I am Murat Altunay. I am the director of LGBT mental health services at the Cleveland Clinic, and today I'm very happy to have my good friends and colleagues here. We have Dr. Cecilia Ferrando, who is a trained OBGYN specialized in pelvic floor reconstruction, who is in charge of our surgical team in our transgender medicine program. We have Dr. Jason Lambrisi, a child psychiatrist who runs the PEATS psych program, and we have Dr. Henry Eng, who is an internal medicine specialist and also head of our transgender medical program. Here are our disclosures, and today we will be talking about our team where we take care of transgender patients. We will start with my talk, where I will give you a lot of background information and overview, and then we will talk about surgical procedures, internal medicine, and child psychiatry in taking care of transgender medicine. All right, so as I said, I will start with talking about... Oh, sure. Is this better? Okay. So good? Okay. Okay, as I mentioned, I will give you a lot of overview about LGBT mental health, understanding gender development and transgender identity, and also talk about the role of a psychiatrist in a comprehensive multidisciplinary team. So why are we talking about LGBT mental health? Because LGBT people are already a part of our patient care system, and we have to provide equal care for all of our patients, prevent discrimination, and as psychiatrists, we really do need to understand the depth and multilayers of patients who come to see us, and if we don't do that, we cannot provide good care. It's a public health issue, not caring and not understanding LGBT populations, and also we need to meet the professionalism standards. All right, so there's a long history of LGBT disparities, and when patients come to see us, they actually come with years of history of discrimination and difficulties in access to care, so we also need to understand that when we start seeing patients. Historically, LGBT people have less access to insurance and health care services, which is causing delay and refusal of care, mistreatment, and LGBT populations historically were also not included in outreach programs, education, and research. Again, as a group, this population has higher rates of smoking, alcohol, and substance use, and also at a higher risk for mood and anxiety disorders. There's a reason for that, because historically, again, health care providers didn't feel comfortable seeing LGBT people. If we look at the data from the early 1990s here, in a national survey, 35% of physicians said that they did not feel comfortable seeing homosexual people. One-third of them said that homosexuality was a threat to the society. Again, another survey in the early 1990s done on internists, family practitioners, general practitioners, and OBGYNs said that a homosexual relationship between two men is just simply wrong. In psychiatry, we also have a bad history in terms of homosexuality being in the DSM as a mental illness until 1974, and conversion therapy is still legal in a lot of states. And because of all of these reasons, LGBT people struggle with self-esteem and social relationship issues, employment issues, access to health care, and poor general health and mental health. Things didn't change much in the early 2000s. When we look at the AMA GLMA Physician Survey here, physicians do not feel comfortable seeing patients who are in the sexual and gender minority, and especially if you look at the section right here, MTF and FDM. So transgender people, especially, they don't feel comfortable seeing. There's an Italian study that looked at the perceptions of health care providers towards sexual and gender minorities, and as we can see here, there's a lot of homophobia or transphobia in the health care business. So men were found to be more transphobic compared to women. In terms of perceived transphobia, female transgender people were targeted more than male. Religious fundamentalism was associated with transphobia, but there was no correlation between age, educational level, or economic status. Transgender people also are subject to a lot of different kinds of barriers before actually being able to have access to care. It could be on an individual level, and in terms of individual level, it could be the patient themselves in terms of age, socioeconomic status, perception of rejection, perception of lack of rights. It could be on the health care level, health care professional level, which would be a lack of training or lack of skills, organizational level, lack of information of resources, community level, taboo against transgenderism, and also on a political level, insufficient legal standards. There is a reason why health care providers don't feel comfortable around sexual and gender minorities, because in medical school we are taught very little of LGBT health, let alone LGBT mental health. The average time allocated to LGBT health in four years of medical school was around three hours and 26 minutes in the in the 90s, and later it was reduced to two and a half hours. In Cleveland, at the Cleveland Clinic, we try to increase it as much as we can. I think, again, I would probably say it's not much better than this, to be perfectly honest. A survey done in 2011 in terms of the time allocated to LGBT health in the osteopathic schools was around five hours in four years of medical school. And it's not rocket science. When medical students are taught LGBT health, they become better history takers, and they are more inclusive and understanding of LGBT health. We talked about this a little bit, so there's not enough research outreach programs for LGBT people, which ends with poor mental and physical health. And as a result, you know, people don't have access to care. And LGBT people do report this as well. Again, historically, if we look at the National Transgender Discrimination Survey in 2011, 19% of the transgender people said that they were refused medical care because of their identity. 50% of them said that they actually had to teach their providers about transgender health. And many people postponed medical care because of discrimination or simply because they were not able to afford the treatment. Another survey from 2013, again, the same thing. They felt like they received substandard care, verbal abuse, forced care, such as forced psych admissions and unnecessary physical examinations, insensitivity, and displays of discomfort from health care providers. So we'll talk a little bit about gender identity development, because again, as psychiatrists, when we evaluate gender dysphoria and the development of an expression of gender, we need to have a better understanding of how gender really develops over time. So biologically, there are two key states where gender development is important. One is the intrauterine embryonic development, and then the second one will be the puberty. So within the intrauterine phase, there is the prehormonal phase, where this is orchestrated by genetic factors such as SORI genes, etc. And then the prenatal gonads and brain, by the help of hormones, cause sexual differentiation and development of the external genitalia. And if there are variations in this state, we talk about differences in sexual development, such as ambiguous genitalia and intersex conditions. So that's the intrauterine part, which was an important phase. The second development, in terms of sexual identity, is puberty, where sex hormone related brain organization happens during puberty. And if, again, there are variations in terms of this organization change in the brain, then we talk about gender incongruence and sexual differentiation hypothesis. So what do we mean by sexual differentiation hypothesis? So when we look at neuroimaging studies, we realize that there are certain variations in the brain's functional and physical structure in gender non-conforming people. So the postmortem studies that looked at structure showed that there was some structural resemblances between the transgender person and the gender identity that they identified with. There were also some volumetric brain changes, such as gray matter volume or cortical thickness. Again, even before starting HRT, there were resemblances between the transgender person and the gender that they identified with. And in terms of functional connectivity studies, again, in terms of the connectivity and function, the brain resembles the gender that the person identifies with, which is, I think, fascinating. Transgender identity. So what is a transgender identity? So in order to understand this, I think we need to talk about a couple of other descriptors here that we use frequently. So gender non-conforming stands for people who simply don't identify with the gender expression norms that they were assigned with at birth. We usually use this term for youth when, you know, people who are younger than 18 because their identity is still developing. And instead of using the terms transgender youth or transgender child, we use a gender non-conforming child. Transgender means, you know, when people who don't identify with the assigned gender at birth, we use the term transgender. And cisgender stands for a person who identifies with the gender they were assigned with at birth. Again, these are somewhat simplistic descriptors of gender identity, but we primarily divided into binary and non-binary transgender identity. Binary would be an identification with male or female transgender identity, and non-binary it could be anywhere from agender, non-gender, genderqueer, genderfluid, and there are so many different kinds of descriptors in terms of describing the non-binary gender. And of course, on top of all of that, transgender people also have to explore their sexual orientation, which is independent from their gender identity. So what is gender dysphoria? Which, again, as psychiatrists, this is what we're going to be dealing with in our office when the patients come and see us. So let's look at the DSM description. When somebody's incongruent gender identity creates a functional, social, and occupational problem, we coined the term gender dysphoria. So not only the person has to experience some incongruence between the identified gender and the gender at birth, they have to have some level of dysfunction from the distress stemming from this mismatch. It came a long way since the first term was coined in 1974. It entered DSM-3 as transsexualism. We normally don't use that term anymore. In DSM-4, they tried to improve this by calling it gender identity disorder, but then that kind of insinuated that the person had a personality disorder or identity problem, so that also didn't really quite fit. And most recently, in DSM-5, now we use the term gender dysphoria, which doesn't necessarily target the person's identity, but talks about the distress that they're in. And as psychiatrists, that's essentially what we're actually helping them with, with the distress from the gender dysphoria. In order to treat gender dysphoria, of course, you know, from a psychiatric standpoint, we have to help them, but we also have to help them from gender-affirming treatments, which could be anywhere from hormone treatment to surgical care, which we're going to talk about in detail today. A lot of psychiatrists, even people who are specialized in this area, can actually confuse major depressive disorder with gender dysphoria, considering there are a lot of overlapping symptoms, such as dysphoric mood and lower functionality in terms of everyday life. And there's a historical understanding that transgender people or LGBT people in general have high rates of mood and anxiety, but when you actually look at the data, you realize that earlier in their transition period, a lot of transgender people are misdiagnosed as depressed or anxious, where we are actually