Transgender and LGBTQ Mental Health

Dr. Laura Roberts (00:13):

The second chapter in your book is about understanding the gender spectrum. And I do think it's the nomenclature of the field is rapidly evolving and it's hard for people to really understand. So I was wondering if you would talk about gender orientation, kind of a spectrum idea versus binary models of sexuality. Could you comment on that?

Dr. Eric Yarbrough (00:40):

Yeah, absolutely. I actually put that chapter second because I think it's probably the hardest thing for people to get around. So of all the chapters in the book, I think that's the hardest for people that are going to accept. And it's the hardest to teach people. And so what I try to do, especially when I'm teaching classes, I tell people that if you can get past the place in your mind where there's more than just male and female, that males don't have to be male and females don't have to be female, meaning everybody possesses a little of both. And also people possess neither at the same time. Then you were in a place where you can work with transgender people. Everybody exists on a spectrum somewhere. So this dichotomy of maleness and femaleness doesn't necessarily exist and it's something that's been largely culturally created. We do have sex as far as male and female sex, but as far as male and female gender, that's a whole different thing.

Dr. Eric Yarbrough (01:40):

And I think that trying to teach people to look at each person individually and approach their gender identity individually and try not to assign rules to it, it's going to be the best thing that you can do to help a patient as far as accepting themselves. Now sexual orientation is quite different from gender identity and it makes the whole matter much more complicated. And I think people get overwhelmed with all these different terms that people use and individuals are going to come up with terms to identify themselves. As a clinician it's going to be easiest for you just to approach people as an individual and let them explain to you who they are, who they like, who they love, and how they identify. And, the more you can do that, it's going to be easier for you in the long run and it much easier for your patient. So that chapter talking about the spectrum or the gender spectrum is just trying to reinforce the idea that people can present in a variety of ways and our jobs as the psychiatrist is to accept them.

Dr. Laura Roberts (02:27):

Great. I love your key points. At the end of this. Chapter six refers to anatomy and genders in the mind. Gender's not a dichotomy, but exist as a spectrum. People can identify as male, female, both, neither or anywhere on the spectrum, and that clinicians must be aware of their own gender stereotypes when working with TGNC patients. Clinicians should respect patients' pronouns. Mis-Gendering is calling a person by the wrong pronouns. CISGENDER refers to those who sex assigned at birth and gender identity are congruent. Intersex refers to people born with ambiguous genitalia and is not the same as TGNC and that there are about 1.4 million TGNC people living in the United States. Each of these points is so profound and so important. I think many listeners would be surprised by the number of transgender patients. Where do you think, where did you get that number and, and how reliable a number do you think it is?

Dr. Eric Yarbrough (03:29):

I think it's pretty reliable. I think it's probably higher than that number actually is, that number comes from the Williams Institute. So identifying anybody who's LGBTQ has always been difficult because saying for instance how many gay men living in the United States, you must first define what is a gay man. And, that adds all kinds of questions. So are we talking about CIS gay men? We talking about gay men who have sex with other gay men? Are we talking about people who just call themselves gay men? So just identifying how many people in the country that identify as transgender for instance is difficult too. And I think what the Williams Institute did that was quite unique is that number one, had people say how they were assigned at birth as far as male or female. And then number two, how they identify now. And that is something that we could refer to as transgender.

Dr. Eric Yarbrough (04:21):

You have people that might qualify as transgender according to the DSM or have gender dysphoria, they might not identify as transgender. So there are some people that are assigned male at birth and they identify as female, but, they don't identify as a transgender female. They identify as female and they might not call themselves transgender on a survey like that.

Dr. Laura Roberts (04:42):

Right.

Dr. Eric Yarbrough (04:42):

So it's those types of things that make me think that number is even higher. And then there's also the whole thing about people in their own minds and being aware of who they are and how they identify. It's really hard sometimes getting passed their own prisons that we make for ourselves, so to speak.

Dr. Laura Roberts (05:08):

Hi, I'm Dr. Laura Roberts, books editor and chief of the American Psychiatric Association and welcome to the APA books podcast.

Dr. Laura Roberts (05:18):

Today we'll speak with doctor Eric Yarborough. Dr Yarbrough is a psychiatrist in New York. Doctor Yarbrough's new book. His first with the American Psychiatric Association books is Transgender Mental Health. This book draws on his experience as a clinician and his hope is to provide mental health professionals with a guide to understanding the particular health issues faced by transgender and gender nonconforming individuals. He also provides a history of the TGNC experience in our society. So Eric, so happy that you are able to speak with us today. So what led you to focus on LGBTQ mental health issues?

