Hi everybody and welcome back for part two of the Sexual Minorities and Gender Diverse Persons webinar. This webinar series is created with grant funds through the Office of Victims of Crime and at this time we would like to offer the following disclaimer. The opinions, findings, and conclusions or recommendations expressed in this presentation are those of the contributors and do not necessarily represent the official position or policies of the U.S. Department of Justice. Right now we're going to use chat functions for questions posed during the presentation as well as any that might arise while you are listening to this presentation so go ahead and use that for questions. Evaluations will be sent within the week for CEs by any Valentine and this webinar series created with grant funds is for the same program project with IAFN. At this time I would like to introduce Michael Munson and Ashley Stewart, your presenters today. Ashley go ahead please. Thank you so much Shay. Hi everyone I'm really excited to be here and I'll introduce Michael and myself in a moment. The first thing I'm going to do is just go over the learning outcomes and we'll do some introductions and start to get through some of the content today. Michael and I are pretty laid back so if you want to answer or ask any questions in the chat as we're going you are welcome to do that and Amy and Shay may stop us and we can answer those or you can wait to the end and we can give those as well. I will also send the slides to them when we're done so that that can be given to you as a handout if that's helpful. Some of the things we're going to go over today is hopefully increase your knowledge of gender inclusive care when performing sexual self-examinations. We're going to start to discuss medically supervised transition a little bit and discuss a little bit more how that can impact your examination when you're examining someone after assault and then we'll identify the implications that the treatments may have on your medical forensic exams and some of those options as we go. I'm Ashley Stewart. I'm a forensic nurse and have been for 14 years. I live in Winnipeg, Canada and coordinate the same program here who sees all ages and all genders of sexual assault and domestic violence. I teach at Duquesne University and my background in gender inclusive care is I used to work in a transgender health clinic which would support people as they were going through medically supervised transition services and my pronouns are she and her and I'll hand it over to Michael. Cool, thanks Ashley. I'm Michael Munson. It's good to see some faces or names at least from last session. I am the executive director of FORGE which is a 28-year-old trans anti-violence organization mostly headquartered in Milwaukee, Wisconsin but we have staff across the country. We are a national training and technical assistance provider focusing exclusively on trans issues and anti-violence with a lot of emphasis on sexual assault. I generally use he him pronouns but any pronouns are good for me. Thanks. Thanks Michael. I just want to do a brief acknowledgment for the land that I practice and work on in Winnipeg, Canada. So I acknowledge that I live and work on the Treaty 1 territory in Winnipeg, Canada. This is home and territory of the Anishinaabe, Cree, Dakota, Dene, Métis and Ojibwe nations. So before we get into some of the content, Michael and I want to talk a little bit about some stats. Talk about the risk of violence. You all heard from Michael in part one where we went over some of this a little bit more in detail. Some of the statistics, the marginalization and some of the language around being gender inclusive. One thing I want to touch on again today though is to talk about the risk of sexual violence in gender minorities or folks who identify as trans. So one acronym you might see me use throughout the presentation has two Ts in them and in this and I wanted to describe what that second T is and that refers to people who identify as two-spirit. Usually that is in the term that folks who identify as Indigenous use. So what that's what that second T is, it's two-spirit. So this population is at high risk for victimization and violence as I think all of you are aware by now but specifically has a much higher risk of sexual assault and sexual violence. So as nurse examiners and as first responders we need to make sure that we're tailoring our assessments to our patients needs, that our practice is gender inclusive and that our patients feel safe so that they can come access care instead of not receiving that medical infrensic care at all. Cochran also looked at a small sample of homeless youth and in that population found rates of physical and sexual victimization were higher as well. They found that those who identified as LGBTQ have higher rates of sexual assault and specifically in those who identified as male. So we know this community has higher rates of poverty, stigma, marginalization which are also all additional risk factors for sexual assault. I'm going to let Michael talk now a little bit more specifically about some of these statistics. Cool, thank you. So some of you might have seen this slide last time and this is a repeat for some of you. So what we know from multiple studies and like Ashley just said there are many studies and we can get different data from those different studies but in general about half of the trans population has experienced intimate partner violence which sometimes includes sexual violence sometimes does not and about 60 or 66 percent of trans folks have experienced sexual violence and we're seeing a pretty dramatic increase in those numbers in the last three or four or five or six years at least here in the U.S. and you can all put the pieces together about maybe why that is but as we see more challenges with COVID, with the economy, with some political tensions or polarizations, we're seeing some of those numbers skew higher and higher within some populations within the trans community as well as the whole trans community. Next slide. Thank you. So one of the things that FORGE always likes to try to mention in workshops is what the ratio is between feminine identified trans folks and masculine identified folks. A lot of times we think that I knew that as soon as I started talking I'd want to cough so excuse me so a lot of times we think about trans femme folks as the ones who are experiencing sexual violence because that's what our culture tells us and teaches us that women or trans women or fem identified folks are experiencing higher rates of violence. FORGE's research as well as many others if we actually look at the data carefully shows that the rates of sexual violence and intimate partner violence and childhood sexual abuse are pretty much the same across gender vectors. Next slide please. And we were really surprised when we asked 10 years ago in a survey that had a little bit over a thousand folks, we had people check off the boxes of what types of victimization have you experienced and we thought that our data was faulty when people had checked multiple boxes like oftentimes all of these boxes so hate motivated crime, stalking, intimate partner violence, dating violence, adult sexual abuse or adult sexual assault, and childhood sexual abuse. So we were really surprised by that so we looked at our data more carefully and it really was true that people were experiencing many different forms of violence and I think that really plays a role when people are entering the door for a forensic exam or a medical exam because they're walking in with all of that trauma not just what they've currently experienced as to why they're entering care. Thanks Michael. So I'm sure we've highlighted by now the importance of providing gender-inclusive care but it's really important like I think Michael and I have already mentioned that patients feel safe coming into our centers wherever you're providing that medical forensic care that they know you're inclusive welcoming place not only because of the higher rates of victimization but even if they wasn't higher rates they need to make sure that they're getting that care like any of our other populations so we need to make sure that we're welcoming and people know that they can access from us so they're not sitting at home not accessing that care. We know anecdotally and as well even just through research and polls that a lot of trans folks or people across the gender spectrum don't even get safe care sometimes from some of their family practitioners, family doctors, nurse practitioners, primary care so they may not even be getting that care in those places so we need to really make sure we are working hard at this. So there's a couple different things we can talk about to implement gender-safe practices and make sure that you are a friendly safe welcoming space. So one thing I like to do is to start by looking at your setting from when your client enters to when they're discharged and you know Michael's organization FORGE has a great tool that you can access on their website as well that will help you assess your practice and see if it's a trans positive space. So when someone comes in for example I mainly work in the emergency department what is the education of the first person they see and for us that's the screening person and then a security guard and then it's a registration clerk and then triage nurse so it's