All right. I'll get us started. Welcome to everybody. We have two speakers this morning. One is Harper Barrowman and the other is Nelson McKino. I will just start with Harper, Harper's transgender individual, who has bachelor's degree in bachelor's degree in counseling with minors in social work and psychology. And he'll graduate with a master's degree in clinical mental, how counseling in June Harper did receive his gender affirming surgeries here at Boston Children's Hospital. Harper came to work with Boston Children's in 2020, and he worked as a milieu counselor within the Department of Psychiatry. There he educated his co-workers on the way to support gender diverse individuals and how gender identity often goes hand in hand with mental illness. Harper also worked with both patients and their families to foster an understanding of gender identity, as well as help them understand the resources available within Boston Children's Hospital and the larger community. He's spoke at Children's Hospital to both the anesthesia and urology grand rounds, as well as the Pride Month celebrations in order to help us better understand issues relating to gender health. In 2021, Harper moved to Portland, Oregon, where he began work as behavioral health therapist at an adolescent in patient psychiatry unit. He continued to advocate for gender diverse patients and educate parents and co-workers. Harper then returned to Boston Children's Hospital in February 2023 as a behavioral or senior behavioral health counselor, and has continued his efforts to advocate for gender diverse youth in the inpatient psychiatric setting. He continues to utilize his personal and professional experiences to pursue a career as a mental health therapist for gender diverse youth, and I want to thank Harper very much for coming back and talking to us at this point. The other speaker is Nelson Aquino, who needs little introduction here. Nelson is a senior nurse anesthetist within the department of anesthesiology, critical care, and pain medicine. He's been here for about 15 years. Nelson is highly respected for his clinical expertise, and I would say would not be too much say he is much beloved for his approach to patients, families, and the improvement in environment he brings to all of us that have a privilege of working with him. He received his undergraduate education in nursing, and his doctorate in nursing practice from Seton Hall University. He received his training for certified nurse anesthes at Northeastern University. Nelson has really been an amazing individual. He has demonstrated exceptional leadership and innovation in research and advocate for transforming our perioperative care for transgender individuals. He has done this locally, nationally, and internationally. His binary work, particularly in establishing a specialty anesthesia team, known as the Gender Affirming Curgical Perioperative Program, or GAS, has really been foundational to the care that we've been delivering here in our department. He's really significantly advanced anesthesiology practice, both locally and nationally. He developed and implemented the first gender affirming enhanced recovery after surgery or e-rass pathway for chest masculinization surgery. This protocol reduced hospital stays, and the observed 45% decrease in median surgical drainage output, leading to fewer patients returning to the OR for human-to-month evacuation in first 24 hours after surgery. He's a co-principal investigator in a multi-center database known as Part A, or the perioperative anesthesia registry for transgender adults and youth, which includes two pediatric and four academic adult hospitals. His database collects and benchmarks national data, including clinical practice, advocacy, and meaningful solutions that address critical gaps in care for transgender patients. And just to get this started, I think I will just briefly address the fact that we all recognize that the current political environment we're in will undoubtedly, to one extent or the other, affect gender health care going forward. However, in my personal opinion, Harper and Nelson have demonstrated some of the best traditions of Boston Children's Hospital in essentially trying to optimize care for everyone that walks through our doors. And I'd just like to say that regardless of the context we find ourselves in going forward, this is the mission that we are dedicated to, we will continue to pursue. So thank you all, and I think Nelson is going to get us started. Good morning, everyone. Thank you for being here today. It is truly a privilege to be here today to share my passion and the work that I have in our Department of Anesthesiology. My presentation is entitled Bridging the Gap, Improving Parioperative Outcomes for Transgender and Gender Diverse Surgical Patients. I have no conflicts or financial disclosures, but I do have some supplemental disclosures. I am not a gender affirming an immunokinologist, surgeon, or psychiatrist, but I am a doctoral, prepared nurse and us that studies the anesthesiology outcomes and the therapeutic outcomes for this population. Recent executive orders concerning gender affirming care for transgender individuals, along with no protection for their providers, have created significant uncertainties. And this presentation will focus on our clinical practice and research. For questions