Providing Gender Inclusive Care to Survivors of Violence-Gender Inclusive Care

Gender Inclusive Care

Video Transcription

Hi everyone, thanks so much for coming. So today, Ash and I are going to talk about providing gender-exclusive care to survivors of violence. I'm Ashley Stewart, and in a minute, I'm going to introduce Ashley Gan as well.  So I'm just going to talk about the disclosures. The planners, presenters, and content reviewers of this course disclose no conflicts of interest. Upon signing in on the attendance sheet, attending the course in its entirety due to the criticality of the content,  and completing the course evaluation, you will receive a certificate that documents the continuing nursing education contact hours for this activity.  The International Association of Forensic Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation.  So let's move on to now the learning outcomes of today's session. So we hope that after this session, you will have an increased knowledge and feel confident and competent in seeing non-binary patients and providing care that is gender inclusive.  You will increase knowledge related to gender terminology and gender safe practices, and identify and discuss the increased risk for violence in gender non-conforming individuals.  Next, we will introduce ourselves and I'm going to hand it over to Ash first and introduce yourself. Hello everyone, thanks for having me and thanks for showing up.  My name is Ashley Gan, I use they, them, she, her pronouns. I'm a trans support worker at Clinic Community Health Centre in Winnipeg, Manitoba, Canada.  I'm currently a student at the University of Winnipeg, doing a double major in psychology and women and gender studies.  We're just going to call myself Ash, just to not confuse things since there's two of us here today. Yeah, and that's it, Ashley.  Thanks. So my name is Ashley Stewart and my pronouns are she, her. I'm a forensic nurse in Manitoba, Canada, as well. Same place Ash lives and practices.  And I coordinate a forensic nursing program here and then I also teach as adjunct faculty at Duquesne University in Pittsburgh, Pennsylvania.  And then formally, I practice as a nurse in a transgender health clinic here in Winnipeg.  Okay, so I'd like to add the, I guess it's in the resources, we have a website that you can click on to called My Gender Journey.  Ever since we are born, gender has been imposed upon us both overtly and covertly.  Societal norms and the status quo have kept us to a script despite us all being somewhere on the spectrum of gender to varying degrees.  Diversity within organizations are beneficial. People of different experiences and backgrounds within a workplace can create modernization and diversify points of view and innovation.  Research shows that diverse teams are more creative and outperform correlative teams.  Diversity and perspectives allows for innovative complex research questions and problems to be understood. Research shows a direct link between diversity and quality of scientific work as measured by peer review.  But before we go any further, how many of you see non-binary folks in your setting? When you introduce yourself to your client, do you introduce your pronouns? And can you identify your bias?  Oops, I kind of got ahead. That's the first question there. We'll give everyone a minute and you can answer and then we'll go to the next question.  So everyone probably saw the results of the first question, so we have a good mix, which is excellent. And hopefully at the end of this, everyone will learn, hopefully we'll all get to be introducing ourselves and asking our clients their pronouns.  And then the second question has come up as well about identifying your biases. And we have a good mix as well. Yes. And then some not sure so we're going to get to that at the end as well. I'll let you keep going Ash.  Oh, I think I'm done on that side.  Perfect. So I'm going to talk a little bit now about the importance of providing gender inclusive care. So we know through a lot of research now that folks who identify as non binary and folks that identify as transgender experience significantly higher rates  of violence, specifically sexual assault, intimate partner violence or domestic violence and sex trafficking as well. So it's really important that in all areas that we're working in, especially forensic nursing that we are making sure that we are  safe, inclusive space. If we're not doing those things and folks are not going to access our care. And if people aren't accessing forensic healthcare or healthcare in general, we know that leads to a number of other different issues in life as well.  Increased stigmatization and having non gender inclusive care or not safe care we know we see a lot higher rates of suicide increased mental health symptoms.  You know marginalization people experiencing homelessness and then other secondary health concerns that can be impacts of violence as well.  So that's why we are here today and we're going to talk a little bit about how to make your service, a gender inclusive and a safe service, so that folks are going to come present to you when they need that care.  So you guys are going to see another question come up.  Now, so we want to know if you feel that biases whether that be conscious or unconscious bias impact the care you give to your client, whether that's forensic nursing care or healthcare in general.  Again, some people say yes, no, sometimes not sure. And we're going to revisit this question at the end again, and see kind of how we feel once we talk about this content a little bit if we feel like those biases impact the care and the health of  our patients.  And this just gives you a little bit more of a visual of kind of what I've already talked about on the last slide but just that really increase in violence and folks who are non binary or identifying on the spectrum are impacted by.  So if you look at this is the US study but a lot of this is quite consistent.  Unfortunately, so we see the increase of serious violence is significantly higher and folks that are LGBT LGBT or across the spectrum, you know, rape, sexual assaults, robberies, aggravative assault, any assaults including a weapon are significantly higher.  What does termed a simple assault, any violence that is including injury, and then what business to classify the serious violence and including involving injury.  