SPEAKER 0 Good afternoon. Welcome to the transgender health program. Grand rounds series. My name is amy pumpkin Pie you. She and her pronouns. I'm the program manager for the transgender health program and a committee member for our grand rounds planning committee. I want to welcome you today to our session. Our title is body image eating disorders and weight, trans and gender diverse community perspectives on dysphoria, dysmorphia and health at every size. A big topic today that we will hope to do justice to and recognize that one hour is not nearly enough time for the complexity of this topic. I want to warmly welcome our panelists and our moderator for today who I will turn this over to shortly um and want to acknowledge the efforts of our grand rounds planning committee to pull together a wonderful series this year. Um this event is recorded. We will have some question and answers at the end of the panel presentation and we also welcome your questions through the chat. Uh this session today does provide continuing medical education and I will put the evaluation link of the chat that chat. That evaluation will be required to get your cmI credit. SPEAKER 1 I want to put a plug to that this academic SPEAKER 0 year. Our series will be this year's series ending in april and our next Grand rounds event. Our topic is titled beyond the transition community perspectives on gender fluidity and expansiveness. I will soon put a link in the chat for that. If you'd like to add that to your calendar for later this year and before we dive in. I want to just make some Acknowledgments uh, that this grand rounds series. Unlike what we might see from other departments um, in an academic center, um are transgender health program is not specifically part of an academic department. We've taken this grand rounds series from a very community based community driven perspective to recognize that the experts on trans experiences are trans communities and for that reason we feature the expertise of community members to share on this topic. We know that uh lectures and conversations delivered by cis gender people about trans experience has been harmful at best and at the very least dismissive of the needs and desires of trans folks when it comes to speaking for themselves about their community health care needs. We are here to celebrate all of our trans and gender diverse community voices and discuss ways that health care providers and teams can improve their assessments, their interventions, their discussions when it comes to the areas of health and needs from community. We are particularly committed to our values of representation of diverse voices and our committee aspires to actively demonstrate these values and recognize still there's more work to do to continue ensuring that this takes place and we truly have representation of all aspects of trans community. We also want to name that uh patients. Community members are the experts of their own bodies And today we're honored to have panelists who are willing to to discuss the ways that providers can support a gender affirming medical system and society and we have to remember these are just a few people's experiences and not representative of every voice and every experience that's out there. And we also want to acknowledge that some of the content that might be presented today can be activating. So please do what you need to do to take care of yourself as you need to and again the session is recorded. So if you feel the need to leave you can come back to our website and view it later. We have some questions that we've prepared ahead of time for our panelists and um we also invite your questions for our panel to uh to also attend to and with that I will turn it over to our esteemed moderator, Jessica, thank you so much for being here uh to lead our session today. SPEAKER 1 You're so welcome. It's a pleasure to be here. Um I am Jessica Wilson. I'm a registered dietician. Currently I am at Lyon martin health Services uh mostly queer and trans healthcare provider in san Francisco. I also um I am an eating disorder, I won't say expert but folks have said as such, particularly for folks who are marginalized. Um and that is how I ended up here. I am one of the co founder of amplified mela native voices as well. That was two years ago um drawing really attention to folks of color and putting us at the center of our own storytelling. So with that I would love to have the group The panel take two or 3 sentences and introduce yourselves SPEAKER 2 in any order. Thank you. Hi and welcome everybody. My name is Tommy shoemaker and I'm here in Portland Oregon. I am a patient at O H. S. U. And have been for a lot of years. I identify as non binary. Fat were um a few other things, but for purposes of this, this that's how I identify. Thank you for having me. SPEAKER 3 I'm happy to jump in. Very honored to be here. Y'all thank you for having me. My name is Shane S'more. I use he him his pronouns and I'm a trans man. I'm fat. I'm queer. And I think um one of the things that I did particularly to to learn more about how fatness and transit experiences intersect kind of through my own story was I I started an instagram account called plus size trans guide to be the representation that I needed when when I came out that I so desperately needed. And so I'm excited to to share my experience here today and and continue to learn as well. So thank you for having me and then Naima, are SPEAKER 1 you still with us? Mhm. Love does someone want to check in with, she's able to rejoin. SPEAKER 4 It looks like she left and so she must need to rejoin. SPEAKER 1 Yes. Okay. Um we'll let her jump in. She's seen the questions ahead of time as well. Um my pronouns are she her? I ended up here because I'm working also on B. M. My requirements for the san