about gender affirming medical management, please consult with the patient's direct providers for legal concerns, contact the Office of General Council. And so my objectives today are to share with you the new structure of the Gender Health Program here at Boston Children's Hospital. I'll update you on our gas anesthesia team operations. I'll discuss the creation and implementation of a gender affirming enhanced recovery after surgery pathway and our future research. And perhaps the heart of this entire presentation. We're going to enhance our gender affirming care knowledge through one patient's experience. I'll share with you just some impactful data. The most recent and the largest US Trans Survey of about 92,000 adult respondents, ages 18 or over, there also is a population of patients that they looked at 16 and over, show that 40% of individuals at least had one negative experience interacting with a healthcare provider, whether it was misgendering verbal abuse, physical roughness. However, in this study, they did find out that there was huge life satisfaction, whether it was with social transitioning, medical transitioning, or surgical transitioning. There continues to be data to show that transgender and gender diverse individuals have increased suicide rates for transmasculine. Adolescent, it's a 50.8% attempted suicide rate for trans feminine adolescents. It's almost 30%. And when you compare that to the general population of adolescents, it's 14%. And lastly, I just wanted to share in a youth risk behavior survey done by the CDC, if you have one adult that is accepting, you can decrease that suicide rate by 40%. So anyone here today, we have an opportunity to be an ally and support the patients that we care for. So I'll begin with the evolution of the Center for Gender Surgery here at Boston Children's. It started with the Gender Multispecialty Service, or known as the GEMS Program at Boston Children's, and this was founded in 2007. And it was the first major program in the U.S. that focused on this population. The GEMS Program supported gender diverse children, adolescents, and young adults, collaborating with experts across many fields, including primary care, adolescent medicine, and endocrinology. In 2017, the hospital established the Center for Gender Surgery provide transgender patients with access to surgical options that meet the World Professional Association of Transgender Health Guidelines. It's important to note that not all patients wish to have or pursue gender affirming surgery. And between 2017 and 2022, the Center maintained the robust, clinic, and operating room schedule. And we were performing at least 30 gender affirming surgeries, including superlum and plants and removals each month. In 2019, especially anesthesia team was created to support these surgical services. And in this flow chart, it illustrates how patients were streamlined through the Center of Gender Surgery and how our anesthesia team was a big part in the complex perioperative planning process. In August of 2022, we experienced a wave of hate emails, including bomb threats and death threats directed at our gender teams. And this backlash arose due to the commitment that our hospital was to provide gender affirming care and surgeries for adolescents and young adults. And being a gender affirming provider at a children's hospital, we've recently become targets for hate groups that misrepresent our work on social media. And this has made it challenging to share our team's work and research openly. And one example is now like when we send publications for review, we have to have it reviewed by our legal team. And as a result of this hostility, the Department of Plastic Surgery made the difficult decision to cease the provision of certain gender affirming procedures in January of 2023. Today, the Center of Gender Health replaces the Center of Gender Surgery. The new Center emphasizes a multidisciplinary collaboration that aligns with the WPAST standards of care aid. And within the Center, Gender Surgeons, Mental Health Providers, including our Department of Anesthesiology, closely work with and support our transgender patients and families. And in this pathway, patients are encouraged to engage with the Center of Gender Health Pathway and fulfill all their medical, mental health and biopsychosocial guidelines before their surgical consultation. And this collaborative approach ensures a comprehensive care and supports informed decision making for each of our patients. Today, our surgeons will offer the following gender affirming surgical procedures. In the Department of Gynecology with Dr. Grim sat in their team, they offer a Volvo Vaginoplasty Lackerscopic Gender Firming His Syrectomy and Fertility Preservation. Our colleagues in Urology with Dr. Yu offer Mototo Plasty, Penile Implantation Fertility Preservation and other urological services related to complications from previous genital procedures. Our colleagues in ORL offer Condra Leringer Plasty, also known as Tracial Shaving and Vocal Harmonization. And our colleagues in general surgery support the implantation of superland and removal of implants. We also have our endocrinology colleagues in the GPU that are doing this without anesthesia, with our sedation team or using VR technology. And the Center of Gender Health along with Dr. Grim sat, who is the leader