Dr. Eric Yarbrough (05:55):

Well, I grew up in Alabama, it was a very different place from where I'm at now, which is New York City and I grew up as a gay man in Alabama. So it wasn't a very accepting place. And when I got to New York, I really wanted to have a psychiatry practice, which focused on LGBTQ people. And in my residency training I asked for patients that fell into that community. And over time I developed a small practice, full of transgender patients. And just by meeting with them and talking to them and working with them, they basically taught me all the information that's in the book.

Dr. Laura Roberts (06:28):

Could you comment a little bit more on access to care in the LGBTQ community?

Dr. Eric Yarbrough (06:33):

Yes. People that live in cities, I don't think think about this too much, but if you go outside of the cities to rural America, there's not that many clinicians that are experts and working with the LGBTQ people, especially the transgender population. And so they go to doctors and they have to end up teaching their own doctors about how to provide them care. And the hope is is that we can educate doctors to learn the basics of working with trans people, uh, things like I'm just using particular pronouns, how to prescribe hormones or knowing about hormones. And then also these gender affirming surgeries. There's not many psychiatrists that know how to approach these problems or help people that want access to these things.

Dr. Laura Roberts (07:16):

What kinds of changes have you seen in the psychiatric community over the last 10 years? And thinking about how best to take care of TGNC patients?

Dr. Eric Yarbrough (07:23):

I think the biggest change that happened, happened with the introduction of the DSM-5. Changing the diagnosis from gender identity disorder to gender dysphoria. That really went a long way into the depathologizing the transgender population. And so you're basically, or the APA is basically saying that gender is more of a spectrum, that there are diverse ways people can present with their gender and it's not necessarily a mental illness. In fact, it's not a mental illness.

Dr. Laura Roberts (07:50):

You know, affirming that people who are transgender and nonconforming are not necessarily living with mental illness. And yet some individuals do find that they're in psychological distress or experience depression or issues around transitions. So I'm wondering what advice would you have for individuals who are in the TGNC community, about when to seek care from a psychiatrist, when to get some help?

Dr. Eric Yarbrough (08:16):

Absolutely. I really think that the distress and the way it's defined kind of mirrors what happened in the 70s with the DSM and homosexuality being taken out of the DSM. So understanding that sexual orientation can, can be on a spectrum and understanding that there are different ways people can present themselves as far as their sexual orientation. It's very similar to what's going on now with gender dysphoria. So what I'd say with anybody that has feelings of gender dysphoria, so maybe feelings that they might not be aligned with the sex they were assigned at birth. I would have asked him to get help as far as talking to other people that might feel the same way, looking at websites and reading about what people say that feel the same way. When it comes time to talking to a clinician, it really gets complicated because gender dysphoria in itself, it's not necessarily a mental illness, but there's all kinds of problems that can arise from it because the society and the way people view it. So if you grow up in a place, that’s not accepting of gender diversity, then you might end up with things like anxiety and depression and even more serious illnesses like PTSD and symptoms of that, not because your gender dysphoric, but because you live in a society that doesn't accept you.

Dr. Laura Roberts (09:30):

You're listening to Psychiatry Unbound APA's Publishing Podcast. We'll be back in a minute.

Dr. Laura Roberts (09:39):

So, Eric, I have to tell you, one of the things I loved about your the draft of your book was how you framed every chapter with a wonderful quote. They're so apt and so moving. And maybe I could just ask you to read the quote that you start the primary care chapter with?

Dr. Eric Yarbrough (10:23):

"In a society that has yet to fully accept transgender individuals. One of the most valuable things the provider can offer is compassion and acceptance."

Dr. Laura Roberts (10:29):

Right. And if you could follow that with the quote, which I understand is from one of your own patients. That's at the beginning of the plurality chapter.

Dr. Eric Yarbrough (10:38):

Yes. , "They would always say that I'm not right for this clinic, but really these clinics were not right for me".

Dr. Laura Roberts (10:44):

Yeah. I think these two quotes put together really reflect how we, we have a lot to do. We have a long way to go to be able to really support transgender individuals and seeking care and feeling supported in our society and in our healthcare system. What are your thoughts on what we can do to try and be more supportive, be more welcoming, demonstrate that transgender individuals have a rightful place in, in our healthcare system?

