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"Advancing Transgender and Gender Diverse Visibility and inclusion and Data Accuracy in Oncology"

March 23, 2022

Yale Cancer Center Grand Rounds | March 22, 2022

Presentations by: Drs. Juno Obedin-Maliver (she/her/hers) and Ash Alpert (they/them/theirs)

ID
7595

Transcript

  • 00:00Take To introduce away our speakers
  • 00:03for today's Smilow Cancer Hospital
  • 00:05and Yale Cancer Center grand Rounds.
  • 00:09Hosted by the Office of Diversity,
  • 00:11Equity and Inclusion at Yale Cancer Center.
  • 00:15And I'd like to start by introducing Dr.
  • 00:17Obannon Malaver,
  • 00:19who uses the pronouns she, her, hers.
  • 00:22She is an assistant professor in the
  • 00:24Department of Obstetrics and Gynecology
  • 00:26at Stanford University School of Medicine.
  • 00:29She specializes in gynecology and
  • 00:31reproductive health care of needs of
  • 00:34sexual and gender minority people,
  • 00:36which include, but are not limited to,
  • 00:38lesbian, gay, bisexual, transgender,
  • 00:41queer and questioning people.
  • 00:44This interesting experience.
  • 00:45Grabs her research interests towards
  • 00:47promoting the health and well
  • 00:50being and equity of LGBTQI people.
  • 00:52She is the director or Co director of
  • 00:54the PRIDE study, a multi site online,
  • 00:57prospective longitudinal cohort
  • 00:58of sexual and gender minority
  • 01:00individuals based at Stanford.
  • 01:02She is also an incredible advocate
  • 01:05in this space and has been
  • 01:07very active in health policy.
  • 01:09Doctor Ash Alpert,
  • 01:10who uses the pronouns they them,
  • 01:13is a current T 32 fellow in HealthEquity
  • 01:15at the Center for Gerontology and
  • 01:18Healthcare Research at Brown University
  • 01:21at the School of Public Health.
  • 01:24Doctor Albert's research investigates
  • 01:26community solutions to improving
  • 01:28the experiences and outcomes of
  • 01:30transgender people with cancer.
  • 01:32They work with an Advisory Board
  • 01:34of transgender people who've been
  • 01:35diagnosed with cancer and whom
  • 01:37have they have conducted research.
  • 01:39Published manuscripts and applied for
  • 01:41grant funding over the last two years.
  • 01:43This includes a young investigator
  • 01:45award from conquered cancer to ask
  • 01:48a foundation to develop patient
  • 01:50centered and non stigmatising gender
  • 01:52identity data collection methods.
  • 01:54Doctor Alpert is also very involved
  • 01:57with advocacy efforts.
  • 01:58That includes the ASCO sexual and
  • 02:00gender Minority Task Force and the NCCN.
  • 02:03So it is our great pleasure to
  • 02:04hear from both of them.
  • 02:05Today I will pass the baton they will
  • 02:08be presenting on advancing transgender
  • 02:10and gender diverse visibility and
  • 02:12inclusion and data accuracy and oncology.
  • 02:15Thank you.
  • 02:19And thank you so much for this
  • 02:22kind welcome and introduction.
  • 02:24We're both very honored to be here.
  • 02:27Thank you. Doctor Collins as
  • 02:28well as all of the attendees.
  • 02:30Also to Renee and other folks who
  • 02:33have helped with the logistics.
  • 02:35It often takes an army to to
  • 02:38make these things happen.
  • 02:39So thank you so much. And.
  • 02:44Overall, we'll be focusing today on
  • 02:47specific mechanisms for improving
  • 02:49visibility and inclusion of
  • 02:51transgender people in oncology,
  • 02:52and thereby ensuring that our
  • 02:55data in clinical decision making
  • 02:57are accurate and efficacious.
  • 02:59You should say, I'm Juno,
  • 03:01open in Malibu,
  • 03:03and everyone just calls me
  • 03:04Juno and I'll let Doctor Albert
  • 03:07introduce themselves.
  • 03:10Hi I'm doctor cash.
  • 03:13So we're going to talk for a moment
  • 03:16about what brings us to this work.
  • 03:19Will then review some of the epidemiology of
  • 03:22transgender and gender diverse populations.
  • 03:24Some linguistics and terminology as well,
  • 03:27and then move into how this all relates
  • 03:29to cancer is specifically describing
  • 03:31the experiences of transgender and
  • 03:33gender diverse people with and without
  • 03:36cancer and healthcare context all
  • 03:38towards proposing a new model of how
  • 03:40we think about bodies and how we.
  • 03:42Think about the care that we're
  • 03:46providing and moving away from
  • 03:48oversimplified notions of sex or sex.
  • 03:50Assigned at birth and being more
  • 03:53broad and expansive to really
  • 03:55take care of whole person health,
  • 03:57and this will turn you know,
  • 03:59finish with a discussion of how the Cancer
  • 04:01Center could improve visibility, accuracy,
  • 04:04inclusion some steps that you can take today.
  • 04:07And then of course, the longer range,
  • 04:09goals and activities our slides
  • 04:10will be available to you,
  • 04:12so there's a lot of.
  • 04:13References and action steps as well.
  • 04:16Don't worry about trying to capture all
  • 04:18of those and will move to the next slide.
  • 04:22We are also so very grateful to the
  • 04:26following folks who have worked
  • 04:28with us in in various capacities
  • 04:31and whose insights and wisdom are
  • 04:34shared here specifically.
  • 04:36The transgender Cancer Patient
  • 04:38Advisory Board that Doctor Albert
  • 04:40works very closely with next slide.
  • 04:44So we have no relevant financial
  • 04:47disclosures to this presentation,
  • 04:48but have been supported by some of
  • 04:50the following grants and activities.
  • 04:52They don't present any conflict here,
  • 04:55and our job here really is to give you
  • 04:58some of the foundational understanding
  • 05:00of how invisibility in accuracy and
  • 05:03exclusion among transgender and gender
  • 05:05diverse people plays out in oncology
  • 05:07and thereby foster future action
  • 05:09and learning towards visibility,
  • 05:11accuracy and inclusion,
  • 05:12and ultimately towards HealthEquity.
  • 05:15And so to do that,
  • 05:17we really see these three objectives
  • 05:19describing the exclusion of
  • 05:20transgender and gender diverse people,
  • 05:22and sensitize you to some of the
  • 05:25health sequelae that follow.
  • 05:27On from that exclusion,
  • 05:29describe some conceptual frameworks
  • 05:31that hopefully will be useful to you in
  • 05:34your work and sensitization to these topics,
  • 05:37including linguistic and systemic,
  • 05:39come and support you in addressing
  • 05:41health disparities by enhancing
  • 05:43visibility and inclusion.
  • 05:45And then to identifying some
  • 05:47key steps that can be taken.
  • 05:49So we wanted to start here by talking
  • 05:53about some of the ways transgender
  • 05:55people are often invisible in the
  • 05:57medical landscape in our language,
  • 05:59in our documents,
  • 06:00and the effects that that has on
  • 06:02transgender and gender diverse people.
  • 06:05So two staggering statistics.
  • 06:07Next slide, sorry, Doctor Albert,
  • 06:09thank you for driving the slides.
  • 06:14Or are these two that nearly one half of
  • 06:19transgender people will attempt suicide in?
  • 06:23Their lifetimes.
  • 06:24It's a really staggering number.
  • 06:26It's actually probably much higher
  • 06:29given the poor data collection that
  • 06:32we'll talk about here in a moment.
  • 06:35And that's in comparison to 1.6% of
  • 06:39the general population of adults.
  • 06:42Actually, one transgender person
  • 06:44is murdered every three days,
  • 06:47so if these don't story,
  • 06:48if these statistics don't grab your heart,
  • 06:50you know and just bring you into this.
  • 06:54We wanted to share a little
  • 06:55bit more about our stories,
  • 06:56so uhm and and we hope that this
  • 07:00really starts to bring to visibility
  • 07:03the interlocking systems of
  • 07:05oppression that don't recognize
  • 07:08transgender people's existence.
  • 07:09And I'll start by saying that.
  • 07:12You know I'm a cisgender queer woman, uhm.
  • 07:16I live and move in LGBTQ spaces
  • 07:19and had been for a long time and
  • 07:22working and living in San Francisco,
  • 07:25working on LGBT health and it was in my
  • 07:28internship year when I really started
  • 07:31to recognize how transgender people
  • 07:34weren't considered even as part of
  • 07:36that bigger umbrella of LGBTQ plus.
  • 07:41It was an intern I was working in the in,
  • 07:43in the ICU,
  • 07:44and a transgender woman who was
  • 07:46very well known to our hospital
  • 07:48system came in with complications
  • 07:50of her longstanding lung disease.
  • 07:53Shortly after she arrived,
  • 07:55UM,
  • 07:56code processes began as she went
  • 07:59into respiratory failure and
  • 08:00as part of this process,
  • 08:01she was undressed and when she was undressed
  • 08:05it was noted that she had a penis.
  • 08:07At that point,
  • 08:09all code activities stopped.
  • 08:10People lost their composure and
  • 08:12critical activities were halted.
  • 08:14People actually stepped away from
  • 08:16the bed and there was this long,
  • 08:18terrible pause where people lost
  • 08:21their professional activities and
  • 08:23all the steps that they should have
  • 08:25been taking to help save her life.
  • 08:28Concurrently,
  • 08:28her wife was being called urgently
  • 08:31and asked if she wanted extreme
  • 08:34measures taken for her wife and
  • 08:38our patient was misgendered,
  • 08:40saying,
  • 08:40you know whether we should sustain life
  • 08:43or you know ** *** it and it was terrible.
  • 08:46So at the point of her death this
  • 08:50woman was dis respected and invisible
  • 08:53ized in that you know her death
  • 08:55wasn't seen as the death of a woman.
  • 08:58In this setting,
  • 09:00and that her wife takes that forward
  • 09:03into thoughts and memories of what
  • 09:06happened in the end of her wife's care.
  • 09:09So this blatant disrespect and lack
  • 09:11of human decency really propelled
  • 09:13me to start to think about how I
  • 09:16could do better and how we could
  • 09:18all do better in medicine.
  • 09:20With that I'm going to turn it
  • 09:22over to Doctor Albert.
  • 09:24Thanks for that very
  • 09:26beautiful and moving story.
  • 09:28So I'm ash I'm I'm nonbinary,
  • 09:32and I'm here and I wanted to
  • 09:33share a very different story from
  • 09:35back before I actually even knew
  • 09:37that I wanted to be a doctor.
  • 09:39I was in college and about 20
  • 09:42years old and I fell in love with
  • 09:45somebody who is transgender.
  • 09:47And I remember sitting at a
  • 09:50dining table and listening to her
  • 09:53tell the stories about her life.
  • 09:55And I had this very strange sense
  • 09:58that the world that I understood
  • 10:00was was breaking open was changing
  • 10:02and that everything that I thought
  • 10:05that I knew about my gender and the
  • 10:08genders of other people that I had
  • 10:10taken as a given was in fact not a given.
  • 10:13It was a very strange and scary feeling.
  • 10:17But it was also incredibly freeing
  • 10:20and that that person that I had
  • 10:22fallen in love with was also very
  • 10:24interested in issues of social justice.
  • 10:26And it really felt like in that moment
  • 10:30that I was seeing the possibility
  • 10:32of a revolution and transformation.
  • 10:35Later, when I was in medical school,
  • 10:37I started doing qualitative
  • 10:39research with LGBTQ plus people.
  • 10:42And I noticed a similar feeling
  • 10:44that the stories of transgender
  • 10:46people in particular had in them
  • 10:49the possibility of reviewing the
  • 10:51assumptions of our medical systems and
  • 10:53creating the possibility for change.
  • 10:57So I'm hoping that what you'll hear
  • 11:00today is both the urgency of making
  • 11:02changes to our systems to save
  • 11:04the lives of transgender people,
  • 11:06and also the beautiful possibility that
  • 11:08if we change our systems in these ways,
  • 11:11we might also provide more nuanced and
  • 11:13efficacious care for all of our patients.
  • 11:18Turn it back to Doctor
  • 11:19orbiting Alberta, continue.
  • 11:22Thank you so much Doctor Albert for sharing
  • 11:25your perspective and wisdom as always.
  • 11:28So from the stories that you've just heard.
  • 11:30What what will and what will present today?
  • 11:32We want you to take away from
  • 11:34some central concepts and themes.
  • 11:36One is that systemic oppression
  • 11:38which is experienced daily levels,
  • 11:41leads to cancer disparities as it's an
  • 11:44undercurrent of catalyzing other things
  • 11:45that we know worse than the incidence,
  • 11:48prevalence and severity of cancer.
  • 11:52Invisibility,
  • 11:53which is ubiquitous in our world.
  • 11:56Just look, you know,
  • 11:57at any magazine, any media.
  • 11:59There's certainly more visibility of
  • 12:01transgender and gender diverse people,
  • 12:03but it's pales in comparison to binary
  • 12:06assumptions about gender and who people
  • 12:08are and how people move in the world.
  • 12:11And this actually leads to data
  • 12:12in accuracies for all people,
  • 12:14not just trans people,
  • 12:16and limits our understanding of
  • 12:19how the world works, frankly.
  • 12:21And we hope to demonstrate some of
  • 12:24that and and more specifically leads to
  • 12:27substandard care for transgender and
  • 12:29gender diverse people and then stigma,
  • 12:31which can be implicit or explicit,
  • 12:34leads to poor experiences and outcomes.
  • 12:35And we see that in many different
  • 12:37characteristics and domains,
  • 12:38but specifically we'll be talking
  • 12:40about limited notions of gender here,
  • 12:42and we'll see that these 3 threads run
  • 12:44through the rest of our presentation.
  • 12:46Next slide, but first.
  • 12:47First thing is first we have to level
  • 12:50set on a little bit of terminology.
  • 12:52Likely many of much of this is
  • 12:53familiar to many people in here,
  • 12:55but without assumptions,
  • 12:56these are some of the terms that we
  • 12:59use LGBT sometimes LGBTQ plus LGBTQIA.
  • 13:05Those are all meaningful different
  • 13:08abbreviations, but broadly speaking,
  • 13:09same for lesbian, gay, bisexual,
  • 13:11transgender, queer questioning.
  • 13:13The plus is really speaking to the fact that.
  • 13:16The the diversity of communities that
  • 13:19are not cisgender and not straight
  • 13:22and or not straight up is broad and
  • 13:25actually represented them more than
  • 13:27just these few letters and subpopulations
  • 13:30and so in recognition of that,
  • 13:33actually academia has said we needed a
  • 13:35bigger term to kind of get our arms around.
  • 13:38The folks who are not cisgender
  • 13:41and not and so this umbrella term,
  • 13:43sexual and gender, minorities, or SGM.
  • 13:46Is what's used in academic spaces,
  • 13:49so not much really yet or at
  • 13:52all by communities.
  • 13:53It is used by the NIH and SGM people
  • 13:56are recognized as a health disparities
  • 13:59population for research by the NIH.
  • 14:01Transgender term that we've used a number
  • 14:03of times already in this population.
  • 14:05Someone whose gender differs from that
  • 14:07commonly associated with their sex.
  • 14:09Assigned at birth,
  • 14:11so that's in some ways the opposite
  • 14:13of this other term cisgender,
  • 14:16which again, really.
  • 14:17Came from academia,
  • 14:18which is someone whose gender is
  • 14:19the same as is commonly associated
  • 14:21with their sex.
  • 14:22Assigned at birth,
  • 14:23so I use that term in reference to myself.
  • 14:25I said I'm a cisgender queer woman.
  • 14:28That means I was assigned female
  • 14:29sex offenders have what's commonly
  • 14:32associated with typical female
  • 14:34reproductive organs.
  • 14:35I I challenged that terminology,
  • 14:37but uterus, ovaries, dudes,
  • 14:39etc and and identifies woman today.
  • 14:43And then transgender man and woman.
  • 14:46It's really important that we always use
  • 14:48terminology that affirms peoples gender,
  • 14:50UM,
  • 14:50and a transgender man or man with
  • 14:54transgender presumably assigned female
  • 14:56sex at birth and non binary person who
  • 14:59is not simply a man or woman may have
  • 15:03multiple genders or outside of the
  • 15:05non binary outside of a binary man,
  • 15:08woman identity or girl boy identity.
  • 15:12So these are some. Important terminology,
  • 15:15one thing that will point out is
  • 15:18that not everybody who is transgender
  • 15:21uses that terminology for themselves,
  • 15:23so really important to use the language that
  • 15:26people use for themselves and reflect that
  • 15:29back to people and and similarly cisgender.
  • 15:32A lot of people who we would classify as
  • 15:34just gender don't know that terminology.
  • 15:37Don't use it, so there's a difference
  • 15:39between when you're working with individual
  • 15:41people versus doing research policy, etc.
  • 15:45Next, slide for accuracy.
  • 15:47We also need to discuss some foundational
  • 15:50concepts and central to this is the
  • 15:53understanding of sex or sex assigned
  • 15:55at birth as distinct from gender.
