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OK, let's make a start. So um I just introduced myself first. So I'm Alec, I'm an F one doctor working in Yorkshire at the minute. Um So this is a 12 part webinar series. This is the first one. We're gonna be talking about lots of different things over the 12 sessions. So next week is HIV and prep, we'll have a session on sexual health, uh reproduction and fertility, uh Children, the elderly patients. Uh and then it kind of culminates in AQ and a session at the very end uh where we'll have a panel of people um not within medicine but just a any people really that are part of the community. Um And we can put questions to them for, well, anything really advice on how to treat them better as patients, what their life is like trying to navigate the healthcare system, how we can improve that for them. So, you'll have seen on the registration form, there was a space for um uh a question uh if you want to ask anything at that session. So that'll be on every registration form um for every session. So you'll be able to ask a question. Uh If something comes to you in the future and at the end of the session as well, I'll share my um mind, I believe email address and you can send any questions to there as well that can be included in that session. Um So let's crack on, shall we? I'll um turn my camera off the microphone off and hand over to honor. Thank you. Cool. Thanks for the introduction. So, um I'm Lorna, I'm an F one at Aden Brooks Hospital. Graduated from Cambridge last year. Um I'm gonna be doing a quick introduction to the general topic of gender and sexual minority health with a focus on how gender and sexuality impact health um more broadly um because we've got lots of different webinars which focus in on all the individual topics. So I won't be going into loads and loads of detail on any one. But yeah, um I use she, her pronouns um and I identify as bisexual. Um And yeah, feel free to just put like comments in the chat as we go along if you want to ask any questions or you can save them till the end. OK. Um All right. So this is just a kind of quick rundown of what we're gonna cover. So we'll start with some definitions um Pretty basic just making sure people know what we actually mean when we talk about different gender and sexual minorities. Um And then we'll dive a bit deeper into this topic of health inequalities and how it relates specifically to, to queer people. Um We'll cover a bit about sexual health because that's obviously, you know the big topic when it comes to sexuality and healthcare. Um we'll talk a bit about drug abuse and chem sex, talk about safeguarding and violence because I don't think that's covered in um any anyone talk later on specifically. Um And it's useful to know about how to sign, post people to the resources they need and what your kind of responsibilities as a clinician are. Um And then nearer the end, I'll briefly mention some of the more kind of topical um aspects of quit healthcare, including the CAS review, which is the big thing that happened last year for trans healthcare. And then at the end, I'll kind of wrap it all up thinking about how we as clinicians or as medical students, which some of you might be um can you know, either be allies or be kind of proactive members of the community in helping other patients or other members of the healthcare profession. Um Cool. Um I was going to show a video here but because um meal is a bit annoying, I can't do that. But essentially it was just a video about like the history of queerness in the UK and about how, you know, it was only until the late 19 eighties that homosexuality actually stopped being a diagnosis in the DSM. Um And only in 2013 was actually excluded from the disorders of sexuality category. Um And obviously, in a lot of the world, it is still illegal. Um It's not just an illness, it's actually illegal. And in some countries you can, you know, be prosecuted and rarely, you know, some people get the death penalty for being themselves, for being queer. Um And, you know, the other big point of history is not just that homosexuality was treated as a mental disorder. Um Queen is, were generally treated as mental disorder. Also, the, obviously the HIV pandemic of the eighties and nineties, which saw this kind of decimation of a of a huge part of the um gender and sexual minority population. Um and the consequent stigmatization while all of that was going on at the same time. Um OK, so essentially, there's a huge amount of kind of what we call minority stress in this particular subpopulation, this particular minority. Um And even though we've made strides, even though, you know, we're not the country that kills gay people, there's still a lot of um we've still not reached kind of parity. Um You know, they're still a growing reactionary conservative right wing that is seeking to take away the rights of um sexual and gender minorities, not just in the US, but also in the UK, the survey is a bit older. Um It's the last kind of official national survey that was published um in 2018. And it kind of goes to show that even though, you know, we um legalized same sex marriage in 2013, et cetera, et cetera. Everyone has the same equal rights. Um Gender and sexuality is now a protected characteristic. You know, the experiences of queer people still show that discrimination, harassment happens on a daily basis. Two thirds of people are scared of holding hands in a, in a public place with their same sex partner. Um More than a third of trans, trans people have a negative experience when they access a healthcare service because of their gender identity um and so