Hi, everyone. My name is Clint Peebles, and I'm a board certified dermatologist in Washington, D.C. and suburban Maryland, and I'm honored to be a part of the American Academy of Dermatology's Medicine Without Barriers program. If this particular presentation is your first exposure to content focused on sexual and gender diversity in this series, welcome. If you've already viewed the other modules related to this content in the series and other levels, welcome back. Either way, I'm happy that you're here, and today in the context of sexual and gender diversity, we'll be addressing advocacy and allyship. So I have no relevant relationships with industry, and I also want to acknowledge my privilege as someone of Caucasian background and perceived male gender expression. I do not speak for the entirety of the gender and sexual diverse community, and I hope for the empowerment of all voices to drive meaningful change, and I hope that all of you will help me to do that. And I also want to acknowledge the ancestors of indigenous people who have suffered from colonization, including genocide, ethnic cleansing, stolen land, and forced removal in this country, along with those of African descent who have been subjected to forced labor over the few centuries of our country's existence. And I want to encourage everyone to commit to social media engagement with indigenous and African American advocacy organizations based on race, ethnicity, and culture, participate in educational events, advocacy through policymaking and institutional commitments, and responsible consumerism, and to engage actively in this work and to explore all the resources that are available. So first of all, if you were not present for level one, the previous module, just to outline some of what was discussed there, and you can revisit it if you like, or see that module if you haven't already, we looked at foundations, terminology, and concepts of sexual and gender diverse health, themes of intersectionality, power, and privilege, and consequences of discrimination, along with a look at the national and global sociopolitical landscape. In level two, this module we're talking about now, we're going to be discussing what it means to be an effective ally, and themes of effective allyship, the welcoming space, and advocacy, and how you can engage. So why does this matter? Well, ultimately, we know that individuals identifying as sexual and gender diverse are composing an increasing number of the general population. And by the latest Gallup poll, LGBT identification in the United States has tipped up to about 7.1% of the population. It was as lower than 6%, about 5.6% in 2020. But one in five Gen Z adults now identify as LGBT, identification is stable in older generations as LGBT, but it's consistently rising in younger generations, bisexual identification is the most common in terms of sexual diversity, 0.6% of US adults now identify as transgender or gender diverse. And to put that into perspective, that's more than the number of adults who have type one diabetes. Gender expansive identities are more frequent among younger people, 1.8% of American high school students identify as transgender, but depending on the specific community you're looking at, in some areas, particularly some urban settings, up to almost 3% of high school students identify as gender diverse. But it's also important to recognize that adults who identify as transgender are more racially and ethnically diverse than the US population overall. So adults who identify as Black, Latinx, or Hispanic, or of another race or ethnicity are more likely than white adults to identify as transgender. So really speaking to the importance of an intersectional emphasis. And to that end, we discussed this in level one, but just to recognize that there are numerous different facets of identity and human beings are not monolithic. We all have different identities and backgrounds and levels of engagement with those identities. And so recognizing that all of us likely have elements of identity that are privileged, as well as elements that are not privileged or considered oppressed in some way, shape, or form, and also recognizing that identities can actually evolve and change over time. So in particular, background as it relates to literacy, age, socioeconomic status, and other elements. So just recognizing that there are so many different colors of the human experience, as illustrated by this circular graphic here, and that there is this dichotomy between privilege and oppression and the ethic of domination that's so pervasive throughout society. And it's important to understand how that relates from a social determination of health standpoint when it comes to patient care and how we provide and deliver that care and how it's received by our patients and their ability to access it. And that's part of what we're going to be talking about here today. In keeping with that, the sexual and gender diverse community is not monolithic either. There's, as we've already talked about, there's great intersectionality when it comes to race and ethnic background among these populations, but also when it comes to the ability space. And there was actually a great paper that recently came out of the American Journal of Public Health as a result of the PRIDE study, basically showing that in the study, more than 30 percent of LGBTQ people were living with a disability, which is higher than national estimates on the general population of those living with disability, which is about a quarter of the population. LGBTQ people with disabilities were more likely to delay seeking medical care, not have health insurance or otherwise be unable to obtain care than their abled counterparts. And so what does this mean? It basically means that there's increasing number of barriers for health care among those LGBTQ people with disabilities compared to their non-disabled peers. And that has a direct impact in terms of access to care, whether it relates to appointment availability or cost, insurance coverage and even things like transportation issues and the logistics of the clinical care space and other aspects of where it may be located and different themes of access. So just to emphasize the fact that all sorts of issues play into the ability of an individual to seek care, some of it based on identity