within that, is optimistic with the possibility of the Brigham and Women's Hospital collaborating with us to bring back chest mask-alizing surgery in the future. Now that we've completed our first objective, we can transition to discussing the creation of our specially anesthesia team. In 2018, we noticed a significant increase of transgender individuals in our operating rooms. Many of these patients reported experiences of misgendering and a lack of gender-affirming care, and we realized that we were unprepared to effectively manage this population. So in response, our specially anesthesia team began as a grassroots effort, consisting of four CRNAs and three anesthesiologists. And our primary focus was to support our patients through the parioperative journey and just play a crucial role in the surgical planning process. In 2023, Boston Children's Hospital officially recognized our efforts, and we allied to establish a formal program within our institution known as the Gender-affirming Surgical Parioperative Program. If I had a slide, it would be the entire Department of Anesthesiology, but now as we look ahead in 2025, we build a strong leadership team that includes our anesthesiologists in chief, our parioperative division chief, and anesthesiology representatives from all areas, including the parioperative clinic, cardiac anesthesia, our satellite locations, the acute pain service, regional anesthesia, and the critical care environment. You know, our team also includes vital support, research nurse and administrator, our research coordinator. And most importantly, we are proud to have two members who identify as transgender on our team, Dr. Julia Galvez, an attending anesthesiologist, and Harper, who you'll meet today, one of our patients. And their voices are and experiences are truly invaluable as we continue our commitment for inclusivity. So for any of our nursing and surgical colleagues, if you have patients that require our consultation, please email us. In 2022, our team published our first case series on gender-affirming surgeries in a manuscript detailing our evolution and our experiences. And this work has been cited about 16 times and has established a benchmark for interdisciplinary collaboration in gender-affirming care. And as a result, many hospitals have created their own teams and reached out to us for protocols. This slide represents the participation of our gas team and patient care based on ICD codes for gender and congruence. And from 2019 to 2023, we provided care for nearly 2,000 patients who identify as transgender. And of these patients, 40% have undergone non-gender-affirming procedures, while the remaining patients have chosen to have gender-affirming procedures. As our hospital advances with EPIC, our team is diligently working to stay current with our IT development in our anesthesia department to ensure like accurate data collection and quality improvement and research initiatives. We also work to participate in the care of any patient that identifies as being transgender, whether they're coming for an elected procedure or a gender-affirming procedure. And you can see here we have the ICD codes and we have, for example, the day of surgery and you can see the procedure and they can ill state what room they're in. And on the schedule, you'll notice that there's a black bar and it says gas. And what that means is that one of our team members is in that room that day to participate in the care for the patient. In six years, our team has achieved a lot. We've earned numerous accolades and established new evidence in anesthesiology and parlioperative outcomes. But what makes us incredibly proud is our collaboration and our mission to educate and just share how we can improve the care for our patients. In this bottom slide, Brennan Martin, one of our nurse's nurses, spoke at the health equity rounds for the Department of gastroenterology. We've also spoken for the Department of Radiology, the Department of Adolescent Medicine and our GEMS program and with our nursing colleagues. And so after completing our second objective, I'd like to share our experiences with creating a gender-affirming enhanced recovery or E-RAS pathway and evidence-based strategies we use to develop and implement them. Before diving into that, I just wanted to share a little bit about definitions. So an E-RAS pathway, many of us are familiar with in the adult world, is a multi-modal pathway to enhance the recovery by decreasing length of stay, minimizing opioids, reducing complications and promoting a quicker return to normal function after surgery. And we're starting to streamline that in the pediatric discipline as well. Evidence-based practice is a systematic process of integrating the best available evidence, clinical expertise and patient values to inform our decisions about improving the quality and safety of our care. And quality improvement enhances these process and outcomes with healthcare settings by continuously monitoring data and to improve efficiency and reduce variations in care. And so during my enrollment in the Doctor of Nursing Practice program, I had an opportunity to discover the Iowa model of evidence-based practice to promote excellence in healthcare. And many hospitals globally use this as a framework to optimize patient pain management, create protocols, decrease infection and