dealing with gender dysphoria, and all of these symptoms actually get better as they go through their medical and surgical gender-affirming treatments, which was shown in a study done in 2014. So essentially, when somebody comes with gender-related issues, instead of diagnosing them with major depressive disorder right away, we need to understand that some of that dysphoria and anxiety could be coming from gender dysphoria, and we cannot really fully diagnose somebody with major depressive disorder before ruling out gender dysphoria. So what do we do as psychiatrists? So number one, and again I think this is going to be a recurring theme in this talk, we cannot really do this alone. So one of the reasons why we have the multidisciplinary team is psychiatry really is one of the key players in a multidisciplinary team in transgender medicine, and who are some of the other key players here? So we have primary care, we have surgical care, we have legal, bioethics, social workers, and in our clinic we also have peace psychiatry, who is the mirror image of what we do in the adult program. And as a psychiatrist, in addition to being a key player in helping in diagnosing gender dysphoria, we have a couple of other roles in terms of treating this patient, and I'm going to come to that in a second. And the other thing we need to do as psychiatrists is, in addition to clinically understanding where the patient is, we also have to see all of the other layers that people have in order to have a full understanding of that person, and that's where the term intersectionality comes in. So in addition to their clinical diagnosis and background, we also have to look at their disability, their religion, their ethnicity, their socioeconomic status, and their national heritage, and all that. So gender is just one of the slices of this multi-layered presentation. But if we were to summarize what we do, we diagnose with gender dysphoria and other psychiatric conditions. We counsel the patient and the family in terms of the range of treatment options and their implications. We assess eligibility and readiness for a gender-reforming treatment. If needed, we refer the patients to other medical and surgical colleagues and educate families and other colleagues in terms of gender dysphoria and how to treat transgender people. Again, we're going to get into details of all of this later, but primarily in terms of gender-affirming treatments, we can broadly categorize it to HRT and surgical procedures, and we're going to get into details of that later in the talk today. One problem that we will experience a lot as psychiatrists is to be seen as the gatekeepers, because we are the ones who sometimes say no to gender-affirming letters of recommendation for surgical or hormonal care, and that can become a problem. So my usual go-to in terms of explaining the patients is that it's never a hard no, but today may not be the best day to do this. So we will get you there, but let's do it at your healthiest state and not necessarily when you are facing homelessness or significant mental health crisis. Okay, that's all I have. We're going to move on to Dr. Henry Ng, unless you have any questions, and we're going to have a Q&A at the end also. Thank you. Good morning, everybody. I'm Henry Ng, and I'm the director for the Center for LGBTQ Plus Care and the Transgender Surgery Medicine Program at Cleveland Clinic, and I'm going to talk to you a little bit about some of the medical focus care elements that we have in our program. So the Cleveland Clinic has an overlapping set of services between the Center for LGBTQ Plus Care and the Transgender Surgery Medicine Program with right now 82 caregivers participating in some element of this care. We have a multidisciplinary and interprofessional approach, really trying to support our patients, their families, and then provide navigation as appropriate for them to get through what you can all have seen, what you realize are sometimes challenging situations for them. Combining our teamwork with nursing, our mental health colleagues, as well as our APPs in primary care surgery and the various specialties, as well as our primary care team, we really want to have wraparound care for our patients. And some of the specialties that you see listed are on the right with adolescent medicine, behavioral health, endocrinology, ENT, GI, and many, many others. What we try to do is, you know, shepherd our patients through what can be a very confusing and challenging process. So this is the care path that we've developed over the last several years, has also been refined and changed through our experience with the COVID pandemic and the emergence of telehealth. So when we see our patients or when we first come in contact with them, they will call us and we'll perform an intake registration process with our navigation team members. And then our patients are scheduled for their initial visit with one of the medical team members, including myself, behavioral health services and or surgery at that time. For our patients who are new to the program and system, we'll get a chance to sit down with them at the very first visit, just getting to know them, understanding their lived experience of gender, gender identity, gender expression, disclosures, just seeing where they are at this point and what their needs are, what their goals of care are, and how we can support them. History and physical is done as well as appropriate laboratory studies. And then the referrals will be offered to them. If indicated, if there are complex or challenging situations that arise or clinical conditions or concerns, then we have the opportunity to meet as a multidisciplinary team, and we do that on a quarterly basis and on an ad hoc basis as well. And then hormonal therapy initiation can be started using informed consent model with our medical team caregiver. And then our follow-up care generally for those individuals is quarterly. And we want to check in with them and see how they're doing, how they're progressing on their care, if they're experiencing side effects, any types of concerns, answering all their questions, and again, giving them the support that they and their family may need during this time. And I mentioned medication monitoring is done monthly for the first year, and then we can start to space that out as clinically appropriate. So the topic of gender-affirming hormonal therapy, you might see GHT or GAT abbreviated in some of the literature. The details of this type of care is going to be beyond the scope of today's talk. However, we want to make sure that you're familiar with some of the core elements of this care that you may be able to review any of the references at the end of the slide deck. You know, we do follow evidence-based hormone therapy protocols. Some of these are listed either through WPATH or the Endocrine Society or Transline Prescriber Guidelines. For estrogen-based therapy, we have options with oral estrogen, transdermal patches, and injectable estrogen, either intramuscular or subcutaneous with estradiol, so Pionate or Valerate. We offer our patients antiandrogens with the form of spironolactone and finasteride to help with suppression of testosterone and decreasing some of the unwanted characteristics related to testosterone. And then progesterone is sometimes prescribed also for patients to have additional development of breast tissue supporting their overall gender goals. And these can be with majoxyprogesterone, injectable Depo-Provera, or micronized progesterone. Similarly for testosterone-based therapy, we have a number of options now. These options, though they're varied, their accessibility depends on insurance status for our patients. And most recently, one of the options, transdermal patches, were discontinued by the company that makes this product. So we do have options with oral testosterone, injectable testosterone with Cipionate or Ananthate, as well as testosterone gel and pellet. As you heard from Dr. Altenay, we are guided by the World Professional Association Standards of Care. This is now version 8, which was updated last year in September of 2022. These are the guidelines that exist to help support and optimize well-being, health, and comfort for transgender and gender-diverse people who we serve. We want to really emphasize the importance of our interdisciplinary, interprofessional, multidisciplinary communication. For us on the medical team, our goals are to support and provide information related to the risks and benefits of gender-affirming hormonal therapy. We talk to our patients about the topics among things like thromboembolism, the various metabolic effects, including the obesogenic effects, like hyperlipidemia, hypertension, type 2 diabetes, and the risk for cardiovascular disease. For those taking testosterone, we will follow their blood counts because we wanted to ensure that they did not develop significant secondary polycythemia or unmask medical problems like hypoventilation syndrome or obstructive sleep apnea. We want to address other primary care things, including cancer risks. And also talk about our interactions with other treatments and medications that may impact this community of patients, like HIV, HIV prevention with PrEP, interactions with medications like neuroleptics, and of course support mental health. So thank you for the opportunity to give you a very quick whirlwind of some of the medical information, and I'll hand things off now to Dr. Ferrando to talk about surgical care. Hi. Good morning. I love giving non-surgical, surgical talks. So thanks for being here. I know it's the end of the conference, right? So it's nice to have a little bit of a crowd. But I'm going to provide an overview of gender-affirming surgery, but really focus on that team of people. I'm going to take an approach and speak on how important it is for us to work with our mental health providers and what we're looking for and what our patients are looking for. There's a lot of nuance when it comes to, I think, mental health care when it comes to the perioperative process. And I think these are really important points to talk about, and I hope there are questions about this later. And if there are not, it just means that I did a really good job telling you all the things. So I think there's a common theme right through this entire panel discussion in that the multidisciplinary team approach is really important. As surgeons, we cannot really be very successful in caring for this particular subset of patients without a team that specializes in many disciplines. The team is really responsible for assisting and determining what we call surgical readiness. So there's this concept of, you can be a great candidate for surgery physically, meaning that you meet BMI criteria, perhaps some surgeons request that patients undergo smoking or tobacco cessation if they're smokers, lots of different things that patients need to do in order to get ready. But there's also a mental wellness component that comes with having surgery, and that is a component that I would say that many surgeons aren't probably qualified to assess. Many can have intuition about it, but the real assessment is done at the mental health professional level, whether that be a psychologist, psychiatrist, social worker, and anything in between. And there's also the need to manage medical and psychiatric comorbidities. So I rely heavily on our medical team to optimize our patients medically. So if we have patients who need weight management, endocrinologic optimization, cardiac optimization, pulmonary status, we have our medical team assist us with that. But then when it comes to our psychiatric comorbidities, we really rely on our mental health care team to let us know that our patients have their comorbid conditions under control in such