Dr. Eric Yarbrough (11:15):

I guess it's best for us to speak out a psychiatrist when these disparities exist. People need to understand that transgender people are not mentally ill. And even I have conversations with people that I know socially that think transgender people are mentally ill and I have to take the time to talk to them about that. For each person that we talked to we're just educating one more person. The history of working with transgender people in psychiatry is both positive and negative. It can get sorted at times. And Psychiatry has been in the past known to try to change people that are sexually diverse as far as the sexual orientation or diverse regarding their gender identity. And what we need to do is communicate to our patients that we don't think that that's a mental illness and that we're not going to try to change them. We're going to try to help them be better versions of who they already are.

Dr. Laura Roberts (12:04):
There's another wonderful quote, in the gender dysphoria chapter where a woman of trans experience says, my problem isn't that I was born transgender. My problem is that I wasn't born female. I'm sure that some version of that is mentioned in many of your encounters with transgender patients. Can you describe what it's like when, especially when you're first sitting for the first time with the transgender individual who's seeking care from you?

Dr. Eric Yarbrough (12:31):

Yeah, they come in all different ways. Actually. I not only see patients for Callen- Lorde, but in my private practice as well, at Callen-Lorde I work with not only people who are transgender, but those who also have chronic and persistent mental illness and just walking in the front door at, Callan- Lorde, they already know we identify as an LGBTQ clinic. So these people are generally out. They kind of have an understanding of who they are. They might identify as transgender or gender nonconforming and usually walking across the threshold to the door, they're already in a place that they're accepting of themselves, at least somewhat. Now, oddly enough, in my private practice, there are a lot of professionals that are transgender identified that are not out to anyone, not to their family, not to their work. And so they come to me because I've identified myself a certain way on my website and they want to tell somebody and sometimes they come to me just so I can tell them they're not mentally ill. And these are high profile people. Some of them are executives, some of them are clinicians even. And so to have a psychiatrist sit with them and tell them that their diversity is not a pathology, it's a very healing thing for them.

Dr. Laura Roberts (13:42):

I remember when I was interviewing residents for a resident candidates for training program, one person asked me, what's kind of, what's the best experience you have with a patient? And I said, you know, one of the things I love most is telling people, well, given what you've been through, this is pretty normal. This is a pretty normal response. And it is, it's very, very affirming for people. There's a chapter where the quote is very touching. It's a, sounds like you're quoting a patient and the patient is saying, "To the little boy, I never got to be, while everyone was grieving over the loss of a daughter, I still mourn for you". And it really raises the issue of grief and sense of loss and the expectations and experiences of other people around a transgender individual. I just found this quote particularly touching. I would love to hear where it came from or what experience you, brought this quote from?

Dr. Eric Yarbrough (14:42):

Yeah, absolutely. You know, that actually wasn't a patient of mine. I came across that quote when I was doing searches online about working with trans- identified people. So that's been a lot of time watching videos of trans people talking about their experiences with hormones, with surgeries. I wanted to hear more firsthand accounts of what people experienced. Usually online people aren't as quick to censor themselves, like they are in a clinician's room. And so that quote popped up in a poem that I read online. Now you're talking about grief with trans people. I think that, you know, all queer people, so LGBTQ in total, have to grieve at some point the loss of the person they thought they were going to become. And people aren't born with the ability to identify in diverse ways usually, meaning that not all families are accepting of diversity. So people develop a sense of self that might not be who they really are or a false self. And once they come out or once they start to figure out who they are, that person in their mind that they thought they were going to become. They do have to grieve that person to some degree. And then at the same time they can figure out what parts of that person they can incorporate into who they are now.

Dr. Laura Roberts (15:58):

One of your early experiences in becoming a physician really was working on a suicide hotline. And could you just comment a little bit about the issues around suicide and suicidality, emotional regulation with the transgender population?

Dr. Eric Yarbrough (16:18):

Now when it comes to suicidality and the transgender population, you know, recent studies, especially one that even came out last year, show that up to 50% of trans identified people have attempted suicide at some point in their life. And that's just not the patients that show up in clinics, but all transgender identified people. So people that don't show up in clinics. So that's, you know, a very high rate and it's something to always be aware of. And I think a large portion of that is due to societal nonacceptance. So people living in places where they just can't be themselves and they have to live hidden, suicide might be the only place in their mind for them to turn to. And I, you know, when working with clinicians at Callen-Lorde where I work, I tell them, I said, suicide should always be something that you're considering as far as evaluating a patient. And you should always be checking in about that regardless of how the patient is doing. You don't want to pathologize them and making them think, maybe they, you know, should be suicidal when they're not that it doesn't work like that, but you don't want to overlook someone who's doing well and forget to ask about things like suicide.