So, as you can see, we see a lot higher rates and folks who identify as non binary and so we should be seeing those patients in our practice but we're only going to do that if we have a safe and we have an inclusive environment.  So sometimes we talk about providing gender safe inclusive care in the context of sexual assault, but I wanted to make sure that we're talking about this and all of our different friends that practices and disciplines, and some of you may do a forensic  nursing practice but you might also practice and other medical or nursing areas and this applies to anywhere you are working and practicing and seeing people.  When we talk about forensic nursing practice I wanted to highlight that this is important across the life spectrum as well. So whether you seeing folks who are experiencing elder abuse, people in incarceration so either forensic psychiatry or forensic  corrections. You know that is a large area where we see a lot of gaps as well, even in child abuse so we kind of, you know, exclude our young folks as well.  You know what gender do they identify and making sure we're inclusive with them and their families as well and making sure they're safe, we're safe place for them.  Human trafficking, sexual assault, intimate partner violence or domestic violence another large area we need to make sure that our practices inclusive as well so you know when we're advertising our services are we portraying a binary and a heterosexual  image when we're advertising our services, or are we inclusive to all types of relationships and all types of genders, and then family death investigation as well right.  So I just kind of wanted to highlight that we talked about having inclusive care. It really does go throughout our forensic practice but also across the lifespan as well.  So, gender refers to various roles rights and responsibilities of men and women, as well as their interactions.  It does not simply refer to men or women but how their characteristics behaviors and identities are formed because of socialization.  Gender is often associated with an unequal power and access to options and resources, historical religious economic and cultural realities affect women's and men's positions.  These roles are responsible and responsibilities can do can and do shift over time.  Gender identity is how a person sees themselves, it is their internal sense and personal experience of gender.  Some people whose bio biological sex does not match their gender identity may make physical and social changes to express their identified gender, and may also involve medical changes such as taking hormones or getting gender affirming surgery.  This process is called transition. Next slide please. Okay.  Gender expression includes all the ways a person communicates the gender based based on societal factors, such as gender norms and perceptions.  Some people have the same gender expression, all, all the, all the time whereas others may change their expression over time or based on circumstances.  Some people use gender expressions for theatrical person purposes or drag a Victorian era theater kind of slang.  People can choose to express their gender identity in different ways at different times, it can be psychologically distressing for some people who do not feel safe or comfortable expressing their gender identity.  Next slide please.  The term trans is frequently used as an umbrella term for variety of other terms including transgender transsexual which is an outdated term and should kind of be avoided, and can also refer to terms like gender queer a gender by gender, etc.  Some people may identify with these or other specific terms, but not with the term trans. Similarly, some people may identify as trans but not with other terms under the trans umbrella.  To put it simplest each of these terms has commonalities with the term trans, and yet are all unique in their specific reference to the context of and specific relationships between conceptions of gender identity and assigned sex.  And I'll just kind of go through some of these terms that are used, which might get a little long winded so strap in.  Transgender, which could mean are referred to a trans mask trans femme or trans person period.  Transgender is an umbrella term for people who's a gender identity differs from one assigned to their physical, physical sex and includes the above kind of things I'd said before trans mask trans femme, and just trans in general.  Transgender refers to anyone whose behavior or identity deviates from gender stereotype senses, such as man or woman, that kind of binary kind of thinking.  Transgender people can be straight, gay, bisexual, or any other kind of sexual orientation, sometimes abbreviated by the term trans but not necessarily applicable to that.  It's assumed that anyone who dresses in a certain manner is maybe what they what what the bias of the person interviewing the client kind of would see a gender is a person that does not have a gender, the body of an agenda gender person doesn't always  respond with their lack of gender identity therefore again, like making judgments off the way a person's dress on what their gender is is somewhat erroneous and androgynous person is someone who identifies as neither man or woman or physically appears as neither,  but can also play within that kind of background of like woman man kind of dress cisgender, this is just means the same side, right, as the gender that you were born or the sex that that you have been perceived to be.  Same as trans trans just kind of means the other side, or corresponding with the opposite sex, I guess, if that makes sense.  Gender fluid is a person who does not identify as a male or female but rather is one or the other depending on the day, time, our minute.  This refers to being flexible with one's gender expression which is distinct from one's gender identity. Again, it can kind of get confused with androgynous kind of performance within that gender fluid, then there's gender queer this person may identify  as male or female is, or as between or beyond genders, or mixes the two so somewhat similar to gender fluid.  Then we can move on to intersects which refers to a group of medical conditions in which a person is born with chromosomes genitalia and or section secondary sexual characteristics that contradict the traditional definition of male or female body.  