Primary care doctors play a valuable role for young gender-expansive children by providing a safe environment, facilitating discussions and understanding current medical options. Our pediatric endocrinologists provide guidelines and answer common questions on gender care.
All right, thank you everybody for joining. We're really excited today to talk to you about the way that we approach the care of our gender. Expansive youth as well as be able to answer many of your questions um and get to know you a little bit as well. So just to get started I wanted to first take a moment to introduce myself. I'm one of the newest providers here um in our endocrinology department at BCH Oakland. I've been here for about a year, but California is my home. I grew up in sacramento and then I went off to the East Coast for both college and medical school and then I went to um made a pit stop in Chicago for about nine years for my residency fellowship. And then I worked there for a few years as well until I had the good fortune to come back home um here to northern California, where I see outpatient and inpatient endocrinology and diabetes in Oakland and also serve as a medical director for our child and adolescent gender center on the East Bay campus. Um Today we're going to spend some time learning a little bit about the prevalence of transgender folks here in the United States as well as share with you all the history of the child and adolescent gender centre um as part of our BCH campuses and we'll talk a little bit about how we approach the care of these patients, the treatments and services that we offer as well as share um what you guys as general pediatricians can do in your clinics to support some of our patients there as well. But I'd like to first turn this over to one of my amazing colleagues, dr steven Rosenthal, who is really one of the true pioneers of pediatric transgender care and was the original founder of the child and adolescent gender center on the san Francisco campus. Um, he's going to share a little bit about the history of our, of our center. Thanks Rachel. I'm very, very happy that you're here. Um, you're, you've been a wonderful colleague and I know that we're all really, really thrilled that you're here and happy to have you be part of our team. And I want to thank you for sharing a part of this, your webinar time with me. Um, so, so as as Rachel just said, I'm going to very briefly like a few comments about the prevalence of being transgender in the US with a focus on adolescents. You'll see in the next slide, which don't won't get to yet. And then a bit about the history and the mission of our child and adolescent gender center, which we just the acronym, we use C A G C. Um, just one very quick comment before I actually take you through these next two slides on prevalence and that is, um, as you probably already know, there is no way to know what somebody's gender identity is other than by asking the person. So there's no, there's no blood test, there's no X ray, there's no brain scan. Uh, the only way we know somebody, what somebody's gender identity is is based on what they tell us it is. So whenever we're looking, pardon me looking at prevalence data, we have to keep in mind that there are certain limitations that mean these kinds of studies. Number one, what is that person's degree of self awareness and number two, what is that person's willingness to share that information with a person that's asking the questions? So just understand that any of the data you're going to be seeing on prevalence is all based on surveys and with those potential limitations in mind. Sorry. Uh I think it's the smoke in the air that just were praying for rain. I know it's probably not likely to happen before november. But in any event, this first slide comes from uh the Williams Institute which is actually part of the U. C. L. A. School of Law published just a few years ago. And the data here, um you can see on the left part of the slide, you can see age groups starting with adolescents and young adults and older adults. And then you see the prevalence and this is all based on state level population based surveys in CDC surveys. And you can see that in adolescence which is the focus of our care, That this is not a rare situation that that's .7%, which is about 140. So the next slide basically looks at uh if you can afford to the next line, Oh, home, Thank you. So the next slide is specifically looking just at at adolescence. And this comes from surveys um from 10 different states in the us and then nine large urban school districts outside of those 10 states, these are all high school students. And basically over 130,000 were surveyed. And in this particular study just published last year, Um there was reported overall prevalence of transgender identity of 1.8%. So again, this is not an unusual situation and certainly something that we need to be cognizant of. Okay, next slide please. Um, so, so Rachel, you've been here a year. I just celebrated my 41st anniversary UCSF in July. So I don't I don't know where the time has gone, but um and The really the last almost 12 years now, the focus of my work and work with my colleagues has been related to gender health. And this all started really serendipitously. So almost 12 years ago in January of 2009 um in my role as general director of the I'm sorry, is director of the general pediatric endocrine clinic. We were approached by a family that had a 12 year old that was designated female at birth, but that identified as a male. And they came to us looking for care. And frankly, I didn't