a way that the perioperative process won't add additional stress or bring up certain traumas that can make recovery really, really difficult. And those things are really hard to predict, right? But the added bonus there is also that they're optimized to be able to know what their resource is after surgery. So sometimes you can't control whether, you know, if trauma comes up during the surgical process or if patients have a harder time. And this is often directly correlated with how many social supports they have. But also just making sure patients are ready to be able to access their services is part of readiness also. And that is encompassed in perioperative support and care. For instance, at Cleveland Clinic in our surgical program, as part of our perioperative check list to make sure patients are ready for surgery, we confirm with patients eight weeks before surgery that they have a four-week post-op visit with their mental health care team, meaning that they have a touch point to make sure that any of the stressors that have come up are well managed. And sometimes there are no stressors, and it's more of a social visit. But I would argue that that in itself is also really helpful in a patient's recovery. Everybody likes going to visit their therapist, right, if they have a good relationship with them. So as mentioned, there is this professional society, the World Professional Association for Transgender Health. And they have standards of care that help guide us in the way that we care for patients. And so these standards of care have existed for decades. And I'm seeing people taking pictures of these. Great. Wait for the next slide, because these are old guidelines. But I wanted to just point out what the guidelines actually look like, because there's been a really big shift in how we're caring for patients through these guidelines. So these guidelines were meant to be a framework for us to work from. They're not set in stone. They essentially are a multidisciplinary team of experts got together and said, these are the things that we think patients should have in order to be able to be considered ready for surgery. And that was a formal diagnosis of gender dysphoria. Again, there's been many shifts in the actual diagnosis. There was a huge shift in moving away from the sexual pathologic diagnosis of having a disorder because you're transgender and sort of focusing more on the symptom. This is ever-evolving. At some point, I think it'll formally just be gender non-congruence, I think, is where we're moving towards. There needs to be this good control of the comorbid conditions. Previously, patients have been requested to be on 12 months of continuing hormone therapy for a couple reasons. Physiologically and anatomically, it actually optimizes surgery, things like chest surgery, so breast augmentation. With hormone therapy, you actually get a certain amount of breast tissue that grows with the use of exogenous estrogens in feminized patients. So having patients on 12 months at least optimizes that amount of breast tissue, which gives patients a good sense of how large they may or may not want their breasts with surgery. That's just an example. But then there was also previously this requirement of having somebody have been in this, what we call, it used to be called the real-life experience, but having a lived experience for greater than 12 months as themselves, being able to present publicly as themselves, whether it be at work or with family. And the real goal of this was really to make sure that patients were feeling comfortable in their skin as much as they possibly could, right, before surgery to make sure that doing surgery was the right thing. I'm hearing myself say these things, and you can tell there's sort of this certain amount of, you know, I put on this slide, like gatekeeping with this, right. I'm talking about this and sort of making sure that you are who you are, living as you are before I actually give you a surgery that you are coming in and requesting. So it feels right some of the time when you meet certain patients, and then there are other patients where it feels so wrong to actually be demanding these things of them. And most of that is related to sort of their mental health evolution, right, how well they've been cared for, whether they actually have comorbidities. I think we are wrongfully assigning mental health conditions to transgender and gender diverse individuals. Not everybody actually has mental health comorbidities who, like, identifies as a gender diverse individual. So I think we need to sort of be careful with that. And then previously for certain surgeries, there was a requirement that there be one or two letters of referral from a mental health provider that was, quote, qualified. And does anybody in this room write letters currently for patients? Okay, great. Anybody in this room think they might write letters for patients after spending 90 minutes with my esteemed colleagues? Maybe. Okay, good. The whole actual point is to sort of maybe help you feel empowered to open up your doors to this patient group. Because I will tell you that everything that I've learned, even as a surgeon, other than the actual surgery, has been from my own patients. So as soon as you open up your door to patients, you'll learn a lot from them and hopefully get more comfortable caring for them. So these were the previous guidelines. In the last year, there's been an update from the standards of care that has completely changed the game. There was a lot of complaints from patients, but also just care providers who had significant expertise in this area, that we were really, quote, gatekeeping patients. There was all of a sudden this shift because you have to understand culturally what's changed in the last decade. Ten years ago, many of us, I mean, we used to be an interest group, right? And now we run a huge program where we've seen over 3,000 patients in the last seven years come through. But for a while, there was no insurance coverage for any of these service lines. It wasn't until the Affordable Care Act was put in place that patients actually were starting to get coverage and financial support to have these services. That was only eight, nine years ago. And so there's been this massive shift, and so now we're seeing more and more patients. Patients before were basically getting what we call underground care, right? They were getting care from whoever was willing and able, rather than qualified and part of a community that actually shares ideas and learns from each other and actually has created standards, right? And so these were set in place, but what was starting to happen is I'll tell you as a surgeon what I sometimes get is I get these letters from a patient who essentially has never established rapport with a mental health provider. They show up and they met them once and they paid $75 for a provider to write them a letter that says that they're ready for surgery. And we started seeing this shift because we were relying on a checklist list of things that patients needed. And this sort of defeated the whole purpose of actually what we were doing, which is trying to just take really good care of patients and make sure that we weren't traumatizing them further at a really challenging time in their lives. And so there was sort of this snowball effect. These were put in place to protect patients and providers, but it started to shift and really only protect providers, but I would argue that nobody was really being protected by any of these things. So that's just like 50 minutes on the history of gender affirmation care. So in the past year, the WPATH has updated these guidelines. This is the eighth version that currently exists. This took a really long time and there were a lot of edits on these. And they've really sort of loosened the guidelines around how to care for patients. So they've changed the diagnosis now. It's diagnostic criteria for gender incongruence. Patients need to understand the effect of gender affirming surgical intervention on reproduction. So there actually needs to be, the onus is now being shared across all of the providers caring for patients. Our mental health providers talk to patients about what it means to be on gender affirming therapy. Are you ready to give up some of your fertility potential? What does that mean to you? If you think about it, there's a direct line with somebody's gender journey, understanding their own fertility potential, where they came from, where they're going, who they are as a person. Do they want to be a mother or father or a parent? However term they'd like to use. There are plenty in our group. We see patients who are transfeminine individuals who are fathers and transmasculine individuals who are mothers and vice versa. Those are all just labels. And it becomes an important part of somebody's sort of gender identity and who they are. And so somebody's desire to parent actually is part of that discussion. And so there's this new encouragement to actually have that be part of, part of, not sort of the focus. You don't have to be an expert in reproductive endocrinology and infertility. But actually understanding someone's goals when it comes to fertility. Patients there's been data showing that patients have regretted not being able to have that discussion with somebody after they started hormones. About one in three patients in their adult lives wish that somebody had talked to them about parenting and what it would mean to be a parent. And so this becomes an important part and it's now in our framework. Good control of mental health conditions hasn't changed and that's just an obvious one. But now the need for hormone therapy has shortened. There's now a requirement for only six months of hormones. Most of this came from the fact that surgeons have long wait lists. And so by the time patients actually see them, they've usually been on 12 months, 18 months, two years of hormone therapy. And when surgeons were demanding that patients wait, be on hormone therapy for at least 12 months, by the time they actually got to see them, right, it was months and months. So they've shortened this. And there's also this thought that physiologically by six months, the physical affirmation type changes are in place. There's no longer requirements to have that lived experience. I've had personal experiences where I've had, whether it be feminine or masculine patients come in and basically tell me I'm not out to certain members of my family for very good reasons, right, or I haven't at work. I live in this, I work in a certain workplace. I'm a factory worker in Mansfield, Ohio, right. I don't need to tell them who I am in order to have my job and be able to support my family. That shouldn't prevent me from actually being able to have surgery. That seems pretty reasonable to me, but when we were going based upon the previous guidelines, then that was really where we were gatekeeping. And then the letter requirement has changed. For a lot of surgeries, we only need one letter now, and it needs to be from a healthcare professional. It doesn't actually have to be from a mental health professional. So we can take PCP letters, letters from individuals who've been prescribing hormones, but who has the competencies and the assessment of these individuals. So there's still a lot of gray zone, right. With WPATH what I imagine is going to happen is clinicians who are caring for this patient population are going to have to show certification that they've taken the time to actually do CME through WPATH and have there's something called the global initiative through WPATH. I would look it up if you're interested in taking care of these patients. They do a ton of virtual CME. You can sign up where you do you know two days lots of panel discussions with