for Gastrointestinal Endoscopy and the Diversity and Inclusion Committee appreciates your participation today in this discussion on the top 10 do's and don'ts for clinicians interacting with the LGBTQ community. My name is Michelle Akers and I'll be your announcer for this presentation. Before we get started, a few housekeeping items. First, you can submit a question at any time online via the Q&A button on your Zoom control panel. Following this event, in about a week, you can access a recording of the discussion which will be posted in GILead, ASGE's online learning platform. Now it is my pleasure to introduce our moderator for this event, Dr. Rabia De La Torre. Dr. De La Torre is a double board certified gastroenterologist and therapeutic endoscopist at New York University Langone Health. She is an assistant professor of medicine at NYU School of Medicine and the director of endoscopy at Bellevue Hospital. She received her undergraduate degree from Cornell University, medical degree from Stony Brook School of Medicine and completed her internal medicine residency, gastroenterology fellowship and advanced endoscopy fellowship, all at NYU School of Medicine. Dr. De La Torre is a clinical researcher with over 30 scientific articles and presentations at national scientific meetings and several ongoing clinical studies. She serves on the training committee of the ACG and serves on the ASGE diversity and inclusion committee. I will now hand the presentation over to Dr. De La Torre. Dr. De La Torre. Thank you, Michelle. I now have the honor of introducing Dr. Matthew McNeil. Dr. McNeil is currently a gastroenterologist at Summit Health and a clinical instructor at NYU Langone Health. Dr. McNeil focuses on a wide range of digestive and liver diseases as well as symptoms. He has a special interest in colon cancer screening, inflammatory bowel disease, and LGBTQ health. He completed his undergraduate degree at Duke University where he graduated cum laude with a degree in public policy and he went on to obtain his MD at the University of North Carolina School of Medicine. Dr. McNeil relocated from North Carolina to New York City for his internship and residency at New York University School of Medicine. Recognized for his outstanding patient care and passion for education, he was selected to serve as chief resident of the NYU Internal Medicine Residency. He remained at NYU for his gastroenterology fellowship where I had the pleasure of getting to know him, where he served as chief fellow and was elected into the Gold Humanism Honor Society. He's a member of the ACG, the AGA, the ASG, as well as the New York Society for Gastrointestinal Endoscopy. Dr. McNeil, the floor is yours. Thank you so much, Dr. De La Torre and everyone else. I appreciate this and I'm very excited to be here tonight to talk about a very important topic. Today we're going to talk about the do's and don'ts for clinicians interacting with the LGBT community. Of course, it is Pride Month and so there could not be a more opportune time for us to discuss that. In terms of our overviews and objectives, though, I want everyone to be able to grasp the importance of this very important topic, considering all the historical and the current social and political environment, both positive and negative. I hope everyone's able to develop a basic understanding of terminology, which I acknowledge can be confusing and frustrating, both what to say and what not to say. And also, I just want to review some common diagnoses, treatments, situations, and considerations that affect the LGBTQ community and our patients and hopefully open up a floor for a good conversation as well. In terms of disclosures, I have no financial disclosures or conflicts of interest related to this presentation. That being said, I'm also certainly not an expert on all things LGBTQ and I am, however, a gay man, so ensuring that all clinicians appropriately interact with our LGBTQ patients is of interest to me, interest of many of my patients, and also interest of my friends. And just in case we're starting a baseline, our LGBTQ acronyms, because there's gonna be a lot of acronyms tonight, stands for lesbian, gay, bisexual, transgender, and as well as questioning or queer. And we use the plus sign to include lots of other groups, which can include both asexual, intersex, and other types of gender identities and sexual orientations. So to get started, first I want to talk about why this is an important topic for all of us. You know, it's not a surprise that most LGBTQ patients do prefer LGBTQ providers. However, on the flip side of that, most providers are not LGBTQ. And studies have shown that during our medical training, we get about five hours of specific training, which is applicable in terms of treating the LGBTQ patients. However, discrimination and stigmatization of the LGBTQ community is very much a historical, present, and future problem affecting both socioeconomics, physical health, and mental health, and thus leading to various health disparities within the community. And you don't have to look very far in order to see where this is very evident. The headlines just from the last month really, really show it. We're seeing it in these don't say gay bills, in bathroom bills, LGBTQ book censorship, trans athlete bans, all these things that make people feel less, but also lead to furthering these health disparities that we see. I don't want to go too much into all the details of the health disparities because that could be a whole nother talk. But just to give a sense of a few of them, you know, we see these because there's legal and some illegal discrimination from families, from religious institutions, from our governments, very much so, social programs, school systems, and all these together have contributed to this persistent pattern over the years that lead to health disparities and continue to perpetuate health disparities in all aspects of the LGBTQ community. From a socioeconomic standpoint, we see much increased rates of homelessness, especially among our youth, higher rates of unemployment, especially in the trans population. And we have much lack of protection, both on the state and federal level, both for the trans population and for the gay and lesbian populations. From a mental health perspective, we're seeing much higher rates of suicide, especially in our youth, higher rates of substance abuse, including alcohol and tobacco, much more likelihood of bullying and violence, especially in our youth. In our lesbian communities, we often see decreased rates of preventative care, like pap smears and mammograms, partially due to access to care or just not willingness to go see doctors because of fear of stigmatization or discrimination. In our gay populations, we often see higher rates of STIs and HIV, especially in persons of color, as well as higher rates of eating disorders and body dysmorphia. And in our trans populations, we see a wide range of higher rates of HIV, depression, suicide, higher than any other group. And in terms of access to care, not only are we having issues with patients getting health care, but they are explicitly being forbidden from seeking gender-affirming care. And in our elder population, many of whom have experienced the AIDS epidemic at its worst, we see higher rates of depression, suicide, as well as limited access to elder-specific LGBTQ accepting programs. And these are all continually perpetuated and things that we need to be realizing