>> Hi. My name is Deborah Dunn. I'm a family practice PA at Chase Brexton Health Services. I specialize in gender, medicine, transgender, and gender nonconforming. Also, I was part of a team that helped write a program called Gender JOY, which serves the trans youth and families. We just had over-- hit over 700. My patient start at age six and they go all the way up to seniors, up to 70s and 80s. So what I'd like to do today is talk to you as one practitioner to another, as a practitioner and you are the patient. There's-- You're going to see a lot of slides and the slides are going to have a lot of studies. But you can read them as I talk but I would-- I think it's more important that I educate you about the-- what happens face to face in the doctor's office. For two reasons. First of all, we all know that transgender medicine is not taught in any medical curriculum. Reports have shown that transgender people-- a lot of studies have been done and the studies are showing that transgender people just aren't comfortable or feel like their practitioners are knowledgeable. And so that acts as a barrier for transgender to people come to see us. So it's important that you get educated that you go to conferences, that you read, there's a lot of evidence-based medicine now. There's websites like WPATH which is a-- WPATH, wpath.org, where you can find like treatment guidelines for transgender people. There's the LGBT health resource websites that you can go to and you can watch webinars. So I encourage you to do that. If you are a patient or if you're a transgender person, it's very important that you find a practitioner who makes you feel affirmed. People ask me all the time, "So what is transgender?" And I really don't like to use definitions. I really don't because we-- as we all know, we identify [inaudible] gender and we identify what the gender not because it's the gender that we were told we are when we were born or because we have a certain genital being female for me. If I have breast or not, I'd still be gendered female. And just I love my transgender children because they get it. They-- I am a girl. I am girl. A child psychiatrist tells us that people know their gender from age three. If you ask a girl or a boy what their gender is, they could tell you I'm a girl or a boy. And, you know, they get it right. And so, a lot of their parents are coming to me saying, you know, is it something I did, is it because of divorce? You know, if you think about it, is there anything, any life event that could happen that could make you change your gender, probably not. And let us start encouraging everyone to start looking at gender in a non-binary way that there's no longer the male and a female, almost male, almost female, trying to be male, trying to be female, a male trapped in a female body, a female trapped in a male body, we're all free to gender-express. And how do we know that gender? We just do. We just do. If you ask-- We're going to over some basic definitions. But if you ask a person a gender now, they may not identify as male or female. There's now-- A lot of my patients are saying queer, or non-binary, genderfluid, these are all terms that we're going to start hearing now. And what it just simply means is that somewhere on a spectrum, someone's gender-- and identifying as a certain gender that they feel deep-- from somewhere inside that they are. Same thing with pronouns, I ask patients. When I walk in the room, "I'm Deborah Dunn." And your gender, I ask people their gender. And so-- And then I ask the pronouns or preferred pronoun. It may no longer just be he/she, it could be they. And there's an umbrella, large numbers of terms for people that use pronouns now. And the same thing with sexual orientation, we're no longer hearing people just say that they're gay, straight, bisexual. People now are saying pansexual, poly, demi, there's lots of them. And so what we have to get in the habit of doing is making sure that people have opportunities to express their gender and their gender and their sexual orientation. And in just a minute, I will show you how to do that on forms and your electronic medical records. A couple of things, though, before I start that I think is important that you know that Healthy People 2020 says that transgender people are at the top six for health disparities. And a lot of this is because of discrimination, social and economic marginalization. Because of these things, transgender people experience higher rates of substance use, violence, harassment, mental illness which a large number of people have said or reported suicidal thoughts and attempts. The second thing that I think is really important for you to know is that it's-- that we have to do a better job at documenting data and tracking data, gender. Just as 2011, the CDC just added gender identity to reporting forms. So in other words, doctor's offices are places where people were diagnosed with HIV, people who are being reported as their gender at birth and not the gender that they are identified with. It's so important that we start documenting proper gender, because it will help us to design programs that target this group of people. And it will also help us to know what the health disparities are, so we can know what needs to be addressed. Starting this year, it's going to be kind of mandated that we start collecting sexual orientation and gender identity in our electronic medical records. And again, you know, who not-- who doesn't wanted to be counted? It's important that we're documenting gender properly so that we can set up programs, so that we can address different health disparities. And if you're a transgender person, I want to say to you that I want to advocate for yourself. If you walk into a practitioner's office or wherever you are, because if you're at the Department of Housing, we need to start getting this data so that we can-- you know, even the Department of Housing needs to know about programs aware what groups of people need to be addressed. But if you're a transgender person, you really-- it's important that your practitioner is reporting your gender properly and your sexual orientation properly. So advocate for yourself. If they're not asking you questions and if you're not seeing it on the forms, then I want you to volunteer that information to them. When you walk in