Dr. Laura Roberts (17:26):

The authenticity of those case examples actually throughout the entire book are really, really clear and it reflects, I think, why you were just the right person to prepare this book, which I think is really beautifully written and very attuned to the real issues that people are living with and clinicians are dealing with. I think it's a wonderful contribution to the literature. I want to thank you so much for bringing it, bringing it forward to our field and bringing it forward through APA publishing.

Dr. Eric Yarbrough (17:53):

That's an honor. I'm just happy that I had the opportunity to do it.

Dr. Laura Roberts (17:57):

Like you told me that your friends are celebrating the publication of your book, other than just being happy for you. What are they, what are they celebrating with the publication of this book?

Dr. Eric Yarbrough (18:08):

Oh, goodness. I think that a lot of my colleagues that work with the trans community understand that there's a lack of access to care out there. And so a lot of us are trying to do some of the heavy lifting, talking to people, not only within our own practices, but I get calls and emails from people across state lines. I've even had conversations with psychiatrists and other countries trying to figure out how to work with this community. And I think my hope is a book like this, will teach people that it's not horribly difficult and it only takes a little bit of effort to go a long way. And just kind of expanding our own mindsets around the issue and learning a few facts about the issue will help so many different people out there. There, there's a lot of patients that are very isolated and very alone and what they need are compassionate doctors that are going to sit with them and listen to them and be supportive of them. And my hope in writing this book was to reach those people somehow through their clinicians.

Dr. Laura Roberts (19:12):

So Eric its really clear that attitudes towards sexuality, but also understanding of gender identity is really changing and young people I think have a pretty different perspective then kind of the older generation at this particular point. Can I just ask you, what could medical schools do? What could residency training programs do to help embrace this new way of thinking that really young people, they're already there, but we're failing to develop curricula or educational experiences that really are far enough along in this field. So what advice would you have for educators on how we could get medical schools and residency programs to the place where they need to be?

Dr. Eric Yarbrough (10:59):

Complication question. I will address all those points. The first thing I'd like to say is while there might be some sort of age difference as far as who identifies as gender diverse and how they identify. I have met tons of young psychiatrists who are not there. I've met, you know, tons of young psychiatrist who are very resistant to the idea that there is a gender spectrum and are upset by the idea that people might be gender diverse. And these are professionals within our field and they're under the age of 30. So I don't think that there's this, you know, new young generation that's necessarily all accepting and all knowing, popping up. I think that there's a lot of work to do with young people as well. All that being said, I do think that medical schools, residency programs, the main way to teach people how to work with gender diverse people is exposure.

Dr. Eric Yarbrough (20:57):

They need to meet them, they need to have time to talk to them, they need to hear their stories. And once they start to internalize those stories in their mind, then they'll have a framework for what to work with going forward. And we really need to prioritize that. So having patients that are willing to talk, willing to tell their stories, it's just like with anything else you really need psychiatrists that have met gender diverse people from all different types of backgrounds and different presentations. There are classes that people can teach. And by the way, as far as classes go, residents in psychiatry are taught very little about LGBTQ mental health. And that could change. Yeah. So we need to, we need to start there from an academic standpoint, but also creating places for gender diverse people that come to clinics and meet with residents and trainees that's the best way to learn.

Dr. Laura Roberts (21:53):

So Eric, one of the things that I absolutely love about this book is that you frame each chapter with an amazing quote that is so attuned to the content of the, of the chapter, but also often really speaks to the heart. And could you tell me which quote is your favorite of all of the ones that you included in the book?

Dr. Eric Yarbrough (22:12):

Yeah, my favorite quote is from chapter two, right at the beginning of the book. "I believe gender is a spectrum and I'll fall somewhere between Channing Tatum and Winnie the Pooh" said by the Great Stephen Colbert.

Dr. Laura Roberts (22:24):

He's quite the philosopher, isn't he? And so tell me it's marvelously funny, but what is it that you like about that particular quote?

Dr. Eric Yarbrough (22:33):

I think it really makes people think about what gender identity is. I mean people and their mind might have an idea of who Channing Tatum is and they might have an idea of who Winnie the Pooh is and trying to put those individuals together into one gender identity will really make people stretch their brains a little bit. And I think that humor is a very good way to teach people, it lowers their defenses and it gets right through to them. And I think a quote, like that really can open up more people to being open about the gender spectrum.