as we take care of our LGBTQ patients. So moving forward, we're going to start with the terminology. So it's always important to try. That's the word I want to start with. Do try to use the right terminology. And that implies to use sexual orientation, which is the pattern of emotional, sexual, or romantic attraction to particular gender or particular genders. Gender identity, which is one's individual and internal sense of their gender. And then gender expression, which is how one expresses their gender to the outside world through their appearance, mannerisms, and speech. And I think it's important to note when we're considering all these that all are on a spectrum and can change. And change doesn't mean that someone who is gay is all of a sudden going to become straight. What it means is that they are trying to figure out exactly who they are. So to get going, first, I want to start with sexual orientation, which I want to focus on encompasses behavior, identity, and attraction. It is not just related to sexual activity. And I think that's something important when you're thinking about your patients. In terms of terminology, we've really moved away from homosexual, which really just involves same-sex attraction, and also terms like MSM, which is men who have sex with men, which is commonly used in medical jargon, but basically bottles the patients down to their sexual activities as opposed to the wholeness of being someone who's attracted to someone of the same sex. I think it's also important to note that it's not treated like a choice or like a fad. Words like sexual preference or gay lifestyle have very much gone out of favor in the most recent years. In terms of commonly accepted terms, we've very much moved toward gay, lesbian, bi or bisexual, pansexual, which applies to someone who has attraction to people of all different gender identities, non-binary, queer, cisgender, transgender, male, female, as well as asexual, which is someone who may not have attraction to anyone. And I think it's also important to note, especially with the new laws, that patients can and will read your notes. So moving forward, it's something to be cognizant about as we write our notes. It's important to really try to use the right terminology. In terms of gender identity, this is one, as I mentioned, internal sense of being a boy, man, male, girl, woman, female, another gender, non-binary, or no gender at all. With your patients, it's extremely important to affirm that which the person identifies, regardless of their legal or surgical or medical background. Try to use their chosen names and their pronouns and avoid dead naming or misgendering. The name that which someone had previously in their earlier life but no longer identify with can be very triggering for patients. So I would strongly encourage people to avoid using that terminology in referring to their patients. It doesn't take much just to ask a person what they want to be called and then use that term. But it really makes the world of a difference. Commonly accepted terms include transgender man or trans man. Or we sometimes use FTM in a medical terms, something like female to male. Now, it was pointed out to me by Dr. Newman, which is true, a lot of these terms are in flux. We say trans man as one word. Sometimes we're now using trans as an adjective and just saying trans space man. Additionally, the FTM or the MTF terminology, which is typically used in a medical setting, is somewhat being replaced by assigned female at birth or assigned male at birth, which very much acknowledges the change that has been made over the course as a person has developed their gender identity. We also use gender queer, which is usually something that someone would identify as on their own. They will probably make that known. And then cisgender, which is basically you are identifying with the same gender that you are assigned at birth. And I know that a lot of this can be extraordinarily confusing. And there's a lot of terms and pronouns out there. But all you have to do is not be afraid to correct yourself if you mess up. I want, I encourage everyone to be proactive. And one of the best ways to do that is to have your practice figure out ways to correct the intake paperwork so that you can acknowledge all the encompassing demographic data at the beginning of a visit. Inquiring about pronouns, about gender identity, about sexual orientation as patients come to you can remove a lot of any of the stress that with the conversation that any provider may have. It's important to note patient's preferred or chosen names in their chart and notes because a lot of times, unfortunately, their given names or their legal name may appear, especially when you're dealing with insurance. But in the notes and in your chart, you really should try to identify the preferred names so that patients are identified and interact with as they choose to be. And to make this easier, just standardizing a question across all your patients, regardless of whether they're members of the LGBTQ community or not, can just make this an easier process across the board. And when in doubt, just ask politely for a clarification. It's okay to mess up, but just try not to keep messing up and acknowledge when you do, and most patients will be extraordinarily forgiving as it comes that way. Next, don't make assumptions about your patients. You know, the LGBTQ community has a lot in common with all other communities, but there are also frequent differences. Many members of the LGBTQ community have children, but it's important not to assume about how they came about having children. Surrogacy, fostering, adoption, or having children by birth is common in the LGBT community. It's also important to acknowledge that LGBTQ patients have committed relationships, but the relationships may not follow the same rules that you're typically used to. You know, there's commonly found in open relationships, commonly not in open relationships, commonly not married at all, but just committed. Just to get going, it's important to assume, to not assume anything about your patients. Many of them want the same things that you want, just many don't. Many may not want marriage, may not want children. And a lot of this has to do with the fact that some people grew up in a time, and many of us did, when marriage wasn't even an option. So, you know, it's just don't make assumptions about your patients. And as it comes to gender and identity, it's important to realize that the degrees to which trans patients pursue gender-affirming care is also a spectrum, much like gender identity itself. Not all trans patients will wish to pursue hormonal or surgical options, but that doesn't make their gender identity any less valid based on that. Okay, moving forward. Don't forget to talk about sex, baby. Okay, sexual health. It's a very important part of the human experience affecting physical, mental, and emotional well-being in our patients. It's extraordinarily vital that we consider the different ways that LGBTQ patients experience and value sex. This starts with using language that makes patients feel comfortable, but also you need to make sure that you're using language that you're comfortable with, while also trying not to over-medicalize it. So, whether that means saying anal-insertive, anal-receptive sex, or just common colloquial phrases, things like top, bottom, first, things that your patients will be familiar with. Whatever makes you feel