All right, hello, everyone. Thank you for coming. Thank you for coming to our session, Radiologists' Role in LGBTQIA-plus Health Equity. Everyone's going to introduce themselves. So just to review our learning objectives, one, identify barriers and challenges to radiology for LGBTQIA-plus individuals. Evaluate how increased awareness and education on LGBTQIA-plus health care can positively influence various facets of radiological practice, including advancements in imaging techniques for cancer diagnosis. Learn to effectively engage with LGBTQIA-plus patients, tailor treatment approaches, and make well-informed medical decisions to improve overall patient care in radiologic settings. Hi, I'm Herschel McGinnis. I'm an interventional radiologist in Boston, Massachusetts. I want to thank RSNA and Dr. Zavala in particular for this opportunity. So this talk really begins with two of the scariest words I encounter, can you. I'm asked frequently, can you give a talk? Can you write something? I'm like, yes, I can. Yes, I can. And then it's like a series of things, denial, grief, procrastination. But then eventually, it leads into the work. And so I sat down, and this time I didn't do research. I decided I wanted to sit down in something I'm not an expert in and just list all the things that I think are the biggest LGBTQ health disparities. And then I went online and did the research, and it turned out my list was almost spot on. That's not an interesting talk. I derived a lot of deep insights. You know, the LGBT population is derived from every racial, ethnic, and socioeconomic part of the country. Why? Why do we have this heterogeneous population with this specific array of disparities? I knew to understand the whys. I had to better understand the past, our shared and sometimes forgotten history. Now, I derived this image, I think, were squarely at least the fifth, if not the sixth, great wave of the human rights movement for sexual and gender minorities. And I had to go way back to the origins. It's 1890, and we are in Berlin. This is Professor Magnus Hirschfeld, a physician and known as a sexologist. He's a real pioneer in this area. He really employs the tools of empiricism and age of reason approach to studying sexual and gender minorities. He forms the first gay rights organization in the world in 1897. Two years later, there's a formal journal with scientific data. And they even have their own institute, a physical place for people to be together. There's a clinic, a medical clinic. There's a library with over 20,000 volumes on this topic. There's a museum, and there is a lecture hall. This becomes a real gathering place for sexual and gender minorities in Berlin. He advances ideals, saying that homosexuality is inborn. It's natural. It doesn't have to be cured or punished. They want to repeal paragraph 175 in the German penal code that imprisons people for these behaviors. He's a pioneer in contraception and originates the concept of consent. His motto, the guiding motto, justice through science. Now, 1920s Berlin saw a swift expanse of almost transgressive expansion in personal individual freedoms. But this abuts against the conservative forces in rural areas as well as the cities. And almost predictably, there's a profound backlash. In May of 1933, one of the very first things Nazis do when they get into power, they go to the Institute. They ransack it. They take the volumes from the library. They all but destroy it. And four nights later, on the Operplatz, there's a very dramatic burning of the books. You can see them with Professor Herzfeld's bust. This is an act of political theater. They could have just destroyed the books, but they didn't. They had the fire. This was meant to quell dissent and keep subversive forces from challenging the infrastructure that was on the rise. Now, things were about to get a lot worse for queer people in Europe. But that wasn't the end of the story. They could burn the books, but they couldn't extinguish the ideas and ideals of Dr. Herzfeld. Sparks from that fire drifted up and ignited the imagination of like-minded people across the world. In 1924, right here in Chicago, Henry Gerber, a German immigrant, founded the Society for Human Rights, the first LGBTQ rights group in the United States. And suddenly, across the country, more and more of these organizations are formed. 1950, you have Harry Hay and the Mattachine Society. Harry Hay gives us gifts that we use every day now. This is an early picture. There's almost no pictures of these people because so much was at risk. The first gift he gives us is we are an oppressed cultural minority. We're just like African-Americans and other minorities that didn't exist until Harry Hay. The second thing is he says homosexuality isn't what we do, it's who we are. This is an intrinsic part of our being. These are important things to know. Mattachine Society sprouts up all over the country. They take an educational approach. They're very polite. They have their own journal. And you can see the quick growth. In 1955, the title page, Are Homosexuals Neurotic, just three years later, I'm Glad I'm a Homosexual. A healthy, integrated concept of what it is to be queer is starting to emerge. Women have the Daughters of Belitis in their publication, the latter. Now, this first wave is doing very, very important foundational work. But they're polite people. In some ways, they're very establishment. They're going to picket. Now, what's going on in medicine? This is very important. An analysis of historical terminology going back into the 1800s reveals medicine's central role in creating categories used to rank, judge, and marginalize humans according to their sexual desires and gender expressions. We have a lexicon of stigma. It starts with words, perverts, deviants, sexual predators, inverts. This is what medicine gives us. Then from words, it goes to behaviors and practices, such as this. All sexual and gender minorities needing medical care, you get a psychiatry. You have an asthma attack and you're queer, you go to psychiatry. You have a seizure disorder, you go to psychiatry. You have a heart disease, you go to psychiatry. You treat the behavior, you ignore the disease. The third and most potent form of this behavior is when these words and these behaviors get enacted into policies and laws of stigma. Welcome to the DSM-1. Homosexuality is a sociopathic personality disturbance. You have all sorts of strange ideas about how people become homosexual. They presume everyone to be innately heterosexual, but you get there through these strange pathways of being bisexual or being psychotic, schizophrenic. These things don't hold up water. And if you don't give in to the cure, you stay sick in their minds, you're no longer a patient. Now, you're a sex offender, and you're not in the medical system, you're in prison, or you're in an insane asylum. Cross-dressing will get you six months in jail. Sodomy, 20 years. To be an unrepentant homosexual, life in prison. This is akin to capital murder. This is where we were. Now, they also give us in medicine the concept that sexual and gender minorities are sick and have to be cured, intersex people