and some of it not. But this intersectionality is incredibly important. Along with that, we have to look about or think about social determinants of health. And we know that poverty disproportionately impacts sexual and gender diverse people who are more likely to be homeless or less likely to own their homes. And also to remember that there's no federal protection from housing and rent discrimination. And there's also no federal law preventing discrimination in insurance coverage and health care. And as we talked about in the first level or module of this series, Section 1557 or the non-discrimination provision of the Affordable Care Act is the law of the land that prohibits discrimination in health care based on sex. But that is not enshrined legislatively at this point. And it's also subject to quite a bit of regulatory interpretation. So by no means does that constitute a federal law that supersedes all other types of judgment. And there's also a shortage of physicians with sufficient training to treat transgender patients and also more broadly, sexual diverse people in general, in addition to gender diverse individuals. And so all of these disparities have set the stage over time for what is known as the minority stress model. And you may have heard of this before, but it's been outlined by numerous scholars and over various contexts. And it was actually first introduced by Virginia Brooks in the early 1980s. And unfortunately, history has erased her in many settings. But she presented this concept as it relates to sexual minority populations, in particular, lesbian women. And the minority stress model emphasizes the process by which levels of stigma, along with maladaptive coping mechanisms and an absence of structural mitigation of those disparities, fuels health disparities and marginalized communities. And so just recognizing that there are many different aspects to this, not only the impact of identity, but the stressors that individuals experience based on that identity in concert with barriers to care and the level and ability of coping and resilience of those individuals and what comes out as health disparities on the other side. And we're seeing more of this lately and the sense that the landscape is rapidly changing from a sociopolitical standpoint. We've seen more legislation targeting the ability of transgender people, in particular, transgender youth to live their authentic lives and to seek important gender-affirming health care this year than any other year in the nation's history. And you can see here the states that have some form of gender-affirming care ban on the books versus those that have gender-affirming care shield laws or executive orders in place. For more information on this landscape, please reference the Level 1 module in this series. But that being said, this landscape is rapidly changing because of judicial challenges and other efforts in the advocacy space. But to really emphasize the fact that all of this is creating a public health concern for transgender people, in particular, transgender youth. And we know that two thirds of sexual and gender diverse youth have reported that this legislative activity has adversely impacted their mental health. Just being a part of these conversations and seeing this play out no matter where you live or how welcoming and affirming your particular state or locale is, hearing about these things is certainly prompting mental health issues in the gender diverse community who already experience disproportionate concerns with bullying at school or otherwise feeling unsafe, being threatened, considering suicide, struggling with anxiety, depression and even substance use. And we also know that hate crimes are on the rise. There's been a 30 percent increase in crimes against transgender people over the last few years, more than 50 percent increase in anti-lesbian, gay, bisexual hate crimes. And so all of this is actually playing out in the public space to a significant degree that is becoming increasingly more detrimental. So how do we go about creating the welcoming and affirming space in health care, which is really the last place that anyone should expect to experience discrimination and stigma? And this really plays into how we can become better allies, no matter your identity, no matter whether you're a member of the sexual or gender diverse community or not. This is important for us all to be engaged in. We all have a role to play in making everyone feel welcome. But just to kind of set the stage for this, we know that there is discrimination in health care against LGBTQ people, whether that's outright discrimination in the form of refusal of care or denials in insurance coverage, issues with misgendering or not using the correct terminology or pronouns or name that an individual wants to use or being denied care for other reasons. But we do know that health care has historically not been the most affirming space for sexual and gender diverse people, and that has improved in many aspects over the years. But there's still quite a bit of work to be done. So from a conceptual standpoint, you know, in terms of how we approach our active engagement with advocacy and support of the sexual and gender diverse community, it's really no different from the approach for other marginalized communities and just cultures that are different from our own. And we may have kind of grown up, so to speak, with this understanding of the need for so-called cultural competence. And this has been deeply ingrained in medical education for about three decades or so at this point. But in my opinion, this is overly reductionist simplistic and it's a static depiction of culture that really serves to only normalize socially dominant cultures. We have to understand that culture and cultural competence is not something that can be attained or achieved. And it also the notion of that individualized failure to get that competence without taking into account structural power relationships that can't be altered individually. And so where should the emphasis be instead? Well, first, we need to emphasize structural competency. This is the capacity for health professionals and anyone in the health care space to recognize and respond to health and illness as the downstream effects of broader social, political and economic structures and