know what to do. There was very little, I certainly had no training in this um what we now take for granted as the endocrine society clinical practice guidelines. Those hadn't even been published yet until june of that year. So there was very little in the literature really to guide us. But there were some very important uh papers out of europe in particular, out of the Netherlands, that really showed some very compelling uh information that I know Rachel is going to be discussing as the rationale For uh the treatments that we offer. But basically it became clear that this was an important service to provide back in January 2009, and I was very excited to to have a opportunity to play a role in this and quickly found out that there were some other experts in the Bay Area on the mental health side, the legal and advocacy side, but no one that was doing the medical work for transgender adolescents. And so we had a meeting of these, these various experts and all realized that we shared of the same vision and over the next three years we worked informally together and then finally in May of 2000 and 12. So just over eight years ago we had everybody credentialed at UCSF are full multidisciplinary team and began to see patients in our child and adolescent gender center, then at the Parnassus site. And then of course our services have moved to Mission Bay in 2015. And so our initial services were quite uh um intermittent. It was basically two clinics a month with a multidisciplinary team. But four years later we were very pleased to have a satellite uh clinic related to the C. A. G. C. That was directed then by Dr Ivy S Land, also a pediatric endocrinologist. And so clearly there has been historically and an important commitment on both sides of the bay to the care of transgender adolescents and gender diverse adolescence. Okay, next slide please. So just to give you an overview of what we currently provide. Fast forward to two september 2020. So basically we now have a clinic offerings in four different sites around the bay. We have two on the west side and two on the east side. And it really is um a blessing and a relief for me to be able to share the medical director responsibilities with Rachel. I really appreciate her coming in with tremendous enthusiasm, already an incredible knowledge base and certainly a tremendous commitment to this work um on the west side of the bay. As of a few months ago, we had served over 1400 patients and families since we opened. And uh Rachel uh noted on this slide that there have been 300 unique patients that have been seen on the east side of the bay. Um, I have not ceased to be uh basically continuously amazed at the referral patterns. I figured this would, would just level off, but it hasn't. And I would say that we continue to have um in the range of 18 to 20 new consultations per month on the west side of the bay. And as you can see about 5-10 per month. Currently on the east side of the day, our multidisciplinary team really consists of four disciplines. We have mental health providers, probably the most important that includes psychologists. We also have access to a whole network of mental health professionals that include social workers and psychiatrists, uh marriage and family therapist, et cetera. Um We also have on the medical side um pediatric endocrinology of course, but we also work shoulder to shoulder with our adolescent medicine physicians as well as our primary care physicians. And then we have a director of education and advocacy as well as a legal director and I'll tell you about the research in just a moment that's like in fact that moment is here. So um one of the things that I'm sure is apparent to you is that this is still relatively a new field and we recognize we recognize that while there are some very compelling data that support current clinical practice guidelines that Rachel will be summarizing, it's also quite clear that there is a tremendous need for long term follow up of just how to really optimize care for our gender diverse youth. And so recognizing that gap in knowledge, we made a commitment really almost from the inception of our program that we would do our best to try to increase the knowledge base, particularly since this can be such an emotionally charged issue uh to really try to inform discussions with scientific evidence. And so I'm very proud to say that our center along with colleagues at Harvard USC and also Northwestern, where where as you have heard Rachel, was that larry Children's that we pooled our resources and rather than compete with each other, we decided to work together. And in 2015 we received the first ever grant, multi center grant ever funded by the National Institutes of Health to assess the impact of medical treatment of transgender youth according to current clinical practice guidelines. They never fund more than five years at a time. And we recently found out just at the end of june that the score for our five year renewal is looking very much like it's in the fungible range. So we're very hopeful and very excited to be able to continue this work. We have been the recipient of the second grant from the NIH, which is focused just on the trajectories of of pre puberty, all Children who are gender exploring to really know how best to support these kids. Again, with the same for centres involved, we also have another NIH grant with our colleagues at stanford that focus on the brain uh impacts of current uh models of care. And then finally um you could advance the slide again, please. Mhm. The the SAn Francisco Department of Public Health