for-- from like the front desk to the back, from the call center, you know, we got to get used to not using pronouns, he, she, mister, miss , please come back for your appointment now. I recommend using sign-in sheets. Put name on one side and use preferred names on the other side, and start calling people by their preferred name until you know or you're able to identify the-- their gender. And for-- some examples on forms that you need to say, is not husband and wife but use words like spouse and partners. Instead of using mother and father, use parent and parent because we know that they're the same sex partners, couples now that have children. So try to stay gender mutual. It's really important. The minute your patient feels like you're not being welcome in a firm and they won't come back, I ask what is your-- When I walk in a room of a patient, I'm like "I'm Deborah Dunn. I ask your name. Is this how you would like for me to address you?" I ask about gender and then I ask about preferred pronouns. And I write it down, and that's what I address them by. We have had several examples of patients or seen or heard several examples of people they misgender or not using name. For example, I had a small child that-- well, eighth grader who fully transitioned. And whatever grade, third grade, and, you know, we accidentally went to the waiting room and call by the boy gender. And she was suicidal. We have to do better. We have to try to get it right every time. We have to realize that the name on the insurance card maybe different than the name a person identifies with. So, set up systems that you get it right, because we as health care practitioners, we need to be in a business of helping people and not damaging people. Don't make it hard for your patients to figure out what bathroom they should go to. It's-- You know, a family bathrooms, you know, have neutral-- gender-neutral bathrooms. Because imagine if, you know, your patient and trans patients, I want to really strongly encourage you to not allow your doctors or practitioners or people not use your name and your gender. So, let's get it right and let's get it right every time. You know, I hear people say it's hard, it's new for me, but you don't like to be called by the [inaudible] name. No one does, right? So, let's start calling-- let's start being sensitive about that. In our electronic medical records at Chase Brexton, this is what our form looks like under the gender history. If you go down to the bottom, under gender identity, that dropdown is not just male/female now, it's other options, for example that one says transgender female to male, also transgender male to female. So we give people other options. And in your intake forms, if you're not comfortable asking people their gender or sexual orientation, have that-- those questions on your forms and then let your patients fill them out, and then you can read them. If your patient-- Again, if your patient-- if people aren't asking you, you have to let them know, you should be telling them. This is our sexual history. I'm going to take a minute really on this form, because this is how I identify my patients who need PrEP, pre-exposure prophylaxis. I ask, are you in a relationship? People say yes or no. And I'll ask, are you sexually active? And people say or no. I'll ask, how many sexual partners have you had in the last two months? They could say zero to over 20, is I hear all the time. And I'll ask, in a year, the same thing. And if my patient tells me that they've had over two partners, multiple partners, then I immediately start talking about PrEP. I explain how it's an HIV medication that have taken once a day for HIV negative people, it can help prevent you from getting HIV. I also-- If you look on the right-hand corner of this form, we also ask about gender. I ask the gender of your partner. If people tell me they're sexual active, I'll say, what is the gender of your partner? Again, they may say nonconforming, non-binary, genderfluid, but our dropdown has more than just male and female or man and woman. It has several different options. People are saying they're active trans. So, it's important to ask the questions and if you're a trans person, make sure you tell them. Don't worry about people being bias. It's important because it will help us to better know how you should be tested and how we should counsel you about things like pregnancy. And behavior, sexual behaviors, you got to ask people if they're having oral sex, anal sex, vaginal sex. You have to ask. This is another way we're going to identify people who are at higher risk. I've seen people who have come back to me several times with this chronic sore throat. They've been in the emergency room. They've been to doctor's offices. Everyone is testing for strep. No one is asking, are you having an oral sex? And some people are. And I'm testing them and it's chlamydia. And as you know, penicillin is not the treatment for chlamydia. Patient-- I mean, trans people, patients, when you go to the doctor's office, you have to disclose this to your doctor. If you're having oral to anal, tongue, mouth, lips, anything around the anal area, you know, you have to know that there are some infections that are associated with that. If you're having some diarrhea or some stomach cramping, things like that, then, you know, you may need to tell them that there's an incident of GI bugs that you can get that way. If you're having vaginal sex, you know, vaginal, oral, and anal, you should be testing, more screenings regularly for GC and chlamydia. We should still be teaching our people about barriers. It's up to us, health care practitioners, to help lower the transmission of HIV. People are always talking about condoms. People are always talking about condoms but we should be teaching our people about dental dams. I've seen dental dams in several doctor's offices, were not teaching. And they're just sitting there. They can sit there for a year and rot people or not-- you know, if you taught your patients how to use them, they would use them. I don't keep these in my exam rooms. Dental dam looks like this. It stretches against their genitals and-- you know, it protects as oral barrier against oral, you know? So, people do got to lick on top of this. Also, women who have sex with women, it stops the transmission of body fluids