awareness of interpersonal privilege and power hierarchies in health care that directly impacts how we provide care and how our patients receive it. So taking a critical look at the structure in which we find ourselves in health care and then cultural humility, which in contrast to cultural competence, emphasizes this lifelong process of self-reflection and learning with this interpersonal willingness to learn from others and to have tough conversations, recognizing that an ability to engage and interact with and understand a culture is not a matter of a single educational event and checking a box and moving on. It's ongoing self-evaluation and self-reflection and active desire to fix power imbalances and to actively partner to advocate for those who are in need. So as we approach allyship, what are the essentials of how we approach this? Well, there's a variety of different forms. We need to cultivate an affirmative treatment approach, really actively elicit the patient's story, use the right language, avoid missteps, apologize when necessary and importantly, preserve patient autonomy. Now, in terms of recognition and affirmation, what does this involve? Well, it simply notes that we have to demonstrate a positive view of sexual and gender diverse identities and relationships. So when someone comes into your office, it's important for them to understand that you view them positively and that you affirm them and validate them. In other words, they are not a pathology to be fixed or treated, but someone to be understood and to be met where they are. And this often will involve addressing the negative influences of phobias and heteronormativity and cisnormativity, which means the notion whereby heterosexual and cisgender identities are normalized as the dominant identity in society. So this involves embracing every identity and every person for who they are, validating feelings and emphasizing individual value. And in some cases where appropriate, acknowledging that we may have a lack of data for the management of certain conditions in certain populations, but emphasizing that the management approach will be done ethically and appropriately based on the best knowledge and data that we do have available. So in other words, this notion of depathologizing sexual and gender diverse people and their identities, as well as sexual behaviors and recognizing the impact of homophobia and transphobia and readily acknowledging the failure of the medical system to historically meet their needs and that there is active effort to change. So the patient story, this simply really boils down to the fact that everyone has a story that needs to be told and arguably, more importantly, needs to be heard. It's about having a genuine curiosity about the lived experiences of every human being that we see and what they can teach. And this goes back to that emphasis on cultural humility. So understanding the differences between those stories that are told and those stories that have been silenced and getting an appreciation for why those differences exist and why there are some stories that have been told versus have not. And that understanding that we learn about ourselves through learning about others and that many life stories have been built and shaped by prejudice and stigma, and that it's important that we understand that. And so let's talk about language. So we all know that language is incredibly important, especially when it comes down to words that we use to describe ourselves and to characterize our lived experiences. And we all know that when someone fails to validate who we are based on the terms that they use for us, that that can be incredibly stigmatizing and uncomfortable. And so a few things to be aware of. So first of all, the chosen name or the name that someone uses in contrast to their dead name, which often refers to the birth name of someone who has changed their name. So perhaps the name that was assigned to them at birth based on their sex assigned at birth is not the name that corresponds to their gender identity. And that it may be that dead name or legal name may be the name still on their legal and administrative documents or other sources, but that may not be their chosen name or the name that they actually use. And it's important to distinguish between those and to use that chosen name when it's known to you. Chosen family would be the group of people in a person's life that satisfies the typical role of a familial support system. For example, if based on sexual or gender identity, they may have been marginalized from their birth family. Important to understand pronoun usage. So not only do we have binary pronouns like he, him, she, her, and then they, them, but there's also something called neopronouns, which are essentially pronouns that were developed to expand beyond a binary approach to pronouns. And there was a survey of 40,000 gender diverse people recently that found that 4% of them, or a couple thousand actually do use neopronouns. So we're seeing more of them. So Z, sir, and other pronouns like that, that basically affirm a non-binary identity. And so we understand that even though we may not hear these neopronouns as much lately based on where you live and the populations you work with, that we're probably gonna be hearing more of those. And importantly, if you do elicit pronouns or ask for pronouns, which everyone should, it's important to be able to use them and to understand how to use those pronouns in conversation and to get comfortable with that approach and using pronouns that you may not be as familiar with. Terms to generally avoid, things like homosexual, transvestite, transgendered with an E-V, transsexual, and kind of more research terms like MTF, FTM, or male to female, female to male, which don't really characterize how individuals identify, but rather use it in mostly research contexts. And some of these terms like homosexual have fallen out of favor due to the fact that they hearken back to being listed as a pathology in the past, particularly in the DSM that was changed in the 1970s to eliminate homosexuality from that source. However, it's always important to recognize the patient's language and their own wishes and preferences because some of these terms may be embraced by a given individual, so we should never assume, but these are terms that