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I ever on. Thanks so much for coming to this talk. We'll just wait a couple of minutes. Just so let's, um, more people in and then we'll get going. Okay. Okay. So hi, everyone on my name's bath and I only and medical she represented for stash. Thank you so much for joining us tonight for our took this month, which is equity in healthcare for trans and gender diverse people. I'm so delighted. Teo. Welcome, Doctor Kate. Number she's co founder of Clinic T, a sexual health service for trans and gender. Diverse people is based in Brighton. She's worked in sexual health since 2003 and specifically in Trance healthcare since 2012. Currently, she also works is a gender could clinician for the Welsh under service in Cardiff on she has a chair of the bass gender and sexual minorities Special interest group. Thank you very much. Doctor number for joining us tonight. If anyone has any questions, please feel free to just pop them in the chat. And then we'll do a question at the end. So I passed on to you, Doctor Ambien. Now you want to shut your screen. Okay? Fantastic. Thank you so much for inviting me. I've actually been so super excited about dizziness talk. It's It's always a pleasure Teo to speak Teo people who are starting off in their in their career in medicine. Particular topic is very dear to my heart. It's something that I've I've worked on for for a lot. And I wanted to really focus on the whole idea about equitable healthcare records in healthcare for transgender, diverse people. So, um, this is may I don't have any painting interests, and I've left my email there. If you want to get in touch with them or email, you're very, very welcome to this. Any questions you have? Um, or you can contact me via Twitter as well. If you want to post anything on social media, that's absolutely fine. Um, so, um, I want just to start off with just by by having a little bit, we'll talk about this whole notion of quality versus equity. Um, Andi, it brings me a mind off a story that Ah, that something that happened to me while stye was presenting about the work that I do a clinic tea. So it was a bash meeting and Ah, a sudden stood up and said to me to be really need to have a specific set Health service for for transfer all. Can't we just work Teo Worns? Just including Trans, you know, inclusion within standard sexual health services on that kind of Give me a report for force with thought because yes, you know, and equal service would be everybody gets the same thing. Everybody gets access to us into it to a sexual health service. But when you're when you're in a situation where you are dealing with a minority population, particularly a marginalized population, sometimes you have to go above and beyond what is just a quality. You have to do a little bit more. And actually, that's not an unusual thing. You know, we have that for young people services. We have that outreach services in in certain areas. You know, we don't do that for everybody. We provide additional care for people who are in in difficult situations where there are there, particular, particular minorities on. That's what it really means Teo have. This whole notion of equitable care is more than just giving everybody the same level playing field. It's giving people enough off. Ah, boost. Enough of a booster there, there, the ability to access care that they're going to have the same result is everybody. So I think the, uh, one quote that comes comes to mind when when we're thinking about the difference in the quality and equities from now he designing And he said, the quality is giving everyone shoe equity is giving everyone a shoe that fits. I think that's what we're what we're trying to do with trans engendered of us healthcare. That's what I want to talk about today is what about how we give everybody a shoe that actually fits thumb. So what are the inequalities that effects on trans people? Um, on there, there are quite a few years I picked on a picture of you don't come. Every things are not completely comprehensive. But I think, really the big one is around access to, uh, gender affirming healthcare on this is actually a ah headline from From the Garden. That's the back of this is back in 2016 on. I was giving a talk to bash conference of the time in 2020 16, and it happened to be on the day that I was given the talk, so I just sort of clip this and put it on, Put it in. But this has been the case for for years. It's not changed. In fact, it's got even worse. So the numbers of people being referred into clinics has got gone up and up and up on waiting lists of Gone Up a swell. I haven't kept pace at all with that, A zit says on the side of the treatment centers are all completely overwhelmed working one myself, you know? I know. I know what that's That's like, um, if we look at the weight in this worked for general ent clinics, these ah, correct has off a zoo last month. You can see these enormous waiting times, you know, their their clinics certainly know sort of 50 months, 60 months. Weight turns in in England. The service I work in Wales. It's two years from from first referral T to be seen all the way. In some cases, we do protest. People see people, Um uh, before that in in the next in Scotland are more geographically Ah, ringfencing. That's why something That's a much shorter waiting time with the ones in England particularly control from all around the country. So that's that's a really big problem and it has a knock on effect. It has has a really, really profound effect on people's mental health. We can see that the, you know, the gender and congruence itself. Being Trans isn't classified anymore is a mental health disorder. W to remove that classification in the in the latest addition of the city 11 actually moved into conditions. And so this is the central health. You know, we can have a debate whether that's the right wrong place for for for it to be. But certainly moving it out of our mental health has, has, has helped was, should help to reduce stigma. It should help to improve care. But we said we certainly see that a number of trans people really do struggle with mental health there. A number of studies that have shown much high prevalence of depression, anxiety and substances on down over half of transplant reported a history of self harm with a time of this particular study which was done in the UK 11% current home, and that's an enormous number of people um and you know, over a third of people had attempted suicide a teaspoon once. She's a really alarming statistic. A lot of it comes down to this this this issue of minority stress, that just being able to to do the things that we all just hate for granted I was going to a public loop. I'm is fraught with a huge amount of stress. And I remember a semetic ulcer. Don't I transitioned as a medical