Francisco Bay area when it comes to gender affirming surgery and researching how those uh B. M. I. Requirements got to be. So, some of our conversations will revolve around that gatekeeping. So I just want to give folks a preview of what they can expect today. So for the first question for the panelists, um how would you define fat phobia and gender affirming care. And how does it intersect with transphobia? SPEAKER 2 Had a bit of trouble. Sorry about that. I guess I will go first. Um Can you say the question again in order. SPEAKER 1 Sure. How would you define fat phobia and gender affirming care and its intersections with transphobia? SPEAKER 2 Yeah. Um fat phobia is for me, my experience of fat phobia is um that based on somebody's size or weight people are um treat us differently and not always fairly and make certain assumptions about us. Um And gender affirming care is care that recognizes the the the the gender that I feel on the outside of my body might be different from the gender I feel on the inside of my body. And the goal is to try to even that out. And one of the things that I always have a difficult time with is a lack of autonomy when it comes to fat folks. Um And gender affirming care because I don't have any autonomy when it comes to saying when I can and cannot have, um, not just surgery, but other things in the line in the name of gender affirming care. That makes sense. Thank you, definitely. SPEAKER 1 Thank you. And I wanted to note that was able to rejoin so high again. Uh, would you like to introduce yourself to the audience? SPEAKER 4 Sure. And my apologies. Uh, webex does not launch properly on my organization's network server. So I'm joining from my phone. Um, I am Naima Sanchez. I usually hear pronounce um, I'm a proud thick trans Latina from the East coast pennsylvania. Um, yeah, so that's an introduction of who I am. SPEAKER 1 Thanks for joining us. We're looking at that first question. Uh, we'll have change up in if you want to review the question for a sec. SPEAKER 3 Yeah, absolutely. Tommy. I think, I think your definitions in regards to fat phobia and gender affirming care were spot on. I experienced them very similarly. I think, you know, to, to highlight fat phobia. I think particularly in a medical sense, you know, and outside of the medical world is just that people with larger bodies and people with fat bodies and who have more fat on their body do not experience the world in the same way that people that are thinner do. And I think thinking about the word phobia. There's a true fear. I think that is very deep rooted in our society and you know, in a in a fear of being too fat or a fat, a fear of being too big. And I think that's where the phobia comes in around this very intense pressure to diet lose weight, where we see um so many people sacrificing their autonomy, their happiness in this journey to be a certain size that is deemed appropriate for care or appropriate to be loved or valuable or or seen as important in society. And I think for gender affirming care the way that I see them them intersect is fat phobia really prevents many people who are trans and fat from receiving the gender affirming care that they desire and that they deserve. And I think um you know when I think about gender affirming care and when I think about how it intersects with transphobia, I think about when I came out as a trans person, really the only people that I saw to look up to or representation wise were white thin, trans masculine people who were fit and kind of like this ideal image or striving to be an ideal, whatever that may be quote unquote image of what it means to be a man uh in America in the United States and I had never looked like that and I really felt a struggle around being able to come out as trans and really feel um a part of the trans community are able to own my autonomy and my identity because I didn't think I was ever gonna look like that. I've been fat for as long as I can remember. And so I think there are lots of ways that it intersects, but those are one of the many ways that it did for me at the very beginning of my transition. SPEAKER 1 Thanks jane. Yeah. Jump in. Yes, you're on mute, but please jump. SPEAKER 4 Yeah. And just adding on, I just think that even coming from my personal experience as a trans woman, um the perception of femininity in society, like the hips, the curves, you know, bodacious and uh this is something that for most transwomen we gravitate to, we uh transpired to or we aspire to fit this perception of of what femininity is, right? So when it comes into uh a phobia and jennifer and care like for me 17 years on HRT before finally um having access to surgery per like really set me up in a way because now at a point that I'm chemically castrated and I have no testosterone and highly levels of estrogen. Now I have this increased weight gain that is caused by the treatment plan of H. R. T. Right? And as it intersects with the transphobia aspect of like the fat phobia and and and how it intersects with transphobia is that, you know, I feel like the the stigma or the stereotypes that like this perfect being for surgery, like or perfect body type for affirming care is there's no one way to that. So when folks look at it, they look at it through a model of the perception of what the perfect person, the perfect patient should be to prevent uh complications. But that's holistically not pool because I mean it adds to the mental, I I want to say the mental health decline of the patients who want seek to achieve gender affirming care and to seek gender affirming care in a facility that is not being phobic, whether it's to uh their body type or to their gender identity, right? And how those identities intersect and jane something you said SPEAKER 1 the other day, um what you saw in the media