CME OnDemand - On The Same Page: The Remedy - Queer and Trans Voices on Health and Health Care-AOFAS On the Same Page: The Remedy (Book Club Discussion)

AOFAS On the Same Page: The Remedy (Book Club Discussion)

Video Transcription

On behalf of AOFAS, I wanted to welcome you to tonight's program of AOFAS on the same page. It'll be moderated by Dr. Jacqueline Nguyen from AOFAS and Dr. Joseph Ledzelter from Pride Ortho.  You can find tonight's agenda and disclosures in the program document posted in the chat box, and in the On Demand Education Center.  I'd like to run through a couple of housekeeping items before we kick off the presentation.  For technical difficulties, please try to close your browser and log back in the same way you did.  For registered physician attendees, you may earn one hour of AMA PRA Category 1 CME credit by completing the evaluation and the CE claim form at the end of the webinar.  And you can find that link for the CME in the chat tab as well. And we will also follow up with the email following this broadcast.  So the webinar is being recorded and will be available on demand viewing on the On Demand Education Center contents in the library in approximately 24 hours.  So we do encourage you to ask any questions during the presentation, send your questions to the faculty, click on the Q&A tab on your navigation bar.  If you can't get your question answered during the live broadcast, faculty will reach out to you following the broadcast to respond.  The AOFAS Diversity, Equity, and Inclusion initiative is funded by the Orthopedic Foot and Ankle Foundation, supported by a grant from Stryker.  AOFAS is committed to diversity, equity, inclusion, and will be hosting several events this year, including a hands-on bioskill workshop. This workshop is for medical students.  We will have a second AOFAS on the same page discussion in September. And a DEI symposium at the AOFAS annual meeting with special guest speakers.  So we hope that you attend these events, and we'll now turn the program over to Dr. Nguyen to begin. Thank you very much.  Okay, so we're happy to have everyone joining us here tonight. This is the joint book club with AOFAS and Pride Ortho.  The book for tonight is The Remedy, and this is a collection of short essays by various authors explaining their experiences in healthcare as queer and transgender patients.  But before we get to the book, we have a short introduction.  And so in the U.S., I found this interesting.  A recent poll just as of a year ago showed that in the past 10 years, the percentage of Americans who identify as LGBTQ has doubled from 3.5% in 2012 to 7.1% just last year in 2022.  And what we see is that this really differs by generation. And with the younger adults, much more likely to identify this way.  Gen Z, so anyone ages 18 to 25, 21%, that's a little over one in five, are identifying as LGBTQ, which I thought was really pretty incredible.  It's a really big change, especially as we look with the older, as people get older, we see baby boomers, it's less than 3%, and traditionalists, anyone over 77, it's less than 1%.  So it's a big change, but overall on a societal level, we're still in the early stage of even recognizing and accepting this group.  It was only in 1973 that the American Psychiatric Association removed homosexuality from its psychiatric disorders list. So it really wasn't very long ago.  And of course we know that these attitudes take a long time to change.  But basically, you know, we're treating these patients, whether we know it or not, as healthcare providers. And so the more that we learn about, you know, their experiences and identities, the better that we'll be able to serve them and just create a better  experience for everyone. So with that, then I'll hand it over to Joe, who's just going to go over a few of these definitions.  I just want to say that slide right before is like it's one of those slides that makes you really happy but also makes you really sad.  So many of the younger generation is coming to terms and able to express who they are, but then you look at the traditionals and the baby boomers, and frankly, this is not something that's dictated by society, but it's inherent in who you are.  And it just means that so many of the older generation are hiding or just not comfortable coming out still, which is the sad portion of it.  Anyways, well, let's get back to the definitions. I won't really kind of go over every definition, but I'll just kind of pick a couple that I think we should probably just kind of come just briefly kind of go over, and you can read everything.  I think it's really important to know that an ally is just someone that who supports LGBTQ community and it can be someone that's straight or cisgender or any anyone within the LGBTQ community.  So it doesn't necessarily have to be someone that's straight. A cisgender person is someone that is used to identify someone whose gender identity aligns with their sex at birth.  So gender identity is the innermost concept of male and female or both or neither, and it's how individuals perceive themselves and what they call themselves.  So this may be the same sex that they're assigned at birth, but it may be different.  Intersex is a person that is born with a variety of differences in their sex traits and reproductive anatomy, so they may not have the same sex traits and the same gender binary sort of model that we have.  Go to the next slide.  So, a non-binary person is someone that who does not identify exclusively as a man or woman. A pansexual has the potential for emotional, romantic, or sexual attraction to people of any gender, although that may not be all simultaneously.  Transgender is just an umbrella term for people whose gender identity or expression is different from the cultural expectations based on the sex that they were assigned at birth.  So this is not specific to sexual orientation and I'm sure you guys kind of came across that multiple times throughout the book we read, where patients, or not patients, but people that were writing were transgender, but they was getting confused with their sexual orientation consistently.  I think I'll stop there and then I think we can move on to talking about the book.  Great.  So yes, we thought that, you know, by first we'll highlight some of the passages, or some of the essays, but really, anyone, you know, this is, this is pretty informal so anyone at any time, feel free to just chime in even if you haven't read the book or the passage, it's fine.  So, one of the first ones that I will bring up is the essay called Our Caregiving Ourselves. And this was about a couple, two women, and their experiences in the ICU.  So one of the women was chronically ill with cancer in the ICU, kind of at the terminal stage of her illness, and her partner describes what it was like, you know, being in the ICU as the partner.  And what the focus of the story was basically explaining that, you know, they, the two of them, they were partners but you know they have a whole community, lots of friends who really consist of their family.  And so it brought up the concept of, you know, what is family, what do we define as family, and what are our assumptions about it. So, you know, we, we know that there's a big heterosexual assumption and I have to say by reading this book it, you know, really  made me aware of how incredibly, you know, just it's such a big assumption that we have everywhere, but we also have an assumption of the, of what family is, and it's often the, you know, traditional nuclear biologic family.  And so in this essay, the author describes the ICU's rule of only being only having one person allowed at a time, but really it was that the staff was just really uncomfortable with the fact that, you know, their family consisted of multiple people, you know, a  big group of people shuttling in and out, and they were just really kind of overwhelmed by the fact that there could be so many people who would be considered family so I, you know, another aspect of this is that, you know, I think a lot of people, a lot of us know this but LGBTQ people are often isolated by their own family.  