Dr. Laura Roberts (23:16):

We're going to be interviewing one of my favorite people on the entire planet today, this is Larry McGlynn. He came to Stanford's Department of Psychiatry and Behavioral Sciences in the year 2000. He now is a Clinical Professor of Psychiatry and Behavioral Sciences at Stanford University and he directs the HIV Psychiatry Program. He is just the right person to talk with about this wonderful book by Eric Yarborough on transgender mental health. So Dr McGlynn, Larry, welcome to the APA books podcast.

Dr. Lawrence McGlynn (23:48):

Thank you so much for having me.

Dr. Laura Roberts (23:50):

Yeah. So thrilled to talk with you. Can you just tell me kind of settings or for what populations of mental health professionals will this book be useful, do you think?

Dr. Lawrence McGlynn (24:03):

I think really for all levels cause they, he addresses, you know, first of all, when a person is thinking about going to a clinic that's going to be considered friendly or a transgender or gender nonconforming, focused clinic or a clinic where these patients are going to be seen. He really puts it out there that, that the sensitivity, the knowledge, needs to start from the very beginning, from the moment the person first walks into the door of the clinic. So the front desk people, the nurses, the social workers, and then ultimately to the providers. I think parts of it where I thought, wow, there's areas here where he leaves you kind of wanting for more. He's got great references. So for me, thinking about, well, what about prescribing medications, where there might be drug interactions, he's got some great references in there.

Dr. Lawrence McGlynn (23:58):

So it keeps the book very focused and at the same time, you, there's areas where you can go to find more information. So I think from a sort of a general mental health clinic or even a primary care clinic, it seems to be applicable for almost everyone, even the primary care providers who need to know what do we look for in terms of labs, in patients who are on hormones or what do we think about when referring someone for surgery? What kind of advocacy letters are needed? So I think across the board a lot of different people will benefit from it. And not only that, but again, it was very accessible in terms of the terminology used, the simplicity of the way he presented things like surgery and medications that a lot of people could understand it.

Dr. Laura Roberts (25:48):

Yeah. And that's wonderful. So tell me a little bit about you and how you first came to work with transgender individuals.

Dr. Lawrence McGlynn (25:57):

Well, it really goes back a long way. I think back in residency for instance, I was starting to get referrals for patients who are transgender to manage their medications and, they were virtually all what we would say trans men or, or excuse me, of trans women, that is men who are transitioning to become, to become women to trans women. And so what we saw as we still see is there is an incredibly high rate of HIV in this population. So as I came to work at Stanford working in the HIV clinic, the patients I was seeing who are trans women were ones who had HIV. Since I've come here, we've opened up our clinic now to become more of General LGBTQ clinic. So we see people who are HIV negative and HIV positive. So now we're getting a more diverse section of people who are either trans men or trans women.

Dr. Lawrence McGlynn (26:57):

But what I noticed in this area in the San Francisco Bay area, particularly the South Bay, is that our transgender patients were really having a difficult time finding the health care that they wanted. So a number of them were either getting their hormones from the streets or what we were seeing a lot more of probably five, 10 years ago were parties where they would go to have injectable oils injected into the breasts, buttocks and leading to profound infection. So it really, it really sort of laid the groundwork for those who were in positions of policy making that we really needed more attention paid to this population. So the latest surveys that have been done in the south base focusing on Santa Clara County reveals that the primary care providers are really coming up to speed. There's more and more of them who are willing to take on patients who are transgender. However, what's lacking is mental healthcare providers who are either showing an interest in seeing transgender patients or who are a well trained in that area.

Dr. Laura Roberts (28:06):

Yes. Thank you for that. I mean, I think one of the great developments in our field is that the fact of being transgender is not considered a mental disorder in any sense, but there is the issues that people who are nonconforming in identity sometimes suffer. and may have either adjustment issues or issues where to live a full quality of life, their best life, a little mental health support is really valuable. And then of course there is these medical and psychiatric complications that come with the transitioning process and I think are really very important.