This person is not always aware of their condition, but it is an identity that some choose to share.  And finally, we'll just cover gender non conforming gender non conforming refers to a person who either by nature or choice does not conform to gender based expectations of society.  This person's gender identity. Excuse me goes along with those with a lot of the ones we see about.  Think about gender stereotypes out there, such as pink for girls and or guys having big muscles and cars and things like that. This person may choose to not conform to those to these or may identify as the opposite sex such as transgender individuals, and then  have a mix of like interests, right. Okay, next slide. Perfect.  On the spectrum, there's a range of gender identities between and outside the categories of male and female from cisgender to gender neutral to transgender, and in between, it is different for all of us.  Gender identity develops development happens from birth until death.  It is not a product of the mind, it is influenced by nature, nurture and context, and various other influences within our environment.  It's not a correct style of expression for males or females and it's healthy for individuals to experiment with these kinds of things such as a more common kind of commonly accepted thing of women wearing pants, or something that's a little more difficult  but still, it's, it's come a long way from, especially from when I was growing up is men wearing dresses and still being men right.  And it was always confusing to me being Scottish, because like kilts, right.  Generally transgender or gender nonconforming is normal and healthy historically gender nonconforming children have been given a psychiatric diagnosis. However, the manual used by psychiatrists was revised and updated an updated version was released in 2012  to not consider transgender or gender nonconforming children to have a disorder. Again, there's a pathologizing kind of effect going on within that kind of thing just off of psychology or psychiatry kind of definitions of things, and trying to understand.  Thank you.  There's a spectrum of gender and sexual identity identities as two spirit LGBTQ plus this includes two spirit lesbian, gay, bisexual, transgender, queer or questioning intersex and more, as denoted by the plus use of the acronym is important in various  aspects of an individual's journey. Many other factors factors intersect within this categorization, such as religion, ethnicity, age, physical and mental abilities, social circumstances, geography and unique life experiences.  And we are reminded that we are all having our unique human experiences and deserve respect and dignity in our autonomy unlabeled is a term that has recently emerged, although the term may be growing in usage, and is significant significant and well sourced  conclusion on this wiki or on wiki Wikipedia, it may still be relevantly relatively unknown outside of the platform or community where it is organized, the exact definition and name may not have been have stabilized and may have changed significantly as more  people identify with other other, also known as no label or non labeled.  It's a term that used by individuals who do not wish to identify with terms such as like bisexual agender lesbian, gay, and just for the connotations that maybe don't like social connotations that those kinds of words stir up for people.  to avoid like that kind of thing altogether so it's it's good to be mindful, just like in how in defining ourselves that can be used as a weapon against us to is a double edged sword right so just to be nuanced within your practices on how people wish to have  to share their identities with one another. Next slide please.  So, to spirit, as it was introduced red tailed hawk hovered above symbolizing of a positive spiritual message at a meeting for gay and queer indigenous people in Winnipeg.  Sorry the name, the date escapes my mind at the moment I was hoping to be more prepared with that. But it did originate in Winnipeg.  It describes gender identity male female third gender sexual identity, lesbian, gay, bisexual, queer, and with the spiritual identity having both male and female spirit.  This can vary again from location and tribal values.  This is a term of that has been used to reclaim indigenous queer queer identities and things like that just to differentiate from colonial practices which can be kind of missing in a spiritual connotation has to do with sovereignty and reclamation,  the future of to spirit indigenous queer normality has roots embody sovereignty and in the personification of a non dualistic nature envisioning this understanding evolving through a diverse culture that experiences violence, despite this right to exist  as a pure expression of creation in the face of colonial attempts at erasure in comparison with the reclamation of the term queer, which was used as a slur to denote non conforming conformity in the preferred gender roles of Western society.  Dr. Wilson, a professor at the University of Saskatchewan and a member of the Osaka Hawaii, wacky Cree Nation, I apologize for my pronunciation.  Dr. Wilson being an organizer with the I don't know more movement through which they develop the model of a coming in for individual indigenous queer experiences of expression in relation to the reclamation of indigenous ways propagates direct relations with  empowering to spirit indigenous voices, a coming in narrative offers reflection on the reclamation of indigenous queer identities in contrast to the mainstream coming out narrative of queer identities.  This is all cool I'm quoting some of this from Wilson and Lang paper done in conjunction with Dr. Wilson, Alex Wilson, who they had a dialogue about education and to do with indigenous people.  And again, reclaiming the word to spirit or queer. Even in body and land queer indigenous youth have a relational perspective to the land  and reflect direct influences of the natural world. Reclaiming the body through land and water sovereignty is returning to a traditional understanding of connection  with one's environment. Thus, coming into the self is a way of coming in direct relation to the environment, creating a deep spiritual relationship that  enriches the actor's presence in the world with respect in one's representation and reflection. Next slide.  