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So our next be here is M Karen Tree. So her talk is on Prism, LGBT Q plus surgeons and healthcare. So Karen identifies as gender queer. They have been interested in orthopedic surgery since fourth year of medical school and is currently a trauma orthopedic specialty registrar in London on the Staal Rotation. Karen is the current Vice Chair of the Prism Committee and the vice president of the British Orthopedic Training Association. 2023 Karen is passionate about increasing diversity, equity and inclusion in health care, promoting the environment in which surgeons and patients feel proud to be their authentic selves. As Vice Chair of Prism. Karen hopes to lead and build prism to be a safe and inclusive community for LGBT Q medical students, junior doctors and surgeons to celebrate their identities in their work with Bota. Karen is a strong advocate for training education needs. Karen strives to increase diversity and equity in orthopedics and promote an inclusive and compassionate work culture that suits the modern surgeon. Um No, hello. Can you hear me? I've got my Britney M on. So this is fantastic. Thank you so much for having to speak. Thank you for the kind introduction, Kate. So my name is Karen and I'm speaking to you here in the capacity of the vice chair of prison. We've had some really inspiring talks and I've been really moved by how brave people have been to be so vulnerable to speak about what makes them different. And that's really given me the courage to come up to speak to you today, particularly about LGBT Q health. My talk is a little bit more um data orientated in the beginning, but then I'll speak a bit, I'll kind of give them some personal experiences in between and a bit more about my motivation, speaking about it. But I think to have this platform to speak about LGBT Q health, which don't think it's taught very well or spoken at at all in medical school or postgraduate training. Um As an advocate, I really wanted to raise awareness about the health disparities that the LGBT Q population faces and how that impacts us as surgeons and as clinicians. Um So I'll briefly go through um some statistics and then some papers and with some stories in between. So the LGBT Q population, the UK census 2020 found that 3.2% of the population identified as LGB in the latest census. This has increased from 2.7 in 2019. So there's estimate about 1.4 million people in the UK. And they found that people aged between 16 and 25 are more likely to identify as LGB. And the national survey in 2017 found that I had over 100,000 responses, which is the largest survey in the, in the world at the time. And just to point out that, you know, this three, this 2.7% increase to 3.2% is in just, people are just becoming LGBTQ. It's more that people are feeling safer to come out, they're feeling more comfortable and we are giving them the safe space but also the language to understand themselves a bit better so that they're identifying as. So and this is a bit of the data from the National LGBT Q survey results. Um So in proportion, identify as gay or lesbian, but as we know, the gender spectrum is expanding and as our language expands, there will probably be more people, especially in the younger generation who identify as more gender diverse along the spectrum. So today about that LGBT health inequalities, a lot of my research is actually from a lot of this book which is really fascinating but also quite um depressing to read because this population who is not accounted for have go have a lot of health disparities that not many people know about clinicians don't know about and they don't know how to ask about it, don't know how to collect the data on it. Um But essentially what it shows that LGBT G population do face society stigma discrimination, denial of civil and human rights, which makes them and unable to meet the health outcomes that compared to their sister and their peers do. And furthermore, violence and victimization have long term effects, not only on the individual but the community as a whole. Um And a big part of it that will speak about is about barriers to health care. The LGBT population are less likely to seek health care and I kind of expand on the reasons why and how we can try to overcome that. So talking about physical health, the LGBT Q population are data has shown that there are high risk of chronic conditions like stroke, ischemic heart disease, um poor general health, obesity, tobacco and substance use. This paper is from the American Heart Association that was published in 2022 2020. And it has shown that the LGBT Q adults experience significant social stresses that compromise their cardiovascular health purely just because they are in the community and know the minority stresses that they are placed under part of this is related to increased obesity and also tobacco use. But they say that furthermore, gender forming care that we're coming, seeing more and more common may have an impact on cardio metabolic changes in the body and this will affect our patients um in their preoperative care. But also how we look after them. Furthermore, they are less likely to participate in cancer screening. Um This could be a variety of reasons. But from the papers that I've seen is a lot of them is to do with lack of trust with their healthcare providers. They are afraid to tell them that they are in the part of the LGBT Q community. Um If they are afraid to speak to their healthcare providers because of societal stigma, they therefore won't participate in their cancer screening and will present much later and this affects us who perform cancer surgeries. Furthermore, a bit more data about females, the data has shown that people who identify as lesbian or bisexual are more likely to be overweight and disability and men have a higher risk of