  • 15:57So sex assigned at birth is identification
  • 16:00usually made by looking at external
  • 16:03genitalia.
  • 16:03In my field, often in at the time of birth,
  • 16:07sometimes before birth, right?
  • 16:08We're getting more and more information
  • 16:10from ultrasound, genetics, etc.
  • 16:11Often by healthcare providers,
  • 16:13sometimes by parents.
  • 16:15And that's a different from gender.
  • 16:17Someone internal sense of themselves
  • 16:18as a woman, a man, another gender.
  • 16:22There are many more than one gender,
  • 16:25and this also breaks down
  • 16:27into gender identity.
  • 16:29Clothes you wear.
  • 16:30Sorry gender identity,
  • 16:31which is something only you can
  • 16:33know by inside your own head,
  • 16:35right?
  • 16:35You would have to ask someone and they would
  • 16:37have to feel comfortable disclosing that
  • 16:39to you for you to know their gender identity.
  • 16:41Can't know it by looking at
  • 16:43them versus gender expression,
  • 16:44which is known.
  • 16:45Or is something that is red and how we
  • 16:48move in the world here makeup clothes?
  • 16:51How we cross our legs,
  • 16:52vocal intonations.
  • 16:53Those are all markers of gender expression,
  • 16:56and those don't necessarily quote
  • 16:57UN quote line up in ways that we've
  • 17:00tried that they traditionally do,
  • 17:02and that's really different
  • 17:03than sexual orientation,
  • 17:05which is comprised of individuals,
  • 17:07sexual attraction, identity behavior.
  • 17:09So there's actually many components
  • 17:11of sexual orientation as well,
  • 17:13which may or may not quote a line so.
  • 17:17Some lesbian women do have sex
  • 17:19with men and that is a distinction
  • 17:22between behavior and identity.
  • 17:24There are many sexual orientations,
  • 17:26and people have both a sexual
  • 17:28orientation and a gender identity,
  • 17:29and we need to think about
  • 17:32those as different domains OK,
  • 17:34and make sure that as clinicians
  • 17:38and administrators,
  • 17:39but that we are really teaching
  • 17:41and distinguishing between sex
  • 17:42assigned at birth and gender,
  • 17:44they are so commonly completed.
  • 17:46In medicine and research.
  • 17:48OK, next slide.
  • 17:49So some of you at this point
  • 17:51might be wondering.
  • 17:52Gosh great lots of concepts here,
  • 17:54but how important is this?
  • 17:56How common is this?
  • 17:58Why am I listening maybe?
  • 18:01And wanted to present a little
  • 18:03bit of that began genealogy,
  • 18:05so I've talked about this bigger
  • 18:07umbrella LGBTQ plus and current
  • 18:09research would say that you know,
  • 18:13actually,
  • 18:13the most accurate question answer to the
  • 18:16question of how many LGBT people are there,
  • 18:18or how many transgender people are there?
  • 18:20Is that we don't know because
  • 18:22most research Census,
  • 18:24American community surveys,
  • 18:26all these others.
  • 18:27Don't ask people systematically.
  • 18:29Their sexual orientation,
  • 18:30sex assigned at birth.
  • 18:31And gender identity for us to really
  • 18:33understand who's in our population.
  • 18:35However, we have some data and we
  • 18:38think of these as floor statistics,
  • 18:41not as a ceiling because not everybody
  • 18:44feels comfortable answering questions
  • 18:45like from a random digit dial are.
  • 18:48So these data which come from Gallup
  • 18:51show that 7% actually over 7% of adults
  • 18:55in the US today identify as LGBTQ plus.
  • 19:00It's more than all the children of
  • 19:02five and under in the United States,
  • 19:04including 20% of Generation Z adults,
  • 19:08and among that 1% are transgender.
  • 19:10So next slide.
  • 19:13And if we look a little bit more
  • 19:14closely into the transgender
  • 19:16population and epidemiology,
  • 19:17we see that overall about 1%,
  • 19:19or which translates to at
  • 19:21least 1.8 million people.
  • 19:22And we do know that there's a
  • 19:24difference by age and generation,
  • 19:26and the numbers here.
  • 19:27But there's really good evidence
  • 19:29to suggest it's not necessarily
  • 19:31that population prevalence
  • 19:32statistics are changing,
  • 19:33but rather there are real differences
  • 19:35in terms of comfort with disclosure,
  • 19:37changes in understanding and
  • 19:40representation of various gender
  • 19:42norms and concepts of gender.
  • 19:45We do see that in the youngest generation,
  • 19:47one in 50,
  • 19:48or identifying as transgender,
  • 19:50and we know that that's a lot less
  • 19:52than probably who is and and thinks of
  • 19:55themselves and or has the experience
  • 19:57of being trans one really important
  • 19:59thing is that trans and gender diverse
  • 20:01status is not unique to a particular age,
  • 20:03race, ethnicity,
  • 20:04income,
  • 20:05bracket or education level,
  • 20:06and many people have multiple identities,
  • 20:09so the take home is you are
  • 20:11taking care of transgender people
  • 20:13whether you know it or not.
  • 20:15And it really is critical that
  • 20:17we all work to make sure that
  • 20:20our spaces are welcoming.
  • 20:21And with that I'm going to
  • 20:22pass it to Doctor Albert.
  • 20:27So while we have limited data
  • 20:29regarding cancer incidence and
  • 20:30outcomes for transgender people,
  • 20:32many aspects of the lives of transgender
  • 20:35people may predispose us to increase
  • 20:37cancer morbidity and mortality.
  • 20:39For example, the majority of trans
  • 20:41people who were out or perceived as
  • 20:43transgender in schools experienced
  • 20:44some sort of mistreatment,
  • 20:46and one in five dropped out as a result.
  • 20:49One in five transgender women will
  • 20:52be incarcerated in their lifetimes.
  • 20:54One out of three transgender people were
  • 20:56fired in the last year or experience
  • 20:58some sort of mistreatment at work.
  • 21:00One out of three transgender people
  • 21:02will experience homelessness one
  • 21:04out of three are living in poverty.
  • 21:06One out of two experienced
  • 21:08sexual assault in our lifetimes.
  • 21:10One out of four or unable to
  • 21:12access hormone therapy because
  • 21:13of lack of insurance coverage.
  • 21:15One out of five transgender people will
  • 21:17participate in the underground economy,
  • 21:19including in sex work.
  • 21:21One out of two black and Latino
  • 21:24trans women are living with HIV.
  • 21:27One out of two transgender people
  • 21:29are currently experiencing mental
  • 21:31distress and mental illness.
  • 21:32And so you can imagine that the indirect
  • 21:35and direct effects of some of these
  • 21:37things lead to increased cancer morbidity.
  • 21:39Mortality,
  • 21:40for example,
  • 21:41increased rates of HIV related
  • 21:44malignancies and HPV related malignancies.
  • 21:48Transgender people also have
  • 21:50negative experiences with physicians.
  • 21:52And that likely also leads to
  • 21:54barriers to care.
  • 21:55So you can imagine that if one in three
  • 21:57trans people had negative experiences
  • 21:59with physicians in the last year.
  • 22:02That it makes sense that a number
  • 22:04of transgender people would not
  • 22:06present to healthcare for regular
  • 22:08preventative care and cancer screening,
  • 22:10and also that people may not
  • 22:12have symptoms evaluated.
  • 22:14So if people aren't presenting to care,
  • 22:16this likely leads to presentations with
  • 22:19later stage cancers and worse outcomes.
  • 22:22And in fact,
  • 22:23Sarah Jackson recently published some data.
  • 22:26Suggesting that that's in fact the
  • 22:28case that transgender people with
  • 22:30specific types of cancers present late
  • 22:31and have worse outcomes as a result.
  • 22:36We frame our research and
  • 22:37scholarship within a conceptual
  • 22:39model that acknowledges the ways
  • 22:41that interactions between oncology,
  • 22:42clinicians and transgender people with
  • 22:44cancer are affected by the structure,
  • 22:46culture and policies of the
  • 22:48institutions in which we find ourselves,
  • 22:50as well as the systems policies
  • 22:52and social context around us.
  • 22:54So because of that understanding and
  • 22:56changing the experiences and outcomes
  • 22:58of individual patients will require
  • 23:00not just us learning more and changing
  • 23:02the ways we interact with people,
  • 23:04but also changing the systems
  • 23:06and policies around us.
  • 23:09For example, guidelines of organizations
  • 23:11like ASCO and NCCN impact research,
  • 23:14clinical practice,
  • 23:16and institutional policies,
  • 23:17and ultimately the experiences
  • 23:19and outcomes in patients.
  • 23:21For this reason, Doctor Overton,
  • 23:22Malaver and I have been working
  • 23:24closely with NCCN and ASCO
  • 23:26to change guidelines to be
  • 23:27inclusive of transgender people.
  • 23:29In other words,
  • 23:30to acknowledge transgender people
  • 23:31in our language and the ways that
  • 23:33we're thinking about guidelines.
  • 23:37Similarly, transgender people are also
  • 23:39impacted by state and national policies.
  • 23:41So for example, this is a map
  • 23:44representing Medicaid policies
  • 23:45that cover gender related care,
  • 23:47such as hormones or surgeries.
  • 23:49And so, although this hasn't been
  • 23:51investigated as far as we know,
  • 23:53these policies likely also change
  • 23:55people's access to cancer screening
  • 23:58and and other types of care.
  • 24:01So you can imagine that the
  • 24:03experiences of transgender people
  • 24:05living in state Connecticut,
  • 24:07where Medicaid policies coverage
  • 24:08under related care might be very
  • 24:11different than the experiences
  • 24:13of transgender people and their
  • 24:15primary care doctors and their
  • 24:17oncologists living in Texas.
  • 24:19With that,
  • 24:19I'll turn it back to doctor over
  • 24:20and over to explore this further.
  • 24:24Thank you and so one of the things that
  • 24:27we need to ask ourselves as providers
  • 24:30is how can we signal to transgender
  • 24:33and gender diverse people that the
  • 24:35space is the clinical spaces that we
  • 24:38are offering are places that are safe
  • 24:41for them to disclose their identity
  • 24:44and to have a welcoming experience.
  • 24:48And so I want to propose this model of the
  • 24:51four doors that that has been very helpful.
  • 24:54I think to easily start to think about and
  • 24:57do a landscape analysis of your own setting.
  • 25:00So the first question is what happens
  • 25:03when someone comes in your door?
  • 25:05What is the signage that
  • 25:07they're seeing the graphics on?
  • 25:09The the wall? Is it?
  • 25:11If it's a place where you are
  • 25:13primarily taking care of uterine,
  • 25:15ovarian, tubal cancer,
  • 25:18is that the Women's Cancer Center
  • 25:21or are the is the signage all pink?
  • 25:25These types of things same with
  • 25:27breast cancer and we'll see more of
  • 25:28this later then and are the people
  • 25:31who are taking insurance cards.
  • 25:33People who are parking folks,
  • 25:35people who are rooming individuals
  • 25:38comfortable with working with
  • 25:40people of all genders.
  • 25:42Next, what happens behind closed doors?
  • 25:44And I think Doctor Albert,
  • 25:47if you can click once,
  • 25:48I think those four that that great.
  • 25:50Thank you so much.
  • 25:52So then what happens behind closed doors in?
  • 25:54Histories and physicals,
  • 25:55and the information that you're asking,
  • 25:57are you asking about gender
  • 25:59affirming processes and procedures?
  • 26:00Thinking about who someone
  • 26:01is in their totality?
  • 26:03The next is what happens.
  • 26:05Even if you've done all of that
  • 26:06work in your own specific clinical
  • 26:08space and behind closed doors
  • 26:09in your history and physical,
  • 26:11what happens when you were
  • 26:12first and went out to another
  • 26:14department or another institution?
  • 26:15How's that information carried forward
  • 26:17in a real and respectful, accurate way?
  • 26:20And then finally,
  • 26:22what happens to welcome people
  • 26:24into the door so?
  • 26:25Not just that,
  • 26:26we are taking care of transgender and
  • 26:28gender diverse people by happenstance,
  • 26:30but really making ourselves
  • 26:33a destination of choice.
  • 26:35Next,
  • 26:36so one of a group of colleagues
  • 26:39and I wanted to address the fact
  • 26:42that many organizations have really
  • 26:45recognized non discrimination
  • 26:46policies as a good marker and signal
  • 26:50to communities and reflection of
  • 26:52the culture of an institution,
  • 26:54of how they're taking care
  • 26:56of different communities,
  • 26:57including the LGBTQ plus community.
  • 27:00And so we performed a web based analysis
  • 27:02to evaluate the landscape of patient
  • 27:04nondiscrimination policies at NCI.
  • 27:06Designated cancer centers and
  • 27:08we found that while 82% of
  • 27:10cancer centers had a patient,
  • 27:11non discrimination policy that was
  • 27:13accessible in their website in 90% mentioned,
  • 27:17protection by sex and 70% by
  • 27:20sexual orientation a little
  • 27:23less 67% by gender identity,
  • 27:25none of the policies included sex assigned
  • 27:28at birth or LGBTQ plus or SGM identity,
  • 27:31and so a big.
  • 27:34is that there are actions that we
  • 27:37can take that are feasible and
  • 27:39within our control to help signal
  • 27:41and make spaces more welcoming.
  • 27:43We'll talk about a little bit
  • 27:45more of what happens
  • 27:47when spaces aren't welcoming
  • 27:49through the qualitative research
  • 27:50that we've both conducted,
  • 27:52and there's some illustrative
  • 27:53quotes and experiences that Doctor
  • 27:55Albert will go through next.
  • 28:02Go ahead, OK. Thank you so much.
  • 28:05So now we'll get into some of the
  • 28:07details of what happens to patients
  • 28:09when they present to clinic,
  • 28:10and we'll be presenting from both
  • 28:13of our qualitative research,
  • 28:14and there'll be a few themes that
  • 28:17will describe throughout this
  • 28:18section and the first one is that
  • 28:20our institutions themselves may not
  • 28:22be welcoming of transgender people,
  • 28:24and may actually inadvertently exclude them.
  • 28:27So I'm going to read a quote from a
  • 28:31project I did exploring the experiences
  • 28:35of transgender people with cancer.
  • 28:37So one of the participants who was a
  • 28:39white non binary person said I needed
  • 28:41to have a lot of follow up mammograms
  • 28:44until I had top surgery and pretty much
  • 28:46every time this wasn't aggressively
  • 28:49gendered experience to the point of no,
  • 28:51I'm not putting on that pink floral gown.
  • 28:53You can't make me.
  • 28:54You can do it in nothing.
  • 28:55I'll put on this rap I have or
  • 28:57you can get me. Something else,
  • 28:58but I'm literally not doing this.
  • 29:01And having to push back really hard against.
  • 29:04I don't want to change in the
  • 29:05special woman to changing room.
  • 29:07I don't want to hang out in
  • 29:08the special goal mammogram.
  • 29:09Word. Thanks Shirley.
  • 29:10This is a whole hospital.
  • 29:12No doubt you have other places I could
  • 29:14sit and you can imagine that you know
  • 29:18already experiencing a cancer diagnosis
  • 29:20and dealing with treatment and the follow up.
  • 29:23It may be very difficult to
  • 29:25be in spaces and be given.
  • 29:27Clothing to wear that.
  • 29:30Explicitly are in,
  • 29:31in contrast to how you see yourself.
  • 29:35So not only do we need to change
  • 29:37how we're talking to people,
  • 29:38but the the institutions in which we work.
  • 29:43Another way that cancer centers may
  • 29:45signal inclusion or exclusion to
  • 29:47patients is through our intake forms
  • 29:48and what happens at registration.
  • 29:50For example,
  • 29:51in another study of Latina Trans,
  • 29:53Woman said, starting with how to identify,
  • 29:55you don't have options during registration.
  • 29:58It's easy for me to sign in as a woman,
  • 30:00but then the provider ends up
  • 30:02asking me inappropriate questions.
  • 30:04For example, when was my last period,
  • 30:06or if I might be pregnant?
  • 30:09And if somebody is asking about
  • 30:11your last period,
  • 30:12or if you might be pregnant,
  • 30:13you're put in a situation.
  • 30:15If you're a trans woman to have to
  • 30:17either lie or or come out to someone
  • 30:19who it may not feel safe to come out to,
  • 30:22and then after somebody asked
  • 30:23you that question,
  • 30:24it may be even more difficult to.
  • 30:28To choose to explain to them that
  • 30:30you're transgender because they've
  • 30:32already signaled that they don't
  • 30:33know that or think that you're.
  • 30:36Existence is a real thing.
  • 30:41So the language used by oncology
  • 30:42clinicians may also not reflect the bodies
  • 30:45or experiences of transgender people.
  • 30:47For example, a weight nonbinary participant.
  • 30:50Said, I remember somebody saying it's OK,
  • 30:53you're still a woman.
  • 30:54You can probably still have children.
  • 30:56Thank you. No thank you.
  • 30:59And so I'm sure that clinician was
  • 31:01really trying to, you know, create,
  • 31:03build, repor and be close to the
  • 31:06patient by by making this statement.