student, But I'm going to sexual health clinic at the time. And they, uh, a lot in the door. There was a a sign for the cream. I weigh two rooms I mail way to, you know I go to and I can't look to the side of my God do. I walked into the women's way to my sat and I was escaping. That was giving that, uh, that supports for thought. It made me think. Well, how many other people have looked at that? The signs and decided I just can't do that. I can't. I don't feel I don't feel confident enough to be able. Teo, take that space and t to be that person and to go into go into that room, particularly early on in transition. Um, and that that effect that minority stress affect it has has a detrimental effect on on mental health. And we've seen that over and over again in research that's being done not just in transfer, but in in so many other in areas of life. 30. It's translated into increased mortality for a transfer, and this is this is a study that was done in the Netherlands. Enormous study in new 3000 TRANSLUMINAL and, uh, 1600 transmit, uh, you know, over 20 years worth of follow up for for both. So you kind of add up. That's an enormous number person year. Follow up for a for a cohort. And but they looked at a little number of things. But I looked on mortality and read in a home. And if you're familiar with these Captain my Plattsburgh, just talk, talk you through them on. These are plots of mortality, so that amount of people surviving has shown on the Y axis on the number of times the amount of time in years has shown on the on the X axis. Have everybody survived, which obviously doesn't doesn't happen to people die of natural courses in or for all sorts of reasons. Then you'd have a horizontal line going straight across. So every time someone dies, the line drops down a little bit. So the fast the line goes down or steeper, the slope of the off the line, the mawr, the more quickly people are dying for, for whatever cause. And you can see that there's a statistically significant difference between the rates of death for transgender women in particular compared to the rest of the population, it's it's not. It's not statistically significant for transmission, although the the line is below that off the general population. And if we look into more detail about what's causing people to die, what's causing transferable T dy the main causes air, actually, perhaps quite surprising HIV and AIDS was that was, that was, that was the top cause on most of those. Death, to be fair, were in the earliest part of the cohort. Things have changed a lot of tension terms of treatment, but it's still a significant proportion of people dying because of HIV AIDS. Um, suicide, illicit drug use, um, lung cancer probably associate with much higher smoking rates. So I think one of the things that that comes out of this is that there's a lot of worry and concern placed around. You know the risks associated with gentle, foaming Korman therapy, but is like cardiovascular risk from a mullet. Risk on such fight aren't the main causes for people dying. If I did see, it's the it's the stuff that's often much war much easier to prevent its in some respects. Ah, you know, looking after sexual health in terms of HIV prevention after mental, have particularly glad to see you're so prevention that she could Teo do much more in terms of protecting people from perimeter or death talking about HIV on. So this is a little complex slide because this is a stash meeting, and so I think we should should talk a little bit about sexual health, so we'll talk a little bit of it. HIV Well, one thing that we do see when we look at studies that are done throughout the world is this huge variation of preference. If you look in trance women, it goes somewhere between 1% on, you know, 49.6% in studies and things analysis and some of it in Norton, 8.3% interest and trans women on. So it makes you think, Well, why? Why is it different from from one place to another wise one study did it different from one place to another. When we look at a another meta analysis, and this is one that's being being talked about, a lot of anybody seen my previous talks you have seen we talked about about this one. When you average it all out, you can see that the HIV prevalence overall is really, really high. So you know, 19.1%. And if you don't look that in context, victory prevalence in in men of sex, it meant something 14% sex workers, something around about 12%. This is an enormously high prevalence, but I think the key thing really year is to go back to that that previous, like I think about you know why it's so variable. What is it about the country India that has such a high high? It should be a preference in in their in the trans women in their compared to a country like stray Dio. It hasn't been much, much lower. A lot of it comes down to the social Democratic factors that are affected transportable. If you're in a situation where new are more marginalized, you can't find work. You have no legal recourse. Teo Protection People are often forced into situations where they are. Wasn't into sex. Work against that will. Sometimes traffic sometimes exploited in other ways that sometimes the only route is through that travel economy To be able t o gain money, People can't access healthcare to be able to get HIV testing and to get treatment on. So you were put in a situation where the HIV prevalence is is increased because the risks that people faces are increased. And it's not just that the provinces high the effect off having HIV were living with HIV on being trans exerts, a sort of multiplicative affect. This is really an effect off intersectionality where where the the's separate Uh um, factors that that ah causing people to TB stigmatizing society are are interacting on because see this In the study that was involved in a while ago, we saw that people living with HIV were transfixed. Here. It's higher rates of work with harassment for social family exclusion, job loss, involuntary job change, physical assault. When we look at her healthcare specifically, you can see that there's an increased rate of people avoiding health care if they were transplant. People who are cisternas weren't trans uninterested rates. People been treated differently, so being perceived has been treated differently within different healthcare sittings. Again, looking at looking at what's happening with in the UK actually were doing pretty well, if it could look, if we if we look just purely it at what's happening in terms of HIV treatment. So really know diagnosing people were were pretty, pretty transferable on two on 200 far off therapy. And actually the rates of our suppression a little bit better in transport for pertussis people in this particular instance, positive always study from a few years back. But it's a very different story when you look at health