anal cancer. Men who have sex with men, sorry have a higher risk of anal cancer, but not many people are aware that the HPV vaccine can try to prevent development of anal cancer. Some of the studies that there's actually a wealth of studies and data is coming more and more and I think it's really worthwhile for us to be aware of this because the population is going to continue as more people identify as such. This is going to affect our practice specific with breast cancer. They found that in lesbian compared to heterosexual women, part of the reasons why they are at a high increased risk is due to cardiovascular risk, smoking, but also some lesbian and women may not have any Children. And so nli poverty is actually a risk, alcohol use et cetera. And so all these different effects that we may not think about. If we don't collect the data on LGBT Q demographics, then we may not even be aware that this may be affecting our patients specific about the HPV vaccine in men who have sex with men. It's that people are not even aware of it because they don't even go to their health care providers to speak about this. And so part of it is about education. But as providers who provide health care, we need to ask these questions so that we know what specific questions we need to ask within a history in terms of mental health. So these are supposed to come in animated but just a brief overview, higher risk of mental health disorders, high risk of anxiety and depression, the high risk of bullying, victimization, personal violence, high risk of domestic violence and having to hide your identity actually increases the risk of psychological distress which can impact your mental health. And this is as patients but also as LGBT Q colleagues and clinicians that we have more data and we're looking at the LGBT Q youth 2 to 3 times more likely to attempt suicide. I think this is really disheartening and really sad. And if we can, if we're aware of this, then we can increase our education and have awareness of this so that if we do treat an LGBT Q youth, we can be able to intervene and provide the support that they require. The elder LGBT population also a high risk of isolation and for the transgender population, there are even, they're, they're in the worst of the worst they face even high discrimination. They don't seek health care, high risk of mental health and physical health disorders. And this hers I think is a really harrowing the statistic that there are 7 to 10 times more likely to have attempted suicide. My friend who is a clinician, sorry, she's a pediatrician. And last week, a couple of weeks ago, she was in clinic was speaking to a patient and my my friend was using she her pronouns and using a female name. And she said that during the whole consultation, this patient was just completely closed off reserve, didn't engage in the consultation. Afterwards, the nurse came to speak to her and said, like by the way, this patient actually uses key and pronouns and told them their chosen name. My friend unknowingly used their dead name, which is the name that they used for transitioning throughout the consultation. She didn't know this. But when the moment she found out she brought the patient back in and just apologize. Like I I'm sorry, I really had no idea. Um I'll change all your names and your pronouns on your data on, on your um on your patient information. And she said immediately it was just a whole complete change of the consultation. They opened up they spoke, they engaged in their consultation and if that interaction can change how our patient provider relationship is. I think it's just it can do so much more for other transgender youth. But we need to be aware of this and we need to be more culturally competent in the needs of LGBT care health population. The data about sexual health. So again, an increased risk of sexual health in the data shows that in, in 2019, the diagnosis of IV, maybe historically, we thought it was only in the LGBT population, but we found that 41% was in gay and bisexual men and 37% in people identified as sexual sexual. So I think this historic stigma is changing and we just need to look at the data and understand that we may have, you know, prejudice about what happened previously, but the the data is showing that slightly different. Now they're also at higher risk of um S ST is and I think the misconception about women who have sex with other women is that they are not at risk of, you know, cervical cancer or they are not at risk of sts, but that's just untrue. It's a myth and it's still questions that we should still ask if we know that our patients are women who have sex with other women and that they still need the same type of sexual history taking and screening and to provide the care and the information that they need. The LGBT K youth are also more like to be homeless. They lack social acceptance by their family. Um And in, in general, they're in society, they are discriminated against and they felt like they are marginalized. So hopefully, this is something that we can take into account. Because if you are of poor social health, we know that social health is a big factor that determines, determines your general health condition. I have a whole side just for transgender health because I wanted to reiterate again, the fact that our transgender patients and our transgender colleagues are in a subgroup that puts them at a higher risk of discrimination, stigmatization. Their issues are a higher prevalence in terms of physical mental and social health disparities and also transgender individuals seeking health care is particularly difficult for them. They experience gender dysphoria. Trans men may avoid cervical screening altogether because they feel like it increases their gender dysphoria. They are uncomfortable with the provider and they don't know how to have these