Everyone.
Good evening everyone.
I like that.
Good evening everyone,
and welcome to this year's Larner College of Medicine
Vito Imbasciani George DiSalvo LGBTQ Health Equity Lecture.
My name is Dr. Margaret Tandoh
and I'm the Associate Dean
for Diversity, Equity and Inclusion.
I would like to welcome you all,
both here and our friends joining us online,
and thank you for being at this event.
And now I'm gonna introduce Dean Page,
Dean of the Larner College of Medicine
to get us going.
Before I do that though, Dr. Longsbarry, for our students,
please log in for your attendance,
M1, M2,
and then if you having any trouble,
please let Dr. Longsbarry know. Okay?
Now I'll turn it on to Dean Page.
Dean page?
Thank you very much, Dean Tandoh,
it's wonderful to see you all here.
Exciting.
Dean Zale and I decided to wear our white coats
to remind the second years that you've had them
for almost a year now.
And just to incentivize the first year students
that we're looking forward
to sharing the white coat ceremony with you next month.
It's really my pleasure to welcome you all today
and hello to everybody in Zoom world as well.
We've got a packed house here
and this is really a special event.
This is the 10th annual Vito Imbasciani PhD, MD class of 85,
and George DiSalvo, LGBTQ Health Equity Lecture,
which this year is entitled Gender Affirming Care
as a Model of Health Care.
I'd like to express my personal gratitude
to Dr. Imbasciani and Mr. DiSalvo.
Vito and George, we're tremendously grateful
that you could join us here today.
Would you please stand up and let us recognize you, please?
That was completely off script.
They're going to have it with me later,
but it's only proper that we acknowledge your generosity
and allowing us to deepen our understanding and knowledge
of the issues of the LGBTQ healthcare.
We really appreciate the support you've given us
over the last 10 years,
and we're grateful for your enduring generosity.
This was the first,
and may still be the only endowed lectureship
at any medical school in the United States
that concentrates on issues
of furthering the goals of healthcare
by shining a light on the specific needs of this population.
This lecture is consistent with our college's core values
and our statement on professionalism,
which emphasizes that we treat everyone
with cultural humility, kindness and respect.
And we recognize that we must fully commit
to promoting equity and support of our community
and every community.
That this makes for a better, more diverse
and inclusive society.
It makes us better doctors.
I'm especially pleased that we get to hear today
from a visionary healthcare leader, Dallas Ducar,
who serves as Chief Executive Officer of Transhealth,
a pioneering organization committed
to transforming healthcare.
I'm personally really looking forward to this talk,
having spent the last hour with Ms. Ducar
and learning about her story and her commitment
to the position that she's in.
And here to introduce our speaker is now Dr. Pamela Gibson,
who serves as professor
in the Department of Pathology and Laboratory Medicine
is faculty advisor
for the Medical Student Gender Sexuality Alliance
and Vice Chair for Culture and Inclusion
in Department of Pathology and Laboratory Medicine.
Please join me in welcoming Dr. Gibson.
Thank you, Dr. Tandoh and Dr. Page.
I especially wanna thank Vito and George for being here
and for your generosity and creating this lectureship.
This has become an integral part of our curriculum
as it's now it's required
for first and second year students,
and it is an important component
of our continued learning as a community
related to our LGBTQ Health.
And I wanna welcome everyone here.
I have the honor of introducing Ms. Dallas Ducar,
our keynote speaker.
She's the founding Chief Executive Officer of Transhealth.
She's a visionary healthcare leader
who started this pioneering organization,
which is committed to transforming healthcare.
Transhealth is the first standalone transmedical
and mental healthcare organization in the nation.
Dallas, in addition to being CEO and president,
holds several degrees and appointments.
She's an advanced practice registered nurse
with a master's in nursing,
certified as a psychiatric mental health nurse,
and is a fellow of the American Academy of Nursing.
She's trained in narrative therapy,
mindfulness based stress reduction,
informed consent, harm reduction,
patient-centered care and community-based
participatory approaches to care.
She's also a faculty member
at the University of Virginia School of Nursing,
Columbia University,
and the Massachusetts General Hospital Institute
for Health Professions.
She's extremely active in shaping health policy
related to equity, ethics and gender affirming care.
She serves on multiple board of directors
that work to improve access and quality
for the transgender community.
As you'll hear today, Dallas is passionate about advancing
gender affirming healthcare in novel ways
that can serve as a model for all healthcare.
Welcome, Dallas.
Hello. Everyone hear me?
Wonderful.
I'm here today to talk about gender affirming healthcare
and how gender affirming healthcare
can serve as a model for all of healthcare.
For folks who might feel like this is the DIA lecture
or the lecture, that's kind of the cherry on top of it all.
I believe that this is foundational.
It's foundational to being good doctors,
it's foundational to being good clinicians.
This is, I believe a model of care
that really can shape how we practice
in any clinical environment.
So what I hope to do today is talk a little bit
about gender affirming care.
I'm not gonna really go into depth about
how to provide gender affirming care,
hormone therapy, different surgeries.
All of that can be learned elsewhere.
But I wanna get down to the philosophy of this,
the philosophy of what it means to affirm a patient,
the philosophy of what it means
to care for someone holistically.
And then give some examples
from our own clinic of Transhealth.
And then talk about what we can do
in really a world that is scary right now
for gender affirming care.
Really a world that has more news items
related to gender affirming care than I've ever seen.
Raise your hand if you've seen gender affirming care
in the news in the past month.
Yeah. Every major medical organization
supports providing gender affirming care,
and yet we've seen it become a extremely hot button issue
and centerfold to political campaigns specifically.
So we're gonna talk a little bit about advocacy too.
So today we will analyze the present landscape
of gender affirming healthcare environment in the US.
We'll understand strategies
for providers to deliver individualized and attentive care
for trans and gender diverse patients.
And we'll assess and implement effective strategies
to promote organizational change.
So I wanna start by redefining what we talk about
when we talk about good healthcare.
So what we know is that healthcare,
pathologizes bodies and identities.
Think about when you walk into a room
and you're assessing the patient.
You're looking for someone that's in distress, usually.
You're looking for someone who's in pain.
Maybe if someone's barreled over,
you're wondering what's wrong,
you're working through an assessment right there.
Healthcare teaches us to start with a lens
of what's wrong with you, rather than what's right with you.
And that's really critical to being a good clinician,
being a good provider, being good doctor.
But gender affirming care tries to flip that on it's head
and says, we are actually gonna lead with affirmation
and we're gonna say what's right with you.
Now, gender affirming healthcare
is based on informed consent as well.
Who here is filled out or given an informed consent form?
So it's not just the form itself,
it is actually asking how one should be referred to
how they should be referred,
and who they should be referred to.
Using the right pronouns with the right person
when you're on the phone,
knowing if you have informed consent
to talk about someone's gender identity or sexuality.
And trauma-informed care,
ensuring that the care that we provide,
that everyone that we work with,
we assume that someone may have experienced trauma
and start with that conceptualization,
so as to not re-traumatize the individual.