and quality of life on DMA, need more transfusions, said that they felt depressed or anxious, reported their health is being about, or very bad on experience problems with self care. Um, I think that one of things that I think is really clean real important thing to very mine is that we you know, we have this data take of a grant it that way. We have data that counts. Transfer it. But if you look back a few years, that wasn't the case. You know, myself and other people would really hard Teo to ensure that we were actually starting to count people within the HIV data within the sexual health data so that we could generate it. Ah, research like this and they could identify what the problems are. These are the problems. These that was what we need to face. One of the really big things is in so many other areas of healthcare, there isn't that. And I think that the problem of not counting transport pulse is really, really serious. And it's something that I think that has taken a long time to percolate through Teo Teo, the two people working in public health, people in the Department of health and in government. But I think that when when when we when we talk about our county people, I think that the worst liver and cocci actress really, really come to come to mind. And she said, what message. Are we sending those who are trans and gender nonconforming? We don't even count them. We suggest that their identities don't even matter. And I think that it's it really, really is so, so important that you know, if we are, if we're not counted, then no, we don't count where we raced. We are rendered invisible. And I think just the sheer fact off being able Teo to know how many transfers there are coming to a to a service of that you can adapt and you can. You know what? What are the particular areas that you need to focus on is a vital thing that we need to do that more so there's a number of things that really exacerbate these. These these inequalities. Another talk about these in huge data. But I'll just go over the ones, and the first one, in particular with healthcare, is really about about medical education and training. You know how many of you have had specific training or teaching within, You know, about about trans healthcare? Probably. If you look a medical schools throughout the UK it Zain or itty, I know there are places that there are doing it. It's only have been doing it in in bright and then this other school of the middle schools that have started to incorporate that within within the Christian. But no, we really need to, you know, much, much more of that, particularly with with, um, doctors who have already graduated. I think that that the, you know, more senior doctors in particular it Zraly really important that we don't We don't forget the whole whole medical work force because, uh, that this There's a lot of people out there who have very, very little knowledge about about trying to help you. We don't have a memory commissioning of services. We can see that from the data from the GS CS. This this issue about cysts normative, itty. So there that we we sent sent a sister and her experiences that people aren't transfers being the normal, um and then think about transplant was having an abnormal something, something that something being abnormal about being trans on, I think. But that's that comes through so much. It's often is often so in a very subtle things, often very. It's something that isn't isn't isn't necessarily a parent. You don't you people just do it, but they don't realize that they're doing it on. It goes down to the comes out to This is Well, this is this notion of religion icing, jet trans and gender diverse. It entities, I think in the moment what we wear working within, within transferred care. Ah, really facing up to it is moving from a model which which centers trans as with ology where you, you, you you interview someone you you make a diagnosis, you make a plan. That's what we we're all used to doing in medicine, on moving from from from that transit pathology and moving towards trans as human diversity. That's happened. That happened years ago when we when we talk about homosexuality, that was pathologize So at one point, it's sort of a a mental illness nowadays, if you if you if you if you told me something about it, think you're crazy. That was the case. We would hope it would think that would. That's crazy, but it's still the taste that for transfer all the notion of off off the abnormality of pathology is still there on that side. The release, The rise of Transphobia on. We see if you look it. Look, the the press in the UK this relentless transfer be it's honestly, it's it is is exhausting and upsetting Every time you you you see another another article in the dating mayor Times are the telegraph just, you know, it's that that just eating away that about that horrible herbal. Yeah, uh, it just absolutely horrible on decidely at least this If if you if you see trans being such a negative thing, then you marginalized people further and you make people vulnerable. Teo Hate crime and, um, server from stone water the media third of transfer over a third of transplant. Let's uptake. And this was back in 2017. Um, studies have done been done since then Option similar rates. Um, older Lord really said it well, when it comes to this, and she said, That is not a difference is that divide us. It's our inability to recognize except on celebrate those differences on. So I think that when it comes to those things that that really exacerbate that inequity on your quality, it's it's the first thing that we need to do is to be able to celebrate the difference than recognizing. Except, um So how can we make a difference? What can we practically do, Teo? Improve the lives for the people that we look after our transportation? Trans people more generally. Well, I think the first thing really comes down to this. It's this notion of cultural humility. We often hear about the term cultural competence, which is disturbing your understanding, the things like the language that the the culture that people are living in the courtroom bility goes a bit beyond that acknowledges that that, you know, doctors bring a baggage with their own own country and athlete backgrounds along with the culture of medicine. Um, it's it has its own curve. Very, very strong kind of identity and culture. We take that to the patients bedside, and those may not necessarily be superior on. I think about that quote, I think, is really, really important. We need Teo think beyond you know, we've always done this because But you know this is the way you talk. Don't have to do it. Well, this is this is the way that, you know, maybe I've been brought up there for this. Is that this is that this is the norm and put without aside when I take it early, when we, when we approach transport, will pay