discussions. But if we, if they don't come for the screening, then we're going to be catching them later as I mentioned before. And it's about having this awareness that hopefully you can take back to your practices to, to be aware of and maybe also to educate your colleagues about as well. I think transgender community is not advocated for enough. And I really hope that during this talk, I can really bring it forward. Furthermore, transgender women may avoid prostate screening again due to gender dysphoria that it takes up brings about. And also the exogenous hormone use can actually increase or then modify their breast cancer risk profile. So it may be something that's still relatively new for some of us, but something to consider, it also impacts their perative care. And there are more studies that are coming out to, you know, to looking into how we should be considering transgender individuals when they do have surgery, how the effects of anesthetic, what we need to take into consideration with the medications that they take as well. Research is lacking, but hopefully that we will continue to do it as more awareness is raised about this. This is about intersectionality and how different parts of our personality, all of our identities um that may means that we are from different marginalized groups may compound each other and also worsen your disadvantages. So someone who is a, a queer um ethnic minority person with a disability will face discrimination and stigmatization and disadvantages of all of these identities. And these can actually compound each other. An example is that they, they did a study looking at tobacco use and they found that cis gender women and heterosexual women, tobacco use is actually it it's high in the LGBT Q population. But actually, if you break it down in the data, even more black women are 2 to 3 times more likely black. So black women who are part of the LGBT Q community are 2 to 3 times more likely to have higher tobacco use and substance use. And this is an intersecting um intersectionality of their race and their gender identity and sexual orientation. That if we don't collect the data on, we will not be able to identify this particular group that is actually at increased risk. So it's just to take bear that in mind when we are doing our research, when we are speaking to our patients, to take into consideration the different parts of their identity that may impact their health. Um Some of us, some of the, so again, this research is building um about different disability and sexual um sexual sex and gender minority adolescents, the health disparity between them sexual orientation and smoking stigma and and how intersex with race um and discrimination. Lots of studies are coming out about this study that you can't see. Sorry is about how black and African American Children are under are overrepresented in foster care. And then they did another study to found actually black Children who are of a sexual or gender minority are even further overrepresented in foster care. And how can we best support them in understanding the reasons behind this and ensuring that they are getting the support that they require. So I think this is just something for us to it. There's so many different parts of our identity that intersect. But if we try to distill it down and understand how they can compound each other and further disadvantage patients. Hopefully we can improve our care for our patients and also our care for our colleagues as well. The barriers for health, for the LGBT population when I break it down, I can think about it in terms of individual, systemic and environmental factors. So individual, each patient may be worried about discrimination within health care, within the health care environment. They don't trust their providers, they feel like they will be enter a hem healthcare system which doesn't consider them. And so they won't seek it systemic. There is lack of provider, education and competence about what the LGBT Q population needs are and also the lack of research and data. So if we don't have the data to show these disparities, how do we therefore start addressing them? So I'm hoping that we start starting to change and also environmental in the hospital or in the clinic, you have psychological safety and then you also have the physical clinical spaces. So in terms of the psychological safety, I actually saw this on my own call. Um The other day, the there was a trauma com and the patient came in, he was a, an Asian middleaged um male came in on a trauma call. Um there was a car accident, he was color blocked and on a spinal cord. And after doing our primary survey, we asked him. Do you want us to call anyone for you? He hesitated. He's like, yes, can you please call my partner? And he said, ok, what's your partner's name? And asking him? And finally, the patient said, Pete, my husband and without missing a beat, the, an E reg said, ok, we'll give Pete a call. I think I was observing this from the end of the bed and I could just imagine what was going through his mind as someone who is LGBTQ. If I was to be in an environment where I don't know how people will react. Am I going to be facing homophobia discrimination for having a male partner or same sex partner? And I would be in such a vulnerable and stressed state. How does that make me feel? And I, when I saw how the an reg interacted, I was just, I was really impressed by how they were so culturally competent and able to create a safe psychological space for this patient to say that we're here to look after you, no matter who you are, you're safe in our hands. And I thought that was it really, I think the an reg didn't even consider how that interaction impacted the patient. But for me, I could as a person who could put myself in those shoes, I understand that actually, that interaction probably made a lot