  • 31:08But in fact, really made an assumption
  • 31:11that was in fact not the case,
  • 31:13and they have eroded reform made it even
  • 31:16more difficult for that person to be there.
  • 31:21Similarly, in a study about sexual
  • 31:22and reproductive health care,
  • 31:24transgender participants said if you start
  • 31:26out the conversation talking about female,
  • 31:28this or woman that are only male and female,
  • 31:31just a simple statement of female
  • 31:34reproductive system or whatever.
  • 31:35It's just so triggering for gender,
  • 31:37expansive folks and trans
  • 31:39people that it's like,
  • 31:40regardless of what comes after that,
  • 31:42there's already a disconnect.
  • 31:43It's like this person is basic and
  • 31:46they don't understand who I am.
  • 31:52So clinicians are taught to think
  • 31:54about gender and sex as synonymous,
  • 31:56and because of that they may
  • 31:57tend to get the names, genders,
  • 31:59or pronouns of patients wrong.
  • 32:02This is called misgendering and this may be
  • 32:05even further exacerbated when clinicians
  • 32:07know that patients are transgender.
  • 32:09So in one of our qualitative studies,
  • 32:11transgender people talked about
  • 32:12their experiences after physicians
  • 32:14found out that they were transgender.
  • 32:16And for example,
  • 32:18one black transgender woman said
  • 32:20it wasn't until after I told the
  • 32:22Doctor that I was on hormones for
  • 32:24transition that I started being keyed.
  • 32:26In other words,
  • 32:27the physician started referring
  • 32:28to her with he pronouns and
  • 32:30his accidental or whatever.
  • 32:31As it was, it was after.
  • 32:34Before that it was she.
  • 32:37So in other words,
  • 32:38transgender people may face a very
  • 32:39difficult dilemma of choosing between
  • 32:41the dangers of being open about their
  • 32:44identities and the dangers of not
  • 32:46giving clinicians all the information
  • 32:47they may need for clinical decision making.
  • 32:50For example,
  • 32:50that they're on hormones,
  • 32:52or that they've had particular surgeries.
  • 32:56In the same qualitative study,
  • 32:58we investigated the experiences
  • 32:59of transgender people who reviewed
  • 33:01their own electronic health records,
  • 33:03and we felt that this was very important
  • 33:05given the 21st Century Cures Act,
  • 33:07which mandates patients
  • 33:08access to their own records.
  • 33:11To nearly all the patients in
  • 33:12our study who had accessed their
  • 33:14electronic health record noted,
  • 33:16the use of the wrong name
  • 33:18pronounced gender marker.
  • 33:20Often referred to as misgendering,
  • 33:21which I which I think I mentioned.
  • 33:24So even in the context of otherwise
  • 33:26positive relationships with clinicians,
  • 33:28and even when clinicians displayed
  • 33:30other signs of being welcoming.
  • 33:32They described the seeing
  • 33:33misgendering or stigmatising
  • 33:34language in the electronic health
  • 33:36record really eroded their trust,
  • 33:38not just in that particular clinician,
  • 33:40but the medical field as a whole.
  • 33:44So for example,
  • 33:45one participant said there's like stickers
  • 33:48that are like LGBTQ affirming blah blah.
  • 33:51Yet they both misgendered me in their notes.
  • 33:56And many people in the study did
  • 33:58talk about their performative,
  • 33:59but sometimes performative
  • 34:02nature of inclusiveness.
  • 34:04So it brings up the question
  • 34:05of how we can really like,
  • 34:07be authentic and all the places
  • 34:09we're communicating with patients.
  • 34:11Participants also describe the
  • 34:13intersectional nature of transphobia
  • 34:15and racism through use of the word such
  • 34:18as hostile or aggressive in the health
  • 34:20records of transgender people of color.
  • 34:23For example,
  • 34:23one chicken X nonbinary person
  • 34:25described the ways that those
  • 34:27words were carried forward and
  • 34:29used against patients they said.
  • 34:31In the electronic health record,
  • 34:32those details that people added in the notes
  • 34:35can definitely get used against the patients,
  • 34:37especially if you're a person of color and
  • 34:40you're trying to be enforcing pronouns.
  • 34:41You'll usually get labeled as hostile,
  • 34:44and then that establishes a pattern
  • 34:46near medical record that then is used
  • 34:48to treat you poorly or should not
  • 34:50be listening to what you're seeing.
  • 34:52And in fact,
  • 34:54there's other literature that supports some
  • 34:56of these concepts because we know that.
  • 34:59From that research,
  • 35:00we know that negative language in the
  • 35:02electronic health record influences
  • 35:04the attitudes of other clinicians and
  • 35:06causes them to treat patients differently.
  • 35:08For example,
  • 35:09to treat pain less aggressively.
  • 35:11So these these things are very concerning.
  • 35:15Oncologists are also trained to
  • 35:17follow guidelines. As you all know,
  • 35:19but these may not always be in
  • 35:21line with patients priorities,
  • 35:23for example NCCN.
  • 35:26Prioritizes fertility sparing
  • 35:27interventions that may not be in
  • 35:30line with the needs of patients and
  • 35:33particularly transgender patients.
  • 35:35And we don't always have a lot of
  • 35:37guidance about what to do when guidelines
  • 35:39are different from patient priorities.
  • 35:41So for example,
  • 35:42a white non binary person with
  • 35:44ovarian cancer said because
  • 35:46I had a really large tumor.
  • 35:48They talked about doing the full hysterectomy
  • 35:50or just taking out the one ovary.
  • 35:52I wanted the full hysterectomy
  • 35:54and they were like you don't know.
  • 35:56In a few years you might change your mind
  • 35:58so they did fertility sparing surgery.
  • 36:03Hum. It's very. It was very distressing,
  • 36:06especially in that focus group that
  • 36:08this person had gotten this surgery that
  • 36:10was not the one that they wanted and
  • 36:12really brings up the question of how
  • 36:14we can really share decision making of
  • 36:16patients and center their priorities
  • 36:18and making decisions about their care.
  • 36:22Last concept that we wanted to
  • 36:24introduce in this section is that
  • 36:26oncology clinicians may be providing
  • 36:28incomplete or inaccurate information
  • 36:29because of the simplistic ways,
  • 36:31clinicians and systems we work
  • 36:34in manage information regarding
  • 36:36gender anatomy and Physiology.
  • 36:38So one concern is that we have very
  • 36:40limited data regarding the health
  • 36:42outcomes of transgender people with
  • 36:44cancer and any role that hormones may
  • 36:47play in improving or worsening outcomes.
  • 36:50And I think this is a concern for
  • 36:52patients and clinicians as well.
  • 36:53So for example,
  • 36:54one transgender woman in one of our
  • 36:56studies said it was good in one way
  • 36:58that the doctors had no issues with
  • 37:00me continuing hormones and that they
  • 37:02thought about it in relation to cancer.
  • 37:04And they were like no, no problem.
  • 37:05Go ahead, it's fine.
  • 37:07But there is no really good
  • 37:09critical thought about, oh,
  • 37:10you're going through this major
  • 37:11hormonal shift at the same time as
  • 37:13you're going through chemotherapy,
  • 37:14and there wasn't any discussion about that.
  • 37:17It's like, OK,
  • 37:17you let me do what I needed to do,
  • 37:19and you didn't interrupt that.
  • 37:20Portion of my transition,
  • 37:22but you didn't give me any information
  • 37:24you didn't even try to think critically
  • 37:26using your doctorate knowledge.
  • 37:30One problem clinicians may have and
  • 37:31having these types of conversations
  • 37:33with patients is that the data
  • 37:36regarding connections between hormone
  • 37:37therapy and cancer are of very poor
  • 37:40quality and it may be difficult to
  • 37:42know how best to counsel patients.
  • 37:44So for example, in the last few
  • 37:46years there were two studies
  • 37:47out of the Netherlands that both
  • 37:50had retrospective data regarding
  • 37:51cancer risk for transgender people.
  • 37:53Transgender women specifically.
  • 37:55And this one got a huge amount
  • 37:58of media attention,
  • 38:00partly because of this sentence
  • 38:01that was in the popular press.
  • 38:03That trench and the woman had a 47 foot
  • 38:06higher risk of developing breast cancer.
  • 38:08But as I mentioned,
  • 38:10these studies were both retrospective,
  • 38:12so correlative and and there was no like
  • 38:15ability to establish a causal relationship.
  • 38:18And also what was less well publicized
  • 38:21is that transgender women in these
  • 38:23studies have lower rates of breast
  • 38:25cancer than cisgender women.
  • 38:28So it it brings to mind how the media
  • 38:31may be influencing our conversations
  • 38:33with patients and what what we do
  • 38:36in the absence of quality data.
  • 38:39Around the same time this study came
  • 38:41out that was looking at prostate cancer
  • 38:43risk and transgender women and found
  • 38:45lower rates of prostate cancer and
  • 38:46transgender women compared to standard men.
  • 38:49And interestingly,
  • 38:50this study got almost no press attention.
  • 38:54Which brings up,
  • 38:55you know what's what's in our mind
  • 38:57because of the popular press and what does
  • 38:59that do to our conversations with locations?
  • 39:01So we know that hormone therapy and surgeries
  • 39:05decrease suicidality for transgender people
  • 39:07who want them and improve quality of life.
  • 39:10So when having these
  • 39:11conversations with patients,
  • 39:12it's really important too.
  • 39:14Understand patients priorities and to
  • 39:16weigh the known benefits of hormone
  • 39:18therapy and surgeries with the unknown
  • 39:20but potential risks of hormone
  • 39:22therapy in the setting of cancer.
  • 39:28The systems that we work in also have
  • 39:29been set up to deal with gender and
  • 39:31and sex assigned at birth data in
  • 39:33various simplistic ways that do not
  • 39:35extrapolate well to the bodies of
  • 39:37transgender people and other patients.
  • 39:39So for example, the laboratory data
  • 39:41normal ranges are based on research
  • 39:44done on cisgender women and men,
  • 39:46and research suggests that transgender
  • 39:47people have a normal lab values
  • 39:50that fall outside of these ranges.
  • 39:52So this ends up meaning that the lab
  • 39:54values in the charts of transgender people
  • 39:56are often flagged even though it may
  • 39:59not be of any clinical or other significance.
  • 40:03So consider a transgender man who's
  • 40:05registered as a man and flagged as anemic,
  • 40:08but is actually not because he
  • 40:10meant straights and so has a
  • 40:12half a non pathologically lower
  • 40:13hematocrit than cisgender women.
  • 40:17And this did come up in one of our
  • 40:19qualitative studies have changed under
  • 40:21man said when I get labs done they
  • 40:23have me as female for my lab levels,
  • 40:26and so they're always a little bit
  • 40:28off and it freaks me out and I'm
  • 40:30like is this normal and it is very
  • 40:32difficult that patients who now have
  • 40:33access to their medical records,
  • 40:35as well as clinicians or left to
  • 40:37interpret these for themselves.
  • 40:40Possibly even greater concern,
  • 40:42chemotherapeutic dosing is sometimes
  • 40:44based on creatinine clearance which is
  • 40:46based on the sex or gender marker and
  • 40:49we don't have robust data regarding
  • 40:52how these algorithms apply or do not
  • 40:54apply to transgender people who've
  • 40:56had surgeries or on hormone therapy.
  • 40:58So in the future,
  • 41:00we could consider revising our laboratory
  • 41:02ranges to be based on more objective
  • 41:04measures that would be relevant,
  • 41:06such as volume of distribution,
  • 41:08body composition, hormone levels,
  • 41:10renal or hepatic function,
  • 41:12or a host of other factors that
  • 41:15influence drug metabolism clearance.
  • 41:20And so, with all of those really
  • 41:23important voices and stories in mind,
  • 41:25and building on this idea of where
  • 41:27where oncology practice may be missing,
  • 41:30a mark is that our systems
  • 41:31may be holding us back.
  • 41:32So this is a screenshot from my EMR use epic,
  • 41:37in which one of my patients
  • 41:39that I was taking care of,
  • 41:41a nonbinary patient of mine who had
  • 41:44mail listed in their medical record,
  • 41:47assigned female at birth,
  • 41:49had a cervix.
  • 41:51Needed contraception and and I was
  • 41:54taking care of them for cervical
  • 41:55dysplasia and I got you know this
  • 41:57this hard stop saying this diagnosis
  • 41:59of dysplasia of the cervix uteri
  • 42:01is not valid for the patients X
  • 42:03which of course was not true.
  • 42:05I was performing the exam
  • 42:07person was in front of me.
  • 42:09It's very valid for their experience
  • 42:10but I was not allowed to charge
  • 42:12and that's obviously a problem
  • 42:14just for that individual patient.
  • 42:16But then if we extrapolate out it hinders
  • 42:18care more broadly and also hinders research.
  • 42:21As medical charting,
  • 42:22diagnosis codes,
  • 42:23etc are the foundation of much
  • 42:25research endeavors, Qi Work etc.
  • 42:28Next slide please.
  • 42:29So it's really important that we
  • 42:32cease the traditional conflation
  • 42:34of sex and gender and we need to
  • 42:37disaggregate these important concepts
  • 42:38of the organs that somebody has at
  • 42:41birth and currently which of course
  • 42:43may differ both for transgender
  • 42:45and gender diverse people as
  • 42:47well as cisgender piece people.
  • 42:49And disaggregate that from somebody's
  • 42:51gender identity which we do need to know.
  • 42:53It's not just about origins but
  • 42:54we need to know and take care of
  • 42:56somebody's gender identity as
  • 42:58well as their sexual orientation.
  • 42:59And actually we have a rubric you
  • 43:01know in medicine to do these things.
  • 43:04We systematically go through
  • 43:05and we ask medical history,
  • 43:07surgical history, meds, family etc.
  • 43:09But we need to be sensitized to
  • 43:11how we bring gender into that and
  • 43:13how we bring gender affirming care
  • 43:14and processes and experiences of
  • 43:16transgender people into all of those
  • 43:18components 'cause they influence.
  • 43:20Every single one of those,
  • 43:21and I bring up this picture
  • 43:23partially 'cause I'm in OB GYN,
  • 43:24but also because I think it's a really good.
  • 43:28Just visual model to consider which is
  • 43:31the picture on the left are two gay men.
  • 43:35One is a transgender Kaden in
  • 43:37the front who's carried 2 carried
  • 43:40and given birth to two children
  • 43:42that he and his partner Elijah,
  • 43:44a cisgender gay man.
  • 43:48Have and they're partnering together
  • 43:50and and we can only imagine that
  • 43:52their experiences are quite different
  • 43:55as two black gay men raising kids,
  • 43:57then this presumably white cisgender
  • 44:00couple that we see who I actually don't know.
  • 44:03But we're just,
  • 44:04you know,
  • 44:05in terms of all of these different
  • 44:07multiplicity of experiences,
  • 44:08and we need to ask and think about
  • 44:10how those differences will play out.
  • 44:12And unfortunately there's a lot
  • 44:14of missing data,
  • 44:16and in accuracies here that we
  • 44:17need to start to debunk.
  • 44:19And address so next slide
  • 44:21you know if we think
  • 44:23about research, this is a.
  • 44:27Just a presentation of some
  • 44:29inclusion criteria from a clinical
  • 44:31trial about prostate cancer,
  • 44:32and if you look on the left,
  • 44:34the inclusion criteria,
  • 44:35says male greater than 18 years of age.
  • 44:38But what about women who may
  • 44:40also have prostate cancer rate?
  • 44:41Transgender women and also,
  • 44:43you know participants must agree to using
  • 44:46condom if they having sex with a woman.
  • 44:48So what do they mean by sex and
  • 44:51what do they mean by women here?
  • 44:54There are obviously assumptions of
  • 44:57that are threaded throughout this,
  • 44:58and in addition in terms
  • 45:00of the exclusion criteria,
  • 45:01they mentioned hormone
  • 45:02therapy for prostate cancer.
  • 45:04But as Doctor Alpert mentioned,
  • 45:06we know actually the transgender woman
  • 45:08likely have lower prostate cancer,
  • 45:09at least in one study.
  • 45:11We need more studies right?
  • 45:12And So what about estrogens for transition?
  • 45:16Finally,
  • 45:16when we think about excluding people,
  • 45:18current infections such as HIV.
  • 45:21Unfortunately,
  • 45:21currently transgender women have very high.
  • 45:25Prevalence of HIV,
  • 45:26and so we may be excluding whole swaths
  • 45:30of population who still get prostate
  • 45:33cancer despite also having HIV.
  • 45:35So who's being included,
  • 45:36who's being excluded and we need
  • 45:39to think very strategically about
  • 45:41this so that we're providing
  • 45:43accurate and inclusive care.
  • 45:44Next slide,
  • 45:45please.
  • 45:46So we reviewed with some colleagues
  • 45:49ovarian cancer guidelines and we noticed
  • 45:51the word woman appears 100 times.
  • 45:53It's just one example,
  • 45:54but you can imagine.
  • 45:55These guidelines will not promote
  • 45:57use of gender consistent language
  • 45:59with people's identities for men
  • 46:01or nonbinary people with ovaries,
  • 46:03and you can imagine that providers
  • 46:05then aren't sensitized.
  • 46:06How to take care of people?
