have to stabilize, because once that youngster leaves your office, that is their survival. Okay, and that is their community. So I so appreciate that you highlighted that and really called that out. And I just want to put in a shameless plug, as you mentioned how other communities are important, particularly the faith-based community. One of the initiatives that we're actually integrating in our More Equity in Mental Health is gonna be this conversation around faith and mental illness and treatment and how they can all coexist with not only the young people, but their family, to really bring them all together to have this conversation. So again, I just, I totally agree with you, Dr. Benton, that just to highlight that piece is just so important, particularly for communities of color. Okay, Dr. Laguerre-Frederick, this is for you. So I know in our conversations before, you've talked about in your work setting, you really sort of have adopted this sort of collaborative care model in terms of primary care, working with mental health professionals, et cetera. How has patient-centered health evolved over the years that you have worked in the Philadelphia area with young people and their families, particularly as it relates to LGBTQIA+. Yeah, so over the years, I think we've learned so much and we're, particularly at our program, we're always trying to do our best to be better at this, to do better and to get it right, right? Because to sort of rest on our laurels and to sort of accept sometimes outcomes that are unacceptable, a low, one of the, I mentioned it before, this open access policy is a response to the no-show rate. And that we see that sometimes they come in for an STD and somebody talks to them about PrEP, but when we were constantly beholden to that schedule, we wouldn't see these patients and sometimes they miss four appointments and then we see them with a positive HIV test, which is a disaster. And so I think we have to accept that cultural context, accept that ambivalence that we see, understand where it comes from and try to address it. When we have an open access policy, we are saying to that young person, right, and assume if they make contact with us and want a PrEP appointment, we will part the waters and you can come in because we want to sort of meet their interest with urgency on our part and say, we affirm you. We agree that your life has value. Even if you're not completely sure, we are sure, right? And this is why we're gonna part the waters and see you no matter what. We do everything we can to make sure that young people understand that we are gonna meet them where they are. We have a huge sort of prevention program that we apply, not just medications or injections for PrEP. We always present an HIV prevention toolbox and we help the patients to know whether you take medicine or not, we are here for you. And I think the more you kind of bring cultural context to every single encounter, right? A trans female who's from the Dominican Republic or family is from the Dominican Republic and they were born here has completely different barriers to HIV care or HIV treatment or mental health than somebody who's a young black man who has sex with men. And I think the more we sort of try to individualize and get that information, not put it on the patient, right, the patient isn't responsible to teach us. We have to do our homework before they get to us, right? And to put in that time and effort, do that work so that we can be prepared to provide those safe spaces for young people. And I think for the most part, I think in particularly in HIV medicine, I think we are really understanding that and moving towards every single day being better at creating that environment, that safe space for youth of color. Okay, so now that I have warmed up the audience for questions, I have a lot of questions over here by the way, but just, you know, I don't wanna like hog the questions. I wanna make sure that those who are either in the room or who are in the virtual space have an opportunity to ask questions. So I'm gonna open it up and see if there's any questions in the room or virtually, if not, I will continue with my questions and we'll just move from there. So are there any questions in the room? And if there is, please identify yourself and your affiliation and then ask your questions, so. There we go. All right, we do have a question from Julio online. And their question is, what the new rules to dismantle DEI programs in some states. What advice do you have for practitioners to create programs that celebrate the strengths of queer young people? I think so, when it comes to programming and taking care of patients and people, I'd say one of the first avenues, you're right, DEI in general, that umbrella term, some institutions have had a hard time with it. Others of us are still chugging along, right? But I think when it comes to taking care of patients or clients or people, I always essentially bring it back to providing families and patients with the care that they need, right? And so I think, and the beautiful thing about what I do is not everybody loves what I do. I do so many different things and it is often politicized. But what I remind my leaders, my bosses, right, is that we have to meet all children where they are and give children the care that they need. And they deserve and they're families. So whether or not you understand it, you want to couch it as DEI, whatever, we understand that families are different. They have different needs and we want to meet them there and support them in those endeavors. And that is my job as a pediatrician and adolescent medicine physician, right? So I bring it back to that all the time. You can remove the labels and focus on caring for the people we're taking care of. But I also, I was going to say, I think that takes a certain amount of humility, okay? And you know what, I used to think we were all going to reach cultural competence and I'm now, okay, I'm not as hopeful. However, you know, because cultural competence is like a whole set of skills. But I think we can all develop cultural humility, meaning that we can step, I mean, like unless you have some other issues like personality disorders and stuff, but other than that, most of us can reflect on how we care about our patients and wanting to know about them and wanting to understand them and respecting them and valuing them enough to partner with them around what they want for their care. And so the cultural humility requires that, the ability to approach your patients and families with a genuine sense of inquiry and respect and understanding what their values are and getting comfortable with understanding your own values and recognizing when it's your values versus the family's values that's driving your decision-making. And I think we all have the capacity for that level of self-reflection. And so that's what I try to support clinicians in doing, that's what I try to support myself in doing. And I also, I definitely reject those labels that people try to, this is clinical information, right? If your clinical outcomes are not good because you're not addressing these issues, you have to do something about it, whatever you call it, right? And so we are committed to making sure that we are continuing to make sure our staff is competent. And when I talk about this, about creating a safe space for youth and particularly youth of color, it includes everyone, including the front desk, right? Every member of your team is an ambassador for your program, representation of your program, right? You could have the best providers in the world, but if the person at the front desk messes up the check-in process, you have shut that patient down, right, from the start. And particularly for those of us in PEDS, in adolescent medicine, for taking care of this