not enough to just say all the nurses and aides in the department need education it's all of those people because if they encounter that first individual and don't feel like it's a safe welcoming space and are misgendered or treated inappropriately and it's not inclusive then that person is going to leave right there and they're not going to come back. So kind of looking at all those spaces what about when they go get blood work done if your lab personnel does that what is the practice of the person who's doing their registration is that first thing saying hi Ashley or just looking at their medical card and saying you know what name do you go by what pronoun do you go by what are on your forms do we still have boxes on those forms we know people don't fit into those boxes so instead can you have forms where there is gender and a line so people can write in how they identify can they write in their pronouns is there a spot on our lab documentation where when my patient goes to the lab I can write at the top patient goes by this name and this is their pronoun and when I used to work in a community setting that's here we do our own blood work but in a community setting that's how we would flag when our lab personnel would call someone from the waiting room because I didn't want them to misgender them and call them by the wrong name so even though it might say this on my medical card we don't have to go by that I can write on the top of my lab requisition you know my patient or my client goes by this name and this pronoun and I often would circle that in a highlighter or even though a lot of us are using electronic medical documentation a lot of those have options as well where there can be a banner at the top or the bottom sometimes a flag can come up as soon as you click on that patient's chart patient's name is this pronoun this is what they go by just so that we can make sure we're providing that wraparound care our organization finally after years came out with some signage that we can put in our department that says we want to get your pronouns right tell us your pronouns or signs where our staff can say this is what my pronoun what is your pronoun signs that we can put up in our exam room so that it makes our clients know that we're thinking about this and we're trying to get it right and it maybe makes them more comfortable and safe to start that conversation or even by us starting that so like I said we're talking about the training that staff has I even think this goes beyond the hospital so for example if you're working in the same program or an F&E program what is the education of the other people in your multidisciplinary team so this goes up to the attorneys that I'm working with your prosecutors it goes to the victim services staff that's working with your clients the police officer it's great if we do a really great job at the hospital and strive and we get there but then if they go to the police station and they're interviewed in that setting and they get they don't get that same treatment we're going 10 steps backward or when they go into court so I really want to strive that our documentation carries that through and our patients not always having to re-educate every person that they're with or being misgendered or called out so those are some things we can do to start making that place feel more gender inclusive in a safe space the other thing we can do and like I talked about as well is when you go see your patient you go in and I say hey I'm Ashley I'm one of the forensic nurses that works here I go by Ashley and my pronouns are she her what name do you like to go by or what name do you go by and what are your correct pronouns that we can use here and then making sure that's translated into your medical record right away so that's carried through looking at our forms that we're using so one thing that we have tried to do and we keep trying to go back and look at them is what is on our forensic documentation and our medical documentation that we're using and our forensic documentation in my practice is what carries through to the other systems so making sure I have a line on there that says gender and a line and I can write what that person's gender is and I can write in my patient's pronoun so that when that goes to police and if it goes to a prosecutor that carries through with them so looking on your documentation what are your traumagrams look like so when you are documenting body injury can you have gender inclusive traumagrams that you can be using as well so those are some things that we can do the other thing I think that can help make your place be more gender inclusive and feel like a welcoming space is what we portray so if we only portray images of a certain person a certain body type you know white females those they're only people who are going to feel that they are safe coming in for the longest time we would often get calls saying oh do you see men in your practice as well and that was a really good prompt for us especially when we're doing any media stuff articles to say we see all ages and we see all genders because here we see from birth up until and death and so that people know if that's in any of our communication on our website that they know that they're welcome here same with what's portrayed on any of our posters our pamphlets our website and what those images of people look like so that people know that everyone is welcome in our space the other thing you can do is can you you know have a trans support worker so a clinic I used to work in they had a trans support worker that could be there they had an advisory panel from the community who could look at their services and provide some advice on how they can make those more gender inclusive so those are some things you can think about as well another thing I think we often don't think about is what is your signage look like what are your bathrooms like so if you go into your hospital your clinic setting your emergency room do your bathrooms fit into a binary do they just have male and female on them or is that signage removed so that anyone feels that they can be welcome in there I think one thing many things that I was very naive to when I started working in the trans clinic is I took for granted that I've gone through life being able to go to the bathroom when I want and it made me incredibly aware and sad when I would see clients specifically if they were working in school where they would have to avoid the bathroom the full day because they didn't fit into those boxes those two bathrooms and so that's a real luxury that I've had and I try to be aware of now so that's something to really advocate for in your systems even your workplaces right do we have that inclusive space where folks can access a bathroom and not have to fit into the sign that goes into one of them and that just goes along into advocating for that inclusivity in your systems and in your policies so whether that's on an HR level or it's your policies with how you're seeing clients your medical records your laboratory staff your SART team I really think that there's kind of endless possibilities and this is an example of some of the gender-inclusive traumagrams and I'm actually pretty sure that IFN has this example because I think this is where we got this from it might be state of California that has this gender-inclusive traumagram that you can use as well other things that we can do and should do is educate ourself this is not our client's job right so our client is not our education tool they are not there to answer our questions so it's up to us to seek out that information and we're very lucky right now that there are many places to access that education many places we live and also have organizations where for a fee they can come do that education and that inclusivity training with your staff as well but we can get a lot of information and Michael and I have a lot of suggestions and resources for you at the end as well that you can start with that journey and getting some of that education being aware of our biases and our assumptions is really important as well so when we see someone do we have a bias do we have an assumption about that person and this is really important to be aware of even those implicit biases so that we can challenge those and we can be aware of those so that's not portrayed onto our client I think an example of this is when I started working in our trans health clinic I definitely had an assumption when folks came to see us to transition that transition looked a certain way for individuals and I learned very quickly that transition is very different for everyone and what someone needs for transition what someone desires what they require is different for every single person so letting that go you know Michael talked a lot about in our first part as well about that gender spectrum and that looks very different for everyone right even how I identify is a spectrum for every single person so kind of getting rid of that bias if someone says you know I'm transitioning or identify as this to try to get out of that image that might be portrayed in their head on how we think that they should express their gender get involved in the community seek that community feedback maybe you can have a committee or go to one of the organizations that can help provide that feedback to design that safe service and and help get feedback on what you can