require medical intervention and correction, and the cornerstone is androcentrism in medicine, saying that the cis male adult body is the standard by which everyone else has to be measured. So you have all these forces, government, journalism, medicine, employers, all coming down on the queer community and cross-informing one another. So if you get arrested, they tell the press. The press puts it in the pages of the newspaper. The newspaper is read by your employers, you're fired. All these things create a really toxic stew. And of course, they want to give cures. Hypnosis, LSD, conversion therapy, aversion therapy. In their most potent form, ECT, and even lobotomy. Okay. Here's the foundation, the engine is now running. We're gonna pathologize natural states of being, infusing people with stigma and shame and harmful treatments, penalizing them in all these core matters. And now we derive the two buckets of disparities. One is largely reluctance to seek medical care, leading to untreated diseases and later stage presentation. And then the mental health impact and the high-risk activities. Okay, let's look further. We know we have the red scare. Again, the words go into the practices, go into the policies. Suspected communists are being rid from the government. But it's important to remember, McCarthy also claimed that gay men and lesbians were more dangerous than communists because they were susceptible to blackmail by foreign agents, transforming the red scare into lavender scare. Again, we have the words, we have the policies. And in April 1953, the president signs Executive Order 10450, saying that sexual and gender minorities cannot serve in government, even though there was not a single case where it was proven that there was espionage by a sexual and gender minority person. And they take more than 1,000 federal agents to start investigating people. More than 10,000 people fired. This doesn't even capture the people that were allowed to quietly resign. It doesn't capture the impact on the private workforce. What does it do? It takes a whole lot of people and makes them mad. And this is more fuel for this early queer rights movement. That was not repealed until 1995, by the way. Everything's not bad. We have the Kinsey Report saying, yeah, same-sex behavior is quite common. Evelyn Hooker does an analysis of gay men and their straight male counterparts. You can't tell the difference psychologically. There's not an inherent brokenness in gay men. And then we have Reed Erickson, very wealthy transgender man that funds the first gender identity clinic at Johns Hopkins. Okay, this is the first wave. It's very polite, but they're not getting anywhere. But that all changes on that summer night of 1969. We're somewhere very, very different now. We are now in the era of gay liberation, okay? Now there's a fully formed gay identity. The messages stop the harassment, especially the police harassment. Number two, how about some sexual freedom? They take on the APA and they win, they win. This is the thinking that they were up against. When you have a homosexual person whose heterosexual function, remember the word function is crippled like the legs of a polio victim, are you going to say this is normal? And Harry Hay says, absolutely, because you're talking about function, what we do. This is who we are. And on the same day that the APA took this out of the DSM, New York City refuses to grant a bill for homosexual rights. So still, housing, employment, education, you're still under these very difficult burdens to exist in society. And the APA iterates. They wind up having an ego dystonic gay disorder. And of course, when it comes to gender identity, up until this day, they still have a lingo in there, pathologizing people's natural states. What did healthcare look like? A lot like this, STD clinics. Integrated care, it didn't exist. It just did not exist. There was a little spark of light in Boston with the Fenway Community Health Center, one of the few places doing this kind of work. But again, everything changes in the summer of 1981. Now we're someplace different. We're in this place where government failed to meet the moment. Medicine wasn't ready for this. Basic science wasn't ready for this. The legal system wasn't ready for this. And who suffered? Patients. The medical community deemed it to be a manifestation of a perverse and diseased existence. That's why this virus has taken hold. And LGBTQ people would often avoid care because they perceived it to be deadly. And for the next decade, medicine viewed homosexuality primarily from an infectious disease and public health standpoint. What are we gonna do? There had to be a response. It comes from ACT UP. We had to transform what would become a sexual freedom movement back to what it originally was, a human rights movement. What does ACT UP tell us? You become the expert on the issue. You write the policies. You build campaigns around solutions that are reasonable, winnable, doable. And you establish the institutions to solve your problems. This is how we get STT clinics turned into things like this, fully integrated healthcare systems. When the Fenway Community Health Center opened in 2009, their new building, it was the largest structure opened by an organization with a specific mission to serve the LGBT community. Now you know New York's always competitive with Boston, so they had to build a bigger one a couple years later, but that's okay. And then there's the Hedrick-Martin Institute that serves gay youth. And also providing integrative care. So now here we are in 2001, what I call the era of equality. Domestic partnerships, civil unions, marriage equality. Yes, these things do expand access into insurance, but not everyone is in a relationship. It doesn't remediate the economic disenfranchisement that this community is suffering from or the legacy of past harms. So now here we are in the fifth wave. What will the future hold? I made this slide six years ago. And what I said is this wave is about acceptance and integration, pseudo-acceptance and pseudo-integration, backlash, or redefinition of what sexual and gender roles really are. I just want to say, you have to remember the example of the 1920s, when expansive freedoms lay in close approximation to staggering oppression. Does it seem familiar to you? We have the lexicon of stigma. We have the behaviors and practices of stigma. We have the policies and laws of stigma. We are at the final rung. We have book bans, we have drag bans, we have sports bans, we have bathroom bans. Look at the tremendous increase in LGBTQ laws that have been reported by the ACLU throughout the country. And today, this very day, our Supreme Court is waging judgment on whether or not transgender citizens have the full complement of rights. And yes, you look at all the data, and it shows there are pervasive and persistent healthcare disparities. Even the NIH says there's less access to care and also not enough research on this topics. So where's the hope? The hope lies with all of us. There's an increasing number of LGBTQ people in the population, and among Gen Z, it's now over 20%. When you look at medical students in the US, you