So that we can then instead say,
"Where do you wanna be and how do we help you get there?"
So gender affirming healthcare
is really putting the patient in the driver's seat.
It's asking where do you wanna go
and how do we help you get there?
And I believe that care for a gender diverse individuals
can be a model for all of the healthcare that we provide.
So if we look at models of gender
and we think about where we first interacted with gender,
if we think about something as early as the NICU,
for example.
If you're assigned female at birth, people may say,
"Oh, she's so delicate.
"Oh, she'll get through this."
Or if you're assigned male at birth, "Oh, he's a fighter,
"he's tough, he's got this."
The language that we use with children
before they have any identification of gender,
when the child is pre-verbal,
gender is used linguistically around that child everywhere.
And the associations that we have too.
Now, if we think to family, think back to your chores.
Who here was asked to wash the dishes in your family?
What about carrying out the groceries,
carrying in the groceries, rather?
Now thinking about yard work, for example,
thinking about different divisions of labor,
some people depending on the gender roles in your household,
might have had different divisions of labor in your family
and based on your culture too.
And so the way family structures are developed,
the way schools, what schools we might be able
to have access to.
I went to a all boys school, a Catholic school
and was not allowed to go to the all girls school.
What school we go to,
what educational opportunities we can afford
based on where you are in the United States.
What healthcare access you might have right now
if you have access to reproductive healthcare.
Where you might be incarcerated.
All of this, is defined by your gender
and how society interacts with gender.
Male physicians still get paid more on average
than female physicians.
Same in nursing too,
in a predominantly female oriented field.
And so it's an economic issue as well.
This isn't just, you know,
it's talking about gender,
but it's talking about all the intersections of gender.
And then how race and ethnicity intersect in these as well.
So what we know is that 50 to 70%
of all trans and gender diverse people
report based on recent studies, report discrimination
and large scale mistrust.
50 to 70%.
So if you are trans or gender diverse,
you are less likely, much less likely
to trust your healthcare provider.
That number increases at the intersection
of race and ethnicity.
And what we know too is that if we are able
to provide a patient-centered,
trauma-informed holistic approach,
that we'll see higher patient retention
and we'll see more patient satisfaction.
And so this, and what we know across the research too,
is that access to care is just not enough.
We just don't have enough access
to specialized LGBTQ competent care,
but especially care for trans and gender diverse people,
especially when we're seeing it being increasingly
politicized across the country
and banned in certain states.
So what we know, at least according to more recent reports,
is that in terms of discrimination,
nearly half of trans people report discrimination,
including 68% of trans responsive color
more than half report postponing or avoiding care,
including 60% of trans respondents of color.
And experiencing insurance denials
around 46% of all trans people
and 56% of trans respondents of color.
So there's a good reason not to trust healthcare providers
if you're trans,
and especially if you're a trans person of color.
We also know that around 40% of trans people
report suicide attempts.
This isn't suicidal ideation, this is a suicide attempt.
This is a staggering number compared to the national average
of suicide attempt rates.
And as a psychiatric clinician,
I don't know of any intervention
that's as effective as what I see here,
that this goes down 82% just with support.
This is not something that's inherent in transgender people.
This is born out of a society
that otherwise does not support transgender people.
And so one of the best interventions you can do,
just starting out,
is actually asking about support,
understanding support networks,
understanding where people receive their support.
If we know that trans folks don't have access
to care predominantly and experience distrust
in healthcare systems,
it's no wonder that with a lack of support,
especially familial support,
so many trans people may find it so difficult to live
or get out of bed in the morning.
And we know that this is much more likely
with unsupported families.
And so one of the most important interventions
that you can do, is begin to educate
working with families, especially if you're interested
in pediatrics, for example.
Especially if you're talking about gender early
and gender identity.
And what's really staggering here is that these individuals
who responded to this survey
are those who live to report suicidality.
This number is actually likely higher.
So there's something critical going on
and something that we can do
in providing patient-centered care
and good comprehensive care.
That's really pretty simple.
So where are we right now
on the landscape?
Well, we're seeing widespread disinformation
that's propagating across the United States.
We're seeing people who provide gender affirming care,
be called child mutilators, for example.
We're seeing that physicians and nurses
are forcing this on kids.
And over 20 state governments now
banning gender affirming care for kids in general,
including discussing gender.
When we know that kids begin to explore gender early,
including discussing gender and sexuality in schools too.
And so this medically informed care
that has been practiced, we've seen since,
I mean, we've seen histories of kids in the United States
transitioning as early as 19,20 now
has become a cultural flashpoint
that has then led to vilification, ostracization,
legislation and violence.
Violence on trans people, violence against providers too,
violence against physicians.
And if we look at LGBTQ policy
in the United States right now,
we see many individuals, especially in the south,
continuing to fight against a minority view
for liberation and the ability to express oneself
and the freedom to be able to express oneself.
And specifically in the trans community,
we see again, over 20 states now
that have ban pediatric gender affirming care.
Some states now also attempting to ban
access to adult care too,
if people are following Florida specifically.
And Florida's Medicaid program
and threatening to cut all adults
from access to any gender affirming care.
People that have been on hormonal replacement therapy
for their whole life.
And then the state intervening.
And we've also seen at least as last Pride for example,
does anyone recognize this picture?
Raise your hand if you do. Yeah, some folks.
So you know, White supremacists showing up at Pride marches
with weapons attempting to lament violence.
And pediatric children's hospitals as well being threatened
with bomb threats too.
In the end, especially as clinicians,
we all want healthcare that cares
for the whole person.
And unfortunately, many of those who might react
with violence aren't really gonna be hearing this message.
And so instead, it really relies on us as communities
of providers, as clinicians, as people who care as healers,
to rely on facts to be able to provide those facts
and to be able to provide access to quality healthcare.
And so really what we're seeing in the United States
is an increase in violence against healthcare providers,
and especially in places that are caring
for marginalized communities.
And we need people to feel safe.
And so part of the work that we've been doing,
at least at Transhealth and our advocacy work,
is to really ensure that there's additional funding
to ensure that providers and the clinicians
that health systems are safe
so that people can provide evidence-based care.
Because I think the worry in the gender affirming care space
is that if people don't feel safe to enter into this care,
who will be providing this care
in the next generations, right?
So gender affirming care in my viewpoint
is simply good healthcare.
It's evidence-based care allows for individuals
to better know themselves, their identity,
their medical needs.
And nothing is being done overnight,
which we'll get into.
Clinicians are acting thoughtfully and deliberately
because these interventions are lifesaving.
And whenever I tell someone who doesn't really understand
gender affirming care,
that it's a model that respects individual choice,
it's guided by science,
it gives you the time that you deserve to be known.
I'm generally met with a response,
"I wish that my healthcare was like that."
Isn't that what we all want from our own healthcare
is to be known is, to be cared for,
to be able to be understood?
To be able to have time.
So the fact that the national discussion
around affirming care is so divorced from the actuality
of what happens on the ground,
you know, affirming care really deeply,
it respects deeply held principles of freedom and liberty
and acknowledges that you can pursue your own happiness.