for people who don't like things like grinding. But the number one use for this, my patients, is oral to anal. Spread the cheeks, put this across and lick on top, you know? So, also, there're now the female condoms. I've seen this everywhere. They go into the vagina like this. This hook goes along the cervix. Again, the number use for it in my patients is anal. The ring stays in or comes out. It goes into the rectum like that and the anal sphincter holds it in touch. And you don't have to be a practitioner to teach your patients. It could be your friends, staff, people should be teaching their children. Also, if you're a trans patient or a person, go to your doctor's offices and ask about these barriers. Ask if they have them. You can buy them at stores. But it's very important to help protect you against getting sexually transmitted. There's HPV of the throat. Doctors, providers, dentist look in the mouth. Do Google images that look like. It's doesn't look like warts, it just looks like raised areas. So get yourself familiar. A little bit about the epidemiology, HIV in trans women. What a lot of people-- People are constantly hearing that men who have sex with men are the number one people with HIV. Well, I can tell you now that recent studies now are showing that trans women are taking the lead, more than two times. And black trans women are more likely to have HIV than non-black. So these are the latest studies that are showing these or showing this. Why such a high HIV prevalence among trans women? Again, think about it, you know, think about it. If the studies are showing that people who are substance abusers, promiscuous sex, marginalized, depression, things like that, are at higher risk of HIV, then it kind of explains it. Because if you've being rejected by family, churches, things like that, you're going to, you know, find comfort where you can find comfort. You're going to find comfort in maybe substances, in maybe drinking, maybe in promiscuous sex. You think about it, you know, that person, you know, accepts me for who I am. And I just think it's important for-- if you're trans that you realize that this increases your risk of getting HIV. These are just some studies. This is one I took the slide from your doctor telling [inaudible] who practices here at Johns Hopkins of 47 people in Baltimore. And this study, you know, it shadows other studies. Trans people are having difficulty getting jobs. People are going to job interviews and they're like, oh, they may be trans, you know, I'm not going to hire. People are losing jobs. People are getting kicked out of, you know, housing. People are getting-- having problems getting access to HIV services. Physical abuse, harassment. Studies are just showing, you know, that there's a disproportionate number of trans people who are sexually assaulted, being arrested, abused. And I can tell you from my practice that families that are opening and affirming and practitioners who are opening and affirming that are helping the transition of trans people definitely have improvement in quality of life that there's lower rates in incidence of all of these in any of these. So again, it's another reason why you need to identify who your patients are and that you help address the issues that causes these things as physical abuse, harassment, things like that. Then I have to move a little bit. Transgender women, younger women, very little studies are done but I can tell you from my practice in this study that you're seeing on the screen right now, that there are some increased-- younger and younger people are getting HIV now. My 16 to 24-year-olds have just blowing up all of a sudden, getting one to two diagnoses a week sometimes. So, we-- it's really important that we do start doing HIV testing very early. Start early. Start identifying the patients early, I can't say that enough, and then start testing earlier. Ask about age when you start having sex, teach our young people about barriers and test them. It's not-- They're not too young to test at age 13 and 14-- 12, 13, and 14, start testing. But if you're not asking, you're not going to test. So, it's really important that you start young-- which are younger people. And through the slide in here, a transgender women getting tested, they are but the studies are showing more that that they're undiagnosed people with HIV. So, we need to go where we need to develop programs where people will comfort testing but also we need to go. We need to get involved in a community. We need to go to [inaudible] events, set up tables, bring your-- we have a power project van. And we're testing. You know, we're targeting the group-- the community that we know are high risk and we're testing them on the sites. We're parking in front of clubs. When we know there's a drag show, you know, these are places where you can do testing. I'm part of a group called trans action group in Baltimore City that actually outreaches trans women that are sex workers. That's 11:00 p.m. to 4:00 a.m. And we have a van and we're given Target gift cards for people that come test. If you're a transgender person, please go get tested. Look for opportunities where you can go get tested. It's very important. Because studies do tell us that there's a large number of you that are HIV positive but don't know it. And then move along. What is the main mode by which transgender women become infected? All right, again, there's not a lot of place where you can go and read this. I'm going to do this based on my practice. So, we still know that people are getting HIV through receptive and insertive anal intercourse. And through IV drug abuse, we know that blood transfusions, having sex obviously with a person who is HIV-- unprotected that is HIV positive. But what I want to say to you is, again, the importance of doing sexual behavior histories. Because we have to ask our transgender patients, gender nonconforming, genderfluid, and when I say transgender, it's all inclusive about receptive and insertive anal intercourse. The terminology that they've-- that our patients may be more familiar with are top and bottom, so sometimes you have to use to language that people understand. It's important that you know transgender women are top and bottom. OK. It's just, you know, that a lot of people think that transgender women are not top, but they