Well, thank you, everybody, who's here for coming. This is the session, Promoting Women's Mental Health in a Difficult Environment. Our colleague, Carol Warshaw, could not be here today due to a family health emergency, but she sent her slides and notes. And so we'll cover some of her material, but she sends her regrets. This was a sudden issue that she had to take care of. We'll go through some of the little bit of factual material and then divide into groups and try to do a little brainstorming around possibilities that we could use as psychiatrists. So there are three of us here, and one here via slides. I'm Evan Eiler. I have no conflicts of interest. I'm joined by Dr. Leslie Guise, Dr. Amanda Corey, and Dr. Carol Warshaw in spirit. What we're going to do in this session is to review some of the recent legal and policy developments in the United States that can negatively impact the mental health of women and girls. If you're from another country or another part of the world, we can also discuss that in the group session, but this is really focusing on the United States. We'll give an update regarding related patient experiences, probably things that people are seeing in practice, people who are needing to continue pregnancies that they are not doing voluntarily, people who are coerced into pregnancy or birth, exacerbation of discriminatory harm by other structural factors, forced masculinizing puberty for trans girls who are unable to get puberty suppression. And we'll talk some about strategies. How can we, as psychiatrists, scale up as best we can in our clinical practices and promote the mental health of women and girls in the currently very challenging legal and social environment that we'll be discussing? And then we did a somewhat similar session together previously. And that time, people who came also wanted to discuss their own stress and feelings of burnout that went along with feelings of helplessness, feelings of being unable to really mitigate the suffering of patients as they would want to, and so forth. This session is not a debate. We're sticking with the established APA policy as reflected in the position statements regarding women's health and care of trans women and other trans people. What we're going to do instead is to share information, talk about clinical practice options, and provide support. So first of all, what is current APA policy in these matters? The APA has a specific policy on misogyny and gender bias and their adverse effects on the mental health of women. This is similar in many ways to the policies that the APA has opposing racism, opposing religious discrimination, opposing discrimination based on sexual orientation and gender identity, et cetera. But it calls out the effects of gender bias and misogyny in terms of very direct negative effects on women through sexual assault and other aspects of violence and harassment, and also just throughout the economic, legal, and social spheres of society, and states openly that these effects combine to restrict the autonomy and opportunities available to women to increase economic and other hardships and to negatively affect physical and mental health. That's in the position statement section of the APA website. And therefore, the American Psychiatric Association condemns all forms of misogyny and abuse of women, opposes discrimination, and specifically recognizes the negative effects of misogyny and discrimination on the physical and mental health of women. And we support policies and laws to reduce this burden, as well as the other things listed there, particularly attempts to eliminate the pathologizing of women as a result of these experiences. APA has also supported legal access to abortion for decades, holding the position that abortion is a private matter and a medical procedure and has positions about abortion and contraception also in their position statement section of the website. The position regarding treatment of trans and gender-diverse youth has been around for approximately five years and recognizes that due to the dynamic nature of puberty development, you know, once it gets started, it's a runaway train. Then the lack of gender-affirming interventions, things such as puberty suppression, counseling, family support, this is not a neutral decision. And youth often experience worsening dysphoria and mental health as incongruent and unwanted puberty progresses. So as an organization, we also support treatment of trans youth, both supportively for trans youth and their families and also when indicated, puberty suppression and medical transition support. And the APA specifically opposes legislative attempts to limit access to services for trans youth and specifically to sanction or criminalize the actions of physicians and other clinicians who provide them. That's one real difference between the current crop of anti-trans legislation and when this sort of first got started is the criminalization of physicians rather than, you know, some more mild form of sanction. So meanwhile, what has been happening in the Supreme Court has unfolded over the last couple of years. There have been more and more both decisions that are adverse and also sort of statements by some of the justices that there's more to come. So Dobbs versus Jackson Women's Health supposedly returned decisions about abortion to the states. But clearly, the target is a federal ban on abortion. And there has been some pretty open discussion about that. There was a case involving Mifepristone. Griswold versus Connecticut is one of the hallmark cases having to do with contraception. And that has not yet been overturned but is stated to be a target. There have been cases that specifically had to do with LGBTQ rights, such as the Philadelphia Catholic Social Services case. And the target there ultimately is thought to be Employment Division versus Smith, which is a case that has also been considered settled law for quite some time that essentially says that generally applicable laws do not require religious exemptions. So a religious exemption is required if you are a religious organization or a religious school or whatever. But if you're just providing ordinary services that they should be open to everyone. And that is thought to be coming under attack in the not too far future. So then there's the questions that would arise as a result of that. Can businesses that are open to the public refuse to be open to certain persons like LGBTQ identified persons? Could a healthcare organization do that? And in terms of trans women specifically, but trans people in general, could sex be redefined at a federal level? It possibly could be. The age that state laws have restricted care for trans youth has risen. The initial bans were age 18, then they were 21. There are two proposed now that would be age 26. And clearly the target again is to eliminate care for transition related services entirely. So then there's the question of, you know, Medicaid programs are administered by the states, but with federal funding. Even