more, made the whole experience much less intimidating for the patient in terms of physical and clinical spaces, wearing Rola bo lanyards. When you have your patient identity forms, you can ask about pronouns and gender identity, not asking about husband or wife, asking about partner, significant other mix of kin. All these little cues that can tell a patient that actually I do feel safer. I feel like I can trust this provider. I don't feel like they will be homophobic or transphobic because I'm coming to you and essentially putting my health in your hands. I want to be able to trust and develop this relationship with my healthcare provider about these little things that can to facilitate patients to be more trusting in our healthcare system. I hope something for us to think about when you go back to your practices as well. This is about the um LGBT Q survey. Um It gives a bit more information about the LGBT Q population's experiences of going of seeking health care. Um 38% experienced negative experiences due to their gender identity. Um 51% reported long waiting time for mental health services. 80% of trans um transgender individuals reported difficulty accessing gender identity clinics. And we know this is an issue. We the gender identity service in the UK currently right now is not up to standard. The waiting time is about 23 years and that impacts not only the patient's mental but also physical health. So it's I'm glad that the government is putting in resources to find out more about this. But I think we're at a point where we need, we need a bit more from them because we have patients, young people, adults who are waiting and being impacted and they don't have the quality of life that they want, that they deserve. And so this idea of cultural health care provider, cultural competence is the ability for providers and organizations to effectively deliver healthcare services that meet the social, cultural and linguistic needs of our patients. And I think to build cultural competence, we we need to identify that there is a lack of it and then also be able to reflect on that and see what can we change. And some of the recommendation I spoke about, but I really wanted to go through about actually, we need to start at medical school. We need to start in medical school and address their curriculum. So the evidence shows that in medicine, dentistry and nursing, there is a lack of LGBT Q inclusive um curriculum and studies have shown that the students want more, they, they don't have very much interaction with LGBT populations, but when they do, they don't know what to do. But when you give them a bit more training, they feel more confident to be able to ask the questions that they may have been afraid to ask before. And this is not just in the UK, this is in Europe, this is in the US. And so what we I think what a lot of the work that glad is doing, for example, is to try to embed LGBTQ issues in our medical school curriculum. And this is through a variety of ways, different formats, lectures, small group discussions. Some studies have found that having LGBTQ health staff there to answer questions, made this space more safe, that people feel like they could ask questions in a safe environment. Um But it's about recognizing that this is a population that has continued to grow. You know, it's right now, 3.2% in the UK. But next census, this, this number may double. So it's about identifying that these patients have specific healthcare needs and also the history taking and the consultation that is required needs to be culturally competent for this group of patients. This is something from the Boston University Medical School and they have um actually the whole curriculum about how to embed LGBT Q and medical school curriculum into their, into their program. And I think it's, it's really fantastic work that they are really thinking about it in this way, this talking about medical schools. This is the charter on conversion therapy. So conversion therapy is, which is now banned for lesbian, gay and bisexual individuals, but not for transgender individuals in the UK. And that's something that we are still advocating for. But this is a charter that is written by Glad and it's, it's spear headed by Dr Joseph Hartland and they are a fantastic medical education leader who identifies as non binary. But essentially, we're asking medical schools to sign this charter to ban so called conversion therapy. It is illegal, it is harmful. And the data in the science has shown that it is not effective, but this is still happening. And the fact that we haven't signed it for the government has said that it's illegal for transgender individuals. This shows how much work we still need to do, especially for the transgender community. This is Dr Michael Brady, who is our National LGBT health adviser. We have a National LGBT health adviser. I'm not sure how many people who knew about it, but it's reassuring to see that the government is thinking about this more proactively and there is a whole action plan that he's put together talking about the LGBT health priorities because they have recognized that the disparities exist and that this is something we need to do about it. We can't ignore it and there's different ways that we can address this through education and training, data, collecting and collecting more research and also providing the support for medical schools for postgraduate training. So in summary, from the data point of view, LGBT health population face societal stigma, discrimination, harassment, which means that they have health disparities in all different aspects of health, physical mental and social health. And there are different barriers that exist, that means that they don't seek health care and So what we, what we need to do is to provide education and training so that our healthcare providers are