are. You know, it's-- we can't-- we have to stop classing people based on stereotypes. There are sharing of needles to give estrogen to one another. One night I had the privilege of following one of the trans outreach who was with us at the trans action group. She took me into a place that was a pump house. I saw this non-medical person use a vial, use the same needle and syringe. Went into the vial, drew out, injected in one girl, told a woman that it was estrogen. I don't know what was in there. And took that same needle and syringe and went back to into that vial, went to the second person and did it three times. And you could see that the fluid or whatever it was in there, I'm not sure was estrogen, it could have been water, was blood-tinged. Same thing with silicon. Silicon was bought from Home Depot. I could see it on the on the can, using a needle and syringe drawing from that and injecting and feminizing cheeks, breast, hips, thighs not using any kind of incasing. So this is another way that our patients are being-- are transmitting HIV. And you have to ask. You have to ask, are you using-- getting hormones off the street and how are you getting it? You know, are you using and sharing needles? There are some IV drug use with transgender women, most of the substances, is crack cocaine that I'm seeing a lot of alcohol, not as much heroin. I do see some heroin though. Trans men is mainly alcohol. A lot of our patients are having sex with known positive partners. And, you know, they're being told, I'm on HIV medicines or my viral was undetected. They're doing what's called barebacking anal intercourse without using condoms or any barrier. And, you know, it's up to us to educate our patients about how they can get HIV. And transgender males, females to males, they are not-- There's no data, no studies. And so, I can tell you in my practice that transgender males, I'm seeing more and more that are HIV positive. You have to do sex behavior course setting. Ask about using-- having vaginal intercourse, anal and oral testing of all of those size but most importantly doing HIV testing. And that another group of people that I think we're going to start seeing of higher rates of HIV. PrEP and the transgender community, there have been studies-- The iPrEX, I won't go into that study. The bottom line is that PrEP can work but inherence is crucial. The studies are showing that when there is Truvada, which is the medication for PrEP, in the system, then they are protective. You see a lower rates of HIV transmitted. However, compared to men who have sexual with men, transgender women are, you know, not taking the PrEP at the same amount that men who have sex with men. So, I have a script that I give every time to my trans women, trans men, gender nonconforming, genderfluid that you have to take it for to work. You have to take it everyday. You can't take it as a day after pill. It doesn't-- You know, you can develop resistance. You can-- You have to take it everyday to be protected. It has to be in your system for a period of time for it to work. Again, if you give me a history that you've had unprotected sex, anal, all of the things that we know increases your risk of getting HIV, I immediately put you on PEP, that's post-exposure prophylaxis, for like 28 days and then I go to PrEP. I'll just write the prescriptions. I do the test and I will write the prescriptions. Studies have shown that if women at least taking them four doses per week, they're protected. Doctors is so important, health care providers. It's important that you are comfortable prescribing PrEP. You have to. It's easy, you know? You prescribe Truvada. You do the test for HIV and hepatitis, all the hepatitis. I do a CMP. Check kidney, renal functions, and you just prescribe it. You have your patients come back every three months. Transgender-- My trans patients, trans people out there listening to this, go get prescription for PrEP. If you know you fall in this class, this category, then ask your doctor about it. Find places that prescribe it. Some of the things I hear-- Some of the reasons I hear our trans women saying why they don't take PrEP or they're not taken HIV medicines, because they feel that it lowers the effectiveness of their hormones. And if you feel like it's going to impact your transition, then you may not be likely to take it. But I'm here to tell you that PrEP, Truvada does not-- has been shown through studies not to lower the efficacy of your estrogens. So it is important that you explain that to your patients when they come in. And compliance is very important. Then I'll quickly go through some key messages here. Number one, please be open in affirming, learn, go to conferences, read, go to different web places. WPATH is definitely one that you wanted to go to so that your patients they'll be comfortable around you. Make sure you're using proper names and pronouns. My trans patients, please advocate for yourself. Make sure you're doing-- you're documenting, you're collecting data of proper gender and sexual orientation on your forms, in your electronic medical records. Make sure that you're doing sexual histories and gender histories, get comfortable with it. Get your staff comfortable with it. Don't forget about barriers. We've stopped teaching people about how to block but it's important that we still. And it's not just condoms that come in every flavor or size, but there are other barriers. It's important that you ask people about sexual behaviors, you're testing, and that you're finding to your T group of people, you target your group of people that you know are high risk. And now that you know that trans people are at high risk, then definitely do testings, start doing testing at a much earlier age. Just start doing. I mean, just do it. And get comfortable prescribing PrEP, very important. And explain about the efficacy of the importance of taking it everyday. Explain about the importance of-- that you still have to use a protective. You still have to use condoms. You can still get sexually transmitted diseases. And also it's important that you design and that you become allies and you develop programs that allow people to come in for testing that allow your patients to come in to be prescribe PrEP. Again, I'm Deborah Dunn. My email address is ddunn@chasebrexton.org. And thank you very much.