comfortable, but also makes your patients feel comfortable, is going to be something that's very important moving forward. Additionally, considering how medical conditions, especially RGI conditions, often negatively affect sexual health is vital to our dealing with our patients. Whether we're dealing with IBS, hemorrhoids, inflammatory bowel disease, it's not just about the abdominal pain, the diarrhea, or any of the other medical conditions and medical symptoms that are associated with this, because often that is very negatively affecting patients' sex lives, which can affect their pleasure, their mental well-being, their psychological well-being, and of course their physical health. So, when you're considering and having those conversations with patients about many of these conditions, it's important to bring up that aspect of their condition and their comorbidities and say, how is this affecting that, and come up with a plan to try to take that into account or ways that they can work through that. And lastly, it's important to consider how different sexual practices may impact the medical conditions and risks. This is true for patients in the LGBTQ community and other communities, but anytime you're having sex, whether it's anal sex, oral sex, vaginal sex, genital sex, any type of sex you're having, you should be using STI testing that is applicable to that. So, that can mean including pharyngeal and rectal gonorrhea and chlamydia testing and acknowledging that that may be something that is leading to some of the symptoms that your patients are experiencing. It's important to take that into account and advocate for that testing while you're seeing your patients. It's important to know common LGBTQ medicines and procedures. This includes PrEP. PrEP is for our HIV negative patients as a way to prevent HIV. It is a United States Preventative Service Task Force grade A recommendation to recommend PrEP for anyone who's high risk, and that includes men who have sex with men who have inconsistent condom usage, have recently had an STI, or any IV drug use. I know that is commonly accepted nowadays and people are well aware of this, but mistaking a PrEP medicine, such as Truvada, Dyscovia, or Apertude, which is our IM version, for an antiretroviral therapy, you can easily confuse someone from being on PrEP and not having HIV to being undetectable and having HIV or vice versa, which can make patients feel, one, uncomfortable, but also create some doubt about your knowledge, which obviously can create other issues in itself. It's also important to know the common antiretroviral therapies. As we mentioned, there's higher rates of HIV in our LGBT populations. Genvoia, Biktarvi, Complera, Atripolistribil. Also, hormone therapies. They can serve more than one purpose. Estrogen, testosterone, while used for gender affirming care, also can be used for perimenopausal and postmenopausal care. It can be used for patients with low testosterone. So, it's important to not always make assumptions about when patients are on these medications that they may be undergoing gender affirming care or for the purpose they're using it for. In terms of surgeries, we have moved away from language such as sex change, pre-op, post-op. It's much more accepted to use words like gender affirming or top or bottom surgery. As I brought up before, we should always acknowledge that surgery does not equate to gender affirmation. You can have a gender identity without having any type of surgery at all. Lastly, with our screening, preventative care should still be based on appropriate risk. That means anyone who has a uterus and a cervix should undergo a pap smear. Anyone who's due for a mammogram should still undergo a mammogram. These can be a bit awkward conversations, and you do have to get a good surgical history with your trans patients when you're talking about this, but it's important to acknowledge, hey, we're here to help make sure that you are taken well care of. Okay. Especially appropriate during this month, it's important to show an outward sign of acceptance. Whether it's a pin, a window decal, a badge sticker, and all these present signs to patients, and trust me, LGBTQ patients are looking for these signs that says, hey, I can open up to this person, I can feel safe to this person, and you're going to get the most honest interaction with your patients if you were to have that. You don't have to necessarily have it on your person, but even in your office as a sign can create a great, can be really changing for patients. And lastly, I would say do go the extra distance. You know, ask about your LGBTQ patients' lives and relationships just like you would any other patient. Talk about their boyfriends, talk about their husbands, talk about their girlfriends, talk about their wives. It's okay. You don't have to feel uncomfortable doing that. If a patient brings up an unfamiliar topic, ask an LGBTQ colleague or do your own research as you prepare for a future visit. And it's, as we always talk about the value of open-ended questioning, it's important to inquire with your LGBTQ patients about what makes them comfortable or if they have any other specific concerns. You know, sometimes just saying, hey, do you have any other issues that you want to talk about at the end of the visit instead of just moving on will allow them to open up about something that may be bothering them. Okay, so hopefully I caught up there in that last minute. I apologize once again, but in conclusion, at the end of the day, LGBTQ patients are patients. The worst thing that you can do as a provider is provide inadequate care because of lack of fear or knowledge or understanding. So it really takes minimal effort to address patients as they want to be addressed, but it makes a world of difference in their eyes, both for the positive if you do it and for the negative if you don't. Because LGBTQ patients' biggest fear is being judged or discriminated, and having that subsequently affect their care and their health. So any way that you can go out of your way to show this will not be the case will be immeasurably invaluable. And finally, when in doubt, ask politely. Most patients would prefer to educate you about their sex lives, about their mental health, about what they're doing on the weekends than wonder if you just do not know what's going on with them, and thus they're unsure if you are going to be adequately able to take care of them. But at that conclusion, I wanted to quickly say, you know, some really great resources that are out there. GLAD is amazing. The Fenway Institute is amazing. The U.S. Department of Health and Human Services is doing a lot more research now, especially on the LGBTQ population. It's a great source of information if you ever need some out there. And then there's most cities, especially New York and San Francisco, have great centers that actually have a lot of great, excellent resources as well. On that note, I want to wish everyone a happy Pride Month. And New York and San Francisco, I think a happy Pride weekend this weekend. And hand the floor back over to Dr. De La Torre. Thank you, Matt. That was so informative and extremely helpful to just learn about all the different healthcare disparities and things that we as physicians can do. So I want to add some additional voices to the discussion for our roundtable discussion. And after that, we will have a Q&A to address any questions from the audience. It's my absolute pleasure again