experts and the curriculum for the mental health care professionals is the largest one that actually that currently exists. So this change in guidelines from WPATH has significant implications right. So less gatekeeping for sure. Theoretically increasing access to patients. If you need less things to get surgery you'll be able to get there faster and probably a victory for patients. There is however a lag with our insurance companies. Insurance companies as soon as guidelines were published took advantage of this and said well if WPATH quote requires this framework right that clinicians are supposed to be using as guidelines we're actually just going to make them insurance requirements. So they kind of robbed us of our ability to be a little bit creative and make help do and have shared decision-making with patients about them and so now the insurance companies use the WPATH guidelines as their criteria to cover surgeries. We're now in this very funny gray zone where WPATH has changed their guidelines but insurance companies are still relying on the old guidelines. So patients are feeling very confused. I think over time we'll have this no pun intended transition over to what the eighth guidelines are but there's still this funny gray zone and surgical offices are supposed to help patients navigate this. We also this also provides though and you know our team has been talking about this now that there's these new guidelines are a lot looser it creates the opportunity for our multidisciplinary teams to create our own care paths which we really sort of highly recommend. As soon as you take a guideline than a framework that's really loose now the onus is on your team to actually use those to create guidelines that you think is going to help you better care for patients and so our team now is soon going to get together to basically say well what do we want at Cleveland Clinic to make patients feel like we're not gatekeeping but where can we sort of meet in the middle so that we feel like we're taking really good care of patients. So now I'm just going to go over briefly what the surgeries are and what's available to patients. So for transmasculine patients so these are individuals assigned female at birth so they're biologically female but self-identify as masculine along that spectrum. They can have chest surgery which is very simply mastectomy but it's not just like a mastectomy there's chest contouring to really create the male chest wall that's an example of one of our patients who's had surgery. There's genital surgery which includes removal of the pelvic organs hysterectomy creation of external genitalia. There are two types of phallus creation one is something called a metoidioplasty which is a much less involved surgery and involves creating a micro phallus using what's just what's there. You elongate the clitoris you create you use the labia to create a small shaft or there's a complete phalloplasty which is the use of flat local flaps to actually create a phallus and the urethra can be lengthened and patients can have a quote normal peering phallus whatever that may mean and a urethra and the ability to avoid standing up. In terms of transfeminine surgery so again these are individuals assigned male at birth who identify as as along the feminine spectrum. They can get breast augmentation they can get something called thyroid chondroplasty which is a reduction of the Adam's apple or tracheal shave. Facial feminization there's tons of procedure options to contour and reshape the faces in order to be able to appear female and then there's genital surgery which includes orchiectomy removal of the testes and or feminizing genital surgery and this is an example of a bunch of vulvas that we've created at the Cleveland Clinic. So in terms of pre-op optimization we need good letters of referral from our mental health team and I'm going to my last slide is going to be on what these letters are because that's what's really pertinent for you. Some patients need hair removal and our providers actually talk to our patients about hair removal. I encourage anybody who's writing letters to know who your surgeons are locally and go find out what the requirements are what it's like to be their patient so that you can actually act as a facilitator of care and help them get to the right place. Also I just feel like knowledge is power right if you know what the patient's going to go through you're better going to be able to talk to them about the process and do that assessment of readiness. Optimizing overall health is really important right plenty of mental health clinicians talk to their patients about their struggle with smoking cessation why are they smoking like where does that come from and especially if they've been smoking since they were children. Weight management you need self-efficacy for these things right and you can imagine that a vulnerable patient population that's experienced a lot of trauma lacks a lot of self-efficacy if you don't have self-efficacy it's hard to change lifestyle behaviors. And then medication management and planning is really really important we talk a lot especially our patients who are on benzos preoperatively right we want to know how to manage them how much are they actually taking we work directly as a meant as a team to be able to make optimize that we don't want patients in withdrawal after surgery we also want to know if we should be prescribing it while they're in the hospital and being careful not sending them out with things that they may have at home already. And then this is a really busy slide but it has sort of all the things that are a really great letter of referral for a patient and so I'm not going to read it because I'm going to you know and I think you have access to our slides I don't know if they hand them out you can also find this on the WPATH website okay but in brief we want to know that you've known the patient that you've met them that you've spent time with them that you are yourself able to use their correct pronouns that you understand that where they're sort of coming from in terms of their gender journey that you believe that they've explored their gender and that their self-affirmation of themselves is in fact sort of a you know a stable identity that leads you to believe that having surgery would benefit them in some way and that you have assessed their understanding of complications as it results to surgery that their expectations are in line with reality all of those things make for a really great letter what I always look for is to see how long the patient has actually or client has been in rapport with the mental health provider writing the letter that is very useful I do believe that good assessments can be done in only a few visits especially if it's clear that that patient has had a really good mental health support prior to that visit so it doesn't mean that if you have a that's that would be gatekeeping if you told somebody it's going to take a year for me to really feel comfortable if you they've already had a therapist for five years and they've explored that but that's where the art of it I think comes in and just as a really quick patients have a lot there's a lot of post-op care for all a lot of the surgeries especially anything below the waist they have to do vaginal dilation if they're feminized if they're having a phalloplasty it's about 14 months of three stages of surgery where they have to go back and forth and see their surgeons and have catheters removed and out and replaced and management of any complications that come out come up they have to explore their bodies there's all this sexual health education that happens once you do general surgery they need assistance with return to work in school sort of going back after surgery can be challenging sometimes patients need to dilate in between work sessions which can be very tough there's sometimes a lot of stigmatization they worry about discrimination and then some of them just need simple help with gender marker change after surgery and that can be even a difficult process for some so there's a lot of after care too so there's getting them to surgery and then there's after and there's nobody better place than the mental health care professional who's been involved in their process to really help them through that entire longitudinal process along with the surgical team so I'll leave you with this I really think that as surgeons were not gatekeepers to care that's sort of an antiquated view but I think that should be sort of put on all of us who are taking care of these patients we're actually facilitators so our job is to get them there our job is to make sure we take into consideration all of these neat unique nuances that are associated with being TGD accommodate these factors not make it more difficult for them but really engage and share decision-making with patients so thank you and I welcome your questions later hey good morning I'm Jason Lee breezy I'm a child adolescent psychiatrist and I'm here representing the pediatric arm of our LGBTQ clinic and our gender team so just to give some background in terms of the state of mental health we all know it's a pediatric mental health crisis in general right now and we're seeing a lot of need in the LGBTQ population so the Trevor project did an online survey of LGBTQ plus adolescents and young adults and asked them to report symptoms of anxiety and depression we see here that the cisgender men and women who identify as LGB to be sort of in this group still report a high level of anxiety and depressive symptoms but we see a real spike in number of symptoms for transgender individuals who are seeing like upwards of like three-quarters of transgender adolescents and young adults reporting symptoms of anxiety and depression so we're seeing a lot of mental health comorbidity that we can really help with one of the variables that's considered is how supported the young person is in their homes and schools and community so this question asked about people in the home and how often they're respecting the patient's preferred pronouns and half of individuals said no one in my home is using my preferred pronouns about a quarter saying some individuals are and only a quarter of adolescents young adults saying everyone that I live with respects my pronouns and we see that then correlates with mental health outcomes okay so what we will see is that there is an increased risk of suicidality when nobody in the home is using the pronouns but the risk of suicidality does decrease when everyone in the home uses the pronouns this has also been looked at with regard to preferred name and so this study from a few years ago looked at the use of preferred name across different settings home school work and socially with friends and found that for each environment the preferred name was used there was sort of a dose dependent decrease in depression and suicidality so even if you couldn't get someone to be support in all these domains of their life even just getting support in some of these four domains provides some relief from depression and suicidality this site from a few years ago look specifically at the risk of suicide and transgender teens like dividing it down from just either LGBTQ and not delving down to not even just transgender versus gender but for different transgender identities we do see a really high risk of suicidality that 50% of transgender boys are reporting suicidal ideation 40% of gender non-binary folks and 30% of transgender girls so the sample sizes clearly are different we are seeing these big differences where any transgender identity does have a higher risk of suicidality but even within that different subgroups have different risks really consider this through the minority stress model the CDC also use their youth risk