enhance patient care. And this conceptual framework resonated with me and guided us through our initiatives. So over four years we collaborated to incorporate the key evidence-based strategies. And our goal was to translate and inform evidence-enhanced recovery after surgery pathway for chest-masculizing surgery. And the key elements of this model really focus on addressing frontline issues that were important to us as anesthesiologists, nurse and SSS, and for our patients. It really emphasized a multi-disciplinary collaboration, balance, decision-making that integrated research evidence, clinical expertise and patient preferences with the commitment to continually assess quality improvement to drive some sort of systemic change. And the first step of the Iowa model is to identify the triggers for opportunities. And so for us, what we found was many patients reported unintentional microaggressions and barriers to care. We noticed that there was practice variation with some of our gender-fermi surgeries and a lack of standardization. And often as clinicians we were wondering why do we even do it this way. And some of the opportunities that we found were we could advance gender-fermi care within our department, within our hospital, perhaps improve perioperative outcomes, all at the center of keeping our patients at the center of these efforts. And so the next step of the Iowa model was to state the question. So our team posed the question, how can we implement evidence-based interventions to reduce, for example, post-operative nausea, vomiting, reduce opiate use or minimize any adverse outcomes for our transgender patients having gender-affirming, masculizing surgery. And the next step was to formalize a team. And we were very fortunate to collaborate with our plastic surgeon Dr. Gnore and his PA Haley. Our gas team maintained an open communication with our nursing colleagues and our gym leaders throughout the entire process. But a crucial element was to identify the key stakeholders within our department, which included Dr. Chaco, our E-RAS director, our anesthesia clinical leadership in the main hospital and our satellites. But we greatly value the participation of all our anesthesiologists, our CRNAs and trainees, which whose involvement really was essential to our success. This slide presents a literature review conducted between 2019 and 2020, focusing on evidence related to gender-fermi and chest reconstruction practices. And with the help of an expert librarian and doing our own literature review, we found a significant gap in evidence regarding gender-affirming E-RAS guidelines and recommendations specifically for gender-affirming chest reconstructions. But we did find a handful of high evidence level scientific evidence to help support cisgender E-RAS pathways for breast reconstruction and best breast mammopathy procedures. And these included systematic reviews, meta-analysis, randomized control trials, and E-RAS consensus guidelines that address issues such as like decreasing hospital length of SA, PEO and V pain management. And the reduction of hematomas, which we empirically observe in our ambulatory center. And for this, we use what was currently in the literature to develop a clinical guideline and a key part of this process was involving balanced decisions that integrate what was in the literature, but with our clinical expertise. And having this team, we were very fortunate because we participated in 99% of the chest reconstruct cases from 2019 to 2020. And we learned many lessons. We also analyzed the preliminary outcomes from our chest reconstruction case series from 2017 and 2020. And combining those, we created a clinical guideline. And our pilot guideline included looking at the transgender biopsychosocial factors and proving gender-affirming care and applying some of those E-RAS recommendations. And as I mentioned in our patient population, we noticed patients coming back for hematoma evacuation. So we contacted our local expert, Dr. Susan Gooby, with whose studies trans-acemic acid. And we looked at the evidence and we applied a 30-mg per kilo bolus with a 10-mg per kilo per hour infusion for our patient population. Our team met monthly to review feedback. We analyzed real-time data and we tried to form consensus for this guidelines. And we implemented those clinical guidelines and we analyzed some of our quality improvement data and then we formalized a chest reconstruction E-RAS pathway with Dr. Chaco. And in this protocol here emphasizes the patient-focused interventions. And these include gender-affirming care principles, reducing mis-genering and alleviating dysphoria as well as smoking sensation. We incorporated preoperative ancillosis. A lot of our patients had pre-existing traumas and PTSDs. A careful assessment of substance disorders with suicidal ideation and harm. We also addressed unnecessary HEG testing aim to lessen dysphoria. Interoperately, we established strict anti-emesis protocol and hemastasis protocol that included trans-acemic acid and vasopressors to maintain baseline blood pressures for the surgeon during hemostatic control. Our protocol did not include regional anesthesia but we did provide that for some of our patients. And this was because of the evidence that we found in our low-pacute pain scores, inpatient pain scores and our improved surgical techniques