And so the family and community that they create is, is really critical.  So I didn't have necessarily a specific question but just wanted to see if anyone had any thoughts on, you know, the assumptions around family and any experiences like this.  Go ahead, Sheldon, please. No, Gary, go ahead. You start. You raise your hands first. Go ahead.  Oh, I was just going to, I was just going to say, you know, I'm not, thank goodness, in a mode of ICUs as much anymore. I'm more as the family now, whereas as an orthopedic resident and a resident medical student, you know, I would be in, you know, kind of going into people's spaces.  And I was just taken by the fact in this particular essay how there was some bonding between a very religious group of family as well as, you know, another family.  And I was happy to hear that the hospital personnel, you know, the blockage in terms of being able to connect with the outwardly family was not due to them being gay or straight.  It was more of they felt like the mechanics of the hospital and how maybe you could make the mechanics of an ICU more welcoming.  But then there was some bonding there. You know, I practiced in the Deep South, although in the city of Atlanta, but also in rural Georgia as well.  And you'll see that. And what I was taken by is that family was family, and there was a little bit of a nod there, like, this is how you can get in with your family.  We're just switching a sweatshirt. You know, you can switch your outwardly appearance. And some of it is if you can, you know, all of us in the hospital, you know, we almost are like, yeah, go ahead and do that.  Give me an excuse, unfortunately or fortunately, to let you have your community. It would be nice to break down those barriers.  But I bet at some point the hospital personnel figured that out and they just were like, good. But we need to remove those barriers to family. And I took that from this a bit.  Yeah, Jacqueline, I would say I echo your thoughts. I have personally seen, you know, sadly, I still go to the ICU at our level one trauma center and where people come in.  And these are families, not only other personal, I would say, like biological families, but also like members of all different gangs and such.  And the ICU nurse goes, you're not family and they won't let them in where you have to like then as the physician step in and go, hey, this is actually part of a big family.  Let's just you would walk them in. And I think that the hospitals slash ICUs do have these artificial barriers, these artificial rules that sort of make it, I don't know why, more comfortable for the staff.  But it doesn't really accept this concept of family and such. And I would agree with, you know, Gary, I was glad to see over time there was more and more acceptance, but sometimes the physician needs to step in.  Anyway, I just probably echoing what you read in that chapter itself and what Gary just said, but it's just I've seen this also is just sort of frustrating what I consider the hospital bureaucracy also. I don't know. Just a personal observation.  Yeah, I definitely agree with that. I think the author also mentioned that because she, the author was a nurse herself. And so she even said that she understands the rules because sometimes it is too much to have too many people in the room.  Things can get too chaotic, but that didn't seem to be the issue. It seemed to be more that they were uncomfortable with the fact that a family could be so large and could consist of so many different people.  Let's see, Joe, did you want to bring up another one?  Sure, yeah. I will talk a little bit. I thought all these stories had something really special to say, and they were all like had a different lesson for me.  And I don't know, I felt like I, even though I'm part of the LGBTQ community, I feel like I'm constantly learning new things. And I don't know, this book, this book probably taught me more than that, more than I've learned in a long time.  But TransGrit on page 137, I thought was a really interesting story. I felt like there was like highs and lows here and then like a really good kind of message at the end.  And there was, you know, sometimes a lot of the stories I felt like there was a lot of like exposing what was going on with the system.  In this one, I felt like there was some exposure of what's going on with the system, but then like this like kind of optimistic look at the future.  So this story is basically about a trans person who was started off like in a group meeting and was kind of agitated by a younger person that was complaining.  And one of my favorite parts about this is really when, if you go on to page 143, he was kind of misgendered and not appropriately identified by the healthcare provider.  And the healthcare provider goes, so he goes just, sorry, I may be misgendering them, but so the person goes, just so you know, I am trans, a silent O wide in the aperture of her mouth.  So then, so what you're saying is this picture doesn't really apply to you. And exactly, I say, and she taps my upper arm and she goes, well, good job. I never would have guessed.  And really what is going on here is the person is telling, the nurse is telling the person that they did a good job of being trans.  And so often I feel like in the LGBTQ society, and I can't really speak so much to the trans counterpart because I don't identify as trans, but I feel like they probably feel this more often.  Is we're told that, oh, you pass really well for being gay, or you pass really well for being a lesbian, or in this case, you're doing a really good job at being a trans man or trans woman.  And they think, so many people think that that's a good thing and really most of us don't really want to necessarily be, you know, passable or viewed as that, as like conforming to standards and this story kind of highlights that.  So, before I say anything else I just want to see like, does any, you know, does anyone had experiences with this or how do people, how do other people feel, and then people that are not LGBTQ,  is that something that you guys had always kind of thought and how do you feel about that?  I'll just start by saying, I think that's a really good point. And I'll step back by also saying that I learned a lot from this book and I thought it was very well-written  and also really appreciated all the authors sharing their experiences. They're very personal stories. And so, yeah, it was really great.  But yeah, I hadn't actually thought about that aspect until I read this story either. And it's true that we as a society, we do say that as if it's a good thing  that they're conforming and that they look straight. And really, it's making that person feel more invisible  and that they're just not comfortable to be themselves, however that may be. And I just, I underlined another part from that essay.  And, well, two things. He says that he was not ever quite fully alive. And then the other part was, I exist, I am possible. We say standing right in front of their incredulous,  condescending, confused, and irritated faces.  And I just, I mean, I think having to defend one's identity  and especially with a healthcare provider,  just trying to defend your own existence and preferences has gotta be not only so stressful, but so exhausting time after time.  Yeah.  Yeah. I think one of the things of reading this book,  it was very easy to read and the stories are very to the point.  I just, it's one of those things that  having a book club and discussing it, there are so many cringeworthy moments of thinking about myself reading this book and reading people's experiences and thinking, man,  and I'm not gonna admit to it, but I would just say that as a healthcare provider, where, when I always think of it as a privilege when people come in and want your help  and someone is asking for help, and then you don't do it, you don't give them the help that they need. And I think what was really great about some of these chapters and the honesty  and the true criticism or just the telling of experiences  is that this was an opportunity to read a book, kind of think about how you're caring for your patients  and are you really doing it correctly? And it's almost like a blueprint if you read these stories about how to take care of your patients appropriately.  