do better if you're and hopefully everywhere you're living has a Pride Month and Pride Festival. Get involved, have a float. If there's the ability to have a booth there, have a booth, talk about testing, talk about what medical care you give, and really get involved with the community. Get involved in activism and supporting that community, and just get some of that support and feedback so that we can make our services more inclusive, but that we also can be part of that community and not just being a face there as well, but actually getting involved. When we're doing training or hiring individuals, so again, depending what's in your job descriptions, making sure that we're being open. I had a call recently from one of our advocate groups and asking about, do we specify about what gender that we hired? And we had a really great conversation there as well at saying, you know, this doesn't happen anywhere else, whether it's emergency department or our medical clinics. So we shouldn't be describing and assuming that our patients want a certain gender of provider when they're coming in. So that's kind of another way that we can increase that inclusivity. When we're doing training with our nurses and our new hires, making sure that we're having a good representation of scenarios. So making sure you have non-binary standardized patients who are coming in so that your nurses, again, are getting that education in a number of different ways to be able to provide that safe care. When we're seeing someone who has a history of sexual violence, there's a couple of things that we want to highlight to be mindful of. So the one thing I, you know, try to be mindful of, and I think is important, is being mindful of past trauma. So someone is seeing you because of experience of trauma and they've experienced sexual violence, but always being aware if that's happened in the past to them, going slowly, explaining the process. And like we do with all patients, making sure our client knows that they have options throughout the process, that they are in the control and the driver of this, and really making sure that we're being diligent of explaining things as we go. And Michael's going to talk a little bit more about body dysphoria and how that can impact that exam as well. This is very important to me, only ask and document what is relevant to why your client is coming. So if my patient is coming in because they've experienced or been victimized by a rectal sexual assault, it shouldn't matter to me if they've had anything else other than some rectal surgery, right? You know, I might do my same health history and maybe surgical history like I would any other patient, but I know don't need to inappropriately inquire about anything else that's going on with that client. So make sure we're documenting what's relevant. That also goes along when we're reporting maybe to the other providers that might be seeing our patient. So maybe I'm reporting off to one of the physician, or maybe one of the nurses are going to be taking care of my client after me. We don't need to disclose what is not relevant to that person's care. So their gender history, their gender journey is not relevant to everyone else in the department if that client has shared that with us. So just being really mindful and very diligent with that information and keeping that private. So yeah, not being inappropriately curious about someone's gender. I often say, you know, if someone came up to me and asked me what my genitals look like, I would be very offended. So it's not appropriate to ask anyone else that information. I'll let Michael talk now about the audience for you. Cool, thank you. So I was thinking about this as you were talking because it's, I normally have my own like, you know, lead up into this, and it's always interesting to have somebody else talk about stuff before. So with that caveat in mind, you know, I think that we all know that survivors generally experience some level of body dysphoria, not everybody, but a lot. And with trans and non-binary folks, there's oftentimes this kind of confluence of assault-based body dysphoria, as well as potentially gender-based body dysphoria. And as you were talking, actually, I was thinking about like, you know, we don't celebrate bodies at all. I mean, in our, well, maybe you'd all do in Canada, but we don't do in the United States. And, you know, and trans bodies in particular are not celebrated. And so what impact does that have when we don't celebrate bodies? Does that encourage people to feel dysphoric about their bodies? And this is for trans people or non-trans people. And, you know, also actually like you were talking about, like, you know, like where does somebody enter the system and how do they, you know, go through and who do they talk to? And, you know, if somebody at like a reception desk looks at somebody funny, you know, kind of like, oh, like, you know, what are you? That can really enhance or heighten somebody's body dysphoria. So they may be doing kind of okay about feeling good in their body, but, you know, when somebody gives them that look or something, that can really enhance how they feel about their body. The forensic exams might be one of the very few places where people are actually getting medical care. So they may not be getting medical care elsewhere. And so that medical experience may be very dysphoria inducing because they're not used to, you know, removing their pants or having somebody touch them or touch certain parts of their body. So that could be really, again, an enhancement to what they're already experiencing as dysphoria. And I think one of the things that's really important to kind of think about is what is dysphoria that's internally generated? So, you know, do I feel uncomfortable with my gender and what is externally kind of created? So is it assumed that certain people of certain genders are supposed to look a certain way? And if you don't, are you made to feel bad about your body? And so I think we need to kind of pay attention to the chicken or the egg because not all trans people do feel dysphoric, but can be made to feel dysphoric by the culture. Want to move to the next slide? Thank you. So having body dysphoria for folks, again, either gender-based or assault-based or the combination of the two may result in a lack of services being received or a change in the services being received because people may not feel comfortable sharing about their body, talking about their body, having anybody touch any part of their body. There might be some kind of no-fly zones, which is what I kind of talk about as like, you know, it might be somebody's chest, it might be their genitals, it might be their arm, whatever it is that feels really uncomfortable to them, they may not want anybody to examine. And that obviously can have some really substantial implications if somebody is harmed in that part of their body that really does need care, but their dysphoria is really affecting the care that they can receive. And all of that can affect, you know, that one-on-one relationship with a victim service provider, whether it's a medical provider or an advocate, it can affect, you know, what happens after they leave that medical setting in terms of support groups and moving on. So that internal sense and that external pressure around bodies can really make a huge difference in service implications. Ashley? So I'm going to go on and talk a little bit now about medically supervised transition and how that can look like during your examination. But before that, I kind of just wanted to take on to what Michael said and thinking about an experience where I was doing a pelvic exam on an individual for cervical screening and someone who had a uterus but identified as male and was through the process of transition. I vividly remember the dysphoria that that person, you know, was experiencing and verbalized and how fearful it was for them to come in and take care of their health in that way to get the cervical cancer screening because they were very overdue and had risk factors and needed to get that done. And so it was really important to really work with that client when they were ready to come in, when they felt it was safe to come in, and working through with that client how we could do that exam and make it the most comfortable we could for them. So, you know, was it them helping guide the speculum in? Was it, you know, what was the room looking like? Who was supporting in there? So really just talking through that with your clients and seeing kind of what you can possibly do, how you can work with your clients, how you can advocate them so that they can get that medical care that they need but do it in a way that's safe for them and maybe if that today's not ready. And I think for that individual, we tried a couple times and when they were ready to come in and work through that, we did. And if we would get halfway and that individual was not at a place where we could keep going, then we'd stop and we'd try again. So just making sure we're doing what's right for our patients and really working at them to be the least invasive and intrusive as possible. So let's talk a little bit now about transition. And again, the one thing I really want to harp on, and hopefully you will take away from this, is that transition looks very different for every single person I think I've met and worked with. So let's let