So diversity creates more resources, not less in the system. This is because diverse plants and species need different nutrients to thrive  and each generate abundant resources that they can share. They soon realize that they can gain what they need by creating cooperative relationships.  Instead of drawing all the resources from the soil, they start exchanging resources with other species or plants. The shift from competitive to cooperative relationship  creates the conditions for a system based on abundance. Again, drawing from Indigenous thought and sovereignty with what mind and body. For those of us who have been raised  in scarcity of the environment, which is more of a colonial kind of concept and creating that dualistic, competitive kind of nature, it can be challenging to imagine a system that  runs on abundance. These systems are based on interdependent relationships where resources are regularly exchanged because it is both more effective  and it allows for them to contribute to the health of the whole system. This can easily be applied to human systems, right? Next slide, please.  The term sex and gender are frequently used incorrectly and interchangeably. Gender and sex are related terms, but they are different and they are not interchangeable.  Sex is defined as biological, chromosomal, XX, XY chromosomes, whereas gender is what you view yourself as what you most associate with.  Sexuality is one's attraction to someone romantically or sexually. Gender identity is our internal experience of naming our gender. Again, I will refer to, oh no, sorry, moving on.  This is what gender you identify with, male, female, gender neutral. This does not necessarily correlate with the sex that you were assigned with at birth  or does it have any correlation with your sexuality? Whereas physical sex is the development and changes of a person's body over the lifespan.  It depends on various factors such as sex chromosomes, reproductive organs, hormones, secondary sex characteristics and related medical care. Again, I will draw from intersex  just to kind of draw attention to that in that people who are intersex can have different chromosomes or different, their body or their biological system expresses it differently.  So therefore don't fit within that XY, XX kind of chromosomal thing. You can have XYY, XXX and the list goes on. That's just within chromosomal kind of things.  So again, we need to be mindful of our gender and not mixing up with sex. I'm done on the slide, thank you.  So I'm gonna talk a little bit now about creating a gender safe culture where we work. So now all of you, I hope have an excellent background  on gender, the spectrum of gender and sexuality and have some background knowledge that we can put into practice with seeing clients. And so I think sometimes as providers,  we get a lot of questions or myself presenting on this and I'm sure Ash as well, with people having a lot of fear on doing the wrong thing,  saying the wrong things or not having the knowledge. But I think I'm hoping everyone will see at the end of this presentation that sometimes it's much simpler than we think.  It's really about being respectful and being inclusive when we're seeing all types of patients and making sure that that's really forward throughout all of our different practices.  And there's a number of different ways we can do this. And instead of I think feeling fearful of doing the wrong things, something that's important for us to do  is to gain that information ourselves and also not rely on people in the community to educate us, right? So even within the last little while, there was maybe certain little things  that I wanted to look up for this presentation or find some examples. And I want everyone to know how readily available this information is.  And so it's really important for us to educate ourselves on these topics beyond this as well. So some of the things that we can do in our practices  to make our spaces safer is to make sure they feel safe, they feel welcoming. So things that I like to do is to look at our practice and see what is on our promotional materials.  So, you know, a while ago, I looked at what we had in the program that I coordinate and we had a lot of, you know, just female white images on our promotional materials.  And I thought other genders are not gonna feel comfortable,  other races might not feel comfortable and that's not inclusive. So we took those off. You know, when we do any promotion or education or articles about our service,  I'm mindful to say that we see all ages and we see all genders instead of, you know, putting ourselves in a binary. And then folks are gonna know that, you know,  you see all genders, that you're a safe space. What is the education that folks have around you? So what is the education of your nurses, but also the multidisciplinary team, right?  It's great if your nurses and your practitioners have gender-inclusive education or DEI education, but if you're not the first person they see,  then there's other impacts when you think about. So what is the education of the person who's on the entrance of your hospital or your clinic or community setting?  If you're in an emergency setting, what is the education of your registration clerk and your triage nurse, security, the police officers you've worked with, the advocates,  down to the lab technicians or other support staff you work with? So it's great if we can be educated as forensic nurses, but it's important all the steps leading up to us as well,  otherwise they'll never reach us as forensic nurses. The other things we can do, and we kind of talked about this in the beginning of the presentation,  but start with your practice now by leading and stating what your pronouns are and asking your patient their pronouns. So when you go into meet your patients now saying,  hi, I'm Ashley, my pronouns are she and her, what is your name and what are your pronouns? And just making that a practice with everyone. Same when you go into a meeting  or if you go into your Zoom room,  automatically having that up there so that we're normalizing that practice and we're not just assuming when we should be asking people.  