can see the numbers are going up steeply, 165% increase just since 2016, with almost 15% of medical students identifying as LGBTQ. What does that mean? If we graduate 26,000 medical students annually, hopefully in the next 10 years, we'll have at least 26,000 new queer providers. But realize, that's just through the metric of identity. That doesn't capture the parts of sexual orientation of attraction, behavior, and relationships. That 26,000 is a floor, not a ceiling. I know these times are challenging, but the battle we are fighting now has been fought before, and we know how to win. We become the experts, we write the policies, we build the campaigns, we establish the institutions. I'm proud to be a radiologist. We're the discipline that went from this, to this, to this, in just 75 years. And as an interventional radiologist, the journey has been extremely impactful and far. I'm proud to be part of this, but make no mistake, I'm proud to be a part of this too. Movements are made up of moments, spread out over decades, even centuries. Progress is not guaranteed. The backlash can be swift and brutal. Paragraph 175 wasn't repealed until 1994, and marriage equality in Germany wasn't realized until 2014. The battle for justice that Hirschfeld waged, that we're fighting now, has been fought before, and will be fought again and again. Our hard-won rights are not written in stone, but our resolve must be. I want to remind you that there are ethical and moral dimensions to all the great work we're seeing this week in this gathering. To leave no clinical talent uncultivated, no patient population unserved. This, this is our great commitment. I have the feeling that the pioneers were here today, they would have said things more succinctly, much less time, fewer words. Justice through science. May it be so. Thank you. My name is Anne Darrow. I'm a breast imaging fellow at the University of Chicago, and I am so excited to be here speaking with you all today. And I'll be talking about understanding LGBTQIA plus specific health equity challenges in radiology, and specifically talking a lot today about the transgender community. This is a group that within the LGBTQIA plus umbrella is often underserved, overlooked, and a very vulnerable population. Also a population that most of us don't learn about in our medical training. So first, I'd like to talk a little bit about the difference between sex and gender. This is very basic and review for most of us, I'm sure. But sex is something that we think of in medical terminology, sex assigned at birth, male, female, that we see on a birth certificate, and in our medical forms, documents, probably something that we're mentioning in reports frequently as we're looking at radiology imaging. Gender identity is a social construct. For a lot of people, sex assigned at birth lines up with their gender identity. In that case, that person will be a cisgender person. I myself am a cisgender woman, and my pronouns are she, her. For some people, the gender that they identify with is not the same as the sex assigned at birth. These people could be transgender, or they could be somewhere in between identifying with the sex that is on the other side of the spectrum from the sex assigned at birth. And in the middle, we have people who are non-binary and two-spirit and a whole range of different gender identities. And this concept, as we just heard, is not anything new, and it's not unique to our time or our culture. People who are two-spirit, non-binary, intersex have been around since ancient times. You know, think of Joan of Arc, think of historic figures that we've all heard of, and then think of celebrities that we see today. We're all exposed to this more and more. As doctors, just a reminder, sex, even though we think of sex as a binary terminology, male or female sex assigned at birth, it's so much more complex than that. Remember back in medical school, we were learning about the hormones and the embryo development and how everything's changing with hormone exposure impacting gonadal development and ovaries descending to become testes. Any interruption in the hormone flow, any disruption or changes in chromosomes, there are so many different ways that people don't end up in this binary sex category. And in addition to gender being a social construct, sex is also so much more complicated. I'm not going through all of this slide. This is just a reminder of how complicated sex is as well as gender. Really neither of these terms are completely binary. Pronouns are how we address people or how we address ourselves. So one thing that I think is really helpful and can be very affirming for the LGBT community especially for transgender patients, colleagues, and people that we interact with is to normalize using our pronouns. Here's an example of some pronouns that people use. He and she I think we've all heard of and are very comfortable with in general. They is a gender neutral pronoun. It is in the Oxford Dictionary as an appropriate single person pronoun for the last few years. And he and her are other common pronouns that some people may use. So I'd like to take just 10 seconds right now for us all to practice. We might not be familiar with using our pronouns, but I encourage you all after this meeting to take it forward. Include pronouns in your emails. Include pronouns when you introduce yourself to people. So if you could very quickly just turn to the person next to you and say, hello, my name is blank. My pronouns are blank. Thank you. Amazing. Now that you are all experts of using pronouns, I'd like to move on with the talk. But I really I think practice makes perfect. And so you've all practiced that at least once, even if that was your first time using pronouns. Just keep it in mind. It can be a small tool that is affirming for working with the transgender community especially. So why do we want to talk about, think about, and focus on transgender services? Well, in society today and in the media, there's a lot of transgender people and role models that young people are seeing. As we just heard, there is an increasing number of the younger generations reporting that they are LGBT and are more gender fluid than in the past and feel comfortable disclosing it. Maybe in the past, the numbers were the same and people weren't disclosing it. More patients will be disclosing transgender status and sharing their identity and their experiences and stories with us if we create a safe and welcoming environment where we value that and understand where they're coming from. Transgender patients are a medically underserved group who suffer high amounts of health disparities. They have higher rates of mental health symptoms, not because there's anything wrong with them, but can you imagine if every day, every time you had to use the bathroom, someone harassed you? Every time you presented yourself and got dressed, someone said something mean to you on like a microaggression level at the most gentle form of being discriminated against, or you had to physically fear for your life and be a target of violence or homicide. It is a scary world to navigate and so of course, this does end up with people