And who wouldn't want that?
And while we see that every major healthcare organization
supports affirming care,
we see fringe groups resort
to domestic terrorism.
Instead of reasonable debate and dialogue
between scientific and medical experts,
we've seen belief in personal ideology motivate actions.
And so really what this takes
is meeting this moment
with good education,
with facts and with advocacy,
which is what I hope to get into
in the latter half of this presentation too.
How we can actually work towards change.
So one thing that we really have seen here
is that Telehealth has been the key
to expanding hard to reach care.
And we've seen this specifically during the Covid pandemic
with many people that otherwise trans folks
would have to drive up to two hours
to be able to get good competent care.
And we're all setting sometimes three or four hours.
Trans folks also disproportionately
make less than cisgender folks.
And so already having to take a day off of work
and then being able to try to get hard to reach care.
And we've seen that Telehealth has really been able
to expand access to that care,
which has been a huge benefit.
At Transhealth specifically what we've launched
in conjunction with the Department of Public Health
has been access care program,
basically a line that you can submit a request at any time.
Right now it's only for Massachusetts residents
that we hope that it'll be able to expand and replicate.
And you can ask as a provider, as a doctor,
any question that you have around gender affirming care
and have that answered in the moment.
So that we're able to integrate affirming care
into more conversations.
And we're able to integrate it into well child visits.
This doesn't mean, I just wanna be really clear,
it doesn't mean starting any intervention here,
it's just being able to talk about gender.
Because we know that awareness of gender identity
comes on about three or four years old developmentally.
And so being able to integrate conversations about gender
and being fluid and being able to just discuss this.
And same with sexuality too.
When we see, you know, conversations around sexuality,
especially in kids start to come up around puberty or so
a little earlier too, and defining one's sexuality,
it becomes instrumental in being able to just
provide this good care to any person.
And we know from so much research now
that access to gender affirming care saves lives.
And so I believe that we really have a responsibility here
to help support individual freedom
and to help people make their best decisions
with informed consent, based on clinical outcomes,
based on scientific fact.
And we know that we need more spaces to be able to talk
and more time to be able to talk to our providers.
And so it's essential, I think,
to be able to actually start rethinking how we provide
that care in an affirming model
and integrate that into the care that we provide every day.
So, safe care, I would say is really the ground level here,
ensuring that the patient is safe.
And what we're really trying to strive for
is not just culturally competent or culturally humble care
or ensuring that we have informed consent
or ensuring that everyone's educated,
but actually creative, authentic explorative spaces
with patients.
How many folks in this room, by a show of hands,
have felt like you've had a creative,
authentic or explorative healthcare experience?
Couple. Yep.
How many of you would want to experience that
at some point in your healthcare journey?
Yeah, maybe not everyone.
Maybe it sounds, "Ooh, this might be a little too far
"for me."
But being able to provide a space
where you can actually know your patient
and your patient can be better known,
that is what I'm talking about here.
Doesn't mean that your provider or your doctor
needs to know everything about you, right?
But being able to have the trust
to be able to actually have a real discussion.
So before I get into some advocacy
and strategies here really,
I wanna provide a example
of what we're doing at Transhealth in Western Massachusetts
as one example of what this can look like
when specifically geared towards
the trans and gender diverse community.
It does not have to...
I think this model can really be applied
with any population.
But this is one example of how we do it.
So we started by trying to understand
how many trans and gender diverse people
there are in our immediate catchment area.
How likely do people think trans people are to report
that they're trans to the government, to the US census?
Not very likely, right?
Especially if you are also perhaps in the closet too.
But in essence, populations are hard to count for a reason,
hard to count because people don't wanna share,
may not feel safe.
And hard to count because there are maybe systems in place
that don't count.
And if you are not counted, you won't count.
We still don't know the full impact of the Covid 19 pandemic
on the LGBTQ community.
Because at the time the CDC was not gathering SOGI data,
sexual orientation gender identity data.
And so CDC then doesn't know how to adequately respond
to that population on a public health response.
And so the best data that we had
was the behavioral risk factor surveillance survey,
and then also combine that with the best census data
that we have.
And found out that there were quite a bit of trans folks
that likely lived in Massachusetts,
Western Mass, which is where we started.
We did start in 2020, we didn't know
when we were first starting to think about it,
the world was really gonna flip on it's head
and where we all were in 2020 or so.
But we saw Telehealth really expand dramatically.
And we also saw year after year, more and more trans folks
come to Massachusetts specifically as a safe space.
So that's when we started, we started on May 4th,
which is Star Wars Day for all y'all nerds out there.
And what we built was something that was, I think,
much more than any of us expected.
So this is a table that one of our nurses
built in the clinic and just came in one day and decided,
you know, I think the kids need a chalk table here
and just decided to do it and spend his own money.
We obviously reimbursed him,
but he cared that much about the clinical environment.
People beginning to bring in so many different flags.
I mean so many flags,
I don't even know what they are anymore.
And if you want a really fun journey,
go on Wikipedia and just search all the LGBTQ flags.
There are many.
And it began to grow too.
We wanted to make it feel like a nonclinical space
in some way, we didn't want it to feel sterile.
So we wanted to ensure that there was,
you know, a space that had cool wallpaper,
spaces that didn't feel so hospital esque perhaps.
And about 85% of our team identifies
as trans or gender diverse.
So you have a very different clinical environment
when you can see yourself represented
in those that are caring for you.
And the interventions that come up like this
misgender jar for example,
and turning that into a positive affirmation
was just one example of people just being creative
and just wanting to devote their own selves to this work.
Different examples of...
I really need to get some more pictures in here now
because these are old pictures and there's again,
many more flags.
But then allowed us to provide psychotherapy,
primary care, psychiatry, community services
and eventually research and advocacy and education.
And over two years growing to 50 staff members total.
And about 2,500 trans or gender diverse patients.
And that's two years, that's not a lot of time, right?
There's a demonstrated need in building this place.
Core to it or essential to it really is our community room.
And our community room is a place where there's
a Nintendo Wii, you can drop in, you can hang out,
there's drama groups, yoga groups, meditation groups.
There were these kids that put on a play.
And that was just, you know,
I mean that was just a part of the community programming
that was offered.
It was not just, you know, your DBT skill group,
though that's really, really important.
But also being able to rethink,
what else can a healthcare facility offer to
that really becomes a home for people.
One of those is a closet too.
And as many people literally coming out of the closet
able to get clothes and also give some of their clothes
away to other trans folks that were in need too.
You'll see in the back too, a voter registration sign,
we believe that civic engagement
is a part of whole health too.
That's a program called Vote-ER
that started Mass General's Ed
but really getting people registered to vote
and engaged and feeling a part of a community
that otherwise may have they felt forgotten by.
Anyone know Trixie Cosmetics?
Yeah, some folks.
So then, you know, DMing, Trixie Cosmetics Instagram
or something and then getting free
cosmetics and different supplies
that then eventually go into our community closet
and having other members of different communities
donating hygiene products, cosmetics,
different prosthetics, whatever it is,
to be able to have this place be built by community.
