Okay, good morning everybody Thank you all for joining us. Welcome to San Francisco Since it's just a few of us anybody traveling from far away. Where are you coming in from? Jersey, where else? New York Boston Warsaw okay you win the prize. I thought I'd be the farthest I just came from West Virginia, and I've got two of my West Virginia folks here, so we're excited So welcome my name is Tobias Murphy. I'm the chair for this presentation. I'm a geriatric psychiatry fellow at Marshall University You might notice a different name So this would appear to be the year for me personally that gender dysphoria has developed into Needing to take some steps, so I go by Tobias he him this is ash shade a PhD psychology student We'll also hear from two other Child adolescent psychiatry doctors, but they made videos for me because they couldn't apparently leave Arizona to be here today unfortunately So just as an overview I'm gonna give a few minutes. I'm just kind of talking about why this talk is a topic is important especially this year We're talking about providing gender-affirming care and vulnerable patient populations Dr. Tukvi Zhuang, I'm not sure I'm pronouncing her name correctly Also has a video that we've embedded talking about autism spectrum disorder and stages of development Then dr. Mortallaro will talk about gender identity development and autism spectrum disorder I'll chat a little bit in summary kind of wrap things around Mr. Shade is going to talk to us about the human cost of ignoring the research I think we're all seeing a lot of that in the news right now and hopefully leave 30 minutes for questions Hopefully none of us will take too long. So and feel free to stop at any point So I thought I'd start a little bit The human element here. I'm from West Virginia May or may not have seen a recent study on I think it was 2017 different States in the nation and what their per capita rates of transgender youth was West Virginia was the highest in the nation At the same time they just signed a ban on gender-affirming care for transgender youth I think a lot of us, you know, you've been on the wonderful APA pages about LGBT health how gender-affirming care is very important life-saving So this is just one of many states Luckily, we're seeing some states being sort of bastions of transgender protection and care and other states where we're afraid in our own state there was luckily a physician who managed to Push them to sign through an exception for severe gender dysphoria So as you guys might know, there's no such moniker. There's no such specifier in the SDSM So we've now had to assemble groups to say okay as practitioners providers. How can we make sure that we're doing the right thing? As practitioners providers, how can we make sure that youth get the severe gender dysphoria moniker so that they can get the care they need? The rate of suicidal ideation in my state is three times higher than other youth in the state We have high rates of things like domestic abuse Poverty we have rural areas. So Really what you're doing is taking kids who fought so hard to get the care they need and now it's been taken away from them at the state level One in five transgender people in West Virginia According to one study said that they were denied care because they were trans like you got all the way here Sorry, you're trans. I won't treat you and 75% of doctors in my state Say they feel unprepared to treat them in any capacity. You're in the ER. You have a laceration. Sorry, you're trans I'm not prepared to treat you 85% of transgender and non-binary youth nationwide say that their mental health has been negatively impacted by recent debates about state laws in the news I even heard a doctor quoting one patient is saying, you know, why did you attempt to commit suicide? My state doesn't want me. They don't want me alive So it's hitting youth hard Adults as well. The feeling was that this was mainly a youth issue, but there are also states banning adults transgender care And of course every mental major medical organization supports gender-affirming care for youth including the American American Medical Association American Academy of Pediatrics and the American Psychiatry Association So just briefly this year I think this is even higher today. But as of me getting this slide a few days ago 549 bills 49 states 71 passed 376 active and 102 failed. We're really just waiting for a lot of these to timeout You might say well, how does this compare to past years? Well 2015 there was like 13 bills proposed So this amounts to an orchestrated Attempt to not listen to doctors not listen to medical associations not listen to evidence-based Science-based research very similar to some coven type effects But we can see how somehow 2023 was just the year that certain people had their hair on fire about this issue There is no evidence. However that suddenly transgender People are causing so much trouble to warrant this sort of attention So our objectives for this talk and getting into why We understand why this is important. We're going to talk about the current literature that exists regarding autism spectrum disorder and gender dysphoria this being a category where Basically transgender people are six times more likely according to certain studies to have gender dysphoria diagnosis So we'll get into the details of that recognize clinicians responsibilities in treating patients on the autism spectrum We're going to discuss the experience of mr. Ashade here a mental health provider who's transgender including self-advocacy while navigating the legal and medical systems to acquire appropriate gender-affirming care You know if even in the medical field, we're having trouble advocating for ourselves knowing what we know It's it's difficult to imagine how it is for youth We're going to discuss disparities and mistreatment that transgender people experience in everyday life including health care how this is being Compounded for other layers of minority stress like for transgender people of color and How now that you understand hopefully you already did but now that you further understand how important this is How can you consider how to make your clinic transgender friendly from start to finish? So first we're going to hear from Dr. Truc V She'll say her last name. I think it's swan born in Vietnam Immigrated at age 17 to Portland went to the University of Portland There's a lot of great biographical details here I won't read to you because you're wonderful readers of psychiatrists, but currently a second-year child adolescent psychiatry fellow at Kaiser Permanente She studies early childhood trauma LGBTQ plus cultural psychiatry and intimate partner violence She's a 2022 2023 Sam's a minority fellow from the APA And she's trying to target the public health issue of increasing domestic violence and substance use during the kova 19 pound Demick in the Asian community. I Appreciate her also telling me that she enjoys karaoke thriller movies pickleball and her girlfriend her her two kittens My name is me you and I am