  • 46:09And this was the case of Robert EADS,
  • 46:11a man pictured here on the bottom,
  • 46:13who was turned away from 12 oncologist
  • 46:16office for treatment of this
  • 46:18ovarian cancer because they said
  • 46:20that they didn't know how to care
  • 46:22for a man with cancer essentially.
  • 46:24Next up, similarly,
  • 46:26we looked at prostate cancer
  • 46:28guidelines and sort of the same story.
  • 46:30UM,
  • 46:30the word men appears 472 times,
  • 46:33rather than being specific to the organs,
  • 46:35and in that way it wouldn't have really
  • 46:38provided helpful guidance to taking
  • 46:40care of someone like Sally pains here,
  • 46:43who a woman of trans experience
  • 46:45who died of prostate cancer,
  • 46:47and so we have to really think about
  • 46:50what we're putting out and how this
  • 46:52just isn't meeting our population,
  • 46:54so.
  • 46:54One example of potential practical
  • 46:57alternatives is represented here,
  • 47:00where you know the concern for
  • 47:02risk reducing self inject me alone
  • 47:04is that people with at least one
  • 47:06over it 'cause actually that's
  • 47:08the most relevant piece right?
  • 47:09Not women 'cause they could
  • 47:11have ovaries or not, right?
  • 47:12So it's just the presence of the
  • 47:14ovary or people who menstruate
  • 47:16versus pre menopausal women.
  • 47:18So we need to get much more specific.
  • 47:22Next slide,
  • 47:23so as you go back to your day
  • 47:25as we start to close up here,
  • 47:27we want you to just start to
  • 47:29critically assess your own materials,
  • 47:31your own space and think about
  • 47:32you know is what
  • 47:34you're putting out there inclusive.
  • 47:36Exclusive thinking,
  • 47:36certainly about gender but also race,
  • 47:38ethnicity, skin color, age,
  • 47:40gender, ability and size,
  • 47:42and so this can take you into thought,
  • 47:44experiments and and really,
  • 47:46looking at what elements of the
  • 47:48visuals in your clinical settings
  • 47:50promote inclusion and in what domains.
  • 47:52And what images, decoration, signage etc.
  • 47:56Promote exclusion and in what domains?
  • 48:00And the real promise here is
  • 48:01that we can get it right, right?
  • 48:03So you know.
  • 48:05This is also from one of our
  • 48:08research studies where Doctor
  • 48:10Albert study actually said,
  • 48:12you know, as soon as a trans man
  • 48:14I know talked about his gender
  • 48:17experience with his gynecologist.
  • 48:18They were very careful to not use
  • 48:20gender language during exam and
  • 48:21it was all very matter of fact.
  • 48:23They actively took steps to
  • 48:25minimize any chest exposure,
  • 48:26referring to chest tissues,
  • 48:28breasts and things of that nature,
  • 48:30and this is a promising quote,
  • 48:33but it also would encourage us to not.
  • 48:36Wait for us to know you know that this
  • 48:39is a trans person that we're supporting,
  • 48:42but rather just to make all of our
  • 48:45practices welcoming and inclusive.
  • 48:47With that,
  • 48:47I'll turn it back to Doctor
  • 48:49Albert to finish us out here.
  • 48:52So some good news is that ASCO actually
  • 48:54is making changes to their guidelines,
  • 48:57and recently we changed the guideline
  • 48:59template to ensure that all the
  • 49:01guidelines that are created are done
  • 49:02so with gender inclusive language.
  • 49:04So if you want to,
  • 49:06you can scan these QR codes to see
  • 49:09both the new methodology manual and
  • 49:11the first guideline that came out using
  • 49:14gender inclusive language and with
  • 49:16comments about why that's being done.
  • 49:18So there are a number of next
  • 49:20steps that Yale cancer can take,
  • 49:21and these are just some of our ideas.
  • 49:23But really, we want you all to be
  • 49:26thinking about what what you think
  • 49:28would work best for your center.
  • 49:32And then you know,
  • 49:33we talked earlier about EMR best
  • 49:35practices and we would recommend
  • 49:38fees that patients needs genders,
  • 49:40pronouns, or correctly and consistently
  • 49:42documented throughout the EMR.
  • 49:44That words like preferred or identifies
  • 49:46as and describing patients, genders,
  • 49:48pronouns, or names are eliminated.
  • 49:51And that words that may suggest
  • 49:54stigma or blame like disturbed or
  • 49:56hostile or removed from the record.
  • 49:58We would also suggest based on
  • 50:00the recommendations of patients
  • 50:02avoiding unnecessary mention of
  • 50:03sex assignment or so called.
  • 50:05Biological sex,
  • 50:06because often those things can
  • 50:09be communicated by describing
  • 50:12anatomy or other factors.
  • 50:14We also listed some individual
  • 50:16some steps for individuals,
  • 50:18and these slides will be available after,
  • 50:20so I won't go through these in depth,
  • 50:22but we wanted you to have you know
  • 50:24something you could do right now today
  • 50:26to change your practice and change
  • 50:28the practice at your institution.
  • 50:34And then here are some training and
  • 50:36resources that are available for any
  • 50:39Cancer Center in case you want to
  • 50:41do more work around these topics.
  • 50:45And we want to remind oh sorry,
  • 50:47Doctor Overton Oliver.
  • 50:48Yeah, well we we all live in society
  • 50:50today and I think it would be hard if
  • 50:52if you hadn't noticed the news that
  • 50:55there are some very active fights going
  • 50:58on for trans transgender and LGBTQ.
  • 51:00Plus people broadly.
  • 51:02Just to mention that there are 147 anti
  • 51:05transgender bills that were introduced
  • 51:07in 2021 that are being either addressed
  • 51:10or seen now and just two weeks ago,
  • 51:13Idaho House approved legislation
  • 51:14that makes it a felony.
  • 51:15For doctor to provide gender affirming
  • 51:18care and so we as as citizens
  • 51:21need to also be taking a taking,
  • 51:23care and thinking about these things and
  • 51:26advocating because it influences our
  • 51:28patients and it influences our society.
  • 51:30And then the last plug I'll put
  • 51:31in here just my own little plug is
  • 51:33if you have LGBTQI plus patients,
  • 51:35we really encourage you to ask them
  • 51:38and to be involved in research and
  • 51:40so one way it just one study is
  • 51:43the PRIDE study which you can.
  • 51:46Learn about here pridestudy.org,
  • 51:48which is the next slide.
  • 51:50And with that,
  • 51:51I think we'll move to questions and
  • 51:53then know that there's actually dozens
  • 51:56of slides after this that gives some
  • 51:58more information and resources, etc.
  • 52:00So we encourage you to check
  • 52:02out those slides as well,
  • 52:03and our contact information
  • 52:04is here on the next slide,
  • 52:06as well as an evaluation we you know good
  • 52:10for each of our portfolios into in to,
  • 52:13you know,
  • 52:14enhancing our future talks.
  • 52:15So thank you so much for your kind attention.
  • 52:20Thank you so much. So
  • 52:24I just want to really thank you for
  • 52:27your vulnerability first of all and
  • 52:29sharing your own stories, and I'm really.
  • 52:33Giving us the language to start
  • 52:36enacting change and and I really
  • 52:39I think my own take away is,
  • 52:42you know we want our patients
  • 52:45to feel seen and I think we want
  • 52:48you know in language matters.
  • 52:50And so I think so I thank
  • 52:53you for that fantastic talk.
  • 52:55So I'd love to turn to chat
  • 52:58with a couple of questions.
  • 53:01Some were we had a couple
  • 53:03on EHR so one was on.
  • 53:05Thank you for this informative session.
  • 53:07Do you know if any hospitals or
  • 53:09cancer centers have a process to
  • 53:11flag inappropriate EHR notes and to
  • 53:13address the behavior and fix them?
  • 53:18No review can address that. The
  • 53:20short answer, at least from my end,
  • 53:22is no. I don't know of any such.
  • 53:25Policies or procedures in place
  • 53:27to to manage this sort of data.
  • 53:31Yeah, I don't either, but I
  • 53:33think that our patients are
  • 53:35telling us already and so it's kind
  • 53:37of starting from the education place
  • 53:38that we don't fix it. And then we do.
  • 53:41All can be champions now,
  • 53:42so I often notice it and colleagues notes
  • 53:45and I gently pointed out to them and say,
  • 53:48hey, maybe this is a template, but you
  • 53:51gotta fix the template so or you know.
  • 53:55Patient, you know,
  • 53:56came back to me or other patients
  • 53:58have come to me to to not,
  • 53:59you know and say hey can you fix this?
  • 54:02I notice this is inconsistent
  • 54:03throughout the record.
  • 54:05Yeah, exactly and Doctor Albert if you
  • 54:08don't mind sharing and then maybe we
  • 54:10can see bigger perfect that's great.
  • 54:12Thank you for the last.
  • 54:13We'll have five five more
  • 54:15minutes and for questions has I?
  • 54:18I also there's a question about
  • 54:20clinical trial eligibility,
  • 54:21and I think as a Cancer Center,
  • 54:23that's a primary mission
  • 54:24of ours and I think I,
  • 54:26I loved that you brought that up and
  • 54:28you know we have eligibility around
  • 54:31doing pregnancy tests and eligible.
  • 54:33So really, I think.
  • 54:34It's great to raise that,
  • 54:36so one of the questions is has
  • 54:38there been a review of clinical
  • 54:40trial eligibility criteria
  • 54:41for appropriate inclusion?
  • 54:46So again, I don't.
  • 54:47I don't know of any such research,
  • 54:49although I think it would
  • 54:51be wonderful to do that.
  • 54:52We we really, you know,
  • 54:54did these looks at the guidelines in
  • 54:57clinical trial data in preparation for
  • 55:00some conversations with NCCN and FDA.
  • 55:02But I think a more rigorous look at
  • 55:05maybe even a qualitative analysis
  • 55:06or natural language processing tool
  • 55:08to look at inclusion and exclusion
  • 55:11criteria for cancer clinical
  • 55:12trials would be really super would
  • 55:15really potentially give us more.
  • 55:17More data to drive change and
  • 55:20bring these issues to the floor.
  • 55:24Yeah, and I would say in all research
  • 55:26you know we we really need to think
  • 55:29about what we're measuring and why.
  • 55:31So it's actually not appropriate
  • 55:32to just say women, right?
  • 55:34Because if if, say,
  • 55:36you're doing a study on uterine cancer,
  • 55:37only people with uteruses can be,
  • 55:40you know, have uterine cancer develop it,
  • 55:43but that could be transgender men.
  • 55:45It could be nonbinary people.
  • 55:46It can't be somebody who lives
  • 55:48as a woman who was born with a
  • 55:51congenital absence of the uterus.
  • 55:53Actually inaccurate,
  • 55:54so we really wanna say,
  • 55:55you know anybody who has or had a you
  • 55:57know a uterine cancer or depending
  • 55:59on the criteria and just to be
  • 56:01very specific and it may be that
  • 56:03it's really only relevant for you.
  • 56:05Know cisgender women,
  • 56:06but we need to so state and say why right?
  • 56:09And we also need to think retrospectively
  • 56:12about research and point this out as a
  • 56:15limitation where we are extrapolating.
  • 56:17You know I'm extrapolating from studies
  • 56:20on cisgender women to view this.
  • 56:23Transgender man in front of me
  • 56:25and this is the areas that I don't
  • 56:27understand right now and so we
  • 56:29need to partner around that.
  • 56:30This is mechanistically how
  • 56:32I think XYZ would work.
  • 56:34I don't know you know,
  • 56:35and and we're working to fill that in.
  • 56:38And so,
  • 56:39that's that's what the NIH is calling for,
  • 56:41and I would challenge every researcher
  • 56:43here is familiar with the NIH, you know?
  • 56:46A requirement on describing sex
  • 56:49as a biological variable,
  • 56:51and so.
  • 56:52In that statement we need to actually,
  • 56:54you know,
  • 56:55carry that forward and really be critical
  • 56:57and and and what that's really asking for.
  • 57:00And I routinely,
  • 57:00my NIH grants say I can report
  • 57:03on sex assigned at birth.
  • 57:04I cannot report on gender.
  • 57:06I will not report people by men and women
  • 57:08'cause that's actually irrelevant or.
  • 57:11You know some other permutation
  • 57:12depending on the specific research.
  • 57:16Great, thank you.
  • 57:18There's an interesting
  • 57:19question on a chaperoning.
  • 57:22By Doctor Kim, one of our
  • 57:23Gu medical oncologists.
  • 57:24So what are your thoughts
  • 57:26on the use of chaperones for
  • 57:28examining transgender patients?
  • 57:33Well, I think we should think about,
  • 57:35you know. Where it's a great question,
  • 57:39but I think I always like to think what
  • 57:41am I gonna do routinely to make situations
  • 57:44better for everybody and so likely there
  • 57:46is a place where a patient advocate
  • 57:48may be good for every person, right?
  • 57:51So I'm often as an OB GYN who
  • 57:54identifies and reads as as a woman.
  • 57:57Often women patients don't
  • 57:59think anything of it,
  • 58:00but then as soon as a male or male
  • 58:03presenting colleague of mine comes in,
  • 58:05they think about that, but.
  • 58:06You know there's actually nothing to
  • 58:08say that I may be, and I hope I never am,
  • 58:11but inappropriate or do something
  • 58:13sexually inappropriate with a woman
  • 58:14patient just because I'm a woman.
  • 58:16And so if we we should think probably
  • 58:19about chaperoning for everyone.
  • 58:21Understanding that more people in
  • 58:22the room may or may not be better.
  • 58:24And so I think we need to think
  • 58:26about that and or I often have
  • 58:28partners in the room chaperones.
  • 58:29I often have a nurse in the
  • 58:31room for everybody, actually.
  • 58:35I, I think that's a wonderful comment,
  • 58:37so we are nearing the hour in
  • 58:40the final minute remaining.
  • 58:42I'd love for both of you,
  • 58:43maybe in kind of 1 sentence to say
  • 58:47what you are hoping the field will do.
  • 58:50Leave us with kind of a
  • 58:53a dream for the future.
  • 58:55Doctor Albert will start with you.
  • 58:58Yeah, I mean, I think that in my mind
  • 59:00the most important thing right now is to
  • 59:02rethink the ways that we have conflated
  • 59:04gender and sex assigned at birth,
  • 59:06and if we can disaggregate those
  • 59:08ideas and concepts both in the ways
  • 59:10that we're talking to patients and
  • 59:12thinking about bodies, but also the
  • 59:15ways that we're writing guidelines,
  • 59:17thinking about lab values,
  • 59:18thinking about chemo,
  • 59:20therapeutic dosing,
  • 59:20I think will really change the landscape,
  • 59:23not just for transgender people,
  • 59:24but to provide better care
  • 59:26for all our patients.
  • 59:29Thank you Doctor Obit in malver.
  • 59:31Absolutely so many things.
  • 59:32First of all, just thank you everybody.
  • 59:34Uhm, I would say that. It really.
  • 59:38There's often this sort of doom and
  • 59:40gloom kind of idea about working with and
  • 59:43supporting transgender and gender diverse
  • 59:45people who do face so many challenges.
  • 59:47But I also think incredibly strong and
  • 59:50resilient communities who actually have
  • 59:51so much to show us about all of our
  • 59:54medicine and healthcare and and and the
  • 59:57assumptions that we make that really are
  • 59:59a detriment to all of our patients, right?
  • 01:00:02So we could learn so much about you know,
  • 01:00:04hormone management about mechanisms of.
  • 01:00:08Presence or absence of certain experiences,
  • 01:00:10hormones, organs, etc.
  • 01:00:12That and really what transgender
  • 01:00:14and gender diverse people offer us
  • 01:00:17is this incredible gift to examine
  • 01:00:19our assumptions and to become much,
  • 01:00:22much more accurate and actually
  • 01:00:24precise in our health.
  • 01:00:26So this is truly precision,
  • 01:00:27health and meeting people and the
  • 01:00:29diversity people where we're at.
  • 01:00:30And if we can decode the genome,
  • 01:00:32we can actually meet individuals
  • 01:00:34where they're at all these axes of
  • 01:00:37their identities and experiences.
  • 01:00:39To provide really excellent care.
  • 01:00:42Thank you, well thank you both of you
  • 01:00:45for really a fantastic presentation
  • 01:00:47and one that I hope our listeners will
  • 01:00:50have some really concrete takeaways and
  • 01:00:53really become advocates in this space.
  • 01:00:55So I thank you for that.
  • 01:00:58Doctors open in Malvern.
  • 01:01:00Albert have agreed to stay on for
  • 01:01:02the next hour for our trainees,
  • 01:01:04so I encourage the trainees to stay on.
  • 01:01:06But I think if there are other
  • 01:01:08people who would enjoy staying
  • 01:01:09on we would welcome that.
  • 01:01:11You will be so stay on.
  • 01:01:12You will be promoted to host so
  • 01:01:14that everyone can see each other.
  • 01:01:16Doctor Barbara Burtness is here
  • 01:01:17as our associate director of DI
  • 01:01:19for the Cancer Center and will
  • 01:01:21be leading the next session.