The other thing we can do is we can be adapting our forms and our medical records to be gender inclusive. I find sometimes in healthcare and even with electronic medical records,  we get really into a binary system with boxes and forms. And sometimes we get really hung up on what is on someone's identity and their medical cards or their insurance cards.  And that's something we don't need to do. And I kind of give the example of people's names. So, you know, I'm sure we all know someone who has a legal name,  but they always go by their middle name, their legal name. They were just named that because it was after someone in their family. We don't say to someone,  nope, I can't use that name that you go by because this is what's on your identification. It's the same in gender, right? So sometimes we'd, I think, get pigeonholed on,  you know, this is what it says on your birth certificate. I can't use, you know, what your gender is. And so I think we just really need to get out of that practice and realize  that that's just what's on a form. And a lot of times that identification is non-inclusive. We're seeing some of them start to be a bit better, but it's not an inclusive practice.  And so we can change our forms to be that way as well. Instead of having boxes, having on our forms gender and a line there. And in many practices where I work anyway,  I don't need to know the sex that somebody maybe was assigned at birth. Maybe I just need to know, what is your gender? How do you identify? There's obviously some practices.  So for example, if maybe we're collecting forensic evidence and that is going to the lab, then they may need to know that, especially when they're doing some typing.  But in a lot of areas of our practice, we don't need to know that. The other thing we can do is really just advocate for inclusivity in our systems and our policies.  So if you see an area of your hospital, you know, when maybe your folks go to the lab for blood work, what are their policies there?  You know, can you have some impact on their policies that when someone's entering the lab, the first thing they do is, you know, go to the state and ask their patient,  what is your name and pronouns? And writing that on the lab requisitions so that people aren't being misgendered or being called by the wrong name.  So I think we can really have some important advocacy as nurses across our systems as well.  So we've talked about what education our colleagues have, our advocates, and just making sure that goes through. You know, with forensic nursing,  I think that goes right up to the attorneys we're working with.  You know, if you're working in a correctional setting, what is the education, you know, with the other staff, maybe with some of the guards you're working with, you know, how is it,  does it go right up to the level of judges? And so I think we can be a really important advocate on our SART teams and other multidisciplinary teams  that we sit on to make sure that follows through. I talked about this already as well, but it's important to educate ourselves on gender safe practices as well,  versus always expecting folks in the community to educate us. And then one of the last things is to be aware of our biases and our assumptions. And we've started to talk about those  while we've gone through, and I hope while we've gone through some of these topics, folks have been able to maybe identify some of those and see how they impact our care.  The other things we can do is just make sure that we are practicing these inclusive practices in our forensic practices we go through.  You know, what is in your exam rooms? What language do you use when you're taking someone's health history? Do you use gender inclusive language? There's a lot of binary,  even a lot of the medical terminology. So for example, if I'm asking someone about bleeding from their uterus, something like asking what somebody's menses  has a very feminine or female associated term. And so for someone who might not identify with that, it's more inclusive to say, do you bleed every month?  You know, and using terms like that, or asking someone, what terms do you use for your body parts? And then I'm gonna use those as we go through our history and our examination.  So those are some of the things you can use. The other thing I wanna highlight that we need to make sure we're doing as examiners and as practitioners is making sure we're asking  what is appropriate and what is relevant. So when someone's coming in and seeing me for domestic violence or even a sexual self-examination,  I don't necessarily need to know what surgery they've had or if they've had surgery. And that's why we've kind of talked about some things like gender and transitioning,  being really as part of a spectrum and being aware of our biases and making sure that we're not assuming someone who comes in is on certain medications  or transition looks different for everyone if someone is in a period where they are seeking medically supervised transition. So kind of letting go of some of those biases  and our assumptions and only asking what we medically need to know as forensic nurses. So for example, if someone's coming in to be treated for some physical injuries  or they're coming in after a strangulation, I don't need to know if they've had any surgery unless maybe it's had a neck surgery. So really just making sure we're asking  what is really relevant. I'm gonna describe kind of the broken arm syndrome as well. So this kind of goes along with HRT or hormone replacement therapy.  Again, we shouldn't assume that patients are requiring or desiring to be on hormones. And we don't necessarily need to know if they're on any,  if they are coming to us for something where it's not relevant. So there might be certain parts of our exams that hormones may have an impact, but in a large part,  many of the things we do have no relation to that. And the broken arm syndrome is where someone maybe comes in for a broken arm and that practitioner realizes  that they are in a hormone therapy and they find a way to relate that fractured arm to them being on a certain type of hormone therapy. Somebody asked me one time  when they were seeing me for medically supervised transition and they were being discharged out of our care. And the person said, when I go to emergency now,  do I need to always tell them that I'm on these hormones and I've had this type of treatment? And I said, no, if you're going there because you've fractured your arm  or in your car accident, or you're having headaches and it has nothing to do with the other treatments you've had, you don't feel the need to disclose that.  