to introduce Dr. Dimple Bhakta, Dr. Luke John Day, Dr. Kira Newman, and Dr. Mallory Simons. And I want to briefly introduce each of them because they're all so amazing and accomplished and really appreciative for them spending their time with us today. So this is in alphabetical order, so no preference. Dr. Dimple Bhakta is my fellow Diversity and Inclusion Committee member and earned her medical degree from the Medical College of Georgia. She completed her internal medicine training at Baylor College of Medicine and went on to be chosen as chief medical resident. She finished her gastroenterology fellowship at New York University in New York City and completed her advanced endoscopy training at UT Health and subsequently joined the faculty as an assistant professor of medicine in their division of gastroenterology, hepatology, and nutrition. Dr. Luke John Day is an associate professor of medicine at the University of California in San Francisco and the chief medical officer at Zuckerberg San Francisco General Hospital. His research interests center on organizational design and development and efficiency models for healthcare system delivery to vulnerable patient populations. Specifically, his research explores the delivery of healthcare through the endoscopy center, which relates to all of us. He is currently working on developing key innovations that can be implemented at the ZSFG endoscopy center that focus on maximizing staff and physician efficiency, improving patient access to endoscopic care, and strengthening patient satisfaction. Dr. Day is president-elect of the Association of American Indian Physicians and previously was chair of the ASG Quality Assurance and Endoscopy Committee. Dr. Day currently serves as counselor on the ASG Governing Board. Dr. Kira Newman is currently a gastroenterology and hepatology fellow at the University of Michigan Health Systems. Dr. Newman received her undergraduate degree from Yale University, earned her MD and PhD from Emory University, and completed her residency at the University of Washington. Dr. Mallory Simons earned her medical degree from Albany College Medical College and completed her residency at Brown University Rhode Island Hospital Lifespan. She is and serves on the ASG Women's Committee. Thank you all so much for being here. We really appreciate your time and I'm excited to have a wonderful discussion with you on this very, very, very important topic. So I want to open up the panel discussion by actually asking each of you, maybe we'll give Matt a little voice break on this one since he shared with us already, but I wanted to ask you all, if a patient came to you and said what experience do you have caring for LGBTQ patients, which they're encouraged to do if they're making, if they want to make sure that they're receiving adequate care, what sort of resources do you offer at your hospital or your clinics, your institution, and what would you say to that patient? So I guess we'll start with Dr. Newman because I see you at the top of my screen. Thank you for having this wonderful session and thank you for giving such a great presentation, Dr. McNeil. Different institutions have different resources that are available. Many institutions are moving towards having training modules that are optional or required for all of their staff. That's certainly an optional requirement currently at the University of Michigan, but something that we're moving towards having be required for all services and all clinical sites. Some of the other resources that can be available to patients that don't necessarily come up in a lot of our experiences but are useful to keep in mind is that most hospitals will have something to the equivalent of an office of civil rights or an office of patient advocacy. And if you encounter a patient who's had treatment that they feel is inappropriate as a result of their gender identity or sexual orientation, if there are issues with someone being repeatedly dead named or repeatedly misgendered or any other concerns, that's something, that's an office that's important to know the contact for because they can often help patients to either seek more sensitive care providers. They can also give feedback and if necessary create new remediation plans for parts of the hospital or parts of the clinical enterprise that may not be providing excellent care to LGBTQ patients. So those are just a couple of resources that we have and that many hospitals do have. And just remind us which hospital, which region you're from, just for everyone as a reminder. Yeah, so I'm at the University of Michigan in Ann Arbor. Perfect. All right, so we have Michigan represented. I love it. Next up, let's have Dr. Bakta share with us. I would say a lot of the opportunities we have at our program, at least within the Houston area and UT Health, I think starts from the medical school up. So there's a lot of community outreach that happens with the diversity and inclusion committees that are within the medical school as well as the LGBTQ societies and committees here. So I see a lot of community outreach that happens. And then not just UT Health, we have such a big metropolitan city that there's a lot of community outreach that comes from different centers. We have a big center called Legacy that provides a lot of LGBTQ care. And so I think that's where a lot of those kind of opportunities to reach out come from. I would say other ways to get patients kind of involved is what Matt already mentioned, is just showing your support, having the little pins. That goes a long way. I notice patients who then look at them and then talk about it openly. And so that's something that I have done for a very long time. And that's something that I think is really important. It's so simple of a thing, but I think that's something that we can also show our patients as they come in that we are supportive and at least able to help. Thank you. Okay, Dr. Day, you're up. Thank you. First, thank you for inviting me to join tonight. I really appreciate the discussion that's occurring and really want to commend Dr. McNeil for such an outstanding presentation. Very informative and I think very well received. I will echo what I think some of the other panelists have said as well. The way we do it, and I'm based in San Francisco at the University of California, San Francisco. So we sort of do it from an institutional level. So really from our executive team on down, our leadership has made a commitment to diversity, which includes the LGBTQ community. And so there's training that all staff have to undergo very much, I think as you heard earlier, really just to I think educate not only our staff, but also our providers as well about diversity of our patients that are coming in. And then I think there's really the local level, which I think Dr. McNeil highlighted a little bit. What can you do within your GI clinic and within your endoscopy center to really, I think, create a welcoming environment? So at ours, we have pins, we have signs up that say we're a welcoming environment. We ask people their pronouns, what names they would like to be addressed by. I think it's really as soon as someone comes in, not into our hospital doors, but through our clinic doors and our procedural areas, that there's a welcoming environment and that it's an environment that we really want to reach you where you're at and be very patient centered. And then I think we do a lot of partnership with the community. So I