by the surgeon infiltrating local anesthesia into the drains. Looking back, reflecting on this process, we learned a lot of important ways to assess this. But one thing that I wish I could have done differently is perhaps done a more formal quality improvement audit of our interventions and evaluating the outcome measures. I also recognize our value to a delphi design survey and gathering consensus among our team members as well. And so the next step was to disseminate the results. So we shared our findings and experiences with the broader healthcare community. And we actually published an article looking at an observational cohort study of patients. And it's entitled implementation of enhanced recovery after surgery pathway for transgender and gender diverse individuals undergoing chest reconstruction surgery. And the primary aim of the study was to compare hospital and to stay in three epochs. And we retrospectively looked and we had 362 patients. The first group was a traditional group before our team started. And we had about 144 cases and the anesthesia management was whoever was assigned for that patient that day and the team and they decided on how they were going to care for patients. The partial e-rask group was when our team got involved when we created a clinical guideline. And you can see there was 92 cases and that was during the COVID-19 pandemic when there was they weren't doing as many as elective procedures. And the last group we looked at was the e-rask group when we formalized this and we had about 126 patients. In our secondary aims, we identified predictors of length of stay looking at a multivariable regression analysis and we compared outcomes from groups receiving transness hemic acid and those that didn't receive transness hemic acid. So we actually had a study within that looking at two groups and we focused on surgical drainage output and adverse events such as hematoma and the returns operating room. And our key findings that we observed is that there was a decrease in hospital and the stay from the traditional group of 1.1 days to 0.3 days in the e-rask group. Trans-acemic acid decreased length of stay by one day. We had a 45% decrease in median surgical drainage output. But we had a meaningful outcome. We mitigated the returns operating room for hematoma evacuation within 24 hours. If you have an opportunity to read this article, there are many limitations and we acknowledge that for example the Hawthorne effect potential selection of bias with trans-acemic acid and improved surgical outcomes. And so this brings us to the end of 2024 and completes the journey when we question the status quo and to our team developing an e-rask protocol. And recently, plastic surgeons from Kaiser Permanente published a scoping review focused on enhanced recovery after gender-ferming pathways. And this work adds a lot of value to improving care for these patients and this population. And in their scoping review, the authors search five significant databases and in their initial search, they yielded about 951 articles. And after removing duplicates, the authors searched another 608 articles and they narrowed it down to eight studies. And this table shows eight studies. They were two e-rask studies, including our chest reconstruction e-rask protocol and an e-rask protocol on facial feminization surgery that lowered pain spores and short and length of stay. In addition to that, it included was our team study in the development of our program and our outcome study showing the impact and the footprint that we put into the scientific advancement for e-rask pathways for gender diverse individuals. And so we continue to create clinical guidelines using that model. We have several that we work with our surgeons. We have a gender-ferming tracheal shaving guideline, hysterectomy guideline. And we also have a gender-ferming Volvo vaginoplasty guideline. And in our latest cohort of vaginoplasty pages, we observed our clinical practices and outcomes to support new protocols. We looked at the existing evidence. And one example of our outcome that results that we need support for is we found that there was a 56% incident to post-operative nausea vomiting or trans women population undergoing vaginoplasty. And what we hypothesize is that the contributing factors could be the imbalance of estrogen and the absence of endogenous testosterone following or cactinus part of the Volvo vaginoplasty procedure. And so Epic is excellent in providing tools for us to do data analysis such as slicer, Dicer. But our IT department is working hard to enhance our records and work on other dashboards and research efforts. So in the meantime, I just wanted to show a prototype that we're using within our department to look at how we're adhering to these vaginoplasty protocols. And Dr. Julia Galvez created this prototype called the Epic Reporting Dashboard. And so our team uses it to track adherence to the vaginoplasty protocol. And we categorize it by the procedure. And as seen here, we can track in the last three months the number of vaginoplasty procedures we've done. We can see if volatile anesthetics we use, if not no volatile anesthetics for use. And this initiative is really a significant step forward. And I hope it inspires anybody else to perhaps generate some of those ideas on how you can think of improving your area of