though that's a federal funded program, can states set limits and can recipients challenge them? It gets very complicated very soon. And so at this point, we'll turn our attention to some of the specific implications as well as some related aspects of women's mental health. So Dr. Corey is now up to talk about abortion. talk is about promoting the well-being of how we can promote women's mental health and one of the ways that we can do that as psychiatrists is through understanding what's fact and what's myth about abortion and mental health. We can promote evidence-based discussions of abortion and mental health both within our communities, our institutions, and with patients. Really understand patient rights and provide evidence-based mental health care for reproductive age women. Another thing we can do is to be part of the solution in terms of increasing access to psychiatric care for reproductive age women. There are not enough perinatal psychiatrists. So when we look at what's fact and what's myth, I think a lot of it has surrounded this from Justice Kennedy around the 2007 abortion case Gonzalez versus Carhartt in which he stated, while we find no reliable data to measure the phenomenon, it seems unexceptionable to conclude that some women come to regret their choice to abort the infant life they once created and sustained. Severe depression and loss of esteem can follow, which is a pretty bold statement that has no reliable data. So let's look at what is the data then. Is that fact or is that myth? The Turnaway study was one of these major landmark studies. They observed 956 women for five years with very regular follow-up and they compared those who had requested and received abortions to those who had requested and been denied abortions at about six weeks gestational age. At the five-year follow-up, 99% of women reported that abortion was the right decision for them. So regret was actually not a common phenomenon whatsoever and at none of the time points assessed, and these were regularly assessed time points, at no time point was there any increase in negative emotions or suicidal thoughts. If I recall correctly, the predominant emotion was relief, especially immediately afterwards. Abortion does not increase the chance of developing PTSD, depression, anxiety, low self-esteem, or lower life satisfaction, according to this study, and abortion does not increase women's use of alcohol, tobacco, or drugs. However, barriers to accessing abortion care, so delays in getting the abortion, travel time, costs being forced to disclose to others when they would have preferred not to, those factors all did significantly increase anxiety symptoms. So really the negative mental health consequences surrounding the abortion were related to the difficulties in obtaining it, rather than subsequent to the abortion itself. So there's more recent data even. In a 2022 study, more than 7,000 women were, with unintended pregnancies, were studied retrospectively. Psychological distress postpartum was lowest for wanted births, which makes sense, but amongst those in which they did not desire to continue the pregnancy, ideally. So abortion was associated with lower distress scores than adoption and unwanted birth, and marital status, age, economic situation accounted for psychological distress associated with abortions. So adoption is not an alternative to abortion, it's an alternative to parenting, and abortion was associated with lower distress scores than adoption. So I'll highlight that as, like, just all over again. Even more recently, there's a 2023 study of 83,000 women, so we're just getting more recent, even larger, but I have to do to convince everybody, of reproductive age women residing in states that restrict abortion rights after the Dobbs versus Jackson decision that demonstrated that that loss of abortion rights was associated with a 10% increase in the prevalence of mental distress, specifically amongst reproductive age women right after that decision. Men of the same age were not affected in the same way in that data, and neither were women who are long past childbearing age. So even just the prospect of having that restricted was distressing in ways that we can measure. And now we're in 2024 and I've got 718,000 participants of a study that showed that reproductive age female residents of states that had passed trigger abortion bans post-Dobbs decision experienced a significantly greater worsening of anxiety and depression symptoms. And again, this is when compared to men of the same age and women of much older ages. So these rulings affect mental health outcomes of reproductive age women much more broadly, not just those who are denied abortions, just the ambient environment or the fear of it affecting oneself. That affects everybody in that demographic. And this is especially challenging then when we look at how this dovetails, or rather doesn't, with access. So we would anticipate that distress, depression, anxiety, these might all increase post-Dobbs, and yet 23 states have fewer than one perinatal or reproductive psychiatrist per 100,000 reproductive age women. This supply does not meet the demand even as it stands, much less when there are potentially even more pregnancies being carried to term that are not desired, which are, you know, that itself could be a risk for mental health conditions. And in some of my own research, what I found is that more restrictive state policy on abortion was actually correlated with decreased access to reproductive psychiatry. So in the places where the need is greatest, the access is worst. So that is concerning. So I think I have hopefully convinced you that that's a problem, but then this is supposed to also be, what can we do to promote women's mental health? What can we do? So one of the things we can do is help connect patients to community resources. Postpartum Support International has peer support groups for post-abortion support and a specific, you know, separate group also for those who had termination for medical reasons. So that can be a good facilitator-led space for people to gain support, regardless of their insurance, regardless of their location. So it's something that you can advise really regardless of where you personally practice. You can advocate for maternal mental health, and you can increase your own knowledge of psychiatric care for reproductive age women. So that even if you don't see yourself as a perinatal specialist, that you feel like you are comfortable, confident in taking care of those patients, so they don't fall into that vast abyss of access challenges if they do become pregnant. Thank you, that's all I have. So we're going to take a moment here to change slide decks, and Dr. Geis, who is a disaster psychiatrist, will be updating us on women and disaster. Aloha. I'm from New York, but my husband and I moved to Maui 30 years ago, so you're supposed to say aloha. Aloha. Oh, you could do better than that. Aloha. Aloha. Okay, good. This mouse is not working on there. Alright. I have