a child and adolescent fellow at Kaiser Permanente in Fontana, Southern, California Today, I'm gonna briefly discuss the developmental theory among Neurotypical child in the next couple of slides. I would discuss the following theory for a PRJ Erickson and Colbert The first theory we will discuss is from Sigmund Freud Freud idea emphasize sexual desire in shaping an individual personality and behavior For a proposed that human development occurred in distinct stages The first day is oral state from 0 to 18 month During this stage the focus of pleasure is on the mouth and the conflict involved winning off Breastfeeding or bottle feeding the second stage is anal state from 18 months to 3 years During this stage pleasure is deprived from the anus and the main conflict Arrive from toilet training and learning to control bodily functions The first stage is phallic state from 3 to 6 years. The general become the primary source of pleasure During this stage Sigmund Freud proposed a nautical concept associated with Oedipus complex This complex involved young boy Developing sexual desire for his mother and feeling envious with his father in Greek mythology Oedipus is a character who actually killed his father in the story and then get married to his mother similarly in girls Sigmund Freud developed Electro-conflicts involving a girl having sexual desire toward her father and feeling envious toward the mother The next stage of Sigmund Freud theory is the latency stage from 6 years old to puberty sexual impulses are Repressed and children focus on developing social and intellectual skill And this is when you started seeing the cootie concept among young children for anyone that don't know cootie are you to describe an undesirable person of The opposite sex and that person might be infected with germ the last stage is genital stage This is from puberty Toward adulthood the individual during this stage will reach sexual maturity and the primary focus of pleasure shifts to sexual relationship with other people the next important developmental theory that I want to discuss about is from Eric Erickson and If anyone ever taken the child and adolescent board, you have to know this developmental theory by heart so Erickson theory contain eight different stages. The eight stages are trust versus mistrust autonomy versus shame and doubt initiative versus guilt industry versus inferiority identity versus role confusion intimacy versus isolation Generativity versus stagnation integrity versus despair Due to the limits of time I want to focus on stages from 3 to 6 only as they are related to our topic So state 3 initiated versus guilt children during this day will explore the environment Initiate activity and develop a sense of purpose if they receive support and encouragement they will develop a sense of initiative state 4 industry versus Inferiority children acquire new skill and knowledge through school and friendship during this stage if they receive Recognition for their achievement and feel competent. They will develop a sense of industry stage 5 identity versus role confusion Adolescent during this state would explore their identity including their values belief and goal Stay sick intimacy versus isolation Young adult seek close and meaningful relationship with other people During this stage a lot of people with autism Will have difficulty forming a relationship due to their challenges in social connection and communication Next I will briefly discuss the cognitive developmental theory from PHA Here are the four main stages of PHA theory The first one is sensory motor stage from birth to two years during the sensory motor stage infant learn about a world through their senses and motor action and They will develop object permanent as well as stranger anxiety The second state is pre operational stage from two to seven years During this state children use simple language and mental representation to understand and represent the world They will engage in pretend play and their thinking is usually egocentric Meaning that they have difficulty seeing things from the other person perspective the following video Will show you what's egocentrism mean Here the adult and child sit at opposite sides of the table They can see one side of the mountain scene in front of them Once they've had a chance to look at the mountain The adult asked the child to point to which of the four mountain scenes that the adult can see This requires children to think about the mountain scene from another person's perspective Often younger children like five-year-old Brayden They point to the mountain scene that corresponds with their own perspectives of the mountains and not the adults However, a few years can make all the difference Delaney who is eight years old can take someone else's perspective more easily And instead of pointing to the scene from her own perspective. She points to the mountain scene that the adult can see The third state is concrete operational stage during this state children become capable of logical thinking Their thinking is limited to concrete and tangible experience It's limited to concrete and tangible experience They will start thinking about concepts like conservation. The following video will show you what this concept is Same amount, okay Okay, tell me when this one is the same the same the same those two are the same now, yeah, okay Okay Okay Okay, now watch this we're gonna take the blue water from this glass i'm gonna pour it into this glass Now does this glass have more water does this glass have more water or are they the same Has more water this one has more water. Can you tell me why because that one's higher than that? That's higher than that one, right The final state of pha theory is formal operational stage from 11 years old to adulthood during this stage adolescent and adult develop the ability to think abstractly And they can engage in hypothetical reasoning the following video will show the difference between abstract thinking ability of a child and an adolescent It says if you hit a glass with a hammer the glass will break I knew that And then this one says don hit a glass with a hammer I knew that too. So what happened to the glass? It broke. It broke. Why did it break? Because the hammer's hard If you hit a glass with a feather the glass will break. No, it won't And this is the second rule Don hit a glass with a feather What happened to the glass? Nothing, nothing happened. Why didn't anything happen? Because the feather was soft First one says if you hit a glass with a feather the glass will break Okay, and the second one don hit a glass with a feather. What happened to the glass? It broke and why did it break because the rule says if you hit a glass with a feather it'll break So if you hit a glass with a feather broke So The last developmental theory I will discuss today is from Colbert Colbert theory suggests that individual progress through distinct stages of moral reasoning is characterized by different level of moral understanding and ethical decision making There are three