having more anxiety and depression. So among the LGBT population, transgender people do tend to have higher rates of stress that leads to these other associated comorbidities. So if we as physicians can provide treatment that has increased gender congruency, if we can use the correct pronouns in our reports and in our interactions with patients, if we can create a safe space in our offices, in our imaging centers, this will increase well-being for our patients and their social functioning. We need to keep in mind the entire social aspect of the individuals we are working with. So some highlights from the early insights report that is the National Trans Health Survey, this is their most recent version of the survey, surveyed 92,000 respondents and 94% of the people were more satisfied with life after transition, 98% of those people who were currently receiving gender-affirming hormone treatment feel that the hormone therapy makes them feel satisfied, and almost half of them, 47%, reported that they have moved or thought about moving to another state or another area because they don't feel safe or that they are able to access the services they need as transgender people. And just again, higher rates of negative experiences in healthcare settings and in all of society. Last year in 2023, there was a lot of anti-transgender legislature, and lots of states throughout the country are not safe for transgender people for many reasons. This year, for the last five years, we've had record high numbers of bills that impact the ability to care for transgender people. A lot of those do apply to medical care, and even though it's 2024, there are already 36 bills that have been proposed with anti-transgender legislature for 2025 in three states so far. Here's a sample of a bill that talks about not having funding for gender transition procedures. So what are gender-affirming cares and procedures that some of these patients might undergo? For trans women, it could include medical treatments such as hormone therapy like estrogen, which would stimulate breast growth. Also breast augmentation or implants, facial and body feminization, which can be the head and neck with shaving of the facial bones, the thyroid cartilage, and other parts of the body can also undergo numerous forms of feminization, as well as vaginoplasty. It's important to keep in mind not every transgender person wants to undergo any or all of these treatments, but some people may undergo some or all of them, and some people may not. For trans men, similarly, there are different types of hormone therapy, usually testosterone. This will have a physiologic impact on these patients. Breast reduction or mastectomy is another possible surgery that these patients may undergo. Hysterectomy and or oophorectomy, as well as phalloplasty or metoidioplasty. This is not an exhaustive list. These are just some examples of some of the medical gender-affirming procedures, surgeries, and treatments that this population may experience, and a lot of times they have to educate their providers about it, so we should be aware of what they are. What can we do on an institutional level? I'm sure some people here today are in leadership positions, and you have the power to make a change at your institution. You can create a safe and welcoming environment for transgender people, LGBT people, and really for all people to feel more welcomed. Here's some examples of signs you can put up in a waiting area. You can have gender-neutral restrooms and changing facilities. Even if they're not everywhere, signs about where to find that, even if it's just one, that people know where it is. You can create a safe and affirming environment by having pride flags, pride colors, anything pride-related in your environment. You can also use pronouns, as you all practiced today. You can have a pin with your pronoun on it. I wear those a lot of times. You can have a pride flag pin. That's just a nonverbal cue that lets people know you're safe. I know for my family, when we see a provider, when we see someone that has a rainbow on their body, on their outfit, in their office, we feel more safe and comfortable talking to those people. For those of you that came in earlier today, I gave a lot of people pins already, but if you didn't get one yet, we have them up here at the front, and please come talk to us afterwards and grab a pin. We're happy to share those with all of you. In our interactions and reports, we can report gender-affirming medical, hormonal, or surgical history when it's relevant in our radiology reports, as well as an organ inventory, but only if it's applicable. These are good pieces of information to keep in mind and to mention. For example, a 50-year-old trans woman on gender-affirming hormone therapy for 20 years, status post-vaginoplasty, with intact prostate gland, presents with abdominal pain or chest pain or whatever the situation is. That way, you have a groundwork for knowing what you're expecting to see and thoughts in mind of what might be normal or pathologic. As radiologists, we do interact with transgender patients, and there was a wonderful survey published in AJR, and thank you to everyone who helped with this publication, that found that 70% of transgender patients report at least one negative imaging encounter, and 1 in 10 experience insurance coverage issues, and 1 in 5 report having some psychological trauma, even from non-invasive imaging procedures. As we talked about some policy and legislation changes that's increasing over the past few years, I expect these numbers now would be even higher. So there's a lot we can do to try to keep them lower and keep these patients feeling safe and comfortable. So some other ways that we may be involved with transgender healthcare, pre- and post-surgical imaging with planning before, or when people come in afterwards with any complications, we should know what we're looking at and what the normal expected anatomy is and what might be pathologic or problematic. In breast imaging, we may see screening and diagnostic mammograms, ultrasounds, or MRIs, and we should be aware of the recommendations for this population. And then in general imaging, maybe just incidental findings that we will all encounter at some point. So I just want everyone to be aware, if you didn't know already, ACR did release appropriateness criteria for breast cancer screening for transgender patients in 2021. This is just a screenshot from there. You can see it is listed. Feel free to reference it and tell your colleagues about it when it comes up. Here are a few cases that I have with examples of how we might see transgender imaging in our practice. This is a transgender woman with a history of free silicone injections. She's over 50 years old. She has a long-time hormone therapy exposure since her teenage years, and she came in with chronic lump in her right breast. It's been four or five years or so. So we see these silicone granulomas. It's really hard to tell what's going on. And we also see just very normal breast tissue like we might see in any other woman who comes in. Ultrasound, we see these silicone granulomas, and just it's really hard to see