a couple of things to say about what Amanda just said. I actually terminated two pregnancies. One was six months before my daughter was born. I was finishing my training. It was a complete accident with the first and only man I ever had sex with, and I don't know what happened, but my marriage was on the rocks, so it was no big deal. I did stay in the hospital overnight. That's what they did then. It was before Roe v. Wade. The second one was the year after when I'd left him, and that was also an accident, and it just... It was no big deal at that time. So the whole world has changed because working in OBGYN, counseling women, make them feel they had a choice, make them consider the alternatives and pick what was right for them. Women stopped even considering anything besides keeping an unwanted pregnancy, so the world really changed. Also, besides the wonderful studies that Amanda just showed, there was an old, old study from Scandinavia that showed women who had severe mental illness who were denied pregnancy termination, their mental health got worse, but when they were allowed to terminate a pregnancy, their severe mental illness got better. So that's consistent with the later research. So I bring you greetings from the island of Maui, from our beloved Haleakala Crater and our unique Ahinahina Silver Sword plant. I have none of these kind of disclosures. My title is FeminXtrem, Women in Disaster, and our current environment includes... Just in March, two months ago, there were four negative and one positive story in the news. So how can we promote women's mental health where we're daily bombarded by negative reports? Female genital cutting is increasing worldwide. In India, women doing forced labor to cut sugar have to have hysterectomies to keep working. And in our country, in the US, social media makes teens and young women stop hormonal contraception. And finally, fake pornographic videos target girls 7 to 13, and most of them actually contemplate suicide. Excessive consumption of media interferes with recovery from traumatic stress, including disasters, but there was one positive story. President Biden signed an executive order, and Congress agreed to invest $12 billion in women's mental health research at NIH. And back to my day, Joan Baez says, action is the antidote to despair. So my takeaway is pick an issue and advocate. Personally, I think there are two things that we can do to promote women's mental health. One, I think we can push to make the field cover the whole lifespan, not just perinatal, but children and elders are also important. That's my opinion. And I think we could work to connect adult and child psychiatry better. They're kind of siloed. The field of women's mental health has made progress with the APA Committee on Women's Mental Health as of this minute, because the assembly was just over, or the end of this meeting, is being elevated to a council, which has 10 times the budget. It's a big, big difference. And this has been going on for years and years and years, and it's actually happening. And so that's very exciting. And the new subspecialty of perinatal or reproductive psychiatry now has a curriculum. There's an online curriculum, there are fellowships, and many online organizations. PSI, that Amanda talked about, Postpartum International is one of them, and NASPOG, which is half psychiatrists and half OBGYNs under ACOG, North American Association of Psychosocial OBGYN, and also the Marseilles Society, which was always in... Well, the one I went to in the 90s was in England, but now there's a US group, MONA. So there's three organizations really focused on this area, which is pretty exciting. So girls need education about many issues, including sex, gender, menstrual health, sexual abuse, pregnancy, contraception, and substance misuse, which is associated with unwanted pregnancy, and substance use during pregnancy, which has been criminalized and which interferes with both medical and psychiatric care. In disasters, we help mothers cope to foster the well being of their children, but nothing undoes a mom more than a child who's not doing well. So we have to help children to cope, to foster the mental health of their mothers, and this goes for fathers too. And elders are predominantly women, and if they have cognitive or physical impairments, they're more vulnerable in disasters. Of the 100 people who died in the Maui wildfire last year in the summer, almost all were elders. Women are more vulnerable than men in disasters because of social and structural inequities, which are brilliantly outlined in this iconic book, Social Injustice and Mental Health. Women are vulnerable in disasters because they have more mood problems and trauma exposure than men. Pregnant and postpartum women are especially vulnerable, and women have twice the rate of long COVID as men. Compared to men, women experience higher rates of poverty, they live in high risk residences, they live near contaminated neighborhoods, they have inadequate access to resources, which are needed for disaster recovery. So research on gender differences in disasters is limited and mixed, but several studies have found that while women have greater awareness of hazards in their area than men, they're less likely to be prepared than men. Protective factors for women include social support and a strong sense of community. Gender inequity is exacerbated in disasters. Traditional gender roles resurface and women are left out of decision making. There's been gender blindness in the study of disasters, so we need more study of the mental health effects of disasters in women. Four areas in which women are disadvantaged in disasters include the military, intimate partner violence, multiple roles, and access to health care. The military and war have been associated with psychological trauma. In the Civil War, it was called soldier's heart. In World War I, it was called shell shock. In World War II, it was combat fatigue. But it was not until 1980 that PTSD got into DSM. Little was known about active duty women until this 2015 textbook, and you could read about the experience of a woman doctor on a Navy ship who, quote, had to be cautious, not to cross the line and be, quote, too social the first year. But by the second year, could, quote, dance in bars and, quote, enjoy a cigar with the commanding officer. So half of the short, readable chapters in this book are actually on psychosocial topics. Rates of PTSD in the general population are higher for women than for men, but rates of combat related PTSD are the same for women and men, suggesting that training is effective. The major source of traumatic stress for military women is sexual violence. As for women veterans, many do not feel safe in the VA's medical system. The VA has improved, but they need to improve more and be more welcoming to women. Compared to civilian women, military women have higher rates of intimate partner violence and are even less likely to report. And unlike civilian women, active duty women face a greater