for it for anyone, any minorities, population, but any margins, population. So one of the things that you can really do Teo to make a difference here and and really, you know, uh, be formal work off do cultural here humidity when you can commit yourself to learning like lifelong learning tp keep keep up to date on. That, that is is easy. It's easier to use easy to say that, but you know, we have one bottle by having toe try to put particularly get together. One more information. When I when I first started to get given talks, that's very little information out there about transference. And it's one of the nice things I have seen is that there's there's more and more stuff. It's really been put out of seeing medical students themselves, actually saying, saying to medical schools, there isn't the stuff here we need. We want to learn about this very fact that I've been invited to give a talk today. I think is, you know, testament to the fact that you know you want to come and learn. And I think that's amazing thinking about the power of balance and doctor patient interactions, I think is really really he. And it is, uh, yeah, something we don't often often acknowledge in a particular when you have the you know, your money in a busy clinical you're on the ward's like there there's there's there's a distinct in power balance, You know, the one that uh huh is you know, you're the one in charge of, you know, people talk about you in my life in your hands It really is already, is that But try to, you know, trying to level that is a really, really key thing. And then just being accountable, no personal accountability, but also your institution, Then through the people that you work with, building those partnerships between between transcapular trans organizations on there, the organizations that you work with, the think is really, really key here. The more that one of the big problems that this is this what happens when you don't don't practice country military, you end up with things like this. This is a notion of the trans broken arm that this assumption that will medical issues is this somehow must be related to that person being Trans. And I think that for any any transportation transversing people here in the in the audience you'll be really familiar about about this. You know, you go to your doctor and this is sort of need a reactions that all whatever this might be, what must be in somehow related to to your your surgery or hormone therapy or some other notion about it being transferred, it may not may not be a tall, um, and I think that we need to try to move away from from from from thinking that I am just just sort of slapping themselves, are out out of that after that mentality and they say I want to talk about is representation, and I think that really, really is is quite alert. One of the things I was really, really proud to work on was a set of sexual health information for For transcended a diverse people alongside 10 seconds trust in a number of other really amazing contributors to that. And I said of the time, most Trans people, we need to see ourselves and sexual health campaigns and know that the information to it. Um, with us in mind, I really, really well stand by that I think you could say the same by any other, any other minorities population if you're trying to reach out to that group representation, seeing, seeing, seeing transferase is seeing transportable in in that information that you're you're you're putting out their seeing Trans people in the care is that looking after you and then with the doctors, the healthcare professionals is really, really vital when you think about where, what is the information That's really, really culturally relevant on these or booklets that were designed and produced by clinic use that Trans Pacific Sexual Health Service in London on they were really hard, and they they put out information for the for the population that was really geared towards that specific. There's the specific needs of the people that they were coming to their service. That's really, really important. You can only do that if you have that engagement with community. I'm thinking about what's what's relevant in terms of service delivery. This is, ah, service that provided a dean streets, a specific transit, said cervical screening service, first transmit and number of people and it's mean it is being It's been amazing to see how you can um, yeah overcome the reluctance of people you wanted to go for cervical screening by providing services like this where where people can come to somewhere where they know that they will have that little extra time with the condition that I have, um, someone who really understands that needs I'll have the necessary, you know, since their equipment on be able TOB Able Teo, do what is, actually, you know, quite invasive, quite uncomfortable procedure in in a way that minimizes with that dysphoria it Zraly invaluable service. This is what it what it means to go to the heart of actual care. You could just say everybody needs to go to the GP and gets a little screen. That's that's equal care. But this is equitable care, where you actually providing specific services targeted toward the population in conjunction with protection things again. Something that that I was very proud of worked on with some amazing colleagues in Brighton to wonderful mid wives who lead lead on this project of providing a ah guidance and A and an M e t for inclusive pregnancy here. Prenatal care for transfer, all with guidance on gender inclusive language. You might have seen this in the in the press because it was grabbed by some of the, um, with the reaction right When President and, um and and people started talking about erasing women and such, I was complete nonsense I'm going to do without. It's all about running, clued, transforming language within within prenatal care. Think about a new clinical guidance which we worked on the building. I want to spray team so that we could do better. Look, after the transplant were coming to our service Who, uh, pregnant? Well, thinking about pregnancy. But I think that all of this stuff on all of those services that I've shown there's it's articles where we're set up where planned were delivered. Trans people, um isn't this isn't a, uh These are So this is that that were done sort of outside for us. They were done by us for us on this notion about nothing about us without us. Was it a rallying cry that that started off with in disability? Right, since we moved into into into into clear rights and I'm using it here to to illustrate that when you're thinking about what it what it means. TOBA Technical services Trans people you cannot do it cannot do without involving. Yeah, trans people in that in that in that process, you know, right of the heart of it right away through it, things that are successful, things