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. We'll be talking today about sexual and gender diversity, and this first module will be focusing on content and production and basics. And I have no relevant relationships with industry, and also I do 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 also want to acknowledge that the ancestors of indigenous people have suffered from colonization, including genocide, ethnic cleansing, stolen land, and forced removal, and also to recognize the impact of forced labor on individuals of African descent. And I encourage everyone to commit in whatever way they may see personally fit to engaging with an action plan on these issues, whether that's committing to social media engagement with indigenous advocacy organizations or educational events, advocacy through policymaking and institutional commitments, or responsible consumerism or any of those factors, if not others. So as a bit of a backdrop for what we'll be talking about today, I want to emphasize that these issues are nothing new. Gender and sexual diverse people have existed throughout recorded history and in cultures across the globe, and while it seems as if conversations about many of these topics here in the United States are fairly recent, we have had activism in the United States since its founding, with some of the most notable advances in the struggle for equal rights occurring in the latter part of the 20th century, largely catalyzed by transgender people of color, including influential people like Marsha Johnson and Sylvia Rivera, who paved the way for people like Sarah McBride, who was sworn in in 2021 as the first openly transgender state senator in United States history. But the struggle for equality and recognition is ongoing, and more recently we've seen efforts to take away rights and to harm the well-being of LGBTQ people across the nation. And this is having a very direct impact on individuals who are simply trying to live their lives as authentically as possible, and it's important that allies of the community do their part to safeguard these basic liberties in the face of so many challenges, and that's exactly part of what we're hoping to accomplish through Medicine Without Barriers. So before we dive in a little bit deeper, I do want to cover some basics of terminology, because not all of us start on the same page in terms of basic concepts and terminology, and it's important to have a basic understanding of that before we talk further about these important populations. So the first thing to talk about would be the differences between sex and gender, and sex is also known as sex assigned at birth, and that tends to be based on the appearance of external anatomy at birth, and it may or may not align with gender identity or gender expression, so this is more of a biological concept. Gender on the other hand is a social construction, and in a binary model it would refer to constructs of masculinity and femininity as defined by a given social order, or if that social order recognizes gender other than male or female, or man or woman, it would include that as well, and this is more of a sociocultural construct. And so I think we can all recognize that there's nothing inherent to our DNA or X or Y chromosomes that dictates such factors as what we wear, how we act, or the roles we take in society, or who we love, or who we engage with, et cetera, et cetera. And so, so many of the factors that we assign to gender and the roles and expectations that are assigned to gender in society are arbitrarily derived from sex designations, and they don't necessarily have to inform each other. So sex and gender, again, distinct terms and concepts that do not inherently define each other. So a few other terms, transgender describes a person whose gender identity or internal sense of their gender differs from that assumed by their sex assigned at birth, whereas cisgender would note someone whose gender identity aligns with their sex assigned at birth. Now you may hear a variety of different terms, transgender, non-binary, genderqueer, gender nonconforming, and all of these can essentially fall under this umbrella of inclusive terms that we use to denote gender diversity, gender expansiveness, or gender minority, or other terms that you may hear. And also recognize when it comes to terminology that this is not a one size fits all. Everyone may have a different preference in terms of this terminology based on historical precedent or terms that they're more accustomed to or experiences they've had with those terms. The most important thing is to basically recognize the terms that someone, such as your patient, wishes to use and echo those terms back. And also recognize that some terms may be seen as stigmatizing or negative to some people, but they may be fully embraced by other people. A perfect example of this would be the term queer. Queer used to be seen as a very pejorative term. It's now been largely reclaimed, especially by younger generations as an empowering term and a term that denotes diversity and sexuality and the experience of gender. Another term, homosexual. That has some negative connotations as well because largely of it being listed as a mental health diagnosis in the DSM that was stricken many decades ago. But some people might still use that term. It really just depends on that person's experience and personal journey. But if they use that term, then it should be recognized as such. Now when I think about concepts of how to approach sexual and gender diversity, I like to break this down into some rudimentary concepts. And some of this would be this model of identities and bodies and behaviors and how those are distinct, but yet they can intersect. So identity refers to things like sexual orientation, gender identity, and certainly the intersection of those identities with things like race, ethnicity, religion, ability, socioeconomic