go of kind of any assumption or bias that transitioning should look a certain way for individuals. There's a large spectrum of what someone may require, desire, need. So I'm going to start just going through some of the things and the purpose for me going through some of the services that might help someone go through a medically supervised transition and so that you know what might impact your examination and your findings as well. So the first thing I'll talk about is hormone therapy and I'll talk about masculinizing therapy that an individual may be on. So testosterone is the main one that someone might choose to go on for masculinizing therapy. The most common is injectable, but there's also cream and there's gel as well. Again, something to keep in mind and that we've experienced in Canada and I think it's happened in the U.S. as well, is sometimes we've gone through periods where there has been extreme shortages of testosterone and so that creates a lot of anxiety for your clients as well. If you can appreciate having uterus and finally being on testosterone which suppress that bleeding and you finally are able to get some of the masculinizing effects that you need and not not being able to access that and starting to have breakthrough bleeding and starting having all together impacts that. So kind of being aware of it that's kind of going on in the community as well and how that impacts your client. So when folks are on testosterone, usually they're doing it intramuscular. Here where I practice, they were starting to do it simultaneously as well, but usually patients would self-inject and then obviously cream and gel they would self-administer as well. So if it's an injectable, usually what would happen is we would teach someone how to do their injection. If it was intramuscular, usually it was in the vastus lateralis or if they had a friend, family, partner, we could teach them to do it as well. So that's also important if your patients are going through security or anything like that. We would always advocate, especially if our person was ever in our clinic setting going on a plane or something like that, we would write a letter because we don't want anyone to get reprimanded for having that medication, those needles and syringes on them. So keeping that in mind as well. Often patients would inject usually maybe once a week or every few weeks depending on how their plasma levels would be with blood work and how their body metabolizes that medication. Some patients may stay on testosterone lifelong, they might change their dose as part of it. I've had clients that have gone off, gone back on based on what their need is. So some of the effects of hormone therapy, this is a table of some of them. You can get this in the WPASS standards of care and we'll have some links to that at the end. But I'm more or less going to focus on the ones that could impact or you might notice as a part of your medical forensic exam. So the one is obviously cessation of uterine bleeding and that's important to note because even though someone has had cessation of any uterine bleeding, you still need to make sure, and we'll talk about this again at the end, that you are offering that person emergency contraception if they want that, even if they still have a uterus. So keeping that in mind, even if they're not bleeding anymore. Platoral enlargement is something you might see if you're doing a genital exam as well. We're called platoral megaly and that's an effect from the testosterone. Vaginal atrophy, and so with the platoral enlargement, you want to be aware of that if someone's on that medication so you're not mistaking that for a finding for an injury or that it's from some sort of edema or rubbing or something like that. Vaginal atrophy is really common with testosterone therapy as well. So you'll have vaginal atrophy and with that will often come thinning of the vaginal wall tissue and vaginal dryness. So often in folks, if they're on testosterone, you might see an increase in vaginal injury as well after a sexual cell. So being aware of that degree of trauma that you might encounter, that degree of some of those that microtrauma or lacerations. And usually if you are going to do a speculum exam, and we'll talk about if that's needed or not later on, making sure you're using some sort of lubrication or something so you're not increasing the injury and the discomfort during that exam. So those are kind of the main things that are going to impact your exam findings are no uterine bleeding or decrease that vaginal atrophy, thinning of the tissue and dryness, and platoral enlargement. Gender affirming surgery is something that individuals may have as well, and people might as well, but transition is a process. So this doesn't happen over a month. Depending on where someone is having surgery, often where I live, folks are on hormones for a minimum of a year before they're referred to surgery, but that process may be different in different places. So, and not everyone is necessarily going to make a decision about surgery for a while. Sometimes people might make that decision, down the road or in different stages. So transition isn't something that occurs over a three month period. Some of the gender affirming surgeries that someone might have for masculinizing surgery could be a bilateral supine oophorectomy. So BSO and hysterectomy. So with their ovaries and the uterus is being removed, someone may choose or require to have top surgery and top surgery is when someone's having mastectomy. So all breast tissue is removed, unlike a mastectomy for oncological reasons, where all of the healthy breast tissue is left. In top surgery mastectomy, all of that breast tissue is removed and often there will be a nipple graft, which can be done with a few different techniques. And again, depending on someone's anatomy, so that areola and nipple is going to be smaller in appearance. And then usually some chest contouring may happen depending on the surgeon as well. The outcomes and the type of incision that might happen with top surgery as well can be dependent on the surgeon, but also that person's anatomy, how much tissue was present before surgery, if someone had been binding, that elasticity. So you might see scars or incisions in a number of different areas. Another surgery that individuals may have is called the metoidioplasty or folks may refer to it as meta. And this is surgery that folks may have where after someone is on testosterone for a period of time and it has clitoromegaly or clitoral enlargement, some surgeons will do what they call a clitoral release where that clitoris and what we would call the phallus now is released from the clitoral hood, so it can drop down more. And then a vaginectomy is done, so the vagina is closed up. Often then the uterus is removed as well. And then a scrotalplasty can also be done and scrotal implants can be done later. So in that surgery, often that urethra is left in the same place. Sometimes folks can are able to stand repeat with that surgery and all of the nerve endings are kind of left in the same place. With a phalloplasty, a vaginectomy is done as well usually, so the vagina is closed up. A phallus is created using a skin graft from another area of the body, so there's a couple different sites that surgeons prefer and sometimes patients have a preference as well. And then that phallus is created and depending on the surgeons could be done in one, two, or three stages. That urethra could be underneath the phallus where the urethra originally was and then the second stage that urethra undergoes a grafting, so it's elongated and it can cut through the tip of the penis. And then after that, a scrotal implant and scrotalplasty can also be done and then they can have an erectile implant as well. That is done. So that's what a phalloplasty would be. So with those surgeries, and facial mescalinization might happen as well for some folks, with those surgeries, there really is not much that's going to change as part of your medical forensic exam. And we'll talk about this a little bit more as we get through the examples, but whether somebody's had a metodioplasty or a phalloplasty or no gender-affirming surgery to that area, your anatomy and how you're documenting your injury is going to be the same. It's their injury on the scrotum, to the phallus, the penis, if there was contact created with that area of the body. If there was contact with that area of the body, your forensic swabs are going to be similar. So I'm going to do a swab of the shaft. I may do a swab of the mons pubis or the scrotum. So no different than any other patient who has a penis or phallus. Some of the possible surgical complications that may come up with a metodioplasty or phalloplasty could be urethral strictures with a phalloplasty, generally catheters and for a longer period of time, or sometimes rectal injury could occur during the surgery as well. So those are some things that you might encounter. But often I would say there's not going to be any surgical follow-up that's going to be needed unless that surgery was quite recent before the assault. And we'll talk about that in a little bit. So BSL and hysterectomy, I won't describe that surgery in depth, because most of you will know what that is. And it's removing the ovaries and hysterectomy. In the past, there has been a little bit of discussion with medical professionals