to give us insights on delivering equitable patient-centered care. Take it away, Thayne. Thank you so much. So I really have the great honor of highlighting special populations and how we as a care team can understand their patient perspective to improve their care. In terms of the goals of this talk, I really want to help us learn about the need for cultural competency and diversity for underrepresented groups, specifically the LGBT community in gastroenterology. I want us to understand how to navigate gender-affirming care, and I want us to learn how to create a safe and welcoming care center for our transgender and gender-diverse populations. So what does the literature say about discrimination by medical providers and the perception among the transgender and gender-diverse community? There was a national survey of discrimination of more than 6,000 transgender people across all 50 U.S. states, and they found that during the survey, 19% were denied care outright, 28% had delayed their care due to past experiences of discrimination, and 50% had to teach their providers about their own health care. So understanding this data, we can recognize that there is a knowledge void. We do have scarce information on representation of the LGBT community among our GI providers. I think there's a lack of information as related to the optimal care for our patients, and that information is very important because that allows us to address transgender patients' needs, and if we fall short, it can lead to higher rates of inequitable health care. And so it's important that we have education or training related to LGBTQ health care issues. And I know that it's rare, but I think all institutions are trying to work hard to improve this knowledge void or gap. And remember, for patients, every interaction contributes to their overall care experience. So it's important for our members of our health care team to become educated in how to best care for our different patient populations so that we can communicate respectfully, have a sensitivity, and so that they feel that they've been heard, receive good care, and come back to see us again. If we don't, if we continue to have this knowledge void, there will be health disparities in terms of poor access to health care, and there has been data that's shown that there's a shorter life expectancy for those living in high prejudice areas. Now, what are the benefits of having LGBT community faculty and physicians? About 4.5 percent of Americans still identify or self-identify as LGBTQ and need to see this reflection in their health care professionals. It is important for everyone to see and emulate I see my doctor and they look like me. They are from the same community as I am because that positive role or modeling has increases better interactions and LGBTQ physicians decrease both explicit and implicit biases among medical students toward our LGBT patients that they serve. It also helps us to address LGBT health disparities and ultimately we need to increase the research that we do for our LGBT disparities and identify ways that we can fill the void or fill the gap. So, I want to take a moment to describe kind of gender affirming care because it is health care. It really is gender affirmation to create a plan of care in collaboration with your patient that is mindful of their past experiences in care. It also helps us to identify resources for patients as well as providers in regards to education. Now, there is a SOGI or sexual orientation gender identity. SOGI information includes the patient's chosen name, correct pronouns, current gender identity, and sex assignment at birth. This is really important because currently some of our electric health records like EPIC that we use in our institutions may have features to support the correct SOGI information. So, it's important that we all learn about it, use it, and teach our staff on how to do the correct gender identification process. It also is important that patients can update their own SOGI information through either the electronic health records such as EPIC or on paper forms during check-in. It's important to encourage our patients to be involved and active in their own health care. The next thing that I wanted to talk about is not only from the patient's perspective about understanding SOGI and how they identify, but also how do we for transgender and gender diverse populations assess an anatomy or organ inventory. This is very important as health care providers. Now, I'll say patient anatomy and organ inventory is not to be asked out of curiosity, but it's rather important to identify so that we can help in terms of preventative health needs. So, something that we might think about is in order to ensure that you're getting the appropriate medical care and screening, I need to ask you about what anatomy you currently have. That is kind of a way to approach our transgender and gender diverse populations to take that patient anatomy and organ inventory. Once you've had that screening question, only ask certain questions if it's pertinent to the medical exam. For example, abdominal pain, pregnancy tests, cancer screening, but it is important for us to all take inventory for all of our patients. There might be other important questions that everyone on the audience needs to be aware of in terms of what to ask. So, when you're approaching a patient that is transgender or gender diverse, you can simply say, what sex were you assigned at birth? Some of the common abbreviations are AMAB, which is assigned male at birth. AFAB is assigned female at birth. Next, how do you ask about sexual history? Some of the things you can do is ask, do you have a history of anal intercourse? Are you receiving partner or are you the penetrating partner? And what body parts do your sexual partners have? Again, we don't want to ask these questions out of curiosity, but if it's important for their medical care, we need to be sensitive and know how to ask these questions to deliver the best care. The other thing that's really important is kind of learning terminology. So, I kind of gave a snapshot of the don't use and the appropriate terminology. For example, when you're interacting with a transgender or gender diverse population, you don't want to use terms like sex change. The appropriate terminology would be transition, gender affirming surgery, or gender affirming hormone therapy. Other things to think about are don't use the word hermaphrodite, use the word intersex. Also, in terms of sexual preference, for example, don't use that terminology. The appropriate terminology would be sexual orientation. So, hopefully this can be a little bit of a guide in terms of learning the terminology we need to use. So, all of us in our endoscopy center have a goal of providing safe, welcoming, culturally appropriate environment to our transgender and diverse population. And we want to do this because we not only want them to seek care with us at the time of coming into the endoscopy suite, but we want them to return for follow-up care in every aspect of their health. And so, key components that I'll ask everyone to think about is to take a look at your endoscopy unit and decide and see and strategize if this is the appropriate setting for our TGD care. Is there evidence that we have staff training? What do our waiting rooms look like? Is it inviting to the TGD community? Are