recognized that that despite having the center at UCSF and now of course with sites around the bay, that there still was a need for community outreach given that there are still many people who just if not have the resources to come to one of our programs. And so we have worked with them and have now a five year funded uh joint program to develop community outreach in the city and county of SAn Francisco, that we certainly hope to be able to extend beyond those geographical limits. And then finally um obviously we're committed not only to providing uh state of the art and compassionate care but if you can divide one more slide and to try to move the field forward with objective scientific information. But we also have an educational mission and both in Oakland and on the west side of the day, we have been very committed to being responsive to requests for training people that want to come and spend time at the sea A. G. C. And so we have had trainees from around the U. S. And from many parts of the world um uh in the disciplines of pediatric endocrinology, adolescent medicine and nursing. And so I'll turn it over to you again, Rachel and thank you again for the opportunity to summarize the history. Right? Thank you so much. Um And I'm going to continue to actually start my portion of the presentation by just reviewing some definitions that are related to gender and definitions that we use pretty regularly um in the care that we provide. So first before we can even start talking about transgender care, we really need to distinguish the definition of sex versus gender. So sex is really a label that is assigned at birth, typically male or female, and it's assigned on the basis of one's genetic, chromosomally hormonal and anatomical characteristics. Whereas the kind of most crew definition of gender is that it's really just a societal construct of what is masculine versus feminine. Sex and gender are not the same thing and they should not be used interchangeably, even though they often are. So with that there's also the term gender identity and gender identity is how is one internal sense of who they truly believe they are in terms of male, female non binary or perhaps even another alternative when one develops their gender identity, it's really more than just the societal construct that's that's definitely part of it. But it actually reflects a complex interplay between their biology, culture, society and their environment. Gender expression is how an individual presents their gender to other people around them most commonly through clothing or hairstyle, but also through their behavior, their language and the roles that they play in society. Sexual orientation, on the other hand, is defined as who one is attractive to mm gender diverse is an umbrella term that we use to describe individuals that have gender behaviors, appearance or identities that are different than those assigned to their birth sex. Um, it's really encompasses a wide array of gender identities, including transgender, non binary and gender fluid. Um, and it replaces the former term gender nonconforming, which really kind of had more of a negative connotation that we wanted to stray away from. Um, transgender is a specific term used to describe individuals whose gender identity does not match the resigned sex at birth and that this identity remains persistent, consistent and insistent over time, many of the folks and Children that we take care of. You can experience something called gender dysphoria, um, which is a definition, A DSM's definition actually described as distress that one experiences related to their in congruence between their assigned sex or gender and their gender identity. It's often associated with significant impairment in social and emotional functioning. And then lastly, transition is the social medical and or surgical process that one undergoes to live in their affirmed gender. Um, and different individuals go through different phases of this. Some perceived the entire route and some do do bits and pieces. Some individuals also prefer the term affirmation as opposed to transition because they feel that now they're able to live in the way that they believe they really were all along instead of transitioning or turning into something new. So just by reviewing those definitions, you can probably tell the gender development is extremely complicated. I'm just going to take a minute to sort of review our traditional teachings on gender development and contrast up with our contemporary model. So traditionally the teaching was that gender assignment matches the sex that was assigned at birth, which was assigned based on their external genitalia. And if a child was born with ambiguous genitalia, then surgical procedures were carried out in early life to establish their sex assignment and that by age 18 or 24 months a child's gender identity was firmly established. And then the child would just learn how to do that gender and how to conform to those societal norms and that their parents and other caregivers would teach them how to do so if when the child grew up, if they deviated from their assigned gender, the fault was purely of the parents or the caregivers. So you can imagine that we don't really subscribe to this model anymore. We think of this now more as your sex that's assigned at birth, may or may not match the gender identity. And we won't really know that until the child is able to really express who they are in overtime, every child is going to integrate cues from their nature, their nurture and their culture and their gender identity