on and so forth and various issues about employment um which shouldn't be the case because again, gender and sexual minorities are uh it's a protected characteristic. OK. So that's just the kind of laying the groundwork in the historical context. But um OK, so definitions wise, just making sure we're on the same page. Um LGBT stands for lesbian, gay, bisexual, trans and then the Q stands for queer, which used to be um more of a slur, but it's now been reclaimed. Um So it's often used by queer people. Um Asexual means, asexual aromantic, you know, the A means no, so no sexuality, no romantic attraction. Bisexual means attracted to more than one gender. Pansexual means all genders. Transgender is someone whose gender identity is not the same as the gender they are assigned at birth, the opposite of that being cis gender. Um If you do identify as the gender you're assigned at birth, non binary, is anyone who doesn't sit comfortably with either male or female? And intersex is someone whose biological attributes don't fit with the kind of social assumption about what constitutes male or female. So they might have, they might um present externally as male but actually have a uterus, for example. Um And here are some fun flags as well. Um These definitions are more sure with experience. Um I have a feeling that you probably all know what these mean already. Um And this very much isn't a comprehensive list. Um But I'm just gonna kind of skip over this because I'm gonna assume or hope that you guys know um what coming out means. Um What, what dead naming means. Um I think it's important to note that transitioning can mean a whole range of different things for trans people. Um The social transitioning where you kind of adopt the mannerisms of the gender you're trying to transition to. Um and, you know, wear the clothing and so on and then there's medical transition which can involve hormones, it can involve puberty blockers and then it can involve surgery which is, you know, much further down the line. So some people might opt for some of those or none of those or all of those depending on what they're kind of comfortable with. Um So it's not sort of a linear journey for everyone. OK. Um Yeah, so groundwork lead, um let's get into the kind of theoretical stuff. Um So health inequalities, if you guys know anything about sociology, you've probably seen this little diagram before. Um But it just kind of goes to show that um when we think about things affecting people's health, we think about them on multiple different levels, right? So you've got that kind of general socioeconomic level and cultural level where for example, we live in a sort of heterosexist society, right? Where the general cultural assumption is that people are c and are straight. Um You've then got living and working conditions. Um So for example, like being employed, having problems with your employer, not being able to access healthcare, that kind of thing, you've then got social and community networks. So things like actually being able to, you know, form protective relationships within like a queer community, for example, or maybe being rejected by your family, you've got individual lifestyle factors. So that's things like drug, like using drugs or alcohol, making kind of different health decisions. And then the red circle is like your identity, so your gender and sexuality and also your age, your ethnicity, your genetics, et cetera, et cetera. So when we work with patients, we have to think holistically about all of those things which might be affecting their health um both negatively and positively. OK. And this is called the Dahlgren and Whitehead model. Um of social determinants. OK. So coming on to the concept of minority stress, um this was first proposed by this guy called Maya in 1995 when he wrote in his paper that the concept of minority stress is based on the premise that gay people in heterosexist society is subject to chronic stress related to their stigmatization. Um When he originally wrote the paper in 1995 and then later, more kind of uh formula in 2003, he was referring mostly to gay people specifically and thinking about um how minority stress affects gay people's mental health. Um Obviously that the concept of minority stress has expanded a lot since then. But when he first described it, he was thinking about um how different different things affect people at different levels, right? So he had this idea of distal stressors versus proximal stressors. So distal stressors might be things that originate from the actual people or all the institutions that impact the person. So like discriminatory laws or major life events, like being victimized by violence or living in poverty. Um And then just kind of microaggressions, that sort of thing. Whereas proximal stressors more proximal ie they, they arise from more of an early socialization process where like gender and sexual minority people reject themselves for being queer. So internalized stigma and they develop expectations that they will be stigmatized because of that stigma. Um And they hide their identity to protect themselves which she calls identity concealment, which may be protective in some environments, but it also limits access to social support and affirmation. Um So, yeah, those, those three things kind of um external objective events affecting people causing stress, chronic and acute expectations of the events. So the vigilance, the hypervigilance of thinking, you know, am I going to be assaulted today? And the internalization of, of the stigma are kind of the three main mechanisms he was proposing that minority stress worked through um to impact people