And that's what, it's really about being a physician. Like, I don't think that everybody does it perfectly and I don't necessarily think our patients  are asking us to do it perfectly, but to do it better. I mean, clearly from these stories, we are failing.  You know, our patient population in some very important moments. And hearing that story, and you could just almost see that person feeling so good about themselves saying,  oh, you're doing a great job. And they're just absolutely failing at that moment. And I think that it's a cringeworthy moment that whether you've done it or not,  you can maybe not do it by just reading that.  Yeah, Gary, I would say the, you know, so often in healthcare, we see so many of the people we work with that may not be physicians say like, this is not my job.  Like my job isn't to do, like figure out this or do this. And in these stories, like you realize that a lot of people need, and this may be extrapolated outside of LGBTQ,  but need help. And, you know, when they're coming to see us as a orthopedic surgeon, we may not think that certain things really apply to us, but there are significant instances,  I think that we can really probably make a difference in someone's life if we just spend the extra five minutes trying to like figure something out for them  or help them navigate something within the healthcare system.  Yeah, I think another, this I think may have been in one of the other stories, but just the power of not questioning their identity and just saying, or their story,  and just saying, I believe you. I think that was in the sex worker passage, just which the author spoke about a positive experience. And just the provider,  the author had been violently raped and the provider just said, I believe you. I'm sorry this happened.  You know, with your permission, I'd like to run some tests. You know, pretty simple if we just look at the language, but it was so powerful for the patient.  And I think that's something that we can take away is just affirming their story and identity. Just that alone is already, you know, makes a big difference.  Well, along that story, so you brought up sex work, solidarity is healing. I was blown away by this story. I thought this was an amazing story.  And one of the things that she poses to everybody is, she says, I've only had shitty experiences with doctors. What can you tell me that will help me trust you?  And before I kept reading, I wrote down what I would have said. And then I kept reading and I was like, oh wow, I was way off. Like what she wrote was way better.  But I wanted to see like what did it, when anyone else got to this point, like did you guys have an idea of what you would say?  Because have you ever been like stuck in that position where someone like is really unhappy or they have a really bad problem and they're looking at you for trust?  Like, I don't know. Does anyone have anything to say to that? I know, when I got to that part, I was like, hmm, what would I say? And I really honestly would say,  well, what could I do to make you trust me? And I think that's what always comes down with that difficult patient, right? Who's really mad, it's like, okay, I hear you,  but what can I do to make this situation better? And I think just acknowledging that and saying I hear you and I'm listening and then what can I do to make it better?  I think helps a lot in those situations.  My wife is here listening with me and she said to me, probably somehow we as physicians need to provide respect or somehow transmit that respect to the patient.  And I was thinking about that actual, that a sex worker essay or that story. And somehow the physicians somehow need to, or the nurses, the healthcare needs to give the respect  to the patient of who they are, what they are, and not just sort of pity or say, hey, you're doing a great job passing what you're doing.  It's just basically giving them their proper respect. I think that's the key word.  Sorry, I don't know.  I'm more of that little, that baby boomer generation that this was not something that people came out with during my era of high school and college. Yeah.  Yeah, and as I was reading this, I felt torn because I feel like as a gay trans person who's also in medicine, I feel like I'm constantly straddling this line  of understanding where the patients are coming from in terms of having had that lived experience of what the patients are going through, but then also understanding how easy it is  to put our foot in our mouths as providers and how we say things with the best of intentions, but sometimes, my gosh, it just comes out wrong  or we don't know that that's the wrong thing to say.  And I felt like, I mean, I needed to check myself while reading it, but I felt like I was really defensive while reading this book, feeling defensive as a provider  of all of these stories that are essentially in a lot of ways saying that we have failed these patients. And it was like, man, but I'm trying so hard and we are trying so hard.  And so, I mean, I don't even have anything profound to say here other than to just kind of throw that out as like a sentiment that I was just constantly battling  while reading this book. Like, yes, we need to do better for the patients, even patients like me, like I have received many of these comments that were in the book,  but we're also, we're all trying, I think, very hard to be good at our jobs too. And so, it just was kind of this like weird dichotomy that I was feeling while reading the book.  Can I ask people's advice?  I'm blessed to take care of a very diverse population. What happens when we do as providers make a mistake? I'm thinking of one young individual, a high schooler  who there was nothing in the chart that sort of defined a pronoun. And then halfway through the visit, I asked her, is something on your mind?  And she responded that I had been using the wrong pronoun. And I went as far as to change it, to figure out for the first time how to change it in Epic.  So in front of her, I made sure that other providers would potentially not make that same mistake, but we are gonna make mistakes as we learn,  even after sessions like this. Does anyone have advice how to address that when we do make a mistake or inadvertently use the wrong pronoun to just acknowledge it, to move pat?  What would, from your experiences,  would you want your physicians to learn? Were they in that position?  So this is Naomi. I'm sorry, I haven't read the book, but I think over the years, we have had many similar discussions. How do you refer to a black person? Are they a Negro?  Are they African-American? Are they black?  When we put our foot in our mouth, how do we deal with our psychiatric patients,  which have PST, anxiety, depression? And I confess, I don't fully understand the whole LBGT, how the pronouns work,  but I think it comes down in the office of treating people as people and showing an interest to them, asking them questions. I don't try to be condescending,  but I try to understand them. And if I see them pull back, I agree with whoever just said, ask them how I can do it, how I can help them,  because I don't think I'm gonna get the same answer from everybody. I don't think there's a playbook out there that tells me how to do it or tells you how to do it.  And right now, this is some relatively politically new to be a top topic. I still don't know how to address a black person.  And I dictate, I'm like, do I say it's a black woman? Do I say it's an African-American woman? Do I say, I don't use Negro, I know that's bad, but I'll put down, I have Mrs. Smith  is a 47-year-old transgender female. And I try to acknowledge it, but I think the more people try to separate themselves out,  the more hard it is to be included. And coming from as a woman who started practicing a really long time ago, probably before most of you were born, there's the dichotomy of,  are we accepted as women orthopedists or do we have, oh, we're a woman and we're separate? And I think we have to try and incorporate everybody as people. That's my take. Thank you.  