  • 01:01:23So thank you everybody so much.
  • 01:01:30Thank you for that, that wonderful.
  • 01:01:35Tour and completely, I think different
  • 01:01:40to the the kinds of grand rounds
  • 01:01:43talks that we have often hosted.
  • 01:01:46So it's it's particularly wonderful that
  • 01:01:49you're willing to to stay on and field
  • 01:01:52questions and and have some discussion.
  • 01:01:58With with the fellows, so let's
  • 01:02:00just give them a minute to join.
  • 01:02:03Do you know when ash I'm going to sign off,
  • 01:02:05but that was just amazing and I it's so
  • 01:02:08great to see you both and I hope we can
  • 01:02:12continue some collaborations and so I know
  • 01:02:15our fellows will get a lot out of this.
  • 01:02:16So thank you for agreeing to both
  • 01:02:18of these sessions. I appreciate it.
  • 01:02:19Absolutely thank you. Again,
  • 01:02:21thank you so welcome. Bye bye bye.
  • 01:02:32Hi Doctor Burns hi. Doctor Alpern,
  • 01:02:34Dr within Melbourne.
  • 01:02:38So yeah, I was.
  • 01:02:40I was going to introduce you.
  • 01:02:41Ben is one of the chief.
  • 01:02:46And his has actually been amazing
  • 01:02:48in the role we've introduced ADEI
  • 01:02:50curriculum to our fellowship,
  • 01:02:52sort of under his leadership. Purple
  • 01:02:56great, very exciting.
  • 01:02:59I have to apologize.
  • 01:03:00The timing did not workout so great
  • 01:03:02or the scheduling did not workout
  • 01:03:04so well because. Are actually
  • 01:03:07in service. Exam is also
  • 01:03:08today, so portion
  • 01:03:09of our fellows are
  • 01:03:11unfortunately unavailable by I think
  • 01:03:14we do have trainees from some of
  • 01:03:17the other training programs as well.
  • 01:03:19And in addition to hematology oncology.
  • 01:03:23Both. So I wonder if we if the
  • 01:03:26people who are still on if we should
  • 01:03:28go around and do introductions.
  • 01:03:31Or if there's another way we should start.
  • 01:03:37It would also be great to the
  • 01:03:39extent that some of you can come.
  • 01:03:42Turn your videos on. Uhm?
  • 01:03:47I I was, you know, thinking that we
  • 01:03:49would do this in a very informal way,
  • 01:03:51if that's OK with the two of you and.
  • 01:03:57You know, I, I know when
  • 01:03:59you're putting together a talk,
  • 01:04:00even as a single speaker,
  • 01:04:01there's all kinds of stuff
  • 01:04:02you have to leave out.
  • 01:04:03And then when there are two of you so
  • 01:04:07there there may be things that you want
  • 01:04:10to go into in in more depth as well.
  • 01:04:13But so I'll I'll start.
  • 01:04:15I'm Barbara burtness.
  • 01:04:17I'm a medical oncologist.
  • 01:04:19And I'm the interim associate
  • 01:04:22director for DI and.
  • 01:04:25Trying to build a
  • 01:04:28educational environment that.
  • 01:04:30Fosters culture change here.
  • 01:04:40Ben, we already introduced, I guess, Nick.
  • 01:04:45Uh, I presume this may hello.
  • 01:04:49I am a fifth year pH D
  • 01:04:51candidate in the Townsend lab.
  • 01:04:53Do a lot of cancer work
  • 01:04:55in computational biology,
  • 01:04:56and I was a trainee of the
  • 01:04:59cancer biology training program.
  • 01:05:04Julia.
  • 01:05:09I am Julia. I'm a
  • 01:05:11fourth year medical oncology fellow.
  • 01:05:15Doing breast cancer, clinical
  • 01:05:17care and research and will be
  • 01:05:19a breast medical oncologist.
  • 01:05:24Wonderful to see you shine.
  • 01:05:28I just wonder why external advisors?
  • 01:05:29But it's great to have you here. Well,
  • 01:05:32I had this on my calendar
  • 01:05:33'cause I got the permission.
  • 01:05:34I'm not sure how, but I was thrilled.
  • 01:05:37This is a wonderful presentation.
  • 01:05:39My name is Shawn Chang.
  • 01:05:40I'm a cancer epidemiologist on
  • 01:05:42faculty at MD Anderson Cancer Center.
  • 01:05:44I also am a training program director for our
  • 01:05:47cancer prevention research training program,
  • 01:05:49and I'm also an multiple pie of a
  • 01:05:52new course for skills development.
  • 01:05:55We don't have.
  • 01:05:57Not officially got an hour.
  • 01:05:59No gay yet,
  • 01:06:00but our project is to provide early
  • 01:06:03career researchers with cancer education.
  • 01:06:07Cancer Research orientation
  • 01:06:08for those who are interested
  • 01:06:10in SGM Cancer Research, so.
  • 01:06:17Great, thank you.
  • 01:06:18I'm just calling on people as you
  • 01:06:20appear on my screen. Mark Casey.
  • 01:06:28And Renee, I don't know if you
  • 01:06:31want to come. Turn your video on.
  • 01:06:33Renee is our communications
  • 01:06:34director in the Cancer Center.
  • 01:06:42Sure, hi everyone we met
  • 01:06:44earlier before Grandma started.
  • 01:06:45So thank you again for doing this.
  • 01:06:48By helping support. Saidul
  • 01:06:54hi, my name is stagel.
  • 01:06:55I am one of the first year hematology
  • 01:06:58oncology fellows here and I am interested
  • 01:07:00in providing care for the young
  • 01:07:03adult early onset cancer population.
  • 01:07:09Eileen
  • 01:07:19OK, some people maybe.
  • 01:07:22Oh Eileen says her desktop
  • 01:07:24does not have a micro camera.
  • 01:07:28OK, thank you for joining us and I'm Liz.
  • 01:07:37Stop. Can't hear you this.
  • 01:07:50OK.
  • 01:07:53One last person is David Schoenfeld.
  • 01:07:55One of the fellows.
  • 01:07:57David, if you want to just
  • 01:07:59briefly introduce yourself, sure.
  • 01:08:00Hi, my name is David. I'm one of the
  • 01:08:02third year fellows on the research track,
  • 01:08:04so I have a couple more years left.
  • 01:08:06I'm working with Harriet Cougar
  • 01:08:08during kidney Cancer Research
  • 01:08:09and interested in immunotherapy,
  • 01:08:11and I just want to thank you for the very
  • 01:08:13wonderful and interesting talk today.
  • 01:08:16Thank you, so I'm sorry closing now.
  • 01:08:19Oh yeah, yeah we can.
  • 01:08:22Sorry I'm I'm sorry about the lecture.
  • 01:08:25Much like Shine,
  • 01:08:27I got forwarded to me somehow.
  • 01:08:28I'm actually at the Ohio State
  • 01:08:31University I'm James Cancer Hospital.
  • 01:08:33I am an advanced practice nurse
  • 01:08:34and nurse scientist doing research
  • 01:08:37in this area and so when I saw that
  • 01:08:39I do now and ask for presenting,
  • 01:08:41I had to listen in.
  • 01:08:42So I'm just eavesdropping to
  • 01:08:43to hear what else is going on.
  • 01:08:45So thanks so much. Great, OK,
  • 01:08:48well maybe the first thing I'll
  • 01:08:51do is just ask if people have
  • 01:08:53questions that they want to throw
  • 01:08:56out and and if not I have a few so.
  • 01:09:05Doctor Burtness, do you want
  • 01:09:06people to throw their questions
  • 01:09:08into the chat or should we just
  • 01:09:09kind of throw into the form of us?
  • 01:09:11I think people can just.
  • 01:09:12I mean, for those of you who have no Mike,
  • 01:09:15Eileen, postdoctoral fellow in
  • 01:09:17translational oncology in the room lab,
  • 01:09:20part of the CBTP training program,
  • 01:09:23her mic is off,
  • 01:09:24so she will ask her to use the chat,
  • 01:09:26but for those of you who who can,
  • 01:09:28I think I'd like this to be
  • 01:09:30conversational and and interactive.
  • 01:09:32If that's OK with everybody.
  • 01:09:34Yeah.
  • 01:09:37Quick question, I guess I'll I'll kind
  • 01:09:39of give you 2 two lines of thinking and
  • 01:09:42let y'all go down whatever Rd you feel
  • 01:09:46like one is about like the there are.
  • 01:09:51Traditionally, different approaches
  • 01:09:52to care for different diseases,
  • 01:09:54often based on these sort of
  • 01:09:57section formed approaches.
  • 01:09:58And trans people, you know cancer
  • 01:10:01is a disease that that thrives on,
  • 01:10:03like just disruptions and signaling.
  • 01:10:07And it seems like there's a lot
  • 01:10:08of for people who elect to have
  • 01:10:11like a medical and hormonal sort
  • 01:10:13of aspect to their transition.
  • 01:10:18There might be some places where,
  • 01:10:22without you know, necessarily
  • 01:10:23undergoing entire clinical trials,
  • 01:10:25you can adjust the the sort of
  • 01:10:28dosage and care of people based off
  • 01:10:31of what we know about signaling.
  • 01:10:32So I wanted to know if if
  • 01:10:34there was any thoughts about.
  • 01:10:37That or the the the other thing that comes
  • 01:10:40to mind is the need for like because.
  • 01:10:44Medical record and even a
  • 01:10:46medical ontology or like.
  • 01:10:48Require this labeling and hierarchical
  • 01:10:51structure in order for them to
  • 01:10:53just sort of technically function.
  • 01:10:56How is that like?
  • 01:10:57What?
  • 01:10:57What are some tips for addressing
  • 01:10:59trans folk who don't necessarily
  • 01:11:02like applying labels to themselves,
  • 01:11:04especially in ways that don't that
  • 01:11:07aren't founded in medical jargon,
  • 01:11:10I should say.
  • 01:11:13I mean, I can speak to
  • 01:11:15the second question first.
  • 01:11:16I think the first question it
  • 01:11:17might be helpful, at least for me,
  • 01:11:19to get a little more detail about the
  • 01:11:21sort of scenarios you're thinking about.
  • 01:11:23But in terms of the second question,
  • 01:11:25I mean what I can say kind of like
  • 01:11:28broadly is that we know from our
  • 01:11:31qualitative research that oftentimes
  • 01:11:32part of what is helpful and what
  • 01:11:35trans people want is to share the
  • 01:11:37decision making around what is
  • 01:11:39in the electronic health record,
  • 01:11:41and to know, you know, the the.
  • 01:11:43Pros and cons of various decisions.
  • 01:11:44So there may be, you know,
  • 01:11:46various implications to the gender
  • 01:11:47marker in the chart or the other
  • 01:11:49demographics that are there,
  • 01:11:50including issues related to insurance
  • 01:11:53coverage and billing issues in terms
  • 01:11:56of being out and who's accessing
  • 01:11:58the the medical record.
  • 01:11:59So what a lot of people have
  • 01:12:01said in our studies is, you know,
  • 01:12:03I really appreciated when my
  • 01:12:04physician said I need a diagnosis
  • 01:12:06to prescribe hormones,
  • 01:12:07what would you like that diagnosis to be?
  • 01:12:10Or brought up other issues like that.
  • 01:12:14And then yeah,
  • 01:12:15I think in terms of your first
  • 01:12:17question about signaling,
  • 01:12:18I think I would.
  • 01:12:19I would appreciate any specific
  • 01:12:21scenarios that you're thinking of to
  • 01:12:23try to answer your question better.
  • 01:12:28Yeah, I mean there are.
  • 01:12:30It's it's hard 'cause there.
  • 01:12:31It's like there's a thousand different
  • 01:12:32treatments for 1000 different things,
  • 01:12:33but even just thinking like
  • 01:12:35there's speculative roles
  • 01:12:36and pathways for things like.
  • 01:12:40Ben, Jeff isoforms and how they're
  • 01:12:44different among physiological signaling.
  • 01:12:47And thinking about like the Jeff inhibitors
  • 01:12:50as a as a key aspect for him for preventing.
  • 01:12:53Vascularisation and metastases and and
  • 01:12:56cancer, like if there is some some sense in
  • 01:13:01which medically transitioning trans folk.
  • 01:13:03Have physiological states that
  • 01:13:06are neither like are in between or
  • 01:13:09somewhat liminal and signaling states.
  • 01:13:11If there are ways to adjust dosages to
  • 01:13:14represent that sort of liminal state.
  • 01:13:22Well, I would say that's really why
  • 01:13:24we need more inclusion in research,
  • 01:13:26because the the challenge right now
  • 01:13:29is that there are definitely trans
  • 01:13:32folks in clinical cancer trials,
  • 01:13:34but we can't see who they are.
  • 01:13:36We don't know that you know they're
  • 01:13:38dosing on various hormones.
  • 01:13:39We don't know when they're going on
  • 01:13:41and off and kind of cumulative dose,
  • 01:13:43and so we don't know how that's
  • 01:13:45informing things.
  • 01:13:45And so we need to, you know,
  • 01:13:48at the very fundamental level and ask.
  • 01:13:51In respectful, real,
  • 01:13:52relevant ways so that we can get
  • 01:13:55much more specific and understand
  • 01:13:57instead of just saying men and women.
  • 01:13:58I mean we,
  • 01:13:59we all know you know cisgender men have a
  • 01:14:02broad range of you know testosterone levels.
  • 01:14:05Cisgender women have a broad range
  • 01:14:07of estrogen progestin levels, and we
  • 01:14:09there's a lot we don't know about that.
  • 01:14:11But if we're really going to
  • 01:14:12get into precision health,
  • 01:14:13we really need to think
  • 01:14:15for everybody like we,
  • 01:14:16we gotta be doing this better, right?
  • 01:14:17Like why is there a preponderance of
  • 01:14:19certain cancers that are certain hormonal?
  • 01:14:21Dates or whatnot,
  • 01:14:21and so actually this is the opportunity
  • 01:14:23that I was trying to speak to.
  • 01:14:25Is that trans people actually really?
  • 01:14:27Present us this incredible opportunity
  • 01:14:30to understand more about these
  • 01:14:32various components specifically
  • 01:14:34as it pertains to cancer care.
  • 01:14:38I think you know where we are.
  • 01:14:40Some hormones, estrogen, progesterone,
  • 01:14:42testosterone, positive, right.
  • 01:14:43But what does that mean for somebody
  • 01:14:46who's going on and off or was actively
  • 01:14:49using blockers or other things?
  • 01:14:51And how does that then?
  • 01:14:53What does that teach us about the
  • 01:14:55mechanisms of how these neoplastic processes?
  • 01:14:58Advanced,
  • 01:14:58but we just don't have that.
  • 01:14:59We don't have those models sorted
  • 01:15:02out yet for anybody,
  • 01:15:03so if we could really deliver on this promise
  • 01:15:06of more accurate inclusion of variables,
  • 01:15:08and I'm really rethinking and
  • 01:15:10not just saying men and women,
  • 01:15:12right?
  • 01:15:12But really rethinking from
  • 01:15:14an ontological perspective.
  • 01:15:16What is what are the
  • 01:15:18questions that we're asking?
  • 01:15:19So that we can get our arms around,
  • 01:15:22everyone will learn a lot more
  • 01:15:23for everybody's cancer care,
  • 01:15:24I think.
  • 01:15:30Maybe just just building off that.
  • 01:15:33I mean you you've referred
  • 01:15:36to ASCO and NCCN and and FDA.
  • 01:15:39A lot of the most impactful
  • 01:15:42clinical trials and cancer recently
  • 01:15:44have been industry studies.
  • 01:15:47And you know, they obviously
  • 01:15:50right things that FDA will be.
  • 01:15:53Will accept.
  • 01:15:55But unless there's a mandate
  • 01:15:56from FDA to change things,
  • 01:15:58my experience is that they are very
  • 01:16:01comfortable continuing to do things
  • 01:16:04exactly the way they did them in 1975, and.
  • 01:16:08I'm just wondering have have there
  • 01:16:12been formal conversations with?
  • 01:16:14Big Pharma and or have you been
  • 01:16:16involved in in writing studies
  • 01:16:18in with industry partners?
  • 01:16:21Where?
  • 01:16:22You've attempted to to address.
  • 01:16:27Inclusion in eligibility criteria.
  • 01:16:31No, I mean I can say that
  • 01:16:33you know about a year ago,
  • 01:16:35the FDA did convene like a sexual and
  • 01:16:38gender minority like one day workshop
  • 01:16:40where we did start to talk about some
  • 01:16:43of these issues and in fact are writing
  • 01:16:45a manuscript to talk about how we
  • 01:16:47would suggest changing clinical trial,
  • 01:16:49inclusion and exclusion criteria,
  • 01:16:50and a myriad of other factors
  • 01:16:53to really better.
  • 01:16:54Get data that can be extrapolated to
  • 01:16:56all people, but I don't know of folks.
  • 01:17:00I don't know of folks who are working
  • 01:17:02with industry to figure out how to
  • 01:17:04make that more widely disseminated,
  • 01:17:06and I don't really know.
  • 01:17:09What all the steps would be in
  • 01:17:11trying to create an FDA mandate?