to impact queer people's mental health. Um And this is his kind of um diagram showing how all of those things like interrelate um from the original 2003 paper. OK. But since then, um this concept of minority stress has obviously been expanded to think about not just minority stress being LGBTQ plus people. Obviously, this model applies to racial minorities um to religious minorities as well. Um But it's also not just expanding it beyond mental health as well to think about how does it actually affect physical health? How does it affect um long term outcomes, that kind of thing? Um Yeah, and there's kind of, I've pulled together a bunch of papers there, some of them are a bit old, but I think one of these papers showed that queer people are three times more likely um in one year to develop an adverse health, physical health outcome following an objectively measured like prejudice event by like being being discriminated against, um which I thought was interesting. Um And then there's a whole host of research obviously about how queer people have worse mental health and that's mediated through discrimination and so on and so forth. Um And leading to accelerated cognitive decline potentially, although the evidence for that isn't, is, is so strong. Um Yeah, so your physical health inequalities, uh like I said, there's that one study which was quite, you know, it showed quite a significant effect. But I think a more recent systematic review has shown that I think the link is slightly more tenuous, a little bit shaky. Um There's definitely inequalities, but it's quite hard to tease out the relationship between minority stress and physical health outcomes. Um But it might just be to a lack of theoretical understanding of how that relationship works and what measures we should actually be measuring. Um Yeah, I think, and then obviously there's this confounder of like substance abuse issues, which we'll talk a bit about later um because queer people do have higher rates of substance abuse. Um And that has direct impacts on physical health as you can probably imagine. Um and smoking as well. Yeah. And of course, there's also also the fact that specific diseases vary in prevalence according to sexuality, the most obvious one being HIV. Um But obviously, we shouldn't also assume that all gay people have HIV. So, you know, there's certain, there's certain things we should be screening for in certain populations if it is, if it is justified. OK. And then, yeah, I think we've covered the mental health inequalities um pretty comprehensively. Um Stonewalls report in 2018 is like super comprehensive. Um And here's a little infographic from it. Um Yeah, more than half of queer people experience depression, for example, is a slightly insane statistic. Um And yeah, historically, obviously, the psych, you know, psychiatry has not been friendly towards the queer community. So perhaps there is maybe a problem of people not seeking help, particularly people of an older generation and then conversion therapies is something that will come on to you a bit later, but which I think kind of classifies more under the abuse section. Um Yes. Um And then a couple of more specific things. Um Oh, wait, sorry, I was gonna, yeah, I was going to mention one more study here actually. Um So Maya did a study in 2021 actually, which showed that younger queer people were coming out much earlier than older queer people had, which is a sign of, you know, a more accepting society, et cetera, et cetera. But the improved social environment we have now hasn't actually attenuated uh exposure to minority stressors, both those distal stresses of like discrimination and the more proximal stresses of internalized homophobia. And he showed that actually, psychological distress and suicide behavior did not improve and it's actually gotten slightly worse for the younger generations of queer people. So again, just going to show that, you know, although things have changed surface level, a lot of, a lot of those minority stressors and the actual impacts they're having are still having the same level of impact. Um Yeah. Yeah. OK. Yeah. And then a couple more things which are more kind of specific topics within the kind of mental health and queerness space. Um So sexual minority men are much, much higher risk of body image dissatisfaction and eating disorders. Um I think up to, there's quite an old study which showed that up to 42% of men diagnosed with an eating disorder have identified as gay or bisexual. Um And there's various, you know, reasons for this um because they might, they're slightly more likely to internalize an appearance ideal centered around looking, athletic, looking a certain way. Um And then there's also transgender people, of course, who often have really intense uh gender dysphoria around their body. And it's important to differentiate gender dysphoria from body dysmorphia because gender dysphoria is not a disorder, whereas body dysmorphia is a disorder. Um, body dysmorphia isn't restricted to transgender people. It's, it's, you know, anyone who is dissatisfied or obsessed with um something in their body which they feel is not correct. Um OK. Um And then a slightly more kind of hot topic which I've been involved in some research with. Um is this overlap between autism and gender diversity or being trans. Um So a lot of autistic people are transgender and a lot of transgender people are autistic or have autistic traits. Um And studies have shown that the prevalence of autism among gender diverse people is as high as 11% which is a lot higher than autism rates among the general population. But this is, you know, a really important