in general should be avoided. And of course, recognizing too that there is harm that can come from using the wrong language. Misgendering an individual, for example, we all know that we tend to correct folks when they misgender, for instance, our children when they're younger in particular, or a pet. And it's no different in this situation. Misgendering is referring to someone with their name or pronouns that they were assigned at birth instead of the pronouns that correspond to their gender identity and the terms for their gender identity now. So recognizing that this can be potentially compromising to the patient physician relationship and that rapport and that trust that we seek to build with all of our patients. So when this happens, it's important to understand how to apologize, right? So an apology is often something that we may think of as an admission that we intentionally did something wrong or that we have a knowledge deficiency or could even be liable for an error, but that's not really what an apology actually is in all contexts. An apology can just simply be taking responsibility and validating the other person's feelings and an active effort to rebuild trust and confidence in a sincere, authentic context. And most importantly, it's a learning experience. And so just recognizing that an apology is this conscious effort to remedy a relationship that may have been temporarily caught off course for a while because of an issue. And so autonomy. It's a very important principle and concept in the care we provide to our patients that emphasizes that they need to be the ones in control and empower, whether that's consenting for an exam and being able to modify or stop that exam, or even as it relates to decisions about abstinence and contraception when it comes to iPledge registration to prescribe isotretinoin. All of these factors involve and really mandate the active engagement with the patient who's in front of us this notion of shared decision-making opportunities to modify the plan and also acknowledging any trauma history that may be present and to validate any anxiety that may be happening and to guide them through the management process of what we're seeing them for. And so the clinic environment. So there are many different ways that we can convey allyship just by virtue of how our clinic spaces are organized and laid out and structured. And so first of all, staff and personnel training. So regardless of identity or background and regardless of role, everyone who works in the office, no matter what position they have on the healthcare team needs to be involved in cultural humility training, structural competency training to be able to knowledgeably and confidently engage with these populations. Gender neutral restrooms and facilities are certainly very important. Inclusive medical records and data collection that actively solicits gender identity pronouns, sexual orientation, sexual behaviors, organ inventories and the like. Obviously ensuring privacy and confidentiality at all costs and reiterating this at many different steps of the healthcare engagement process. And then of course, setting up your space in terms of artwork and periodicals and media and different elements of visuals in the clinic space. So when you look around your office, is there only one notion of a family unit or how people look or act or one version that's presented of culture or ethnicity or skin type or sexual orientation or gender identity, making sure that there is diversity projected and not only projected, but celebrated in the clinic space, right? And this can also be reflected in the composition of the healthcare team and that diversity as well. And also, think about people wearing lapel pins, for instance, on their clothing, like you see in the corner of this slide that can really affirm at a glance that individuals are welcome, no matter their background when it comes to sexual and gender diversity. And also keeping in mind, as we were talking about before, the importance of language, pronouns, gender neutrality, being respectful about names, and if there is some incongruence between legal name and chosen name, et cetera, considering how to ask and inquire about partners and family terms that they use to describe themselves should be echoed back to them. And of course, only ask for information that is absolutely needed, avoiding asking questions simply out of the sake of curiosity and asking those questions in a sensitive way. So as we think about advocacy and how to put this in action, I wanted to pivot a little bit and really talk about a great example of how all of this kind of comes to fruition, and that would be in the instance of Isatret, Ngo, and I-Pledge. And so we know that I-Pledge was historically discriminatory and exclusionary of gender diverse people in the sense that in order to register someone as pregnant, they had to be registered as a female. So it conflated pregnancy potential with gender identity. Well, this has been recognized for years, and organized medicine is a huge part of how we engage with many of these systems. And dermatology is lucky enough to have the Dermatology Section Council, which is a consortium of dermatologists recognizing various states and specialty societies in the AMA. And years ago in 2017, we brought forward a resolution to the American Medical Association House of Delegates asking for gender identity inclusion and accountability in REMS, or Risk Evaluation and Mitigation Strategies programs. And the whole idea was that we would remove the conflation of gender identity and pregnancy potential. So this was kind of the beginning of that movement from an organized medicine standpoint, and along with many different stakeholders and dermatologists that you see pictured here on this slide, we ultimately saw that iPledge was modified a few years ago to two categories instead of three, patients who can become pregnant versus those who cannot become pregnant. So this is a huge step in the right direction. And even though some of the physician or clinician based information in the program still to some extent conflates gender identity with sex assigned at birth, the patient facing categorization and registration information is much more inclusive now, which is a major step in the right direction. Now, the other thing is thinking about how