as far as what trans mask folks look like is reaffirmed and reinforced by the medical system because when you have those B. M. I. Categories right? Like not only a society looking to um what trans looks like, but the medical model is reinforcing that, but feel free to say anything else. SPEAKER 3 No, I couldn't, I couldn't agree more and I'm so glad that you said that Jessica because I think for me as somebody who's been on testosterone for almost nine years now, you know, top surgery is absolutely something that I've always wanted to get and have the funds for, but a big barrier and obstacle R. B. M. I requirements and the fact that I have no true vision or idea of what I might look like or be able to, how I might be able to take care of my body after surgery. And so it feels like a a big guesstimate to go to go in and then have a surgery when I don't feel like many surgeons or doctors have made people with my body type and even larger bodies than mine a priority to be shown and seen very much to what you said name is around a perfect candidate and someone that is ideal for a surgery like this. And so I'm so glad you said that Jessica. SPEAKER 1 So did folks have anything else on that question or you can move on? Okay. Um let's jump to one on gatekeeping. So we can talk about generally gatekeeping as far as being my requirements. Um Naomi you already started to talk about that as well. Um gender and and then also what are some specific examples of gatekeeping related to body image in size and then we can go in reverse order Nanaimo, do you want to jump in? I mean, I'm I'm happy to, you know, chime in SPEAKER 4 with from, you know, the perspective that I have. Um you know, I've I've did my research went before um actually having uh bottom surgery, right? Gender? Gender affirming um uh surgery if you know, uh and through the four physicians that I like to say I interviewed with because I interviewed my physicians, right? I interviewed their team right? Because I needed to figure out what team would be best suitable for me as a patient, right? And what I found was. And three of those four facilities, however they focused on trans related care, trans affirming surgeries. There was this again the specific focus on like this ideal patient, right? So it really prevented me from accessing the surgery that I desire for my entire life that I could possibly think of, which I feel like was gatekeeping. It wasn't seeing me as a person, it was seeing one portion of me and and which was my weight, right? My size, right? There wasn't a contemplation or a debrief with me or a conversation with me on like you know what my diets were right? Like uh yes, you need a letter from a psychiatrist that have gender affirming surgery. And also, I mean the reality is that some people benji right? Like when things get rough, so I may be in a mental state to have gender affirming surgery, but also one of my coping mechanisms when I get stressed out at work which is not directly intertwined with my gender identity, but my work is stressful. And I grabbed the first thing something that may not be ideally, you know, healthy and choice but when it comes to like gatekeeping in the health care center, I feel like again the 33 out of four providers um that I went and seen and interviewed for me as their um as their patient and them as my providers. I felt like the focus on my weight size and that was it prevented them from actually provided me to quality of care that I needed, right? Um And it also left me leaving those facilities Feeling how I felt for the last 20 years, which was, it's still a resource that I don't have access to. Right? So there's another challenge and when you're in those settings and you are not holistically caring for a person um even for a consultation, like resources is everything. Meeting a person where they're at is another means of resource. That is everything. And when you don't do that, you ultimately prevent that person from acquiring something that they desire for forever, which is gatekeeping. That resource from them. SPEAKER 2 Thanks so much Shane. SPEAKER 1 Do you wanna jump in the middle? SPEAKER 3 I want to pass to Danny because I know I spoke a little bit last time. So do me, if you want to don't want to put you put the put you on a pedestal. But if you'd like to want to give you the opportunity. SPEAKER 2 Thanks Shane. Um I very much have things to say about this part because I for many, many years have been trying to um figure out how to get top surgery. And I, the thing is the thing that kind of surprises me is that I have really fantastic team at HHS you actually and and my my PCP and the whole team, they're all in support of me. But we've I literally had my doctor right to um right to the trans health program multiple times, saying. So has the weight, has the weight limit changed as the weight limit changed? As the weight limit changed? And I literally had to lose 50% of my weight in order to get um top surgery and I'm I still have about £90 to go. Um And but I still I have an appointment um it took about a year and a half to get an appointment for the consultation. So next january a year from now, I have an appointment and I still have no idea like am I gonna have to lose that £90? Like I think I'm gonna be ready to be on the list if I lose that £90 Like how am I gonna lose that? I'm gonna have to have another surgery. I had weight loss surgery partially because of um Some knee problems, but also because I want top surgery. You know, and it sucks that you have to like I'm almost 60 years old and I like I've been in my entire life, I've had I just carried this with me that like, oh you're fat so you can't you can't have this surgery, you can't have bastard. I couldn't have knee surgery. I couldn't even have an abdominal, I should have