about if someone is on testosterone therapy, do they need to have a hysterectomy and a VSO? And the research hasn't been conclusive on that. So there was thought at one time, did it increase the risk of certain types of cancers, but no clear research indicating that. So there's no clear recommendation that one needs a hysterectomy or a VSO. And so again, you know, don't go in assuming that your patient has had that surgery because that might not be something that's in their plan of care. So we'll talk now about feminizing medications. So some feminizing medications that folks might be on is estrogens. And so estrogens could be an oral one, it could be a transdermal patch, a gel or progesterone. Sometimes this has changed depending on the age and the risk of the patient as well. So sometimes if someone gets maybe higher risk for blood clots or certain things, they might be changed to a different mode of estrogen. Folks might also be on antiandrogens or testosterone blockers, and those could be spironolactone, proterone acetate, or finasteride. So you might see those as well, particularly something like spironolactone. You might see a lower blood pressure, obviously, with that one. Someone might have some postural hypotension. So those things would be normal and expected with that medication. With feminizing medications, there's really not a whole lot that's going to impact your exam findings or presence or absence of injury. So there's really not a whole lot. Your patient, if they're on this medication, may have, you know, breast tissue growth, but there's really nothing else that I would say impacts your medical forensic exam, especially generally. So I'm not going to focus on that too much. Gender affirming surgery that one might have if they're doing feminizing surgery, it could be an orchiectomy, connectomy, and a vaginoplasty. Vaginoplasty now might be done with or without a vaginal cavity. So sometimes people will have a vaginal opening or cavity created, and other people may not, and you'll just have the pitorus and the labia and the external anatomy, like your external genitalia, and then other people will have a vaginal cavity. Some people will have a tracheal shave, chest surgery, chest augmentation, and facial feminization surgery. The tracheal shave is just as it sounds, where what some people refer to as Adam's apple or the trachea is surgically shaved down a little bit, so it's a little bit less prominent in appearance. The one I'll focus on a little bit more is a vaginoplasty and how that might impact your examination. So when someone has a vaginoplasty done, often what will happen is their existing phallus or penis is dissected and a vaginal cavity is created, and that skin is used to create the vaginal cavity. Sometimes individuals will be asked to go through electrolysis or hair removal for a period of time, so that penile and skull skin is free of hair, so you don't have any hair growing in the vaginal valve or surrounding where you don't want it to be, and then that tissue is lined, and often the nerve endings from the tip of the penis is going to be used to create the clitoris, and then some of that scrotal and other tissue will be used to create the labia majora and the nora. Often the big change will be is that you won't see a cervix inside, there are some surgeons that may do that, but most commonly you won't see a cervix inside, so it'd be very similar to examining someone who has had a hysterectomy and has a vaginal vault. So that's what a vaginoplasty is, that urethra is going to be where it is in any of your other patients, it's going to be covered underneath the torus, it's going to be moved to that place, and some of the possible surgical complications that you might see with a vaginoplasty if you're seeing someone could be some urinary retention, maybe there might be some urethral structures happening there, clitoral necrosis, some fistulas which can be vaginal or rectal, and then vaginal prolapse can occur as well. So often folks are asked to dilate with medical dilators to keep that vaginal cavity open so that it's not becoming atrophied. So this becomes really important if you're choosing or needing to do a speculum on an individual who's had a vaginoplasty and asking them, do you still dilate regularly? For someone who's maybe not dilating regularly for a number of different reasons, sometimes that's because of the pain that they might be experiencing, then that vaginal cavity may be atrophied and you might not be able to get a speculum in. Your patient will know that, they'll know what depth it is, and if you're able to get a speculum in or not, if you even need to do a speculum. With someone who has a vaginoplasty, again, when it comes down to your exam, the forensic swabs you're going to do, the STI testing you're going to do, and how you're going to document your anatomy is really the exact same in any other patient. When I've examined patients, I still have a posterior forceps, there's a fostenovic filaris, there's labia minora majora, there's clitoris, so how I'm examining, documenting my findings are the same in any other patient. We have some resources at the end, and particularly if you go to the Papillon Centre, there are some pre- and post-surgical images on there that patients have given permission for that surgeon to use, if you want to see how that anatomy is the same, but really it's going to be no different. When we talk about STI testing, we'll get into this a little bit more, but in those folks, I'm often doing the urine gondolia and chlamydia, we're not doing the cervical swab, but otherwise, everything else you are doing is really going to be quite similar. A brief word on adolescence, and again, I think it's really important that we are carrying this inclusive work throughout all of our places of work, but across all of the ages of patients we're seeing. So please don't assume that your patient needs gender-inclusive care just when they turn a certain age. So whether you are a practice that sees pediatrics and you see someone who's five, or you see someone who's 50, or 60, or 70, it's the same practice, right? So that's really important for us to be aware of as well. If you're seeing adolescents, just a brief word, some adolescents who are experiencing and going through gender dysphoria may be on GnRH analogues to suppress puberty. So sometimes they're called hormone blockers. Sometimes these will be started anywhere from Tanner stage two to age four. So you just won't see that same puberty development if you know someone is on those and if they disclose that during their medical history or if you're doing a medication history. Some adolescents may be starting a hormone therapy, so they might be on testosterone or some feminizing medications as well. Again, depending on where you live, your practice, your state, often where I live, surgery is usually not done before 18. Maybe chest surgery is, but usually genital surgery isn't. But again, that might vary as well. So now we'll go in and we'll talk about the medical forensic exam a little bit. We'll talk about discharge and testing, and then we'll give you some really great resources at the end and look forward to some of your questions. So when we're doing our medical and forensic history, when we're seeing a patient after sexual violence, again, I can't probably harp on this more, but be curious for the right reasons. So what do we need to know for our assessment and our examinations? What do I need to know other than, you know, once I have my assault history and I know where they're assaulted, I don't need to go into depth about anything else. I just need to know what might impact my exam and my findings. And I need to know what my patient's exposure was. So I know what to test them for, for sexually transmitted infections and bloodborne infections and what medications or prophylaxis I might be offering them. So what is really medically necessary and not being inappropriately curious. Make sure we're using gender inclusive language as well. So particularly when I, you know, hear people asking about menstruation, menstruation seems to be a very feminized term. So instead ask your patient, do you bleed every month? That seems to be a very binary term. Don't assume someone's sexuality. So don't assume the gender of the assailant, if someone's in a relationship or you're seeing them after intimate partner, same thing. Don't assume what their sexuality is as well, and kind of getting rid of those assumptions and biases. When we're asking our history, also make sure that we're using gender inclusive language throughout our history as well. So instead of saying, was there any contact to your breasts, I'm asking, was there any contact to your chest? If we're maybe looking at what medications we're going to give someone, and I want to know if people are doing any chest feeding, I want to ask about chest feeding instead of breastfeeding. Again, it tends to be a very feminized term. So being a bit more gender inclusive. Often if I'm going to do an assault history as well, and I know there's been some genital contact, instead of using anatomical terms, maybe I have to maybe at the beginning to differentiate what area of the body was assaulted, but after that, I'm going to use bottom or ask the client, you know, what area, what terminology, what names do you use for your parts? So that I'm not saying vagina or penis repeatedly, if