we kind of put some of these concepts together in terms of a core holistic framework and looking at the human being and their totality and how this comes together in the context of isotretinoin. Well, we know that part of our clinical engagement with the patient revolves around emphasizing and validating their identity. So sexual orientation, gender identity and the intersectional variables among those. But we also know that we need to know information about their bodies. So their anatomy, their organ inventory, and that informs their pregnancy potential, but then also their behaviors. So are they engaging in behaviors that would actually put them at risk of pregnancy? And that directly informs how we register them in iPledge. So if you can become pregnant or not is based on your anatomy. And if you need contraception, if you're able to become pregnant, that would depend on your sexual behaviors. So recognizing that these terms are not the same, they don't define each other and that there are distinctions between them. And we have to actually ask these important questions in order to get a good understanding of this that's accurate and helps to inform how we go about managing patients in this setting. And there's many schematics that can kind of help clinicians to really go through this in terms of recognizing pregnancy potential based on organ inventory and the need for contraception. And there's many resources just like this one here. But one thing that I do wanna emphasize as a very specific nuance here is this notion of dysphoria and how that may or may not relate to pregnancy potential. So we know that dysphoria is this persistent discomfort or distress that results from incongruence among gender identity, expression and a sex assigned at birth, but it's not universal. Not all gender diverse people will experience dysphoria and not all transgender people who experience it will do so in the same way. And the reason this is important is because when it comes to pregnancy potential, there are some, for example, transgender men who fully embrace their ability to get pregnant if they are in fact able to, and they may not see that pregnancy potential as in conflict with their transmasculine gender identity. However, for some other people, it may be a substantial source of gender dysphoria. And so it's important to understand and untangle what that dysphoria actually means to the individual patient and how that relates to pregnancy potential and testing and the terms that are used for anatomy and behavior so as to limit that dysphoria. So allocations for serum testing rather than urine testing perhaps, or as long as we're able to still do so, thinking about the allowance for home pregnancy testing in terms of what's allowed with iPledge and what's not, but just thinking about ways in which we can accommodate those who may have significant dysphoria when it comes to that pregnancy potential and pregnancy testing and the verbiage that goes around that versus those who may not have any significant dysphoria about that. And also remember gender neutrality, of course. Now, this is not a mandate to substitute all of these terms that are listed here. Sometimes this does have to be personalized for the patient who's in front of you. And really it just goes back to recognizing and validating and echoing that patient's language. And so understanding that sometimes gendered language may trigger dysphoria for those who have undergone trauma or significant challenges in their lived experience based on their gender identity and the expectations of society. And that using this gender neutral language for many individuals can be a source of great validation and comfort. And also thinking about the conversational approach. So as we think about taking a gender and sexual history, asking about current gender identity, what was your sex assigned at birth and pronouns? And then thinking about the organ inventory, what sexual and reproductive organs do you have? What terms do you use for those? Asking about surgical history. And then in terms of sexual history, do you have sex? Recognizing that not all people do. Are you currently sexually active? And then if so, is this, what are the genders and bodies of your partners? How do you have sex with them? What body parts do you use? What parts go where? So thinking about the exact history that we need in terms of stratifying that risk for pregnancy and also that of sexually transmitted illnesses and targeting that screening appropriately. And if they're not sexually active, is that by choice? Do you feel a desire to have sex? Is there some need for counseling there or exploration of unfortunate trauma? And if you have the capacity to become pregnant, what is your pregnancy desire? Do you use anything for pregnancy prevention? And then I also tend to screen for intimate partner violence as well. And all the while recognizing that all of this should be framed in terms of a trauma-informed approach to care and that we have to recognize the disproportionate impact and prevalence of intimate partner violence and sexual violence in general in these marginalized populations. And so the Academy has many resources that are available. One is the LGBTQ Sexual and Gender Minority Edspurt Resource Group. And there's a website, lgbtqderm.org, where you can engage with that group and get access to resources and events that may be going on. And the group is primarily in place to facilitate communication and collaboration among dermatologists who have an interest in promoting these issues, who want to be allies or otherwise engage with the community. And also feel free to reference the Academy's position statement on sexual and gender minority health and dermatology, which was unanimously approved by the Board of Directors in 2019. And it really serves as a guidepost for the organization in terms of advocacy, education, and research on these issues. And the full statement can be found on the Academy website with the rest of the position statements. And with that, I just want to thank you for your time. Please don't hesitate to email me or contact me with any questions or concerns. And I hope to see you on another module at some point soon. Thank you.

advocacy

gender diversity

inclusive care

healthcare access

terminology

affirming identities

healthcare policies