really incredibly vulnerable youth, you have one shot, right? A once-a-year appointment to uncover something that that person hopefully is going to confide in you that literally could change that person's life in terms of what you can offer them, tools that you can put in their hands that could change their life in terms of mental health and medical outcomes. And we are so pressured, we feel a certain level of pressure to make sure that we get it right. And you cannot get it right until you address these cultural issues. So I definitely strongly encourage people to move away from labels, and particularly in medicine, this is a clinical training that is required, that is really needed for you to be able to effectively do your job. And I think all of us come to work with the goal of being effective, right? And so if we wanna be effective, we have to make sure that we move towards cultural competency regardless of what we call it. Yeah, and I would just wanna underscore, I think all of you touched on the issue around being culturally sensitive, and I will underscore as well, cultural competence, that's a lot. To be competent in every cultural background of every patient that you see is difficult, if not almost impossible. Cultural humility, on the other hand, is extremely reachable, it's a goal that you can actually reach, so I definitely agree with the cultural humility piece. Cultural competence, you know, you may or may not get there, but thank you for bringing that up. So thank you, I'm Dr. Anita Everett, I work at SAMHSA, an HHS agency, Substance Abuse and Mental Health Services Administration, and I am also a past president of the American Psychiatric Association, but I'm not here in that context. So I wanted to ask you, one of the things we've been working on really aggressively over the last two years now is 988 and the development of the National Crisis Response System, which includes someone to talk with, someone to respond, hopefully as an alternative to law enforcement and a place to go. One of the elements that we added recently to 988 is a press three option when you call that's specific for LGBTQ youth. It connects people to folks that are aligned with the Trevor Project and or work at the Trevor Project. I'm just wondering if you've had any experience with that or know about that, or that might be something you could help us sort of put forward as an option for kids when they get to a point where they're in a crisis. So I definitely would love to utilize that, I didn't know that was an option. So we offer all of our patients when they come to our program, I have a health card that essentially has the text hotline number, the call number, all sorts of other community resources and places. And I think that is definitely great to know and to utilize. And so I will definitely make sure we put that in a place where we are. But I was not aware of the press three option, but I am aware of the hotline, the text, and we utilize it a lot. I wasn't aware of that new option either. Is that relatively recent? I mean, 988, I think it's been pretty successful, at least for us. And the feedback we've gotten from adolescents who use 988 is they like it because sometimes they can get a peer counselor. But I was not aware of the new option. So that's like really wonderful. And I think for LGBT youth, I think they're so hesitant about connecting with mental health services. And I know how much it means to have a provider who understands, a provider who is trained in helping LGBT youth. And I think that having that option and publicizing that that option exists may take a person from considering calling that hotline, but maybe not doing it because they're worried about how they're going to be taken in by that person, even on a hotline. And to know that there will be somebody dedicated to their group, I think might actually push that young person in the direction of actually making that critically important call. So Dr. Everett, just to make sure that we all, not only in the room, but in the virtual room, hear what you just said about that option, 988. And if you can pass her the microphone. Is I just want to make sure everyone is aware of it because if our panelists are learning this for the first time, I think we really need to reemphasize. So it is an option, that's right. If you call from any landline or cell phone right now in the United States, and actually for the last two years, but there is an option. It'll talk you through, if you're a veteran, push a certain number. If you're calling about LGBTQI related issues, press three. And so press three is an option that is directed from anywhere you are around the country to staff that are specialized, trained in acceptance and working with the context of the kinds of crises that kids for whom that is relevant to their crises are experiencing. So it's a press three option, but you get talked through it when you call. So just 988 is now connected. There was a lot of details in working all that out. At some point in the near future, what we're working on will be to include a geolocation component, which 911 has, but 988 currently doesn't have, but that's on down the road. But right now, it is the case that if you call 988 and you push three, you'll be directed to someone who's particularly trained in working with those kinds of issues. Thank you so much for sharing that. Hello, Dr. J here. I wanna say thank each of you for the work that you're doing. I mean, amazing. I'm enjoying this panel. My question as someone who has worked the past several years with black males, black boys, black men, do you see support shifts for young black males or boys that identify as queer? And when that support level shifts, what is your sort of method on getting them to speak up? What is your support to sort of minimize the suicide ideations that is increasing amongst black males that identify as queer? I think for black males, especially in the queer or gay or bisexual group, we face particular challenges there. I think the black community obviously continues to struggle with this issue. And because we haven't sorted it out when our young people come out, it is something that could be disastrous, right? Because they're so isolated. I think we have to recognize that, that a lot of times they are completely isolated and try to create those safe spaces and connect them to other youth, help them to see that things generally do get better. I think particularly when they're very young, like I would say 14 or 15, they have this sort of apocalyptic view of what's to come, and that they would never be accepted, particularly for our trans youth. It's hard for them based on the toxic environment they're unfortunately sometimes experiencing to perceive that it could ever be better. And so I think the more we do to kind of create those safe spaces and connect them to other people, and I also, if the parent is involved, we try our best, because I think sometimes we are, I am, yes, an advocate, and I'm gung-ho on doing everything I can to help parents to support their young person, but I do think it's important for us to realize culturally what this means to folks and address it head on, talk about it, right? Don't let it be this thing that you can't even address in the room, and not sort of approach how it makes this situation particularly complicated. I think we have to address parents' grief around what they thought was going to be for their child. I think that, I know for a fact that when you provide those services to a parent who is willing and part of that child's journey, because sometimes the parent is not involved because they don't feel safe, but when the kid does feel safe and you have that parent-child pair in front of you and you can see them really struggling, I think it's important to recognize the pain of both, right? And