  • 01:17:12I know that the FDA has issued some
  • 01:17:16guidance around exclusion criteria
  • 01:17:17as it relates to HIV diagnosis,
  • 01:17:20and I think like similar.
  • 01:17:23Strategies could be employed to talk
  • 01:17:25about some of these other issues,
  • 01:17:26but I.
  • 01:17:27I am not 100% sure what the way
  • 01:17:30forward will look like,
  • 01:17:31but I am very interested to to
  • 01:17:33figure that out and to work with
  • 01:17:35with all of you too.
  • 01:17:36Build something better than
  • 01:17:37what we currently have.
  • 01:17:41And there are efforts from the FDA,
  • 01:17:43so building on what Doctor Albert
  • 01:17:45just mentioned, I think that you
  • 01:17:48know it's a slow process and there's
  • 01:17:50a lot of areas of of unknowns.
  • 01:17:52But the FDA actually born out of the Office
  • 01:17:55of Women's Health has been looking at
  • 01:17:57this and what I put in was a presentation.
  • 01:18:00Actually that was done and hosted by the FDA
  • 01:18:04from the Office of Women's Health two years,
  • 01:18:08three years ago now.
  • 01:18:10In their slides where they you know
  • 01:18:11they say sex is not gender and
  • 01:18:13they and they start to like,
  • 01:18:14you know break that apart.
  • 01:18:15So I think that there is increasing awareness
  • 01:18:17and I think you know it's it's kind of
  • 01:18:20like a bidirectional challenge, right?
  • 01:18:21Like we we needed to come, you know,
  • 01:18:23from the FDA we needed to come from
  • 01:18:25researchers who were saying like
  • 01:18:26this doesn't work and challenging
  • 01:18:28that and and there's office.
  • 01:18:29This handshake,
  • 01:18:30especially in academic medical centers where
  • 01:18:34industry initiated studies still work with,
  • 01:18:37you know,
  • 01:18:38academic colleagues to.
  • 01:18:40To run them and and vice versa so
  • 01:18:42you know if there's challenges
  • 01:18:43coming from all different directions,
  • 01:18:45I think that's how we can start
  • 01:18:47to move forward.
  • 01:18:50Great, thank you.
  • 01:18:54I have a quick
  • 01:18:54question specifically about the
  • 01:18:57types of cancers that are hormonally
  • 01:18:59driven in their pathophysiology,
  • 01:19:01and also that depend on
  • 01:19:04hormones for our treatment.
  • 01:19:05So thinking about breast cancer, my field.
  • 01:19:08Uhm? Would you have any?
  • 01:19:13Suggestions in terms of of how to deal
  • 01:19:17with that potentially conflicting?
  • 01:19:21Mechanisms of. For example,
  • 01:19:25are treatments for breast cancer
  • 01:19:27that might be directly conflicting
  • 01:19:29with with a medication that
  • 01:19:31someone is taking for transition.
  • 01:19:35How do you handle those situations?
  • 01:19:42So I mean, I think that you know all
  • 01:19:45people have hormones in their body.
  • 01:19:47You know exogenous or endogenous hormones,
  • 01:19:50and there are various ways that
  • 01:19:51we feel like we need to to change
  • 01:19:54hormone levels in patients based on
  • 01:19:56the type of cancer that they have.
  • 01:19:58So I think just like all people
  • 01:20:01with hormones talking about,
  • 01:20:02you know the risks and benefits
  • 01:20:04of continuing to have the same
  • 01:20:05levels of hormones in your body.
  • 01:20:07So I think in the case of like an
  • 01:20:09estrogen receptor positive breast cancer
  • 01:20:12for a trans woman on estrogen therapy,
  • 01:20:14I think probably the conversation is
  • 01:20:17very similar to a cisgender woman who
  • 01:20:19needs to go in a room at ACE inhibitor.
  • 01:20:23But I think that.
  • 01:20:24What I think can be really important
  • 01:20:27is just making sure that we're.
  • 01:20:30Understanding patients priorities
  • 01:20:32understanding their their concerns.
  • 01:20:35Talking about the real data that we have,
  • 01:20:37even data that we need to extrapolate
  • 01:20:39and then like making a joint decision.
  • 01:20:42I've definitely heard transgender people say,
  • 01:20:46you know, I'd rather.
  • 01:20:47This is like services, different scenario,
  • 01:20:49but like I'd rather die having had
  • 01:20:51the surgery that I wanted than than
  • 01:20:53not having had it so I think the
  • 01:20:55best that we can do for our patients
  • 01:20:57is talk about risks and benefits
  • 01:20:59of any intervention in therapy and
  • 01:21:00then like work with them to make the
  • 01:21:03decision that feels best for them.
  • 01:21:06Thank you.
  • 01:21:08I think there's also.
  • 01:21:09There's just this added
  • 01:21:10piece of like if it is, say.
  • 01:21:12A breast cancer in a transgender man
  • 01:21:15who's already had top surgery, right?
  • 01:21:17Like understanding that there's like this
  • 01:21:19whole other potential layer may or may
  • 01:21:22not be relevant for anyone individual,
  • 01:21:24but of like you know,
  • 01:21:25or you trinkets or for a transgender man,
  • 01:21:28you know that there may be
  • 01:21:30this other layer of like God.
  • 01:21:32This piece of my body and experience
  • 01:21:35that may not be like in line
  • 01:21:38with my identity is now this.
  • 01:21:43You know is now gonna kill me or
  • 01:21:45potentially you know these kinds
  • 01:21:47of questions come up for people.
  • 01:21:48Now that's not true for everyone.
  • 01:21:50And I that's actually something I
  • 01:21:52was very surprised about in in my
  • 01:21:54work on pregnancy and fertility
  • 01:21:55in transgender expensive people,
  • 01:21:57I expected you know,
  • 01:21:59along before I did my first
  • 01:22:00study on pregnancy experiences
  • 01:22:01and and trans masculine folks,
  • 01:22:03that everybody would have a bad
  • 01:22:05experience with being pregnant.
  • 01:22:06And, you know,
  • 01:22:07that was just my assumption going in.
  • 01:22:08And then a lot of people,
  • 01:22:09didn't, you know, they're like,
  • 01:22:10yeah, I'm a pregnant guy.
  • 01:22:11What's the deal like I have this organ?
  • 01:22:13It works, it's.
  • 01:22:14How I became a father,
  • 01:22:16so you know.
  • 01:22:16But then certainly people did have this
  • 01:22:18for it and some people were like yeah,
  • 01:22:19I just you know stomached through this very,
  • 01:22:23you know woman.
  • 01:22:24Gendered experience of like dealing with
  • 01:22:26this organ that everybody associates with
  • 01:22:28motherhood and womanhood and whatever.
  • 01:22:31So for some people you know I really am
  • 01:22:34working with them and saying, like, yeah,
  • 01:22:37I know that this is this added element of.
  • 01:22:40A gendered experience that
  • 01:22:41doesn't work for you?
  • 01:22:42How can I support you in that?
  • 01:22:44For some people it's like,
  • 01:22:45well, cancer just sucks.
  • 01:22:46So like we're just gonna deal with that.
  • 01:22:49But knowing that you know there's
  • 01:22:51there's a potential there that it
  • 01:22:53has this additional element and
  • 01:22:55it's really just about meeting
  • 01:22:57that person who's in front of you?
  • 01:22:59Knowing that you know discrimination,
  • 01:23:01stigma,
  • 01:23:02and pervasive gender norming is
  • 01:23:05at play in most scenarios and and
  • 01:23:08being willing to talk about that.
  • 01:23:10So like when I send somebody for a
  • 01:23:12transvaginal ultrasound, I say hey,
  • 01:23:14how do you feel about that like is is that?
  • 01:23:17You know, have you ever had one?
  • 01:23:18Are you concerned about it?
  • 01:23:20Some people like Nope, not a problem.
  • 01:23:21Some people like.
  • 01:23:22Yes, I don't wanna be, you know,
  • 01:23:24there's no way and and I do that
  • 01:23:27with my cisgender patients too,
  • 01:23:28you know?
  • 01:23:29So I just like that's something that
  • 01:23:31actually I've learned from a lot of trans
  • 01:23:32people to really stop and slow down.
  • 01:23:34Like what are we doing to your body?
  • 01:23:35What are my assumptions here?
  • 01:23:37How am I talking about these procedures?
  • 01:23:39Is this gonna meet you?
  • 01:23:40Is this gonna affirm you?
  • 01:23:42How can I make it better?
  • 01:23:54Ash and you know,
  • 01:23:55I don't know if you could.
  • 01:23:57See what was in in the chat,
  • 01:24:00sure, but Eileen had a question.
  • 01:24:05About bystander intervention and any advice
  • 01:24:07for trainees to interrupt gently correct,
  • 01:24:10more senior colleagues and and then actually.
  • 01:24:15Really resonated with with me as well,
  • 01:24:19because we've had a lot of conversations
  • 01:24:21here about just people really
  • 01:24:23don't know what to say and they.
  • 01:24:25Yeah, so maybe you could address Eileen's
  • 01:24:29question as globally as possible.
  • 01:24:33Funny that that question just
  • 01:24:35showed up in the chat because
  • 01:24:37I was actually just thinking of
  • 01:24:39asking the trainees if they'd like to
  • 01:24:41share any experiences they've had,
  • 01:24:43like this one where they're seeing maybe
  • 01:24:47patients being treated in a stigmatising way,
  • 01:24:51or they themselves have experienced
  • 01:24:53stigma from patients or colleagues
  • 01:24:55because I think that these
  • 01:24:57conversations are so important to have,
  • 01:24:59maybe not even as a question and answer.
  • 01:25:01But how can we all talk collectively about?
  • 01:25:04These experiences and and what we're
  • 01:25:06doing about them because I think that
  • 01:25:08I know that this is something that I've
  • 01:25:10struggled with throughout medical training,
  • 01:25:13so I would love to hear any
  • 01:25:15experiences you all want to share.
  • 01:25:18Both about like situations that have
  • 01:25:20been difficult or how you manage them.
  • 01:25:34Maybe maybe I can start so actually
  • 01:25:37one this is. This was one question,
  • 01:25:39one topic I want to bring up this
  • 01:25:41question of like my standard.
  • 01:25:44Scenario isn't training and I I
  • 01:25:46guess I don't have one specific
  • 01:25:49example specifically about
  • 01:25:52sexual minorities that comes
  • 01:25:54to mind, but what I can say
  • 01:25:55is that in all of our previous
  • 01:25:58discussions during this the the DI
  • 01:26:03series that Doctor Bernice had mentioned
  • 01:26:05this is the number one question that
  • 01:26:07always comes up and one of the most
  • 01:26:10important topics of discussions is.
  • 01:26:12You know what, what?
  • 01:26:14What are actionable items and how
  • 01:26:16can we go out on an individual level.
  • 01:26:19Making changes in the environment.
  • 01:26:23So I don't know that I have
  • 01:26:25like a specific example,
  • 01:26:26but it is something that
  • 01:26:28hopefully we can discuss further.
  • 01:26:30Maybe other folks have some
  • 01:26:31examples to provide as well.
  • 01:26:33I know it comes up all the time.
  • 01:26:36I think we see it on a daily basis
  • 01:26:37in terms of gender discrimination.
  • 01:26:39More broadly in terms of.
  • 01:26:44You know, underrepresented minorities
  • 01:26:47in both clinical and also
  • 01:26:49professional academics and situations.
  • 01:26:52Yeah, I was actually shined.
  • 01:26:54Gonna just call you out because
  • 01:26:56you put in this comment.
  • 01:26:59You know that you're sort of grateful
  • 01:27:01that you don't have to face this in
  • 01:27:02the clinical space, but I wonder if.
  • 01:27:08Speaking up as a bystander isn't pretty
  • 01:27:12similar in many different arenas.
  • 01:27:16And you know,
  • 01:27:18I think that there are components.
  • 01:27:20There's there's sort of role playing.
  • 01:27:22There's practicing.
  • 01:27:23There's learning how to to speak up.
  • 01:27:25There's being part of a community
  • 01:27:26where everybody speaks up,
  • 01:27:27so that gets modeled for you.
  • 01:27:30There's affirming people who speak up,
  • 01:27:34and, you know,
  • 01:27:35giving them some credit for it.
  • 01:27:36But just from your training perspective.
  • 01:27:41You know, I'd I'd love to hear
  • 01:27:44what you owe and Junos just
  • 01:27:46put in a thing about Stanford,
  • 01:27:47stand up or upstander training, but
  • 01:27:52that's very cool.
  • 01:27:53I've just clicked on it and
  • 01:27:55will be sharing that with our
  • 01:27:58trainees to thank you for that.
  • 01:28:00So my training program we are starting
  • 01:28:05to work more on impostor phenomenon
  • 01:28:08ability mindset and perceived
  • 01:28:10discrimination and the intersection
  • 01:28:12of these experiences with our with
  • 01:28:16regard to training research trainees,
  • 01:28:19but the conversation here is about if
  • 01:28:21I understand more correctly that it's
  • 01:28:24really more about like in a clinical
  • 01:28:26setting and you know how to sort of
  • 01:28:29manage that power dynamic if you're.
  • 01:28:31Seeing something happen and how to intervene.
  • 01:28:34So this is sort of the, you know,
  • 01:28:36just as Juno sent us about upstander
  • 01:28:40or bystander intervention so.
  • 01:28:43I'm not very good at this.
  • 01:28:45I'm still learning how to you know
  • 01:28:47what many tools there might be,
  • 01:28:50but one of the things I always
  • 01:28:52think about is asking questions.
  • 01:28:54You know, oh, I didn't understand that.
  • 01:28:57Could you explain more about that?
  • 01:28:59Things like that.
  • 01:29:00One of the things I was about I was typing
  • 01:29:03Barbara when you were calling me out,
  • 01:29:05there it was.
  • 01:29:07Something I used when I was a postdoc,
  • 01:29:08which is to request in service
  • 01:29:11training for everyone.
  • 01:29:13So I wonder if maybe you know junior
  • 01:29:16colleagues trainees can ask for in
  • 01:29:18service for everyone on these topics.
  • 01:29:20How can we do better?
  • 01:29:22How does this affect our patients?
  • 01:29:26How can we support each other?
  • 01:29:27And so once the request is made and once
  • 01:29:30it is delivered then people have a more
  • 01:29:33common basis for having these conversations?
  • 01:29:36Because then you can remind each other.
  • 01:29:38Oh, remember at that you
  • 01:29:39know workshop that we have.
  • 01:29:41We talked about this.
  • 01:29:42Oh,
  • 01:29:42let's you know blah blah blah.
  • 01:29:45So I have a lot to offer but I think that
  • 01:29:49perhaps there might be others who have.
  • 01:29:51You know,
  • 01:29:52some training or better training
  • 01:29:54and we can request their help.
  • 01:29:56Out.
  • 01:29:57Juno, can you tell us
  • 01:29:59about the Upstander life?
  • 01:30:02Yeah, so this is an initiative out of
  • 01:30:05Stanford and really recognizing this,
  • 01:30:07you know that that this is, I think,
  • 01:30:10just like you were mentioning.
  • 01:30:12This was like the most common thing that
  • 01:30:14was coming up and so the response was
  • 01:30:16to really like how do I help people?
  • 01:30:18And recognizing that like by standards
  • 01:30:21or what through this training is
  • 01:30:24called up standards or hopefully
  • 01:30:26to champion people like actually
  • 01:30:29acting and being engaged and being.
  • 01:30:32Champions through being upstanders UM
  • 01:30:35is moving away from just by standards,
  • 01:30:38and that those are the often the
  • 01:30:40largest percentage of people in the
  • 01:30:41room or who are witnessing things,
  • 01:30:43and that that's actually those are
  • 01:30:45the folks that need to be mobilized
  • 01:30:48to really create culture change.
  • 01:30:50But how do we do that?
  • 01:30:51And so this was Stanford's response to.
  • 01:30:55You know people ask him for tools
  • 01:30:58and and department by department.
  • 01:31:00These trainings are happening
  • 01:31:02and it's really.
  • 01:31:04Did initiate in terms of sort of thinking
  • 01:31:08about discrimination and sexism in in
  • 01:31:11sort of the most traditional concepts
  • 01:31:13and and thinking about equity for women,
  • 01:31:16and then has has broadened out to
  • 01:31:19really recognize diversity across
  • 01:31:20the gender spectrum and other
  • 01:31:22axes of identity and difference.
  • 01:31:24So actually across the traditional,
  • 01:31:28like quote, UN quote, traditional,
  • 01:31:29like sexism and racism were like.
  • 01:31:31Kind of the two pillars that
  • 01:31:32people were like.
  • 01:31:33How do I say something now that I'm sort of?
  • 01:31:35Sensitized and and now people have understood
  • 01:31:38that this that's actually broader than that,
  • 01:31:40so this is, you know, sort of 1 approach.
  • 01:31:43I think the big thing is,
  • 01:31:44you know recognition and
  • 01:31:45and talking about it.
  • 01:31:47And I think also I really
  • 01:31:50am empathize with trainees.
  • 01:31:51I think trainees are in a really.