main stages of Colbert theory The first stage is pre-conventional level The pre-conventional level consists of the first two stages of moral reasoning The first one is obedience and punishment orientation at this stage individual focus on avoiding punishment and obeying authority figure the second stage Individualism and exchange in this stage individual begin to consider their own need as well as the need of other people One example at this stage is if you scratch my back, I will scratch yours right the Second stage of corporate theory is conventional level. So this level includes stages three and four State four is interpersonal relationship and conformity at this stage individual value social approval and comfort from social expectation The fourth stage is Maintaining social order in this stage individual focus on maintaining social order and upholding the law and the rule of the society So the moral decisions are based on the sense of duty obedience to authority the last Level of Colbert theory is called post-conventional level this level Contains two stages five and six in state five social contract and individual right at this stage Individual realize that societal rule and law can be flexible and they can change So their moral actions Are based on the principle of fairness justice and individual right? Basic universal principle and ethical consideration at this final stage Individual develop their own set of ethical principles that are guided by universal Moral value such as justice equality and respect for human dignity in summary from zero to six years If exploring my genital feel good and everyone else is enjoying it and feel good as well why stop From seven to eleven years if playing with them is bad, and I want to be a good kid I'll propress and reject anything in that realm from 12th year and older I still have the urge to realize that they are acceptable and unacceptable way to act on them Let's see what the society and other people involved think about this proposed course of action So part of why i'm a geriatric fellow is I always have to learn those again before each test I don't know if anybody else feels that way But um, dr. Chuang was very nice enough to discuss this Hello everyone, and thank you for joining us today. So I am Gino Mortallaro. I am the Assistant Chief of Psychiatry for Kaiser Permanente in San Bernardino County. And I am an Assistant Clinical Professor with the Kaiser Permanente School of Medicine. I have no disclosures, but if someone wanted to throw grants my way, I'm happy to add to this slide at any point in time. So I wanna start, we're gonna build off of what Dr. Duong has presented to us. And I wanna start with a quote from a patient that just happened to occur naturally during one of my intakes. And I let them know I would add to this, and they were very excited. So this was a 15-year-old patient on the autism spectrum, normal developmental IQ. And when I just asked my screening gender question, this is the answer I got, right? I've been exploring, but I think that people like me on the autism spectrum don't really learn or connect with the constructed forms of gender. We just see it differently. Like I'm just a person and so are you. And it's a great lead-in to what we're gonna talk about today. So let's talk about kind of where the research is, what the background is. For lack of a better way, right now there's a trend towards studies indicating that there seems to be a higher rate of quote-unquote comorbidity for gender dysphoria and autism spectrum disorder. Unfortunately, there's some limitations in this that have kind of led to inconsistent results and some barriers that make it kind of understudied. And the first is the idea of gender development being a comorbidity. So some studies have treated the way that they measure and capture gender identity based on a gender dysphoria diagnosis, and others have treated it like a normal process and more just looked at the idea of discomfort with sex assigned at birth or variations on a cis-gendered identity that maybe aren't resulting in full dysphoria criteria, things like that. So there's definitely been some sliding definitions, including changing between DSM-IV and DSM-V around some things in both gender dysphoria and autism spectrum diagnoses. So we've also kind of changed our own metrics for what would qualify into these brackets. Some studies have only looked at children, others have looked only at adults. And these are protected populations, particularly autism spectrum disorder being a protected population and research in minors being a protected population as well. So a few people really take it on to kind of work with research in a double protected population, if you will. And then what I cutely call the Fultoner Theories. So what I mean by this is, if we say like, okay, X and Y equals E and X and Y are either one or two, right? The binary idea. If I said, okay, guess what Z is, there's a third of people who will just guess it correctly, right? Because there's only so many ways that that can manifest. But if I then said, okay, well, guess Z, but X is one to infinity and Y is one to infinity, you're not gonna guess it, right? And so why do I make you look at that example or listen to me or any of this, right? It's important that we are understanding that autism itself has a very wide spectrum of how it manifests, how it's expressed. And every person who's on the spectrum is not necessarily like the other person on the spectrum. Hence, it's an autism spectrum disorder. And similarly, right, we talk about the gender spectrum outside of that binary perspective of male, female, be all end all, right? So as gender has started to also be looked at and explained on a spectrum as well, we're talking about trying to isolate and categorize in research, which loves clear discrete categories for these infinitely expressed variables. So it's one of the other reasons that I talk about as to what some of the limits are in being able to really do a good sort of meta analysis on that previous studies, but also in sort of what we're talking about in terms of these diagnoses has changed and has evolved and become wider. And so, we're trying to capture something that is still in and of itself comprised of two parts that we don't really have a great capture of in general. So there's a lot of moving parts in this. So additionally, right, context is what do we do though? So for us, it's gonna be incredibly important that we really understand where each patient is in relative developmental domains. So that's why I wanted to have Dr. Duong lead in with a nice little review and refresher of those. That's gonna help us understand our patient, communicate and advocate for them and their goals. And a reminder is that someone may have an incredibly high IQ being on the autism spectrum and seem fully independent in pretty much all aspects of life. But that doesn't mean that they're not gonna still have potentially a rigid or concrete thought process that can really make it difficult to connect with these more