been able to and later it was it was changed. But they wouldn't even do an abdominal surgery on me for uh, for a What's that thing called? When a muscle poked out to you. It's very common and I'm missing the word hernia. Yes, thank you. But I couldn't even get a hernia fixed. Like it's just, it's that was, you know, 20 years ago, but that it's just kind of ridiculous. It feels terrible. Um, so it's affected me a lot the gatekeeping around, especially when there's not. I mean, I recently gained a lot more access to people who actually work in transgender health. I've known somebody for many, many years who has, but that um, recently and and there really doesn't seem to be a good, good reason. A very good reason anyway. For for there not to be a reason why I can't get my breasts cut off. Like I really, really want to and have since I was knee high to a grasshopper. Um, that's all you have to say about it right now because I'm starting to get speak quickly, which means I'm done. SPEAKER 1 That was great. Thank you so much for sharing and being vulnerable with the audience Shane. Did you pass entirely or were you waiting to go? SPEAKER 3 No, I'm happy. I'm happy to go. But I just, I mean to me, that was a very powerful story, I think. Um, and so thank you for sharing and thank you for your vulnerability. And I think what sticks out to me, I mean Naima and you said so many wonderful and powerful things already. But what stood out to me is that every part of the process to navigate transition as a trans person, there is an obstacle and a gatekeeper at some point. And I think more than anything, I think there are more gatekeepers than there are people trying to figure out how to open the door around. How do we make things possible and getting curious and really investigating um education that we've had around health and weight and fatness and I think really investigating the origins of things. I mean, you know Jessica we talked about this a little bit but the B. M. I. System being inherently racist for what it's continued to do in our society. And really I think a lot of gatekeeping doesn't come intentionally, right? Like I don't think people want to harm individuals. But I think people rely on assumptions without question to say this just is impossible. Rather than looking at each individual patient as an individual case and doing the best to make informed decisions with informed consent around risks and around options. And so I you know, we'll get into this a little bit later. But I think the biggest thing that I always want any provider that I work with is instead of just relying on what a textbook has taught you or you know what what you've read about or learned in class is really getting curious and doing research and investigating and and broadening the scope around where can I get in new information and from from people and mentors to really have a revolutionary practice rather than just more of the same that continues to create barriers and gatekeeper access to lifesaving healthcare. Um I think that's just a really big piece around gatekeeping is that I've never met somebody who intentionally wants to harm but just doesn't take the extra time to be curious and creative and intentional. And so I think that's a big piece that's important to me. Um I know I'm speaking a lot but I just like in my own aspect, I wanted to affirm that there are very few surgeons, I mean they're already very few surgeons doing gender affirming care, but also living in the middle of Missouri, there are very few primary care physicians specialists, we're doing anything around gender affirming care and a variety of different things outside of surgery. And it feels incredibly overwhelming to have to continuously only rely on my own ability to research and inform practitioners about why I deserve or why this care is safe. Um and I think gatekeeping just continues to put trans people in a vulnerable aspect. I think um close to half of the trans population will attempt suicide at some point in their lives. And that is a very real, very raw statistic around emotionally. And I think what I always try to empower people is that each decision you make around health care, each decision you in your everyday life around some of the things that you do to support trans people or not support trans people impacts that number. And I think gatekeeping is a big aspect of that. So I know there was a lot but that it was important to share. SPEAKER 1 I think that's great. Um, and you said it gender affirming care is lifesaving care, right? And putting all those barriers in place is really just exacerbating what folks already going through. So all those great thanks. Um, with my uh research. So barrier probably has more uh surgeon shame than all of your state. But there's, I don't know, 10-20 here. And what really is stuck out to me, right? Is there are there's at least one who will operate on anyone of any size. And you know, the conversation will be like the equipment or the people or there's something. And I'm like, how is this special unicorn able to do this when you all are just unwilling right? Not unable, but unwilling um, to serve your patients. So there is, you know, someone here, there's folks sprinkled very sparsely across the country and speaking to B. M. I. Specifically for any providers on here. You know, the surgeons in the area did all over their training together. So they have a max being my cut off of 35 some will be like, oh well you do 36 P. M. And I'm like, that's that's delicious. It we're not doing anything different here. Um and the assumption there is like care after surgery for some folks um for vaginal plasticky, you know, the concern is like people will people be able to dilate themselves after surgery? And you know, the question is like, so then would you not provide