Having a tree, this tree now stays up all year round.
We did put it up and it's just there
and it's different ornaments at different times of the year.
But really what I'm talking about
is what this kid wrote here.
This is what I mean when I talk about gender affirming care,
being nice
and having fun stuff
and rocking.
And it's not really rocket science here.
I mean if you practice gender affirming care
in primary care, it's pretty basic primary care.
If you're practicing it in psychiatry and mental health,
it doesn't take whole core curriculums.
And at the end it starts with or at the beginning rather
it starts with compassion
and starts with patient-centered care
and treating people as human beings.
This was written by an inmate
at Gardner State Penitentiary in Massachusetts.
And he wrote to us and had said
that during this time he was not an LGBTQ person,
but that learning about us on the news
helped him better understand his transgender daughter.
And that during this time we had become
a beautiful and caring light.
And then went back to try to help the LGBTQ affinity group
in the prison to be able to have more resources
because he cared so much about his daughter.
So in these ways, healthcare can become a source of hope
and healing in so many other ways
that are not just defined by insurance,
that are not just defined by a pharmacy benefit manager,
not just defined by a relative value unit,
but defined by what we pour into healthcare
and that relationship that we built
and the community that we built.
So you'll see here some examples do include
our Covid vaccine clinic
that we partnered with the Department of Public Health Fund.
BIPOC Joy groups.
Support groups, notice that the support group
for trans and gender diverse parents.
So it's parents who are trans or gender diverse.
And so really providing some niche groups,
some of them supportive,
some of them a zine workshop.
Who here has seen a zine before?
Yeah, I found my first zine there. Yeah.
And spaces that are creative, but fitness classes too.
Blackout poetry classes, body work sessions,
Fall Social Name & Change Clinic.
Farm shares.
Just really trying to expand
what we mean when we talk about community-based care, right?
And imagining how we can provide that care
outside of the one-to-one patient to doctor relationship.
So also right now
in healthcare specifically,
it's really hard to hire
in the workforce in general.
There's a lot of, especially with folks
in support staff roles, many spaces,
nursing too, it can be difficult to hire folks.
And one of the best predictors of retention
is whether somebody at work cares about you.
One person at work really cares about you.
And when surveying our team at Transhealth,
we saw that a hundred percent agree
that someone at work caress about you.
This data is not often seen in healthcare environments.
And so this creation of a community,
it's not only creating community for the patient
and for the community, but for our team too.
A space where everyone's able to feel safe,
known, affirmed, where you can be yourself,
where you can be yourself at work.
And when surveying our team, again,
we see a hundred percent of our team
says they can be themself at work.
That's probably not the most important part
of being a healthcare provider, clinician, doctor.
But it probably helps when you can show up at work
and be authentic and not have to shove parts
of yourself down to be able to do your job.
When we ask our patients
and patient satisfaction can be really hit or miss sometimes
in trying to really understand how patients feel.
But when asking if Transhealth affirms patient's identities,
we see that about 93% agree
with Transhealth affirming identity.
Around 89% of patients saying that they can be themselves.
Now remember that 50 to 70% of trans folks
report discrimination.
So this is a very different statistic
going from expecting discrimination
from your healthcare provider
to being able to be yourself.
As one patient said, "I like never being dead named
"or having staff who aren't familiar with me get confused
"on how to address me.
"It's especially nice to not have to explain my existence
"or wonder if the person across from me is an ally.
"There's a difference in being in an office
"that's working to make you feel welcome
"and being in one where you never even have to consider it.
"There are some things that are intangible
"and are beyond being able to adequately explain
"to those, not of that experience.
"Other practices were okay mostly
"they checked all the boxes.
"But at Transhealth, I'm not a box to be checked."
I promise I didn't pay anyone to write that.
It was online.
I promise I didn't pay anyone for this either.
"The care of Transhealth has been better
"than my wildest dreams
"and it's a big reason why I stayed in the area
"as long as I did.
"I doubt I'll have a more knowledgeable, kinder,
"more responsive care team again.
"Thank you so much for what you've done, continue to do.
"And I honestly feel bad for all the cis people
"who can't go to Transhealth for their healthcare."
I promise you everyone is welcome at Transhealth.
It just so happens that we have a lot of trans people there.
I wonder why.
But we do not discriminate and we'll see anyone.
But imagine being a patient and staying in a location
because of your care provider.
Even in an of area of Telehealth too.
Or not being a box to be checked, right?
Or having your patients feel like
they don't have to be a box to be checked,
whether your patients wanna stay because of you.
So we focus on clinical care
and we also focus on our other pillars too.
Education, research and advocacy.
And that's supported in our foundation, is community.
So at the end of the day,
we are nothing without our community.
And while all of these are separate departments there,
it really relies on understanding
and listening to the community.
These are just some examples
of some of the headlines that came out.
We did not advertise since day one.
And people were like, "Well, like are people gonna come?"
And we, you know, waited by the phone literally on day one
and within a week we were flooded.
This was the impact in the first year.
A heat map showing different concentrations of folks.
And this was the impact after year two.
Now, just to clarify, there's a difference between
gender dysphoria and leading with a diagnosis
versus gender diversity in someone's identity, right?
Outside of a diagnosis.
So many of these people identify as gender diverse.
It doesn't mean that this is based on any diagnosis at all.
It's people who felt safe and comfortable and cared for.
So I wanna talk a little...
I think it's nice to hear about Transhealth
and that's like really cool Dallas, but like what do I do?
And so I want to focus a little bit more on what you can do.
And this is gonna be a little outside
of maybe the traditional medical school lecture
that's focused on here's how you care for a patient.
I think that everyone's probably gonna learn
how to care for trans patients.
I think it's much more about the impact
that we want to have,
and especially in this moment right now,
as brilliant, brilliant humans.
How do we stand up for evidence-based scientific healthcare?
So some just general misconceptions,
I just wanna point out too.
I think everyone probably understands these,
but puberty is irreversible, right?
And the choice to do nothing is really a permanent one.
So when blockers, GnRH agonists
are provided to a kid, for example,
that is at the age of puberty specifically.
And blockers are used very often in precocious puberty,
in cisgender populations.
This is with lots of discussion,
lots of discussion with both guardians or parents
or whomever has legal custody of the children
and a pediatrician and a mental health provider.
And that there's lots of discussion that's involved.
It's not something that's happening overnight.
And the decision to not do anything,
to not pause for a moment and have more time
to be able to make an informed decision
with the whole family present and the entire team
is more of a permanent one.
It's also not a conveyor belt too.
So we're just not feeding people into a system.
This is an assessment with a large team,
including multiple mental health providers,
pediatric care and parents at every stage.
And so assessment and treatment planning
is really according to expert standards of care.
And we also know that no two transitions are exactly alike.
Transition is very individualized, aged appropriate process
that is a long-term partnership between the provider,
patients, patient's parents or guardians.
And one commonality that we see
is that the rate of regret is incredibly low,
lower than regret with knee replacements.
We see more gender affirming surgeries
happening in cisgender populations
than transgender populations, for example.