point. Um Being autistic doesn't mean that your gender, your, your trans is, is just a manifestation of your autism if that makes sense. Um It's quite easy to fall into these ables stereotypes that autistic people don't really have the self knowledge to like understand gender expression. Um But, you know, research shows that that's just not the case and being autistic shouldn't preclude you from accessing gender affirming care. Um because yeah, that, that correlation is, is quite a common one. OK, so we talked a bit about physical plus mental health um inequalities um onto the more kind of practical aspects of like the day to day sexual history stuff you might, you might encounter and for example, like an ay if you're a med student. Um So sexual history, it's really important to remember that sex is different for everyone, especially for queer people. It doesn't necessarily mean, you know, penis going in vagina, which is usually what the kind of heterosexist um idea of of sex is. Um So the important thing to get to actually establish when you are taking a sexual history is what actually went where, which is really important for determining sti risk, like, you know, what physically contacted, what, how many partners were there? What were the sexual characteristics of the partners? Did they have a penis? Did they have a vagina? Did they have something else? Um Were there any drugs involved? Um that's a fairly important one as well. Um And obviously, like, it's really important to be sensitive when you ask those questions. And I think there might be a session later on about communication. Um So hopefully that's kind of involved in that. Um And yeah, try and be as non judgmental as possible. Don't make assumptions. Um ask use, use open questions. Um And you know, ideally, you know, have these conversations in a very private place where no one else is around. Um OK, important things to remember. Obviously, lesbians can get S ti s um transgender men can get pregnant. Um Only barrier protection stops all ST transmission except pubic ice, which I didn't know about until someone told me about it. Um So P pubic Ice is the one S ti that like nothing can stop. Um If, if you, you know, if you use a condom, it doesn't prevent transmission because it's on the hair. Um And yeah, it's important to know the prep and P EP guidance, which I'll have on one of the latest slides as well for HIV. And yeah, know about high risk behaviors like drug taking chem sex and group sex. But don't assume everyone engages with that. Ok. So, yeah, I'm briefly mentioning hiv AIDS. I'll be quite brief. I there's a whole session about HIV AIDS. Um, men who have sex with men or MSM um, are still the most affected by HIV in the UK. But new diagnoses of HIV are actually now more common in heterosexuals than in gay men because the rates of prep and pep are so high in gay men now, um which is really encouraging, probably like um it is important to encourage basically everyone to get tested if you think they are at risk. Um So generally new diagnoses are decreasing. Um and people living with HIV in the UK are taking treatment, so they have an undetectable viral load. So, transmission is, you know, usually generally quite low. Um and remember, undetectable calls, untransferable. Um When you're thinking about risk, it's, it's highest in the receptive partner. So, whether anal or vaginal, so generally post exposure prophylaxis should be given if the person was anally receptive and the partner was of unknown HIV status or if they were of positive HIV status, regardless of um sorry, with a detectable or unknown viral load. And there's comprehensive guidelines published by the British HIV Association um which are all available for free online. Um So just if you're not sure, just go and have a look. Um ok. Um And yeah, so prep preps er is usually Truvada which is the reverse transcriptase inhibitors. Whereas pep is Truvada plus raltegravir, which is the HIV integrase inhibitor. So, post exposure prophylaxis is like the combination of the two. Whereas pre exposure prophylaxis is just the one usually. Um and post exposure prophylaxis has to be taken within 72 hours for it to be effective, but it should be taken ideally as soon as possible. Ok. Um and yeah, this is a side note on HPV vaccination which used to only be available to um girls, school age girls. But um HPV is spread by any form of sexual contact. It's not specific to vaginal sex. Um So yeah, so in order to help reduce the rates of um anogenital cancer in men, um they introduced the HPV vaccine to boys as well. So nationally uh boys and girls are getting it in England. Um and now um men who have sex with men who are under the age of 45 can get the HPV vaccine for free if they didn't have it at school. Um And that's only accessible via sexual health or HIV clinics, which is a bit annoying because I think that women can get it through their GP surgeries as well sometimes. Um Yeah. Ok. So that was a rundown of sexual health. I think we've covered the main bits. Um So drug use and chem sex, I'll mention these Shelly briefly. So drug use is a lot higher in queer populations. So the most recent national statistics were published, you know, 10 years ago in 2014. And they show, you can see in that diagram, you can, you can see that for both men and women, gay or bisexual men or women always take more drugs than their heterosexual counterparts. Uh And generally the rate is higher is the rate is higher for gay men than for gay women. Um Yeah, so three times, yeah, three times higher for men, four times higher for women proportionally compared to the to their straight counterparts. Um And