I wanted, thank you, Naomi, for that. And I just wanted, Gary, if you wanted to answer her question on how it's a little bit different, but how we could address black people.  I think in terms of addressing black people, it's mostly how you do it.  Obviously, Negro and colored aren't something we use, but really kind of the thing is black or African-American. And from what I understand, and from my own personal thing,  I can never speak for all black people, but black is always gonna be good. And if you say African-American, I think most people are gonna believe  that you're just trying to do a good job. I think when it comes to that, it is more of how you're treating the patient. If the patient can get,  and I bet it works for transgender, LGBTQIA, same as well.  As long as you're actually addressing the patient's issues and making them feel as a person, and about some obvious terms that we all know we can't use, it's gonna be good.  But black or African-American, you're gonna be okay.  Lorena.  Hi. So I mean, a few comments. I think I can echo some of the things that other people are saying, that I think we just need to treat that person individually.  I think showing empathy makes a big difference for the patient. I, if I'm not familiar with what their activities or what they're doing, I always make sure I ask for details.  And I also think that asking for the expectations, what are they looking for? What are they looking for? Where they come to see me? And things like that.  And I like understand a little bit more how, what they are as a person. I think that make it like help them to feel connected with me.  I have a lot of female patients that come to see me just because I'm a woman. And sometimes we try to connect with more different things.  So I feel like just showing like, okay, I care about you. What are some of what you're looking for when you come to see me? And can I understand those things?  Of course, there are things that comes easier to me because I'm Hispanic. And if I see somebody with a Hispanic population, I know. But I also think that sometimes if we have,  if we're interested in, or we have certain population that it comes in some variety, maybe it might be a little bit more of homework for us, but just like learning what are the,  like the things that can be more prevalent in that population as we have learned from previous books. Like when we learn more about what that population is exposed.  Like we have talked about it with Gary, like African-Americans or Hispanics are more predisposed to diabetes and those kinds of things.  So kind of like learn a little bit more about our population the same with the LGBT community. What are they looking for? Like even if it is somebody that is identified  as a male in the chart, but then he comes and he says, well, but I like to wear heels, for example. You need to understand those needs and what they're looking for  and like address their problem towards those things. So I feel like I can learn a little bit more about what they want and what they're looking for.  Yeah, absolutely. Tanya.  So, I mean, I love the discussion that we're having and I just had an aha moment in that, in the age of EMR, I don't dictate race. I feel like that's not pertinent to the individual  unless it absolutely needs to be dictated. But I just say, it's a 47-year-old male or female but I never thought about the non-binary individual.  And epics can sometimes automatically pull that stuff in. And I'm like, I'm thinking of one of my non-binary patients that I actually see on Thursday.  I'm like, I'm gonna have to actually see how was that pulled in? Because let's face it, we just go through, yes, I wanna dictate and get done  and close that note as soon as possible. But this is something that they see now because of our Love and Wonderful Cares Act.  And if they're seeing that I'm dictating a male or a female and that's not how they identify, I mean, I'm just striking out right there. So I feel like that's something that,  because of reading this book and I love that these discussions that we're having because it's changing our practice to make us better, this is one way that I can go back  and make sure I'm actually dictating the right thing so that when they see that note, they feel like, oh, she's actually paying attention, she gets it.  Yeah, absolutely.  I'm gonna bring up another passage and it's read this before your next clinical visit. There were some, I think a lot of interesting things here,  but the part that I'm gonna point out is actually not just pertinent to the LGBTQ plus community, but really to all patients. And he pointed out that going to the doctor  is like going to a job interview and you have to connect with the provider right away. You have to state your story succinctly and really advocate for yourself  and you don't have a lot of time to do that. And first impressions really matter. And I just thought about it and thought, gosh, that's really true.  It is like going to a job interview. And I realized that something in myself that if I'm meeting a patient for the first time and they're taking a long time to get to the point  or they can't really answer my questions and I get frustrated with that and I feel like I'm like, ah, can you just get to the point? And I think I'd probably,  I start making judgments about them just by their sometimes inability to answer questions succinctly.  So I just thought that that was a good point. And his recommendation was to be in touch  with your voice and your story and make friends with people in the healthcare community so that they're, or help with healthcare providers so that they want to help you basically.  And then the other, another point that he made was just with our EMR  and with the technological advances. And of course, the more specialized that everyone is becoming, we as providers are only seeing one fragment of the patient.  And so of course, like for orthopedics, we take a quick glance at their post-medical history and everything, but we're really focused on one thing  and everyone's, except maybe the primary care doctors is really doing that. And so I guess just, yeah, as we get more advanced and more specialized,  we see smaller and smaller fragments of each patient.  So I just wanted to see if anyone else had any thoughts on that or anything from that passage.  So one thing I've tried to do within my own language is I no longer assume that they have a husband or a wife. I will put spouse or partner because that leaves the door open.  You know, they're here with their companion. They're here with a spouse. They're here with a partner. And I don't have to say it's husband or wife  because I don't like pulling my foot out of my mouth when I've made that kind of statement sometimes. Oh, this is your wife?  No, you know, I think there are ways we can still identify who's with them, but we can show we're respecting them.  To that point, Naomi, is that one of the things that I read today, because this was one of them that I read more recently, was the remedial asexuality.  And that was something that I think, you know, I was trying to go through the book and certain things hit me, the pathologians, trans, and then, you know, kind of trans grit.  There were, you know, and then the queers and trans health innovation profiles. I thought those were all great. But Jacqueline had recommended this particular passage.  And so to even associate spouse or sexuality,  and then that was something completely new. And, you know, this is being recorded. So I just hadn't thought about that particular,  you know, I thought that was so new and that was so unique. And this book was written years ago  to realize that I may have patients that I've been making assumptions about, you know, even saying spouse,  you know, if someone is asexual from reading this, you know, you're not meeting them, we're not meeting them where they need to be met. And I just think that it is so important,  you know, and you may think, oh, this is foot and ankle, but no, I mean, we could be dealing with someone who needs an amputation for whatever reason.  