So a lot of the disinformation out there,
it starts with being able to really dispel misconceptions.
Another piece of disinformation that is out there too
is around the amount of transgender people
in the United States.
And this belief that transgender people or LGBTQ people
are increasing over time because of exposure to media,
social media or exposure
to other LGBTQ people who are grooming folks.
And there's no evidence for it, first of all.
But what we do know instead is that,
if we look at left-handedness
and starting at around when we get to the forties
and fifties or so, when we start to see left-handedness
not be pathologized and people who are left-handed
not be victimized and they're being more social acceptance
for left-handedness, we see more people
that are able to be left-handed.
When you have more social acceptance of a population,
you see more people able to express their own identity.
And so it makes sense.
You know, we were talking to some medical students
earlier today and we were talking about how
it was 1972 that the DSM
had homosexuality as a diagnosis.
And we forget how much progress has been made
since the seventies.
And so while it may not always feel like an affirming,
a more caring culture right now in this moment,
it's only natural that we'd see over time,
more and more kids that feel safe enough
to be able to talk about who they are
and to be able to come out to parents or others.
And what we know is that in general,
I know there was a ton of doom and gloom earlier, right?
But what's really important to remember
is that eight in 10 Americans,
this lecture is largely gonna focus on the United States.
'cause that's where I'm pulling my data from right now.
But eight in 10 Americans support non-discrimination.
That's a large number of people in this country
compared to where we used to be.
We see that Republican politicians from Florida to Idaho
are attempting to turn trans rights
into a divisive national issue.
But in my experience as a trans woman
who's lived across the country,
these positions seem really out touch.
The conversations I've had with conservative neighbors
in Arizona or centrist friends in Virginia
are different to the ones that I now have living,
say in liberal Massachusetts, North Hampton.
They're not different, rather.
And the vast majority of Americans believe in general,
in values and liberty and don't believe it's their business
to be regulating the identity of other people.
And so these attacks on trans kids and trans people
might create headlines,
but what we really see in general
is that voters' priorities,
and we're coming up on another election
whether we like it or not,
voters' priorities are the economy and healthcare.
And we see that time and time again.
And when you look at priorities,
even in Republican or Democrat or independent polling,
trans people, trans kids do not make the top 20 of that.
It's just a non kitchen table issue.
So when you narrow that question down to attitudes,
you do find that eight in 10 Americans
support non-discrimination protections
for LGBTQ individuals,
including 65% of members of the Republican party.
2021 poll found that two thirds of Americans
opposed bills limiting transgender rights.
And this follows big picture trends
like decades long evolution
that led to the legalization of same-sex marriage in 2014.
Where the trend among the next generation of voters,
where 5% of youth now identify as gender diverse,
three times the rate than the greater population.
We see that this is a manufactured marginal issue.
And we've seen dozens of states passing laws
restricting kids from participating in sports,
limiting access to care,
mentioning LGBTQ history in schools.
But we've seen the four recent elections
in American history rejecting that extremism
at the ballot box.
And we saw that in 2008 midterms
when these issues were elevated,
those who elevated them
did not necessarily succeed.
And we've seen the 2022 midterms
where people who were denying elections
and anti-abortion extremism also got crushed too.
So extreme policies are really good
for winning primaries,
but they're really great for losing the general election.
And each time, the conventional wisdom in the media,
even on the left,
was that you might be steamrolled by bullies.
We see four clear wins later that that's not the case.
And so I think we're seeing
a continued trend in general support
for people to be able to identify how they identify
without intervention by the government.
So at the core of our democratic values
relies the promise of liberty,
freedom and the pursuit of happiness.
And I believe that this pledge really should extend
to all citizens and non-citizens too,
including transgender individuals.
And the ability for trans individuals to be able to direct
their own care, it's not just a health issue,
but a testament to foundational rights.
It speaks to the essence of parental rights
when you're talking about youth
and also the sanctity of the family unit
and should be free from government intervention.
We pride ourselves on these values.
And so when discussing affirming care,
I mean, what we know from the Covid pandemic
and talking about vaccinations in general
and trying to get people vaccinated
is it's not science that's gonna convince people.
You can talk about the science of a vaccine all you want,
but it's illustrating shared values.
It's talking about the care that you might have
for maybe an elderly relative, for example,
and why it's important to get vaccinated.
And same here, really identifying the shared values,
identifying the audience that you're talking to
and saying what are those shared values
that we hold together?
And how do we have a conversation together?
How do we emphasize our shared experience?
How do we illustrate the concrete scientific harms
that lead to increased suicide attempts
amongst trans kids, if we continue to see trans kids
being vilified.
And instead cut through the disinformation
and talk about the truth of what's actually happening,
while not reinforcing those negative beliefs.
Everyone in this room is extremely privileged
to be able to be a doctor.
You'll be a doctor,
you'll have a moral authority
and you'll have a duty to do no harm.
And so your voice is incredibly powerful in this
from a fact-based perspective,
but also by talking about shared values
and how to prevent additional harm against trans kids
or trans people in general.
Every major healthcare organization
says it's the duty of that profession to advocate.
And so, your healthcare organization,
the AMA, is saying advocate for that patient,
not just right there at the bedside,
but at the State House and on Capitol Hill.
And this is why I'm talking to you today about advocacy
because your voice is critical here.
What we can also do is begin to, on a clinical level,
adopt universal precautions.
So just as you might clean your hands
before entering into a patient's room,
just as you might have a standard assessment
when you're walking in to greet the patient,
being able to incorporate in your universal precautions,
introducing yourself,
introducing your own pronouns,
and then asking the patient for their name
and their pronouns.
Not their preferred name
because our names are our names, right?
It's just our names.
Not preferred pronouns, but just our pronouns.
And I was telling some medical students earlier today
that when I was a nurse on a psych floor,
the sheer act of me asking a patient's pronouns
led the patient to disclose that they were trans
after 40 years of repressing their trans identity
because they lost access to hormones early on in their life
and then were kicked out of their home,
had no access to economic resources,
had to live on the street and had to detransition
forcibly really on the streets to survive
as a male instead of a female,
so that they were not assaulted on the streets.
And it wasn't until I asked that patient
who everyone presumed was male,
what her pronouns were
that she was able to disclose
for the first time and felt safe enough doing it.
That then kicked off a lot of scans
that found that she had terminal cancer
about six months left to live,
and she was gonna be released from the psych unit,
in patient psych to the street
until we identified that she had about six months left.
We advocated for her to get access to hormone therapy,
estrogen, but due to the clotting, it was unclear.
And so an ethics consult was called.
And finally she was able to get access
to the estrogen therapy
while she also moved to hospice care.
And she was able to die
the woman that she knew she was.
And she didn't deserve me asking for her pronouns
for that to be the time.
She deserved to be able to be known as herself
40 years before.
So asking for pronouns is incredible intervention.
Yes. And it should be just a part of the basic assessment,
but that should not be the ceiling,
that is the bare minimum that we can do as healers.
It's not just about how we engage with our patients,
but how we engage with others that we may disagree with
and how we have conversations with those
we may disagree with.