our bathrooms unisex? Does our team understand correct terminology? Do we know how to use SOGI in our forms to get the best information from our patients? So, what are some of the best practices? Ask every patient their pronouns, okay? Not just for our TGD patients, but for all patients. Try to use patients' last names to call them back or greet them. Don't use salutations or first names. It's also important to gather organ inventory. Have an understanding of the fluency of the terminology. Know what the latest terminology is and correct yourself and then move on if you make a mistake. Don't try to dwell in the moment. And then, importantly, all staff from the front to the back of the office need training in this care. I wanted to take a moment to show everyone a YouTube video that's available. It's called Vanessa Goes to the Doctor. I'm going to ask Bernie some help because I think that this video really illustrates kind of our goals in terms of understanding the patient perspective, specifically for the transgender and gender diverse population. I'm really nervous about this appointment. I haven't been to a doctor in years, but finally, I have health insurance. I chose Dr. Miller because he is in my network, but I don't know anything about him. As a transgender woman of color, Vanessa Shepard has had mixed experiences with doctors and hospitals in the past, but it's the bad ones which stand out in her mind today. Immediately upon entering, she begins to scan the environment for clues. Will she be welcome here? Will she be safe? Do the posters reflect a diverse patient population? Is there a non-discrimination policy posted? Will she be able to communicate with her family and friends? Will she be able to communicate with her family and friends? Do the posters reflect a diverse patient population? Is there a non-discrimination policy posted? No, there is not. Hi, my name is Vanessa Shepard. I have a 10 o'clock appointment with Dr. Miller. Looks like this is your first time here. Please fill out all the pages on this form. Bring it back to me when you're finished. Thank you. Intake forms are a powerful and early indicator of the safety and welcome LGBT people can expect in a healthcare setting. What am I supposed to do here? Do I have to lie or how truthful can I be? Name? I'm just putting Vanessa. Sex? Only two choices? I hate this. I guess I have to check male, the sex on my insurance card. Relationship status? With these options, I guess I have to choose only single. Thank you. Can I have your insurance card, please? I have to make a photocopy of it. You can have a seat and I'll call you. Would you come here, please? You gave me the wrong insurance card. This one says Robert Shepard. I used to go by Robert Shepard, but now I'm Vanessa Shepard. So, Robert is your real name and that's the one we're going to have to use. Have a seat. The doctor will call you. Mr. Shepard? Mr. Shepard? That's me. I called for Mr. Shepard. You are? I'm Vanessa Shepard. Who are you? I'm Vanessa Shepard. Okay. Come in. Vanessa is humiliated. Now let's see how it could be done better. Vanessa scans the walls upon entering the waiting room and immediately spots a non-discrimination policy and yes, it includes both gender identity and sexual orientation. A rainbow sticker. Yes. Oh, and they have the advocate. Great. Hi, my name is Vanessa Shepard. I have a 10 o'clock appointment with Dr. Miller. Oh, it looks like this is your first time here. Please fill out all the pages on this form and bring it back to me when you're finished. Thank you. It's immediately clear that this intake form reflects a medical practice with a diverse clientele, and that the providers here want to know who their patients are. The form has a place for Vanessa to write her legal name and her preferred name. It has more than two sex options, and a place to indicate she's in a committed relationship. All done? Thank you. Can I have your insurance card please? You'll have to make a photocopy of it. Have a seat. The doctor will call you. Mr. Oh, excuse me. Ms. Shepard? Hi. Hi. Welcome. Come on in. And now the appointment begins. These first interactions with the provider subtly indicate to LGBT patients whether they can be open or need to be guarded. Let's see what happens between Dr. Miller and Vanessa Shepard. Just to get started, I saw on your intake form that you did not check off when your last period was. Yes, I'm a trans woman and I don't get a period. Oh, so that means you've had the surgery then, right? No, I don't know what surgery you're referring to that would make me get a period. Okay, so you have sex with men which would just mean that you're gay. No, I'm a woman of trans experience and I identify as lesbian or bisexual. I have no experience treating patients like you. I really think you need to be seeing an endocrinologist and not me. Well, I only came in here because I've been coughing for three weeks. This is not going very well for Vanessa. Now let's see what an LGBT welcoming provider might do differently. I see that on our intake form you checked off that you're transgender. Do you prefer to be called Ms. Shepard? Yes, I prefer to be called female pronouns, please. Okay, great. So sorry, I got it wrong in the waiting room. Thank you for your patience. Do you currently have a healthcare provider I do go to a clinic but it's really far away so I was hoping that I could do everything today here with you. While I have experience with the LGBT patient population I've never been the provider of hormones for a transgender patient. That said, I think it won't be a problem. I've prescribed hormonal therapy to other patients and as long as you're willing to be patient with me and we work together I think that should be okay. The other thing before we get into what brought you in today is I always like to remind my patients how important it is to be tested for HIV. Can you tell me when the last time is that you were tested? Dr. Miller knows that transgender women of color have particularly high rates of HIV infection due to multiple barriers to care and discrimination. And many HIV positive women have never been tested. Okay, so now that we got that out of the way tell me what it is that brings you in to be seen today. Well, I've been coughing for three weeks. What a terrific doctor! This could be the beginning of a long relationship. As we've seen, a doctor's appointment is a complicated set of interactions with the environment, with forms, and with the health care staff. There are many places to get it wrong and many opportunities to do it right. Thank you so much. So hopefully everyone got a chance to see how this video can demonstrate the way that we all can learn how to provide better care for our transgender and gender diverse populations, to look at our waiting areas, to allow ourselves to have the correct sexual orientation and gender identity forms and processes in place, the ability to know how to communicate well with our patients, because that patient experience really can dictate whether a patient is engaged in their health care or it tracks away and we engage in health disparities. So the next slide I just wanted to use is just as references in terms of available resources that all of us can use to get more education. So thank you.

equitable patient-centered care

LGBT community

gastroenterology

cultural competency

gender-affirming care