And we're discussing, you know, amputation with them. That's a very severe thing, very life-changing moment. And we may be making an assumption about the person,  you know, like sometimes I would say, you know, bring in your spouse. And I would think I was being so good, not using husband or wife or whatever.  And they may be an asexual person.  And I just blew it, just blew it.  And, you know, so, you know, that's where I believe that we as physicians,  you know, it's our job to be knowledgeable. You know, the patients are coming to us. You know, sometimes people kind of have ideas about how they're gonna have their practice  and what they're gonna say, but someone has walked into your office asking for your help. And I think that, you know, we have to meet them where they are. You know, it's our job.  We're the educated people. We've got this big medical doctorate there and it took a lot of work and we're proud of it. But, you know, we could say spouse  and they may be an asexual person. And that whole 10 pages was very thick. There weren't pictures there. There weren't little quotations. It was 10, it was a 10 page essay  of someone that has clearly needed to speak. And so I just think that's something to consider.  Yeah, thank you for bringing that up, Gary. I really, that essay was eyeopening for me too. I had heard of the term asexual before,  but really hadn't read about it or looked into it.  And reading that made me realize that I have held the assumption  of what the author stated, which is most people assume that having sexual desires  is just part of being human. And I definitely assumed that.  And so I really learned a lot from that and realized that I've been, you know, viewing that incorrectly and just not including the asexual person in the realm of possibility.  So yeah, I totally agree.  And actually, I'll just add on that note, the sex worker passage in that one stood out to me for another reason too, because they both mentioned being excluded and othered  even by the LGBTQ community. And so they really kind of made a point about that. And I just thought it was interesting because I think these populations  are clearly having such a hard time  because they mentioned, you know, hoping to be in the safe space of the LGBTQ community,  but then still being othered or criticized or excluded in one way or another  basically everywhere they turn.  Right, I mean, I think that sort of echoed in that one essay, I think on page 305 about the bisexual population as well,  which I didn't even think about. I thought that was very interesting how both communities sort of attack them  because they're bisexual. I was like, whoa, that's interesting concept.  I don't know. I was thinking about how their research, how they were, you know, in terms of research, you know, if you're a bisexual male,  I think it was said you are thrown into being, you know, your research is in your statistics when you're being looked at are being thrown into as being a gay male.  And then, you know, if you're a bisexual female, I think they said you're in, you're not, if being bisexual in terms of looking at data, there's no real data sets.  You just get kind of lumped and clumped, which we all try not to do, right? And we're doing research. And so the data in order to best focus on the needs  of that particular population just aren't there because they get lumped and clumped. And it was, that was, you know, I just kept finding myself in this book.  This was a great book to not necessarily read cover to cover but just kind of just go from chapter to chapter. So many facts in it.  I feel like it should be required reading for med schools. Maybe it is.  Yeah, Gary, I agree with you. I feel like there was a lot of almost like calls to us as providers to kind of expand the way we do research  into the LGBTQ community for their health outcomes. Like, I mean, in so many different articles that were like, we need to, like there needs to be more research into this  focused on transgender patients or focused on, you know, specifically lesbian patients.  So I think, you know, maybe that's one thing that we can take away from this is like, you know, we can start looking more closely at, you know, identifying specific sort of studies  that can help benefit these groups. With an ortho, it may not be so applicable but I think there are some instances that, you know, we could probably do stuff to help.  So do you think, Joseph, they're gonna have different outcomes for bunions or for fractures or orthopedic care? How do we start researching that and separating that out?  Yeah, so just while I was like thinking about this, I was like, I wonder if you could do a research on bunions in trans women and compare it  to the general population of cisgender women and see if there's a difference in outcomes or a difference in treatment and just kind of compare like their experiences.  But honestly, I don't know if there would be a difference or not and I think that's why we would probably. One of the things in that chapter.  Approved for Menko International, I wanna read that. Yeah, well, one of the things in the article talks about how the percentage of men and the women who are bisexual,  how they fit in from a household income in the bottom fifth and it could be that linkage of the lack of funds or, you know, economy is what's leading  to the healthcare outcomes and the impact. And we've seen how it affects clearly, well, working in Newark, which some of our patients are very poor,  how it affects their overall diet, their general health, lifespan. I mean, a lot of health-related outcomes. It could be that it's a financial slash that leads to the poor outcomes.  I don't know, just a thought. So Tanya, you're MPH, what do you think?  She's calling you out, Tanya. I know.  It's tough. I mean, yeah, I think it's harder in ortho, but it definitely needs to be in other aspects of, you know, our healthcare.  You know, I have a comment to make about that. So I'm a part of the Pride Ortho Education Committee and actually some of the stuff that we're working on right now  is actually compiling some of the limited data that we do have. And actually, especially in the trans community, there are a lot of things that we don't know about orthopedic care.  So people that are on gender-affirming hormone therapy, what's their VTE prophylaxis rate or what do we need to do for VTE prophylaxis? What do we need to know about bone health  in trans population? And we don't have a lot of research about that. So if you're going to do a bunion surgery on someone who's osteoporotic, that's probably important to know.  It's probably important to know if you have a trans feminine patient who's on gender-affirming hormone therapy, what their bone health is like. And we just don't have that data yet.  We can't agree on what to put our patients on for VTE prophylaxis for any type of surgery, let alone for people taking different types of oral contraceptives, estrogen therapy  in the post-menopausal community or population. We don't know any of that stuff. It's a lot of it is, and the more I'm thinking about this stuff  and researching it and working with our education committee, there's a lot that we don't know. And if you don't know something, if you don't even know the problem exists,  you're not going to know how to address it. So there's a lot of, oh, I'm surprised at how much overlap there is, especially with the trans population in orthopedic care.  And you're right. You're exactly right. Sometimes it doesn't matter whatsoever, but VTE prophylaxis and bone health, those are 100% in our wheelhouse.  Yeah. Yeah, thank you. And even just those two alone come up frequently. So, yeah, we'll move on to some of the programs  that some of the authors have done, just because I thought that was interesting. And it's always good to hear about people taking action to improve things.  