I'm going to be doing very basic terminology that is English-centric because that is my primary language. If you know this information already, then bear with me. If it's new to you, then welcome, and I hope that I can help you with some understanding. Why does terminology matter? Well, for one thing, with the Cures Act, more and more patients are going to be seeing your reports in the language that you use in them, but more importantly is that words in general matter. We want to make our patients feel safe and comfortable, and honoring who they are as people is an important part of that. The right words help transgender people feel safe, and a medical environment, even in radiology, is stressful and anxiety-provoking for many patients. So a common complaint about terminology is that it changes all the time, and it does because this is what living languages do, and as they change, we have to change our usage, and Rosalie Maggio, who was an advocate for inclusive language, said it best when she said, if there's one thing consistent about language, it's that it is constantly changing, and the only languages that do not change are those whose speakers are dead. Some of the terms that I'm going to be using are still debated and will be debated, and I've done my best to choose the most widely accepted words and definitions. So I'm providing the gender unicorn, and here's the website, because everyone should take a look at this on their own time and be very honest with yourself about where you fall on these spectrums. We're not going to discuss sexual orientation or romantic attraction because it's completely separate from gender and outside the scope of this talk, but just note that these dots are here, but there is no beginning and no end. All of this is a spectrum. So on to our definitions. Gender identity is a person's deep-rooted sense of their gender, their internal sense, and this is set for many people at the age of four, although it can take a lifetime for people to come to terms with their gender identity. A gender role is how society expects you to perform your gender. Gender expression is the way that a person expresses their gender to the world, and this does not have to match gender identity, and depending on safety and resources and even at different times or preference, gender expression may not be indicative of a person's gender identity, and that is important to understand. Sex assigned at birth is a controversial topic, and this is where we get these terms assigned female at birth, assigned male at birth, assigned intersex at birth, and this is when someone looks at a baby's genitalia when they're born and just announces their biological sex. But there are at least six biological sexes, and there are many variations in chromosomes, hormones, the brain, and this says nothing about gender, so this is currently quite a controversial topic. Intersex according to the Intersex Society of North America is a general term for a variety of conditions in which a person's external genitalia or reproductive anatomy doesn't seem to fit the typical definition of male or female, and this would include those chromosomal variations. This is at least 1.7% of the population, probably more, and so it's not rare. It's as common as green eyes or red hair. Okay, so now we have cisgender. Now, this is an adjective or descriptive term, not a noun, and this is a term that describes a person whose gender identity matches their sex assigned at birth, so if a doctor said they were male or female, their identity is in fact male or female, and I came up with some examples. One is a funny actor who is able to laugh at himself, but also a stereotypical male, cisgender male, and that's Dwayne The Rock Johnson. Now for a cisgender female, I chose a funny, strong, no-nonsense, beautiful woman who's going to outlive us all, and that's Betty White. Transgender is the same thing. It's a descriptive word or an adjective that refers to, it's an umbrella term for anyone whose gender identity does not fit their sex assigned at birth, and that's not the opposite of cisgender. That is just anyone who is not cisgender, so it's a large group of people. For examples, I have Admiral Rachel Levine. She's an amazing person regardless of her gender identity, but she's the first transgender four-star officer and the assistant secretary for health and also a pediatrician. Here we have Elliot Page, who came out as a transgender man in December of 2020. He's an actor and a producer and was the first transgender man to be on the cover of Time Magazine. So non-binary is a difficult concept, and I've set up this slide to try to explain. On this side of the slide, we have cisgender or transgender men who identify as 100% or nearly 100% male in their identity. On this side, you have the same thing, but with female. Cisgender or transgender, 100% or nearly 100% female in their identity. Non-binary is an umbrella term for anyone who fits anywhere in between the two binary sides of the spectrum. There are many, many terms. I've just chosen a few here. We have two-spirit, which we're going to talk about in a minute. Gender fluid people, their gender identity and expression can shift over time, day-to-day, week-to-week, month-to-month, and it can go back and forth. They're very fluid in their gender identity. Transgender people do not have gender as part of their identity at all. Andergine people can be any sex assigned at birth, but they're in the middle of the spectrum and they're androgynous in their gender identity and typically in their gender expression. Genderqueer is not a bad word. Some people think that, but it is not a bad word, and it's a word that some people use to describe their own gender identity in the non-binary part of the spectrum. I've chosen some examples here. We have Janelle Monae, Asia Kate Dillon, Reign Dove, Eddie Izzard, Sam Smith, Maury Turner, India Moore, and I could go on and on. There are many examples of non-binary people these days. So I'm going to explain this concept of two-spirit a little bit. Most indigenous cultures all around the world, they