when you support the parent and help them in a culturally competent way to work through what's happening, that is incredibly protective for that child, right, for that young person. And so whenever that opportunity presents itself, I always tell our adolescent medicine colleagues to, you know, when you're talking about PrEP, don't do the parentectomy, right? You want to make sure that if the kid identifies the parent as somebody who's involved in their life, to not only talk to the young person about PrEP, but also talk to the parent if the parent is involved, because I think that the cultural context of this is incredible, and whenever we can, we should be out in the community and talking to people. I often tell parents, and particularly mothers of young black males, you know, you don't have to have figured this out. I don't have to ask you. I know you don't want your child to be sick, right? We can help you to, you know, sort it out and to come to some kind of peace if that's something that maybe is in the future for you, but either way, we don't want your child to be sick, right? And we have so many tools that we can put in place and sort of have access for both you and your child to kind of process this and get through it, and you don't have to have figured it all out, right, to sort of come into our program. And I'll just echo the, so clinically in a scenario, I make sure my parents understand, especially for my young adults, who when their parents come, it is of their own choosing, right? Because when you're an adult, you can consent to your own care. Their parents don't have to come. But when they come, I make sure they understand how much their presence is needed and valued. And I am thankful that they're here supporting their child. And I will say, I love when all my parents come. I love when my parents of color come even more because so many of our kids don't see it. So I have families who have newly immigrated from Central America, from Cameroon, from all over the US, right? But I make sure they understand that their presence is valued and is significant, right? As far as their kid getting whatever care they need and support and their love. And then I would echo what we're just saying as far as community involvement. A lot of my significant work is outside of my clinic practice too, in talking to communities of color, right? Whether I'm giving some sort of discussion on sexuality to parents or to young people, right? I want to normalize this conversation. I want people to know that this clearly existed, has always existed, it is not brand new. People are like, oh, the rates are rising. People are feeling more comfortable identifying and coming out. People have always been there who have been gender diverse or trans or LGBT plus, right? Like we just have not allowed that space to be here. And so I think the more we can get out in the community, out of medical practices and out of your actual clinical environment and continue to talk about this and encourage support, that only continues to further our cause and help our young people out. Yeah, I just did want to comment though, that I think that for families of color, particularly black families who are coming into your care, will have a very different experience than most of them. And so the barriers to mental health care and health care broadly for youth of color, but I want to talk specifically about black men, because for black boys and black men, the gaps from my perspective are quite glaring. And so when we look at the increase in rates of suicide for black youth, this surprising phenomenon that the rates are increasing at the highest between black boys between five and 11 is staggering if you think about it. And the reality is that health care systems in general are not necessarily friendly to black men who are seeking care, and that mental health care is often not available. And so when we even think about black boys presenting to emergency departments with suicidal ideation or suicide attempt, more than 50% of them never have a follow-up appointment after that visit, where the chief complaint was suicidal ideation, suicide behavior, or suicide attempt. And so I just think that there's a perception that a lot of times that the problems are forensic, that there's really that there's a fear and a failure to recognize that population as a population in need of treatment. And so many youth of color end up in the juvenile justice system. Many youth of color are in the child welfare system where those services are not necessarily made available. So I mean, I think right now, I think the country is seeing some vulnerability for boys in general, but I think that is especially true for young black boys more so than other groups of boys of color. And I think that we really have to increase our focus on access for all the people who need care. Thank you. Hi, Nima Sheth here, senior medical advisor under Center for Mental Health Services working with Dr. Everett. Thank you so much. This is such a rich panel. And as a mother of two young boys, I'm taking lots of notes for the years to come. So my question was around compounding risk factors and structural injustices. So I'm wondering if with Ural's families and the youth that you're seeing, the kind of compounding structural racism and historical traumas that we are seeing now, things like the school to prison pipeline, the prison industrial complex, as well as what we're seeing internationally, right? We're in the middle of two genocides in which many youth have stood up, Sudan, Gaza, amongst I'm sure others. And how do you talk about those issues when they come up in clinic and they're compounding other stressors? Because our youth are upset about this. They're standing up, they're saying something, they're protesting, they're out there. And so how do you address that with the families? And how does that parlay into the other issues that are going on? It's like, this is something I always struggle with. So what I can just kind of talk about some of the work that we're doing within my own organization and nationally. There's a lot of work that we're doing in the American Academy of Child and Adolescent Psychiatry about how we talk about racism along with other organizations. I think first of all, it's important to recognize racism as a social determinant of health. And the assessment for youth of color who come into our practice include those as questions about their experiences. Because interestingly, there will be kids who come in who will say to you that they don't think that's affected them. But one, you have to ask the questions and then you have to get comfortable with listening to the answers. Because that's where I find most people fail. So a youngster might say, I think this, you have experienced racism, this happened to me. And the response of the provider is, are you sure that's the reason that, that's the wrong answer, the wrong question. And so I think that it has to be part of your assessment and your interaction with any family. This whole concept of colorblindness, I think people need to put that aside. It's not real. And it's also disrespectful because you don't validate who that person is in front of you. And we have to talk about those issues. And we have to understand them. And so I think that it starts with our own education about what structural racism is. And I think people tend to think it's a personal thing. Like I like black people just fine. I like Latino people just fine. It's not about that. It's about how these things impact your life on a daily basis. And so it is understanding it for yourself, your own education, your own willingness to be humble and ask questions, understanding how those impact your patient's presentation, which means that you have to ask those questions, which is a routine part of our assessment. Have