dynamic or fluid concepts of gender and sexuality. So we talk about Kohlberg's gender theory. So in this early age, zero to four years old, right, there's a presence of magical thinking with gender. The idea that just because I wish I was, I was born a boy, I wish I was a girl, in this age group, they think, oh, okay, but maybe I'll wake up tomorrow as a girl, right? And so the idea of object constancy and consistency hasn't really set in yet. And so, we don't see frequently too much of gender dysphoria or things like that presenting because of this idea that, hey, I might wake up and be what I want tomorrow, cool. And egocentrism, the world is kind of revolving around them at that point. So everything's great. Five to seven years old is when the idea of consistency starts to begin to develop and become ingrained. This is where you can see some of those social influences around gender norms start to take hold. Cooties being in this age group, there's a strong in-group mentality that exists. And so there's sort of these set rules that are based on these social norms. If a penis equals a boy, a vagina equals a girl, long hair equals a girl, short hair equals a boy, right? And so starting to understand and internalize some of those things. And then once they're past seven, that's when it's internalized and constant enough that there can be exceptions to these social rules. Meaning, just because someone has long hair, that might be a man with long hair, that might be a girl with long hair. So the idea of being able to hold firm to a gender identity regardless of a single variable, which we saw in Dr. Duong's presentation with the child in the liquids. So, all right. So I'm gonna run through quickly on the basis of time, but in your head, as these images come up, right? Think about which sex came up or gender, okay? So we have this pink square. So, probably the majority of the people are initial gut responses like pink is girls, right? But in the early 19th century, pink was actually assigned to males by the social norms. It was spelled to be bold and assertive and blue was the common passive color that was historically assigned to females. And then with the world wars, this social construct of gender norms changed because blue was now in naval uniforms and right around that same time was the breast cancer awareness ribbon, which adopted pink. And so there was a social norm shift to what gender norms would be. Same story here, right? As we kind of talked about, you see long hair, most people are like, oh, woman. But this one has an interesting role in evolutionary biology. So keeping healthy long hair is hard. You have to have enough nutrients to nourish it, for it to growth, for it to not fray, split end, fracture off. So historically, it was not a gender representation. It was just a sign of like health and wealth, right? And then more recently in our time as humans, has long hair been associated more with female? The competition needed to keep enough nutrients in our body to have long hair certainly is no longer as big of an issue. The majority of us will consume enough calories in our day and enough nutrients to meet the demands of long hair. And so the idea of primping and extra time and things like that, slowly evolved into a female presentation in our social norms that we've set. So if anything, I hope I've at least illustrated this idea that gender is a construct, right? I know you've heard this sentence before, but I want to help us conceptualize it and contextualize it. So gender expression certainly has social influences that really manifest it. That varies by culture and time for sure. And so even the idea of differentness is based on those societal standards that are set. You can't be different without the idea of a de facto norm. And so the reason that I want to highlight this is that part of being able to deliver this care regardless of a patient is letting go of binary thinking, male or female, right? Gender dysphoria does not mean that someone is transgender. We have certainly continued to evolve the field and recognize non-binary identities, third genders, two-spirit, you name it, right? So there's multiple gender identities that exist that are not simply on a binary kind of male over here, female over here at the end. So, and agendered, right? Which doesn't exist on sort of these kind of same spectrum ideas. But, you know, that's important because we're talking about gender identity and autism, and we're gonna get into why our own thought processes will be helpful. But just as again, a refresher view, you know, the idea of the dysphoria as I alluded to, it's not really gonna be common in under five because of this presence of magical thinking, right? Dysphoria's early manifestations in children are gonna be severe rejection of these gender tropes that we talked about. And that's as children develop that theory of mind and that constancy that we talked about, right? So basically they're starting to understand what is the societal expectation of me based on my sex, and if that's, you know, egocentronic with my gender. And by puberty onward, you know, gender structure is largely internally solidified and consistent for the individual, but the journey, the exploration and the expression are definitely gonna be complicated by those external factors around us. If I think I'm gonna be accepted, you know, all these pressures that muddy the waters in terms of feeling comfortable expressing my own gender identity, or really being able to even tap into what my internal sense of gender is. So, and then I wanted to highlight some of the autism spectrum disorder criteria from the DSM that are relevant here. So, you know, deficits in social emotional reciprocity, AKA shared interest, right? So there's a certain retention of some egocentrism, deficits in nonverbal communication, right? Which we just talked about gender constructs are a large nonverbal communication. And so that may be something that just doesn't really register or resonate. There can be difficulty in interpersonal interactions, not really knowing how to even engage in them, how to sustain them. What should I talk about? What shouldn't I talk about? A tendency towards kind of rigid thought processes, which can manifest in this black and white kind of binary perspective on gender and restricted obsessive interests as well. So, you know, some of the fictions that come across frequently when discussing autism or in media and the facts around them, right? That autism is visible or identical, right? You know, there's an infinite number of combinations and expressions. You certainly cannot look and just definitively know. Autism comes with intellectual delays. No, certainly not. You know, there are many people on the autism spectrum who will have a very normal or even above average to superior IQ. So you cannot operate on a artificial conflation there. Not interested in friends. No, that's schizoid. You know, people on the spectrum may not know exactly how to make friends or may think that either people bullying them are