don't have a binary concept of gender, or perhaps they have four or five genders. And on this side of the world, in 1990, the pan-Indian term two-spirit was coined to denote any native person in the LGBTQ spectrum. Now traditionally, and some native people feel that this should only be used to denote someone who has that traditional masculine and feminine energy and spirituality within that one person. These people were sacred and had special cultural and spiritual roles within their tribes, and more and more tribes and native people are taking this identity back. This is my friend Ohen Crawford. He is a two-spirit citizen of the Cherokee Nation, and he's a traditional artist and dancer. And on this side, you can see Ohen exhibiting that feminine energy and the more feminine regalia. And on this side, you can see Ohen dressed in the more masculine regalia and emitting that more masculine energy. I think you can appreciate that in this picture. And this is how I've always seen Ohen doing his traditional dance. Gender non-conforming. Gender non-conforming is an umbrella term to describe a person whose gender expression falls outside of traditional or societal expectations of their gender. And these people are not necessarily transgender. They can be, but they can also be cisgender people. And then there's the term gender expansive, which is used for younger people. And typically, these are people that either are still exploring their gender identity or are simply more flexible with their expression. Some examples that I have here are Prince, Billy Porter, Ruby Rose, Jonathan Van Ness, Tilda Swinton, and Lil Nas X. And you'll note that many of these people are actually cisgender and just gender non-conforming. So here's a few more. Gender dysphoria. This is distress caused by the mismatch of gender identity and sex assigned at birth. For some, this might be mild, but for many, it is moderate or severe, and it can even be life-threatening. And that's why transition is life-saving therapy for people. Transition is this journey of change and growth that a transgender person will go through to better align their gender presentation with their gender role and gender identity. And different transgender people will take different steps in transition from no outward transition at all to every option that exists for transition. So this can include socially transitioning, medical transition with gender affirmation hormone therapy like estrogen and testosterone, or surgical transition with gender affirmation surgery like top surgery, bottom surgery, masculinization, or feminization surgeries. I did want to talk about deadname. Deadname is a term to refer to the name that a transgender person was given at birth, and many times people can't or haven't changed that name legally when they come into the medical setting. It's important to ask a person's chosen name and then use that and not use the deadname. It's harmful to use the deadname for someone. So personal pronouns. If you don't know someone's pronouns, introducing yourself and giving your pronouns and then asking for their pronouns is a good practice. Note that it's not preferred pronouns. These are people's correct pronouns because someone's identity is fact, it is not preference. There are some languages like Mandarin that have one pronoun, ta, in the spoken form, and that's for people regardless of their gender. Other languages, unfortunately, they only have gendered pronouns, but in English we're lucky because we actually have the singular pronoun they, and we've had that singular pronoun since 1375. It actually predates the singular use of the pronoun you, and they has been commonly used if you don't know someone's gender, and you've probably been doing this your entire English career. But there are many other additional pronouns, and there are new ones added frequently. So additional pronoun options include, but are certainly not limited to, ze, fay, ay, purr, zay, and there are many more. And the point is not that you need to memorize or be familiar with these pronouns. It is good practice to wear a pronoun pin and to ask your staff to wear pronouns pins as well, because that makes people feel safe. And always ask what someone's pronouns are, and then use those pronouns, whether you've ever heard of them or whether they make sense to you or not. And don't tell that person that you've never heard that pronoun, or you would have thought their pronoun was something else. And don't undermine a person's identity by talking to someone else, even out of earshot, about how you thought their pronoun would be something else. That's discriminatory, and it's disrespectful to that person as a human being. If you make a mistake, correct yourself without apology or explanation, no fanfare, just correct yourself and move on quickly and conversationally, because if you seem uncomfortable, it's going to make that person uncomfortable. So just move on. And if you need to, ask someone to sit, someone else to sit with you outside of the room to practice so that you can use the person's correct pronouns without making mistakes. Here's my references and resources. I encourage you to take a look at these for further information. Thank you. Thank you for coming at 8 in the morning to come hear us talk about this. So I'm going to be covering a very, very expansive topic in a very short amount of time. I'm also told I talk fast, so bear with me and let's explore this topic together. I'm also going to be going over gender-affirming care. So I really try to condense this down to a very surface-level three overlying topics. So gender affects many domains of life, that gender affirmation is medically necessary, and as human beings and as consultant Starr refers, radiologists have a responsibility to understand gender and gender affirmation. So let's think about these a little more deeply. First that gender affects many domains of life. What does that mean? And Dr. Weir had just gone over these terms, so I'm not going to go over it in detail, but just to revisit that and summarize what we had just gone over. So