And we don't have the need or the requirement as providers to ask that information either. So I think that's really important just for us to be aware of.  Ash, do you have anything else you wanna add on that before I go on to microaggressions?  No, that was pretty straight ahead again,  but I guess I'll make an amendment to the hormone replacement therapy. Just stating that a lot of studies have been based off cis trials of hormone replacement therapy.  And usually doctors have no problem with prescribing hormone replacement therapy to cisgender people, but then have a problem when it comes to transgender individuals  when it's not much different. That is all. That's a really great point. And I think sometimes medical practitioners, again, it goes along with that pathologizing  and really gatekeeping. And that's something that we need to be away from as well. Because as Ash mentioned, if I have someone else who comes in to the medical system  and they feel like they need hormones for whatever symptoms they're having, they get those a lot easier and have a lot less barriers and a lot increased access.  Next thing I'm gonna talk about a little bit is microaggressions. And so microaggressions is a term that's used for daily verbal, behavioral, or environmental slights.  So those can be intentional, but they also can be unintentional that communicate hostile, derogatory, or negative attitudes towards stigmatized or culturally marginalized groups.  So it's really important when we're providing gender inclusive care and inclusive care for all folks that they're really aware of those microaggressions  and we're aware of our unconscious bias. So examples of those microaggressions can be assuming someone's name and pronoun, misgendering someone, using the wrong pronoun,  assuming someone's sexuality, assuming the gender of someone's partner. Those can all be microaggressions that have a really significant impacts on the folks that we're seeing.  Even if I'm seeing someone and I'm assuming they are in a certain type of relationship or monogamous and not realizing that they might be in a polyamorous relationship,  or I'm assuming what kind of care they've had or what kind of medications they have. Those are all microaggressions. Things like addressing people with sir or madam,  or in the beginning of maybe speeches saying ladies and gentlemen, those are all microaggressions. Using prefix and suffix, so Mr. and Mrs. So some folks might use a mixture instead  or just eliminating those. And I think just being open and asking all of the clients we're seeing, not just people who we think we should be asking, how do you like to be addressed?  I've seen some really great graphics come out of some institutions recently, recently because of Pride Month where Ash and I live, our organization finally came out  with some good graphics and posters that we can post in our exam room that says, my name's Ashley, my pronouns are this, and I can either have that on my ID badge  or having a sign on the decks of triage that says, we wanna get this right. Please let us know your name and your pronouns. And so there are little things like that  that we can think about so that we are being more inclusive, getting more involved in your community. So do you have Pride Parade? How are you involved with the community?  Do you have any community advocacy committees where they can help advise the care you're giving?  Having your service be represented maybe at some of those community events so that folks can come up and ask questions and you can get involved in the community  and get to know people. So those are some of the other things that we can do as well to provide some more inclusive practices. So as we start to get in  and talk about some of the resources, there's another question that's gonna come up in your poll. And it's the same question that we asked you before,  but we wanna know now as we've gone through this, how do you feel now? Do you feel like some of our unconscious or conscious biases impact the care that we give our clients?  And I'll give everyone a little bit of time while they answer that. And then I'm gonna go through some of the resources and then Ash and I will stay on for any questions.  Okay, great. So I see the poll and the answers have changed a little bit from before, right?  So I feel like we have a little bit more variety now where folks are saying, yeah, I actually do feel like my biases impact the care or yeah, sometimes they do. So I think that's  really great. I feel like everyone really has reflected as we've talked about some of these things. So I'm going to go through some of the resources here. Ash and I have listed  a couple of these and Ash I'll let you jump in after as well. One is called the gender spectrum, my gender journey. And this is a really great resource for absolutely everyone  to go through and to do some of the work there on where they could be on that my gender journey.  So that's a really great resource. There's some other resources. One is Sherbourne Health.  They have a lot of great resources for healthcare providers on providing gender inclusive care.  We also have the World Professional Association for Transgender Health called WPATH. So their  site has some information. They have annual conferences, both in Canada and across globally  as well. Gender Unicorn. So there's some great ones on there. And then the last one is the Ontario Network of Sexual Assault and Domestic Violence Treatment Centres. They have some  free modules and education on providing trans affirming care as well in context of sexual assault. Ash, do you have anything to add before I go on to the second page of resources?  