what's going on in this picture, but she does get an MRI, and it turns out she has this large enhancing irregular mass, and this was cancer. So we just need to keep in mind anyone with breast tissue is susceptible to breast cancer, and there are screening guidelines for trans women. Here's another case. This is a transmasculine patient who had gender-affirming care, including bilateral mastectomy and body masculinization surgery, including targeted liposuction of the flanks and the anterior abdominal wall with chest revision, who came in with some abdominal pain. And so we need to keep in mind, what am I looking at? What's normal? What's not normal? And this patient just had a stone. So this is something we would normally see in a lot of patients that come in. We see this stone here right at the uretero-vesicular junction, but we need to keep in mind. Like, what else could we be looking at? And for head and neck imaging, we may see some presurgical planning when people are planning to do feminization procedures that soften the angle of the mandible, for example. I had the good fortune of partnering with DEI leaders in my state to put together outreach and talks and do presentations on this topic, so I'd like to thank my mentors and colleagues who are listed here, including my former Program Director, Dr. Wong, and my Fellowship Director as well, and other colleagues throughout the area. So in conclusion, I encourage everyone to use gender-appropriate language in reports, include hormone therapy and risk factors and history when appropriate, follow the ACR appropriateness criteria and create a safe and welcoming environment as an institution and as an individual. Thank you. And feel free to reach out to me with any questions. Hello, everyone. Good afternoon. My name is Nicholas Freeman. My pronouns are they, them, their. I'm currently a transitional year resident at Memorial Sloan Kettering Cancer Center in New York and an incoming Diagnostic Radiology resident at Brigham and Women's Hospital. And my name is Evelyn Carroll. I'm an Assistant Professor of Radiology at Mayo Clinic in Rochester, Minnesota, and I specialize in radiology. I'm also the Director of the National Center for Radiation Research. Today, we are excited to present this topic, trauma-informed care in medical imaging. So for this particular talk, we have three learning objectives. First, to describe the principles of trauma-informed care, or TIC, and its role in medical imaging. Two, describe potential sources of trauma in LGBTQIA-plus populations. And three, explain how principles of TIC can be applied to a hypothetical case of an LGBTQ-plus patient in a radiology practice. We hope that this presentation is interactive and leads to thinking about these principles going forward. So in terms of some definitions, trauma can be described as an event that a person experiences that can be harmful or threatening. And this specific traumatizing event can have lasting negative effects on a person's well-being. And it's important to note that trauma is widespread and pervasive. And we are seeing a growing interest in researching and increasing work on trauma and trauma-informed care, especially from the Substance Abuse and Mental Health Services Administration as well as the CDC. We'll be talking more specifically about examples of trauma and what it can look like specifically in LGBTQIA-plus populations. But at first we can think about different sources of trauma, physical, sexual, emotional, and medical trauma. It's important to note that trauma can increase the risk of, and even worsen, medical conditions in our patients. So to help combat the widespread trauma that we may see in our patient populations, we can think about using a trauma-informed care framework to try to address this. And so this framework is built on four key assumptions as well as six principles that I'll be going into here. First is that trauma's impact is widespread. Second, we need to be able to recognize the signs of trauma in our patients as well as integrate trauma-informed approaches into policies and practices. And finally, trying to resist against actively re-traumatizing our patients during an imaging encounter. What does this look like in terms of these principles? In terms of safety, we should be able to provide a physical and psychologically safe imaging encounter for all of our patients, no matter what their sexual or gender minority identity is. We should look to build trust and transparency with patient populations, as well as be mindful of the peer support resources for LGBTQIA-plus populations, especially in high-risk encounters that we'll see an example of later on. Then mutuality, trying to build relationships between all levels of the radiology staff and practice and patient groups, empowerment, voice, and choice, giving patients the opportunity to take as much of their own care in the imaging encounter as possible. And finally, cultural, historical, and gender issues. So why TIC in radiology? It's a growing field of study here. A 2023 literature review showed 12 peer-reviewed journal articles about TIC in medical imaging and radiation therapy. We can also think about imaging encounters as being a potential source of re-traumatization in our patients. We should be able to recognize signs of trauma in our patients, as well. You can think about it like this. Patients who may have a physical or sexual violence history and undergoing these traumatic events, they are at risk of undergoing re-traumatization when we image those particular body parts. So you can think of potentially sensitive exams like pelvic ultrasound, for example. In terms of sources of possible trauma in LGBTQIA plus populations, the Department of Justice published in 2022 some statistics, recent statistics, about how LGBT plus patients are 2 to 2.5 times more likely to be victims of violence compared to cisgender heterosexual populations. You can also think of misgendering for our transgender, non-binary, and gender diverse patients as being a form of repeated trauma that can occur daily, even multiple times a day. And more medically, we can think of sexual orientation, gender identity, change efforts, also termed conversion therapy, medical procedures which are associated with, can be associated with pain and a long recovery process, as well as ongoing healthcare bias and discrimination. In our case here, we have a 46-year-old transgender woman who presents for a mammography screening. She has used estrogen-based gender-affirming hormone therapy, or GAHT, for eight years. Based on her personal and family history, she is average risk. I think this comes as a very pertinent example after Dr. Darrow's talk. With the 2021 ACR Appropriateness Criteria, we can see here in the arrow that the patient falls into this bucket. Prior to the exam, the patient discloses that she has been worried about breast cancer ever since starting GAHT. She mentions to the technologist that, quote, the doctors haven't made it easy for her to receive GAHT. She is worried about how breast cancer would impact her ability to continue this medication in the future. So I'm just going to ask very quickly if anyone has some