Dr. Lawrence McGlynn (28:42):

Yes. And it does put us in kind of a precarious sometimes position whereas for supporting our patients and yet the insurance companies and sometimes the surgeons will want us to really put out there the gender dysphoria diagnosis, where in many cases, yes it's true, but in order sometimes for their surgeries to be covered we need to specifically say they do qualify for gender dysphoric disorder. so sometimes the patients, we have to work with them and sort of understanding what that means. And we're not saying that they're mentally ill per se, but rather sometimes there are these steps through the advocacy process and letter writing where we need to detail and document these kinds of terms. A lot of the issues that you point out, you know, in a adjustment, we see elevated rates of substance use, unfortunately suicide, shame, trauma, of course HIV and then isolation. But the one thing I've really in my working here, with this population is the resilience is really impressive. People who've survived, you know, rejection by their families, society, seeing laws that affect them that are past involving military, marriage, et cetera, but they just bounce back. And so it's been in that regard very, very rewarding to work with this population.

Dr. Laura Roberts (30:09):

Yeah. I'm always inspired by the courage of my patients. And it sounds like you have that experience every day.

Dr. Lawrence McGlynn (30:16):

Oh yes.

Dr. Laura Roberts (30:18):

It's been really interesting to me to see this wonderful progression of transgender individuals in high political offices and taking tremendous leadership roles in society. And it does seem to herald a greater level of acceptance.

Dr. Lawrence McGlynn (30:35):

Yes, absolutely. It should be wonderful for all of us to see because you know, whatever one may believe, ultimately someone who comes along may end up with a child who is transgender and I certainly believe that they would want the best for their child, their friend, their offspring, their parent, whoever that might be.

Dr. Laura Roberts (30:59):

Could you offer any specific advice to trainees either in primary care specialties or in psychiatry and how to be sensitive to nonconforming patients, but also how to stay a little bit ahead? I mean, I feel like I'm, I see us kind of work in organizations, in psychiatry, in psychiatry itself, in medicine, always a step behind where the patient population really is and needs to be. So what advice do you have for people coming into the field on how to help anticipate the needs of vulnerable populations and special populations generally?

Dr. Lawrence McGlynn (31:38):

Yeah, I think the first step is, you know, keeping an open eye in, uh, in the clinic itself. Uh, you know, just starting off with is, is this a clinic where patients are treated all patients in general, treated with respect and not just transgender patients, but then going a step further are the transgender patients who are coming to the clinic, having their needs met, uh, go to the next level is, is reaching out to organizations like WPATH or this book, which is really great and getting to learn a little bit more. I think this book really laid out very well, all different aspects of what, when we should focus on, depending on what their role is. Once a person is one on one with a patient. I think the things that I've really learned sort of along the way and I think this book really emphasizes, is really allowing the patient to identify who they are and whether they see themselves as transgender, as nonbinary, you know, they don't want to identify one way or the other as, as being attracted to men or women. Both. Neither, so that's, you know, really I think an important lesson is allowing that patient to identify who they are. Allowing the fluidity that it may change. But also I think the lesson I've learned to kind of the hard way is that, is that even though a person comes in transgender having transitioned, sometimes they're not even ready to talk about it. And I've had a couple of patients who as I've, you know, very carefully addressed, let's look at your medications. They see that you're on, you know, maybe female hormones. What was this like for you growing up? Who at that point may not be ready to talk about it at all? They, and why do you want to talk about that? Because many of them had been traumatized and think maybe I'll start talking about more body issues, which goes another step of, of sensitivity.

Dr. Lawrence McGlynn (33:33):

So really allowing that to develop and, and keeping in mind that perhaps the idea of you're going to get all the information out of them in the first visit. It may take multiple visits before they're even ready to talk about it. So letting the process sort of happen naturally that they all come from different experiences and their journey is probably different from every other person who is of a transgender experience. So I think that's it at least as I've learned and in fact that's what I really, I think really appreciated about this book also is that he puts out there the, you know, what's cited in the literature, but when I really appreciate it was time to time he'll throw in his own experience and use the word I, and I would look at it this way and those are really I me who sees a number of patients who are transgender. I really appreciated that.

Dr. Laura Roberts (34:26):

Yeah. As your talking though, it kind of, it breaks my heart because think about how hard it is to access care if you have mental illness, think of how hard it is to access care if you're a transgender identity, how hard it is once you get into care to have longitudinal care. These are really, really incredible access challenges that we face in our society today.

Dr. Lawrence McGlynn (34:51):

That's it. Those are great points because they may have the right insurance, they may have the way to get in the door, but perhaps the idea of having, you know, a caregiver that they can trust. And so at least in HIV, we know a number of our patients who their priorities to get the hormones over even over their antiretroviral medications, are the meds used to treat HIV. So but yeah, that access to care covers so many realms of, of health care.