will be established in that way. Um there has been the terminology and some of the social literature called the gender web that just to highlight that there's so many contributors to one's gender. Um, some of some of these contributors are science and biology, and others are really environment and family and values and um, and societal um, societal cues as well and that as parents and as caregivers, it's important for us to facilitate and support the messages that the child brings us, um, so that they can explore their gender and develop their gender identity in the most supportive way possible. So gender expiration is a very normal part of child development as general pediatricians. I'm sure you've seen many Children who are, um, you know, boys that wish to wear dresses or girls that want to be construction workers. And a lot of that is just normal play and normal exploration. But there's some percentage of Children that are really persistent in their gender nonconformity and those are the Children that were talking about, that we really need to listen to carefully um and help them help them live the way that they feel most comfortable. And that's important because we know that gender diverse Children are at very high risk of many negative outcomes, including depression, anxiety, suicidal ideation, suicidal attempt. And these Children are at much higher risk of these negative mental health outcomes than their cis gender counterparts. Um and and on top of that, gender diverse Children who are not supported by their loved ones and by their caregivers are at even higher risk. So that's why it's really important that we are we are cognizant of them and that we do what we can to support them. And just to highlight that even more, I pulled this quote from an article from one of our directors of mental health dr Diane erin's act, whose again, a wonderful pioneer in this field. And she writes when transgender youth are valued for who they are and are supported by their families and other important adults in their lives, secure attachment and resilience is fostered. So I just encourage you to keep that in mind as you approach these families and patients. Mhm. So in order to do that, we at the C. A. G. C. Utilize what we call a gender affirming approach. And this gender affirming approach is what is um what is recommended to be done as well by the Endocrine society, by the World Professional Organization for transgender Health and for other other well known national organizations. Our overall goal of this center is really to aim to help youth live safely in the way that they feel the most comfortable and to allow for gender exploration in a safe, supportive and affirming space without any Presumptions about what they may desire in the future. We use a fully individualized and comprehensive approach because we know that one size really does not fit all in the care of gender diverse Children and their families. It's really important for us to meet them where they are and hold their hands and guide them through the process. Um any medical treatment that we provide by our team requires this comprehensive approach. We utilize um our mental health specialists to help perform psycho social evaluations to help Children and their families really know that this is what they truly desire and that when any sort of medical treatment is initiated, we require that that mental health specialist provides us with a letter of support indicating that they have met with a child and the family and um and explored, explored their gender together with them, We provide comprehensive education on the risks, benefits and the unknowns of any therapies that we're going to use. Um As Dr Rosenthal mentioned before, this is a relatively new field and there's a lot that we don't know. What we do know is that by treating them the best that we know now with the evidence that we have now, we are helping them long term from a mental health standpoint, but that we do have to be aware that there is risk that we may be putting them at that. We're just not aware of that at the time. We um provide fertility counseling to all of our patients as well. Um This is a little bit more challenging, particularly in pre puberty or early puberty. Children who may not be thinking about whether or not they want to have families in the future, but some of these medications that we use can impact fertility in the future and it's important for us to talk about that with them. Um We require some baseline labs and imaging that are really related to side effects of the treatment and then all patients and their parents are already ins have to sign a consent form before treatment can proceed. So I'm going to shift now to just share some clinical vignettes of some Children that I've had the pleasure of taking care of in order to highlight some of the services that we offer. I'm here in our clinic. So first this is an eight year seven month old child who was assigned female at birth, presented to the clinic stating there a boy, the parent and the child gave the following history. At age three, the child said, I wish I were a boy at age four and five the child refused to wear a dress. Is wanted to wear boys underwear. At age five, the child said, I am a boy requested being called a boy and using he him pronouns and wanted to use the boys bathroom all the time. At age eight, he chose a typical male name. Um and he's been lucky that his school and his family have been supportive throughout. There is no signs yet of puberty in this child. So this is a child who we can support initially by helping them