trying to be their friends. So there's a misunderstanding of some of those dynamics, but it's not the absence of interest in that. Similar for romantic connections, right? People on the autism spectrum still have romantic interests, and just because there's difficulty in understanding how to pursue them does not mean that they don't exist. And then that, you know, oh, well, people on the autism spectrum are kind of unaware of these social inputs and pressures. Like, no, they can recognize it. And a lot of times they're aware that they may struggle with it, but it's not a aloofness to it. It's maybe some of the nuance or that metacommunication that can really be a pitfall. So, if I am someone on the autism spectrum and I know I have a rigid idea of gender, how do I make sense of the fact that, you know, Brad Pitt has matched his hair to every girlfriend he's had? If a haircut can tell me someone's gender, how do I make sense of that? Because the boy and the girl have the same haircut here, right? How do I make sense of Billy Porter's incredible tuxedo dress? Boys wear a tuxedo, girls wear a dress. How do I make sense of this in my binary thoughts, right? So, what can we do, right? So, as I kind of hopefully elucidated and explained, you know, that black and white thought process, which is pretty common in autism spectrum, can really make it hard in separating out gender identities that fall out of that binary. So, you know, non-binary, agender, gender fluid, we can help facilitate that education, that exploration and help our patients on the spectrum really find their accurate gender identity that's not predicated on some of these difficulties in that gray area, right? You know, and from the studies that are in my references section and from, you know, advisements with the newer released versions of standards of care aid, right? It's okay to take your time in working with these patients. You know, we will expand our traditional gender intakes and gender assessments to be more appointments if we need to. And if the patient's really struggling to connect with their own gender identity and expression, sometimes it becomes a course of supportive and explorational gender therapy before we kind of, you know, land on any steps to take. And it is okay to take that time. And I think when you're working with the patient, emphasizing that this isn't a no, this isn't, you know, rejecting your experience or invalidating your experience, but it's to help us make sure that we really get to the most accurate experience you're having so we can help you in the best ways possible. And, you know, in my own two cents, gender identity is not a comorbidity. We all have a gender journey, whether you're cisgendered or not, right? Everyone can remember their teenage years and very few of them, you know, are remembered as a easy peasy, nothing to it kind of process. So just reflecting, even if you're cisgender, your teenage years were still difficult and there's changes and it can throw us all for a loop. So what can we do? So I won't belabor this, but at least some bullet points that I wanted to highlight from this article. I would probably butcher that last name, Schalkwik, Skalkwik, oh, I butchered it, but the full article's in my references. But it's important, individuals with autism spectrum disorder should enjoy equal rights with regard to treatment for gender dysphoria. Clinicians can assist individuals in understanding this aspect of their gender identity in broadening the social frame, right? We are not here to define someone's gender, we are not here to force someone's gender, but we can help in expanding this black and white thinking and understanding the nuances of some of those social constructs. And remember, we're an ally in this gender journey, right? And as is referenced here, gender narrative, we're not the gatekeeper. We are facilitating exploration and expansion of the social frame. So in tying it all together, autism and gender, both spectrums, understanding the relative developmental levels across these multiple domains that Dr. Duong presented and I talked about with Kohlberg can help us approach the patient in that exploration a little bit more and really start to develop some of those skills further along to help connecting with gender and identifying any particular developmental delays that may make it hard, such as persistent magical thinking, that concrete, rigid, black and white thinking, or a real difficulties understanding social construct or nuance, because these are other areas that we can help expand and explore. So practical steps, again, I'm not gonna belabor this. You can see, I highlighted it here for you. This is pretty much figure two on page 110 from this article from Strang et al. And so again, it's just to belabor the point that I've made as my time comes to a close here, that we have to address both diagnoses concurrently and help with cognitive flexibility. And again, not to conflate orientation with gender identity as can be a potential pitfall in this sort of black and white rigid thinking. So again, I pulled another little quote from an article that I love, then I'll stick to the first sentence of it. If gender is a social construct, then autistic people who are less aware of social norms are less likely to develop a typical gender identity. So just to highlight that we need to be aware of these social impacts as well. So here's my references, and I want to thank you for tuning in and listening. And in my ideal world, I'll be there to answer questions live on virtual as well. Thank you. So Dr. Mortallaro was just emailing me that there is not a live link, but if we have questions, we can call him and Dr. Duong. So we'll see what we can do. So I'm gonna talk for a few minutes, some summary, some conclusions. Not all of you are child people. We'll talk about some adult specifics, and then Ash will finish up. How many of you are aware of this big survey that the National Center for Transgender Equality did? I'm seeing a few nods. So we're gonna get an update. They did more data in 2022. I'm glad you're aware of it. I won't go into too much detail, but I think what we're all finding as psychiatrists in general is that we have many, we have such a spectrum of human experience, so many levels of minority stress. You know, we've got ethnicity, we've got language, we've got gender. So I think the main idea is that already somebody whose transgender is gonna face some disparity, and that depending on the other areas of diversity that they experience is gonna be compounded. So I was really, really amazed by that. I think a person who maybe grows up in the majority group and somebody who grows up cisgender might think, okay, I can go to the store. If I need a job, they're gonna treat me appropriately. If God forbid I go to jail, they're gonna treat me appropriately. If I'm homeless, I'll be able to get shelter, but what we find is that there's so many things that cisgender people in the majority group take for granted that just don't, it's not found for people who are transgender. So basically, I think as mental health professionals, you know, we need to look at these increased statistics like increased rates of suicide, mental health comorbidities, that there's even abuse that people experience for being transgender by mental health providers and healthcare providers. Basically, what can we do to be part of the solution? I won't go into it too much since you guys, a lot of you seem to have read it, but basically, we're seeing discrimination in statistics in all areas of life, employment, housing, education, family, community services, and medical care. So as a kid, even as a strange queer nerdy kid, I could go to school and know that I was going to be taught and not abused, but unfortunately, you're even seeing things like harassment and abuse in school and at home. So 47% of those surveyed mentioned being sexually assaulted at some point in their lifetime. 