So there were four different programs that were described and I'll just kind of briefly describe each of them. One was the Q-card project.  And this was a communication tool to help queer and trans youth educate their healthcare providers. So it's kind of like a business card that fits in the wallet.  And it described their sexual orientation, gender identity, the pronouns that they like or want to be used and then any specific concerns.  And I really liked this idea because again, just having to, I think, explain your identity, explain your story again and again and again must be really quite tiring.  So being able to give it to whether, not just healthcare providers, but teachers, anyone in the community, I thought that was a great idea.  Then another one was the kind of on that same theme  was the affirmations deck. And so this was 62 affirmative statements,  kind of like mantras affirming the queer and transgender experience. And there were some really great examples. I don't have it right in front of me,  but I'm just remembering one off the top of my head was it's okay that you started the fight over at a family gathering and various things like that.  And so the author described that these cards could be used for anything, really. You can put it in your locker, you can hand it out to other people,  put it up in your room, in your bathroom.  And this was really also targeting the youth, which the kind of teens and young adults have a high suicide rate. And so that was another one.  And then the trans buddy program, this was out of Vanderbilt and it was pairing trained peer advocates with trans people seeking healthcare.  And the point of this was to just help them navigate the healthcare system and learn ultimately how to advocate for themselves within the healthcare system.  And then the last one was a wellness center. And this was a health and wellness center for trans and gender diverse people. They offered medical services, counseling,  free legal advice, sexual health, a kitchen, a yoga studio, and just as a physical space provided for them as well. And everything was free in the community.  So I was just wondering if anyone has had experiences with any of these types of things. And I haven't, but I think they sound great. And if you could implement one in your hospital  system, what would you choose? For me, it would be the Q card. I think that's a little bit of what Naomi was talking about.  Part of it is when you're dealing with patients, it's almost probably a defense mechanism. And that allows you to have better patient care. It cuts through the let me make the  job interview part that you talked about. Let me make the doctor feel comfortable so that this doctor can help me with my problem. If you hand me a Q card and I can read everything  beforehand and then it just, I bet for those folks, it is like, well, just help me, man. I know sometimes as a black person, I feel like that too. Like, gosh, I could tell you're  really uncomfortable, but I've got this math here I really just want you to look at. You don't have to worry about anything else. Just see me as a person. And I think that Q card  is a very helpful thing. One thing about reading those, we see so many bad actors on social media  and TV and in the world. And there's some really good actors. That's something that should go viral  with all of those programs were. And there's people that are really doing good work. And here in Atlanta, there's tons of that. But in terms of being a selfish provider, the Q card.  I agree. That was the one that I was going to choose as well. I think it's easy and it's  it's just you can get a lot across and just even just a minute or two.  There was one particular story that I read that I, sorry, Joe, go ahead. Oh, no, no, go ahead, Gary.  I was just going to say it was the black intra. Oh, yeah. I mean, that was. Yeah. And so for me to read that and just the intersection of so many  things, you know, and being a 70s baby, you know, I mean, that means that you grew up in the 80s. And for those of a certain age, the 80s were just their own thing.  And just to have to have all of the kind of you read about the general gender assigning and  people putting, you know, the DSM diagnoses and.  It's one of those things where you I was just watching someone on social media, this woman from Kentucky advocating for trans rights and how passionate she was.  And when you read this story about this intersex person,  you can see you're like, this is a person. You're a physician. You know, there's you should have no problem figuring out how to reach your patient.  And it's pretty it was clear that there, you know, there's medical malpractice right there.  And it was it was sanctioned medical malpractice to remove body parts from this person that would  have been possibly if they were gender affirming. And then the whole part about transitioning,  uh, because there's this thought for, you know, for folks that there's going to be you're done transitioning like, oh, you reached it or there's this certain goal you have to meet.  When in this particular essay, this person was saying that, you know, where I stop where I feel I am, because I am this I am a person. I'm not a goal.  And that was just so poignant. I just have so many people I just wish could read that  essay. And, you know, it's just all about I mean, we're treating people. These are humans.  And so these are people and to not meet them where they need to be met and to see this complete malpractice throughout this person's life, which is so very powerful for me. I don't  think I'll ever forget this essay. I almost want to print it out and hang it somewhere.  Yeah, I was really, gosh, blown away by that story as well. And just for anyone who hasn't read it, it's a black intersex man who was born with androgen insensitivity syndrome.  So born as an X, Y, but his body is not didn't respond to androgen, androgens are testosterone. And so we had the male gonads, but looked phenotypically a lot more female. And so  I'm pretty sure that when he was born, the pediatrician told his mom, oh, she's you should raise her as a girl. She looks like a girl. Just she's going to be a girl.  But he never identified that way. Just really always a very 70s patronizing thing, though. Yeah.  Yeah. And the mother, actually, the pediatrician wanted to have the gonad or testes removed  very early on as a baby, but then the mom refused. But then the pediatrician, when he was a teenager,  13, the pediatrician was pretty insistent on it. And so the mother agreed. And I just  couldn't believe, you know, there was a quote. So at 13 years old, he had his testes removed.  He described it as being extremely painful and then was given hormone replacement treatment with  estrogen. And he described not only the physical pain, but also just feeling such a loss of the  testosterone and the change in his voice. And it was just such a such a shock. And he said,  at no point did anyone ask me what I wanted to do with my body. And I just I was like, gosh,  it's just such a drastic thing to do. And no one he's 13. Nobody asked him how he felt. What did  he identify with? What did he want? He then eventually transitioned to live as a man. And I actually found online a video. I haven't watched it yet, though. But there's a video  where he went. This is his story was broadcasted on the news. And as an adult, he then confronted  the surgeon who removed his testes. So, yeah, I anyways, I thought that was a very powerful story.  But I guess, you know, we're we've reached our hour mark. So we can just kind of, you know,  end with any any concluding thoughts. And, you know, I guess if there's one thing that you feel like you will do differently, you know, what would that be?  And anything else that anyone may want to add?  