  • 01:31:54Complicated situation and that
  • 01:31:56that has to be recognized and that
  • 01:31:59there are really intense power
  • 01:32:01dynamics in the hierarchies of
  • 01:32:03medicine where we could say Oh no.
  • 01:32:04No talk about it.
  • 01:32:05But there are sometimes
  • 01:32:07there really are reprisals,
  • 01:32:08and there really is backlash.
  • 01:32:10And so we really understanding like what
  • 01:32:14are safe spaces for people to to do that,
  • 01:32:18and also noting that up standards there's
  • 01:32:21a vulnerability there and people may be
  • 01:32:23sensitized being up standards because it's.
  • 01:32:24Part of their own identity or
  • 01:32:26experience and then that may put
  • 01:32:28people in a very vulnerable position,
  • 01:32:30and so some some of the strategies around.
  • 01:32:33You know, partnering with.
  • 01:32:34Essentially,
  • 01:32:35this is the place where allies.
  • 01:32:38Come in, you know.
  • 01:32:40So like if you are a white cisgender.
  • 01:32:46You know able body person like
  • 01:32:48really taking that step as a.
  • 01:32:50You know when you see it,
  • 01:32:52you know when I see it,
  • 01:32:53it's like it's it's on me to act.
  • 01:32:55If I'm seeing racism happening,
  • 01:32:58it's it's so I'm seeing,
  • 01:32:59you know, ableism happening.
  • 01:33:00If I'm seeing really disparaging
  • 01:33:03remarks around transphobia.
  • 01:33:06Other things because I'm not as
  • 01:33:08personally vulnerable and it's.
  • 01:33:10Effectively,
  • 01:33:10therefore easier for me and takes
  • 01:33:13that burden off my colleague who is.
  • 01:33:16In in even more vulnerable situation,
  • 01:33:20that having been said,
  • 01:33:21you know thinking about how that's done,
  • 01:33:23so it doesn't. Take away or you know.
  • 01:33:28Do it in such a way that that disempowers or.
  • 01:33:33Takes voice away from individuals and
  • 01:33:35or comes in as a savior, you know?
  • 01:33:37So it's. It's not easy.
  • 01:33:38If it was easy,
  • 01:33:39it would have already been solved,
  • 01:33:40but I think just this like active training,
  • 01:33:43we get trained on so many things, right?
  • 01:33:45Like so this is active training.
  • 01:33:46We all need to do and challenge
  • 01:33:48ourselves to do everyday.
  • 01:33:51If I could just make a personal comment to
  • 01:33:54the junior people and I I'm by no means,
  • 01:33:56am I suggesting that you go
  • 01:33:58out and you know become target.
  • 01:34:01Practice for people in power but.
  • 01:34:04If you don't say anything,
  • 01:34:06then 30 years later you're working
  • 01:34:08in the same crappy environment that
  • 01:34:10you hated when you were training.
  • 01:34:12Plus it's on you that you
  • 01:34:14never said anything you know,
  • 01:34:16and I think I was a generation
  • 01:34:20that felt like.
  • 01:34:21Well and and I really I came right
  • 01:34:23after the class action suit first class
  • 01:34:25in my medical school that was 50% women.
  • 01:34:28First class of interns at Yale that
  • 01:34:29was 50% women like I was right
  • 01:34:31at that time and I think we had
  • 01:34:33this naive idea that as long as we
  • 01:34:35could show that we could do all the
  • 01:34:37work the same as everybody else,
  • 01:34:40it would work out.
  • 01:34:41And you know, 30 years later,
  • 01:34:43that's clearly not what happened, right?
  • 01:34:45And so you know, absolutely you have to,
  • 01:34:49you know, be careful.
  • 01:34:51But I also think there is a burden
  • 01:34:54on you keeping quiet as well.
  • 01:34:57Be pile
  • 01:34:58onto that comment, Barbara.
  • 01:35:00I think that often we think as
  • 01:35:03individuals that we have very little
  • 01:35:06power and and sometimes that's true.
  • 01:35:08But what I have learned,
  • 01:35:10especially being an empty neologist,
  • 01:35:11is that when we band
  • 01:35:13together and we collect data,
  • 01:35:14we have a huge amount of power.
  • 01:35:17And I love that slide that Ash and
  • 01:35:20Juno that you shared at the beginning
  • 01:35:23about I wrote it down actually
  • 01:35:25about how systemic oppression.
  • 01:35:28Leads to disparities and invisibility
  • 01:35:31leads to in accuracies and
  • 01:35:33substandard like yes yes yes.
  • 01:35:35And we can dispel that with data.
  • 01:35:38So when junior people band together
  • 01:35:40and they and they say, oh we,
  • 01:35:43we took a survey of all the residents and
  • 01:35:46fellows and we found a very you know,
  • 01:35:49high level of dissatisfaction with.
  • 01:35:51Turns out the people in leadership.
  • 01:35:53They kind of quake in their boots.
  • 01:35:55You know they really don't
  • 01:35:57like that kind of thing.
  • 01:35:58And so.
  • 01:35:59Sometimes it's about recognizing
  • 01:36:00that you do have power,
  • 01:36:02but you have to harness it.
  • 01:36:03You have to collect the data
  • 01:36:05and then you have to have a
  • 01:36:06unified voice to make a request.
  • 01:36:09That's what I was saying about you know,
  • 01:36:12being able to.
  • 01:36:13You know,
  • 01:36:14ask for things you ask for the in service.
  • 01:36:19You know I'm coming from a junior level.
  • 01:36:21It's appropriate for you to ask
  • 01:36:23for for in service stuff that then
  • 01:36:25benefits everybody so you can have
  • 01:36:27your hidden agenda that will,
  • 01:36:29you know, help fix the world.
  • 01:36:31But you know,
  • 01:36:32be sure to tap into the power
  • 01:36:34that you actually have.
  • 01:36:35So I you know I,
  • 01:36:37I tried to tell this to students
  • 01:36:38as well because students often
  • 01:36:40feel like they have no power.
  • 01:36:41And I say actually you have so much power.
  • 01:36:44Because the faculty hate when you are
  • 01:36:46unhappy because it causes trouble for them.
  • 01:36:48So same for you.
  • 01:36:50Know people in training
  • 01:36:52all people in training.
  • 01:36:53It's really important.
  • 01:36:55And yeah,
  • 01:36:56there are dinosaurs at the top
  • 01:36:57and in leadership,
  • 01:36:58but they're also advocates
  • 01:36:59and champions as well.
  • 01:37:01So you just have to find them and get them
  • 01:37:03to help work from all different directions.
  • 01:37:05Just like Ashland, you know we're
  • 01:37:07saying it has to be everybody together,
  • 01:37:09not just the leaders or the
  • 01:37:11seniors or whatever.
  • 01:37:12That's what I used to think
  • 01:37:13when I was a junior person.
  • 01:37:15I'll leave it to the adults,
  • 01:37:16let them fix everything,
  • 01:37:18and then when I'm a senior person I'll help.
  • 01:37:21Well, no, no no.
  • 01:37:22That's not how it works.
  • 01:37:24That's not how we advance.
  • 01:37:25Change, at least not my lifetime.
  • 01:37:27So it has to come from everywhere.
  • 01:37:29Which is,
  • 01:37:30you know,
  • 01:37:30the message that ash in June
  • 01:37:32we're sharing with us and and
  • 01:37:34Barbara to thank you,
  • 01:37:35yeah?
  • 01:37:36I would also say I think it it's
  • 01:37:39it's dangerous though to like only
  • 01:37:41rely on the trainees because it it.
  • 01:37:43You know, recognizing that there is just
  • 01:37:46incredible vulnerabilities, you know.
  • 01:37:47So I get emails all the time from Elk
  • 01:37:51plus like. Med students, undergrads,
  • 01:37:53residents fellows saying you know,
  • 01:37:56can I be out like this is a
  • 01:37:58significant portion of my work?
  • 01:37:59I don't know. I was asked.
  • 01:38:01Totally illegal, egregious things on
  • 01:38:04the residency and fellowship trail.
  • 01:38:07Still, I get asked.
  • 01:38:08Terrible and egregious things as an
  • 01:38:11assistant professor like you know.
  • 01:38:13So all that's the say,
  • 01:38:14I totally so much agree and it
  • 01:38:16has to be multidirectional,
  • 01:38:18but I think it's also really
  • 01:38:20important that we protect our
  • 01:38:21trainees and recognize that like.
  • 01:38:23There are certain things that we could
  • 01:38:25do today, you know, stroke of the pen.
  • 01:38:27So how are you asking about gender unlike,
  • 01:38:30you know, intake forms, interview forms.
  • 01:38:33Are we asking people prone?
  • 01:38:34I mean those things like that is that
  • 01:38:37is settled science like we should all
  • 01:38:39be asking that actually like no more
  • 01:38:42is needed from our trainees to say.
  • 01:38:44And sadly I think that the challenges
  • 01:38:46that I see trainees spending so much
  • 01:38:48time and energy just trying to make these
  • 01:38:52spaces safe for themselves and for.
  • 01:38:54Patients and her colleagues that
  • 01:38:56they actually are at a disadvantage.
  • 01:38:58Actually in terms of grants in
  • 01:39:01terms of papers in terms of just
  • 01:39:03studying for whatever tests because
  • 01:39:05they are working so hard.
  • 01:39:07So I would never say don't work on it.
  • 01:39:10But also I'm like we don't need anymore
  • 01:39:12actually research on racial disparities
  • 01:39:14to know that we need to change things.
  • 01:39:17We also actually don't need much more
  • 01:39:20on gender differences to realize
  • 01:39:22like we've just missed the boat.
  • 01:39:24In terms of having a binary notion of gender,
  • 01:39:27and we have a lot of solutions out there
  • 01:39:29that we all just need to enact and.
  • 01:39:32Yeah.
  • 01:39:34And I I didn't mean to suggest
  • 01:39:37totally. No, I just wanted like
  • 01:39:39say that because I am there as
  • 01:39:42a mentor like to people who are.
  • 01:39:44You know, and and myself too.
  • 01:39:46I mean, I was told many times
  • 01:39:48not to do this as my career list.
  • 01:39:52Last night I'd be shunned in the world
  • 01:39:54of medicine, and I couldn't not.
  • 01:39:57But it's been hard, very hard, you know.
  • 01:40:01Frankly, it would have been a
  • 01:40:02lot easier to study like preterm
  • 01:40:04labor or something, you know but
  • 01:40:06well, but that's not what we do,
  • 01:40:07right? We go for this stuff
  • 01:40:09that's important to us,
  • 01:40:10and in that passion we can do better.
  • 01:40:13So thank you for doing that.
  • 01:40:15Thank you for taking on that challenge.
  • 01:40:17Now as a senior person,
  • 01:40:18I will say that I have an obligation.
  • 01:40:20I have a responsibility to help the field
  • 01:40:23and so that means pulling people up.
  • 01:40:26OK, so when it comes time for promotion
  • 01:40:30and need for support and things like that,
  • 01:40:33I want people to come to
  • 01:40:34me and say would you?
  • 01:40:36Would you be able to write a good
  • 01:40:38letter for me and I say yes absolutely,
  • 01:40:40because we need better people.
  • 01:40:42More better people.
  • 01:40:44More thoughtful, different perspectives.
  • 01:40:46All that kind of stuff to populate the
  • 01:40:49field at all levels so you know the idea of,
  • 01:40:52like, you know,
  • 01:40:53knowing who the Champions and advocates
  • 01:40:54are is really critical because
  • 01:40:56you know what the junior people,
  • 01:40:59what the trainees cannot,
  • 01:41:00and maybe should not take on themselves
  • 01:41:03that can be shared with other people
  • 01:41:06who have positional power and tenure.
  • 01:41:09You know to take the hit right totally.
  • 01:41:12You know, so you got it.
  • 01:41:15You got it.
  • 01:41:15I have to learn the system and
  • 01:41:18how to manage it.
  • 01:41:19No, you know when to lean in and when
  • 01:41:22to hold back and let others lean in.
  • 01:41:25So you know the mentorship is important.
  • 01:41:28So oh, and Ashley,
  • 01:41:29that's a great time for me to do
  • 01:41:32a shameless plug for our program.
  • 01:41:34I'm going to put it in the.
  • 01:41:38Oh my gosh, not here it is.
  • 01:41:41Put it in the chat.
  • 01:41:43We have not updated it because we only
  • 01:41:46got our score a couple weeks ago,
  • 01:41:48so we haven't gotten the money yet
  • 01:41:50and so we're we're in the process of
  • 01:41:52about to get organized to get the
  • 01:41:55courses moving, so just you know,
  • 01:41:58go to the website.
  • 01:41:59Keep an eye on, you know,
  • 01:42:00put a tab on it and you know look
  • 01:42:02for our promotional emails when it's
  • 01:42:04time to sign up for the workshop.
  • 01:42:06So and if anybody is, thank you.
  • 01:42:09If anybody is going to the LGBT health
  • 01:42:11workforce conference in New York.
  • 01:42:13At the end of April we'll be
  • 01:42:14there and we'll be celebrating.
  • 01:42:16So come by for a little champagne.
  • 01:42:23One of the things I wanted to do
  • 01:42:25was ask both Ashland and Juno,
  • 01:42:27just what was it that you had to not include
  • 01:42:29in the talk, but that you wanted to,
  • 01:42:32but there wasn't enough time.
  • 01:42:34I think that. That such a rich topic I'm,
  • 01:42:38I'm sure you both had. Other things that.
  • 01:42:43You had to to kind of make room. With.
  • 01:42:54Oh, ask. You go first, please.
  • 01:42:57I wanted to say one other quick thing
  • 01:42:59about this bystander conversation
  • 01:43:00we were having, which I don't know
  • 01:43:02how helpful it'll be or not be.
  • 01:43:04But in my experience, every situation
  • 01:43:07in which I'm witnessing mistreatment
  • 01:43:10of another person is very different,
  • 01:43:13and in each of those situations
  • 01:43:16my own personal safety.
  • 01:43:17You know, either physical safety or safety
  • 01:43:20in terms of my career is very different,
  • 01:43:22and so the tactics that I use in
  • 01:43:25these different situations vary.
  • 01:43:26Greatly like for example,
  • 01:43:29I remember being at a tumor board where.
  • 01:43:33There was, just like very clear,
  • 01:43:34misogyny between attendings that were
  • 01:43:36that were much more senior than I was,
  • 01:43:39and it was from people who were
  • 01:43:42very aggressive in their approach
  • 01:43:44and and were in leadership.
  • 01:43:46So I, I felt in the moment that the best
  • 01:43:48I could do was just like, clear my throat,
  • 01:43:51very loudly, over and over again,
  • 01:43:52like just to kind of say, like,
  • 01:43:54hey, something's going on here.
  • 01:43:56That's not OK.
  • 01:43:56And then to talk about it with the
  • 01:43:59other Chinese and then talk about it
  • 01:44:01with my attendings, but I feel like.
  • 01:44:04Dumb.
  • 01:44:04In my mind,
  • 01:44:05I I try to be very forgiving of myself
  • 01:44:08and to just do the best that I can
  • 01:44:10in any given situation and to try to
  • 01:44:13do whatever seems possible and safe.
  • 01:44:16And then I think that the other issue
  • 01:44:19about training is that we're so busy
  • 01:44:21that there's very little time to
  • 01:44:23process these things that happen.
  • 01:44:25But I think one thing that I find very
  • 01:44:27helpful is having close colleagues
  • 01:44:28that I can call up and and just say like hey,
  • 01:44:31this is what happened today and kind
  • 01:44:33of like talk through, you know,
  • 01:44:35a strategy,
  • 01:44:35a different strategy that I could have
  • 01:44:37used in the moment or a strategy that
  • 01:44:38we could use together now in terms
  • 01:44:40of like what are we going to do about this?
  • 01:44:42Faculty member who continues to make
  • 01:44:44fat phobic comments about his patient
  • 01:44:47in clinic or or whatever it is?
  • 01:44:49Uhm?
  • 01:44:51And so I just I guess I want to also
  • 01:44:53express like a lot of empathy and
  • 01:44:56admiration for all of you for really
  • 01:44:58trying to do this very difficult work.
  • 01:45:01OK, so then,
  • 01:45:02in terms of the top I I don't want.
  • 01:45:07I guess there's two
  • 01:45:08things that come to mind.
  • 01:45:09One is that I work with a Community
  • 01:45:10Advisory Board of transgender people
  • 01:45:12who've been diagnosed with cancer,
  • 01:45:13and we've been working together
  • 01:45:15probably for over three years.
  • 01:45:17Some of us and.
  • 01:45:20Last night we were talking about
  • 01:45:22actually Juno and I are working on a
  • 01:45:25chapter for the ASCO book together.
  • 01:45:26And so I brought it to them and we
  • 01:45:29had a conversation about it and dumb.
  • 01:45:31It was a very difficult conversation about
  • 01:45:34how we're talking about data collection,
  • 01:45:35in particular whether we're asking
  • 01:45:37about sex assigned at birth or not.
  • 01:45:39And inadvertently,
  • 01:45:40I like I kind of like pushed,
  • 01:45:45pushed through instead of like really
  • 01:45:47listening and it ended up being.