expertise or a patient population that you're interested in. The prototype is a work in progress. And the simplest way to put it is. Medical health. Medications in a master file, which is often different than the medications are anesthesia record. And so merging those two sets of metrics is not really that straightforward and requires a lot of mapping. But what we can find is that we can see what is being done. Are we using TXA as part of protocol? Are we doing the anti-emetic measures? What type of epidural infusions are being used? And as far as metrics, you know, Epic is primarily designed for adults, but the packet outcome measures that we can specifically look at our first packet pain scores and the highest packet pain scores and rescue anti-emetics that were given. And so you can see here that no rescue anti-emetics were given in our patients that had vaginoplasty procedures, but we did realize that we had high packet pain scores. So if anybody is interested in developing this type of dashboard, I ask you to reach out to Dr. Galvez who sits on the Epic Analytics and dashboard subcommittee and she'll be happy to help you with this. And so what we're doing is we're using that real time information to enhance our clinical practice and refine our protocols. As I mentioned, these high pain scores reported raise concerns for us. And so there could be a number of contributing factors, but one intervention that we were trying to do is we're trying to start the epidural mix infusion earlier in the operating room. And we're also considering using long acting narcotics or value to help with the recovery phase. And to end this part of the presentation, I just wanted to share some of our team's future research. Currently there are no prospective studies in anesthesiology and perioperative transgender care. Like many studies, our studies are retrospective and focus on single center outcomes, but looking ahead, our research goals to expand that into multi center. And our research goals are prospective data collection and our surgical colleagues have created a trans registry, which is a long longitudinal surgical outcomes registry specifically for vaginal class, the invulval vaginal class procedures. And it collects data on several key variables. And for these surgeons, the most important ones were patient reported outcomes that includes assessments of quality of life. And the most important thing about clinical variables is they looked at where health history, operative practices and post operative events and let us stay, but there were no specific anesthesia management or perioperative outcomes. And so that brings us to the part A, which is the prospective multi center research registry that we created, the perioperative anesthesiology registry for transgender adults and youth. And so we were giving a grant. We looked at the experts within the field and we created a collaborative. We also created ways that we can improve this. And so we have an IRB now where centralized IRB have Boston Children's Hospital and we have currently six sensors and one of them being Oregon Health Science University, which is the largest gender affirming surgical program right now in the United States. And it has collects numerous data for anybody ages seven to 100 years old. Anybody coming in for both gender affirming procedures or non gender affirming procedures is de identified data. We look at surgical history and anesthesia management, land to stay, functionality and medications. And so this registry as mentioned is a co investigator with Dr. Pervero. I run this registry with another colleague at Stanford Children's Dr. Travis Reese win our team is very involved. And you may notice Dr. Eugene Kim, who was an anesthesiology resident and an anesthesiology fellow here in the department and then the nanesthesiology attending who we nominated as our steering committee chair and we have steering committee research leads. So for any of our centers that are involved, we can go to the steering committee and choose what areas you want to focus on. So this brings us to bridging the gap in transgender care will our registry validate some of a hypothesis and related to biopsychosocial factors for trans and their patients, you know, we're questioning whether do previous gender affirming surgeries such as vocal harmonization and facial feminization increased perioperative risk for airway interventions during elected procedures. We're trying to determine if gender affirming hormone therapy is associated with a higher incidence of deep vein thrombosis, which is inconclusive right now, but across the lifespan. We also want to assess if gender affirming hormone therapy influences the effectiveness of certain medications, muscle relaxants. We know with hormonal contraceptives in the fears with sugamitex and the new anti-emetic aprepetent and this information could help us refine our medication protocols and improve outcomes for our patients. As I mentioned with postoperative knowledge and bombing and our trans women population. And are there differences in anesthesia management practices, you know, there's a lack of standardization and we really want to look across centers whether implementing standard protocols such as e-rass pathways for other gender. Feminist procedures can improve outcomes and enhance overall functionality and our goal is really to