threat to their military careers and do not have the freedom to leave their abuser. Disasters are associated with increased rates of intimate partner violence, which is a hidden feature of disasters and a public health issue, and it's associated with adverse health outcomes. Violence against women increased after Hurricane Katrina, the Deepwater Horizon oil spill, the Haiti earthquake, the Ebola outbreak, and the COVID-19 pandemic. The characteristics of disasters themselves can trigger violence, like fear and uncertainty, economic insecurity, the physical and social isolation of pandemics, reduce health service availability, and the inability of women to escape their abusive partners. Essential healthcare services for women who've experienced IPV, intimate partner violence, include emergency contraception and pregnancy termination, which are now illegal in many states. Safety is the first principle of psychological first aid. Disasters threaten personal safety. Along with war and terrorism, interpersonal violence is one of the most stressful human experiences. Family violence is linked to economic stress, so giving food and cash, like SNAP, the Supplemental Nutrition Assistance Program, reduces violence against women, and cash support helps women leave abusive relationships. Disaster preparedness includes identifying households at risk for violence and considering income support, like cash transfer programs for women, including child care vouchers. Women's caregiving demands increase in disasters, while access to services decreases. During the pandemic, school closures increased the burden of care for women, for mothers with children at home, and exemplified by this YouTube video of an eight year old girl doing an impression of her mom multitasking while working from home. So, paid parental leave and subsidized child care would help. Disproportionate lack of access to healthcare. Our healthcare system discriminates against women. This inequity is exacerbated in disasters with lack of access to care, exposure to exploitative relationships, and financial hardship. During the pandemic, resources shifted to the public health emergency and disrupted reproductive and sexual health services for women and girls, resulting in an increase in teen pregnancy and maternal mortality. During the 2014 Ebola outbreak in West Africa, there were more deaths from maternal and fetal mortality than from Ebola. In the US, insurers charge women more than they charge men because women use more medical care than men, so we have higher healthcare costs. Our National Affordable Care Act was supposed to have eliminated gender rating, but states charge women more than they charge men. Private insurers consider being a woman a pre existing condition. In conclusion, women's mental health should cover the lifespan, and we should better connect adult and child psychiatry. Women are vulnerable in disasters because of the social and structural inequities. Rates of PTSD in the general population are higher in women than in men, but rates of combat related PTSD are the same for women and men. VA medical care needs to be more welcoming to women. Disasters associated with increased rates of intimate partner violence, which disproportionately affect women, giving food and cash reduces intimate partner violence, and individuals at risk should be targeted for interventions. Women are more vulnerable than men in disasters because disasters increase caregiving demands while decreasing access to resources. Paid parental leave and subsidized childcare would help. Women are discriminated against by the US healthcare system. This inequity is exacerbated in disasters with lack of access to care, including women's reproductive healthcare, exposure to exploitative relationships, and financial hardship. Real healthcare reform would help. I leave you with this beautiful picture of the West Maui Mountains that I see out of my window every morning, and if you want a copy of this talk or the slides, you can email me at leslieg at maui.net or call me at 808-283-9095. Thank you. Thank you. One sec while we get back to Carol's slides. Carol was very upset that she couldn't be here until the last minute. She was thinking, could she fly from Chicago? Would it be okay? And blah, blah, blah. But I think it just didn't work out. Yeah. Her partner had been quite ill and then some things happened, but... Oops, I'm sorry. This is... Let's get back to Carol's stuff. Okay. So, Carol is the Director of the National Center on Domestic Violence, Trauma, and Mental Health, and frequently talks about the difficulties with the intersection for women between mental health care and substance use disorders, and also with the spiraling social and mental health difficulties that are often involved. So she starts out with some facts about domestic violence and intimate partner violence, noting that enormous percentages of women who access substance use disorder treatments report having these experiences. 47% to 90% of women in treatment for substance use disorders report domestic violence sometime in their lifetime, and 31% to 67%, depending on the study, report experiencing domestic violence within the preceding year. Victimization by an intimate partner increases the risk for depression, PTSD, substance use, and suicidality, often in a synergistic fashion with triple rates compared to control populations for PTSD, major depressive disorder, and self-harm, four times the rate in suicide attempts and six times the rate in substance use disorders. And then what about women who are accessing care for mental health conditions other than substance use disorders? There are also rates of domestic violence are very high, 30% roughly on average of women in outpatient settings, 33% of women in inpatient settings, and up to 60% of women in psychiatric ER settings report victimization by an intimate partner in the last year. So that alone is very disturbing, but less well recognized are the ways in which people, usually men people, who abuse their partners engage in coercive tactics that are targeted toward their victim's mental health or use of substances. So this has been looked at in terms of substance use coercion, and the results are grim, that intimate partner violence is often targeted toward undermining a partner's mental health treatment and recovery. So that then fosters continued dependency and makes it less likely that she will be able to leave the relationship. And it is often also targeted toward undermining a partner's substance use disorder treatment and recovery and she provides some statistics there that are that are also very disturbing as well as specifics in terms of qualitative findings in this research. So research really drilling down in terms of substance use disorders and intimate partner violence finds these types of problems. Coerced use, women who begin using substances with pressure from the partner, being pressured to use with the partner he's wanting to use and so wants her to use with him, being in situations in