And engage in value-based discussions that might be hard.
How we work to change institutional policy,
to recognize our own power
and to show up authentically at work
to be able to have a place where you can be yourself.
And that requires the whole team,
that requires the institution's commitment.
What we can also do,
we're concerned about larger policy issues,
is work with state equality organizations in other states.
We, again, carry so much power.
So writing op-eds, writing editorials,
working in the legislative process,
information sharing, we at Transhealth
created a pediatric affirming care coalition
that now has 500 pediatric providers
across the country in every state.
That information share about what do we do
in this moment right now.
It's so valuable to be able to even just engage there.
An engagement with the AMA.
So I do believe
at Transhealth, this is just one model of what we can do
in healthcare altogether.
But we can shift healthcare from a treatment centric model
to one focused on prevention,
one focused on affirmation,
one focused on community.
We can directly counter what the nation's top doctor
just declared an epidemic, the loneliness epidemic.
And that starts with building community
and preventing deaths of despair and suicide.
We know that places like Transhealth
have shown very high patient engagement
and I bet have saved a ton of lives
that otherwise might be lost to suicide.
And we can do that for any of our patient populations.
One way we've done that is we've extended the time
we spend with our patients.
We have hour long initial visits or 30 minute visits,
which can be somewhat unheard of in primary care these days.
But we want to create a space
where that patient feels known,
where that patient patient feels seen,
and that takes time.
We also really have tried to prioritize real world concerns
over whatever insurance says is what we should be
really the priority of our assessment.
So now we're gonna listen to what the patients say
that they need.
And that's been community surveys,
that's been then responding with community classes
as you saw there, community closet,
many other things that are outside of the scope
of the initial visit.
We also have tried to really focus on staff wellbeing,
addressing systemic staff burnout,
dissatisfaction by trying to create a more compassionate,
affirming work environment.
We know that the physician suicide rate
exceeds that of active military members
returning from Afghanistan.
That's terrible.
And so by creating a more affirming place
where your colleagues care about you
and you can be known as someone who's a part of a team,
that's what we're trying to strive for.
So that this is wellness for everyone here
and not a system that just burns people out
and churns 'em through.
And then in focusing on community engagement,
patients becoming active community members,
fostering social connections that mitigate loneliness.
And that's all been possible.
You're like, "Dallas, how is this possible?"
Well, through revenue diversification
and not just relying on primary care RVU's
to provide all this money,
but thinking about creative financial ways to augment
the time that then patients are able to spend
with their providers.
I believe, I'm sure y'all have heard
about value-based healthcare
and have talked about value-based healthcare.
I believe that this is value-based healthcare.
I believe that when we focus our shift towards
intervening at the right time at the right place,
we're able to actually care for that patient
when they need it.
We don't commit to overuse of care or underuse of care.
And so it's not the patient who's been discriminated against
that waits and waits and their problem gets worse
and they don't go to urgent care.
And then they finally show up at emergency care
when the problem could have been handled in primary care.
But instead that that patient trusts
their primary care physician
and that that patient can show up right there.
And that costs the system a lot less money.
And it also costs the body a lot less too,
and likely prevents against death.
And that starts with trust,
rebuilding trust in our healthcare environment
and the relationships we have with our patients.
And I believe really wholeheartedly
that we need a way to tackle the loneliness epidemic
in this country.
And we need a way to be able to foster community.
And we need a way to be able to help us all
have a space where we can come back to each other.
And I don't know of any other vehicle
that can do that as well as healthcare.
It's not the tech industry.
So think of your own care.
Think of the last time that you went
and received healthcare.
How well did your physician, your provider,
your clinician know your dreams?
And what would you want them to know?
Could they have known you better?
What could that care have looked like?
And what is one action that you can commit to today
that you can walk out of here with,
be able to change your camp.
I'd encourage you to maybe write that down on your phone
or on a piece of paper or somewhere.
But something that you will take out of this room
with you today, carry with you,
that will change the way that you practice moving forward.
Thank you very much for your time,
and I'd be happy to answer any questions.
Thank you very, very much Dallas for that talk.
And we have microphones across both sides,
so we're open for questions.
And I don't know if Bruce is here.
I don't know how will I get questions
from our online provider?
[Bruce] I'm here Dr. Tandoh.
All right questions from the online,
people that are online.
[Bruce] I don't have any so far.
Okay.
So Dallas, let me start off,
as a provider, as a trauma surgeon, you know,
the last questions that you put out,
like what do my primary care know my dreams?
And I was like, "No."
But I mean, the thing is, you know,
being realistic, I was like,
"I don't think they have time to even ask
"about knowing my dreams." You know?
Yeah.
So is the system that we have created
and how do we go about changing that system?
Because I'll be honest, they barely know the medicines
that I'm supposed to be taking,
and then the one I don't take I don't tell 'em
that I'm not taking, you know.
So, you know, so even to get to that point, you know,
it becomes pretty difficult.
-Yeah. -Yeah.
Yeah.
I mean, I think it starts really
with the philosophical shift
and starting with
thinking about
you know, how healthcare can become a space
where people are able to discuss their identity
in some way, right?
I mean who they are in some way, right?
And at Transhealth, it's like second nature
to be talking about your identity
and your sexual relationships and who you are,
who you want to be.
And it's really very much a part of the conversation
with a provider.
And I think that's because at the starting point,
you know, the provider is really starting,
I'll take with our amazing physicians for example,
is starting with questions that are very open-ended
and very much, they are not leading questions,
but you know, what should I know here?
What are your values?
What are your goals for care?
And starting there.
And working with the family there too.
And that requires having enough time.
-Right? -Right, right, right.
So I mean, one, it's a philosophical switch
and two, it's a time allocation too.
And then three, it's like the patient
actually knowing that that's what they're signing up for
in a way too.
Because I can imagine you going into your primary care
next week and they're like, "So tell me about who you are."
And you're like, "What?"
(both laugh)
Like, "No, no.'
So it requires a shift.
-Right. -Right?
And people to understand what they're signing up for
in a way too.
And not everyone will want that,
but we have created a space
where people are able to discuss that.
And like how many times do you get to discuss your identity
in a healthcare context?
-Right. -Yeah.
That's great. Questions?
Yep. Dr. Gibson?
Hold on till you got the microphone.
[Dr. Gibson] Thank you very much. Excellent.
Can you talk a little bit more about
getting additional funding?
It sounds like not just what the insurance will pay
for the visit to help support the Transhealth,
community structure that you've developed,
the patients, the longer visits, all of that.
Can you talk a little bit more about that?
So part of that has been,
so I mentioned those different pillars, for example,
part of that's been through advocacy work,
which is why the advocacy work is so important.
And having testimony on the hill is so important too.
And part of that was say protecting reimbursement models,
having pay parity for Telehealth visits in Massachusetts
to make sure that there was not,
I think there were proposals for insurers
to lower it down to like 70% per in-person
in Telehealth, for example.
So trying to first protect payment parity, right?
And what we've already seen is some gains
also working advocacy to increase payment rates too.