surgery for somebody who's B. M. I. Is under 35 like and who has no arms? Like? So like you will assume that those folks have support. Like can we give and ensure support to folks so that they can have the surgery. It's confusing. It's clearly fat phobia because you would do surgery for something with for someone who was not physically able to do. So Um that has come up, it also has come up like somebody, one surgeon want to be in my under 18.5 because they're concerned about bed source for people who are very thin, which is wild. Uh that can also be something that is solved with support. So really what is happening is these artificial um barriers because the fat phobia and you know, outcomes and I, you know, so often that falls on the surgeon and what is reflected that folks are happy with their surgery afterwards And we already talked about like, what does this look like for folks with A B. M. I over 35 because we don't have resources readily available. Um on surgeon websites for what surgery will look like for folks, whoever uh B. M. I. Of 35. So the things that people make up to justify their gatekeeping is wild. I have found in my own experience, um something that we got into a bit of eating in just this last part. There was mention of, you know, large amounts of weight loss, there's mentioned of binge eating disorder. Do folks have anything that they would like to share? Um either about their experiences and their lifetime with surgeons? Um Something that I think about is how indeed people end up with eating disorders trying to get into A B. M. I. Of less than 35. And what does that look like and why are we asking people to starve themselves, which ends up, you know, compromising their ability to recover from surgery but do anything to add for eating disorders. SPEAKER 2 Thank you. Um I was talking to my partner about this because I, in my head, I have not ever thought of myself as somebody with an eating disorder. I do fully know that I do use food and um drink like, you know, like a book shakers or whatever. Um but for comfort and stuff, but I also know that when I first started getting breasts when I was younger, I was like really athletic and stuff and I couldn't, they couldn't I couldn't stand the sight of these things protruding from my body that were much larger than most people my age first of all. And then I started gaining weight to to sort of be equal with my size and so that people still couldn't tell that it was, I mean they still could, but like I tried to grow my body as big as my professor, you know, and I didn't realize I was doing that until much later and through therapy and some other stuff. Um I couldn't, I could not stand the idea of having these huge prominent breasts like my mom had, you know, so I have these huge prominent breasts, but I have a huge prominent body that kind of match. So, you know, um uh so I've been like people in the medical community have tried to push me towards eating disorder stuff, but I'm pretty aware and and I don't have a lot to say about like eating disorders other than my own disordered experience, you know? So, but I really wanted to say that because I think people assume lots of different things and this is just one way that I coped with having Yeah, thanks, SPEAKER 1 thanks so much for that. And sharing again, jane Yeah, I think the only thing SPEAKER 3 that I wanted to add is again, dummy similar to what you said. I don't think throughout my 30 years of life I've ever thought of myself as someone with an eating disorder and particularly now in a space for finding myself more in a space for fat liberation as I look back on my past, I'm like, oh, maybe maybe I didn't receive or understand um more about my own experiences with disordered eating and also particularly around exercise. I think for many times when when I came out as trans, my first thought was based on kind of the representation and what I had seen as I was like, I've got to lose weight. That's the only way. In addition to gender affirming care that I'm actually ever gonna feel happy in my body and seeing how those things intersect really put me in a in a difficult place in regards to not prioritizing rest, making myself more susceptible to injury or over working out and doing these things um that were more harmful to my body rather than like, you know, nourishing it in a in a variety of different ways. And I think um I'm still on a journey every day. I think many of people in fat liberation work or in um you know, people who are trying to abolish, you know, diet culture and all of these other things um find themselves in a day by day taking it day by day as they navigate it. Um and still find myself trying to think about movement as an opportunity for my body to move and experience joy. Um and for food to do the same as food, is that in a variety of different ways. All food can be nourishing for a variety of different reasons. Um And being more intuitive and intentional about that practice in my life. But I do. I remember as early as I was eight years old, I like I said I've always been fat and I've always been in a larger body and I remember my pediatrician telling my parents like if you ever want your child to not have health concerns, you need to have your kid run up and down a hill. You have Shane run up and down a hill with a £10 backpack on his back like at eight years old. And may not understanding like you know just how much that was going to impact me for a very long time around how to control my body rather than love it in a lot of ways and not even love it. Just exist in it. So not even. SPEAKER 1 Do you have something you want to add? No you're good. Um I'll share the story of the experiences of two clients that I'm thinking about. I just wrapped um with one trans woman who is looking for surgery and R. B. M. I. Is