which because of the power dynamics of the relationship she feels unable to refuse or is manipulated or threatened into using or in some cases actively just injected by a partner forcibly or drug through some other means. They report treatment interference or sabotage of recovery. Women report being prevented from attending AA and NA meetings by partners, being prevented from attending medical and therapy visits, having transportation sabotaged, child care that was agreed upon withheld, being harassed into leaving treatment programs, having medications controlled or diverted, substances being brought into the home during or after treatment, having the partner use in front of them and insisting that they watch, hoping that they will be triggered and also finding that in relationships that already are marked by violence that the violence can escalate when she attempts to stop using substances or even just to reduce use. Substance use related sexual coercion is not uncommon. Coerced or forced sex, pressure to use substances and have sex, pressure to have sex after use of substances, which ties in with some of the themes that we've touched on earlier. Blaming the abuse on the partner's use, benefiting in the power dynamic, the abuser benefiting from stigmas around women and substance use and then also threats that, you know, if use is curtailed or if the relationship is ended, that she will be reported to Child Protective Services, police or probation officers, employers. This could be a true allegation or a false one. In addition, in legal settings, the partner who is making the report is often believed over the one who's being reported on, even if there is not validity and when it's a heterosexual relationship with the man being the reporter, that tends to be more so. This diagram looks at these different factors and how they interact to magnify the impact on intimate partner violence survivors and also secondarily on their children. So it's similar to the old power and control wheel, but fleshes this out in terms of substance use disorders. So, you know, the trauma that goes with the violent dynamic to begin with, the substance use coming into that picture in one way or another, as we've touched on, abusers actively undermining sobriety, undermining mental health, undermining parenting, abusers controlling treatment, medication access, sabotaging recovery, and then using the substance use that either is occurring or has occurred to interfere further with treatment and other sources of support. And then also the ultimate threat, using those things as threats regarding child custody should help seeking occur. At the bottom line, experiencing a mental health or substance use disorder places individuals, particularly women, at greater risk for being controlled by an abusive partner. And stigma associated with these conditions contributes to that effectiveness of the abuse tactics and also to the barriers that people experience when they seek help. And then that is further exacerbated by the structural violence that makes it harder for women to access services and get out of situations that are hurting them. She elaborates further on implications for the civil and criminal, legal and child welfare systems regarding that intersection again between coercion with regard to mental health and mental health treatment, substance use disorders, and reproductive coercion. At the time that she put together this presentation, and it may even be slightly higher now, 24 states and the District of Columbia consider substance use during pregnancy to be child abuse under civil child welfare statutes. Three states consider it grounds for civil commitment. And 25 states and the District of Columbia require health care professionals to report suspected prenatal drug use. Eight states require them to test for prenatal drug exposure if they suspect drug use. The implications of that are really obvious in terms of the interaction between needing care and at the same time being fearful of care and needing to avoid care due to this intrusion and the fear that rather than getting treatment that this will result in loss of child custody or of prosecution. There have been cases in which women who had used substances or had had some other event that may have been under their control miscarried and then that was considered evidence of prenatal child abuse and resulted in legal sanctions. There's also the reproductive coercion that goes with intimate partner violence. This includes sabotage of birth control, coerced pregnancy, and pressure to become pregnant when this is not wanted. The definitions that are provided there, birth control sabotage is active interference with a partner's contraceptive methods, things like stealthing in which a condom is used during heterosexual PIV intercourse but during the act the condom is secretly removed so that there is no condom at the time of ejaculation or damaging barrier devices in some other way, getting rid of oral contraceptives, things like that. Pregnancy pressure is exactly like what it sounds, pressuring a woman to become pregnant when she doesn't want to or coercion in terms of threats or acts of violence. If a pregnancy is either terminated when the perpetrator does not want that or continued when the perpetrator wants the woman to terminate the pregnancy, it's not the question of whether the pregnancy goes forward or not, it's the question of who's in charge of that and in that case it is the abuser. And we already talked about the prenatal child abuse concept, the wrongful death concepts, etc. Substance use is a major cause of child removal in a way that is out of proportion. You know, treatment would be the better option, let's just say that. The war on drugs promoted that dynamic, we're left with the types of biases that got sort of baked into the system during those years. Intervention by the courts is really not the same as support and should not be conflated with helping children or families. This is another disturbing graph showing the prevalence of parental substance abuse, much more moms than dads, as a factor for child removal in the U.S. over, you know, basically a generation's worth of time that that just has ticked up and up in a, you know, almost linear fashion. This is another one in terms of substance use as a factor in women's incarceration. If we look at statistics about the incarceration of women, even controlling for a variety of intersectionality factors, a generation ago rates were much lower and at this point women are being jailed at higher rates than ever. Over the past 35 years total arrests have risen 25% for women in the U.S. but at the same time have decreased for men by 33% and this is largely driven by substance use and often linked to child concerns in the way that we've discussed. Perpetrators of intimate partner violence leverage these punitive systems and policies against their partners, resulting in arrest and incarceration or child removal related to substance use. It totally distorts the idea of seeking