Starting with places like,
at least in Massachusetts Mass Health, for example,
our Medicaid program.
And then from there it's also been
trying to work with government partners
and trying to bring in additional sources of funding
through government itself
and through some of our advocacy work.
It's also been through pharmacy programs too.
So we've seen specifically
through drug pricing program
called 340B, that that has been helpful.
It's not something ever to rely on fully,
especially because there's been some challenges to it.
There's also just, I think
considering other service lines too,
I mean at least for the trans and gender diverse community,
that can include things like, and we don't do this yet,
but working towards surgical programs for example,
or working towards
like dermatology as well.
Maybe that's laser hair removal,
maybe that's electrolysis too.
And then also, you know, I think for the long term,
it's also thinking about all those lives that are saved
and how we incorporate that into our quality models.
And we incentivize that and say, "Let's capture
"how many lives are saved with a community care based model
"and how that actually translates
"to better patient outcomes."
And then, you know, reimbursement the rates too.
But it's really been through that revenue diversification.
And then also impact donors too.
Yeah.
I have one person there.
And then Dr. Imbasciani.
[Audience Member] Hello. Oh, hi.
Well first of all, absolutely wonderful talk.
I really loved it and I feel like I learned a lot,
so thank you so much for your time.
Thank you.
[Audience Member] Also, I just kind of wanna make sure
that I understand because you kind of mentioned
like this is just good healthcare,
you know, like this model is just
what good healthcare looks like or should look like.
And I think maybe I'm a little confused.
Do you mean that this is a good model
for primary care in general?
Because I think I'm having a little trouble
visualizing how this model would work for,
you know, different, you know, surgical subspecialties
or just other subspecialties.
Like, I don't know if I really wanna talk about
like my sexual relationships with the guy
that's replacing my knee.
Yes.
[Audience Member] And that kind of thing.
So just, I think this model is wonderful,
but I guess I'm just a little confused
as to what you mean when you say
that this is what good healthcare looks like
and how that's applicable to other specialties.
Yeah. Yeah.
Thank you. That's a great, great question.
I would say primary care, mental healthcare generally.
I think that you could see elements of this
in inpatient care though too.
You know, good person-centered care
that provides space for people to be able
to talk about who they are.
And it was probably not the person
who's replacing your knee.
But one example I was talking to the medical students
about earlier today too, was,
and this is specific to the LGBTQ context,
I was wearing a Pride flag on an inpatient unit,
for example and there was this,
a team of folks that was rounding,
that was trying to get some good collateral on this patient,
and this patient was talking about her boyfriend.
And it wasn't until after the team had left
and they weren't able to get any type of collateral at all.
And you know, she wasn't really giving
the boyfriend's number or anything
and they just weren't able to find out
if she could be discharged to a safe place.
Then I came back in and she was like,
"Hey, so I don't actually have boyfriend,
"I have a girlfriend."
And that opened up a space where she could actually
disclose more about what her actual connections were
in life that didn't involve her sexuality,
but it did involve her sexuality in a way,
but really just involved a space
where she could experience trust
and she could disclose something
that then allowed us to us to, you know,
get some collateral and find out she could be discharged
to a safe space, essentially.
But, so it doesn't,
in that way it's not necessarily talking about sexuality
or gender in that space,
but being able to experience trust perhaps on an inpatient.
Again, not applying to every specialty,
but I might say that or suggest
that probably every specialty could have more spaces
where you could have some more conversation or more trust.
But let me ask, a trauma surgeon though,
just listening to you and your last question,
is, what I would take out of this.
And what I'm taking away is even as a trauma surgeon,
emergency general surgery, right?
When I walk into the emergency room,
I usually have the patient's name,
but what I'm gonna start doing
is instead of just going in saying Mr, so,
or just say, introduce myself and say,
"How do you want me to introduce,
"how do you want me to address you?"
You know, I mean that's one of the thing
I'm taking away, you know?
Yeah.
So it doesn't have to be like primary care
or I mean, it could be in anything you do,
-like that you were saying. -Yeah.
And part of this too is just checking assumptions, right?
So there was a really terrible incident that happened
at a Massachusetts based hospital
where there was a man who was admitted to an ED
and the team, he had said that he had taken
a positive pregnancy test earlier in the day
and the team just, it did not fit in their conceptualization
of this person and did not work this man up
for the possibility of a pregnancy.
And later in the day, the fetus experienced fetal demise
and that was just a lost chance at an assessment
in an emergent situation
that just required some checking assumptions
at the door a little bit.
So it doesn't mean that maybe we're taking 30 minutes
or an hour with someone, right?
There are emergent and critical situations,
but just watching our assumptions
and incorporating that into our universal precautions
that we do.
Right. Dr, Imbasciani?
[Dr. Imbasciani] Yeah. Hi Dallas,
if you don't mind, is this on?
Yes.
[Dr. Imbasciani] Yeah, great.
Wonderful talk. Thank you very much.
I'm not sure, I'm sensitive to pronouns,
but I'm not sure it's not enough in certain circumstances.
I'm wondering if you have advice to,
I'm a urologic surgeon, but to others
who are screening adults for generally based cancers.
So breast, uterine, cervix or prostate,
you're respectful for the pronouns,
but certain trans patients may have a sensitivity
to the discussion around organs
that conceptually have been left behind.
Yeah.
[Dr. Imbasciani] Am I saying that okay?
-Yeah. -Conceptually left behind.
Yes, yes. I understand.
[Dr. Imbasciani] Yeah. So do you have advice
for how to engage in that conversation?
Yeah, it's a great question.
I would suggest whether it's...
And this question was actually asked
somewhat in a tangential way earlier too,
when we talk about the patient
or we talk about the patient's body,
I would really recommend always deferring
to the language that that patient is using.
And in speaking about it in that way,
speaking about the patient in that way too,
but also operating with informed consent too.
So if there's a need to say chart,
you know, a certain organ for example,
or use a certain name, informing the patient
of why you need to put this in the chart in a certain way
because the chart is the patient's property, right?
And the patient will be able to view their chart.
And so I think there's kind of two conversations
that are happening.
There's how we chart and how we refer to the patient
in the chart and then how we refer to that patient
in person.
And then what I would say is asking that patient,
what do you call, you know, this organ for example.
Some people may use the term,
for example, front hole for example.
And some people may use another term altogether.
And so trying to be respectful to the term that they use
and then also inform the patient of, well,
and when I transmit this information to someone else
for the purpose of charting, for example,
this is why I need to be able to use a term
that others will understand.
So just operating with informed consent
and inform consent and asking what name you can,
so what words you'd use.
Not to obscure by any means,
but just to be really sensitive
to the patient's experience.
Does that make sense?
Yeah.
And on that question too, when we just think about EMRs,
some people have asked also,
you know, how do you refer to the patient
when you're starting your note, for example.
So a 30 year old transgender man, right?
I would really recommend especially say
if you're using Epic for example, using the three asterisk,
but creating a blank space there and asking the patient
how they refer to themselves and putting that again
in the patient's own property,
which is their medical record.
Because otherwise some folks may, I see this a lot.