behavior surveys to indicate that there is sort of around 2% of high school students who were surveyed identified as transgender and we're seeing a lot of concerns at the school with schools being unsafe that commute to and from school being unsafe or a lot of bullying happening there it's really sort of points that the importance of the school environment so we're seeing when folks are supported in their homes and in their schools which is very basic steps of affirmation like using the name and pronouns that the young person asked for we see a lot of improvement in mental health outcomes so with that background in mind I want to talk a little bit about the services that we have at the clinic to give you a sense of how our team is set up that all the different sort of models for how these multidisciplinary teams come together so our team is the guide team we'll have to have an acronym so ours is gender understanding identity and expression and we provide care to folks under 18 we sort of have the sort of agreement that once someone hits their 18th birthday they would start receiving care from our adult colleagues and we'll see on the next slide who our team members are but we really try to integrate mental health primary care and specialty care for these patients our team is pretty virtual so we will each meet with patients individually and we meet virtually as a team once a week to discuss cases to talk about clinical questions or to refer patients to each other patients will see us sort of in our own practices or sort of virtually but there are some clinics that are set up where you come in and see mental health and then you see pediatrics right afterwards and you sort of do it all as one sort of morning because of our sort of honestly geographical separation as providers we do sort of operate more as a virtual team but we do have that sort of weekly touch point together to make sure that we are talking about sort of patients and making sure we're linking folks up to the care that they need so our team does include a variety of specialists so child and adolescent psychiatry represented we have pediatric psychologists colleagues from adolescent medicine who can both provide primary care as well as specialty care including gender-affirming hormone therapy pediatric endocrinology and then support from nursing social work and bioethics and I think as you've heard a lot from us this morning the importance of the team and it really is for having this team that's come together over the last six years since I've been there we've really seen the more supports we can have together the more robust care that we can provide to patients so what is it that I do you've heard a little bit already about the role of the psychiatrist and to sort of highlight what we do as child and adolescent psychiatrists well one is gender dysphoria which does remain a DSM diagnosis I see it's our job to do that assessment and provide that diagnosis if applicable and talking to patients but why we're providing the diagnosis of gender dysphoria let him know there might see this sort of on their chart now and to indicate it's not because their identity is pathologized but it reflects the dysphoria and distress they're experiencing and then allows them to access medical care if they need it in the future we're also in conjunction doing just a complete psychiatric assessment right we're still psychiatrists and so we're better understanding someone's mental health history and current psychiatric symptoms and if there is any comorbidity we want to treat that at the same time as we're understanding their gender journey and helping them through the next steps we're providing a lot of support to families as well I think the sort of two referrals I get are either my kids ready for a medical intervention help them with that or my kid just came out a week ago we don't really know what to do we're here for some guidance and so I'll really work with patients and families to understand the gender journey of the young person up until the point of seeing me and better understand what their goals may be in the future to help provide a lot of psychoeducation to patients and families and if young people are interested in a social transition maybe changing their clothes or hairstyle or name then talking with them and their families about how they may want to go about doing that in which domains of life that makes sense to do that for right now I myself I'm not often providing the ongoing psychotherapies I want to make sure my patients are linked with an ongoing psychotherapist either on our team though it's very limited access so working with our community providers who have expertise in working with LGBTQ plus youth also working with the schools and making sure that patients are supported at school if they want the school to be using preferred name and pronouns I'm having them understand what they sort of can ask for at school as we move closer to thinking about medical interventions I see our job as part of this readiness assessment is sort of like a capacity assessment I explained to patients do you know what you're signing up for that's my goal I don't prescribe hormone therapy don't do the surgeries but I have a basic enough understanding to make sure that the patients and the parents can really understand what sort of those next steps look like so I want to understand what are the goals the patient has for medical intervention and are those goals achievable by the intervention they're asking for so if a trans feminine patient wants start estrogen so that their voice changes we have to have a conversation that's not an expected outcome so are their goals for medical interventions actually things that the hormone therapy can do and really can they understand what their risks and benefits are because they're under 18 we're often providing informed assent for care and asking the parents to provide consent so we're having those discussions in the mental health realm before I refer them to my medical colleagues for medical treatment and finally we'll provide the referrals and as you heard a lot about letters already we'll provide sort of the letters of support if needed so when a patient comes see me I can sort of be wearing all these different hats during the initial assessment but also during my ongoing work with patients and families so in patients were referred to us we initially sort of set up this very linear path that had a lot of positives it was very consistent from patient to patient and you'll see where mental health is really sort of the first stop of the train so in patients would call us we'd send some paperwork to complete and reviewing the paperwork we would have their first point of contact to be with the mental health provider either myself or a psychologist we would start those conversations and then talk some more with our team before referring to a medical treatment if that was the right thing for the patient the sort of linear nature of this I think was really beneficial it was really clear-cut the biggest challenge to this model is that there is a logjam at the referral to mental health right access is already a challenge for a pediatric mental health care and so we're already sort of limiting that even more so when I first started and had a lot more access it was easy for me to sort of be the first stop for a lot of these patients but as my access has become more limited as well as our psychologists whereas people were waiting four or five months for an initial assessment with me to say oh you need to be doing ongoing counseling let me refer you into the community and that was a long wait for that discussion to happen it's really trying to think ahead of time as patients are coming in now and what's the most appropriate first stop for them although mental health you'll see as an important sort of central component of our care we don't always have to be the first patient the first provider that families meet with so where we're sort of moving towards and we're sort of actively rethinking our care paths now is we'll get referrals from families themselves will Google us and find us and call primary care providers can refer to our team or outside mental health providers as some of the counselors and psychotherapists in the community that we work with will sometimes refer to us for either psychiatric care or for consideration for a medical intervention. So all of these sort of referral sources will come into our team. But now we're really trying to through, at this point, a brief phone triage, but trying to really sort of beef up our triage system to think through what's the first provider someone should meet with. So we may at that point actually just let someone know, ongoing counseling or psychotherapy in the community may be their best bet. For someone who just came out, the parents have a lot of questions, they need ongoing support. If our psychologist doesn't have the access to see them an ongoing way for psychotherapy, we may just divert them directly to a community provider. We may have one of the mental health providers on our team. So particularly if there's a question around needing for hormone therapy, we may have them start the mental health provider since our medical colleagues want that mental health assessment. Or if someone clearly needs psychiatric intervention, they may get onto my schedule for that reason. Other times we'll have the patient start with adolescent medicine. And sometimes this is our stop for, we don't quite know what you need, and we need more of an assessment to figure that out. Because our adolescent medicine colleagues just have better access than we do in mental health, they can sort of through their training, have a mental health lens as well as the medical lens and can talk with patients and families about what their questions are, what their goals are, and then determine if there's a different team member that maybe needs to be brought into the care. So we're trying to figure out from a sort of point of referral and triage, what might be the best path for patients to start with. And we're continuing to refine this process. So when patients come and see us, there are different treatments that we can provide. So number one, right, mental health. So we want to provide the assessment, psychoeducation, and psychiatric treatment if needed. And then sometimes patients follow a very linear pathway. So we do nothing more than mental health and social support pre-puberty. But once a young person has started puberty and is in TANF stage two or three of puberty, we can think about using pubertal suppression. So off-label continuous GNRH agonists to suppress puberty, to allow the child's time to further explore their gender without the stress of ongoing puberty happening sort of in the background. We can then think about things like gender-affirming hormone therapy. This sort of guidelines used to say you had to be 16 years old in order to be eligible for hormone therapy. There's a lot more flexibility now that suggests one can start hormone therapy with estrogen or testosterone under 16 if the young person has the cognitive ability to make that decision. Where we see a lot of mature 15-year-olds, a lot of immature 17-year-olds. So actually having age as a cutoff was a little bit sort of arbitrary. So we're trying to make it more individualized to the understanding of the young person. So for some young people who started on pubertal suppression at 10 or stage two, whatever their chronological age was, once they're around 15-ish, we may sort of think about starting hormone therapy if that continues to be a goal of theirs. And then once they are 18 years old, then surgical options are potentially available to them if that's something they want to explore. So this is sort of the most linear path that folks can