30% homeless at some point. Again, if you're seeing boundaries to employment, it's gonna make homelessness more of a problem. 19% were refused medical care because they were transgender and that's always staggering to me. 50% had to teach doctors about transgender care. I think a lot of this is just developing empathy, right? If you're sitting in the seat, whether it's the dentist or, you know, the gynecologist or wherever you are, imagining teaching your doctor how to treat you, just how awful that would be. 28% harassed in medical settings specifically, and 2% victims of violence, not just harassment, but violence in doctor's offices. Unfortunately, many staff members, clinicians, may hold negative views about transgender people and use their position of authority to actively discriminate. Basically, the beauty, I think, in this study is it has just about as many non-transgender participants as it does transgender participants. We can compare that, although the general US population, say, 5% might experience mental distress in the prior month, that would be 39% for transgender respondents. If 4.6% of the general US population has attempted suicide in their lifetime, that's 41% for transgender patients. Then we add an extra layer, so transgender respondents of color, 59% reporting distress in the prior month, and 54% attempting suicide in lifetime. It's important to understand these companioning layers of stress and how it's really just assault after assault makes, basically, it harder to get through. So, in essence, I wanted to just consider, as a thought exercise, think of your own practice, think of your own hospital. How do patients even know your name? How do they get to you? How do they make appointments? Where do they park? Who's the security guard? What are the bathrooms? What are the forms? So I think a lot of us might think, okay, I imagine how I got through the process, or a patient might have got through the process as a young white male, but based on the patient's presentation, do I need to be doing, say, training for the security guards? Are patients gonna be afraid? Is the area of town maybe a cheaper area for me to work, but that might mean, then, that patients who park might be facing some sort of feedback when they come that's gonna be discouraging? So kind of just thinking through that, training office staff, forms. It's funny, APA, my legal name is there, but there's no place for what's my preferred name. So how will you avoid even the patients coming to your door and being misgendered and feeling like it's not friendly? All right, also automated messages, automated mailings. A lot of these are gonna be based on EMR, so are they gonna be misgendering people and make them uncomfortable? I feel like a lot of my work is knowing referrals in the area. As these bills come out, it's gonna push even doctors in the closet, right? So you kind of have to have a list of who's gonna be appropriate and friendly with your patients. Signage can be a big deal. So is there anything in your waiting room that says, you know, I serve a diverse patient population? Are there pictures of diverse patients? Do you have signs that might say something like, all are welcome? I think really important in the past few years has been the informed consent model. If you're dealing with a patient who has capacity to make their own medical decisions, treat them like an individual, ask them what they need, ask them what they prefer, and follow it. I've had people ask me, like, how do I even approach a transgender patient? But I feel like we were all taught things like beneficence, right? Non-maleficence, justice, autonomy, and confidentiality. Basically, as you go through these ideas in the media, you know, is it justice if we're allowing treatment for one type of patient but not another and it's the same treatment? So no matter how much internal conflict you might have or lack of understanding, you can always think, am I friendly? So one thing I've noted also in coming out is people start looking at you with these open eyes like they're scared of you, they're afraid to say your name, they're afraid to talk to you. One of the first things a lot of people said to me was like, I'm so sorry if I use the wrong name and pronouns. I'm like, you're already putting distance between us, you're already assuming that you're gonna do wrong and that I'm gonna be a bad guy when you are. So basically, trying to make sure that you're using the same tone of voice, the same warmth with each patient, regardless of the layers of diversity. And also, we're more than our gender identity, don't get distracted. So if I'm there for depression, if I'm there for my knee, if I'm there for my sports injury, like, don't get it all twisted. It doesn't have to suddenly be the wrong topic. So with that, I know we're trying to leave as much time as possible for questions but we're running a little behind, it's 8.57. I'm gonna let Ash talk as long as he wants and hopefully we'll have some time for questions. The introduction Ash gave me is that he's a therapist, attempt survivor, minister, father, and trans man from Huntington, West Virginia, where I'm also from. Received his bachelor's and master's from Marshall and currently working on a doctoral degree in behavioral health. And I'll let you describe more, Ash. Thank you so much, Tobias. Everybody can hear me correct? Awesome. Well, I've immensely enjoyed our other presenters today. But I kinda wanna switch gears to kinda close us out. Because I love the statistics, I love the academic portion. I love seeing how studies are done and all the intricacies of human behavior. It is my bread and butter as somebody who teaches psych. But I also think it's incredibly important when we're talking about these layers of diversity to see the human cost. What happens when the rubber meets the road? And with that, I wanna tell you a story. Anecdotes only do so much scientifically, I know. But I also do think it's important to see where academia and patient care kinda collide. And as the autistic trans man who went viral for being the pregnant man, I would love to tell this story to you. Because I think it