help. Women will not seek help for substance use disorders or other mental health conditions if there's fear that their children will be removed and then if the substance use disorder has led to other activities that are illegal such as sex work theft or being involved in dealing of drugs, that can be compelled by both the physiological dependence and also coerced by the abusive partner who also is using and she will bear the brunt of that economically and in terms of freedom. We've talked about the ways in which partners can interfere with treatment required by probation but that also extends into sentencing agreements, family reunification plans, etc. Program requirements very rarely take into account intimate partner violence or substance use coercion and so the conditions that are imposed may be difficult or impossible to comply with. Also, mandating clinicians to do the things that we talked about is not a way to get safe or effective treatment for women who are experiencing domestic violence or substance use coercion and also custody evaluators and judges are usually not trained to factor in these types of dynamics and coercion. Psychiatrists have a critical role to play in supporting survivors of these contexts in terms of taking a careful history and recognizing the role that coercion may be playing in the development and exacerbation of mental health and substance use conditions, in the ability to access treatment, in the risk of relapse in the failure of recovery efforts and so forth. Strong advice is to incorporate this into routine practice in a trauma informed and culture and gender responsive manner. To have information and resources on intimate partner violence available to patients but also to train staff in that regard. So much of the time front-end staff are the people who interact with patients first, have the least training and to look at the systems from a structural standpoint with attention to safety, confidentiality and privacy in terms of documentation. For people who are involved with the EPIC record, you know, it's now easier than ever before to access records from a lot of sources that patients may not realize are generally available. And then there's the question of actual physical safety from abusive partners in the process of seeking treatment. Strong advice to integrate conversations about coercion into assessment processes and ongoing treatment and then to strategize about ways to access services and mitigate effects in the safest way possible. It's in Carol's world, there needs to be a much stronger partnership between domestic violence programs and counseling around intimate partner violence in the context of mental health and substance use disorder treatment. We'll talk further in small groups about brainstorming ways that, you know, possibly this can be operationalized and made actionable. There's also a list of resources that can help us to uptrain in that regard as well as the contact information for the National Center on Domestic Violence Trauma and Mental Health. So Carol sends her regrets and would be pleased to be contacted by anybody who had additional questions beyond what we can address today. Thanks. Last bit, and then into small groups. Talking a little bit about trans youth, particularly denial of medically necessary services resulting in forced masculinization of trans girls. Trans boys and non-binary youth also need services often, and there's a lot of non-binary youth also need services often, but the stakes are different for trans girls. Raise your hand if you really enjoyed puberty, even if it was in the right direction and was the one that you wanted. Puberty was great, yeah. I never get that response ever. People sort of chuckle and have that look like, oh my gosh, I somehow got through it, but here we are. And then imagine if it were in the wrong direction, particularly for youth who are psychologically girls and who are heading into a very unwanted male puberty. That, you know, if there were a non-trans girl, which occasionally there is a cisgender girl who has a masculinizing tumor and is becoming hirsute and is having skeletal changes and so forth, we get very excited about that in terms of let's get services immediately. Well, what about girls who are trans and this is happening endogenously? The distress is often absolutely no less. Over the last sort of 15 years or so, trans people have been in the media much more than was the case before, which has resulted in greater visibility and in some cases good things in terms of acceptance, but also has resulted in targeting of a vulnerable minority. This is a little bit from the CPAC, the conservative conference that happens every year, that a quote from Michael Knowles, for the good of society, transgenderism must be eradicated from public life entirely, the whole preposterous ideology at every level. So he was asked, well, isn't that basically the same as saying that you want to get rid of trans people? And he said, oh no, no, just this ideology, which makes really no sense. Religious persecution is a persecution of people, not just of a particular system of belief or way of interacting with the world. Politically and dynamically, uniting against the feared other has been a technique for consolidating power that has gone on for hundreds and thousands of years. Pick a group of people that is in some way vulnerable and not too big or numerous and make them the cause of all of the problems, and people will unite against them much of the time. For people who are trans, or in some other way, gender diverse, this is not an enormous group of people. Historically, the number of folks who were transitioning gender was very small. In the 90s, it was less than 1 in 20,000 people. In the Netherlands, which was one of the most welcoming environments in the world, who transitioned gender. At this point, there are more people because it's more possible, and the persecution has been less. But even so, all LGBTQ identities together, not just trans people, in the youngest adult generation, the Gen Z in the U.S., has stabilized at around 7%. And with older age cohorts, it's much less until you get down to the 1 to 2% range in the oldest adult cohorts. Trans youth, especially trans girls, are often a target in the guise of parental rights, which is another one of those, sort of, it's the exact opposite of what it says, situations in that most parents do support their trans children. It's been pointed out by political analysts that anti-trans rhetoric may be more palatable to more people than misogynistic and anti-abortion rhetoric, just as numbers. And so, it may be a preferred political strategy. Ways in which the targets that are being pursued at present involve attempts to redefine sex, to eliminate trans people or the possibility of changing one's sex in law and policy, and to restrict access of services for trans youth, the goal being eventually trans adults as well. The initial, as I mentioned before, the initial bans on services for trans youth were sub-18, and