create consensus guidelines. And one important study that just came out in 2023 was the Pride Pain Study and it noted that LGBTQ patients have pain disparities and have pain differences with chronic pain. So is there ways that we can improve this with our pain management strategies for our gender affirming procedures? And lastly, we in our collaborative have mentored many trainees, other colleagues and one person in particular that is really special to us is Kyle Sanchez, who was a CA3 in a CZology resident at Massachusetts General Hospital. And Kyle really was passionate about transgender care and anesthesia outcomes. He contributed as a resident, significant scientific evidence. He was part of our part A registry. He helped us with our red cap registry and he worked tirelessly to educate colleagues across different fields about gender affirming care. And Kyle was set to become our principal investigator as an anesthesia resident after convincing the MGHRB to get a faculty sponsor. And we were in the final stages of approval when he tragically passed. But Kyle's legacy lives on through part A our registry and all his contributions, including our last article, which we looked at a comprehensive details related to considerations of transgender and gender violence. And gender and gender diverse patients per opera. And I put the QR code here for those of you that are interested. And thank you so much for listening to this part of our presentation. I want to thank everybody within our department, our CRNA group, our part team, anesthesia IT and all our colleagues in surgery. Thank you. So it's truly an honor to introduce my friend, a patient, a colleague, Harper Berryman. And I hope that you listen to his journey and learn from this. He's a wonderful person and could I do here's Harper. Thank you Nelson and everyone with us today for the opportunity to share my story. My name is Harper Berryman and I'm a senior behavioral health therapist on the inpatient psychiatry unit here at Boston Children's Hospital. The graduate student working towards my master's degree in clinical mental health counseling. And as you all know, a transgender man who had life changing gender affirming procedures done here at Boston Children's Hospital to properly explain just how important my experiences with the gender affirming surgical perioperative program have been. I'm first like a share of it in my background. I've known I was transgender since the moment I was born. I know that sounds cliche, but it's true. I cried and ripped off dresses when I was a toddler. I was only wearing a diaper and a good portion of photos of me as a young child. I was sitting on my brother's old clothes and always played the dad or older brother and family type games with friends. When I was three, I did what any child would do when something was wrong and I told my mom the world, the word trend, gender was nowhere near my vocabulary, but I told her this mom something's wrong. We need to go to the doctor. They gave me the wrong body. I'm a boy. Now my mom's a problem solver. She saw a distressed child had little to no background knowledge on anything to do with being transgender and she replied with the following. No, honey, you're fine. You just want to be like your older brother. Now my brother's cool, but he's not medically changed your body to be like him cool. In that moment, I began to think something was seriously wrong with me. I continued to wear his old clothes and play with the boys until kindergarten. Around this time is when kids tend to become more aware of gender and gender roles. And this is when the bullying started. The boys I was friends with slowly distanced themselves from me and the girls seemed to truly enjoy throwing glitter at the freaky tomboy. The bullying lasted through middle school until I eventually decided to play the part. I went all in. I wore the skinny jeans, the push-up bras, the makeup. I even had a boyfriend. I wanted to fit in and the bullying and stop making others uncomfortable. Yes, I felt and still often feel like it's my responsibility to make others comfortable with the idea of my very existence. But all this occurred at the cost of my mental health. I became those statistics Nelson mentioned earlier. I hated myself and everything about my body. I was miserable. I slowly disconnected from life and retreated to a world somewhere deep within my own head. How can you connect to the world around you when you can't even connect to yourself? I hate what most would call rock bottom my senior year of high school and could no longer keep it together. I couldn't fake it anymore. One day I realized I spent my life being miserable just to make sure others were happy when they weren't doing the same for me. I had a choice to make. Do I fight for myself or continue to fight against myself? I chose to fight for myself and that decision both changed and saved my life. A lot of people have the misconception that once you come out as transgender things get immediately easier. That's not true. Once you share this portion of yourself with the world you can't just take it back. I wasn't a three year old anymore. I was 18 and I was in control of my life. Or at least in theory. And I just had to put my head down and fight, especially during those let's call it awkward stages of second puberty. The public ridicule, the judging