  • 01:45:50I think that one of the Community Advisory
  • 01:45:52Board members felt very they kind of
  • 01:45:54bulldozed over and not listened to.
  • 01:45:56And so I guess I'm bringing this up
  • 01:45:59because I I think that our work with
  • 01:46:02community members is so important and
  • 01:46:04and necessary for doing research and
  • 01:46:07also so so difficult in so many ways.
  • 01:46:09And I think,
  • 01:46:10especially with the time constraints of like.
  • 01:46:13Deadlines Grant deadlines,
  • 01:46:15publication deadlines that it
  • 01:46:16can be really hard to like.
  • 01:46:18Slow down and try to be a good
  • 01:46:21listener and collaborator,
  • 01:46:23but I think that the work with that
  • 01:46:25Community Advisory Board has been like
  • 01:46:27probably some of the most influential
  • 01:46:29of like my career as an oncologist,
  • 01:46:32I mean.
  • 01:46:32Such that it is so.
  • 01:46:35I wish that I had had more time to talk
  • 01:46:37about those relationships in that that work.
  • 01:46:44Thanks. And then I. I mean,
  • 01:46:47I think I always like to give people sort
  • 01:46:50of very practical things so you know,
  • 01:46:53usually it's obviously like many talks,
  • 01:46:56kind of in some ways condensed
  • 01:46:58into one to give ideas.
  • 01:47:00But there's for the folks who
  • 01:47:03are really research minded.
  • 01:47:05I really, you know.
  • 01:47:06And or doing research like to
  • 01:47:07think about things like you know,
  • 01:47:09example table,
  • 01:47:10ones of like if you're studying
  • 01:47:13uterine cancer like these are
  • 01:47:15the various groups you should.
  • 01:47:16Think about it and I have to
  • 01:47:18like mock table ones and those
  • 01:47:19kinds of things that I think is
  • 01:47:20just very illustrative to see,
  • 01:47:22like most people aren't doing that,
  • 01:47:24but should be right.
  • 01:47:25So it would be, you know,
  • 01:47:27cisgender women, transgender men,
  • 01:47:29nonbinary people,
  • 01:47:30and looking across those different
  • 01:47:32groups to really make visible
  • 01:47:34differences and experience,
  • 01:47:35and then for the clinician colleagues,
  • 01:47:38really, you know,
  • 01:47:39how do you ask about pronouns?
  • 01:47:42I mean,
  • 01:47:43how do you document them in your chart?
  • 01:47:46How?
  • 01:47:47Are you asking about sexual activity
  • 01:47:50and or who's who's supporting you?
  • 01:47:53Or you know, going through cancer, right?
  • 01:47:57Like these kinds of things so that
  • 01:48:00it's it's just very real and granular,
  • 01:48:02and so there's that's kind of the whole.
  • 01:48:04Next, you know,
  • 01:48:06201's of like these kinds of talks but but.
  • 01:48:09You know the the hope is at least you
  • 01:48:11know planting seeds like I didn't we didn't.
  • 01:48:14None of us learned how to do
  • 01:48:16a history on our patients.
  • 01:48:17You know, in one talk or you know,
  • 01:48:19learn about.
  • 01:48:21Cisgender women all-in-one talk right
  • 01:48:23so like same same type of thing so,
  • 01:48:26but there's obviously a lot
  • 01:48:27more in terms of really taking
  • 01:48:29care of transition gender,
  • 01:48:31diverse people,
  • 01:48:32and actually all people in a in
  • 01:48:34a more accurate way.
  • 01:48:39Thank you. So I just
  • 01:48:44can't help noticing that.
  • 01:48:48You know, I, I could see the four trainees,
  • 01:48:51bannik Julia and David and.
  • 01:48:55Are you guys OK 'cause you're
  • 01:48:57not smiling and I just worry because this.
  • 01:49:01You know I am new to this area of work.
  • 01:49:04I've only been doing this work for maybe
  • 01:49:06about 5 something years and it's tough.
  • 01:49:09And I just wanted to check in
  • 01:49:11with you or you OK.
  • 01:49:14You look pensive.
  • 01:49:18There's a lot to think about, right?
  • 01:49:19Like part I guess.
  • 01:49:20Part of it is thinking about like the
  • 01:49:23the the the multitudes of scales right?
  • 01:49:25Because a lot of this even assumes
  • 01:49:26that trans folk are getting into the
  • 01:49:29hospital doors at the first instance.
  • 01:49:32And like what sort of skews and and even from
  • 01:49:35like a research sort of stats perspective,
  • 01:49:38like had you account for
  • 01:49:40like what is already,
  • 01:49:41it can be like a a smaller subset,
  • 01:49:44like how do you get the most power
  • 01:49:47to answer and most serve people?
  • 01:49:50When they're just kind of disserved
  • 01:49:52very broadly.
  • 01:49:53And how?
  • 01:49:55When you have like that intersections
  • 01:49:58of identity that even further fragment
  • 01:50:00your your ability to resolve.
  • 01:50:02Thanks for a very data driven standpoint,
  • 01:50:05which I think.
  • 01:50:07You know institutions of power rely
  • 01:50:09on as like admissions of evidence,
  • 01:50:11whereas like things like ethnographies
  • 01:50:13are a little less admitted
  • 01:50:15as evidence in these spaces.
  • 01:50:22Yeah. Very very tough. As
  • 01:50:27a cancer epidemiologist,
  • 01:50:28I think about the numbers all the time.
  • 01:50:31I think about the data all the time.
  • 01:50:34Some of the work that I'm doing is about,
  • 01:50:37you know. How do we get more?
  • 01:50:38You know, sexual orientation,
  • 01:50:40gender identity,
  • 01:50:41data into our electronic health records?
  • 01:50:43How do I get I?
  • 01:50:44I'm at MD Anderson.
  • 01:50:45How do I make it happen here?
  • 01:50:47And fortunately,
  • 01:50:48you know when I have messaged upstairs
  • 01:50:51to leadership they have been positive
  • 01:50:54and responsive but it's still slow.
  • 01:50:57Slower than is desirable,
  • 01:50:59so fortunately you know the time
  • 01:51:01is now and we are moving towards
  • 01:51:03gathering people and beginning to think
  • 01:51:05about how we're going to exert some
  • 01:51:07pressure to really move things forward.
  • 01:51:09And you know, Barbara and I.
  • 01:51:11We were just on a meeting last week together.
  • 01:51:13'cause I sit on the external
  • 01:51:15Advisory Board for the Yale Cancer
  • 01:51:18Center and these issues come up.
  • 01:51:21It's actually in the announcement for
  • 01:51:23Cancer Center support grants now,
  • 01:51:25and you know, we have to.
  • 01:51:28We have to address these issues and we
  • 01:51:30are we have been slow but it has to happen.
  • 01:51:33And you're right,
  • 01:51:35the multitude of.
  • 01:51:36Issues and complexities.
  • 01:51:38And you know,
  • 01:51:39just doing it is not just doing,
  • 01:51:41it's doing it.
  • 01:51:43Doing it appropriately and with
  • 01:51:44consideration and respect and inclusion.
  • 01:51:46And you know multiple perspectives
  • 01:51:49and involvement, so it's hard.
  • 01:51:54But I I think you know the time is
  • 01:51:56really good because there are a lot
  • 01:51:58of really good people who are in it
  • 01:52:00now and want to make it work well.
  • 01:52:04And the other thing I would say is that the.
  • 01:52:08Generation that is,
  • 01:52:10I mean our trainees generation.
  • 01:52:13Is. So much more committed to
  • 01:52:18like a good world, right?
  • 01:52:20I mean you see it in you see it in climate.
  • 01:52:22You see it in in their response
  • 01:52:24to Black Lives Matter.
  • 01:52:25But also I think. When it comes
  • 01:52:30to gender and sexual minorities,
  • 01:52:31much more accepting of each other,
  • 01:52:33much more accepting of themselves than
  • 01:52:35certainly, you know, my generation was.
  • 01:52:37So I I actually.
  • 01:52:39Although it is painful work and
  • 01:52:42and these conversations. Uhm?
  • 01:52:45You know, you remember a lot
  • 01:52:47of things that weren't great.
  • 01:52:49I'm actually more full of hope
  • 01:52:51than I have ever been because I see
  • 01:52:54a new generation coming that's.
  • 01:52:56Not accepting, you know,
  • 01:52:58not putting up with as much,
  • 01:52:59I would say.
  • 01:53:02I think
  • 01:53:02Ben was gonna say something
  • 01:53:03if I missed. Touch.
  • 01:53:07Well, actually, maybe I'll just
  • 01:53:09doctor Albert if you don't mind me,
  • 01:53:11I'll just bring the conversation
  • 01:53:13to the public form. So I was going
  • 01:53:15to ask if
  • 01:53:17Doctor Alper and doctor within Melbourne.
  • 01:53:19If you could expand upon a
  • 01:53:21little bit more about.
  • 01:53:23What's known about sexual and
  • 01:53:25gender minority providers?
  • 01:53:28The experiences of the providers and what?
  • 01:53:30What are other interventions that we can
  • 01:53:32do to make sure that we create an open?
  • 01:53:36In open kind of workplace environments,
  • 01:53:39because I think a lot of the things
  • 01:53:40that we've been talking about so far has
  • 01:53:42been very patient centric and also how?
  • 01:53:46How we can go about delivering
  • 01:53:48better care? But how about I?
  • 01:53:50I think that among colleagues in
  • 01:53:52the interactions that we have.
  • 01:53:55Is kind of like a unique experience
  • 01:53:57as well, slightly different.
  • 01:54:05The Ben and I were talking a little bit
  • 01:54:07in the chat about a paper that a friend
  • 01:54:09of mine published basically doing it.
  • 01:54:11He did a survey of trans and gender.
  • 01:54:15Diverse clinicians and just found
  • 01:54:17that people face face significant
  • 01:54:19barriers during training,
  • 01:54:20including having to hide their identities
  • 01:54:24and witnessing statement discrimination.
  • 01:54:27And I was also saying that you know,
  • 01:54:28I think that I've been talking with
  • 01:54:30various colleagues about building better
  • 01:54:32networks of SGM clinicians across the US
  • 01:54:35that we can better support each other.
  • 01:54:38Probably not as much as Doctor
  • 01:54:40Obannon Malaver,
  • 01:54:40but I have talked to many people
  • 01:54:42who are facing like a lot of really
  • 01:54:45challenging decisions about whether
  • 01:54:46to be out in their personal statements
  • 01:54:48or on the interview trail and how
  • 01:54:51to manage those things so I don't
  • 01:54:53have like more data to quote you,
  • 01:54:56but I do think.
  • 01:54:57But trying to figure out how to better
  • 01:54:58support each other with these things
  • 01:55:00would be would be really helpful.
  • 01:55:04Yeah, I, I think you know it's it's.
  • 01:55:10It would be easy to say like do
  • 01:55:12it be out in whatever and that's
  • 01:55:14actually not the real sadly people are
  • 01:55:17facing it's it's a hard situation.
  • 01:55:19People do face discrimination,
  • 01:55:21people are fired, people are,
  • 01:55:23you know, lots of.
  • 01:55:25The term microaggressions get used.
  • 01:55:26I think there's nothing micro about my God.
  • 01:55:29Persistent microaggressions, right?
  • 01:55:30But you know, even minor things like you
  • 01:55:34know department picnics where like you know,
  • 01:55:37do you know if someone has kid
  • 01:55:39like do they bring their partner?
  • 01:55:40Do they not?
  • 01:55:41Do they bring their you know
  • 01:55:43kids or you know queer or trans?
  • 01:55:45Or you know like all of these things and
  • 01:55:48yet face face that parental leave you
  • 01:55:50know all of all these things that are not,
  • 01:55:53you know, assumptions.
  • 01:55:53I I get asked about my husband all the time.
  • 01:55:56You know, like those kinds of things,
  • 01:55:58even in San Francisco, even you know.
  • 01:56:01So all that's to say,
  • 01:56:03I think there's there's a lot of work to do,
  • 01:56:05and then we all of us need to be, you know,
  • 01:56:08thinking about our language and our policies.
  • 01:56:10We also the usual things when we're thinking
  • 01:56:12about diversity of colleagues, right?
  • 01:56:15So, recruitment,
  • 01:56:17retention, satisfaction,
  • 01:56:19quality of life,
  • 01:56:20equity in terms of pay retention packages,
  • 01:56:23startup packages?
  • 01:56:26Space you know does the does the the
  • 01:56:29trans researcher get the like Little
  • 01:56:32corner office with no window and
  • 01:56:34whatever like versus you know the and?
  • 01:56:37And if that if we're thinking about
  • 01:56:40colleagues you know, I will say that.
  • 01:56:44You know,
  • 01:56:44we know that there's a minority tax in,
  • 01:56:47especially in academic institutions,
  • 01:56:49that faculty and providers of color,
  • 01:56:53women, LGBTQ, plus folks,
  • 01:56:56transgender diverse folks spent
  • 01:56:58a lot of time.
  • 01:56:59You know,
  • 01:57:00everybody wants folks on their committees.
  • 01:57:02Everybody wants folks to mentor folks,
  • 01:57:04you know.
  • 01:57:05So and then, that limits productivity.
  • 01:57:07It limits, certainly quality of life.
  • 01:57:10Sleep.
  • 01:57:11All these other, you know, Wellness things.
  • 01:57:12So we had to really be thinking.
  • 01:57:14I think carefully about this and and
  • 01:57:16thinking about things like you know
  • 01:57:18how much support people are getting.
  • 01:57:21I'm very much for, for example,
  • 01:57:23making visible all of that work right?
  • 01:57:25So you know an academic Medical Center,
  • 01:57:30for example, with it's, you know,
  • 01:57:32pillars of education, training, research,
  • 01:57:38and there's the service component.
  • 01:57:40I think all of those should be visible
  • 01:57:42in terms of percent time allocations.
  • 01:57:44And and part of promotions and whatnot,
  • 01:57:49and should be effectively monetized
  • 01:57:50and considered as part of people's
  • 01:57:53time and percent packages, right?
  • 01:57:55So the fact that I'm on every search
  • 01:57:57committee for new faculty because people
  • 01:57:59want an LGBT perspective, which is beautiful.
  • 01:58:02But it's also.
  • 01:58:03Therefore I don't get to write the
  • 01:58:06papers and grants as much as my.
  • 01:58:08White cisgender male colleagues
  • 01:58:09who are not being asked to be
  • 01:58:11on every single 'cause.
  • 01:58:13There's so many more of them and you know,
  • 01:58:15so these are the kinds
  • 01:58:17of things that we really
  • 01:58:18need to be asking ourselves,
  • 01:58:19those institutions and how our
  • 01:58:21systems are inculcating difference
  • 01:58:23and disparities within them.
  • 01:58:30This has just been a fabulous
  • 01:58:32session on top of your wonderful
  • 01:58:34talk and I think really a very
  • 01:58:37meaningful thing for us here at Yale,
  • 01:58:40where I think we don't talk enough
  • 01:58:43about about these topics and I
  • 01:58:45hope we have a chance to engage
  • 01:58:48again in the future and wish you
  • 01:58:51both well with your with your
  • 01:58:53really important work and thank you
  • 01:58:55again for making time for us.
  • 01:58:57Yes, thank
  • 01:58:58you so much and.
  • 01:58:59And just to say, please any of you,
  • 01:59:01individually you know,
  • 01:59:03feel free to reach out.
  • 01:59:05Our emails are on our slides.
  • 01:59:06We'll make sure that.
  • 01:59:09That Renee has our slides and
  • 01:59:11and they are accessible to you.
  • 01:59:12Please feel free to tweet just
  • 01:59:15speaking to Doctor Lu's comment
  • 01:59:17a question about tweeting.
  • 01:59:19Thank you very much, of course,
  • 01:59:22and happy of course to come back
  • 01:59:24or talk further in other settings.
  • 01:59:26I will just say we are setting up a
  • 01:59:29mentorship network for SGM researchers ASH.
  • 01:59:31I don't even think you know about that.
  • 01:59:34Yeah, it's it's gonna be so.
  • 01:59:36We're working on that through
  • 01:59:38PRIDE study and Pride net.
  • 01:59:40We're also gonna be setting
  • 01:59:41up a researcher boot camp for
  • 01:59:43folks who are interested in SGM
  • 01:59:45research to really train on.
  • 01:59:47Sort of these things,
  • 01:59:48like how do you handle multiple
  • 01:59:50gender identities in your metrics
  • 01:59:52in these kinds of things for
  • 01:59:54community based researchers as
  • 01:59:56well as academic researchers as
  • 01:59:58well as internship programs and
  • 01:59:59postdoctoral programs so we have summer
  • 02:00:02undergraduate internship programs.
  • 02:00:03We have postdocs.
  • 02:00:04We now are gonna have three
  • 02:00:05with the bright city,
  • 02:00:06so there's some various
  • 02:00:08developments to actually train.
  • 02:00:10Built the next generation of STM
  • 02:00:12researchers so please stay in touch.
  • 02:00:15So much care.
  • 02:00:17Bye bye.