You see trans people getting charted
as the transgender person
and then cisgender people not, right?
And it kind of others, trans folks in that way,
but also has the very real consequences
of outing that person,
depending on where that chart goes to.
Especially if you're involved in say, care everywhere
for example.
And that you didn't really have the consent
to out that patient, right?
Now, there might be really good reasons
to put that in the note.
But again, it starts with the philosophy of informed consent
and say, "Let's talk about why this is important."
I don't really know of a reason why it's vital
to talk about someone's gender identity in the note,
especially if the patient doesn't want that.
It might be vital to talk about certain organ systems though
and have an organ inventory,
but that is different than someone's gender identity.
Right.
We have one question over there
and then one up there.
[Audience Member] Yeah, thanks for the really nice talk.
I think on the discussion of outing people,
this is something I've been like thinking a bit about
and kind of curious about.
As I once had a non-binary friend express to me
that they really didn't like when people asked
for their pronouns, because they said
they kind of had to make that split second decision
of, "Is this person safe to come out to or do I lie?"
And I'm wondering if you have any sort of practical advice
for interacting with patients in a way
that creates that space for them to self-identify
if they feel safe and comfortable doing it, so.
But also not like putting them on the spot and saying,
"You need to either come out to me
"or lie about who you are."
Correct. Yeah.
[Audience Member] And so I'm just wondering
if you have any like tips for that.
Totally. Yeah.
That's a great, great nuanced question.
So I think I would start first by acknowledging
the data that we just saw,
which is that healthcare is not a safe place
for trans or gender diverse people, right?
And so it's so understandable
if you're trans or gender first,
that you're not gonna want to disclose
in one way or another, right?
And then you also have to think about the power of privilege
that we as healers have,
where we're getting paid to be in the setting,
probably a good amount more than maybe most people
that we see.
Whereas that person is paying to be there and also not safe,
like not feeling like they're in control of the situation.
Like, you know, provider, like a physician may feel
that they're really in control of that encounter, right?
So there's a power differential
that's really occurring there, right?
And so to try to level that field a bit,
what I generally do is with every clinical encounter,
I would say, you know, my name's Dallas,
my pronouns are she and hers, what are yours?
Or what's your name?
And I just kind of leave it there a lot of the times
I would just introduce myself with name and pronouns
every single time.
A lot of times I say, "What's your name and pronouns?'
And there's never one time where someone got mad at me
for asking for their pronouns.
Like never, people sometimes were confused
about what I was asking,
but more often than not, it was a chance to be known,
or even for some, as I told that one story,
a chance to save someone's,
for someone to be able to die,
at least in the way that they wanted to.
So I would just say starting with that universal precaution
of leveling the playing field a little
and introducing yourself and your pronouns
and then asking what are yours
or what's your name, pronouns
and just not pressing it if someone doesn't wanna give it,
and that's totally fine too.
And then if someone doesn't give their name and pronouns
at all, or you don't know,
then really err on the side of gender neutral pronouns,
they/them until you know.
And just practice speaking in that way.
And I'll say, as a trans person,
I found it really hard to speak
in gender neutral pronouns when I started
and I just kept like practicing the muscle,
like in my head and it became pretty easy.
So it's, you know,
really acknowledging the privilege
when you're walking in the room
and then just not making those assumptions.
Is that helpful?
[Audience Member] Yeah. Thank you very much.
We'll take one more question.
Up there, Krista?
[Audience Member] Hi.
So I was just really curious
a little bit more on the structural side of things
and how you envision Transhealth.
I'm really curious in creating Transhealth,
what immediately came to your mind
in terms of the type of healthcare team
you wanted to create to provide
that gender affirming type of care?
So I guess my question is,
what specific medical specialties, healthcare professionals,
and even non-healthcare professionals
did you think were essential in creating that core team
to provide the gender affirming care
that you envisioned Transhealth providing?
And given an unlimited, not really unlimited,
but an ideal amount of funding,
how do you see yourself like expanding that team
to provide even better gender affirming care?
If you know of an unlimited source of funding,
please send them my way.
(all laugh)
We wanted to start with a what was a minimum viable clinic.
And it was like, what is the bare bones that we have?
So it was not the ideal, but it was like,
what do we need to get things going?
And so we started really with a pediatrician,
a family provider who then happened to be an MP.
We really wanted a doc on the team.
And then we were a little more agnostic on the family side.
And then another family provider, a therapist,
and a psychiatric provider too.
A nurse case manager,
an ambulatory nurse as well,
and a person at the front desk.
And that was where we started.
And that is like not ideal at all, but we were like,
"Let's just see if this experiment runs first."
And like, "Let's see if people show up."
Because we didn't wanna build this
and like no one show up and it's like,
"Well this was a big flop, let's go home."
Like, "We thought there was need and it's not."
And then it just like, the need was clearly there.
So we went from that small team to 50 people.
And when you build an organization out of nothing,
you know, you have to build the handbooks
and HR practices and have lawyers
and like all these things I did not know at all
as a new clinician too.
And then you also, you know, really rely on the wisdom
of a lot of other people too and bringing that wisdom in.
And there were just a lot of people
who came out of different spaces to help us out.
And then with those pillars too,
we really wanted to bring in people
who were skilled in advocacy and research
and education too.
So it grew pretty quickly.
Where I see it going is I really believe
that a place like Transhealth
could mimic something like the Planned Parenthood model
in some extent.
And you see Planned Parenthood organizations
in many different states,
and there's not many healthcare organizations
that have advocacy so core to their mission
as Planned Parenthood.
And I just believe that's a part of good healthcare,
personally, that's my own philosophical conviction.
So you could imagine a growth model in a similar way.
Theirs relies a lot on impact donors.
So it would also have to include probably donations,
but then a lot of other of these
kind of financial diversification models too.
But ideally, it's also,
I mean, it's grown now to community health workers,
community engagement specialists, communications people,
educators, many more primary care providers,
psychiatric providers,
many, many therapists or therapists ratios,
three therapists to one psychiatric provider
so that we have open spots for therapy too.
'Cause it can be so difficult to get that.
And you know, I would say that that ideal model is that.
But then also subspecialties too,
and thinking about surgeries and thinking about germ
and thinking about other spaces
that can be person-centered and it can respond to the need.
Yeah.
It's only been two years though, so gimme a little time.
(Dr. Tandoh laughs)
Well, I wanna say thank you again very much Dallas
for being here and just for talking to us
about gender affirming care being the model
for just general healthcare.
So I would like us to please show a round
of appreciation for Dallas again.
I would also like to say a big thank you
to Dr. Vito Imbasciani and Mr. George DiSalvo
for endowing this lectureship and all your support
around education here for us
producing competent, cultural, humble positions.
And I wanna say very much thank you
to the Imbasciani Lecture Selection Committee.
Thank you very much, Pam, for all the work you put
into this and how you bring us great speakers every year.
And last but not least, thank you
to my office staff, especially Emily and Krista,
for really making this all run.
And Tiffany, who I'm sure is on Zoom
for making this all come together.
So again, thank you all and have a good night.