over 35 who initially presented to her PCP looking for um Oh gosh! Now blinking on it. All I've got is oh fan fan. I was like I've only got methamphetamine and what is it? Uh it's medical meth is what it is. Um And presenting you know just asking for that and we really, you know it's the clinic like really try to honor autonomy and when people ask for things, you know we trust them to know what they need um And without assessment like of what you're already eating, you know the tendency can be to prescribe in order to um you know support a patient. But then you know she starts working with me, she's eating one meal a day like so you know going from like eating one meal a day to eating zero meals a day, first of all, that's not great for her at all ever and two is not gonna be good for surgery even if for PM I falls below 35. So like what is a medical, you know field are we recommending to people? Um And then another example who I can name josh because I have um legal approval because I use his story in my book um you know, came in with an eating disorder and um as he was going through recovery ended up gaining weight right in you know, hips and breasts um that just hadn't been done before because of the restriction forever. So he was in his twenties um before even like exploring gender identity and it was distressing and like it took years and the conversation over and over again and you know at the end he's like thanks for arguing with me because you know it was like is surgery you know in transitioning gonna make this eating disorder better? You know eating disorder gonna make gender better? Like it was just this like desperation and of course I can't answer those things but just the desperation to like need to be better and feel better and like have an answer. You know, we just couldn't couldn't do that. He ended up transitioning getting surgery. And it turns out his quote is the problem with my hips and my belly is that they didn't have fur on them. Right? So a lot of that came through with um affirming care. And then there's a lot of discussion in the chat about health care and I have found in there are good folks navigating and negotiating who are able to get um Insurance to cover surgery with folks of um 35. So having somebody who's very experienced um is typically able to do that. So thanks for all of those. Um We do want to leave time for questions. So let's shift over to what providers can do differently. Um To align with fat folks and trans folks and their work and also just make a plug here for folks to mention the physical environment um that people encounter as they go into um offices. Naima. Do you want to start thank you jess. SPEAKER 4 Um And I appreciate you really raisin or uplifting the physical environment because that's the first line that we we experience when accessing care at any place or access in any facility or resource, right? Is that the actual physical environment. But I do think that um when we think about providing care for um a population we should individualize the care and not generalize the care, right? So um but I loved and I still love because I've had both bottom surgery and top surgery with the same provider was the tentative care that they showed to me right? That they see me as a person. Like they didn't judge me because of my weight. They didn't judge me when I like increase weight size. Like they said, you know the insurance is gonna push back to you push back on this because your uh your B. M. I. Is high right? Um So let's like work out a plan to figure out what we can, what ways we can do to support you. Um Whether it's like Shane said picking up exercise um uh strategies or changing eating habits, right? Uh But when I went in went into the next visit and I increased five more pounds. There wasn't a beat down on me right? There was this um this need to address me as a person and not as a patient, right? So um I think that you know making sure that when we're providing these cares this care for our community for the trans community, trans and non binary community that were genuinely there and intentional about the work that we're doing right, and I suppose not just in a medical setting, but social justice work as well. It's like we are the people who are driving this work. I love that we're having these ongoing conversations because the research just wasn't there before, right? And now we're working together to create this research. So there can be a brief in the future for what it looks like for trans inclusive care, right? So I do think just like not generalizing the care because you're providing trans related resources or trans related care, um not generalized into the community, but individualizing it to the people that are accessing your your facility for services. SPEAKER 1 Tell me do you wanna jump in? Oh, I was I was reading I was reading the SPEAKER 2 I was just reading the sorry, the lively discussion on on insurance, that's all Yeah, I can jump into Tommy SPEAKER 3 while you're reading that. But I think Naima, you said it so well like patients or people and having a person first an individual approach rather than like a generalized approach is really important. Some of the things that that I think about, you know, walking into to a health care provider of any sort is are the chairs gonna fit my body, Is there a door that I can walk through? Is there, you know, a handicap or an accessible door electric door or things of that nature. I think about all of these things around disability justice and accessibility is critically important when we think about um you know, fat liberation and um you know, systems of oppression that really do space wise and physically impact fat folks. I think about when you walk into the room, you know, what chairs are there available? Do I have to be wait are