think if our patients have questions and want to learn more, we have very strong patient advocate groups. We also have a diversity council that partners with many local community-based organizations. And so we can connect our patients with those organizations should they desire. That's really wonderful. I agree. Outward signs of allyship go a long way. It's the small signals, things that aren't said necessarily that I think impact the people around you in ways that you'll never know. And then you are permanently part of their tapestry either in a positive or negative way because of the small things that you do. It just goes such a long way. We talk about tapestry a lot at NYU. So, okay. So Dr. Simons, I have a follow-up question for you, kind of in the same vein of what we were just discussing. Do you think there should be extra certification or a training course that's mandatory to certify someone as an expert in caring for LGBTQ patients, given the fact that there's so much health disparity and things that you should be checking for, very similar to the way that we do certain screenings in IBD patients that non-IBD experts might miss. So do you think that there should be extra mandatory training? And if so, when? And I really love to hear from everyone on this question as well. No, thanks for that question. I think it gets, I think it gets tricky when we say it's a mandatory training. And I think, you know, that I think when we start talking things about mandatory, it makes it seem, I always get worried with that terminology because it has been really advocated that it should be part of the medical school curriculum in general. So I wouldn't say I would term it as mandatory, but I think it should just be known. And I think as time goes on, as we become more open, it should be part of, as fluid, a part of medical curriculum. And so I think that's going to be hard to kind of make sure that in any type of medical curriculum, whether it's in medical school and also through upper levels of training of how to making sure that you're incorporating it, you know, that type of training. But I think it, whether to say that it's mandatory, I think it should be included in training. And I think there's always work to be discussed on how does that incorporating, how do we incorporate it into that? And so I don't think extra training and extra certification is needed, but I do think what we need to start with is before the training is we need to start with the research. Who of our patients is the most affected and how are they affected? Is it just because a lot of our data right now are survey data? And I think so starting off instead of really with saying this needs to be a mandatory part of our curricula, let me teach things to you. It should be more of, let me encourage you to do more research also in this field. So I think that that's really where I would start as well. In addition to really incorporating all the disparities in the, in, in a medical training period, but I think it should also be encouraged about the research and how we can, you know, learn more and, and who's affected, how they're affected and also about the providers themselves. Because as we know, I think where there's a growing number of LGBTQ providers, it's not, and I, you know, there was one study or one survey that was cited in 2020 or I think it was 2021 or 2020, you know, Harvard is almost 20%, 15, 20% of their matriculating medical school class as identifying LGBTQ. So we're going to have a huge wave of providers who are going to be identifying, which is really exciting as LGBTQ. And so I think that push for getting more research is really, I think where we should be also focusing on and not just saying, let's make this a part of the curriculum. Let's mostly, let's make sure that this gets the research and the, and the support to, to, to grow our knowledge base and then incorporating that then into the curriculum as well. Dr. Newman, what do you think? Yes. I think that's a great, you know, Dr. Simmons makes a great point about we need more research. We don't actually have best practices for GI and within GI, what do we need to think about for LGBTQ patients? The other way of thinking about this though, is, you know, we often tell this joke where, you know, instead of asking someone who's gay, when did you know you were gay? You ask someone who's straight, well, when did you know you were straight? And I think this gets to a concept of universal design in how we teach medical students, medical providers to interview patients and interact with patients. And what we don't teach right now is that much of our language is grounded in a white heterosexist patriarchal assumption about the society that our patients are coming from, the world that our patients live in, the role of the doctor in society. And so when we take a step back from that, we start to realize, you know, oh, when we're thinking about our patients, even the question of which seems very open and is generally a good question, but if you say, you know, do you have sex with men, women, or both implies a binary and is itself part of this heterosexist world that we are often implicitly operating in. So I think that's perhaps more useful than saying, let's, you know, pick and choose the few bits of data that we have right now, but instead let's pick the big picture and let's think about how we address people, how we ask open-ended questions, how we ask people about what name would they like to be called, and allow that to be propagated through the medical record automatically, and other sorts of engineering steps to make a more universal access approach. That's a great point. I think from, honestly, from the ground up in our medical training, it's a very heteronormative environment. It just is. The hospital system, the textbooks that teach us, the resources that we have, and it's just not, it's not okay. It needs to be fixed. And so the next question is, how do you go about doing that? It's such a humongous task, right? And so where do you start? Do you start in medical school? Do you start in college? Do you start younger? Like what do you guys think? I'd love to hear your opinions on this. Dr. Day, if you want to tell us. No, it's a great question, and I concur with the other panelists in that, you know, I think one of the main things we have to do is really sort of frame it in terms of it's a communication issue. So how do we communicate with our patients? And I think just like everything else we learn in medicine, there are some basics. And I think communication and strong communication skills is really what's required. And I think what our patients expect. I think our patients expect us to come in without making assumptions, having the medical knowledge, but also being able to elicit information from them and do some from a very empathetic and compassionate standpoint. And so I think we need to put a stronger emphasis on embedding communication through all years of medical school, but also residency, building it on fellowship, and I think just embedding it in terms of us just being practitioners. So it should be something that we have to have as part of CME that our society supports. So really, you know, I think the way we can become better communicators will only improve our patients. I think we make them more willing to come in and actually share information with us and create that stronger therapeutic bond that's needed. I think one of the problems I foresee, and one