culturally competent in providing specific LGBT care. LGBT Q health needs. Further research is needed and especially for transgender community, which brings me on to my next topic, which is pride and surgery for. This is something that I'm extremely, extremely proud to be part of with my chair, Jenny Barber who is also here. And it's, it's just that, I mean, seeing this logo still kind of makes me like very emotional because I am someone who identifies as gender queer. I previously, I know I was like, I knew I was queer, but I identify as gender queer. I use she, they pronouns and I definitely did not think that surgery had a place for me. I remember when I was coming through medical school, I really love orthopedics. I was so keen from the beginning, but then I would see all these orthopedic surgeons, like, I don't know how I can be in that same environment until I went to. And I, I don't know, I don't see anybody else who's LGBT Q and successful as a medic. There was no one out that I knew I had no role model until I went to a glad event. And I sat on a table with other consultants and I've never met another LGBT Q consultant and I was genuinely flabbergasted that people are successful at openly LGBT Q and it really showed me the power of a community and having role models. And that really made me think actually maybe surgery does have a place for me and maybe I don't have to leave orthopedics and do something that is not as fun. And so it's, and to be able to, which is the best specialty and to be able to be part of something like this really means a lot for me because I've had medical students come up to me and say, can you please tell me more about your experience in surgery? Can I be a surgeon? I identify as non-binary? Can I be a surgeon? I'm like the fact that you've been doubted. You can, you're at a surgery conference, you're bright, you are doing well in your career, of course, you can be a surgeon. But the fact that they had the doubt to think that surgery didn't have a place for me and what prism can provide for them is a support and empowerment. It really is something that means so much to me. So this is um oh, it's gone through now. So basically part and it was formed initially when we had a series of podcast during the pandemic. Um Jenny Hair was leading on a series of podcasts about LGBT care community. And through that, we were able to gather trainees consultants, you know, there were from all walks of life, from different specialties, um and from different areas around the country from Scotland, Wales England everywhere. And we were able to come together and talk about our experiences and how it impacted us during our training as a trainee, we move around every I have a new boss every six months and every six months I have to do a safety scope of whether or not I can come out as I become more senior. And because I'm doing more of this work, it's more, I don't have to do that as much anymore. But there are sometimes I'm still have bosses who ask, oh, when are you going to get married soon? What does your boyfriend do? And I just have to think I'm scrubbing up, what should I say? Um Should I just leave this for another day? And then you're sudden, you're like, what are you going to think? Are they going to be homophobic? Do they just assume hetero is normal? And therefore anything else is abnormal? And I still get moments where I'm like, I don't know if I can say anything because I don't know what my boss is gonna think it's gonna impact whether or not they're gonna need me do. Is it going to impact my training? How's it going to impact our relationship? And so as a trainee, it's actually quite stressful being a career surgeon because you don't know what every new job you're going to go to, what the environment is going to be like. And you're on just hyper alert all the time. And as a patient on the table and someone says a trans comment and you're just, there's just so much going on in your head. And so hopefully, as we continue to raise awareness about this, we can make people aware that, you know, some things are maybe not OK to say anymore, you know, ally ship bystander bystander skills is something that we can truly try to promote so that it's not just the queer surgeons or the LGBT Q individuals who are doing this speaking up. And I really hope that speaking to you today, you can bring back to your practice and to your daily practice about thinking about how you can support others because you will never know who's in the room. And the fact that people still assume I have a boyfriend goes to show that you can never, you know, you just don't know who is in the room. Um As we, as we also know from today, there's a lot of, you know, identities that are not visible and this thing is just about making sure that we speak with the appropriate and inclusive language. These are some photographs from our pride and surgery for inaugural conference, um which is actually at the college. It was a pretty amazing day because we had the pride flag flying on the college, which, you know, I think even three years ago, no one would have even thought about it would be possible. But I think we've come so far in our strides in diversity inclusion. Um that this was a really, really amazing day because it was caught out at the college because we, we're not hiding ourselves anymore and we are, we're great surgeons and we're great colleagues and we contribute to our community in a really diverse and wonderful way. And I think we are hoping that this will continue to move forward to show that people don't have to hide themselves. They don't have to worry about whether or not surgery has a place for them, whether or not I can be an orthoped because I'm not six ft or white or play rugby. So it's all straight. So it's um so we're hoping that this will diversity makes us perform better. It, you know, it makes