yeah, this difference is across all age groups and across all drugs of abuse as well. Um Research into why these, you know, queer people show elevated rates of substance abuse is missing. But I think you can kind of intuit why I think a lot of the reasons are because people self medicate to deal with mental health and stigma as we talked about in the in the previous minority stress. But often queer people will gravitate towards like environments where they can feel liberated and safe. And a lot of those do tend to be, for example, nightclubs obviously not a queer people go to nightclubs. Um but nightclubs are places where, where you would probably come into contact with drugs more easily. Um There's chem sex as well which we'll talk about a bit on the next slide. Um And I've heard anecdotes of um trans people using things like MDMA um and psychedelics to help kind of, to help them through that gender dysphoria feeling. And I think there's been some new interesting research in the kind of psychedelic field, psychedelic research field about helping uh trans people um feel more comfortable in their bodies using psychedelics, which is pretty interesting. Uh Yeah. So chem sex is sex while under the influence of drugs. Um pretty self, pretty intuitive. Um It's usually between men. Obviously, it doesn't have to be between men. Um The most common drugs. Um at the moment, the most common one is probably Mephedrone also known as um MCA or Mea mea. Um There's also meth methamphetamine or G HB or GBL. Um Obviously there is a high risk of S ti acquisition during chem sex which is usually group sex. Um and there is that risk of overdose uh dependence and withdrawal, especially because all these things. Uh well, meth and Mephedrone are stimulants. Um There's also poppers which are obviously less, far less intense. These are basically just inhaled um vapors um which used to be legal and since 2016 are no longer legal. Um you can still buy them at some corner shops, but obviously they're not advertised as poppers. Um And yet they're more commonly used by some gay and bisexual men to enhance sexual experience because it, it vasodilates and it helps relax the sphincters of the anus. Um and they do carry a risk of hypotension because of the vasodilating effect, especially if you combine them with Viagra, which is a PDE five inhibitor. Um So that's just something to be aware of. Um generally, you know, the way to ii if you see people like this and for example, a sexual health clinic, you want to encourage them to, you know, basically just be safe and uh use, use as many harm reduction behaviors as possible. So, you know, if they're not gonna use protection, then make sure they're taking prep, make sure they're getting regular sti tests, um encourage them not to mix drugs or if they are going to mix drugs, you know, to look up what the effects might be. Um And obviously keep addiction services in mind as well. Yeah. Um So drug and alcohol services, which are the kind of main addiction services in the UK are often run by locally commissioning charities and they often don't actually offer targeted help for queer people. Um But there are some charities like the LGBT Foundation um that do offer some more specialized help. And obviously, um there are lots of queer therapists out there as well who can help with addiction if needs be. Um And yeah, like I said, um in 2016, they passed the government passed the novel Psychoactive Substances Act, which essentially banned legal highs including p and um nitrous oxide and that disproportionately affected queer people. Um OK, so a bit about violence and safeguarding So this is quite important. Um Queer people are at greater risk of domestic abuse and sexual violence and hate crime often from their own families, potentially from partners who reject them. And obviously from society more generally. Um One in five queer people experienced a hate crime or incidents in the last 12 months in a survey done in 2017. Um and in a gallop survey gallop is like the specialist queer LGBT Plus abuse um service. And they showed that nearly a quarter of queer people who'd experienced sexual violence, it was to convert them to heterosexuality or convert them to their assigned gender at birth or to punish them for their identity. And again, we'll talk about conversion in a bit. Um Violence doesn't have to just come in kind of discriminatory hate crime forms. It can also be, you know, through fication. Um So sexual violence, for example, and hyper sexualization of, for example, pansexual people. So, yeah, sexual violence um violence exists within queer communities to um which is, you know, difficult to hear about but um men can be victims and women can be perpetrators. Um Yeah, and the main resource I signpost you guys do is gallop, which is specifically for que people who have suffered abuse and they've got like loads and loads of, of resources. They've got a helpline, they've got ways that, you know, people can escape from a bad situation. Um And that sort of thing. Um So conversion therapy is essentially any effort to change, modify or suppress a person's sexual orientation or gender identity. Um When labor came into power last year, they announced a plan to introduce the conversion practices bill, which should hopefully um make conversion therapy illegal. Most commonly conversion therapy is a spiritual thing by like religious, like conservative religious organizations. So it might involve like prayer healing or exorcisms, that kind of thing. Sometimes it can be psychological like a talking therapy to try and make you realize that you're not queer. Um And, but historically, it has evolved a lot