are going to see that the ones that are done with with the community on, you know, and by the community Mm. The next thing I think I think that is really key. When you come, it comes to this is about your support and this is maybe slightly slight, slightly off topic. But it's It's in a similar vein because it's not just your patients that you need ta think about when it comes to trouble care. You need to be thinking about the people around you. Your your your colleagues as well. There may be transferred within within. This audience will certainly you know, you may well come across transfer in the services that you do You work in within the medical school that you are. But you went off your student and and I just had a little bit about me, so I I transitioned at the time when I was there was a medical student, and this is, uh, in the in the nineties. It's exactly what in the nineties, but I I started I started my transition. I was at Oxford on the left Oxford after three years and came to some areas which is not part of Imperial, um, on, but, um, it was it was an incredibly hard time. I I think that especially time it's, um, areas I you know, I look back on it, and I I I hardly remember any of the any of the people there. I think you've come up to me and say, You know, I remember you from Exelon. Sorry, I just don't remember. Um, I had, um such a such a such a difficult time struggling with my with my mental health. I'm going through anything that's called up at that time. Um, and a lot of it was down Teo, and it was down to transfer, but I didn't get it done. Yeah, I had some horrible reactions from other students on wood. It's a very nasty things about me because it's probably my my back. Some of the some of the staff were much less than kind. But in amongst all of that, even though, you know, struggling with depression on D was just I looked at one point I thought about just quitting completely. I, uh, was incredibly fortunate that, uh, the medical school, it's a very, uh, given me a personal tutor who always was there to make time from the the doors. I was open and, you know, having a bad time from that day I go and have a have a little chapter her. When I was, I really hit hit rock bottom. She got me to help that I need another I needed, um on, um, I wouldn't be here today without without her that support. I think it's invaluable that support that that you you can give to your your colleagues on, uh, to the people that you might be you you might be working with at some point in the future is is is so precious. So you know, No, never, never forget that. And the last thing I want Teo to say And it comes in, I guess Ah, lot. Along with that. Is this this point about taking a stand? You're not remaining silent. Uh, we talked a little bit about transphobia, but I think that being being an activist as well as a doctor is something which is really, dear Teo my heart or something, which I have spoken about 22 So many people, um, on I think that I'm inspired by the people have come in come before me. This is Elizabeth Gary Anderson, who was one of the first. It was the first woman to qualify as a doctor in the UK back 18 65 um on And, um to she was many things. He was, He was He was credited, determined to do that at a time which was completely mental dominated profession where they were the medical medical establishment of that time. Try their best to to stop it from from from training, um, from practicing medicine. She became a dean of a medical school, but she never forgot that she was also an activist and her sister most enforce it if you have. If you have a go department squares here to see a a statue of her there. She was a one of the, uh, suffragists of the leading suffragists at the time who campaigned for universities are actually going to have a vote on the list with their Anderson was it was right there, right there amongst her. She doesn't. She's normally remembered. It's being one of the first doctors. But she was as much of a campaigner for for for women's rights, a sort of the other stuff. Just about the time on the picture. On the right is, is her having just stormed Parliament the age of 80 and deliver medical school as well. So I think that you know activism when when it when it needs to, including direct action. You know, it is not beyond us a doctor's Teo to do that. I think that, you know that doesn't have you don't have to look back in history can look back, You know, tell what's happening at at at the moment, please. These are These are for people who are like wax lyrical about them. They're wonderful, an amazing people. But I just want to tell you about the woman who's on the on the right Max Fortman, who and suddenly died some little while ago. Uh, but she, um she was a consultant in in in sexual health. It was a pioneer for making prep available on, um, amongst this this group here, how to from allow people Teo safely source print by buying it online before it was available. University through the NHS in the in England. She tirelessly campaigned for practice to be available on she was was, you know, not shy in stepping, stepping out and taking a stand and saying this is an injustice that practice isn't isn't available. We're going to do something about, um I think that's what's needed right at this very moment, you know, we we face this. Ah ah! Barrage off restrictions and on challenges to the established writes off transfer people. This was the news just yesterday from from us that the governor in governor in Texas, not calling our citizens to report parents of trance kids who were receiving gender of firmly care to report them for abusing their Children. Imagine if you you you had a child who was trans and you took up a child along to get treatment. Being reported. Being a child abuser for did for doing that is absolutely horrific. Have situation to be in. Um what? What? What What should we do in that situation? Should we just stay silent? Say it doesn't bother us? It's It's nothing to do with me. Well, should we take a stand? Encourage you to to do that, to take a stand? Because it it it might not affect you particularly. But it may affect somebody who is going to be who might be close to you in my face. Somebody another transfers and might be your patient. I think it's It's, um, is incompetent us, as as healthcare professionals t do that I think doesn't teach you really, really sounded up particularly well when he said, If you are neutral, situated injustice, you've chosen the side of the oppressor. Elephant has its foot on the tail of a mouse, and you say that you're neutral. The mouse will not appreciate it. So I would encourage you that, you know, don't don't remain neutral and face injustice When when that's when that's happening, right? Okay, let's think about what? What? What what would have talked about? Not see if I can wrap