I was thinking going back to Dr. Gus's comments earlier, how what do you do when the  doctor patient visit goes wrong? And I'll be honest with you, my wife and I, my wife was just  talking to me, telling me, really, I always think I thought about this going, I guess you apologize  and say, let's restart, redo. I don't know, like, like the computer, you start the visit again,  and try and by giving them the respect what they want. Maybe that'll help the the new doctor  patient relationship. If it didn't go well the first time, because I was thinking what Dan said,  what do you do when it goes wrong? You can sense it's going wrong, the interview is going wrong,  then I would say, let's start back from the beginning, give them the time and the respect  they need apologize, I somehow sense that you're not happy. And I did something wrong. And let's,  I want to hear why I don't know, I was thinking about his comment earlier.  And probably I said too much already.  No, I think you're absolutely right. And I may not be the best person to say, but I think like  you need to, the best thing to do is probably stop. And like you said, kind of investigate as  to why they're feeling uncomfortable, and then work with them to figure out how to make them  feel more comfortable and basically just show that you're there to, to take care of them and  in the best way possible. I think it's easy to talk about it. And the fact that everyone is  the people that are here are probably not going to be the people that have this issue. But so  often we get defensive if a patient isn't taking our advice or isn't kind of flowing with our flow  the right the way we expect them to, or unhappy with the way we're doing something we so often  get defensive. But like you said, like if you're picking up on something that's not quite right.  I think taking that pause is probably really important and kind of investigating with them how to best navigate forward. Does anyone?  No, I was going to say, I agree with that. And that, you know, I was thinking of Daniel's,  you know, comment of, you know, what can I do to identify that initially? And I literally texted  Gary and was like, you know what, I'm going to look when I get to work tomorrow and say, what's on my intake form? I bet you it's just male, female. I mean, so you're starting right  off on the wrong foot with just the paperwork that we have our patients fill out. So I'm going  to go and change that to see, you know, can I be inclusive there and, you know, starting off  on the right foot and then you're identifying those things and, you know, making the, you know, the person feel at peace. Like, Hey, this person gets it.  Either way, Tanya on our intake form, what we recently changed is it says, do you work? Question mark. And I, we, I realized that stay at home parents,  they work their tail off. They're just underpaid. And so, so we changed that to, are you employed as opposed to do you work? And so these are things that you have to think about  your intake sheet. Absolutely.  A lot of mothers that they put there, do you work? And they put yes. And then next to the line, they put I'm a home, stay mom home. So.  So one thing I, I kind of wanted to pose if we have a second is, you know, you will, you know,  now that we've read this story and we've learned so much with them, you know, we're, we're  organizations that really can kind of like raise awareness or begin to implement change. Is there  anything that we like that you guys learned from AO within the AOFAS group or Pride Ortho that you  think that we can kind of do to, to kind of help prevent some of these issues or help LGBTQ  patients navigate the orthopedic system? You know, I think one of the things that was mentioned  by a couple of patients in the book or a couple of individuals in the book was  just some of the like markers of, like I said, you know, like, you know, just some of the like markers of like a safe environment. And like, I don't think I've ever  been to an orthopedics office that had like a rainbow flag anywhere. Or even just like, there are those signs that say like, all are welcome or any like, honestly, anywhere or  anything like that. I've seen a lot of sports teams, banners, stuff like that. So, I mean,  I think there are little things we could do. I think changing restrooms to say, to have gender neutral restrooms, even just the ones that say that have like the male or female  with the line, like, yeah, that's gender neutral, but it's not really. And that's also not gender  inclusive. So I just like, I think some of those things are more present in like family practice  offices or pediatrician offices or whatever, but not necessarily an ortho. And I think that's a really easy thing that we could do to make patients feel more welcome.  Yeah, I agree with that. I know as someone who doesn't wear a white coat, you know, just to have like a flag on it, you know, just to feel inclusive, like my watch band is actually,  you know, the rainbow, just so that it's a subtle way to say, okay, this is a safe space for you.  You know, all is welcome. Maybe not in my whole office, but at least in my office setting, it is.  I never even thought about that, Ezra, like the sports everywhere can be really off-putting  to like certain groups that aren't interested in sports. And especially if you're already marginalized and you feel like you're going to be kind of like this, like machismo kind  of attitude coming at you, which is common in orthopedics. Yeah, that's a really good point.  That's a great point to make our offices more friendly, you know, every now and then I'll get  a patient that has something political on, and then, you know, you just have to kind of refocus  to make sure you're taking care of the patient. But, you know, to look at it from another way,  how does your office look when you're in the office? How does your office look when you're in the office? But, you know, to look at it from another way,  how does your office look? Is it really inclusive for everyone? And that whole sports thing,  goodness, I mean, orthopedic offices, I'm not even a sports miracle doctor and it happens.  These are great ideas. Love it. Love it. Realize though, that's the reality is they've done  studies, they just Googled it to confirm, like there was a medical study that came out as quoted  in the New York Times that you can predict a physician's political orientation by their specialty, where orthopedic surgeons are the majority, because a lot of the data is public,  right, who you register as a party. And the reality is the majority of surgeons are Republican,  as opposed to like the majority of psychiatrists are Democratic. And whether an issue is politicized  or whether it should be as a completely separate conversation, but that's the backdrop  on which we often function, even at an AOS level. I'd be curious if anybody has ever noticed that,  but that's just the studies that looked at this found. So I moved to Texas, the great red state  of Texas, where there's all these pickup trucks and golf carts flagging Trump signs behind them.  In every surgeon's lounge that I go into, it is tuned to Fox News, which I cannot stand.  I'm sorry, but it tells me what they all think. You're laughing, Jackie. Yeah, no, it's true.  In fact, when I got to the hospital, I went to him, I said, why do you have a locker room that says  surgeons, and you have another locker room that says female staff,  but you don't have anything that says female surgeons. So they've now changed the label on the female staff. It now says female surgeons and female staff.  If you start looking too closely, you'll find it everywhere. Even at our hospital, I noticed that the only Spanish in the operating room is on the disposable  trash bags for laundry bins. But it's not on the anesthesia machines. It's not on anything, you know what I mean? If you start looking closely, you'll notice these things,  which I think we should. I want to grab the remote every time I'm in the surgeon's lounge  and just change it to MSNBC or something. Put it on HGTV. There you go. That's quality content.  Okay, well, this has been really great. And thank you everyone for joining and for participating. So, yeah. And thank you. I think we'll end it here, but hope to see you all soon.  Excellent. Thank you. Look forward to everybody in Louisville. Thank you so much.  Thank you. Thanks, everyone. Good night. Good night.