is one that isn't very heard often. And when you lack all those little social norms and details, you just don't care who you tell. So I was diagnosed with gender dysphoria back when it was called a GID, or gender identity disorder. Different DSM, different time. I was about seven or eight. Very rare, didn't even have a term for trans people back then. I was just a grade schooler. And it was one of the more severe cases in hindsight. I didn't know why I was at a psychiatrist, what's going on, et cetera. So naturally, I'm treated as this horrible illness and sinner, have everything I own thrown away, shamed, kinda the bad boy part of development. It's like, see, everything you do is wrong. So all of this reaches a fever pitch. When I'm about 22, I ended up surviving a really violent suicide attempt. It was difficult, but when you hit rock bottom and you know you can't live another day like this, you'll do anything to get the care you need. So after months and months of therapy, realizing I might end up being divorced because of it, going through the ringer, getting psychiatry notes, therapy notes, referrals, finding an endocrinologist who will even take me and not hang up the phone as soon as I call. Once I'm going through all the hoops and everything else, my husband finally says I'm done, moves another woman in, etc. I forgive him, but we won't go into that. Irrelevant to the story. So I'd already gotten my legal name change done, my ID documents fixed by state standards. I was just any other guy. Passed well, had a pretty normal life. Suicidal ideation decreased. I mean, yeah, I was going through a difficult time because divorce does that to a person, but I coped the best way I knew how, and that was by returning to being an overgrown teenager with internet access and LGBT dating apps. We all see where this is going. What my endocrinologist, psychiatrist, and other doctors on the case failed to inform me about, you can still get pregnant on testosterone, and push comes to shove, and I get a positive test out of the blue. I'm not horrified. I just stare blankly, like, what am I looking at? What do I do? Like, I'd always wanted kids, and I was willing to put up with all the BS, so to speak, just to get what I want put on my blinders, like, tune out the social norms. It's like, this is hard enough as it is, just, I know what I want, and I'm just going to take a deep breath and dive under it, so to speak. Do what you got to do out of love, because I'd like to think that any cis man, if he was put in the same position, would he do it for his kid? But anyhow, a lot of the obstetric staff on the case, psychiatry, etc., I felt like one of those Roswell aliens that just kind of crash-landed into their office, and it was autopsy time. Like, I try not to take offense too much, and I get it's an unusual situation, and kind of a high risk case, but even with all the grace I could provide, I was happy to talk, happy to chat, happy to not even educate, just talk like human beings. It was psychologically kind of damaging to be in this, like, horrifically vulnerable period. It's like, I'm already uncomfortable enough as it is. Do I need to be treated like a little medical guinea pig? I mean, I like guinea pigs, but I just don't want to be one. So it's hard enough to get on the national news and hear that you're a disease, you're every name in the book, that you're corrupting the children. Oh, let's go to Florida and take people's kids away if they're trans, and you're scared to death, you're alone, you're pregnant, and nobody's there with you. That not including all the legal issues, because they put me under a dead name and incorrect gender marker on the birth certificate as well, so now I have to sue, but we won't talk about that. So it's like this absolute kaleidoscope of nuance. You've got the legal aspects, the medical, the social, the shaming of it all, because, I mean, it's kind of hard to hide in a small town. You're carrying this amount of just emotional weight, and the doctors did their best. I don't suspect any ill will, malpractice, anything like that, but having your case tossed around kind of like a hot potato, because nobody wants to take it, because nobody knows what to do. I'm not equipped to talk to a transgender person. I'm not equipped to talk about the elephant in the room at the time. I don't like using that term, but it is what it is socially. So when you've got all this weight, it is crushing. I see why other people develop severe suicidal ideation or substance abuse problems to cope with what their reality is. I can't get health care because maybe they don't take Medicaid. Maybe I'm too rural to get any kind of help. Maybe I've got other intersections of diversity. Maybe I'm a person of color. Maybe I have autism. It was hard enough for me, as somebody who has advanced credentials and can speak clinically, as my friends call it, I have many protective factors, and I'm incredibly, incredibly privileged. In fact, my ability to kind of not internalize social norms as much, I don't think I would have been able to get through my pregnancy in one piece if I didn't just have that kind of nuanced blinder up. It's like, okay, I just want my kid. I'm just gonna go over there and push everybody out of my way. I don't care. Walk out. Best way I have to describe it. But imagine for a second. Am I the average individual either? What about the person that doesn't have a master's degree and they live out in Wirt County, West Virginia? There's not a provider for hours. Half the townspeople would probably literally get violent against them if they were to say anything. How crushing is that to not be able to advocate as well for yourself? How crushing would it be to finally get to your psychiatrist or see someone who is supposed to help and they treat you like a communicable disease? I'm not asking anybody to be perfect, but in an age where misinformation is running rampant and it's spreading like wildfire through the media and almost none of it is even the case, it's a complete straw man when it comes to actual gender affirming care and qualifications needed for it. I won't get into that dough for time because I'll keep you for hours. My point is that there is a very human cost to stigma. You don't have to be the pregnant autistic trans man. Maybe you just need to be an average Joe IQ and 15 points of a hundred. Pretty usual fast food job, maybe working at Amazon. Everything can be crushing to somebody who is experiencing gender dysphoria in any capacity and just want help. We're not asking you to be perfect, but as doctors we ask that no matter where we're at in our life, if we're going through 19 hours of labor while stroking your beard and reading hate mail and just laughing it off because it's all you can do, or if we're trying out our injections for the first time or talking about what it's like to shop for new clothes or facing a legal hearing for your name change or any other document, maybe you're sending in notarized letters from a surgeon just to get your birth certificate fixed