more kind of, you know, invasive stuff like brain surgery, um chemical castration, surgical castration or reversion therapy treatments through like electric shocks and nausea, inducing drugs. Again, psychiatry is not being kind to the queer population historically. Um But yeah, so conversion therapy is not therapy just in case there is any confusion there, it is a form of abuse and it is seen to be illegal. Um OK. And gallop also has resources on people for people who have experienced conversion therapy or have been pressured into it by their family or by, you know, religious groups and that kind of thing. Um So safeguarding the safeguarding processes will be the same wherever, wherever you go, there's no kind of special queer safeguarding process. Um But obviously, it's something you should be a bit more switched on to. If, if you do feel like you've got a queer person who has is making you suspect that they might be the target of abuse, um, or hate crime or if they're homeless, if they've been kicked out of the home, they've got mental health issues because of abuse. Um If you feel like they might have been sexually exploited as a child, or there might be some element of online grooming going on. These are all things that queer young people are at greater risk of um often because, you know, especially with the online grooming thing, young queer people feel like in real life, they don't have anywhere to turn to. So they're a lot more likely to kind of latch on to someone who does appear to accept them. Um Yeah, so generally follow the same procedures as always talk to local safeguarding teams. Um Generally only share information about the child's sexuality or gender if it's actually relevant to the concern. Um For example, if it's like a unsupportive family or if there's an element of sexual abuse, um just because if the, if, if it's not related, then you don't want to unnecessarily out them. Um Yeah, especially if they don't want that. Ok, so those things are all fairly heavy. Um And this topic is also fairly heavy. Um You guys have probably heard of the CAS review which was published last year. Um I'm going to talk about it fairly quickly because there's a whole session later on about trans health. Um in which I assume this is gonna be touched on. Ok. So the case review was a pretty was a landmark review. This is the first of its kind to kind of research the care of young trans people or young people questioning their gender. So the main takeaway from this was that what for what for most people, the main takeaway of this was that essentially it, it led to the banning of puberty blockers um for the treatment of under eighteens with gender dysphoria. It was one of the last things the conservative government did before they left office and West treating the new health minister has kind of agreed with the ban which um yeah, so the the report's author Hillary CASS in this picture here, um Basically in the review criticized the lack of evidence surrounding the benefits and risks associated with these drugs which delay the onset of puberty, um which essentially buy time for trans people, for trans youth to not have to go through puberty, which is kind of traumatic for them because if they're experiencing puberty and the development of the development of sexual characteristics, which they do not want and which makes them feel not at home in their bodies. And it obviously makes transition later in life a lot more difficult if you have developed those sexual characteristics. So puberty blockers help slow that down or prevent it from happening. Um And yeah, so um what was I gonna say? Yeah. So essentially the report was all about how the evidence just isn't there for a lot of um for a lot of things like puberty blockers and indeed for um masculinizing and feminizing hormones to um yeah, and then I think there was a lot of backlash as well. So this is so after having read the entire case review, which took a very long time, I then read a few kind of critiques of it, of it, uh which I encourage you to do as well. Um I think the BMA is also holding its own inquiry overview of the C A review um to see if it actually holds up. I think there's been, I think it's been largely accepted by most if not all kind of medical organizations, but there are a lot of people within trans healthcare, you know, clinicians in trans healthcare who obviously it didn't sit right with them. Um because even though the evidence base is not up to the scratch, up to scratch, it's not up to the standards of nice, it's not up to the standards of the NHS. There's a question of, do we have to just wait until these, these trials are finished? And we have the evidence that puberty blockers work and that, you know, um feminizing and masculinizing hormones work before we actually give them. If we wait that long, there's a whole generation of trans people that are going to grow up and actually require more treatment down the line because they didn't get these things which we know intuitively to work. Um And which kind of s mentally scarred them more than they had to be scarred. Um So it's a difficult, it's a difficult question and I don't even, uh I think I'm not entirely sure of the answer either. Um But I think my sympathies mostly lie with the generation of trans kids that won't have access to what their predecessors had and which their predecessors had with very, very little issue. Um See you anyway, this is just a quote from one of the critiques of the ca review. Um Basically talking, talking about the methods um being too strict or sorry, the standards for evidence being too strict for about um the actual kind of scientific method