socially transition with this child, which this child has already done. So social transition is a reversible um a reversible treatment, I guess for lack of a better word for for gender exploring youth. And it allows for pre pube brittle or pew brittle Children to live and present themselves as their affirm gender by allowing them to use the name and pronouns. They prefer dress in the way that they prefer perhaps cut or grow out their hair. Um Use their preferred gender social rules and their preferred bathrooms as well. Some families prefer to just first start transitioning inside the home or just with family, their start in at the home and then at school and maybe at a later date and some do it all at once. But we do recommend that anyone undergoing social transition is also under the care or the support of a mental health professional to help them um kind of navigate that process and um it and achieve that social transition most successfully. So next we have a 12 year old, six months child who was assigned male at birth but carries a female gender identity and uses she her pronouns and she presents student noticeable changes of male puberty that are very distressing to her. She's noticed pubic hair over the last four months as well as some growth of the Penis. She began wearing dresses at age four and refused to take them off. She wanted to grow her hair out as well. And over time she describes that she just organically began presenting more and more female. She has good support from family, community and teachers, but she's not quite ready for estrogen therapy yet. On physical exam, she was noted to have 10 or two stage pubic hair and her testicles were puberty, all measuring five mls bilaterally. So this is a good candidate for G. And R. H. Agonist or puberty blockers. Puberty blockers help kind of put the pause button on puberty or traditionally used in our patients who have central precocious puberty but can be used in our transgender youth as well. We most commonly used them and transgender youth Who are in early early puberty, at least tanner stage two in order to prevent the development of potentially unwanted sexual characteristics. So in this patient using a puberty blocker could prevent kind of the masculine ization of the face, um enlargement of the testicles, significant growth of the penis. Um things that would might, might make them appear more tradition, typically male when they may not want those changes down the road. It's also helpful to use puberty blockers in patients who are still exploring their gender identity but are experiencing puberty related exacerbation of their gender dysphoria. It helps them kind of again, cause that natal puberty that they may or may not actually want and give them a little bit more time to explore what they do want. Um And then we also use puberty blockers in patients who are transitioning from male to female. Um Just because female hormones like estrogen alone are not enough to kind of fully suppress the needle testosterone, the endogenous testosterone that a needle male would make. Again, just as with the social transition, we recommend doing this with the support of a mental health professional. Yeah. Um G. N. R. H. Agonists are reversible to some degree. Um And if you know when we take them out then their natal puberty would continue. So for somebody who's just exploring their gender it can be a nice way to again put that pause button on um G. N. R. H. Agonists are given by either intramuscular injection or by subcutaneous implant um depending on kind of how long we want the effect to last. But there are some risks and considerations. We never want to put somebody on a G. N. R. H. Agonist or puberty blocker for too long without having any sex steroid estrogen or testosterone because of the negative impact on bone density or potential negative impact on bone density. It can also suppress some of their height velocity or height growth if their sex steroids are suppressed because you are preventing that sex steroid augmentation of endogenous growth hormone function. Um You want to think about how long you want to use it and sometimes there can be fertility consideration for some aspects of fertility preservation. Their endogenous puberty needs to progress to a certain point um in order to harvest eggs or sperm for freezing if if desired. So our next case is a 17 year old child who was assigned female at birth with a male gender identity. And he presents for a clinic stating that he has felt different since he was six. He never felt he was in the right body. Always hated it when teachers referred to him as female or used his given name in middle school, he first learned about the term transgender and realized that that described who he was. He came out to his parents and began using a masculine name and he him pronouns in eighth grade. So he had essentially been socially transitioned um for about four years by the time we saw him um He experiences gender dysphoria with monthly menstrual cycles. And showering is very difficult for him because he does not like to see the female parts of his body. He's been meeting with a therapist regularly both about his gender identity but also for management of his anxiety and O. C. D. And he comes to us now desiring testosterone therapy. Okay so this is a child who has really gone through their own endogenous puberty um and is now a candidate for gender affirming hormones which are partially reversible. There are some effects of gender affirming hormones that will reverse when you stop them, but there's some that are not. Um and the process