initial reactions to this potential situation and how TIC could be employed here, even one or two word reactions. So this particular situation, we have a patient who during the imaging encounter discloses some potential history of trauma. It's not entirely clear from the hypothetical case here all the details of this particular scenario, but it's important to recognize how a trauma-informed care approach on a systems level and a personal level can be employed here to try to help this patient. Number one, there's a really big opportunity here to promote psychological safety for the patient by using empathetic and respectful language. Number two, the technologist could be aware of specific patient resources and be able to direct the patient to peer support resources specifically for transgender patients who are undergoing gender-affirming hormone therapy and may be undergoing these potential stressors. Third, building collaboration and mutuality among patients, radiology practices, and ordering clinicians. The patient should already have these questions answered going into the imaging encounter. And by building that network among these different groups here, these different stakeholders, we can try to make sure that the patient is as prepared as possible so that there are no unanswered questions. »» All right. Thank you, Dr. Freeman. So I'm actually going to get into a little bit more detail about the trauma-informed care framework principles. So first let's start with safety. How do we create a culture of safety for our LGBTQ patients, especially our transgender patients? So the first thing we can do is not misgender them or use their incorrect name. And if this is happening, we need to figure out why it's happening, we may need more education, and then decrease those incidences, hopefully eliminate them completely. We need to create a safe space for our patients. So again, for our transgender patients, that's going to ensure that we have a gender-neutral restroom. And in certain areas of radiology such as breast imaging, a gender-neutral changing room as well. And then we really should be also actively reviewing our protocols for sensitive imaging exams such as pelvic ultrasounds, and also educating our sonographers and technologists to make sure that they're using a trauma-informed approach. So the next principle is collaboration and mutuality. So for our patients, especially, again, our transgender patients, in order to create, again, a culture of collaboration and mutual respect, we can try to mirror their language that they're using. So as an example, in breast imaging, again, that's my area of expertise, if I were to have a transmasculine patient to come in for, let's say, a diagnostic ultrasound for a poppable lump, I would try to mirror their language. So are they saying, like, breast tissue, then I'd say breast tissue. If they're saying chest tissue, then I would use chest tissue. If your institution has LGBTQ plus patient advisory groups, they can be really helpful providing input about some of your institutional imaging practices, especially in areas where you may have some blind spots. The next principle is empowerment, voice, and choice. And there are multiple ways we can employ this principle. One of these examples is an ultrasound. We want to empower our patients and give them a better sense of control during sensitive imaging exams. Again, so pelvic ultrasound, very sensitive exam, especially a transvascular exam. So in this case, we could allow the patient the option to place or insert the ultrasound transducer during that sensitive exam. All right. I'm going to hand things back to Dr. Freeman. »» Great, thank you. And so implementing TIC frameworks at your radiology practices is a specific form of advocacy for the LGBTQIA plus community. We know that LGBTQIA plus patients have negative experiences during patient imaging encounters. We don't know how many of these negative experiences are initial insults of trauma or re-traumatization. This is an ongoing question here. We can also reduce the possibility of re-traumatization by decreasing misgendering, thinking more about sensitive imaging exams as well as staff training and organizational readiness to respond to potential high-stakes situations during the imaging encounter. There's a need for more research in this area. In this growing area of radiology and also all of medicine. We could think about quality improvement and system processes with TIC frameworks as well as staff trainings and collaborations with LGBTQIA plus patient groups as well. So on behalf of both of us here, we would like to thank you all for your attention here and here are the references. Thank you. I'm a pediatric interventional radiologist at Children's Colorado and University of Colorado. My pronouns are they, them. And I'll be presenting with... Hi. Hello. My name is David Jaramillo-Gil. I'm a Program Manager in Diversity, Health Equity, and Inclusion in the Department of Radiology at Weill Cornell Medicine. Thank you and I look forward to speaking to you. Okay, so we want to talk to you about the importance of robust data collection, specifically I know we've all may have heard of SOGI data or sexual orientation and gender identity data. And it's important for reasons of healthcare disparities to recognize healthcare disparities as we've heard, epidemiological insights, quality of care improvement, access to appropriate care and patient trust and engagement. So recognizing healthcare disparities, I love this graph because it very clearly shows that the difference between non-minority and minority patients and specifically disparity, the operation of healthcare systems and legal and regulatory climate and the discrimination, biases and stereotyping and uncertainty. And I know we've heard a lot about that in the previous talks. So what are the causes and effects of LGBTQ plus health disparities? They're not fully understood. We know, we've heard of, we heard from the previous talks, the various reasons why we would have healthcare disparities, but what we know is that we, we need data and healthy people 2010 cites the lack of robust sexual orientation and gender identity data is limited. In healthy people 2020, the initiative emphasized the need for better data collection and healthy people 2030, which we're currently in increasing data collection on LGBTQ health and wellbeing. So it's always been a focal point since 2010, healthy people. In 2020, the 2020 census, our last census did not include questions on sexuality or gender identity. For the first time, it did include same sex relationships. It's hopeful because the American community survey, which is a survey conducted by the U S census Bureau every year, collects information about the social economic housing and demographic characteristics of the nation's population. And in 2024, the ACS will include the SOGI test. And it's just the beginning of the work to ensure that LGBTQ plus people are counted and that community leaders and advocates have the data they need to drive change, to advance equity, and that federal state and local governments, as well as nonprofits have the necessary data to inform programs and