up and got some time for some questions that they have a chance. So what I want you to understand is that that, uh, fighting for equity and strive for protein house in trance healthcare. By doing that, we are fighting social justice. Nothing like nothing. Nothing, Nothing less. Um, we really is a self confessional. See, to commit embrace. Uh, cultural humility. It's. And this whole notion of reputation and visibility is absolutely vital. That's what's going to really make a difference. I never be afraid to offer support. Never be afraid. Take a stand. Thank you. So, yeah. Let's Let's, um Let's have some time. Some questions, okay? Same number that was already informative. I'm thought provoking talk. I thought, Well, the quote c is really and talking about your experiences. Thank you. Big, open and honest. Okay, we've got a few questions in the trap. So the first one is how would you explain culture unity in more ways for people to understand the concept? I like the idea. Um, cultural humility or country unity. Unity. Um, uh uh. I'm not sure what you mean by cut from unity. Humility. Okay, Country minutes. So I think I think the easiest way of thinking about it is is ah, just, um a So it's No, no, not seeing the not trying to see the, uh, but the patient through your own world view on, I would hope you do this anyway. But but But but but thinking about thinking about putting almost putting herself in that person shoes on, uh, three. That is perhaps easy. A lot used to say that to actually do because if you if you don't understand the culture that that person comes from, so let's say, for example, it's still it's not about transfer. Talk about someone who comes someone is a a migrant from another part of the world. That's be great. Good English might be, you know, might be in a bit, you know, a difficult situation. How can how can I a doctor this bleeding brought up with in the UK understand where that person is coming from the What do I do? I see it, you know, purely a month, Uh, with the lens that this is This is this is what this is the what? What? What you should be expecting to do as someone living with in the UK Where do I see it from the dry? Try my best. To see it from that perspective is not gonna be easy to do that. But if you if you if you take a position of humidity and be able to try to meet people with that with where they're out, then you always striving to do that, then that's that's what what what's what I mean by a cultural immunity. And it's not. Maybe not the easiest thing to Teo to describe, but it goes beyond just just the process of learning. It's it's more about a a kind of attitude. Uh, great. Um and he suggested for online resource is modules were ah transouth for conditions. Oh, yes, There are a few things I could probably what I could. What I could do, is is maybe add on a few extra links, and then if I share the slides, that would, uh, which is that was actually one of the ones that's going to link you go. Um, s so do you want it on yourself and tell us about the tell us about that call you? I just thought I'd say I'm shed. I got started sports. And so it's run and buy a collection of individuals and essentially, and it just takes him through. I think there's about six weeks of modules. Is that right? Andi just takes its in various topics and about kind of caring for the transportation is and and some of the issues on and that can arise on just essentially, sir, an increased awareness. And it's tailored for kind of clinicians or health professionals and say absolutely, really interesting Just that I share. Yeah, that's that's great. Thank you for sharing that. It's also a really, really good book. That logo recommend, uh, by a friend of Michael. Been Vincent on, um, it's called Transgender Health. On It's it gives you is a really good primer into a lot of the issues that affect people. Um, it's really really accessible. It's not technical it all. So you know, it's used one of those things that you you can you can pass on t o Anybody working within within, within healthcare. Really, really, really, really good. 1 to 2. Um, eso, um anuses talk. Would you recommend any particular individuals organizations to help bring teaching daughter's on transmitted by a healthcare? Um, I think that, um, not that's actually, uh I don't think it's any specific organizations that they're doing it that come to mind. I think it depends a little bit on what you what you what you want. It's It's It's specific issues around, Um, you know specific things about transapical, for example, if it's if it's about transit Gery then been approaching some of the surgeons or working out in that in that area could be could be really useful thing to do. The there is a There's no cancellation for the British Citizens 100 entity specialists that a renter organization this sees, um, people are working with engendered entity and so that they might be a good, good, good reporter call Tia approach I never, ever talked about, you know, with would they would they want to work a a sort of a port for people Teo approach to to get people to come and come and do do training, But it might be worth worth talking to the TM and are bringing up the person is president of the moment of the organization is something ovary. Well, so, yeah, um uh, you know, if it's, um, you know, there's stuff that I can help with and, you know, let me let me know preop you to to do that. Oh, I can I can certainly point you towards some individuals who might be able to help. So yeah, I just pay me a message or any male on, uh, I'll see what I could do. Yes. So curious. Said his GP trains. Bert, did you health? And the question that was mostly gender from the hormone therapies may affect patient's signature. Got to reference range three parts. Okay. Uh, any specific resources that the address is that there are a couple of a couple of papers that do address changes in reference ranges. The it's I will again if you put if you being a message, I'll happily on forward on those references to, um to you. Uh, probably the easiest thing is just things to Dio after. I'm not to keep this a particular technical talk about about that didn't really want to focus on on that aspect of healthcare, but but yeah, but they certainly are changes that hormones we'll do some things. We'll move from being more appropriate for, uh, for for, say, for example, someone who is on maximizing general for metformin therapy says something like the hemoglobin won't we'll move from being on a female normal range of the start. Actually, being more appropriately is a male normal range, some sort six months to a year or so after being on testosterone therapy. Other things don't work very much. A tall things like the argument phosphatase that's that's doing partly by bicycle little masses. Well, it's but by liver conference, a few liver function stays