first, the gender identity really is who do I identify as? I am a cisgender woman and that's my identity. How do I express or present myself today, tomorrow, next year? Am I going to a formal event right now? Am I wearing a dress under a suit? Am I going to be at home in my bathroom? How is it making me any more or less of a woman? And how do I present that to others who perceive me? And then, as Dr. Weir had just discussed also, sex assigned at birth, a very controversial topic in anatomical sex, and these three subjects together, and we're not talking about this other section, really give us this term of transgender identity and sex assigned at birth and whether or not they are aligned with each other give us the cisgender term and the transgender term. And I think it's important for the next topic, and we're not talking about the other intersex, which is how do these terms align in day-to-day practice for gender affirmation? So gender affirmation is not just a medical term. I know that we had just said in the second line, if you had looked ahead, was it's medically necessary, but there's so many aspects to affirming your gender, right? When you are talking to somebody and we're talking about yourself to somebody, you do things unconsciously and consciously to affirm your gender. And these are the domains that were kind of presented in a Lancet article in 2016, just to give us a way to frame how we understand gender affirmation. So how do you affirm it? One is socially. How do you present your name, your pronouns, your clothing and mannerisms and expression? Psychologically, how do you think of yourself? Do you have access to transcompetent mental health medically? I think that's something that a lot of people are now understanding and trying to do more research on is hormones, reproductive options, transcompetent primary care, gender affirming procedures, voice and communication therapy, and just understanding better guidelines for primary care, gender affirmation surgery, and just overall trans care. And legally, the right to autonomy, right to recognition under the law, anti-discrimination laws, legal name changes, and legal change of gender markers, which are all challenging and all of these interact with each other. You can see that gender affirmation needs deliberate action and deliberate thoughts and action to really carry this to fruition. So full gender affirmation involves all those categories. Here we need to think about gender as a social determinant of health and to really understand why it affects all those domains of life. So one way to think about it is from the socioecological model, which is thinking of, yes, you have the individual who understands their gender and how that affects them. But then you've got that interpersonal interaction, the prejudice and the violence, where even in 2021, you can see that in Forbes, there was this article very recently, where if you have 375 transgender people murdered in 2021, deadliest year since records began, and structural laws and social norms. So all of this envelops the person. And of course, on top of all that, you have routine life stresses, right? Adversity, regular stress, et cetera. And this affects psychosocial factors, behavioral factors, physiological factors that all affect increased risk factors for morbidity and mortality, right? So how do you mitigate that? You have community support from peers and family members, but you also have gender affirmation. And that's why we need to understand that gender affirmation is medically necessary. We have a responsibility as fellow human beings to understand that it's medically necessary and assist in all these domains. But when somebody comes to us for the medical affirmation, it is necessary. It's not an option. It's not a preference. It's a necessity. We tell our insurance companies also that it's medically necessary, because it does affect, as Dr. Weir mentioned, suicidal ideation, as well as increased morbidity and mortality. All right? So in that, the World Health Organization also agrees. In 2018, they started changing their terminology to confirm that this new term that they're using is gender incongruence. And why does that matter overall? I think a lot of people have said before medical school that 50% of the knowledge you learn in medical school will change. And I think this is one of those things that's super important to start thinking about, is in the past, it was really categorized as both a psychological disease, I will say, and then ICD also categorized it as a separate disease. But now it has been removed from the DSM. It is no longer a mental illness. It is only considered a sexual health condition. So even though people may experience dysphoria, right, the medical terminology and for insurance purposes, gender incongruence is utilized. And so the goal of all of this, really, is to tailor gender affirmation individually to suit a person's gender. So medically, that involves multidisciplinary care, as oftentimes many domains do. So just to give some numbers, because this talk, I just want to throw some numbers out there so you're aware of them, 78% wanted hormone therapy, 51% never received it, all right? 