Video Summary

In this video summary, the speakers discuss various programs and initiatives aimed at improving healthcare services for the LGBTQ+ community. They mention the Q-card project, which provides a communication tool for queer and trans youth to educate their healthcare providers about their sexual orientation and gender identity. The affirmations deck is a collection of positive statements to affirm the queer and transgender experience. The trans buddy program pairs trained peer advocates with trans individuals seeking healthcare to help them navigate the system and advocate for themselves. The wellness center provides a safe and inclusive space for trans and gender diverse people, offering medical services, counseling, legal advice, and more. The speakers reflect on the importance of creating safe and inclusive environments for LGBTQ+ patients, such as displaying rainbow flags, using gender-neutral language, and incorporating LGBTQ+ healthcare education into medical training. They also discuss the need for more research and data collection to better understand the specific healthcare needs of LGBTQ+ individuals. The speakers emphasize the importance of treating patients as individuals and actively listening and responding to their concerns. They also acknowledge that mistakes may happen, but it's essential to apologize, learn from them, and work towards building a trusting doctor-patient relationship. Overall, the speakers highlight the need for greater awareness, understanding, and inclusion in healthcare settings to improve the experiences and outcomes for LGBTQ+ individuals.

Asset Subtitle

AOFAS On the Same Page: The Remedy
Presented in collaboration with Pride Ortho

Moderators: Jacqueline Nguyen, MD, and Joseph Letzelter, MD

Featured Book: The Remedy: Queer and Trans Voices on Health and Health Care, edited by Zena Sharman

The Remedy is a diverse collection of real-life stories from queer and trans people on their own healthcare experiences and challenges. The book also includes essays by healthcare providers, activists, and leaders about the challenges, politics, and opportunities surrounding LGBTQ+ health issues.

Moderators and participants discuss the discrimination and challenges the LGBTQ+ community faces in the healthcare system as well as ways to make orthopaedic surgery more inclusive for patients.

Learning Objectives:

Understand the unique challenges and discrimination that the LGBTQ+ community faces in the healthcare system
Identify some of our own biases when treating these patients
Consider changes that we can make as healthcare providers to provide more inclusive care for the LGBTQ+ community

Keywords

healthcare services

LGBTQ+ community

Q-card project

communication tool

queer and trans youth

sexual orientation

gender identity

affirmations deck

trans buddy program

wellness center

inclusive space