sort of take if someone chooses to sort of take advantage of all the options available to them. But not everyone wants all the options on this slide. That doesn't make sense for everybody's gender journey. And depending on what point they enter care, may not be available to them. So for young people who come in after they've started puberty and around 10 or stage four, we may think about that they may no longer benefit from pubertal suppression and would think about going directly to gender-affirming hormone therapy. Again, once they're around that sort of 15, 16-year-old, then maybe they progress to surgery again at 18. Other folks may have no desire for hormone therapy and surgery may be their one treatment option that makes most sense for them. That's a conversation I can start with them before 18, though we don't actually do any of the surgeries until someone's 18 years old. So lots of different options are available. And part of my job, I see, is to really understand the goals of the young person, the understanding of the patient and family, to try to make sure that they are linked up with the right treatment providers. So I wanna highlight some of the key differences that I think can come up when working with youth. And these could each in and of itself be a workshop, so we're just gonna highlight the key points here. So I do sometimes see young people before they start puberty. And a lot of the conversation we have at that point is, does it make sense to start a social transition, changing your clothes, your hairstyle, having schools use different names and pronouns? Or is that not something that we want to do at this point? So we really sort of think through, because pre-puberty, there's a lot of paths someone's journey can take, right? Many kids who are gender non-conforming in childhood don't grow up to have a transgender identity, but many do. And so we want to sort of provide that support that whatever the next step of one's journey is, that we're there and their families are there to support them. So doing nothing can sometimes cause problems. We also wanna make sure if we do support someone's social transition, that we allow for any detours that their journey may take over time. In addition, I sort of mentioned the idea of the capacity assessment. And so we have to really make sure that the young person has that cognitive ability to provide assent to treatment, that the parents are supportive and provide informed consent. And so that can be challenging if somebody doesn't have a good understanding of the treatments and so it's our job to provide some education. But I wanna see, if you're asking me for hormone therapy, what are your goals? What do you think it's going to do? I'll correct your misconceptions, but I wanna see what your general understanding is from the start. And it can be challenging depending on someone's mental health sort of comorbidities that we wanna make sure that they're in a stable point to be able to provide appropriate consent. Because I'm seeing folks under 18, we do need parents to officially provide the consent to treatment. And we ideally have anybody who is a legal guardian provide consent and sort of sign the consent form. And that can be challenging if we have one parent who is supportive and one who isn't. We sort of see these treatments as medically necessary for the treatment of gender dysphoria. And so in Ohio, medically necessary treatment only needs the consent of one parent. Where if you go to the pediatrician for otitis and you need amoxicillin, you don't always call the second parent at work to get consent for amoxicillin. And so we sort of see that in theory, one could argue that one parent consent sort of would suffice legally, but we know that there's a lot more complexity in these decisions, and so we do whatever we can to speak with any of the parents or legal guardians involved in the young person's life, both to make sure they're providing support to the young person, but also to see if they're willing to provide consent. And if not, then we have a discussion with our bioethics colleagues on the risks and benefits of treating the patient with only one parent's consent. You heard a little about fertility already, and these conversations are starting in adolescence if we're thinking about hormone therapy at this time. And so I do see it as my job to, more than once throughout the assessment process, bring up the question of fertility to make sure that folks really understand the risks. Now, of course, as teenagers, everyone says, I don't want kids, the world's overpopulated as it is, I'll just adopt. And I say, well, that might not even be always possible, unfortunately, based on the situation we're in. But I wanna make sure that they and their parents appreciate the fertility risks that come with hormone therapy. And recognizing that at 16 years old, what we all maybe had planned for ourselves and what we have for ourselves as adults might be different. So I really wanna call that out to families, say, I know that this is weird that I'm asking your 16-year-old to make family planning decisions. And for some people, that feels too much, and we hold off on doing anything that could affect fertility. But for others, the risk of not treating their gender dysphoria is too great. And so what we've seen from the literature, as you heard, is the importance of the discussions. I think when folks go through this process and don't have these discussions or appreciate the fertility risks, that's when there's a lot more concern in adulthood. A lot of transgender adults may say, now that I'm an adult, I wish I maybe had that option available, but I'm glad I did what I did as a adolescent or young adult because I needed to treat my dysphoria at the time, otherwise I wouldn't have made it to be here. They just say, I wish I had that conversation more with my providers. So I wanna make sure that folks know the risks are there and to offer fertility preservation options if that's something that they'd like to pursue. A big concern for parents in particular is the risk for regret, right? Particularly if I'm signing on the dotted line and in a few years my child regrets this decision they make, what does that mean for them, for me, for our family? And so we really talk about this and really sort of understand what someone's journey has been up until now and sort of as psychiatrists using previous history to help us predict what future behavior might look like. And I let parents know, I don't have a crystal ball. I don't know for sure that your child's gender journey isn't going to take sort of unexpected turns. So we have to feel comfortable with that. But the sort of longitudinal literature from the Netherlands suggests the risk of regret is between 0.3 and 0.6%. So I share that with parents to say, it's not zero, right? I recognize that it is not a zero risk. Let's not pretend it is. Let's also recognize it is less than 1%. So the risk is small. So we have to appreciate some small level of risk, but we don't wanna sort of blow out of proportion the concerns for regret down the line. There is sort of this phenomenon that's suggested in the literature called rapid onset gender dysphoria. I do have it in quotes because it uses the DSM diagnosis of gender dysphoria, but this is not a diagnosis. It's a suggestion that adolescents sort of all of a sudden sort of quickly develop a transgender identity in the context of social media use and that those folks maybe are getting put on hormone therapy inappropriately. The challenge is that the paper that suggested this phenomenon had a lot of methodological challenges that makes it hard to really interpret this as a potential phenomenon or not. What I take from it is a good assessment is really important. We wanna understand someone's journey. So someone just came out a month ago, I'm probably not gonna do something irreversible today. So we wanna have that discussion that some way have this conversation and maybe saying no to hormone therapy today, but it's a not now. Let's sort of better understand your journey and take some time working together before we make these decisions. And lastly, as you've heard, conversion therapy does still exist. That should also be in quotes because it's not therapy. It's the idea that one can change someone's sexual orientation or gender identity, which we see not only does it not work, but it's actually quite harmful. And on state by state or even city by city basis, governments are passing some bans for licensed mental health providers providing so-called conversion therapy to minors who can't consent for themselves. So with that all in mind, what's the state of trans youth today? This is a clearly timely topic. So in the Trevor Project survey, 65% of the young people who are on gender affirming hormone therapy were somewhat or very concerned about losing access to this care. And here's why. So this is from the Human Rights Campaign. It's a couple of weeks old. So this is probably already outdated, but it's looking at state by state bans on gender affirming care for minors. And this is important not to have a political discussion, but to recognize when the doctor patient relationship is being affected by those outside the system. And we're seeing in red, there are already many states that are banned gender affirming care for youth, many that are considering it as well. So fortunately in Ohio, we have not had a ban yet, but it continues to be discussed at the state house. And would certainly impact my ability to provide care to patients, my patient's ability to access the care that they need. So with that in mind, to summarize what we've all talked about today, you heard a lot about the team, right? The importance of collaboration to provide good comprehensive care for this population that's already facing many health disparities. Want to make sure providing good care for their mental and medical health and provide a trusting environment that I know when I'm seeing someone and they have to mute somebody for hormone therapy or they're graduating on to adult psychiatry that I can say, I know the people I'm referring you to. I work really closely with them and allows patients to feel very comfortable and supported sort of in a very sort of stressful time of their lives. So with that, we will be happy to take any questions that you have. Thank you for the talk. I'm curious and the Cleveland Clinic seems to have a really robust team, which is amazing. I practice in Louisiana and many of our patients and this is first comment, I'll get to the questions who are in the public insurers policy. And what we have found for the letters is that we needed to actually have a standardized letters for the insurance coverage, not necessarily for the surgeons. And what we were able to do is when the denial happened that we're covering all of those pieces. And so it might be helpful to know like if you're practicing and thinking about letters which I would highly encourage everybody to do to actually have a sort of like where the local landscape is. When I talk with non-physicians, clinicians, mental health providers about the letter, the sticking points is the, I think the bullet points that you had in terms of the patient's ability to understand all the risks and benefits by the surgical care. And many felt that that could be done more collaboratively with the surgeons because they're not able to explain, they themselves are not able to share and they can comment on the more of the capacity piece of it, not the detail and worry how that might actually impact. I wonder if you can comment on when you work with the community mental health clinicians in terms of how from the surgical perspective, how do you all sort of handle it in Ohio? Maybe you can start it back. Well, one of the things that we did and I know