you experienced incidents that you believe was related to your race? What is your community like? What is your school like? Those are all the things that we need to know to understand our patients. And then we have to be able to respond in a way that supports them. One of the things I've been really excited about lately is a lot of the focus on a lot of work that's focused on racial socialization as an intervention to support youth mental health. And it was an intervention that was developed by Howard Stevenson and his group, the University of Pennsylvania. And it includes elements like using cognitive behavioral therapy techniques to manage our own emotional responses to racialized events like microaggressions, right? What happens when you experience microaggression? Well, in my experience, I get upset. My heart rate increases. I have to, I perseverate about it. Not so much anymore because it happens so many times I become desensitized. But the reality is that it affects you physically and psychologically when you have those experiences. And there are actually interventions that you can use with children and families that help racial socialization, helps parents learn how to educate their kids about responding to racialized events and protecting themselves. So I think there are things that we can integrate into our interventions that are helpful. But it really starts with recognizing that this is not about how you feel about DEI. It's not about the policies in the state of Florida about DEI. It is really about understanding for that young person and their family how these experiences affect them on a day-to-day basis and how they play out. I think for me, I teach a lot of residents and medical students and trainees and not just in pediatrics and family medicine and psychiatry, everybody rotates through. And I think touching on that cultural humility piece that we talked about earlier is so important, right? Because I think sometimes the impression is, oh, clearly I can talk to someone about their systemic racism experiences and things like that because I'm black, right? But I don't pretend to know what it's like for my kids that have been held in immigration detention centers, but I leave space for them to share that with me. Or same with my patients that identify as trans females or trans females of color, right? Like we understand that they definitely experience other discriminations that I cannot personally speak to as a cisgender woman, right? But I save and I leave space for them to share. And I recognize the privilege that I stand on, though I have my own hardship, it is not the same as every other black child that I see, I leave that space. So we do not have to have had the exact same experiences to be able to create that option, that opportunity for our kids to share with us their experiences that are impacting their lives, right? Just like I don't have to have lived through your trauma, right, we all have our own experiences. I think when we're teaching people and we're talking about it, understanding that and recognizing it, you don't have to know what that lived experience looks like, right? And it is different for each of us. But giving people the opportunity, if they want to share and they want to express how this is impacting their health, their mental health, give them that opportunity. Do not minimize their experience, let them share that with you and provide support and empathy. And I think the training of the sort of new group of folks who are coming through as clinicians, I think is really, really important. I think we want to do everything we can to help them to know that when you walk into a room, a patient doesn't owe you their comfort and don't expect them to automatically feel comfortable. I think it's important to anticipate that they maybe had experiences in the past that weren't completely positive. Ask them about their previous experiences. Tell them why you ask certain questions. I think sometimes we go in and we just start barreling off questions and we don't really sort of appreciate what was their experience before, right? Did they have an experience where they felt like their trust was, that their confidentiality wasn't respected or that they were judged in some kind of way? And so I think it's important to never make assumptions. I go in, I say, listen, you don't know me, I don't know you, I just want to be clear that this is a safe space. There's no right or wrong answer to anything I ask you. It just is what it is. And I ask certain questions because the answers help me take better care of you. If it's not gonna help, I don't ask, right? And when you're talking to patients, we talked a little bit about this before, I always tell providers, especially when you meet somebody for the first time, and particularly somebody of color, I would sort of anticipate that they could have had maybe a negative experience in the past or never had the experience of somebody truly asking them about themselves and particularly sensitive issues of maybe gender identity or sexual orientation. Anticipate that this could be difficult for them. Don't turn your back. Do not take your hands off that keyboard, right? Make eye contact, right? Show them that you are present, right? So that they can sort of experience that this might be a different situation. When you start asking those questions, they have like 30 seconds where they're sort of deciding whether or not they're gonna confide in you. And so much of what happened to them in the past is part of that calculus in that 30 seconds, right? And so if you're not fully engaged, if you're not sort of anticipating that the previous interactions may not have been the same, then you are gonna push the needle in the direction of them not really confiding. And if they don't confide in you, it's really difficult to really connect with them in a way that helps you to know that they're struggling mental health wise, to know that they're possibly suicidal or struggling with depression and dealing with the fallout maybe of coming out. You're not gonna be able to do in that once a year visit, that one shot that you have, you have to do everything you can to push the needle in the direction where folks can feel comfortable and see that this might be a different experience for them. Just one other thing I wanted to mention, on the questions around structural racism and discrimination of any marginalized vulnerable population is we talk about trauma and we talk about it as if it is an event. And one of the differences with racialized trauma or the traumas that marginalized populations experience is it's not just one event and it is ongoing. I mean, the microaggressions activate it and it's not just what you experience, it is what you see happening to other people that are like you around you. And so that frequently when we assess trauma, we're asking about that event or a thing that we can attach that episode to, but for people who are experiencing that kind of trauma, it's ongoing, it's repetitive, it's daily and it's really stressful on a day-to-day basis. And for reasons like that, it's important in our interactions to always ask about it and to always give people the space to share those experiences that happen on a pretty regular basis. And I just wanted to add to make sure we work with our trainees to always say that they have to get away from the what's wrong with you kind of thing and move towards the what happened to you. And I think the more we train clinicians to kind of think about what can be behind what you're seeing in front of you in those clinical spaces, I think that sort of always moves you in the direction of doing better. Good morning. Thank you so much for this online panel and discussion. Omar Escontrias, Senior Vice President for Equity Research and Programs at the