support our communities. So what this means for our LGBTQI communities is that we can have equitable access to healthcare, advanced economic security, and all of the benefits listed here, epidemiological insights. So in order to understand and eliminate disparities in cancer incidents and outcomes among transgender and gender diverse people, clinicians and researchers must have data. This data is very difficult to obtain because gender identity data are not routinely collected in oncology practice health records. There's a national effort. A national effort is needed to prospectively collect this SOGI data as part of a structured data element. Community-led development of gender identity questions and sexuality are important in a patient-centered and non-stigmatizing way. We need systemic efforts to create safe healthcare environments for transgender people. Transgender and gender diverse folks endure many challenges which can jeopardize health. Without mortality data, research cannot identify patterns and correlates to guide prevention. EMR data and NDI data can theoretically be linked, but there's many limitations. Currently, only binary data about sex, male or female, are available in the National Death Index. U.S. mortality surveillance must disentangle sex and gender and must dismantle this sex and gender binary to identify, understand, and address healthcare disparities for transgender and gender diverse folks. Quality of care improvement. The goal of the Measuring Sex, Gender Identity, and Sexual Orientation Consensus Study Report was to improve the quality of data collection efforts and advance research and policy around LGBTQIA plus population well-being. They cite a lack of consistency in data collection measures, introduces concerns about data comparability, complicates data analysis and reporting, and hinders efforts to advance research and develop effective programs and policies focused on improving the well-being of LGBTQIA plus people. Enhancing health systems means deconstructing this gender, sex binary, including sexual and gender minority folks. Care providers of sexual and gender minority patients play a key role in educating and guiding their multidisciplinary colleagues in the care. As this is digital health equity is what I'm referring to. So principles of data collection. People deserve to count and be counted. Use precise terminology that reflects the constructs of interest. Respect identity and autonomy. Collect only the necessary data and use data in a manner that benefits respondents and respects their privacy and confidentiality. We've talked about access to appropriate care. One million transgender people living in the U.S. 33% report negative experiences with a healthcare provider, depending on which survey you reference. The recommendations of this paper are our recommendations leverage the needs of patients, medical providers, and researchers to optimize both individual patients' experiences and the efficacy and reproducibility of EHR population-based studies. We need to educate. We need to educate our medical students more to the healthcare disparities and specific healthcare needs of our LGBTQIA plus populations. Fifty percent of patients had to educate their providers on transgender health concerns. About 30% of patients report postponing medical care because of discrimination. Seventy percent of patients have experienced some type of discrimination in healthcare. Fifty-two percent have reported that they believe they would be refused medical services. And 73% believe they would be treated differently by medical personnel. Also as Dr. Martin Luther King, Jr. says, of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in physical death. »» Thank you, Vess. And as we speak about data, we wanted to have a clear understanding of identity-centered terms which can help us avoid generalizations and ensure that every individual's identity is respected and acknowledged. In return, people are more likely to participate actively in their healthcare process when they feel that their identity is recognized and valid. Additionally, data that reflects these terms help policymakers understand the unique needs and challenges faced by specific groups leading to more targeted and effective interventions. And lastly, well-defined terms ensure that data can be desegregated into meaningful categories allowing for detailed analyses of how various factors intersect with sexual orientation and gender identity. While I won't be covering the definitions of the terms listed here, as I believe most of us are already familiar with them, I did want to emphasize some key terminology related to diverse experience of sexuality and sexual orientation. For comprehensive and inclusive definitions, please consider exploring reliable resources such as GLAD or the Gay and Lesbian Alliance Against Affirmation, PFLAG or Parents and Friends of Lesbians and Gays Organization, the Trevor Project, the National LGBT Task Force, among others. And while I'm highlighting these terms, please note that this list is not at all exhaustive. These are many—there are many other important terms that are not included here. And it is crucial to explore this expansive terminology not only out of intellectual curiosity but also to ensure that we show the respect our patients deserve. It is also important to recognize that individual understanding of their own sexual orientation can evolve over time, and therefore it is essential to remain open-minded about changing experiences and ways of identifying. Perhaps most important is to remember the significant difference between sexual orientation and gender identity, which we already alluded to, which are often conflated, leading to confusion and at times unintended offense. Sexual orientation and gender identity are distinct concepts, of course, but they are frequently misunderstood or incorrectly assumed to be related. When we conflate sexual orientation and gender identity, it can invalidate individuals' experiences and identities and can perpetuate harmful stereotypes or misconceptions. At times, the differences between terms can seem subtle and difficult to fully grasp, leading to misunderstandings or hesitation in using the correct terms. However, it is essential to recognize the importance of being well-informed and respectful when engaging with individuals whose experiences and identities may differ from ours. Remembering, learning about diverse identities and experiences is a lifelong journey, and it is a collective responsibility to engage it with humility. In addition to that, while this presentation has focused primarily on sexual orientation and gender identity, I wanted to take a moment to reflect on the importance of incorporating other yet related aspects of human experience, particularly biological sex and differences in sex development. Endosex is the term that refers to individuals whose physical sex characteristics fit within the typical male or female categories. While it is the most common experience, it is vital to remember that it represents only one part of the spectrum of human variation, and on the other end of that spectrum are those who are intersex, a term