it's tough when you come and listen to a, right, the people who are invited to do these types of panels are these comprehensive teams that have everything built in within our own groups. But one of the things that we didn't mention, so I appreciate your comments and your question is that we have a really strong alliance with our community providers too. So not all of my patients, not everyone I operate on has a letter of referral from Murat. We actually very early on when we started our program, reached out to a lot of providers and they got to know our practice also and we get calls from them a lot or emails about questions about what we're doing and we update them and we have an ongoing list. So when patients call us and say, hey, listen, I know that I need a second letter for my insurance. We actually don't always refer internally. Some of our best assessments are done from our community providers and they have availability and we try to keep our internal providers, because we're talking about seeing a therapist or a psychologist versus a psychiatrist. Not all of our patients need to see a psychiatrist. There's not medication management. Certainly you're one of the best at doing assessments, I would say. But our community clinicians are just as great. And so we have collaborated with them and they know all of the surgeons in our group now. And then whenever, the other thing that we do as a practice, we like it when people reach out to us too, right? So say, hey, I'd love to start sending patients. It actually is really nice to be able to tell a patient or I know that you refer to a lot of them, to them as clients, so patients and clients, be able to tell an individual, I have a connection or rapport with the surgical team. And so I think that that's important. And I've lost my train of thought for a second, but one of the things that WPATH does is that they do these surgeons courses where they offer these two days. It's usually precedes either a big meeting, USPATH or WPATH, or their program that's meant for mental health clinicians. It sort of follows it. And we've had psychologists, psychiatrists, therapists come to the surgeons course, and just actually listen for two days about the surgeries, the requirements that surgeons are asking for. And it's really sort of very helpful because then you can go back and when you're talking to your own patients, talk to them about, you can feel sort of more informed and have a different level of expertise when it comes to that. But I think that communication is really important with the practices. Yeah, and just a couple of things to add. When the referral or the relationship is not as smooth, so what we do is we kind of have a secondary, I guess, process that happens. Like for instance, if Cecile is getting a lot of out-of-state referrals and we don't know the providers who are referring the patients to us, and maybe the quality of the letter is not there, so there are some gray areas. So what we do in that case is I review the letters. If needed, I maybe talk to the patients. And a lot of times, I actually directly call the provider to get some collateral information too. So when the referral is not as smooth and if we don't have a direct relationship with the person referring to us, be it a psychiatrist or a psychologist or a social worker, we do do some background work and try to get some more details about the particular patient or the provider and make sure that we have that taken care of. It is really interesting, though, right? Because I don't prescribe the things I do, these consent discussions around, right? So I don't prescribe hormone therapy or do the surgeries, but I think as physicians who particularly have been trained to do capacity discussions already on medical or surgical procedures we don't do, I feel comfortable sitting in that gray zone in a way that I think our non-physician colleagues have a harder time with that. And even the psychologist on our team and I have had this discussion. She's around this all the time, but says, I'm not a physician. I don't know that I'm the right one to have this discussion. And so I think even when I do the discussion myself, I tell families, you're gonna have the psychiatrist-level understanding of these things. You will meet with someone who's gonna do a whole informed consent discussion with you, the actual prescriber of these treatments. And so for me, it was just sort of sitting down with the providers and saying, what are the most important risks and benefits you need to make sure that they know about and let me create a dot for you so I can always pull that up to reference when I do these discussions and so I think it's for having a little bit of education and the WPAD the standards of care themselves are really available they're easy to access and that provides a lot of that background so we'll sometimes refer other you know community providers to the standards of care to say just look at the highlights there or you know let me get you sort of the cliff notes version of the kind of things you want to make sure folks understand and always sort of let them know they will have this discussion again with a prescriber of these treatments but you know we need to have we need to have a general understanding of the risks and benefits to do the capacity assessment but I sort of allow us to sort of not know all the ins and outs and to sort of be open with the patients and families about that surgeons love having relationships with mental health professionals so if you're interested in being somebody who starts to see a lot of these patients and in writing letters reach out to your local surgeons you know within your community or within like a few there's not a surgeon in every state but the places that you think your patients will probably be heading to and say hey I'm gonna be starting to see patients I'd love to have a relationship with your office so that we can be a touch point happy to see post-op patients too and be a referral from you right and vice versa that's music to our ears because then we have this comfort level with somebody it ends up being a virtual relationship I haven't probably physically met you know 80% of our community providers because I just haven't I'm not in that realm but it's really helpful to know who wants to be part of the care team for those of you who are interested in learning more the GEI course that dr. Ferrando mentioned will be held at US path on November 1st a third it'll be in Westminster just outside of Denver I also think that there may be an option for some of that to be done virtually in addition to the conference in person which will be from the 4th to the 6th so a great opportunity for those of you who are interested or your colleagues to learn more about gender care and the nuances of our team also does try and support our community mental health providers and provide technical support and assistance with letter writing and reviewing those patients in an asynchronous or sometimes just a phone call manner yes thank you I'm working with gender affirming care in Sweden West Sweden and I was just wondering we have an ongoing discussion about the age the debut age debut of gender dysphoria and also psychiatric comorbidity and how you see that in regards to accessing hormone therapy and surgery I'm sorry could you just repeat your question one more time I'm processing along okay okay no but we're having an ongoing discussion if if you have like late debut of gender dysphoria like in the six seventeen eighteen years old or sixteen years old and a lot of psychiatric comorbidity we would perhaps wait longer with hormone therapy and surgery do you do you do the same judgment or assessment yeah absolutely I think part of our job to is to make sure the mental health is as stable as possible right because I want to make sure that they're mentally in a good spot and that they can help them make a solid decision for themselves is that sometimes part of the not now discussion is that I could totally see that this is your gender journey and we're gonna get you to where you need to be but you are actively depressed right now and introducing testosterone into the mix is just gonna make you more irritable like maybe we need to stabilize your mental health first even withstand side effects of hormone therapy and so that's sort of part of the conversation I have with them and to then sort of say you know sort of we talked about right like there's some overlap with depression and gender dysphoria but there's a lot of differences and so I try to talk to the patients about how much of your depression is like depression depression and how much of it is dysphoria depression you know how much is gender dysphoria in some ways the root of your current sort of symptom of depression and to see if they can sort of give me a sense of that overlap and I've worked with a lot of patients where we're treating their major depressive disorder and they seem like you know I'm still feeling sort of crummy but I really think I'm at a point the only thing affecting me now is my gender dysphoria I think my depression depression has gotten better with the treatments that we've done and I think I'm in a better place now to be able to think about addressing the dysphoria more directly so I always say we're gonna think about both of these in parallel but there are some steps that I want to see happen first I do think mental health stabilization is really important and I think the same principle actually applies to adults as well so sometimes people come to us in a really complex presentation and yes we try to stabilize other men medical or mental problems first but I also find myself in situations where it's really a gray area and if I don't help with gender dysphoria right now depression or anxiety will also not get better and they will keep complicating each other and and the patient's functionality will keep going down so sometimes taking the gender dysphoria out of the equation by starting the gender dysphoria treatment can actually help with overall functioning and depression as well so it's so it's never black and white in terms of treating other psychiatric comorbidities versus gender dysphoria and it doesn't always have to be surgery is sort of all or none I think we can all agree on that but medical care doesn't always have to be that way so we've had plenty of team discussions where we've said you know why don't we start this this individual was identifying as a you know trans she's trans feminine or they're trans feminine why don't we maybe start on a low dose androgen blocker right so we're not adding an exogenous feminizing hormone but maybe if we try to lower the androgens a bit it's almost like a gesture we know as medical providers that physiologically that's not going to do it but it's a gesture of working together on moving towards their transition goals and feeling like there's buy-in that we understand their struggle but there's other things that need to be managed this is where the care team is really important I feel like in the community you feel like you have to either write a letter that says they're ready or they're not you know and if they're not ready you don't write the letter right so your letters are that they're ready but if you have are able to establish relationships with the providers that are seeing the patients for the that medical and surgical care you can make recommendations or call them and say you know I'm writing a nuanced letter I think we need to work together on this patient's transition so I can't fully recommend you know just you know gender-affirming care but I am supportive that maybe they meet you right sometimes also a surgeon consult is important we I have gotten you know I'm not ready to write a letter will you write a well you see the patient to just at