of the things that we need to overcome, is that people who don't identify as LGBTQI are afraid of offending anyone who is part of the community. And so they'll actually, like self, in a self-protection kind of way, avoid addressing things that may, they may perceive could lead to something that might offend someone. And I strongly believe that that's impacting patient care and a huge component of why we're seeing health disparities. So, Dr. Bhakta, what are some things that people can do to, as health care providers, you know, what are some specific examples, if you have anything, to try to combat that? I mean, I think Dr. McNeill discussed, you know, intake paperwork to try to like keep it open-ended, like open lines, not just like choose your choice, but like an open-ended line. But what are some other things you think that the LGBTQ community can do to foster an environment where people are not afraid to to ask questions or, you know, to be wrong and to be corrected? I think it's a two-way street at the end of the day, right? There is definitely disparities in the community and LGBT patients. So as much as there's a discomfort from our end as being patients, when I have to discuss that, oh, I'm married, and they assume or start asking questions about a husband, and I'm like, oh, no, my wife, but I politely correct them, and most don't get offended, and they say, oh, you know, I'm sorry, and then they go on, but they address it, they acknowledge it. So it is a two-way street where I open up that line of communication. So I think you recognize a provider who is trying, but then you're also going to recognize the ones that are not, or maybe then get, like you said, they close off. And I think that's always tough, because then you don't want to engage further, and they may not want to engage further in terms of the questions and the rest of your kind of visit. So I think two-way street, open communication as our community, we should be more comfortable with also kind of talking about what we need, but in identifying physicians, other medical providers who are trying, again, the allyship that we talked about, just recognizing those type of people. I think even as providers, you know, you can search someone when you're looking at your physician, and I think it'd be nice if we as allies or even LGBTQ providers could put that into our bios, and I do, and I think that's helpful if you try to actually reach out and try to find those providers. So those are some of the simple things that we can do. Dr. McNeil, you're back. I hope your computer did not- I switched my work PC to my own personal Mac. So, which, you know, cause my work PC is shut down twice now. We'll talk about it later. Tell us what your thoughts are on a database where LGBTQ patients can find doctors that they know, like a safe space where they know that someone specialized in. Like, is that something I can find one, but tell me. Yeah, so there's a lot of groups. Dr. Baca mentioned, you know, about putting those code words in our bios. Like if you go to my bio, as you kind of read out loud interest in LGBTQ health, a lot of patients will look for that in finding LGBTQ providers. Now, there are other ways to do that. Now, a lot of institutions, NYU, for example, I'm sure Michigan and UCSF and Cornell also have them have what's called an outlist, which is a way that you can put your name on this list for saying, hey, I'm an out LGBTQ provider, whether you're a medical student, resident, fellow, or faculty, and have that as an availability, not just as a resource for patients, but also as a resource for trainees and for mentorship as you move forward. In terms of finding providers, the Fenway Institute based in Boston actually has a phenomenal list of this, as well as I believe GLAD has one. And there's also the GLAMA, the Gay and Lesbian Medical Association, which you can register with them actually. And they put on a conference a couple of times a year and they put a big conference on it. They actually have a list as well. I've made sure that I personally have gone out of my way to put myself on these lists as access for my patients. I also personally keep, and I'm a specialist, obvious GI as most people are here, I keep a list of LGBT PCPs and also LGBT colorectal surgeons and the type of providers that I typically refer to for my patients so that I can say, hey, if you specifically have an interest in seeing an LGBT proctologist to talk about your anal fissure, your IBD, or anything like that, not to say that a non-LGBT proctologist wouldn't be as good, but they might feel more comfortable in that scenario, I'm able to provide that resource for them. And in your experience, I know that you have a cohort of patients who are in LGBT and they actually seek you out from what you've told me. So do you have these patients shared with you that they're more comfortable sharing information with you than they might be to a provider who maybe does not wearing any sort of signage or any signs that they're an ally? Almost 100% of the time. But I don't wanna say that to discourage our non-LGBTQ providers from saying that they can't get to that spot with patients because I will openly refer patients out to non-LGBTQ providers and say, hey, they're great. They are wonderful allies. They're open and accepting. And they're wonderful doctors. And that's the most important thing. And we're lucky, I know in New York, we have a lot of, I mean, it's not as worrisome here, but yeah, it's absolutely, my patients do seek me out because I do identify that way and they feel more comfortable and open talking and frankly asking me very personal questions about their health that they may not feel comfortable talking to another provider about. Thank you for sharing that. I wanna switch gears a little bit and ask you guys if you have any specific patient interactions or anecdotes you can share with us that you think that the audience might learn from. I think that these examples are very helpful because someone may have encountered it. I can start, not to take over, but I was in a room the other day with a sedated patient and the tech made a comment about the patient's gender identity and suggesting that based on the appearance of the patient, that the tech assumed that the patient might identify one way or another. And I asked, is that something you confirmed or did you know that? And her response was, no, I just assumed based on the way they look. What she didn't realize is that the medical student who was observing cases in the room identified as gay and really, really, really was upset about what happened and whether or not they identified as gay or not, it's not really relevant, but the student felt like it was out of line, which it was, and was appreciative of the fact that I corrected her in front of the room. And she was upset with me then because she felt like I was a little too harsh with her, but I just didn't feel like it was inappropriate. But it just goes to say in something that Matt and I were talking about earlier today is you just never know who else is in the room and who it might impact. And so showing, doing the right thing in real time is so important and to make sure that you correct behaviors and set an example for others. And my hope is that then that student will go on to not be afraid to correct behaviors like that. In the future, it's just lead by example. And so I was wondering if you guys have examples like that or something you can share with