status, educational attainment, et cetera. And the importance of this really comes down to factors like mental health and stigma, affirming terminology, building resilience, and those types of concepts. Whereas that can be contrasted with things like bodies, right? So we have things like anatomy and organ inventory that defines the bodies or anatomy that an individual has. And that's not necessarily to be informed based on someone's identity. So with anatomy and organ inventory, that would really refer to things like medication counseling, cancer screening, surveillance, surgical considerations, and complications, all of which we really need to know about someone's body and not necessarily their identity specifically for those things. So for instance, if I need to screen someone for cervical cancer, what I care about is that they have a cervix. And if they do, then they need screening. If they don't, then they do not. So it doesn't matter so much what their sexual orientation is, what their behaviors are, or how they identify in terms of gender identity. If somebody has a cervix, they need cervical cancer screening, right? And then we get into behaviors and sexual behaviors, of course, is one of these. And that would inform things more directly like one's pregnancy potential. So while their body would define their ability to become pregnant or not, the risk of getting pregnant would be determined by sexual behaviors. And this also informs things like comprehensive sexual histories and sexually transmitted infection risk and prevention. And so I think I-Pledge, when we're prescribing isotretinoin, is really a perfect illustration of how these things come together. So identity determines how we counsel in an inclusive fashion and informs the reason that we actually struck the completion of gender and pregnancy potential in the most recent rollout of I-Pledge's changes. Body would determine whether someone should be registered as capable of pregnancy or not. And then behavior would determine whether contraception is needed or not. So when we put all of these things together, we can think about sex development. So notions of sex assigned at birth or female or male, and that would also encompass things like intersex or variations of sex characteristics, which is, again, more of a biological construct, of course. Then we get into gender identity. So notion of whether someone identifies as a woman, a man, or non-binary or anywhere on that spectrum, or perhaps no gender at all. Gender expression would refer to how someone outwardly expresses their gender identity. So notions of femininity or masculinity or whether they're gender nonconforming with their expression or gender conforming. And then we have sexual orientation. So who someone is attracted to both romantically, physically, emotionally, those types of things. So these are all distinct, but they can be related. But the most important thing is to avoid assumptions and remember the differences among all of these terms. They are all somewhat related to varying degrees, depending on how they're discussed, but at the end of the day, these are distinct terms that should be recognized as such. In particular, someone's sexual orientation does not necessarily inform their sexual behaviors. So an individual's sexual orientation, let's say they identify as heterosexual, they may actually still engage in sexual behaviors with individuals of the same sex, yet their identity is that of heterosexual or straight. So it just depends, and depending on what we're counseling about or what risk factors we're trying to tease out, it's important to be very direct in those questions. So what is gender dysphoria? So this is the strong or persistent distress or impairment that results from an incongruence between gender identity and sex assigned at birth. And not all gender diverse people will experience dysphoria. Some do, some don't. It just depends on their individual lived experience, and this is mitigated in part through gender affirmation. And gender affirmation refers to decisions, behaviors, or interventions that affirm a gender diverse person's gender identity. And there's a whole host of elements to this. There's something as simple as self-affirmation, so internally affirming your own identity or coming out to yourself as trans. There's social affirmation, name changes, gender expression, pronoun usage, legal affirmation, modifying gender markers on government documents, medical affirmation, which would be gender affirming hormone therapy or pubertal suppression, and then the whole gamut of surgical affirmation. And not all people who are gender diverse are going to desire any or all of these domains of gender affirmation, and people can also bounce among them as well. So nothing should be assumed based on their identity in terms of these gender affirmation goals. Now, where does our approach to treating transgender people come from? Well, there are variations, but in general, the World Professional Association for Transgender Health has issued standards of care. WPATH is the leading global professional organization dedicated to research and development of guidelines for the care of gender diverse people. The first standards of care were released decades ago in the late 1970s, but the most recent iteration came out in the fall of 2022. And a few updates from the most recent standards of care was an acknowledgement that a one-size-fits-all does not work for everyone. It also reaffirmed that the only form of gender-affirming care for children before puberty is social support and not other types of medical affirmation. And that also mental health was no longer a gateway requirement for care, but is recommended for those who need it. WPATH did say last year that teens experiencing gender dysphoria can start taking hormones at age 14 and may be able to have certain surgeries at age 15 to 17, but the group acknowledged potential