that's not the term that that person's used and that causes more dysphoria. Michael's going to talk a little bit about physical assessment. So there's a lot of times I think that when we go into an exam room with somebody, we see something and it gives us the feeling that there's something wrong or that it happened in an assault. And a lot of times there's some things that are very trans-specific that may look like injuries that happened in that assault because they look fresh, and they really may not be related to the assault at all. So I'm going to give you a couple of examples of what some of those things might be. Your client, your patient may not talk about these things. They may not feel comfortable again because of dysphoria or they just, you know, they're there for a different reason. So they're not going to explain to you why they have some of these markers on their body that is really unrelated to their assault. So a couple of examples, you know, not everybody has had surgery or wants to have surgery, can't afford to have surgery, and so may use prosthetics as a way to make their body more in alignment with their identity. So they may use a binder to flatten their chest if they're assigned female at birth and still have breast tissue or chest tissue. They may use packers to create the appearance of a penis in the front under clothes. They may gaff or use tape or adhesives or certain kinds of underwear to pull that penile tissue back towards their underside so that it's less apparent when dressed. So some of these things can have some really interesting views when somebody is looking at them. So I know the picture that's on the screen right now is hard to see for most of us on the screen, but it's got some bruising on the top of the shoulder. And this is a photo of a trans guy who binds his chest basically all the time, almost every hour of the day, which is not terribly healthy for your body, but for him emotionally it's really, really healthy to have that congruence in his body. Well, that bruise that's on the top of his shoulder is from his binder because he wears a binder that goes over his shoulders and around his chest. So it may look like it's assault-related, but it has nothing to do with assault. A couple of other places that you may see bruising or damage to skin, if we keep with the transmasculine side, a lot of trans guys will pack or create that bulge or that prosthetic penis. And some of the ways that that gets placed, sometimes it's with an adhesive, so literally like kind of a glue. So you're going to shave off the tissue and then literally glue that prosthetic. And so if that gets ripped off, I mean, obviously that's trauma-related, if it's ripped off in an assault, but it can cause a lot of very angry looking skin once that's removed. It can also cause some bruising if it's tightly bound to their body. What we see with trans women or trans femme folks is that process of gaffing. Not everybody can afford to buy special gaffing devices that are gentle to your skin. So the majority of trans women that I know, trans feminine folks, use tape to, I'm going to use medical language with penis, to literally tape that tissue down so that it's less prominent in the front. And I think any of us who think about having tape on that part of a body, when it's pulled off, it's going to look very upset and abrased. So again, if you're looking at someone's genitals that has been gaffing, it's going to likely look like it's been assaulted or that skin is going to be damaged. A couple other points for this one is that, Ashley, you mentioned that there's not a whole lot of difference with estrogen use. What we've seen and what we've heard from forensic examiners is that a lot of times skin is more easily bruised or damaged. So it may not be assault related, but people may have a little bit more bruises if they're on estrogen. Not true across the board, but that's one of those things that we've seen with estrogen that's maybe a little bit different. There are some trans masculine folks that use triangle piercings. It's basically to enhance the clitoral or the neophallus and kind of pull it up. So that can get pulled non-assault wise and create what looks like some damage to genitals. A couple of other pieces, maybe that people use pumping. So pumping in terms of like, I don't even know what it's called, but when you use a pump to like a penis pump or a nipple pump, and it can create a lot of redness and a lot of skin irritation. So a lot of trans masculine folks will use it on their genitals to try to enlarge their genitals. Some folks will use it on their breasts to enlarge their breasts. So again, that's going to look like some damage to that tissue and it really is not damaged from that at all. And the last thing I wanted to mention is the rates of non-suicidal self-injury. There is a profound level of non-suicidal self-injury. So cutting, for example, around 45% of trans men or trans masculine folks engage in cutting at some point. So you may see cuts on somebody's arms or legs or chests and may presume that's related to an assault and it is likely not. So those are just a few things that may be seen that are totally unrelated to an assault. Ashley. Thank you so much for bringing all those up, Michael. One thing that I got thinking about as well, while Michael was talking was if you're taking evidence from a patient during the exam, really kind of asking about those things. So for example, if someone's binder is on and it was taken a rip off them, don't assume that it's okay to take their binder. Binders are often so expensive for folks. Sometimes I've only got them. The clinic I used to work at, we had a binder exchange. If someone had surgery, they would give their binder and we'd wash it and someone else wanted to do it. So again, just not assuming that. I even find this, if I have someone who's wearing a bra, bras can be really expensive for our patients. And just saying, you know, normally we'd like to take this as evidence. How do you feel about that? And then along with some of those findings as well that Michael described, asking them. So if they have some redness on their chest or something like that, you can say, you know, is that from the assault? Do you recall if that was there before? What that's from? And that patient will often be able to tell you that. So we'll start to go through the general exam a little bit. And I'm sure that everyone's getting the idea by now at the vital importance of having awareness of how dysphoric and uncomfortable this can be for individuals, especially if they're experiencing that level of body dysphoria, regardless of their gender, but specifically when they're having gender dysphoria. Remind patients that they're in control. Your draping is incredibly important and going through solutions with your client and saying, you know what, I would like to do a general exam. And this is what it would do. You know, first of all, again, we're nurses medically. This is what I would like to do and test for, and this is what I would look for. And then if you're doing, you know, collecting any evidence, if that client wants, this is how we would do this. How do you feel about that? Have you ever had a spectrum exam before, or have you ever had a penile exam before? And what was that like for you? Is it was a difficult experience? What made that better or worse? And work through that with your client. Gender and neutral language, again, is very important. So instead of saying, okay, I'm going to do your vaginal exam now, you know, I'm going to take a look at your bottom. Now we're going to start that part of the exam. You know, making sure you're being aware of their body language and, you know, are they covering their head or are they wincing? And being aware if your client maybe isn't telling you that it's time to stop, that maybe you're checking in with them or just saying, you know what, I can see that you're really uncomfortable right now. We're going to stop right now. We can do this in a different way. And examine and document your findings like any other patient. I think sometimes when I've done the session and talked about this, it goes in feeling that there's going to be maybe a really a lot of enlightening things that I'm going to say. And at the end, sometimes I feel like I've said nothing that enlightening at all, because I'm really telling you that how you, you know, examine your patients, or specifically how you're going to document your findings and what swabs you're going to do is really going to be the exact same. So hopefully I've demystified that. Being aware of your assumption and conscious biases, like I've talked about, don't assume what type of sex your patient has. Don't assume, you know, the type of relationships they have, whether that's intimate partner or domestic violence, and really just making sure that we're being open minded and inclusive. I'm going to touch a little bit now on pelvic exams for folks who identify as male, but still have a vaginal opening or might have a uterus. Again, we kind of talked about this and specifically when I talked about when I've done cervical screening on someone who still has a cervix and a uterus, do you need to do a speculum in that individual? So first of all, have you had a speculum before? Have you had an examination of your bottom? How was that? Was it very difficult? What made it better or worse? And just