National Health Council. So I wanna push the conversation a little bit further. So you talked about how important it is to deliver care, competent care, humility care, but there are 516 anti-LGBTQ legislation in our country since June 7th. So as we have this discussion and talk about how we deliver care to youth, I also want to explore the conversation with all of you is how do you deal with that? Because these are the realities, these are people making decisions. So it does impact not only your work directly as a clinician, but also the delivery of care that you provide for marginalized and vulnerable communities. So can you talk a little bit about that? Because I think there's a toll, not only on you, but also on the care that you provide. I'll start us off with that. So I practice in Charlotte, North Carolina. I'm from New York originally, but I'm in the South at the moment, right? You just had to put that in. Yes, I do, that's very understandable. I'm not from, but you know, anyway, I am in Charlotte, I love it. But yes, it's last year for us. So we are one of those states that have, since last summer, passed some anti-gender-affirming care legislation for youth. And let me say first and foremost, I do not believe politicians have any place in healthcare. Zero. They do not have the right, the ability, the knowledge to tell me how to do my job and work with my families. My parents get to decide what care their child needs. What I always remind people when it comes to gender-affirming care as a physician, my job is not to make anyone go down any road they don't want to go down. Parents have to decide if they are willing to take that step or not. And not all families are ready to take that step. And that is okay, right? We are not there to force anyone to do anything that they are not ready to do for and with their child. That is not how that works, okay? But again, politicians do not belong in healthcare, whether we're talking gender-affirming care, reproductive care, whatever, right? And here we find ourselves in a place where a small but loud contingency in this country are definitely dictating what people can access. And then not only are they impacting marginalized youth, right, so if you look at adolescents, only 1.4, 1.5% of them identify as trans or gender-diverse. That is a tiny, tiny, microscopic percentage of youth, right? And yet here we are bullying and targeting them, right? And then on top of that, I'm gonna use the great state of North Carolina for the moment, so not only did they limit access to care, they then put and snuck into that bill that they passed that not only can I not initiate anybody new after August 1st, so they grandfathered in people who started before, but I can't initiate new care. But they also, if you have Medicaid, will not pay for said care. So it does not matter if your child has been physically and emotionally stable, living their best life as the person they identify as on their medicine for the last two years, they no longer want to cover it. So you're attacking a already marginalized group and then even further, going after people more, right? And so I think it is critical that we continue to lobby on behalf of those that do not have a voice. Children do not vote and they are dependent on us to stand up for them. I will also say it is sometimes difficult to advocate when you live in certain states because depending on who you work for and who you work with, there are rules to how loud you can be. So in 2021, 2022, I was allowed to be as loud as I wanted to be. Talk about all the lovely care I did. And then in 2023, with all the bomb threats and things occurring at Children's Hospital, my administration felt some sort of way and did not want us to be as loud as we were before. And that then impacted how much I could advocate on behalf of the kids and the families that I serve. And that was hard. And I don't know the right way to navigate. We navigated as best we could. We're still trying to support our families as best as we can. But it is really upsetting to be in that situation. And I essentially share my family's pain. I give them the space to share their concerns and their worries and their fears. And I sit there and mourn with them, you know? And I try my best to get them where they need to be. If there's someone who has not initiated care since that law passed, but they're seeking care, where can I send you? Do I send you up to my colleagues in Philly and Virginia and DC and things like that? And how can we get you there? What are the grants that will fund your transportation and that kind of stuff? But it is a difficult journey. It's particularly frustrating. It has this really egregious, brutal movement. Has so many chilling effects, so many layers of chilling effects. You know, all of us, I think every major children's hospital that has anything to do with gender affirming care has had like literal bomb threats. And people like, I have colleagues who, you know, had their first conversation in their lives with an FBI agent. And that just, you know, to me is just stunning that we're at this place that this is happening. You know, it's such a personal decision. It's a parent's decision. It's a family's decision. Politicians should have absolutely nothing to do with this. And, you know, that chilling effect in terms of, you know, the hospitals, you know, who are now sort of grappling with the security issues that are presented by doing, you know, doing just medical care, like essential medical care for people, life-saving medical care for some youth, is just, you know, it's stunning. I mean, part of how you reach people who need you is to talk about what you're doing. And now this has impacted people's ability to feel comfortable, right? Because if I talk about what I'm doing, I put a target on myself, right? If you have trainees who are thinking about going into this field, which we need, you know, tremendously, and they're worried about what impact this is gonna have on them, you know, maybe they don't choose to go into this field where we really need them. It's just, you know, I think anybody in this field feels like rage about this. Yeah, and we do know that since all this legislation started, the mental health of LGBTQIA youth is worse, okay? They've been impacted by it. You know, it's a tragedy, and we have to do something about it. And, you know, I do, you know, I look at the impacts because I think they're bigger than most people realize. So, for example, you know, we, you know, in addition to the fact that our clinicians have been under attack, within these communities of providers who have cared for, you know, transgender youth and others, there are people within those communities that turn on the people they've been working with for years. I mean, it's a really painful thing to watch, but there's also been a level of intrusion into the doctor-patient relationship that I think we all need to pay attention to. You know, we get calls from congressional people wanting to know if our training program has a mandatory rotation for LGBTQ youth because it could impact our GME funding. So the reach is really quite broad. That being said, I think we need to, there are some tools that we have that we need to exercise, and advocacy is one of them. We need to be talking to the people whose salaries we support by allowing them to be in elected office. We need to educate them about what the issues are because I've been struck by how often you talk to our representatives, and they actually don't know about these issues, and that we're not in there having these conversations. And I think some of our actions exacerbate our problems. So for example, when we decide we're not gonna hold a national conference in a place where our colleagues are struggling with these issues, we deprive them of the support of their