25% had some form of gender affirmation surgery. And this is the breakdown of folks that, out of the 25% folks that had gotten that surgery. One-fourth were denied insurance coverage, despite the fact that there should not be discrimination based on sex. And 45% of the LGBT population live in states that do not have LGBT-inclusive insurance protections. I'm not going over employee discrimination or any other, you know, all those other domains we talked about. But again, these are just some numbers to be aware. So when you go back to your institution or think about your state and your laws, if you're not thinking about it, you're coming from a place of privilege where you don't have to think about it. And it's something that's worth exploring and thinking more about. So again, revisit the WPATH guidelines, which U.S. insurance companies use to reimburse that care. Interestingly, there are no radiologists that I'm aware of on that executive board of WPATH yet. And so, Dr. Weird also mentioned this, how many people does this even affect, right? And that's 1.4 million adults. And Dr. Weir had mentioned red hair, green eyes, what's the prevalence? And so if you're not sure if you've ever seen somebody with red hair or green eyes, then that may not be a good reference, but otherwise. Importantly for our understanding is, as providers, is of this population, why does it matter that we're having this talk today? I'm sure we've all heard a lot about discrimination in general in the medical setting, and it's very terrible to hear that of these negative experiences, that also includes verbal harassment and assault as part of that negative experience, which should never happen. That should be like a never happen event. And 22% avoid care due to fear of discrimination. So I'm super thankful we're having this talk today and thinking about this population more generally and to address that. There was a study more recently in 2020 in AJR that was a smaller population where 70.8% had at least one negative imaging encounter. So radiology is not doing great. And also visit the Healthcare Equality Index, the human rights campaign, to check to see for one of 765 facilities that are working towards providing that care. So given all of these numbers and these facts, I think hopefully you now understand radiologists really have a responsibility to understand gender and gender affirmation. So moving on here. And what does gender-competent care look like? You need to cover all of these domains, again, super surface level. You go from mental health, puberty suppression, hormone therapy, reproductive health, perinatal care screening, and gender affirmation surgery. So of these topics, how would this influence your imaging center and your imaging practice? So these, I just highlighted a couple. This came from that AJR article I just mentioned about how people would experience physical discomfort when they came to the imaging center in these categories. If you're an IR, this is unfortunate, 35%. Ultrasound mammography is also areas that people do not feel comfortable. You can imagine if you're doing transvaginal ultrasounds and your techs are not trained, that is a very uncomfortable situation. So workflow is an issue. Forms and paperwork, intake forms. DICOM headers actually put gender into DICOM, as Dr. Zabaleta had discussed and will be talking about later. Multidisciplinary interactions and community outreach. And of course we need to understand, and this is a small piece, and I hope everyone recognizes that I put this as a very small piece of gender affirmation, even though it's gotten a lot more attention from the imaging side, is the anatomy. You know, status quo is hormone therapy. How does different anatomy change or gender affirmation surgery? Do we understand guidelines for breast cancer screening and prostate cancer screening? And there are all these articles that I've cited down here I'm happy to discuss at a different point. Also, bone density screening and DEXA scans after hormone therapy. And so just briefly, at the very end, we're going to go over some gender affirmation surgery topics. And it's expansive. It doesn't just touch on pelvic gender affirmation. So there's also, and genital reconstruction. So I think automatically that comes to mind, right, is changing sexual genitalia. So vaginalplasties and phalloplasties. But there's also body contouring. So mastectomies, augmentation mammoplasties, implants. And also maxillofacial contouring, osteotomies, thyroid cartilage shaving, and mentoplasty and filler injections, which all have post-surgical anatomy understandings and also complications. So again, very expansive topic and articles that you can refer to. But just to go over, for example, just to think about and plant in your head to maybe look further into later, is there are different types of surgeries that can be chosen between. So one is metroidoplasty and another one is phalloplasty. And between these, there's also different flaps that can be used to create the neophallus. So here is a pedicle flap phalloplasty in a 28-year-old. And you can see that this flap has come down, and there's also a foley that's in. And here, this has been complicated by urogenital fistula and multiple abscesses, which is really unfortunate. But you can understand that if you, the reader or interpreter, were not aware of the surgery or the complications, this would not be reported correctly and would cause difficulties with the patient who can now see their records and the provider. So definitely something more to think about. But thank you. Sorry, that was a little bit of a whirlwind. But hopefully you understand now these three topics. And hopefully, if you have any questions, I'm happy to answer them. So again, my name is Evelyn Carrow. I'm a body fellow at Mayo Clinic. I did my residency there as well. And today, as part of this talk, I'll be focusing on the education and training and how we can incorporate that into our medical curriculum with transgender health. So the current situation is less than ideal and highly variable. So for many of you, you may remember your medical experience, and perhaps you had zero exposure to LGBT or transgender health. For those who had it, it's usually only a small part of the medical curriculum. So if you used maybe one half day during that first or second year medical school, a 2011 study found that the average time spent in LGBT health in medical school was only five hours, so essentially about a half day. And as a result, a lot of medical students don't feel prepared to take care of transgender and gender diverse patients. So a more recent study showed that about three to four medical students in New England, a relatively progressive area, did not feel competent in medical treatment of gender minorities. And a third did not feel comfortable treating them at all. And so that's severely lacking. And then the other thing that's lacking even more is actual direct clinical exposure to transgender