and say it's a little wax. Doesn't really change with hormone. Therapy has taken postpubertal. So some things like that don't don't don't really change very much tour on, you know. Other things come come to some some sort of in between in between kind of range. So it's a it's a It's a little bit of a tricky thing with reference ranges, but yeah, happily for without to you on. Then Emily said, I'm interested. Specializing in public health. New bill, it a shin oh, brilliant on. It's interesting this other practitioners talk about transition is when you feel that they're not competent to search translations. That special training makes sense, but the same time I wonder if it could be disservice community to hold off rather than getting started learning on the way you thought. Yes, I do. I think that that's amazing that you want to do that. And I think that particularly for for, uh, trans masculine poke, it could be really, really valuable. Do a bit after a lot of people who struggled with with with having pain, which could be it can be associated with to sister and therapy. People get really, really severe cramp cramp. Public pain is often do to increase in hell it for muscle tone associated with being on on on treatment as well as other other other changes as well to things like, um ah, a little inflammation of journal atrophy and a swell. And so I think that I've I've seen people benefit really, really significantly from perfect floor, predict a physical therapy for that and in some cases have an itch to avoid having things like in your needing to have a hysterectomy. That was often that's sort of the goatee that in the past we've relied on. I think that's often quite quite a drastic dressed, except somebody may want to have instructed as part of their their gender foaming care. But it doesn't necessarily mean that if you don't want to have that actually, the only thing. So, yeah, I'm, uh eso Yeah, Go for it. I think that that is I think that that that, uh, a lot of the experience is that you or the skills that you have, you know, just doing, uh, you know, then if it's apparently are totally applicable that you don't you don't need to have have specialists skills on a lot of it is just down to that about that thing we're talking about before. Just be the meeting. People wear out being able to come in with a with a tube of cultural unity when it comes to TV into here. To your your constipation. I think that helps. Um, where we might but, um have Okay, Beth, do you think it's actually given a long waiting list with thinks that regulations repair a role in supporting trans people? Self sourcing. Woman's one supply per se. But it was raining safety advice. Same way to do the homework on receptor. Yes, very much so from. And I think that I really could be on that and say that that I would hope that people would feel happy if you're in a position if you're ready, for example, your deeply in in helping people Teo obtain prescribed treatment rather than saying you to carry on, you know, self sourcing. I've been doing that for a long time. In my mind, my clinic and within sexual health. Well, things are recognized from some time ago. It it certainly did. Some were looking at the number of people who are self medicating work on the interstate for health. You know, we could we could address that actually, being able to, um, to support GPS in a community. Partly we're training and partly with saying, you know, we'll we'll we'll we'll look after them on, you know, monitor blood tests and on give you advice about dosage in that time and such, like, really valuable exit. You gave GPS confidence to Teo prescribe to Translation tour on the way to MR On Treatment on. It meant that that people could avoid that situation where they were actually pretty self harm by by having Teo by hormones off the Internet on, you know, and I've seen people. Dina, I looked after someone who was spending what little money they had to tear purchase the hormone therapy to the point that they that they weren't eating of the losing weight becoming, you know, you really malnourished because it because of that, desperate to be on the therapy on down now are flourishing. Just REM being able Teo access prescribed treatment. I've seen people who, uh, you know, having Teo. Um, that's one of the things that you know, the within the transom. Unity. We were just a pretty resourceful bunch of that. You know, where healthcare has has has failed us. We don't test to Teo. Try to teach make up. You make that up and the a lot of it's been sharing information through it through the community, a lot of it's helping each other. Sometimes that comes down to, you know, you know, sharing the medications that you're that you're prescribed, people will. People will do that. Um, it almost know how comes back to this of early days of HIV treatment where we're trying to hold a venture. It far off there appears, was incredibly hard, and the new buyers club started to spring up and such, like I think it's it's a shame that we're in a situation a week we have to do that. But But that's as the handed else. And that's what we're that's what What way? You know what? What people are doing When How how do I have I feel about that as a doctor and a transplant to myself? Well, I do. I do my best tea. Try to support people to do it in the safer way. It's possible. So, yeah. Um, okay. Have they help someone trying to get to? I'm going to get these so unnecessary. I've done the public health training struggle, finding support in the UK, France and trainers. The NHS course that said they wouldn't feel confident transporting health since I place and good engine said Okay. Uh, yeah. I only know a few people, but I can I can certainly do that. So, yeah, if you get if you message me, uh, are you putting direction? Okay. Uh, so l East there's what training pathway? Did you take her down? Your career might be different, but similar to health alternatives. Okay. Oh, that's interesting. One I had over sort of weird training, probably. So I, um yeah, I was one of those people who was never sure what I wanted to do. And, um, I was, I guess, fortunate enough that training at the time when I my qualified was a little bit war. It wasn't quite as a strategy is now. And I think that the rigidity can help in some respects to give you some structure with it. But if you're if you're unsure, be able to sort of, you know, try out different things about from one specialty to another is a lot is a lot harder. So I did hematology for a little bit and then came back to sexual health. And then yet, uh, I and then I decided that 11 point that I got really fed up of, of being a doctor, I didn't want to do medicine anymore. So I quit and decided to do a PhD and went doctor, too. Uh, it went up to the lab. And what do you mean? Ology and united by fanatics is when it was my