of gender affirming hormones is to administer either testosterone or estradiol in order to develop the sexual characteristics that match one's gender identity. So I'll start first with testosterone and I'll just briefly review um For time's sake, testosterone can be given by injection by gel or patches and most of the desire changes. Um We'll really start emerging by about six months of usage and continue to develop over the following couple of years. But use of testosterone is not without risk. There's some things we know will increase the risk, such as weight gain acne policy, ischemia, um elevation of liver enzymes, cholesterol profiles, but there's a lot that we don't know either. So we review that with families, um and we, you know, one of the biggest things we don't know is really the true long term impact on fertility, on cancers on, you know, endogenous egg quality. Um In some patients like this patient also or only desire menstrual suppression, which we can offer by the use of progesterone. Only pills, progesterone implants or in some cases intra uterine devices. Um Intra uterine devices are used pretty sensitively in this group because sometimes just the placement of the intra uterine device can trigger some gender dysphoria in a natal female who has a male gender identity, but there are some patients that do prefer that. Um And so when that happens we do like to refer them internally to some of our adolescent specialists or adolescent guidance specialists who are very sensitive to the care of transgender patient um with this procedure. So in contrast, feminizing treatment is with estrogen which is typically administered with a pill or a patch, and then it's used in conjunction with a G. N. R. H agonist or a puberty blocker, which will help block the endogenous testosterone production in some cases. Um In patients who have a lot of androgen effects, sometimes we also would use an anti androgen to block those effects, Just like with testosterone, a lot of the estrogen related desired body changes will happen in about six months, um within the first six months and then progress over the following, you know, 12 months or or years or so. Um But again, there are risks that we know about in many risks that we don't know about. The biggest risks with estrogen therapy are risks of clot uh liver enzymes cholesterol of negative impact on the cholesterol profile. And there's also some concern about hypertension or cardiovascular disease. We don't at this moment really know too much about long term risk of developing breast cancers or other estrogen responsive estrogen responsive cancers as well. So the last sort of intervention we can offer patients is gender affirming surgeries, which are of course irreversible in pediatrics. We're not typically talking too much about gender affirming surgeries. There are some surgeries that will occur in Children as young as 16. Those are typically um breast augmentations or um or mastectomies or what's colloquially known 25 and have surgeons that we refer to as well. But there is a lot of education um and counseling that goes along with this as well because these are really truly irreversible um and irreversible aspect of their treatment. Um so I would be remiss if I didn't talk about fertility and transgender individuals. So many um many people, many transgender patients actually do say that they've never discussed fertility with their health care provider. There was a study that came out a couple of years ago that identified up to 80% of these transgender adolescents said fertility was never discussed. And and that's it's really unfortunate. Um the american Society for reproductive Medicine, the Undercurrent Society and the World Professional Organization for transgender Health all recommends that fertility counseling is provided for transgender and gender non binary patient and that understand understanding of the fertility goals are ascertained before initiating gender affirming care or especially before before initiating any sort of irreversible treatment. Sometimes as counseling needs to happen regularly over time, depending on the child's age. Pew brutal stage emotional age, things like that. Um And one thing I always like to tell tell these patients are that there's many different ways to create a family and we try to discuss all options. We don't have, again, just like with everything in pediatric transgender medicine, we don't have a lot of good long term data on the effects of hormonal interventions on fertility. So we're again honest about that and we talk about what we do know or what we could potentially do. We know that testosterone might impact uterine architecture, ovarian function, um egg maturation. But there have been case reports of transgender males carrying pregnancies to term estrogen might impact a sperm quality. Um and supermodel genesis sperm production. Um But we have also seen reports of harvesting of sperm from somebody who's on estrogen, so things are changing quite rapidly. Um We work very closely with a couple of our specialist in urology and in reproductive endocrinology and O. B. G. Y. N. Over at UCSF who are very keen on caring for fertility preservation for transgender youth. Um And and even transgender early pupil it'll youth. And with the help of these colleagues um we've been able to refer patients for um um sperm preservation for egg preservation as well. Some of the some of the protocols that they follow are really done under research protocols. This is more related to things like lucite cryopreservation or ovarian tissue cryopreservation but for