professional organizations. We need to be in those places where people don't wanna be. Like, we need to be supporting you, whether we live in New York or Pennsylvania, where I live, we need to be where you are supporting the work that you do. But I do think that this is, I think we're all stunned that all of this has happened. Like, you could not have told me 10 years ago that this could happen, but here we are. And I know that everybody doesn't feel comfortable going to Capitol Hill, but I have a cell phone. And I noticed that when I call my local representative's office, somebody actually answers the phone, or they call me back. And I think that we are gonna have to take more of an advocacy position, and that we're gonna have to be more vocal, and say to young people, advocacy actually is protective of your mental health. Political action can be protective of your mental health. So I think that, you know, I sit around and I ponder about how upset I am about it. And then, that doesn't usually help me. I mean, it probably helps somebody. Well, actually, probably it doesn't help anyone. However, for me, I feel like there has to be some action that we can take to do something. and so I think we need to pay attention to the policies. We need to be aware of what's happening as much as we can because people are busy and we need to do what we can which is find a way and it's not always safe to speak out but find a way that you can safely speak about these issues and get people to act on your behalf and hold your professional organizations accountable okay because they're also your advocates. Yes I'll echo that sentiment so I will say living somewhere where it might not be as safe for me to speak out the way I used to speaking through like our North Carolina chapter the AAP and they're definitely OB-GYN chapters and groups that are also there's a lawsuit the ACLU is involved I've reached out behind the scenes and done many things in that respect just not being able to be as physically verbal and out as I was before. So in response to your answer just listening to all the answers one thing I just wanted to underscore which really caught my attention was advocacy could be protective of your mental health and I think that when you were particularly how does this how does this legislation impact young people but to know and to be able to say advocacy can be protective of your mental health taking action can be protective so I really appreciate that. Good morning my name is Kimmery Hughes I'm with the DC Department of Employment Services Office of Youth Program and I'm glad you asked that question because one of the things I was thinking about is this hostile political environment that exists right now towards the communities all across the board how would a young people expressing themselves what are their sentiments because I'm often I'm often interested in the voices of the young people one how they feel what they're saying but more important figuring out how to help to elevate their voices more in this advocacy realm and a political realm so what are you hearing from young people about the impact of these legislative initiatives and just the hostile environment that exists from the political realm that are attacking them. You know I just wanted to comment and I know you helped a lot to say that. Well I do want to hear what you have to say about that. You know Anita you may remember at the SAMHSA meeting a few weeks ago there was a young man who who I met when he was 17 he was testifying before the Senate about a mental health program he had started in his small county but I heard his story for the first time at the SAMHSA meeting and he's he's an advocate he is involved with a peer advocacy program through the National Alliance of the Mentally Ill but I heard him talk about the experience of being a gay male coming to understand that about himself experiencing all the humiliation and shame that comes with feeling like you disappointed your family and being suicidal and now as a college student he talked about for the first time in his life being able to say he's proud of himself and that was a very painful thing to hear but in any event that youngster actually experiences every day all of this negativity around who he is and so young people are expressing that they were getting to a point where being able to feel okay about yourself was kind of the norm if you were a kid who was struggling with these issues and they will tell you the message now is loud and clear that you're not okay that you don't deserve to be here that's what families are hearing and so that is what I'm hearing from young people and I agree with you so much it's just it's heartbreaking honestly and I think that you know I have a lot of young people who may not be very much connected to politics but what the way I think they're impacted where I know they're impacted is that our political leaders you know you know sort of attacking this entire community the way that they are filters into the community right and it emboldens people who already you know sort of had this feeling and maybe some people who who maybe weren't so inclined right now have politicians with a big bullhorn you know sort of saying that this is the approach that we should be taking and this is what our kids experience on a daily basis right you know I have no I've you know I have interactions with people that I've worked with for 20 years who you know I've heard say things that I just feel like oh my god and I say to myself you know I've known them for 20 years I've never heard that like it's especially in a work environment you know what is different now is the politics right and I really have to believe that the two are connected right and that this kind of stuff would never be acceptable I would think 10 or 15 years ago and I think we're in such a different place right now where people really feel completely emboldened to say something that could be incredibly hurtful to another human being let alone a young person and it's think we're in a really bad place for that and you know the and social media to unfortunately gives them lots of different snippets of people you know on a big stage you know saying that their life doesn't have value and you know that that they have to change who they are to be accepted and that's just it's it's incredibly frustrating I will say at a lot of my visits at my gender health clinic specifically I have a conversation about politics and advocacy probably 60% of the time and most of my parents are talking about how they continue to lobby and fight for their kids right because and again I always make sure people understand when you look at the patients I serve in my gender health program it is a skewed population because the people that come here the parents that come here with their kids are at least willing to have this conversation and accept their child for who they are right so my families that are 100% against it are not coming to the gender-affirming clinic right so it is a skewed sampling but those parents especially being in North Carolina are definitely utilizing their connections and their people and organizations like PFLAG and we have some local LGBTQ plus organizations that they're utilizing to continue to advocate Lord knows for a time I slipped some numbers to the ACLU and some other places and things like that but we have these conversations and it's not just with my minor patients my young adults who legally are allowed to continue or worried about things that may change right and so I think making sure they are registered to vote the understanding importance of their vote and many of them do and we have these conversations in the middle of their medical appointment so that they know like they are the future my hope is that we can phase out all these lovely people still in