PhD and then I realized I really missed. I really miss medicine looking back to it. And that was at that point that I came back Teo in trance Healthcare I for a long part of my time. My, my career. I didn't want to have anything to do with TranSouth care, you know, to leave it all behind. Um, so it was only since 2012. I came back to it. And I have Yeah, I loved it ever since it's been found from the area that I really, really love. So how is it different, Teo? Sexual Doctor. Well, I I don't actually do very much sexual health, so I must remember especially doctor. So, uh, I'm not a consultant on, and this is some some benefits to do that and give you some freedom. Teo, create a portfolio career where I do a little bit of sexual health on book in a gender identity connect with the rest of the time. The I mean, it's a bit it's been a weird thing is that at the moment I'm sort of moving from Brighton, Teo Cardiff. So I'm work partly and right. And then what part in Cardiff? And if you look at them out, they're really far apart. So I live in London the moment So I I'm doing a lot of traveling, just just which has been really, really difficult, but, um, it's Yeah, I would say my career pathway. That's not the most representative of how how most people do do do, do their careers. But I think certainly, if you're interested in a career in, in, in in gender, when people come to that in a little different ways. So traditionally used to the mental health and people would just psychiatry. Actually, that's much, much less the case. A lot of people have a prior history in primary care. Quite a few of us are several help doctors and do a bit of help, bit of bit of gender as well on I think that I think that's what or for for the better, that there's a diversity of people. You're working with them. We're working with the gender. So yeah, um, So Yasmin says, I've come across some healthcare professionals who have a home for Bickle transferred interviews because so you got some health versions. If I was a transformative use before, we probably look after beauty. Plus people, Are there any ways to address this in practice? Um, I don't I'm not quite sure what you mean when you say probably look after ultimately people is it that they, you know, positions where they are looking after people but not giving them care or good. My right knee has been experience is one that a lot of us have that we come across. Even it's a student myself that you meet clinicians that, um, yeah, that that holds, have a favorite contracts, babies. And you know that among their patients, that will be It should be two. He plus patients. So obviously. Okay. Yeah, here. Yeah, I think that's I think that's very difficult, because I think that, you know, uh, it is overwhelming scent saying that, you know, you need ta stand on that. She say something. I think that that's ultimately what I would say. Um, I I found it very, very difficulty. That's it. As a student, I I face a lot of people who did have transfer the views and say that to my face. People say somebody horrible things to me. I mean, I was really, really difficult. Uh, Teo to feel empowered, Teo, to say anything. I I think ultimately being be, you know, being feeling free. T t do that is important. And I think that the law is on your side here that if people are on GMC. Actually, a swelling is on your side. There is and pricy of off off. No tolerance to two people who have you know who are phobic and transfer big. Um, Andi, you know, if you're in a situation where you are way you're you're facing that, Then if you don't feel confident to speech that person directly yourself with other buffet that you that you might not talking Teo, your, uh, talking Teo someone that you trust within within, within the within the medical school it that that that your urine might be It might be really helpful talking to the issue in a place where you have inequalities and diversities team, I think most most ventures trustee having talked to, um, the representatives, there could be really, really help. Um, on, you know, in in some cases, and particularly where you know that there has been, uh, discrimination against people who who are cute, us. Then I I think it's really, really important that you do that. So, um yeah, but it is it Is that Is that helpful? Yeah, that was really helpful. Thank you dot Um, you know, he's got one last question Um uh, okay. As a research scientist, like a lot of LGBT, uh, was training is understandably in disc lucidity, medical students and positions, um, lead to a lack of updating awareness to try healthcare is to students result with the selection tender seven electorate entirely rejected. So it's just kind of visual. Pregnant. Um, he have any thoughts on how healthcare researchers and healthcare providers could work together to improve his awareness? And it put in healthcare research that it's an actually brilliant question on, I have to confess there are a lot of the The stuff I've done has been very much more focused towards towards emissions on medical students. And I think that yeah, we do. We really do need to think about how you were brought in that. And you think that, uh, what you're what you're doing in in research? It sort of is forms of fundamental basis of how we how we practice medicine. And if if it's if it's done in a way that is really blinkered towards the experience off extra tiki plus people, then you know, we we're starting off on a really, really ah terrible foundation. So how how can How can we do it? I think I think we just I think we just need Teo. We perhaps need to have more dialogue, and I think that they're often Is this this this'll kind of separation on? You know, I found that when I was when I was in working like that, that the You know what? What? What was happening with conditions was it was it wasn't her world apart on, Although there were some some doctors who who also worked within within, uh, labs. Well, it was almost you kind of left that left that stuff behind. What's that? You know, two different worlds on. I think that that that there is definitely there's definitely a lot of, you know, There's definitely a lot of cross over a lot of things that way could do. Um, I don't have a definite answer for you, but but, you know, I'd love to talk about more about this because I think that we can. There's a lot we continue, so yeah, again. If you want to touch with me on if you got any ideas what you want to put in touch of other people who are doing that then? Yeah, I think I think is a lot. We could We could do that. Give me a lot food for thought, so Yeah. Thank you. Okay. Thank you so much. Doctor Number again for really interested. Thank you everyone for coming. Um, if you got any more questions, I'm just getting touch. You're on. Amazing. Thank you all on You have a lovely evening. You. Thank you so much.