applied, not actually being very robust. Um and just picking it up and showing where the holes are. So, you know, it's important to get both sides. Um So, yeah, I think that's all I'm gonna say about the cast review. But if you have comments or questions, please do raise them. Um And then on a slightly more light note to end the talk, I'm just going to talk quickly about ship and what you guys can do in your roles. So the main thing to do is to just ask people questions and be open. So everyone's health experiences like we talked about before with the different layers. Um There's also you know, within that kind of red circle at the middle, the one about identity, there's all these different intersecting identities as well. So, you know, people aren't just might not just be gay, they might also be black, they might also be Muslim, they might also have a bunch of different identities, um which kind of pile minority stress upon minority stress. Um So all of these different things have to be taken into account and not every queer person's experience is gonna be the same. You know, that sounds like a very obvious thing to say. But there's no, there's no real one size fits all approach, especially with queerness. Um Yeah, so take the time to actually get to know your patients understand their lived experience and ask open ended questions. And obviously, you know, the basic things like ask for pronouns if you're not sure what, what pronouns a person uses, um ask what their preferred name is if they do have a preferred name and then ask if you know, you want them. Oh, sorry, ask if they want you to update that on the system, for example, because you know, a lot of the times trans people's dead name or their old name will still linger on a system. And then, you know, whenever they get called for in a waiting room, they just get dead named over and over again. So just things like that. Um trying to accommodate people. Um And realizing the kind of full breadth and complexity of the person and their different intersecting identities. Um and then ally ship, active ship um is not just kind of passively being like not um uh not a homophobe, it's, it's advocating for change um on behalf of your patients and on behalf of your peers as well because obviously, you know, I think I can't remember the exact statistics, but I think one in 20 yeah, one in 20 NHS worker workers are um LGBTQ class as well. Um And unlearning and reevaluating our own underlying biases to. Um Yeah, so like I said before, in that survey from 2018, at least a third of gender, nonconforming patients have negative experiences with healthcare because of their gender identity. Like that's quite a lot and we wanna be reducing the barriers to entry as much as we can. Um because these are the people who are most vulnerable and who most need access to the healthcare systems we have and you are currently being let down by them. Um So various ways to do this. Um There's a load of courses online, I think. So the Royal College of GPS has some really good modules as well. If you did want to learn more about kind of the theoretical stuff, um you can do courses on inclusive communication and also educate yourself on what services to actually sign posts to queer people to. Um at Adam Brooks, we've got like the rainbow badge scheme. So it's like a little rainbow badge that kind of just tells like it's a small signal that you're an ally and you're like safe to talk to. Um And in terms of thinking about larger scale change, most hospitals nowadays have like LGBTQ plus staff networks, so you can join those and they often are the groups that will be um consulted for like EDI policies or like quit action plans and that kind of thing. So it could be a good place to start if you're quite keen on getting involved at a local workforce level. Um Yeah, so this is my little signposting slide. I've tried to condense it to like the biggest and most useful websites and services out there. So it's very much something to like screenshot if you want to right now. So I'll leave it up for a bit. Um Which ones do I wanna point out? So LGBT Foundation is a big one in the UK Stonewall as well for sexual health, the Terrence Higgins Trust um and Brooke for, for young people under 20 fives. Um Mental health Mind is, is the probably the biggest mental health charity I think. Um And they've got helplines and they've got a, a specific page for, for queer um mental health issues as well. And I mentioned gallop as well. So that's the special LGBTQ plus uh abuse service um for people who need help or will he need to talk to someone about abuse or violence. Um And then specifically for transgender people, there's a few really good resources. So the gender construction kit is like this brilliant website which has like loads of practical resources on like how to go about transitioning both socially and medically, like how to get your name changed from your NHS record, that kind of thing. Um And then Mermaids is a really nice um website for transgender youth specifically. Um And yeah, this is a few selected references. Um The Standards of care for transgender people is a very good read. Um It was obviously published before the ca review. Um I think I don't think that W pa has written a response to it yet. Um Yeah. OK. So yeah, that, that's all I have to say. I have finished with five minutes left. Um So yeah, please do scan the QR code for feedback and let me know if you guys have questions or comments. Thanks so much, Mona. That's an excellent rundown over every possible aspect of LGBT health touching on all of it. So, thank you so much. Um Yeah, if anyone has any questions, please do.