leadership at the moment making rules and the great irony of it is and it's with all things like medical that's politicized right when it impacts those politicians personally they clearly get the help they need for their families and their people and they go around it the laws that they're making to you know monitor and limit what other people have access to but they get what they need and so I think I've had thankfully some positive experiences and in talking to my families have allowed me to to personally deal with the overwhelming sadness like I was so angry last year I'm still angry but but having those kind of conversations with families about the things that they are doing and continuing to do for their child is helpful right and making sure they know how they can advocate on behalf of their kids so so dr. Dixon you mentioned a statement that you in a sense see a skewed population so by the time they come to your clinic they're kind of convinced in the direction that they want to go and maybe if each of you could speak on so what about that percentage who hasn't gotten to that point yet they're not politicians they're not clinicians but they are not the skewed communities that you're seeing how what do you say to them in this whole conversation about a young person of color who's identifying as LGBTQIA plus with some mental health issues what type of conversations do you have with those individuals so a lot of the work that and I'm sure this is true for all of us a lot of the work that we're doing is actually more prevention focused because I heard both of you talk about that which was inspiring and it's happening in the primary care setting sub-specialty care is happening in schools and communities and so you have an opportunity to do more education about those topics so you can introduce you know education there's resources available through our national organizations through the American Academy of Child and Adolescent Psychiatry American Academy of Pediatrics ASAM adolescence what is it it's a it's the Sam the Sam okay that's right because there are two ASAMs but basically there are resources available you know that are public facing that you could have access to for education but I think that education and communities we do education and community churches recreation centers daycare centers schools primary care those are opportunities to educate you know providers and families about about these issues more proactively so I'll see so in my role I serve as half primary care I have specialty care and so I see kids in a gender-affirming clinic but I also take care of many LGBT plus kids in my primary care setting and like I said some of those kids are out to their family some are not and so we have those conversations behind closed doors and how I can best support them in their journey and their readiness to share with their parents and if they're not then we don't but I also you know kind of gently guide and encourage parents to continue to get the support and education they need so they can continue to support their kids and that and like I said I meet kids in the gender-affirming clinic to whose parents aren't ready for meds and that's fine right they're at least willing to come have a conversation about their child identifying differently and what that may mean and what options are available and I make sure they understand not everybody not every gender diverse kid is looking for hormones right like not everybody wants to have this procedure and this surgery is no one right way to be trans right it looks different for different people but my ability to connect to those families on the primary care side depends on that patient and their readiness to have those conversations with their family and some are not some without a doubt will tell me if they were to come out there were you know they would be homeless they were their family without a doubt will not and again I'm not here to out them that's not what I do I'm here to support them make sure they get the help they need and support to help them along this journey to build that confidence and that acceptance of their identity to understand that they matter they deserve to be here regardless of what it is your family may or may not be saying right you deserve the right to be who you are and to be here and I'm here to support you in that journey you know for us I think Christopher's we are you know I think the way that we provide safe space for LGBT youth in terms of mental health and to identify those patients maybe who are suffering in silence which we know a lot of them do we have to have this you know sort of dual method of making sure that all of our health maintenance appointments include standard health sexual health screening because so many unfortunately you know pediatric programs and adolescent programs see the patient but not every single patient gets asked those really important questions right are you attracted to men women or both you know how do you see how do you identify your gender preferred pronouns sexual orientation when those questions are not asked you are not leaving space for that young person if they feel comfortable and we've hopefully have done the work to create that safe space for us to confide for them to confide we have lots of folks who are doing mental health screening with a PHQ 9a for the standard screening for depression and so sometimes you have that on the chart and there's a concern about depression sometimes you know because you don't have the sexual health piece you don't really understand just how vulnerable this young person really is right because if you have identified that they have depression and you know obviously need to have an actionable plan to deal with that but you haven't identified this other piece that really you know heightens the the level of risk for that patient we've done harm as far as I'm concerned and so it's really important that you know we push for every young patient when I think of I have young patients who come to see us and you know the juxtaposition like you'll have two patients they have almost exactly the same story one is getting care at St. Christopher's so has a standard approach to this and gets identified maybe is connected to a prep program is getting seen by a behavioral health consultant every time they come in because behavioral health needs have been identified and then another patient same age same catchment area almost indistinguishable risk factors and they are coming to me as a positive patient with a myriad of mental health concerns that present huge barriers to HIV care that you know they are here without any intervention ever happening before you know this result of this positive test occurs and so I think it's just really important it shouldn't be that where you get care almost as a risk factor right you want to make sure that your institution is not contributing to the problem or you know blatantly not taking the opportunities that we have to identify young people who need our help the most thank you I think we have one last question take one last audience question as we're entering the last three minutes time has flown it's been an hour and a half believe it or not and I've thoroughly enjoyed the conversation good morning my name is Carmen Thornton and I am the chief of workforce development and health equity at the American Academy of Child and Adolescent Psychiatry and I just I know we're running really short on time but I just really wanted to just revisit quickly the piece around cultural humility and how it is so incredibly important for providers to practice that and as a person who comes from a marginalized community herself I have been in a doctor's office more than once and have experienced a really harsh microaggression right and so I can tell you that as a person who's been in that