the audience and we can start with Dr. Newman. Feel free to pass if you want to think about it or pass on to someone else, but want to- I think there are a lot of experiences that we have that come out of our own experience as patients in the medical system where we see some of the failings that happen. So for me, most of my interactions with the medical system recently have been as a new parent. And I've found going through all of the prenatal forms and all of the post-delivery forms and all of the pediatrics forms, exactly how many forms ask for a mother and a father, even though in the state of Michigan, two parents not specifying gender are both allowed on the birth certificate. And Michigan Medicine has made a big effort to try and publicize that they're very LGBTQ friendly, but you realize as you dig down into these documents that they either weren't designed with patient input from a variety of diversity points, or they haven't been updated in a very long time. And so that's something to be aware of is it may not be something that you can see. You may need to ask patient advocacy groups, community groups, colleagues to review the paperwork that you have and review the scripts that people use when they are answering the phone and asking about the patient or their conditions. That's so helpful because it just adds another element to something that we know we need to fix, but not something that if you asked me to make a list right now, I would have immediately thought of, but thank you for that. Dr. Day. Yeah, no, I think about my career, I've seen, unfortunately, a lot of examples that I think would fall into this category. And I think it all stems from what you were talking about earlier, Dr. De La Torre, was around someone making assumptions, whether it's the physician making the assumption, the staff member making the assumption, the patient making the assumption. So I think really it's one, I like the way Dr. McNeil stated it was, how do you politely correct or how do you politely re-engage the individual? We call it humble inquiry at our institution. So could you clarify a little bit more or what makes you think this or tell me a little bit more? Again, really trying to come from the point of view of like just trying to understand why they made that assumption, but then also I think trying to sort of educate during that process as well too. And this is applicable, I think, across many venues. It happens when we round, when we're in clinic, in the endoscopy center. So there's lots of, I think, opportunities to really provide education just for not only our fellow staff and providers, but even for our patients as well. Thank you. Dr. Bhakta. I have a similar situation and then I'm gonna turn it back around and kind of leave it to the group a little bit. But as a trainee going from New York City and being in a great open environment, coming back to the South in Houston, Houston is very diverse and also has a very large LGBTQ population. But a scenario similar to what you experienced where I had, I'm a trainee, we're doing ERCP. We're repositioning patients once they're sedated, they're intubated. And we had a transgender patient and the anesthesia staff along with one of the nursing staff made comments about the, alluding to the genitalia of the patient and because they were gonna give rectal endomethysin. And I, as a trainee, struggled really, really hard. I'm in the room. It was my one, I think, back, I was four weeks in. And it's a new institution. It's a new place, new people. And I really struggled with how to bring this up because fortunately in your situation, you were the faculty, you were the attending and you took charge of that room. But I think as trainees, how would you guys recommend bringing this up? Because again, we struggle as trainees bringing attention to situations where we might be maybe penalized or maybe concerned for any type of other damage that comes downhill to us. So how would you recommend going about this? Because I really struggled. Dr. Simons, we need to hear from you. I think that it's more common. You know, I'm in an advanced endoscopy fellowship now at Cornell. So I have seen, you know, those certain situations. And I think the way that I think about that, and obviously, as the team, chime in if you feel differently, is I have to, I feel like it's important to read the person and say, is this, what is the intention? Is this the intention coming from a side of a little bit of malintent, or is it a joking? Is it a sarcastic type of encounter that needs more of like a, more of a correction that is more urgent and timely and on the spot? Because that's when feedback is more appropriate. Is that right when you have that situation? Or is this something that is really an honest mistake or an honest lack of knowledge? And I think separating those two is extremely helpful because if you're a student or if you're the president, if something is that they're feeling that there is malintent behind something, and that's something that I think needs to be addressed immediately, whether you're in the room or not, or whether you're in the, is this situation or not, or just be like, in clarification, be like, I'm a little bit unnerved by what you just said. What do you mean by that? And I think that those that the malintent, or at least it was perceived as though, I think that needs to be addressed immediately. Whereas there's the other part, there really is the honest mistake that I don't think immediately may need to be addressed. I think it's something that you may wanna go one-on-one with the person. And the reason I say that is because I was, I was that person that was the honest mistake. I have, I've been married, it was like eight years, I think last, a couple of weeks ago, and I have two kids, and my wife and I were pretty, we're completely out, and most of my patients know as well, and definitely the people who I work with. But there was a woman who I, see, I even made this mistake now, the patient just didn't wanna disclose their gender. And I kept messing up the pronouns. And it was, not only was it confusing for the patient, it was confusing for the room. And I was so, I even got all flustered, and I almost was, it affected how I gave that patient care. And I think for me, mine was really just that, the lack of knowledge from my standpoint, and also it was just an honest mistake, that actually I really appreciated the patient was the one who, after her procedure, wanted to speak with me. And I spoke to the patient one-on-one, and was able to really, almost comfort me in that way. And that really shouldn't be the patient's job, that was, but I definitely appreciate it. So I was in that situation, where I was the one that needed to be educated and taught, and even though I'm supposed to be part of the community. And so I think when it comes to those situations, it's really when you separate it, what's the intention behind it? And that can be hard to read sometimes, because even something that may sound like it's coming from not the greatest intentions, it also could be from a place of an honest mistake, and also from just the lack of knowledge. But I think that's how I start that process in my head, because I've been on that other side, where I've made those mistakes, and they certainly don't mean any bad intentions from my standpoint. I don't know, what do you all think? I think that's a really great point. I think everyone's capable of making mistakes, and intent