Um, no, really, just that my gender journey is a really great resource for people who've  never questioned their gender and things like that before, or who easily can kind of identify  with the status quo, just for breaking up biases and like having a fresher view on things. And the gender unicorn is just really cute. So like, there's that. Yeah, and also, usually  in following HRT regimens, and things like that, the WPATH method is generally what's followed for us in Canada here, although we have a CPATH, I believe, but that's not as  popular as WPATH. The WPATH seems to be the more, like overarching kind of professional kind of thing that everything's based off of. And they're going to be, I've heard that  they're going to be changing some of their positions or just modes of operation. So, and I believe there is also a conference in September in Montreal. So if people are interested  in kind of learning more about that, and what the changes are, then there is that. And that's all I got to say about this page. Perfect. So here's some other websites that just have  some really great education and some free resources as well. Rainbow Health Ontario is really great. University of Winnipeg has some more information on learning about Two  Spirit and Two Spirit folks. And then the University of Alberta has a course on Indigenous  and equity, diversity and inclusivity as well. That's really helpful. Is there anything else  you wanted to add on to that before I go on? Just that Transcare BC and the Ontario, both the Ontario resources are really good places to go and source information. It's just a  plethora, like so much information. And I believe I want to say it's the Rainbow Health Ontario. There's another diversity kind of training workshop available through that.  So it's worth checking out. And then the last thing I wanted to mention that I don't have on here, but I thought of is FORGE. So the FORGE website, they have a great resource  as well, where you can go through and you can assess whether you are an inclusive service or ready to serve folks who are non-binary. So that's a really good kind of self-assessment  tool for your service to see kind of where you're at and what you maybe need to change.  And then the last thing I want to mention is with the International Association of Forensic  Nurses, there's a recent position statement that you will see shortly that should be approved  on there as well in providing gender safe care as well to school age children. So you can look  for that as a really great resource. And then this is a documentary that came out not that long  ago, and it's a documentary on folks who identify as trans and there are people on there who are  younger and who are children and then people throughout the lifespan. So anyone who hasn't  seen this, I do recommend it. I think it's a great documentary for you and your staff to also  view together. Also within that documentary, I found it interesting that there was an individual  who was trans and a doctor. So they're very, yeah, I started diving into them more after watching  that. And it was really interesting, especially since there isn't a lot of trans people  providing services to trans people, right? Yes. And they actually have a clinic providing inclusive care in the States. I want to say it's called the Papillon Center,  where they do surgery and they do supportive treatment for folks as well. So yeah.  Oh, sorry. Go Kardash. Something that I forgot at the beginning, I wanted to make a land acknowledgement about the land that I occupy. In Winnipeg, it's Treaty One  place, home of the Cree, Ojibwe, and Diné people. Thank you, Ashley. Yes.  Excellent. Well, thank you both very much. It was a lot of great information. We do have a couple  questions that came in. The first one, which is one we get all the time, is can folks have a copy  of the slides? Is that something that you're both willing to provide after? Yes. Yes, absolutely. So  yes, we will be emailing those out following the presentation. And Beth asked if we can show the  page of resources again, Ashley. So if you don't mind going back. Yeah, absolutely.  The other question, and Beth, those will be included in the slides as well.  There's a question here. Are there certain medications that interact poorly with HRT meds? I'd like to know all medications to avoid drug interactions, reactions.  So that's a really great question. And obviously, as nurses, we're getting a medication history in  the large majority of our patients, and I think that's fine. To my knowledge there, and I'll let  Ashton after, but to my knowledge, there's nothing largely that interacts with some of the medications  that folks are on that I've ever really encountered. So sometimes maybe with something  like sponrylactone or something that might impact somebody's maybe potassium. So that might have an  impact. But otherwise, the large majority, there's not going to be a large impact. And it depends,  obviously, what kind of treatment our patients are seeking. So if we're talking about sexual  assault care, one thing I always like to remind folks of that you're not forgetting about emergency  contraception in anyone that has a uterus. So regardless of the medications we're on, we're making sure that we're remembering to offer that. But otherwise, in that context,  or when I'm up to talk about my practice in general, so whether I'm seeing folks after sexual violence, or intimate partner violence, domestic violence, none of the prophylaxis that  we're giving has any impact on any of the hormones that folks have been taking when I've seen them. That's a great question. Ash, do you have anything to add there?  Just to be mindful, I guess, of vitamins and things like that. I know that there's some in  like St. John's wort doesn't get along with a lot of different things. So just being mindful of  things like that. But there's, I don't know, I think it varies from person to person, right? So  it's good to get to know the individual and what what they're taking and how they might kind of  interact. Yes, that's great. Great. And there's another question in the chat. And this presentation  will be posted to the Online Learning Center. So you can share it with your team, watch it with  your team and reviews. Thank you for that. Good question. If somebody actually raised their hand, Susan, I'm going to put you off of mute, if you would like to ask a question.  Susan, I think you can unmute yourself now.  We cannot hear you yet. I'm going to put you back on mute, and feel free to join  the conversation if you did have a question. Is there anybody else who had a question  they wanted to contribute? And I would love to hear not only questions, but is there something  that you've done in your practice that you thought was really a good way to do outreach?  