patients. It's very rare. I know it wasn't available when I was in medical school, and it's typically only available in electives for students or trainees who have a special interest. So that's where we are currently. Where do we want to be? Ideally, transgender health education should be included as an integral part of the medical student curriculum and in an ongoing manner throughout residency training and beyond. I also think that USMLE step exams and for relevant specialties, this topic should be on them because, as we know, a lot of medical students and trainees study for the exam, unfortunately. So how do we fill these knowledge gaps? So I'm going to walk through five different steps to help us get from the current less than ideal situation to where we really need to be. So the first step starts in the preclinical education. A recent study showed that even just a one-hour didactic session on transgender health improved the proportion of medical students with favorable attitudes and knowledge for at least a year. So even just one hour of exposure is doing a fair amount, but we can do better than that. Students who have a close personal experience or are part of the LGBT community have more favorable attitudes and correct knowledge regarding transgender people, which isn't too surprising. I think we're seeing more and more transgender people just living their lives and contributing to society, and we're just seeing it normalized, because that's all we are. We're just normal human beings like everyone else. Moving on to simulated or direct patient contact, a recent study showed that clinical exposure to transgender medicine improved medical students' preparedness compared to didactic teaching alone. Again, this isn't too surprising. If you have that hands-on educational experience, this is going to continue to help trainees become more competent with transgender patients and transgender health. So ideally, there'd be direct interaction like a clinical setting. This is not always possible. There are typically like just transgender clinics and some medical schools may not have access to that. However, there can also be virtual patient encounters with transgender patient volunteers. And that's important to have an actual transgender community member be the volunteer rather than like a cisgender person pretending to be a transgender patient volunteer. I know at the Mayo Clinic School of Medicine, Rochester, they have, there's a trans woman in the community who acts as a patient volunteer. And I think that's well received. And where I went to medical school, I went to the University of Minnesota. We had an invited community member panel, which was also a good option as well. So what that entails is simply inviting, you know, three to five transgender, gender diverse community members. And they just talked about their experiences, their negative experiences in healthcare setting. And then there's just an open Q&A session, very informal, very helpful, I think for the medical students to learn more about their difficult experiences in the healthcare setting. Including transgender topics on the licensing and board exams. Like I was saying before, the culture of medicine is unfortunately very exam oriented and a lot of people are not gonna really even think about this unless it's on the exam. And I think, especially in radiology, it's highly relevant as, you know, Flo was saying earlier, we will, you will see transgender patients in your radiology practice. Maybe not face to face, although you may depending on what subspecialty you're in, but you will see them, their imaging exams come through. And it's gonna be important that you know the basics of gender affirmation surgery and the basics of what hormonal therapy does to transgender people and what you have expected findings on imaging. It's also, I'll also say it's important that when you report it, that you do it in a sensitive manner. And then continuing education. So providing faculty development in transgender health, participate in many national and international meetings of transgender health topics, like here today and you guys are here, coming to these topics. So give yourself a little pat on the back for that. These are excellent ways to continue to learn about this ever evolving field. And then lastly is us learning and listening to your transgender friends, family members, and colleagues. There are so many great experts and allies in this field and they do such a good job. But it's also really important to create space for our transgender colleagues because they have that lived experience which can provide I think a more enriching, basically more enriching information and can add a little bit to that nuance. Because I've definitely seen some allies lack a little bit of nuance here and there that like a transgender person would be able to pick up on. And then lastly, just promoting a diverse and inclusive workplace. I think this just goes without saying. This goes for anyone, not just a transgender person. But if there's a diverse and inclusive workplace, there's more open communication. People are able to talk about their experiences, good or bad, and you're gonna learn more as a result of that. So these are some really nice resources. The first three are, so this is the UCSF Transgender Care, Fenway Health which is based out of Boston, and then the World Professional Association of Transgender Health. Those are more clinically oriented but those are a really good place to just learn more about the basics of trans health. And then the last three resources do more with like advocacy and activism in the trans community because there are many anti-trans laws currently throughout the United States. So if you wanna learn more about that, those are good options. These are my references. Good morning, everyone. Now that you have a background in transgender and gender-expansive terminology, concepts, and gender-affirming surgeries, I'd like to talk with you about the importance of transgender and gender-diverse affirming radiology care for our transgender and gender-diverse patients. Here's