us think more broadly, gives us different perspectives and life experiences that make our whole community more rich. So this day was a really special day for us and we've gone on to do, um Can we go back aside, please? We've gone on to actually work with the college about in using more gender inclusive language in our, in our cus. So this is the recent census actually, and we advise on this and this is to show that you're not just going to take male and female because that's not, there's actually more we understand that there's more on the gender spectrum now and we're going to include this, we're going to collect the data so that we know that we are, we are aware of you and we want to understand what our community shows. So being able to affect this on the college's census collection data was I think a really big step for prism because we're actually affecting change that we want to see. We recently also um we're building an ally ship toolkit to understand how we can support our LGBT Q colleagues um at work. Um this is a work in progress that we presented at um A S GB I. Uh And it was, it stimulated a lot of different conversations about how we can support um not just LGBT Q colleagues but all colleagues from different minority backgrounds or from different marginalized groups. So there's a lot of work that we're doing and we continue to do with the college. And lastly, this is um a slide about why prism is needed and why it's important for me and other LGBT colleagues studies have shown that the experience of LGBT G surgeons in surgery is poor, is harassment discrimination, homophobic comments. And in the Kennedy report, the, they found people, they found colleagues who heard I don't want to gay in the department or I don't want, you know, NF word in the department. And this is still happening today and this was 10 to report two years ago. And that's not an environment that I think we as you know, members of society or clinicians or colleagues should be accepting is not acceptable to have to hear this and to fear for our psychological safety whilst we are at work and these studies have shown that this is still happening and which is why this work still needs to continue. Because I think one of those papers talking about how 11 trainee, one resident in the US didn't choose a program because they knew that oh, you will not be accepted in there and you're just losing talented people because because of our prejudice and of the the environment that we are not providing for them. So this is just to kind of demonstrate that this work still needs to be done and this work continues to be done worldwide. We know that in Australia and New Zealand, they've recently established an LGBTQ forum for their doctors. This one is about, this one is from America. They have a new association for outs surgeons and Allies. And it goes to show that this is an issue that is worldwide that needs to continue to progress. And hopefully we can learn from each other because we Jenny and I have had discussions with our colleagues in Australia and New Zealand. We've shared our experiences and try to understand how we can improve the environment for our colleagues and those are my resources. This is a really interesting book. If everyone wants to read it, I have a PDF. Copy of it. That's it. Thank you very much. Do you have any questions in the room? Thanks, Karen. That was a really great talk. I think today this and a few other people talking about some of the challenges like um dyslexia or other things has just made me feel a little bit sad because you just think a lot of people when you're operating, you have so many stresses as it is that if you're worrying about other things, we know it affects your performance. And there's good data that more junior trainees can't do simple maths as well and you can't focus on your surgery. So this isn't necessarily to you, but it's maybe for everyone to think about. But I would value your opinion is how do we maybe as consultants dissolve some of this stress. Would it be helpful at the start of the job to maybe give out a survey or a form where people have the opportunity to say, is there anything else that you would like your trainer or your consultant colleagues to know about you? Because having these conversations can be very challenging. But maybe sometimes when you're able to tell people these things, it might be a relief for you. Sometimes it can be stress inducing but just how can we help people. So they're not wasting really valuable energy thinking about interactions. And the other thing is that, you know, you said, sometimes you worry about if somebody else's opinion of you is going to change. I think some, a really powerful thing I was told sometimes is you shouldn't worry about the opinion of someone who's opinion is not worth it. And by that it means that if somebody is going to have a poor opinion of you, then they really don't matter. And it's very easy perhaps for me to say that. But I just think it's something to reiterate that their good opinion doesn't always matter because it wasn't worth, worth it in the first place. Thank you, Salma. I think to answer your first question, I think if a trainer came up to me, is there anything else you want me to know at the beginning of my placement? But the way that they presented it is, you know, I understand that some trainees may have certain difficulties because of certain, um you know, parts of their identity. Is there anything that you want me to be aware of that I can support you? Um And I think even having that open question as a trainee is really reassuring to hear because you don't have to be guessing because the Trini is laying it out for you. Um I think that's rare, but I'm hoping that more trainers will take that approach because as we say, there are so many different things that we don't know about each trainee's