risks of some of these interventions, but it said it was unethical to withhold early treatments when otherwise necessary, which can improve psychological well-being and reduce suicide risk. And just remember also transgender children are not undergoing irreversible procedures and treatments based on the guidelines from WPATH. So these are just an outline of common steps in gender transition that we've already talked about, so kind of a higher level view of that. So getting into the data that we have available, we do know that transgender people with no access to gender-affirming services have a greatly heightened risk of depression. And in particular, looking at transgender youth, gender-affirming care was associated with significantly lower odds of moderate to severe depression, as well as lower odds of suicidality. And this is a busy slide, but it goes over a few seminal papers looking at this notion of pubertal suppression and its impact on transgender youth, showing a significant inverse association between pubertal blockers during adolescence and lifetime suicidal ideation. And that pubertal suppression for transgender adolescents who want that treatment is associated with favorable mental health outcomes. And also importantly, pubertal suppression was not associated with increased subsequent hormone use. In other words, there was this thought that perhaps if you start someone on pubertal suppression, that you're basically just funneling them down a pathway toward hormone use, and that's actually not the case. And also that parental support of a child's gender identity had a strong relationship with receipt of medical-affirming therapy. And again, that affirmation therapy is associated with the lower odds of recent depression and past year suicide attempts for youth under the age of 18. Now, we don't have a huge amount of long-term data looking at hormones for transgender individuals, but we did have a very important step in a positive direction. This was a paper published early in 2023 in the New England Journal, basically following hundreds of transgender and non-binary participants for two years after initiating hormones, again, showing an increase in appearance congruence, positive affect, life satisfaction, and a decrease in depression and anxiety. So the overall takeaways were that withholding treatment may lead to increased gender dysphoria and adversely affect psychological functioning. Regret is exceedingly rare, though we must address that more substantially. And there are unanswered questions, but overall, we do know that this research is ongoing, but again, withholding this treatment is ethically not permissible because of the increase in gender dysphoria and adverse psychological functioning. So we do know that there have been a lot of attacks on this care in recent years. More legislation was filed in 2022 to disrupt the lives of transgender people than any other year in US history, with transgender youth being the most frequent targets. 2023 has actually already broken 2022's record, and there's numerous domains of life that are impacted, not just medical care, but also athletics, education, identity and legal documents, and even entertainment. And the current state of the landscape as of August 2023 is basically that all these states shaded in red have implemented gender affirming care bans, whereas the states in blue have enacted what we call shield laws, either through legislation or executive orders to protect that care. However, it's very muddled because a lot of these states that have passed gender affirming care bans in their legislatures are facing numerous court cases challenging the legality of those laws, some of which have been permanently blocked by court order, although the states that that applies to are appealing those decisions, and many of these bans are temporarily blocked by court order, and others, they're filed and pending and we're awaiting the outcome. So there's a lot to unfold here, and a lot that we still don't know about what the landscape is ultimately going to look like, but just recognize that it's been a very busy year in 2023 with a lot of this legislation. Now what do these laws mean? I won't get into the fine details of these, but the language is variable, but broadly applies to surgery, hormone therapy, and puberty blockers. However, the language is becoming increasingly vague and may be more broadly applicable to even the care that dermatology provides. The language could certainly be interpreted that way, depending on the laws that are being read, and legislators may not simply be aware of a lot of subspecialty roles and gender affirmation, but as they become more aware, specialties like dermatology may be increasingly more implicated. But there's also aiding and abetting language that's prohibited, as well as referral prohibitions, and some of that could certainly implicate dermatology as well. So we do know that all of this legislation is taking a toll on the community, and we know that two-thirds of LGBTQ youth have reported that this legislative activity has adversely impacted their mental health, and this is on top of a backdrop of disproportionate experiences in schools, where students are facing more harassment and feeling unsafe, and facing more mental health concerns and substance abuse issues based on their gender identity as opposed to their cisgender peers. And we also know that hate crimes are going up as well. There's been a 54% increase in anti-LGB hate crimes over the last several years, and a 30% increase at least in crimes against transgender people. And the stark reality is that more than 40% of transgender people have reported attempting suicide based on major surveys. And discrimination in healthcare is actually pervasive, and even though in some ways it's improving, there's still a lot of work to be done. Significant numbers of LGBTQ people report being discriminated against