an outline for my talk. First, I'd like to introduce myself. My chosen name is Vance. My salutation is doctor. My pronouns are they, them, and I'm a pediatric interventional radiologist in the Children's Hospital of Colorado and the University of Colorado. I also lead the work group for gender diversity within the ACR's commission for women and diversity. I would like to go through two made-up cases to sort of set the stage for the importance of understanding why building, creating, gender-diverse affirming radiology department is important. First case, a 29-year-old is presenting for an ultrasound for acute one-week worsening of pelvic pain and difficulty yearning. The patient is noted to have an M listed on the gender mark chart. A technician notes the mass around the urethra and remarks to the patient, oh, you're a boy. Patient reviews their patient portal the next day to find the released radiology report below. He's a transgender male who has a vaginoplasty. There's a large mass around the urethra. It may be the prostate, but he is unclear on whether he has a prostate. Erin identifies as an intersex female. Here's another case. Jack is a transgender man. He is sitting in the waiting room of a breast imaging center. The staff at the front desk call out Jessica, Jack's legal name. Jack responds and walks up to the staff person, the gender of the name called and the expressed gender of the person who walked up are obviously very different. Jack, the other patients in the waiting room and the staff person now are all potentially uncomfortable. It's no longer a safe space for Jack. In order to understand the importance of transgender-affirming care, it's important to know that the healthcare disparities that transgender and gender-diverse patients face, there's a high prevalence of adverse health outcomes and inequities among transgender and gender-diverse folks. This stems from systemic discrimination, stigma, microaggressions and physical violence and unfortunately, a lack of medical education. The 2015 Transgender Survey surveyed 27,715 respondents. The survey showed that 50% of transgender patients have had to educate their providers on transgender health concerns and up to 28% of patients report postponing medical care because of discrimination. More recently, an HRC 2018 survey showed that 70% of transgender and gender-nonconforming patients have experienced some type of discrimination in healthcare. 52% have reported that they believed they would be refused healthcare and 73% believe they would be treated differently. A report by the LGBTQ Institute at Georgia State University showed that young black, African-American, Hispanic and transgender southerners report poorer health, lower rates of insurance and access to care and more discrimination when trying to access care. A report by the Southern Trans Health Focus in 2018 showed that what bothered transgender patients the most was gender-specific, presumptive questioning about relationship status and family makeup, use of non-preferred pronouns, denial of services due to a person's gender expression or sexual orientation. Now let's talk about disparities in radiology care for transgender and gender-diverse patients. Radiology touches almost every patient in the healthcare system. We in radiology played an important role in minimizing healthcare disparities. My colleagues, Dr. Grimstadt, Stoll and Gattis published an extensive survey of transgender and gender-nonbinary patients' experiences during imaging encounters. This slide is courtesy of Dr. Grimstadt and Dr. Stoll. 71.7% reported at least one non-affirming experience. 65.5% experienced discomfort due to gender identity, some or all of the time. 26.1% had greater than six non-affirming experiences. 27.7% had never experienced an affirming encounter. And there was no difference based on geography or urban density. Importantly, the relative frequency of physical and emotional discomfort graphs show that ultrasound examinations and image-guided procedures contributed to the highest rates of unexpected physical and emotional discomfort. Another study by Goldberg et al. surveyed 2,500 breast radiologists across the country, and although radiology has made some improvements, we still have a long way to go in providing a welcoming and safe environment for our transgender and gender-non-affirming patients. The results of this study included most facilities had gender-neutral bathrooms, but were lacking in other basic areas that contribute to providing welcoming and safe environments for transgender patients. Only 15% provided LGBTQ plus training to their staff, and most did not take the mandatory training. Most intake forms did not include questions about gender identity, and 25% of the facilities automatically populated the patient letters with female phrasing. The surveys and studies have shown that a lot of us in radiology are not yet providing affirming care to our transgender and gender-diverse patients. Let's talk about how we can improve radiology care delivery. My colleagues and I put together a publication that details strategies for providing affirming care to our radiology patients. Let's start with patient intake process. Is there a place to convey sex assigned at birth, gender identity, chosen name, pronouns on intake forms? Does the radiology facility have advanced notice that the patient is scheduled? What insurance providers are accepted by imaging facilities? Are there certain necessary documentation steps on behalf of the facility to ensure insurance coverage? Radiology intake forms, like the one proposed by Sanders and Peterson, could be employed. For example, my preferred name, my chosen name, my pronouns. What reproductive organs are currently, do you currently have? Questions about pregnancy in a very gender-neutral terms. In the waiting room, are the facility waiting rooms and exam rooms welcoming to LGBTQ persons? Are gender-neutral restrooms and changing rooms available? Will unrobing be necessary? Will patients need to be prepared to remove binding, tucking, or packing devices? And regarding