we asking for consent to weigh is weight necessary for this appointment? Um You know, does the patient want to see their weight or is that gonna be something that is going to be harmful to them throughout? I think about really taking away more intentional approach to what is going to make your patient the most comfortable for the reason that they're visiting. Um It's really really important, you know, is the table if we're gonna have to do um a pap smear, if we're gonna have to do some kind of other checking or looking at something is that table have like a weight limit that fits my body and am I gonna be able to safely and comfortably access care that's already difficult for any individual no matter what their sizes, but particularly for for trans individuals navigating some of their general um or routine healthcare checks. And so I think about those things when it comes to physical space. And I think the other thing that I think about when it comes to what we can do and I think I said it earlier is get curious and never feel like an assumption or the quick route is going to be the best route. Um I'll use an example of I've had chronic hip pain for the past 2-3 years and it started when I was at a much smaller size than I am now. And when I went into um an orthopedic doctor to talk about what that might be, he said the only reason this is happening is because of your weight. I'm like it doesn't feel like that. And I also this see started occurring when I was at a much smaller size than what I am now. And he was dismissive and was like, you know, you would have to lose the suggestion was 100 £220.03 months before my next appointment, which is terrifying recommendations. And incredibly uh you know, I don't want to say unhealthy but unsafe, unsafe for anybody in any um situation to have to navigate. And so I think about creating intentional time, getting curious and really trying to figure out what are the things that I can do to investigate and bring a patient the best and most informative answer that they can then determine what they need to do for their care and autonomy comes to that. And I think about Yeah, I think about so many things and examples like that that when I come into an office or when I come into a health care provider, the first thing that anybody can blame any symptom on is weight and it takes so much labor and emotional work as a trans person who is already doing a lot of education around trans healthcare in the middle of Missouri. Um but then to then have this extra layer of, you know, can we push past this and look a little bit deeper and more intentionally at what I'm experiencing rather than saying weight loss is gonna be the only thing that provides me with better health. Um and so that's what I would say at first, SPEAKER 2 wow. Um what Nina and Shane both said is incredible and um and I'm taking that in and I read the chat and I think I have super A. D. D. By the way also. Uh so I'm like but a couple, a couple of things that I I want to say that I appreciate it so much and I had no idea, I would appreciate it until it happened was whoever thought of making those little cards, their little name tags that say pronouns, even if I say see someone wearing a rainbow or a pronoun sticker patch. Anything I feel okay, they might be a safe person so we can have this conversation or they might understand about pronouns, I would really really love to say, I don't know if there's anything you could do for like it would be super cool if you could be like make some cools like body positive slogan also and and have people actually, it would be great that people could actually have, um, the more neutral stance on weight and have healthcare ways for healthcare providers to show that right off the bat so that you don't have to worry cause I like, I seriously went to all virtual visits because I can't navigate that ship stuff anymore. I just, it's just too much. It's, I used to be way tougher than I feel more sensitive now and I'm like, I don't have the strength anymore, but, but I do, I mean like, um, like luckily the clinic I go to, they know to put me in a room, they know the room with the right kind of chair. Um, yes, I just saw somebody in the fat and proud, 100% would wear that Nice. I 100% to just, I worked in a city, I saw that in the chest. Um, um, but yeah, I just hope that people can become more knowledgeable about this and more like more knowledgeable and more compassionate about what it must feel like and, and I feel lucky that I have a team that's pretty good about it, but the bigger systems around that surround it is limitations. Yeah, that's all I have to say right now. SPEAKER 1 No, it's great. Um, some instruments that folks didn't mention earlier. Just simple things like blood pressure cuffs. Um, or I've seen ridiculous things like we took it on their wrist instead. Like that's, that's not that's not what people need. I'm having longer speculum, there's so many crutches, wheelchairs, just like things that are going to be around for folks. Um UCSF recently, like went through especially their emergency department and said like, we want everyone to be seen here. We already know that fatter folks, you know, don't receive good care. So it's likely they're gonna end up here in the emergency department. Like we need to have everything that goes up to £800 or else we're not doing our job. So there are, you know, facilities out there, they're few and far between um that are doing this work. And I would say like, if as a provider, you want to provide care, like why are you making it harder for people to come in and get care? Um is always my question when folks, you know, try and talk about fat phobia and say, you know, we're just we have the best interest at heart while we're trying to talk about weight. And I'm like, actually that's