kind of like I would in any adolescent I'm going to see or most of my patients, do I need to do a speculum? What's the purpose of doing a speculum? So if there's bleeding coming out of that bottom, then I probably want to see where that is. Unless they have a cervix and a uterus, maybe it's from there. And I think there's an injury. My patient has a lot of pain. But if I'm just wanting to do a speculum exam to get swabs for DNA, what's my priority, right? So kind of just stepping back and discussing with your patients, this is why you would do a speculum, but I also could do it this way. And again, this might be different where you practice. But where I practice, if I was not worried about any symptoms, any bleeding, any pain, I could do an external generalization and look at that person's tissue on the outside. And I could do a urine for gonorrhea chlamydia. And then I could do a blind vaginal swab for DNA and evidence. And I could explain to my patient the difference between doing that versus maybe more accuracy of using a speculum. But I at least can give that option to my client. Again, I care more about their medical, physical, mental health and their comfort. So just kind of keeping that in mind, instead of always, you know, straight to a speculum, do I need to do a speculum? And how can I discuss that with my client? Again, keeping in mind folks who might be on masculinizing therapy could have those physical effects like atrophy, dryness, that friable tissue. So you might see increased injury to that tissue pain, more microtrauma and lacerations. So I talked about this, consider if you need a speculum needed and using the smallest speculum possible if you are going to use one and using gel if you're able to in your area. If you're examining someone who's had a surgically constructed vagina or a vaginoplasty, some things I might ask them if they've disclosed they've had surgery. So if I know someone's had a vaginal assault, you know, when their surgery was. So if their surgery was only a month ago, I might proceed a little bit differently versus if their surgery was six months or a year ago, right? Even though if their surgery was a month ago, generally, if I was seeing them in the clinic setting, in our medical clinic and our trans clinic, we would be doing a speculum to be looking at the healing and granulation tissue. So a speculum is not contraindicated. But again, just seeing do I need to do a speculum? What's my patient's pain like right now if they recently had surgery? Do they have symptoms? Do I have to be worried about anything that's happened during this assault? If surgery was recent, I might also ask when their last dilation was. Right after surgery, usually folks are dilating at least kind of two to three times a day. And then as surgery goes onward, that's that dilation schedule usually decreases. And so if I know they've dilated not that long ago, that may help me decide if I'm going to do a speculum or not. Again, if you are doing a speculum, same presence as anyone or the premise as anyone else, do I need to do a speculum? What is my rationale and my reason? And if I'm going to using some sort of gel lubricant and the smallest speculum, and again, just making sure I'm communicating to that client what I'm doing, right? Have you had a speculum before? How was that? This is what a speculum is. If you are doing a speculum exam and you meet some resistance during that, often that prostate is left in place so that you're not having more urinary complications. And so what I usually say, if you've opened your spectrum a little bit and you get the view that you need to, to rule out that there's no injury and you can do a swab if you need to do that, you can just stay right there. If you feel like you do need to examine a little bit more and your patient is comfortable, you can usually gently pass, go past, push past the prostate without it being uncomfortable for your patient. And an average vaginal depth in most clients is usually about nine to eight centimeters, again, depending on the surgeon and somebody's anatomy. And again, most patients are going to have no cervix. So you're just going to do both swabs for your forensic swabs. And usually for gonorrhea and chlamydia, I'm doing urine again, if that's the area that has been assaulted. There's been some studies of the vaginal culture in folks with vaginoplasty and vaginal flora and the pH of those vaginas. And it's usually not the same as natal females who are born with a vagina. So usually we're not worried about yeast and trichomonas or bacterial vaginosis. They can still get trichomonas, but vaginosis and yeast usually don't have the same presence of that. So when we talk about forensic evidence collection in these folks, if your patient wants that, again, it's often going to be the same as any other patient you examine. The main difference is someone who's out of vaginoplasty is not going to have that cervical swab, like I already discussed, and that difference in the vaginal flora and that presence of infection. When we talk about treatment and prophylaxis, again, fairly similar, you're going to treat and do testing if that's applicable where you work, according to your CDC guidelines and your blood and body fluid exposure. And remember anyone with a uterus that you're offering emergency contraception, regardless on if they have a uterine bleeding monthly or not, folks who are on testosterone still can get pregnant. For discharge and follow-up, sometimes folks ask if there needs to be follow-up with a surgeon. Usually not, unless the surgery was recent and maybe you noticed some deficiency of some surgical incisions, but usually not. And I will say most patients have such great communication with their surgeons. I've had folks who have had surgery in Canada as well as the United States, and they're usually very well connected and have a 24-hour number that they can check in with that surgeon if they need as well. And then make sure your patient has a healthcare provider that they're comfortable going to for their post-exposure follow-up, so that's really important. Make sure you're sending them, again, to a safe space. And we talked about that emergency contraception. So before we end and take questions, I wanted to go through a couple scenarios. While we go through these, you are welcome to kind of write some feedback or your answers in the chat. So case study number one, we have Susan, who's a 42-year-old transgender identified female who presents to the emergency room after a sexual assault earlier this morning and requests to see your service. Upon meeting this patient, you introduce yourself and your pronouns, and you ask the patient how they like to be referred to and their pronouns. Susan states she goes by Susan and uses she and her. She discloses that she's currently undergoing medical supervised transition and having feminizing therapy, so after some discussion, she consents to a medical infrensic exam and you begin her examination. What do you need to know before you set up for that examination? What is medically and forensically relevant? And you guys can feel free to put that in the chat there. So while I wait for folks to kind of put in the chat what you think you need to know before setting up, remembering that you want to know what's medically and forensically relevant. And so like I would with any other patient, I'm going to do my medical history and my assault history. So I want to know what happened during the assault, where they were assaulted. If my patient was recordly assaulted, I only need to know what's relevant to that area, right? So just kind of needing to know how that person was assaulted and then you can go from there, right? So as Susan discloses that they were vaginally assaulted by a male assailant, you know it's penile, no condom, then you know how that you're going to set up. So Susan says they're undergoing feminizing therapy and they were vaginally assaulted, so it's likely they've had a vaginoplasty, right? So then you get your medical and surgical history and learn that information. But again, you're only asking what's relevant, right? So we're not going to go into the gender journey and how old they were when they started to transition. That is not relevant to our business. So if you have a vaginal, penile vaginal assault without a condom, what evidence would you collect? So you can put that in the chat. And someone says in the chat they would ask about taking a history and an organ inventory and that is a great thing. We actually talked about that in part one. Yeah, so some individuals in different clinic settings will do an organ inventory as part of your medical history and that's something you can do as well. And Michael, you jump in if you have any thoughts in doing organ inventory, but that's something you can also do. So what evidence would we collect if this client discloses a penile vaginal assault without a condom? So the same as I would in any other patient, I would do where I work an external genitalia swab or a vulvar swab. I would also do a perianal swab where I practice and then I would do a vaginal swab. So the only thing I'm not going to do is a cervical swab. And then of course everything else I might collect on my patient according to assault history. But in terms of that genital evidence, that's what I would do. So no different than any other patient. I'll go through one more scenario. So