least talk to them about what surgery will be like because I think we will be able to write a letter at some point surgeons don't love that because a surgeon and consult you want ever consult should turn into surgery but if you're working with a team or at least community relationships then you can actually maybe have that conversation listen I know this isn't going to be a surgery in the next 12 months but I actually think that I'm prescribing a surgical consultation for their mental health well-being can you get on board with that and those conversations are important but the onus is on you to actually sort of help guide the medical and surgical team to getting there so I have a couple of questions is non-binary the same as gender fluid like what's like a good resource website to get a better understanding of all this pronouns and concepts and also I attended another transgender lecture yesterday and I believe Facebook has 50 pronouns I was kind of that was interesting so y'all know about like where the source of the it is 50 pronouns and who came up with that what kind of evidence or what did they draw upon to come up with this is it does someone just came up this idea and they submitted to the Facebook so you know when those things happen the validity and evidence base behind it is shaky and that can harm the actual transgender population I feel because you know someone just oh let's add this pronoun let's give this to it and the other question I have is what based on today's data what percent of transgender people continue to be transgender when they go into young adulthood or even middle adulthood thank you I apologize I'm having a really difficult time with the the speakers to understand most of the questions but I think the first question was is gender fluid the same as gender non-binary is that what your first question was so yes and no so so the gender non-binary spectrum includes a lot of different kinds of descriptors and gender fluid can be one of those descriptors yes so essentially if somebody is not identifying as male or female with those two binaries anything in between can be considered as non-binary but people have a lot of different terminology to describe what that non-binary presentation looks like and gen non-gender age under gender fluid gender queer androgynous feminine or feminine masculine so there are a lot of different kinds of way to describe it but yes it's it's not under the umbrella of gender non-binary and what was the second question so what's good like a good resource or website to understand this pronouns and all these concepts and also I want to point out for the part of the first question is to remember the point that dr. Alton a made in the beginning about intersectionality that these identities that we're talking about today are mostly right now from kind of a Western medical perspective there are Moushe there Hedra there are many to the Fafafine there are many many experiences of non-binary gender identities and expression around the world and they've existed for millennia we try to fit a lot of these experiences and medicalize them and we've pathologized them and we organize them in that way in our structure and thinking I really believe personally as a genderqueer person that we're seeing the evolution of community members of community populations engaging and claiming identities and defining for themselves pronouns and words and tools that lead to autonomy and that's why we see a proliferation of many different pronouns that exist now they're coming from community they're coming from people who are having voice as neurodivergent neurodifferent people and they want to share with the rest of the world how they see themselves not all of us will fully understand that in a medical context but I think part of our job is to make space hold space and recognize what that is as we guide those conversations and begin to try and help them toward whatever gender care and other care goals that they will have otherwise I think we miss a really big opportunity so yeah I find it confusing too but I think that you know this is the conversation that we have and saying look I don't understand everything but I want to work with you okay I think it also has to question around sort of the persistence of transgender identity sort of longitudinally and you know what are the chances somebody made sure to change their identity over time I'll say from the pediatric lens a lot of the older data would suggest children with gender non-conforming behaviors mostly desisted like did not grow up to have a transgender identity though many had maybe a gay or lesbian identity sort of in the future and what we sort of found was we were using gender non-conforming behavior as a proxy for one's gender identity so if you are a feminine boy and you did not grow up to be a transgender girl did that mean that you desist you didn't persist on if we never asked that feminine boy if they identify as a boy or girl then we're using two different identities as proxies for each other we're using their gender expression as understanding what their gender identity is when we start asking kids what their gender identity is we start seeing that persist more on and so I think there is a risk of using sort of how one presents are you a tomboy who grows up to be a transgender boy who grows up to be a lesbian who grows up to be a cisgender girl so we have to make sure we're really understanding one's identity and how they identify to then sort of track that over time even looking to adulthood we do sometimes see folks who desist or D transition and no longer identifies transgender and I think we therefore then assume those folks will regret the decisions they made and I think that those are not one in the same that's sort of our own biases and our own fear is that we supported someone in a transition that they no longer want to be on a couple of patients I've had who elected to stop hormone therapy said you know I don't regret that I was on hormones for a couple of years my body changed in some irreversible ways and I'm okay with that and that supports my identity now but I no longer need ongoing hormone therapy or sort of my continued goals and so I do think we want to allow folks to sort of have whatever sort of journey they're going to be on over time and that we need to allow that folks may go on and off hormone therapy or change their identities and if they regret the decision they made and we sort of push them in that direction that's a different conversation but I think we're seeing a lot less regret even in folks who are choosing to stop sort of hormone therapy and oftentimes the reasons folks give for D transitioning is I'm not supported around me this has been hard and so a lot of our assessment is understanding one social support network to say even if these are good changes to your body it's still changes and you have good supports around you so folks are not supported or live in a system where they don't think they can authentically be themselves they may just be easier to stop transitioning but that's sort of a different risk and benefit discussion for them yeah I know the I got your numbers about point three two point six percent for the surgery I was talking about more like people who are not opting for the surgery and just have this concept and doing hormone therapy based on current studies I know there's not much and evidence what was the numbers that was my actual question yeah not once doing surgery yeah we'll even see that even for folks who just socially transition or sort of you know even just sort of do hormone therapy that they're all sort of these options available and it is not I can't give I don't the numbers are in terms of the number of sort of percent of folks who do stop transitioning we have a national study it's around 8% of adults from National Survey have D or re-transition but again as Dr. Lombrizzi mentioned the reasons are very very complicated from loss of housing loss of employment being pressured by a spouse or another family member to stop medication and treatment to positive things like I've accomplished the body goals that I've had whether they're taking full dose medications or what we talked about is micro dosing a lower dose medication or even decoupling taking one type of medication for example the androgen blockers alone so all of these things are part of the the nuanced care that we drive guide our patients through and even within there are people who stop but stopping is different than regret okay got it so regarding I'm sorry to interrupt but we're actually running out of time and there's I think I think one more person who is waiting to ask a question and we can we'll be available after too if that's okay you sort of answered my question there at the end but I guess I'll try and confirm it with you it sounds like you said the risk of regret in your talk was you know less than 1% but did you just say that the number of people that do decide to D or re-transition is 8% but the number of reasons is vast is that what you described I believe the surgical literature has just recently talked about the amount of regret for surgical procedures is less than 1% from a national survey of transgender adults when they were asked if they had D or re-transitioned at any time stop their interrupted their care by stopping hormonal care reversing something or whatnot that was in the neighborhood of 8% but again the reasons that were listed and offered were very very diverse and they did not always equate with regret and when it comes to surgical you know we use a term regret but surgical regret it's really low and it most often is related to actually complications surrounding the surgery meaning that either the outcome did not meet expectations or they actually are dealing and suffering from a complication that was unanticipated and so there's this sense of regret of having done the surgery at that particular time with that particular surgeon and most of those individuals don't actually say that they regret actually you know transitioning or coming out as trans and seeking care so again it's but this these data are hard to get I mean I can tell you from our personal experience you know we've done about 900 gender-affirming surgeries in the last seven years and we have had two patients one of our own patients and one who has had had surgery on the outside who's come to us for care and so it's quite it's quite low and but those are the patients that need the most support and so now you know we I caught you know we're leveling up meaning that we're beyond teaching people how to actually provide gender-affirming care we're now are leveling you know the next level we're at now is how do we actually support individuals who are who sort of have found themselves in this challenging situation post-transition which is such a small percentage but I would argue they're the most fragile patients and the ones that need the most support in regaining confidence in their gender identity in their in and their journey and so we we could probably do an entire workshop on how to care for the detransitioning patient even though it's such a small portion of the population because I can tell you that in my personal experience patients just thrive after they've gotten to a certain point in their transition we're helping support people live happy healthy lives right this is the reason we're doing this reason I do this right because what I do is irreversible but um so yeah we should come up with that workshop next year all right thank you everyone

Cleveland Clinic

transgender care

multidisciplinary team

Dr. Murat Altunay

health disparities

LGBT health

mental health

gender-affirming procedures

WPATH standards

surgical readiness

pediatric transgender care

parental consent

patient-centric strategy