then 21 states began passing laws, and now there are a couple of bills that would raise the age of consent for gender-affirming care to 26, and the groups that are driving on that say ultimately the goal is to make it unavailable for everyone. Changing what can be talked about in school, as in Florida, and attempting to make religious exemptions overly broad. For trans girls, suspension of the forward progress of puberty is the neutral option while this can get sorted out. You know, there are some kids who are very identifiably trans from very young ages, but there are many others for whom it's not entirely clear what the best path forward is. If puberty is stopped, you know, a lot of kids enter puberty quite young, 11, 10, 9, too young to be making major body-changing decisions, but at the same time, allowing puberty to progress is not a neutral option either. There is no strictly neutral option, but the best that we have is to put the brakes on the puberty process with GnRH analogs and allow a couple of years for cognitive and emotional development to catch up before additional treatments are utilized. Lack of access to puberty blockers, i.e. GnRH analogs, resulting in unwanted masculinization can greatly exacerbate the gender dysphoria, other mental health symptoms, and thoughts of suicide. Stopping the forward progress of puberty can result in relief. It's similar for trans boys, but again, the effects are not totally equal. This is a suicide note from a few years ago from a trans teen, age 16, named Leah Alcorn, and she ended her life. She posted this on a social media account with a timer so that it would go up three days from when she posted it, so that if the suicide had not completed, she could have taken it down, but this was her last note. I'm never going to find a man who loves me. I'm never going to be happy. And then she goes on and on. People say it gets better, but that isn't true in my case. It's worse. Each day I get worse. That's the gist of it. That's why I feel like killing myself. The only way I will rest in peace is if one day transgender people are not treated the way I was, if they're treated like humans with valid feelings and human rights. What had happened in her case was that she was attempting to get puberty blockers, was not able to get them, was taken to a therapist who did not call it conversion therapy, but was essentially helping her, quote-unquote, to get in touch with her masculinity, and so her parents thought that she was getting better because she just stopped talking about her distress, realizing that she was getting no help, but wrote in her journal about, I'm getting so hairy, my feet are enormous. As male, puberty was taking her in a very bad direction and then ended her life. Similar to the data that Dr. Corey presented about for reproductive-age women in states with abortion bans, anxiety, depression, etc., increase even if the person is not currently needing any reproductive services. The same thing happens with trans and LGBTQ identified youth, that laws are reflected in people's mental health or mental health difficulties. I have trouble keeping these slides up to date because this is a very rapidly moving target, but at this point, the attempts to limit or make impossible the access to puberty blockade and other gender-affirming care for youth is escalating. This was from, gosh, maybe, when was that? Eight months ago? And this is a more recent one, that with basically a huge swath of the country blacked out. It doesn't end there. The implication that a group of people are somehow so objectionable that we can't talk about you in school, you can't have the medical services that you need, you can't decide this for yourself, has implications in terms of acts of violence and abuse. This is from a website, I gave you the reference there, where they keep track of all kinds of armed conflict and politicized violence in the US and worldwide. They actually didn't start keeping track specifically of anti-LGBTQ-related violence until fairly recent years, but the curve is alarming, and so is the map showing where the hotspots have been. To my take, attempts to control adult women and to control trans girls are really similar in a lot of ways. Disallow personal physical autonomy, like with the abusive partner. The issue isn't, is the pregnancy going to continue or is the pregnancy going to be ended, it's who decides that. Is it the woman herself, is it the abusive partner, is it the state? Similarly with trans girls, it's framed as parental rights, but actually most parents of trans girls are in support of their getting puberty blockade if that's needed, or other services that are needed at the time. Imply or flat out state the lack of capacity to make these decisions. You do not have the capacity to do that, whether it's continue or start a pregnancy, whether it's gender transition, we will make that decision for you. Then amplify the experiences of regret and ignore the experiences of relief. In the TurnAway study, there was that 1% of women who really regretted their abortion, and it does happen. Regret is freedom projected into the past. You had the freedom to choose at that time, and 99% of people in that study were pleased with their choice, 1% were regretful. I don't think that there's any decision in life that will look much better than that. Use that dynamic to consolidate political power by stereotyping and calling attention to and persecuting the feared or despised other. The same tactics are in use in this country and really all over the world, because the dynamic that they reflect has been in practice pretty much throughout human history. As far as I can tell, it's just that right now, these are the particular dynamics that we're dealing with. I included some resources in that regard. At this point, what we'd really like to do for the next 10 minutes, just a brief, if people can group with maybe sort of half a dozen folks just in your area and reflect on the subjects that we've been talking about, and just come up with a list of, you know, we've got all these psychiatrists here. There's a lot of experience, knowledge, expertise in this one room. What are three things that we can do as psychiatrists that might address any of the things that we've been talking about today? And, you know, if someone can scribe your one, two, and three, then we'll have a little readout at the end and see where to go from here. Okay? So thank you much. Groups of five or six, 10 minutes, a little less. Thank you. Thank you. All right. Let's wrap up and have a spokesperson from each group. That would be tremendous. I'm really looking forward to the ideas that people have. We do have a microphone there on a stand. It might be if maybe one person or two people from each group just came up to the stand microphone and give us your thoughts, and we'll just sort of share what people came up with. Can we do that? Thank you, Leslie. All right. Who's first? And say your name and where you're from, too, so we just get a sense of who we're