policies, does the facility have a non-discrimination policy that includes protections for LGBTQ plus patients if provided to the patients? Regarding staff interactions, are imaging facilities staff required to complete LGBTQ cultural sensitivity training that includes instructions on appropriate gender terminology? Has staff been trained to consistently inquire with patients about pronoun use? Does the imaging facility have a patient advocate or feedback system? Regarding procedures, is the imaging procedure sex-specific, and is there a need to clarify what anatomy is present if the anatomy is native or constructed, and if the patient has chosen terms for their anatomy? Does the patient experience distress regarding the anatomic region of the image? What surgery, if any, has been performed? Is the radiologist aware of the intended goals of the imaging study? Has the procedure been explained to the patient in advance? Are adaptations to the imaging protocol necessary? Is it necessary for the surgeon to speak with the radiologist or for the surgeon to be present with the radiologist? Let's look at radiology reports. Is it necessary to put demographic information in the clinical history? If it is, then we as radiologists can advocate through accurate reporting of information. Templates drawing in age and sex data may not be helpful. They may misgender patients. For example, we know that the EMR and the PACS work together, however, sometimes the data is inconsistent. In PACS, we might see a 38-year-old female with the name of the patient, legal name of the patient, but in the EMR, it might say, or the EHR, it might say that the patient is transgender and their gender identity, and it might say their chosen name. For example, 48% of the HEI 2018 participants use EPIC. Of those participants, 65% are collecting gender identity data and 50% are collecting sexual orientation data. EPIC, under the direction of Janet Campbell, created a sexual orientation and gender identity module which includes the following data points. I'll show you a few screenshots. For example, here we have sexual orientation data and here we have sexual orientation and gender identity data. You can see that we have the patient's legal name, their gender identity, their sex assigned at birth, their pronouns, and then importantly in this module is an organ inventory, which organs does the patient currently have? Are organs present at birth or expected at birth to develop? Organs enhanced or constructed? Organs remotely enhanced or developed? We can use the EHR to help create a more affirming radiology report. And most importantly, in our radiology reports, it's never necessary to place gender terms such as gentleman and lady in the radiology report. Thank you. To share with you about the ACR work group for gender diversity. We are created to serve as advocates for our transgender and gender diverse patients and professional workforce. Our goals are to create educational programs and develop educational resources. We aim to partner with our fellow radiology societies to build and create a transgender and gender affirming radiology experience. We've worked with making the ACR appropriateness criteria more transgender and gender diverse affirming. To the left is a picture of some of us at RSNA 2019. If you're interested in joining our group, feel free to send me an email. I would be remiss to not talk about how we need more transgender and gender non-binary doctors. We need to address diversity and inclusivity in radiology. It's a multifaceted and necessarily, multifaceted and necessarily involves the entire pipeline of trainees from medical students, residents, and fellows. We have to ask ourselves how we can become more culturally competent so that we can better serve our sexual gender minority patients and how we can recruit more SGM radiologists. We have to advocate for our SGM colleagues and patients as well as for ourselves. In this way, we can positively grow our field, promote healthcare equity, and provide the best patient care. Thank you. I'm gonna discuss some aspects of research in relating with the transgender and gender diverse populations. I am a clinical diagnostic medical physicist, and so I don't interact with patients directly, but part of my work in terms of radiation safety has been over the years working with a subcommittee through our radiation protection group for reviewing human use of radiation in our studies at our institution. And we worked in conjunction with the institutional review boards for this. And recently, I was able to join one of those boards. And so I've been noticing a lot of language that is used in our research procedures that might not be very inclusive. And so this is kind of what I wanted to talk about in the talk today. So if any of you are involved in human use research, you have to do your human use training. And through the Belmont Report and some of the other information you learn there, you know there's benefit to partaking in research procedures that you may be able to have some benefit from being in a procedure. And we're basically not gonna cover much about that. But I wanna talk about language and how language does matter when we write our protocols, when we write our consent documents. The cisgender language does not translate very well when we talk about transgender, gender non-binary and other diverse populations. So when someone says that they're transgender or non-binary or another gender diverse identity, it doesn't really mean that they have undergone any type of hormonal treatments or gender affirming surgeries. So none of the anatomy may change for a transgender individual. A lot of the data that we see for the number of transgender and gender diverse individuals are only from people who self-disclose that. I've met many people who will never self-disclose that they're transgender to the public. So I look at those numbers that we see in these reports with much skepticism. I think those numbers are much higher than what is reported. So some things that are kind of triggering to the transgender populations