we have Mark, who's a 26-year-old person who presents to the ER after a sexual assault last night. After talking with Mark, you learn their pronouns are they them and that they identify as male. They disclose that they were sexually assaulted by their partner last night, forced oral contact on their penis and a rectal assault by partner's penis. During the medical surgical history, you learn Mark had a metoidioplasty a year ago and he had a hysterectomy and a BSO. So what evidence would you collect for Mark? So a rectal and a penile assault. And you can feel free to put that into the chat if you want. So again, by the assault history and getting that medical history, this person has self-disclosed. We know there was a rectal assault. If it's a rectal assault, again, I'm not going to do anything different than any other patient. I'm going to do a perianal and a rectal swab. And if it's a penile assault as well, and there's been contact to their penis, I'm going to do a swab of the shaft and around the tip and probably a scrotal swab and a swab around the mom's pubis. So again, the same as any other patient. And if there was any findings to document, I'm going to be documenting the same. This is a great comment that Michael has. We don't know if Mark's partner has a penis that can ejaculate or if they're using a penile prosthetic. So that's a great question as well. So that we know more about the risk of body fluids and exposure as well. What factors do you consider when discharge planning? So for this individual, I'm thinking about intimate partner violence, right? And the one thing I would want to make sure that I'm finding is a safe place to discharge that patient to. I don't know where you all practice, but what I practice, we have a lot of women's shelters. And that's a huge issue when we're talking about gender inclusive services and the risk of intimate partner violence. So I want to make sure Mark has a safe place to go. Where I work, they will put folks up in hotels as well. And some of the shelters are a bit more inclusive. But I want to make sure if there is not that in my community, start advocating for a gender inclusive space. This kind of goes a little bit backwards when we talk about creating gender safe services as well, but what your clinic is called. So you know, something that's come up where I work is when folks are going for hysterectomies and BSOs, we have a main place that does surgeries and it's called the women's hospital. So what more of a, couldn't be less gender inclusive. And so thankfully we have a gynecologist and obstetrician here who does surgeries who started doing them at one of the community smaller hospitals. So folks aren't walking in and being on a huge women's hospital ward. So again, kind of another area that you can really advocate for some practice and policy change. So just some take homes. I'll have Michael jump in after this, before we get to questions. Make sure we're asking what's medically and forensically relevant. Be aware of your patient's body language. Are they uncomfortable? If they need a break, educate yourself. Don't have your client educate you. Use gender inclusive language and practices inclusivity in throughout all of your practices. So obviously in your forensic nursing job, but everywhere else as well and encourage your colleagues too. While I go through the resources here, please type into the chat any questions you have for Michael and I. And Michael, do you have any other take homes or information that you can add? I don't think so. How's that for a really quick answer? I do have more comments, but I'd love to hear what people have questions about. Okay. So go ahead and then type in, or I think Amy can unmute you if you wish as well. So while we're waiting for questions, I'll go through some of the resources that Michael and I pulled together. So Michael's great organization, which is FORGE. You have the website there. We'll send this as well to Amy and Chase so they can distribute this. The gender spectrum, this is a really great thing that I include everybody to do to go through this and go through your own gender journey, right? The gender unicorn can be great for folks as kind of more of a visual. GRS Montreal is a Canadian site. It's our surgical center, but they have some really good, great information on surgeries as well. If you're looking for more information as well as Sherbourne Health. The trans survivors blog, and then we have a second area here. So Ontario network of sexual assault and domestic violence treatment centers has information on providing trans affirming care to survivors. The Papawan Gender Wellness Center. This is a surgical center in, I want to say Pennsylvania, that is created by someone who identifies as trans herself. She went on to become a physician and a surgeon, and now she does surgeries. So she has a great inclusive clinic there. Trans Care BC, Trans Wellness Ontario, Rainbow Health, and then our World Professional Association for Transgender Health have our standards of care as well, which are being updated. So there's some comments here. Great. So this is that Michael put in the checklist in the comments for the self-assessment tool. And yes, Carolyn has a great suggestion. In addition to safety assessment of discharge, ask how to best contact the patient, what their preferences, texting is great as it doesn't impact safety. So yes, great. The other thing, and then I'll stop talking, that I wanted to highlight as well is making sure we're doing a really comprehensive suicide assessment. I know in my community, we have lost a great number of individuals in a trans community to suicide. So making sure we're doing a really good job and making sure that there's inclusive follow up for our folks to go to and making sure we're checking out those resources to make sure that they're safe. Amy or Shade, do you see any other questions for us? I'm going to stop sharing my screen. I just see a comment from Carol, Karen Carol, about not assuming that Mark doesn't want to go home. Yes, absolutely. Yeah. So asking that and if they don't or they aren't safe, then making sure you have an inclusive service. But yeah, absolutely. Don't assume that your patient wants to leave that relationship. So actually, I want to do a follow up question to you about, you mentioned that a lot of times people don't need to see their surgeon. And when I was listening to you, I was thinking like, oh, like, well, why would people need to see their surgeon? And like, what the way I think about it is, I think different than how you were thinking about it. Which is, you know, it's always good. Because I, you know, the way we've had interactions with other SANE nurses is that, you know, folks right now are having so much hate motivated violence, in addition to sexual violence, that their genitals are getting damaged. So it's not like they need to have follow up with a surgeon because, you know, like it's related to their gender affirming surgery, but they need to have follow up because there's been damage to that part of their body. So I don't know if that was like the same as what you were talking about. But it's like, it's caused by so it wasn't. So thank you for clarifying, Michael. That's a great point. Yes. What I was referring to is sometimes I get questions on has the assault created a complication to the surgery that they need surgical follow up? But yes, please don't neglect. And so thank you for mentioning that, that there could have been general trauma that's created just because that hate motivated crime as part of the sexual assault, which you would refer to. I will say as well, again, that often folks have a really good connections with the surgeons in their community, but do your own research. Here are surgeons who do the gender affirming surgery are provinces away. But we also know who in our smaller community who can see people. So some of the gynecology, gynecology team, some folks who do urology, we know we can refer to some of our plastics team, if we have something immediate in the emergency department, whether it's that urinary stenosis or strictures, or there's something else surgically happening that we need to look at really quickly. So this is called trans the movie. So it's a documentary that some folks found helpful. And these are our references here. So you will see that when you get our handout. But also, I just wanted to put up Michael and I's contact information as well. So if you have other questions, here's our contact information, feel free to email your questions to either of us, and we'll do our best to answer. Thank you so much. Just to remind everybody, again, the evaluation will go out by the end of the week, you'll come from Amy Valentine from the IFN. So once you complete that, you'll get your certificate of completion. And thank you everybody for joining us. And I will be sending out reminders for the next webinars in this series that we've been putting on. But I guess without further ado, nobody else has anything else to add, we will go. But thank you both so much for volunteering to do this and for such a very informative series. Thanks, everyone.

sexual minorities

gender diverse persons

gender-inclusive care

safe and welcoming environment

transgender individuals

non-binary individuals

violence and sexual assault

body dysphoria

medically supervised transition

hormone therapy

gender-affirming surgeries