talking to. Okay. Hi. My name is Laura. I am from Chicago but originally from Houston, Texas. So something that I've been thinking about doing in my future practice is staying in Chicago but opening up telehealth access to those in Texas so I can still be safe myself as a person, as a woman in Illinois, but still try to help out people in other areas. So that's my plan. By most state laws, I think, including Texas, it's considered providing care in Texas. But what some people are starting to do is to say, well, what's the closest state to you that has more lenient laws, and could you drive across the border and then call me on your cell phone and we'll do a Zoom visit that way, which is, depending on where the person lives, may be really terrible, but is certainly better than the alternatives. Yeah. Cool. Other thoughts from the group? Hi. I'm Catherine. I'm representing the lovely group in the back. And we came up with a model that I like, three things that I'm going to use going forward. The first one is to be as educated as possible as a provider. The second one is to do what's within our control, and that is to create a safe space for our patients. And then the third thing is to be aware or be able to offer resources or direct patients to resources. That maybe we can't directly provide, but that we can direct them to. Yeah. Yeah. Where are the websites? What are some safe sources? Are there online or on-phone options? Yeah. Terrific. Okay. I'm Sunny. I'm a third-year medical student. Welcome. At the Lake Erie College of Osteopathic Medicine, so incoming fourth year, and this is my group here. And then we have two PGY2 residents. So some things that we were talking about were, you know, from the med student perspective, you know, we haven't had much clinical experience yet. So one thing that we can do is, like we said, talking about it, you know, being very forward with patients, you know, letting them know, like, especially with the substance use in pregnancy. You know, like if, you know, you say it, you know, I have to report it, but this is what you can – these are the resources that you need, which is pretty much what the other group said, in order to stop during pregnancy and make sure that they have everything, but they know that there's that hard line that if you tell me, I have to report it. And then another point was that, you know, these talks, you know, the residents were saying, you know, they hear these things, you know, you've kind of – you're starting to master the history-taking process in residency and things like that. So hearing, like, dynamics and dialogues through these presentations, then you go back to your clinical practice and you're able to recognize that and then act on it, which is another thing that we said. So, yeah. Cool. You know, I've heard Carol Warshaw speak a number of times, but today as I was standing here reading some of the statistics of her slides, it was, again, sinking in even more deeply that, like, you know, this is something that really every patient that I see that, you know, this should be worked in. Yeah, absolutely. Sounds good. Who's next? Hi. My name is Memphis. I'm with this lovely group of individuals from very diverse backgrounds. Hi, group. And so I think we came up with a lot of things, but one main thing is basically stop – as clinicians, stop ourselves from assuming that these issues aren't really affecting our patients in the first place and really letting that sink in. And then, secondly, providing the space for them to be able to openly discuss this, kind of sort of not being able to glance over it, avoid assumptions of what our patients may be going through and just really openly letting them talk about it. And a lot of – echoing a lot of what a lot of everyone was saying is self-educating, not only about how to address these issues, the issues our clients may be going through, but also on top of that, educating ourselves of what is available in the community and their surrounding environment to really support our patients and clients. All of that sounds good. And one of the things implicit in what you said that I would also add, and your group also touched on that too, is knowing what your state laws are. When it comes to reporting substance use in pregnancy, they're really different. In some states, you can have an open, honest discussion and help people get treatment, and in others, as you said, if you tell me more about this, I will need to report it. And absolutely, I think the more that we remain in dialogue with each other and with our patients in a calm and thoughtful way, the better. Other thoughts from anyone else? Closing thoughts from our panelists. In terms of substance problems in women who are pregnant, I never liked addicts. I took geriatric boards before I moved, and I didn't take addiction boards because I didn't like addicts. But then I moved to Maui, I wound up working part-time for eight years in a place treating pregnant and parenting women who had substance problems. So it was the first time that I was doing consultation liaison psychiatry. I just saw people with substance problems who were making trouble, and they wanted you to fix it. But these were people who were trying to recover, so that changed my attitude. And they had a program where they had indigenous women who were going to the prenatal clinics and just connecting with the people there and just giving them education. Every week they would go and give them educational information. Do you know anybody who has a substance problem? Did you ever have a problem like that in the past? And just generally having a connection. And then the facility that treated it, 100% of women who eventually came in there, who crossed the threshold, and they had acupuncture for smoking cessation. They all came for smoking cessation. But once they got there and they found that people were nonjudgmental and they saw a lot of people there that they'd been smoking. Our local speed is called ICE because it's like crack. They saw people that they knew from getting high in bathrooms. Then they fessed up that they were smoking crack. So the stigma, I think, is very overwhelming and that we have to start thinking of preventive strategies and that once these problems develop, they're harder to deal with. Leslie, I'm going to distill from that. You just gave the example. Number one, a lot of times change starts with our own attitudes and self-education. Number two, use local resources and partner with culturally competent care providers. Number three, this takes time and support to get through the stigma and be able to talk about things in a real and genuine manner. And number four, it can be very successful. Or was that number five? Anyway, we're at time. So thanks, everybody, very much for coming. Appreciate it very much.

women's mental health

legal changes

policy changes

intimate partner violence

substance use

abortion restrictions

culturally competent care

systemic discrimination

trans youth support

Turnaway study

disaster impact