that covers a wide range of natural variations in sex characteristics. It is true that identity-centered terminology does not explicitly address anatomical features, which can present a dilemma for healthcare professionals, and physicians often require anatomical language to make sense of the clinical picture. For that reason, we wanted to review two that are particularly important. The idea behind assigned male at birth and assigned female at birth terminology is to emphasize the socially constructed nature of assigned gender to individuals at birth based on their anatomical characteristics. This assignment is not necessarily reflective of how a person will identify later in life, which may differ from the sex assigned to them at birth. In the medical context, the use of assigned male at birth and assigned female at birth terminology helps to ensure that healthcare providers are sensitive to the fact that biological sex and gender identity are not always aligned. It can guide clinicians to be mindful of their language and interactions, allowing for better communication and a deeper respect for patient's identity. Just for clarification, since this term may be of particular importance within the healthcare setting, we wanted to clarify its definition, which you can find here. In addition to that, to clarify, in addition to clarifying its definition, we wanted to highlight the value of using this term. It may provide precise medical context, distinguishing between biological characteristics and gender identity for accurate diagnosis and treatment. It may enable more comprehensive and personalized healthcare by acknowledging potential differences between a sex and gender identity. It may help healthcare providers assess sex-specific health risks, screening needs, and potential physiological variations. It may support more inclusive and respectful patient-provider communication. It may even facilitate more nuanced medical record-keeping. Which brings us to collecting data. This is, of course, an endeavor that is fraught with challenges, yet essential for advancing equity. As we discussed, the intricacies begin with a fundamental question, which is, how can we ensure that language is inclusive, respectful, and representative of diverse identities? Individual understandings of gender and sexuality are evolving rapidly, often outpacing static frameworks. And this leaves researchers grappling with categories that fail to capture the full spectrum of individual experience and identities. Yet the difficulty of the task is no reason to shy away from it. We should embrace change. It's not only necessary, but also a crucial step toward creating systems that really reflect all individuals. Of course, when collecting data on sexual orientation and gender identity, there are major ethical collection considerations to keep in mind, robust privacy protections, voluntary disclosure, clear communications about data usage, and ongoing commitment to patient confidentiality. As we discussed as well, there are some key data points, sexual orientation, gender identity, sex at birth, and differences of sex development, which, of course, are all very different and can provide different insights about the patient, depending on the context. In addition to that, patient self-determination is very important. By enabling patients to self-identify and have their identity respected, providers can really mitigate the historical medical discrimination that we spoke about in these communities, and reduce barriers to seeking care, and create a more affirming health care environment that supports accurate diagnosis, appropriate treatment, and holistic patient-centered care. Finally, we are able to provide tailored care while using the principle of minimum necessary use represents a commitment to human dignity, carefully balancing critical medical needs with rigorous privacy protection. And of course, the goal is not merely efficiency, but a profound respect for each patient's unique journey of health and healing. I will very quickly go over some of the examples that are out there in the literature as to how you can collect data, which I believe are very important. Just for the sake of time, I will go quickly through this. This is how collecting this data looks through EPIC. These are other ways in which organizations are collecting data while exploring both its potential challenges and solutions. So I highly recommend them as well. The National Academies and the Consensus Study Report that we mentioned previously also provides some solutions that institutions can consider to collect this data. Here is another one that, again, would be worthwhile looking into. And finally, the literature really tells us what data we should be aware of when it comes to sexual and gender minorities. In this case, Frances Grimstad and others identify some important aspects of gender diversity, including chosen name, pronouns, stress expressions, support circles. When it comes to the legal aspect of things, name change, gender marker, etc., etc. And finally, we would be remiss not to mention the current political landscape and how it may impact the collection of this data in particular. But I think I jumped a little bit ahead of myself because I'm trying to finish on time. How much time do we have? Just three. Okay. Yeah. So I will go over this very quickly. Of course, we want to have some recommendations such as staff training, workflow integration, consent, and privacy as well. In addition to that, there's a lot of demographic information that we want to keep in mind and also how to collect this information is very important. Political relevance annotations, things to flag for certain notes that one must take in addition to interpretation guidelines, which we also mentioned before. Of course, there is a lot of potential for the field of radiology, both in diagnostic insights as well as future research directions. I think it is a very exciting place to be at and to think about and to reflect upon. But of course, we must push the needle forward. Finally, as I was mentioning before, there are some considerations when it comes to this particular data in particular. There's recent legislative proposals that seek to narrowly define sex based strictly on biological characteristics. This includes the Defining Male and Female Act of 2024, which again, one of the main concerns with this is the fundamental challenge to recognizing gender and sexual diversity. These proposed measures may mandate misgendering of transgender and gender non-conforming individuals, and some of the direct consequences in the healthcare settings could be reduced patient dignity, increased psychological distress, potential reduction in access to appropriate personalized medical care, undermining principles of inclusive patient-centered healthcare. So I do encourage us to think about how we're collecting data and also how we are being restricted from collecting this data. Thank you all. Thank you.

LGBTQIA-plus health equity

radiological care

inclusivity

gender identity

trauma-informed care

healthcare disparities

pronouns normalization

transgender healthcare

data collection

policy reform