Oh, Susan's back. So think about that while Susan raises her hand here. Have you done something  in your practice to either encourage outreach, or do you have a really specific example of?  I know there were a lot of examples earlier of making your practice more gender inclusive,  and inclusive to a lot of different patients. So if there's something that you think you did that was great, we would love those specific examples. I think that that's a really good  way for us to learn from one another. Susan, go for it. We've been waiting. We'd love to hear your question.  We still can't hear you.  Susan, maybe if you could try the chat just because it's unfortunately we can't hear you I do see that you're off mute so we absolutely should be able to hear you but we cannot.  I think while we wait for Susan to type in their question, some of the other things that we've tried to do as well is even looking at things obviously in our practice we use a lot of trauma grams for injuries.  And obviously we have specific ones when we're doing any type of genital exam. But when we're doing any body injuries those are gender inclusive.  And so you can find some great resources for those ones as well I think I have some under the resource tab. So those are some things that we can also do.  And I know we talked about, you know, asking someone what medications are on and that's something that we typically do in all realms of health care. When it comes to surgeries I find I typically like to ask only what's relevant to my care.  For example, if I'm doing an exam on someone who is impacted by domestic violence, I might generally ask if you have any hospitalizations recently on any medications, unless there's specific trauma to a certain area I don't necessarily need to know.  If I'm doing an exam on someone who's been impacted by sexual assault, if it's been a rectal sexual assault, I just might say do you have any history of any type of rectal surgery that might impact my findings, but otherwise I don't need to know if they've had every  other type of surgery on their body right so we tend to do really focused assessments.  You know if I'm doing a rectal exam on someone I don't need to know if they've ever had any type of your nose and throat surgery right so the same in this instance I think that medical folks have a history of being inappropriately curious sometimes and asking  medical folks questions that are more for curiosity and not for medical reasons so I think it's important that we're always really mindful of that, and that we are very private with our patients health history as well.  And making sure that we're keeping those things confidential. And then we're careful about who we're discussing medical information with if it's not medically relevant to anyone else and just the questions that we're asking as well.  Those are really important points, Ashley.  So thank you for for raising that I know in a lot of particularly smaller communities sometimes something that feels like it's confidential or sharing it that's unidentified can easily be more easily be traced back to somebody, particularly in rural or small communities.  And so I think that there is even an additional layer of privacy confidentiality concerns with this patient population. So do you have another question here. Do you have a trauma gram that you prefer to use and can you share.  I do have a trauma gram that I prefer to use I'll give my email at the end and I can share it, I probably got it so I probably found that resource from someone else but I'll be more than happy to share that or easier.  It's easier to send to you Christina and you send it out, or that individual as feel can feel free to contact me by my email at the end as well.  Great, we'll send that out with the PowerPoint slides after.  Any other questions that is kind of a big topic and we went pretty quick. So if there are we'd be really happy to kind of engage in more discussion or to give you an opportunity to ask those questions.  While folks are thinking of other questions I just invite everyone to kind of go back to their practices and start to look through them through hopefully a different lens and look at their friends and look at the questions are asking, and look at what  happens from the entrance point of your service so whether that's an emergency department, or it's a community clinic.  How are folks treated from the very start, what are people's education, are people able to, you know, declare their name and pronouns from when they enter and does your staff person do that too.  And how does that information carry through so if your folks go for your patient goes for an ultrasound or they go through blood work, or they go to meet with the police, is that information carried through just like we try to be trauma informed with our  We don't want our patients to have to keep repeating the same as with our patients and ourselves our name and our pronouns as well so I think it's helpful to put that on my forums if my patient is going to be doing an interview with police, I make sure that's on the front of their form.  This is how this client identifies and this is what their name and their pronoun is and doing that with all of our patients so that it's carried through.  And that person may be experiencing having to be asked that over and over, or we're trying to eliminate people being misgendered or misnamed. If those other folks maybe don't have the same education and training to ask every patient or every client.  Excellent. Well, I don't see any additional questions that have come in, but we really appreciate you both being here and sharing all this really wonderful information it's a lot to unpack.  I think that's, that's just great. So thank you so much for coming today and sharing.  We appreciate that you do have a comment here great suggestion with performing a more focused medical history of all teenage medical history. So who does, that's great.  Excellent. Well, thank you so much. If there is nothing else we can jump off and you often have a little extra time in your day. And thank you so much, Ashley and Ash. Again, we really appreciate you sharing your expertise and your experience.  Thank you.

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