sperm preservation that's really kind of done somewhat routinely now. Um And the previous teaching had been that a child had to be off of puberty blockers off of gender affirming hormone therapy in order to adequately retrieve egg and sperm for freezing. But there's actually been some exciting data in the literature over the last year. In some case, reports that that egg and sperm retrieval has occurred while on puberty blockers or gender affirming treatment. So things are changing um regularly and fast. Some considerations over fertility preservation is cost insurance, so it can be quite expensive. Sometimes the procedure might be okay, but then the cost of storing and freezing and maintaining those storage fees can be a barrier for many patients. There's sometimes a stigma or family stigma associated with this. There's the question of if they would need to stop gender affirming treatments and what that might do for their gender dysphoria. The same with that there might be a requirement that there's some progression that occurred through endogenous puberty in order to adequately um adequately harvest eggs or sperm. And there's also some concern that Children or adolescents might not be mature enough to make these decisions about their future fertility or that they declined fertility preservation because they're afraid that it will prevent them from getting their gender affirming therapies as quickly as they want. So there's a lot of heavy things to discuss around this, but I do think it's really important that we are as open and honest as possible around these discussions. Yeah. So lastly, before we open it up for questions, I want to take a few minutes to highlight the important role that you all as pediatricians can play in the care of our gender diverse. You I want you to remember that you are often the first medical provider that becomes aware of a child's gender exploration. And it's important to always approach that conversation respectfully privately and without any judgment. Um, if you encounter a child who might be exploring their gender, it's always helpful to first ask them how they prefer to be called and to always use inclusive gender neutral and whatever their preferred terminology is and to validate the child and families experience and feelings and recognize that this is hard for them and for everybody. Um and that in these patients in particular we all know that A. G. U. Exam is part of the normal physical exam but just being mindful of how how that's approached and how that might trigger gender dysphoria or frustration on the part of the patient. Um There's also important ways that are that office staff and your office in general can just show respect and inclusion towards gender diverse youth in their families. You think it's important to train and retrain office staff on gender inclusivity and terminology and just posting inclusive signage and waiting areas has actually shown, um, has actually been studied and shown that that that it's it's made transgender folks feel a lot more welcome. So just having a sign, you know, all are welcome here or a sign that says all gender restroom shows um shows patients and their families that they are being supportive at check in always asking the child what their preferred name and pronouns are as just part of a routine script that's asked to all patients and then using those preferred name and pronoun. I think it's important as as caregivers has trusted caregivers to stand up for any child who is being mis gendered and to be accountable for any mistakes you make, we all make mistakes. We all use the wrong pronoun sometimes and if you recognize that you do that apologize and move on. Um, but just recognize that that that you did that. Um, and then one big thing is also having access to a single stall restroom if possible, or labeling a restroom as all gender or gender neutral. Um, so that's a safe place for that person to use the restroom. Here is just a list of some excellent resources that you can provide patients who might be exploring their gender. The first one mind the gap is actually an organization of mental health providers in the Bay Area who provide care to gender exploring you. Um, so you can you can take some of these, um, for more information and then we at the child and adolescent gender center are happy to see any child who's at any point in their gender journey exploring their gender identity. We're happy to see any family who is struggling with acceptance of their child's gender, anybody who wants education around gender exploration or treatment or who's ready to seek treatment and anyone who is needing help accessing mental health services, legal or advocacy support surrounding their a gender. Um, we now have an easy way to kind of just refer to the BCH system in general. There's our our pediatric Access Center that recently launched 877 You see child, you can have families call that number. You can call that number um and refer specifically to the child and adolescent gender center. Um Alternatively, you are welcome to contact us um on either side of the bay. I have the contact information there below, um about any patients you have questions on wanting to know if it's an appropriate referral or not when we can see them what kind of support we can help you with until we can get an appointment. Um, and we're happy to see patients in any for of our locations and with that. Um Again, thank you so much for allowing me to share this um this service with you and I look forward to seeing your patients in the future, and I'm happy to answer any questions, mm.