because they're part of the LGBTQ community, and when engaging with the healthcare setting, many avoid seeking healthcare altogether because of concern about discrimination or denials of insurance coverage or basic services. And you may say, well, isn't this type of discrimination illegal? Well, that's a complicated question that we're not going to get heavily into in this presentation. However, I do want to provide some basic information. It's important to recognize that the health care rights law baked into the Affordable Care Act is still the law of the land, and it does apply. And so Section 1557 is the nondiscrimination provision of the Affordable Care Act, and it basically prohibits discrimination in health care based on sex. Now, sex has to be interpreted in a regulatory fashion, and when the Affordable Care Act was passed, sex was interpreted as inclusive of sexual orientation and gender identity. That regulatory provision was actually removed during the Trump administration, but it's been reinstated in the Biden administration. And so there's still a bit of ambiguity just because the Affordable Care Act does prohibit discrimination based on sex. But the meaning of sex is very important, and it is actually something that is murky depending on the administration who's responsible for regulating that definition. Now, a very important progressive milestone that happened back in 2020 was the case that you may be familiar with, known as Bostock versus Clayton County, Georgia, which is when the Supreme Court upheld that Title VII of the Civil Rights Act of 1964 does indeed protect LGBTQ people from workplace discrimination. So Title VII of the Civil Rights Act also prohibited discrimination and employment based on sex. However, like the Affordable Care Act Section 1557 provision, sex was not explicitly defined as inclusive of sexual orientation and gender identity. However, in this case, the Supreme Court did interpret sex in this law as inclusive of sexual and gender diversity. And this was the first non-executive precedent of defining sex in such a way. So this set a very important precedent that hopefully will impact other domains of civil rights law. This one narrowly pertains to employment in terms of how it is to be enacted and how it regulates the employment sector. But there's still no universal legislative protections that extend to other elements of life. And that's where we need things like the Equality Act, which would implement basic comprehensive protections for LGBTQ Americans, which are lacking in almost 30 states at this point. And it would explicitly amend the Civil Rights Act to explicitly provide those non-discrimination protections across a variety of domains, whether it's housing, credit, health care, education, public accommodations, not just employment. So this has been introduced several times. It passed the House in the last Congress, the 117th Congress, and was stalled in the Senate. We are awaiting reintroduction of that in the 118th Congress. But so far it has not happened yet. Now, just to kind of take a step back from a 30,000 foot view and just go over how this stigma is actually layered across different domains of society. So first of all, what we see is on an intrapersonal level, a person can experience stigma in the form of internalized homonegativity or trans negativity, and that can come through as self-injurious behaviors or mental health issues. Then there's interpersonal stigma. So dynamics between and amongst people, microaggressions, hate crimes, bullying, etc. And then there's institutional stigma. So when there's anti-LGBTQ policies in place, overt discrimination, macroaggressions, police violence, and how that funnels down into a cycle of fueling interpersonal violence and intrapersonal stigma. And so this exists across all aspects and domains of life and society, and we all have roles in combating each of these. And just to remember, too, that intersectionality is an important concept coined by Kimberly Crenshaw in 1989, which really shows how all these different elements of identity fit together and that we all have elements of both privilege and non-privilege. And all of these things intersect together in a way that forms a unique lived experience for each of us. And most of us do have elements on here of privilege and other elements not of privilege. And these can importantly shift and change over time depending on what we attain and where our lived experiences take us. And so it's important to understand how these fit together and how it forms our unique identities. But I also want to recognize that we don't just live in a bubble in the United States. We know that there are issues globally when it comes to sexual and gender diversity. And frameworks in Western countries have often been exported to lower income countries, largely due to criminalization in those areas, which can often be seen as enduring artifacts of colonial era laws. And we know that in about 33 percent of countries in the United Nations, there is still criminalization of same-sex acts and there is a death penalty in several states still. Only 11 U.N. member states or about 6 percent explicitly protect the right to sexual diversity in their national constitutions. But there has been progress made over the years. We'll talk about the Yogyakarta Principles from 2006 and also noting that the World Health Organization, ICD, categorized transgender issues as mental disorders until 2019, now consider gender incongruence within sexual health as opposed to mental disorders. Now, the Yogyakarta Principles in 2006 was certainly a turning point of global recognition, and it was a meeting of international human rights groups that set about to apply precepts of protecting sexual orientation and gender identity and apply those to international human rights law. And these were expanded in 2017 to include sex characteristics and account for intersex individuals