matters so much. And we can obviously tell at the extremes of intent, but there's definitely gray area, and it's challenging sometimes to read it. We are exactly eight o'clock. Now, since we had some technical issues earlier and we lost a few minutes, I'm going to selfishly ask if we can go over three minutes, because we have two questions from the audience, one of which is from Dr. Christie, who was the head of the DEI group or ASG. So I really wanted to make sure I address this. This is actually for Dr. McNeil. And her question was, are you suggesting we bring up questions about sex, even if the patient does not address it, to paraphrase a little bit. And then her follow-up was, I do not always bring this up with my IBS patients. So just curious to hear from Dr. McNeil, what your thoughts are on that question. So I don't always bring up sex with all of my IBS patients. If they bring it up, I bring it up. In my patients who I, especially my gay men, my gay male patients who I see, that's probably the largest cohort of my LGBTQ population that I see, I will bring up just their anal sex and their sex life and how it's affecting them and how their illness affects them often. Mostly because a lot of the treatments that we use, especially for my IBS diarrheal type patients or my, I mean, definitely my IBD patients, I want to express to them what may help them and help control their symptoms, but also how it's affecting them. Because I want to get a sense of like how really, how severe we need to, how aggressive I need to be kind of with the treatment sometimes. Thank you. We have one question from the audience before we say our goodbyes. This session went by way too fast, but it's a great question from Jules. What would be the best way to start a patient interaction in the inpatient setting to ensure that you are being respectful of a patient's pronouns and identification? I'm thinking in the realm of consults or short, quick interactions. Let's hear from Dr. Newman and Dr. Day. So when I meet a patient, I introduce myself the way that I want to be addressed. So I say, hi, my name's Dr. Newman. And then I'll often, if it seems, you know, depending on how the conversation is going, but I'll say, oh, I use she, her pronouns, or some places have badges that people's pronouns can be, you know, visibly displayed. And then I'll ask, how do you, what name do you like to be called? How would you like for me to refer to you? And that gives the patient an opportunity to tell me the things that are important to them. If they don't mention their pronouns, but I have mentioned my pronouns, then I'll just quickly say, you know, what pronouns do you use? And then there within 15 seconds, we have all that information. So it doesn't add a lot to a consult. When you say it sounds so logical and so easy, but you'd be surprised at how challenging that is for people, even for allies to write their pronouns on like a social media page. For some people, that's such a big step, but it means so much to the recipient. And so it's just so important to do that, to show signs of allyship. So thank you for that. I think the big thing is just practice it like any other script. The more that we practice, the easier it gets. And so there are lots of things that we may be uncomfortable talking about, but in medicine, we get really used to it. Like how many bowel movements are you having a day? Probably wasn't the first thing out of your mouth when you, you know, went to college and started meeting people. Yeah. Thank you. Dr. Day. Yeah, I completely agree with Dr. Newman. I follow the exact same script that she did. I always, you know, one, start by introducing myself. And then I say, I'd like to be called, you know, Luke. My pronouns are he, him, his. And then I basically turn it around just like she had said it, and saying, how would you like to be addressed? And I sometimes will say, you know, I'm here to try to understand you, but also I want to make sure that I respect everything about you. And so I'm going to ask you some questions. Like we will ask many questions that, you know, sometimes might make either one of us uncomfortable, but it's really coming from a place of understanding and trying to help one another. I really, really like the idea of the script because I think, you know, if you could write it out, it's very easy to say, it can be very quick. It doesn't take a lot of time, but it makes a world of difference to patients. And so the more you have something you can practice saying, probably like we all do when we consent patients I'm sure all of us have a very standardized way of how we consent patients. Same way we would do for introductions, you know, making eye contact, saying hello, this just becomes a part of it. And it just becomes part of our sort of natural introduction to patients. Thank you guys for that. Really helpful. Dr. De La Torre, just what you were saying that too, I think you asked the question of, should this be mandatory part of the curriculum? I think exactly what Dr. De and Dr. Nguyen were saying is that it should just be a part of a script. And so it should be a part of the whole curriculum in general and how to incorporate it as opposed to really putting it into a box. And I think they said it like so beautifully that it should just be part of it as opposed to really saying like, this is the box that we need to put in and we need to click these CME checkpoints. So I really like how they term that. I think as GI, we are really privileged to be a part of a specialty that tends to see patients when they're at their most vulnerable. I mean, there is the running joke that we tend to see less of their face and more of the rest of their body parts. And so I think being able to really have people have that comfort level with us, we can make a huge difference in our patients' lives. And so I really liked how they incorporated that as an entire, the entire script or the entire gestalt of here's our patient interaction. And I think as GI, we can really make that impact on people especially with what we do. This has been a wonderful talk. I want to thank all of you, this phenomenal panel and Matt for this wonderful talk and helping I think this type of education and the fact that we are going to be able to spread even just this webinar for anyone who is interested in watching it at a future date is going to mean a lot and really help a lot because it's a solid piece of education. So thank you all for your time. I want to hand it back to Michelle now and then just thank you again, Matt, thank you to our wonderful panel, not Matt, sorry, Dr. McNeil, forgive me. We overlapped. So it was meant to be Dr. McNeil, Dr. Simons, Dr. Newman, Dr. Day, Dr. Bukta. Thank you guys so much for your time and for sharing this education with us. Thank you. Thank you. And thank you, Dr. Latour. In closing, thank you all for your participation in this discussion on the top 10 do's and don'ts for clinicians interacting with the LGBTQ community. This recording will be available in about a week in GILeap, ASGE's learning platform system. There's information here if you need help accessing and we want to hear from you. So please reach out if you'd like to be informed or have added resources or have any questions or ideas regarding diversity and inclusion matters. This concludes our presentation. We hope this information is useful to you in your practice. Have a good evening.

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