would be seeing things like prostate cancer in men because, I mean, women, trans women definitely could have prostate cancer. Father a child, this becomes very complicated when we're trying to write our consent documents, and I'll show a little bit about that here in a moment. Transgender men, again, ovarian cancer in women. Women should not become pregnant. Women who are breastfeeding. Even in our diversity talks here at this meeting, talking about lactation services for women, radiologists, what if you're a breastfeeding trans male who has had a child? Are you not gonna be able to use those lactation rooms? Is that something that you're being excluded from? So this is a consent template for concerns for sexually active men and women. How would we best translate this into a more gender diverse population? I mean, I'm currently working with my HRPP office to try to do that and navigate to make this more nuanced to where all genders can participate in the studies and not be triggered by reading a consent document. This is a recent paper where they did an analysis that came out of Albert Einstein College in Medicine. There was a Columbia Trans Empowerment Survey that was put out that had 704 respondents from that. 271 of those were non-binary. 291 transgender women and 145 transgender men. And just as an example, here are some of the results from that survey. So showing how, did they change their name depending on how they identified? And for the most part, names were changed. Sex on ID is less prevalent. Did you change your chest? Did you have top augmentation surgery? Highest was in the transgender men, but you see that non-binary and trans women are not very high in the number. Had genital surgeries. Non-binary, very few. Mostly transgender women. Whether you used hormonal therapy or not, this is more prevalent in the trans women and trans men populations. But it's not 100%, so you don't know what the transgender and gender non-binary populations are actually doing to affirm their process medically. So basically, you can divide this research into either trans-specific research or trans-inclusive research. My work with the IRB is mainly to try to do more trans-inclusive research. So modifier consent documents actually accept this population more readily into our institutional research. This is an article that came out this year by Kennedy et al. out of University of Alabama, Birmingham School of Medicine where they reviewed over a decade of over 200,000 articles out of 106 articles. Radiology journals. And the results came back that there were only 29 transgender-related articles out of this 10 years of publication. And of these, 23 out of 29 used non-preferred terms in the documents. So language does definitely have an effect on how we relate with these populations. This is a multi-institutional article from people from Canada, the US, UK, New Zealand, and India where they went through and reviewed articles to create provisional criteria for IRBs to refer to when assessing ethical orientation of transgender health research procedures. And they came up with nine guidelines that they want IRBs to use when doing trans-specific research within their institutions. So I would refer you to this article that might be able to give you some assistance with that. Also on the social media end, there is a International Transgender Health Facebook group. Recently it went from public to private because of some of the issues that are going on within the social media realm. But they also have what is called a Transgender Research Informed Consent Disclosure Policy. If you want to do transgender-specific research and through their group and get their assistance in trying to recruit people through their organization, then they request that anyone doing this answer these questions to their leadership prior to posting that to try to recruit subjects into research. There are other resources. NIH has the Strategic Plan to Advance Research on the Health and Well-Being of Sexual and Gender Minorities, a good report. In terms of language that you might want to use in your journal writing, as well as if you're involved in the Institutional Review Boards, the American Psychological Association has an excellent publication manual. They're on their seventh edition of this. There's a specific chapter just dealing with gender. I think it's always great to get the feedback from the people you're writing about. This is the Radical Copyright Editor Style Guide that you can get available online by Alex Capitan. I would highly recommend that you go online and take a look at this. But one of the things that is mentioned here is that the language changes rapidly. By the time you write an article, you may use terminology that in the future may not be appropriate. So I'll run through a summary here. Transgender and gender-diverse inclusion in clinical research is gonna require that you use inclusive language. It may have to shift from gender to anatomy and function. I don't know if any of you participate in your Institutional Review Boards, but I would highly recommend that you try to participate in that in your institution. And you could also actually help work on making more inclusive documents. So specific research is gonna require communication and assistance from the communities that you're trying to do research with. And also, highly recommended that you do get transgender and gender-diverse faculty and your staff as well. And again, the language changes rapidly. And just the second part, this is something that I typically say in support group meetings. Mistakes will be made. Accept that. When you make a mistake, apologize and move forward. Second is, it's not about you. And I just wanna end this with a quote that's used a lot with the PFLAG organization, which is the Parents, Families of Lesbians and Gays. Be careful who you hate. It could be someone you love. Thank you.

gender diversity

appropriate language

medical settings

transgender patients

gender-affirming care

healthcare education

cultural competency

inclusive research

diversity in healthcare