so you can have a passport. No matter where we're at in our life, do not be our gatekeeper. Sit at my bedside next time, hold my hand, laugh with me, be sad with me. Even if you don't understand because I get it, my situation in particular, it's got to be hard for people to relate to. I can't imagine what anybody else's world is like socially, but just knowing what I know about people, I get why some of them acted the way they do, but after I've just had five failed epidurals, yeah English, need some coffee, just pushed a baby out, I have social workers coming in because I just got through a divorce, I'm off work for 12 weeks, I'm scared, I'm broke, I'm tired. Just sit with me, meet me where I'm at, help give good advice on the journey rather than slamming the door in my face by bringing up a debate about my sexual orientation, which I've already self-described it. And on that note, if I can say anything else, it's that in an age where all this misinformation is going around, where kids who don't have my protective factors are offing themselves, we are dying out here. Be the voice, even just sitting with us and descending us on our way to the next step of our gender journey, that's one of the best things a lot of us can ask for because we're not used to it. And with that, I would like to close us out for any time for questions. I rant, you'll have to excuse me. Thank you everyone for choosing us for your 8 a.m. session. I know travel is tough. So unfortunately we didn't have a live link, but I do have the other two doctors you saw speak on the phone. They're currently muted and listening, so if anybody has any questions they're also able to speak with us. And also if you guys are ready to move on for coffee, that's okay too, or just want to chat. Yes? This is an excellent question. So I just finished residency, so I spent a fair amount in situations like on liaison consult psychiatry, patients saying, well first of all, you know, I think parents do deserve some sympathy and meeting them where they're at. I can understand this is hard for you. I can understand this is new. You know, tell me where you're at. Tell me how you're feeling. I think, you know, depending on the parent, some of them, honestly, some of the best things have been to recommend things like pop culture references. Like I recommend Pose. Like a lot of people will watch Pose and come back crying like, oh my gosh, I didn't get it. So I think, you know, finding based on who they are, what they're interested in, kind of meeting halfway. Every now and then I have a really angry parent. I had a patient who actually jumped off a bridge because she was outed early, before she was ready, and that transition time is a very difficult time for a lot of people. And, you know, they were saying just very harsh words about their daughter, very angry. I don't use this very often, but every now and then it's as simple as, at some point you're gonna have to ask yourself, do you want a dead son or do you want an alive daughter? I think that can be very harsh, very important to say. I'm not going to say that as being the jerk doctor. I've obviously built a lot of rapport at that point, but I think sometimes they get it when they hear those words. But I do think it's a fair amount of, you know, like any, like that's again part of why I didn't choose CAP. I feel like so much of it is parents are hard, harder than kids. But I think if you show them sympathy and, you know, good cop, bad cop, you know, the right amount of sympathy versus, you know, harshness. What about you, Ash? Anything else there? I really liked that answer. I'm still trying to put that into words there. But I think that is ultimately the bottom line is, do you want a dead kid or an alive one? As somebody who is a parent that is trans. Oh, sorry. I had a long night, guys. Sorry about that. I think he is absolutely spot-on in that regards. I try to have kind of a sympathy, empathy, just sit with people, see where they're at, help where I can rather than dictate beliefs. But that's kind of just the harsh reality of it all. As a parent, I also kind of get it on a parental level. I dread the day my kid does ask questions. I know it's inevitable. It's okay. When people mock me online, when they dox my information, they were always like, oh, that kid's gonna be so confused. I'm like, maybe they should have just a somewhat abnormal parent rather than a dead unhealthy mother who's drinking her life away. I'm like, I think I'll choose the lesser evil, even if there is one. And I'll just tell her outright. I think it does come down to some very hard bottom lines. Does that make sense? And I think the end of the day, we're all changing. Not all of us. Second puberty with your adult peers changing, which is very awkward at times. But honestly, trying to get them to understand a time in their life when they were misunderstood or having difficulty. And often I find even parents who come from very conflicting religious backgrounds, very conservative backgrounds, often when it comes down to, I love my kid, you see some nice breakthroughs. Yeah. Any other questions? Yeah, I entirely agree with what you just said. Even with some secular parents who just don't necessarily have a religious affiliation or they're maybe nominally Protestant, very undefined but kind of cultural Christian, I find that even the least religious parents, when their child does come out as trans, at least in my case, there was that kind of sense of grief on their end. I tried to meet them where they're at. I'm not gonna pat them on the back for it, necessarily. Kind of try to, you know, take my own advice there, sit at their bedside and listen. It was just interesting how they viewed you after that. It's not like you're dead, but it's almost, they act as if they've lost a person. So that, it's still kind of new to me and I'm still learning. I don't really grasp how anybody would think that, but I do think it's a concept worth exploring. It's like, what happens when your idea of a person is gone? Like, how attached were you to a concept versus the actual being in front of you? And when I'm talking to those kinds of people, especially in a therapeutic setting, I meet them there, but I also do have to set that bottom line as well. It's like, would you ever love the concept to death or still have that person literally in front of you, maybe in kind of a different form? Just like, well, now you get to learn the real me and open it up as this kind of possibilities rather than what's gone. I get it must be hard for people and I don't want to pretend to understand anybody else, though. Does that make some sense? Anything for Drs. Mortallaro or Duong? Well, I appreciate everybody for being here. If you have any questions or want to chat, we'll be here. I'll also be hanging out at the AGLP events. Yes.

gender-affirming care

autism spectrum disorder

gender identity

gender dysphoria

healthcare support

neurotypical development

transgender healthcare

legislative challenges

inclusive environments

psychosocial adversity