a not what the research shows and b they're not coming back to you. So really what are you wanting as a provider who's providing care? Um and then something that I will typically discuss um when I am on panels is just like how somebody's are inherently treated as risk factors when we get in the door. So that goes for, you know, black folks and black women, especially in gynecological care. Um fat folks, trans folks like if there is a diagnosis right already for your body or your identity, like you're already a problem. You're already a disease walking in that door. So providers like how are you talking about that? Are you using words like obese and overweight? Like because don't that's already like the person in front of you is you're deciding that they're a diagnosis but actually they're a person. Right? So how are you having these conversations? Are you comfortable using the word fat? Like how are you talking about bodies in a way that makes that person a person not a diagnosis, not a disease, not a problem in your office that you have to solve. Um We still have more time and I don't think I've seen um questions in here, folks want to that's fine. Um I'm gonna give, I'm gonna count to 10 and then we do have another question that I can ask. I don't want people to jump in. Mhm. Okay. Um I will ask about resources so that of course is something that people you know want to walk away with. So are there resources that you would like to share? Um that you used as yourself? I know that some of you all have said that you've looked for images online of what top surgery looks like and for fatter folks um people are always looking for those ones but other any other resources that you would recommend to providers to parents out there to folks who are thinking about all of these things. Somebody just puts the health at every size health sheets and they're those ones I think are great, remind me, jasmine if I am less remembering because you know of over 40 I think those are those are four like patient advocacy and that one's a hard one for me, right? As you know, people and patients like we should know that our doctors are telling us things that are not true and making us a problem and I don't love that people have to advocate for themselves. So if there are providers, if there are friends here, like if they're our allies here, I need to be doing that work. Um thank you mayor for putting um my book in there. I um I am a resource for folks here. You can find me, I'm very online um, and can talk about the way stigma both resources and policies that I've put together other places, the work that I'm doing now. Um but when it comes to resources, like think as somebody who has a lot of privilege, like the stuff that we could be doing, I will call and yell at my friends, um, doctors when they're not getting whatever it is, you know, medication or whatever it is, um because they're fat. So those are things that we can do any other resources that folks. Yes, I just wanted to say this isn't like a SPEAKER 3 wonderful resource. But I think one thing that you were talking about Jessica's really viewing this from an equity lens and understanding that equality and like trying to make everything generalized or just one size fits all is not going to be the approach, but a real thoughtfulness about what are the barriers that fat people are experiencing and what do we do to create opportunity and access for them um and safety for them. I think one thing is that, you know, in 2023 we have so many people and community and resources happening online and I hate to be that person that's like instagram and Tiktok go find some people who are doing fat liberation work. You know, I try to share a lot of them on my instagram plus size trans guy, you can start there but there are so many other incredible people doing even you know, more work than I am doing in this space who talk about their experiences and I think it's important to take individual stories and individual experiences in as informed, you know, knowledge and and research and things to think about. And so um I'll have to think of some names that come to mind that I'll put in the chat, but there's some incredible people if you search fat liberation tags, body liberation, body neutrality um in hashtags and and any of those spaces like Tiktok or instagram you'll find some great people for the most part and I'll pitch SPEAKER 1 it to amy to wrap up. But first I will say that oftentimes social media is underrated, right? And we'd like to say like, oh, you know, that's on social media. I'm not online. Um and our patients are so like we are, we're seeing, you know, we need to be seeing what they're seeing and Tommy at a hand real quick. SPEAKER 2 Just real quick. One of the things that I found super duper helpful with fatty clear disability caucus on facebook. It's been around for quite a while and it's been super helpful and people are super social justice activist type people. And it's awesome. And I put it in the chat and you have to ask to be, it's it's a private group but very, very queer disability companies. SPEAKER 1 Great thanks. Give me your back on. I see you. SPEAKER 0 All right. I just want to say thank you so much Jessica to you Tommy Shane Naima, what a rich discussion today. And I wish we had hours more to continue because there's so much more to say on this topic. Thank you to our attendees who took the time to be here. I'm putting the evaluation in the chat again and we love to hear from you whether or not you want to collect continuing medical education credits. We want to hear from you about our grand round series uh what's working for you and other topics or suggestions. We will be back in april with our next session. Thank you all for being here, and we look forward to seeing you next time. Take good care.