identities and what their abilities are and asking an open question like that, which is a bit more personal, I think will be very effective. I don't think needs to be a survey but just an open discussion. Um I think will really open doors and build your trainee training relationship. And then to answer to your second question, I think as a trainee when you, when everything that you want to do is just please the boss so that he lets you do something or they let you do something or she lets you do something is I use he because all my bosses have been he um it's just, it's so, it's so hard. And I think even like, even though I, I should just say just be honest and open about it, I do really care because I want to have that good relationship with them because it impacts our interaction because we spend so much time together. Um I still think it's very difficult and every job, every time I move to a new job with a new boss, I'm having to reevaluate all over again. Um And maybe as I become more senior and I'm not having to maybe grovel as much to try to do a case, then maybe that would be a bit easier. But I think having spoken to other trainees who identify as LGBT Q, they also have that issue with coming out every six months. Am I going to, what environment is going to be like? Suddenly you have a tension that you don't know how to answer the question that you actually don't have a boyfriend or your partner is some of a different gender. It's very difficult, but I'm hoping as we get more senior and people are more aware of it. Um Attitudes would change. Min ex again. Thank you very much, very, very inspiring talk. Um So i it's really challenging as a trainer sometimes when you try to, to, to communicate with your trainee and ask personal questions, but not too personal. And yet you don't want to go straight to business, but you want to sort of get to know them. I don't personally think you should ask about a boyfriend or a girlfriend or getting married anyway. Not if you're LGBT Q or not, you don't have to have a boyfriend even if, if you're straight. So I don't think you should be asking that anyway. But people still do. But what I want to say is I think that our environment is sort of a reflection of society and society is changing and I can see my Children in secondary school, they are indifferent about, about sexual orientation, indifferent about, about all the, the minorities. It's not that they are tolerant, they don't see it anymore, they don't comment on it. They don't, they don't need to be educated, they just, they already are. So maybe it will take another few years, but eventually it will be reflected in our profession as well. I hope so anyway. I hope so too. I think. Thank you. Thank you for your comment. It's we actually, when I speak to medical students about it, it's a, I don't understand, I don't have any diversity issues when I'm in medical school. Like, because you live in your gen Z bubble and everyone understands each other. But when you come into work, you suddenly have, you know, consultants who were working, like for 40 years, they don't have that same understanding of society that you do. And that's when they and when they enter the workplace, suddenly it's oh, ok. This actually is because I didn't experience it in medical school and you suddenly come to work and like no one here looks like me and suddenly you're exposed to our environment and a profession that is so high stress and so dependent on your personal relationship with your trainer and your consultant and these things start to kind of surface. So I think, I think you're absolutely right that actually the population coming will change. And, but I think because we're hopefully still going to be around, we also need to be aware that the way that our younger generation are thinking are changing. And so if we want to be able to stay, you know, relevant and be able to interact with them, we need to be aware that these are the attitudes that they are bringing, they are, they, they also won't tolerate it. They will say something about it. And I actually really, I have a lot of kudos to them for speaking up so much about what they don't think is right. Um And I think there's a lot and then I think at that point was where reverse mentoring comes in where we can learn so much from our younger colleagues about, you know, society, attitudes, way to behave and understanding about different identities in um within the profession. It was very much on a theme I was going to speak in defense of the ignorance colleagues who we don't, we didn't grow up with this language. It's my kids who have informed and corrected me. And if there is a reason for anyone who is ever thinking about having Children, it is to stay relevant. Um but I would also really encourage anyone who feels marginalized to, to tell people and just because somebody is ignorant and asks the wrong question doesn't mean they are going to feel think worse of you don't assume that they just don't have the language, but then by people speaking out and being vulnerable, you are informing and bringing us up to speed. One last reply. I think it also replies to that is when people do make mistakes, I think we just, we should afford them a bit more compassion and, and to understand that we're all learning together, I make mistakes all the time. I just use he for my bosses even though you know, I shouldn't have, but I was like, you know, I still have these slip ups and it comes with time and it's to be compassionate, to have an open discussion and conversation about it. And because it's not a, it's not a society that they may have lived in or they don't know anyone who is LGBT Q knowingly. And so it's being a bit more compassionate in terms of your, your leadership because you are guiding them on a, on a learning journey as well. Yes, definitely. Thank you. Thank you very much.