as well as gender expression. The U.N. has also sought to condemn violence and discrimination against LGBT people. And in 2016, formed the U.N. mandate of independent expert on protection against violence and discrimination based on sexual orientation and gender identity, which has been consistently renewed over time. And so this basically shows a global sexual diversity policy where same-sex sexual acts are criminalized, where same-sex marriage is legal, the nations in blue, also in yellow, where there are full or limited bans on so-called conversion therapy designed to, quote, unquote, fix someone's sexual orientation or gender identity. And also it goes into the green countries, which are among the most progressive where same-sex marriage is legal and there are full or limited bans on so-called conversion therapy. And so with this criminalization, most of these countries are in Africa or Asia. Europe doesn't have any countries that criminalize same-sex behavior. And this landscape continues to change, with Singapore recently repealing their colonial era, Section 377A, that repealed the same-sex activity ban. But it did limit the prospect of legalizing same-sex marriage. And of course, Uganda enacting harsh anti-LGBTQ laws that include the death penalty for same-sex acts. And also just to emphasize here, this is the global acceptance index that essentially shows that the more accepting nations tend to get more accepting and the less accepting nations tend to get less accepting over time, and that most of these really are looking fairly myopically at same-sex sexual activity and going beyond that to joint adoption and marriage equality and gender markers and the like are falling behind in terms of where these are addressed on a legislative or legal scale in these nations. And this is another outline to show where are the state of global acceptance in these nations and the changes over the last decade, if not longer. Now, in terms of legal gender diversity recognition, there are two equally important but distinct mechanisms. The first shown here is the ability to simply change the gender marker to another designation or option provided on a particular legal document. The second is recognition of a third gender or another gender alongside man and woman. And depending on where you are, one of these may be more challenging than another or might simply be impossible, depending on where you are. And so these certainly have changed over time. In May of 2023, the Federal Religious Court in Pakistan declared the then provisions of gender marker change to be in contradiction with Islam, the official religion of Pakistan, and stated that the gender of a person must conform to the biological sex of a person, not their feelings or self-perception. So that has changed as well over time. Argentina, notably, is a pioneer and model for trans-inclusive policies. In 2012, they upheld the right of all citizens above the age of 18 to access free surgical and comprehensive hormonal interventions without court authorization, as well as the ability to obtain a government-issued ID with their chosen gender without the need to undergo any medical or psychological gatekeeping. But also, this is where third gender is legally recognized. And as you can see, those are fewer than the ones who allow gender marker changes. So lots of work to do. But we do know that global health in general underrepresents the experiences of queer people. And there is still very much an entrenched ethic of cis-heteronormativity in medicine. An intersectional lens is critical. And we have to reform our paradigm and treat LGBTQ communities as identities that should be affirmed and experiences to be understood rather than problems to fix, which is historically how medicine and the medical community more broadly has treated these individuals. And also, we need to empower the rest of the world to participate in this research. The vast majority of studies in transgender health have existed in the United States and not so much elsewhere. And this is kind of a set of wonderful affirming global health practices, realizing that the intersection of medicine with broader sociocultural policies is an important intersection. And this reaffirms the right to self-determination and the awareness of cis-heteronormative social context and the importance of intersectionality and recognition of global best practices in transgender health care and that these need to be developed and better understood and that the importance of lifelong learning and cultural humility should very much be emphasized. So definitely a great set of policies to remember. And I'll close here basically looking at the levels to which we can incorporate gender awareness into our practices and into our lives more generally, basically focusing here from this notion of being gender unaware on this side of the spectrum, which leads to exploitation of people of gender diverse backgrounds and going up the scale all the way to gender inclusiveness and finally transformative gender inclusivity, which actually fully accounts for the experiences, the lived experiences of transgender and non-binary individuals to target sources of inequity and inequality and become transformative in our approach to empower these individuals to live their lives more authentically. So just be aware of where your policies and research and clinical approach fits on this scale and recognizing that to be unaware of some of these issues often leads to exploitative frameworks and practices, and it's important to recognize those wherever they may be. And with that being said, I thank you for your attention and I look forward to any questions or concerns or thoughts or feedback that you may have. And I look forward to seeing you in subsequent modules.

sexual and gender diversity

gender affirmation

transgender

genderqueer

gender nonconforming

gender-affirming care

LGBTQ individuals