kind of experience it can impact your willingness and want to seek care and so at the end of the day it really is about addressing or working through this cultural humility piece I mean I think that's a big piece of it particularly with this community and so I'm just wondering if you have any thoughts around training you know for these people who are going through these training programs and in residency and fellowship but also for the people who are providers you know what type of accountability you talked about your institution you know and and they're being you know forefront coming into a physician's office and saying before the visit even starts you know this is a safe space for you to tell me about who you are just just questions around do you have any thoughts or comments around you know the training aspect of it or even the accountability aspect of it so I would say so this is part of the importance of if you look at analyzing when you think of DEI initiatives and things like that actually looking at the data and so I will say this various institution institution what is being done what's being looked at right like I think we encourage trainees to have an aspect of cultural humility what we're often forgetting is we also need to be continually training and educating our colleagues and people that trained before us that have been practicing for years they to benefit from these educational experiences in these conversations and so I don't think that always happens I can speak for at my organization I'm the vice chair of DEI in our Children's Hospital and so we make a concerted effort to continue to have they're often case-based discussions about health equity and disparities well we have small group discussions and it's well received by some and I'm sure there are others that wouldn't say it to my face but are like why are we still having these conversations but I make sure again when I present these kind of conversations these lectures these experiences it's about the patient care we provide right like we had a lot of courageous conversations in 2020 when George Floyd happened and everybody's taking a knee and I made sure at our organization we talked about the fact I was like let's not just point the finger over there at the legal system the health care system right systemic racism is live in a well you know what I mean right like it's live and well it's it's here and it's still present and I make sure pediatricians right we think we are by far we think we're the nicest of all doctors right but I also had to show them data right we know even within pediatrics we are less likely to get pain medicine to children of color when they present with the same bone fracture than a white child right so don't sit here and pretend it is not within our house and how are we gonna continue to do the work to take care of our children and our family so that's kind of what I couch those conversations on some people are highly engaged and appreciate it and share that and like I said I'm sure I have other colleagues that you know don't feel the same but it is just as important for them and we're gonna keep having these conversations because it is necessary to move our movement forward right so that we can provide equitable care but we have a ways to go I think for the community for the communities we serve I think it's important to ask those questions directly right don't skirt the issue make sure that you're asking the community specifically about their perceptions of our cultural competency right I think it's important for trainees and especially I think particularly for trainees we get we have lots of folks feel that because they're they're younger that they're more open but it's I find that the exact opposite is true and that they need a lot of training to start off on the right foot and so you know I feel like I can't stress enough the training is incredibly important so that you know we are doing everything we can to create that safe space I think you captured it we're a work in progress but I think it's important to give that feedback if you have a bad experience that you feel within health care you had you want to share that whether it's through a survey whether it's through a patient navigator or customer service like you want to make sure you share that and that is okay because we will not continue to get better if no one shares what those experiences look like and what problems they may have had in those visits you know and having staff I'm sorry having staff that reflects the community that you serve is incredibly important and having that reflection in all levels of your staff I have young people like which you wouldn't imagine would comment on that who talk about the fact that coming into our program is the first time they saw providers of color right in their lives and there's some of them are 17 or 18 years old and so I you know and particularly you know to have LGBT members of our staff is incredibly important to this incredibly vulnerable group just their presence right has everybody taken in and trusted a little bit more because they are there period and data supports that health care outcomes are much improved when there is some reflection in the staff of the community that you serve and I just want to add one and that's actually I'm glad you highlighted that that's what I wanted to highlight but I guess one other thing is that I think for those of us who have been fortunate enough to assume leadership positions as taxing as it is we have to be able to speak up and demonstrate the kind of behavior we want to see it is taxing and I think it's important that people appreciate that I think sometimes people think oh they just like to be outspoken no act well maybe I do like that however the reality is that there are times it's taxing okay because you know some of the painful episodes that others are experiencing I'm witnessing those and having the same experience and so I do think it's incumbent upon us to be able to speak out as much as we can you know it's but it's it's a tax you know and but I think it's important so what is the younger generation doing here that so I'd really love to thank our phenomenal phenomenal panelists dr. Benton dr. Dixon and dr. Laguerre Frederick thank you so much in closing I just wanted to share a quote from Audrey Lorde writers civil rights activists who essentially dedicated her life to fighting against the injustices of homophobia classism sexism and racism she said we must commit ourselves to a future that can include each other and we must work toward the future with the strength of our individual identities we must allow each other our differences as we recognize our sameness so again thank you all for joining us and before we fully close out I'd like to personally recognize each of our panelists just with a small token of appreciation so if you can come let's see we'll start with so dr. Benton and for each of you with our greatest appreciation we present this plaque to you for your commitment to achieving mental health equity particularly for our youth of color thank you so much dr. Dr. Dixon thank you so much and thanks to all of you who came in person and all of you who are online thank you so much just such an important conversation love that we kicked off our more equity and mental health initiatives with this conversation more to come please check our website psychiatry org we have a number of things happening all summer into the fall to really celebrate young people of color more education more awareness around the inequities that they face thank you so much

LGBTQIA+ youth

mental health crisis

youth of color

mental health equity

systemic obstacles

cultural pressures

safe spaces

social media impact

advocacy

cultural humility

anti-LGBTQIA+ legislation

racial justice

inclusive environments