looks from strangers on the subway, verbal harassment by drunk strangers. They need to prove to doctors and insurance companies that I was who I said I was. The family therapist telling my parents and siblings not to use male pronouns because it was just feeding into the attention seeking behavior. And they needed to show me they weren't supposed to plan to my games. All the while I kept my head down and told myself I needed to prove to them that this was real. It felt like that was normal. That message of well you're the weird one here they get to question you and say those things was overwhelming. And honestly still something I hear myself thinking when people ask me things such as what do you have down there. Prior to my transition, I was very fortunate to have been in good physical health and not have required any surgical procedures. Since beginning my transition in December of 2015 to date, I've had over 25 surgeries. The first four of these procedures were not done with the team at Boston Children's. And with each of those procedures, the days leading up to them were not filled with excitement for the next step in my journey to becoming me. They were filled with fear and anxiety. Not over whether something would go wrong and I wouldn't wake up. We're about to pain I would be in following surgery. I was scared that people would make fun of me while I was under anesthesia. Just lying there naked helpless defenseless completely vulnerable. What would these strangers really think of me of transgender people? Were they just doing these surgeries because of the backlash they would face if they chose not to? For the money or potentially worse? Were they just indifferent? Not recognizing the life altering procedure they were performing and the power to influence the rest of my life they had. I assure you these concerns were not unwarranted. I don't think people realize how much time gender diverse people have to spend convincing others. Strangers, they are, that we are who we say we are. Maybe it's because the idea of not aligning with your body is so hard to grasp for someone who has never felt such immense discomfort and self-loading in their own skin. Maybe it's because people still believe this isn't a thing. Regardless, it's rare that people will just believe you. To afford these life-saging procedures and have them covered by insurance companies, I had to provide numerous letters of support from various mental health care professionals, as well as primary care physicians, assuring that assuring that I was in the right mind and had been actively living as my chosen gender publicly for at least one year. So much of my ability to live as my authentic self has been rely on on others perceptions of my own gender presentation. Prior to passing, which refers to a person's ability to be perceived in their gender identity by others, I was referred to as it freak and various derogatory terms for lesbians by strangers in public. And in many ways, I was reading. Or maybe I was a pro also. I felt like a freak with various mismatched parts. Whispeech in hairs and a high pitch voice, hairy legs and double-debrests that could not be camouflaged by a chest binder. I did not speak up when I heard whispers of, that's her or him, I guess. Remember the catcher Harper? Yes, she's trying to be a guy now, I guess. On the rare occasions I returned to my hometown. I avoided using public bathrooms at all cost due to fears of being verbally and or physically accosted in either bathroom. Too small and feminine for a men's room and too butch for a women's room. I didn't fit anywhere. Once I finally started to pass, I then began to be othered in a whole different way. Prior to pursuing fellow plastic, I had the privilege of undergoing two cryo preservation cycles to freeze my eggs. This meant having to stop testosterone, thus slowing my physical aggression towards manhood, to begin injecting myself daily with hormones to stimulate egg production. This process also involved going to the hospital each morning for blood work and transvaginal ultrasound. I'd like you all to do your best to picture a 21-year-old Harper. Sitting alone at 5.30 in the morning and the waiting area of the fertility clinic I pursued care at. Surrounded by cisgendered heterosexual couples. I kept my head down, wrote my name on the sign and sheet, found a seat in the corner, and pretended to scroll on my phone to avoid acknowledging the quick glances in my direction, and whispered questions of what I was doing there from nervous couples trying to distract themselves from their own anxieties. Now picture a nurse entering the room and calling out Harper or the smile on her face, only to have that smile turned to a confused stare when I stood up and approached her. I began to walk out of the waiting area towards the room where the labs were drawn as I had done for the past week, but was stopped by the nurse. She told me this facility was only for women. Assuming she was under the impression I was trying to donate sperm, as had been assumed the week prior, I've explained I was transgender and freezing my eggs. She continued to stare at me, briefly glanced toward my pants, then shook her head and informed me again that this facility is only for women. And walked me back to the waiting area. Confused, embarrassed, and relatively defeated, I walked back to the front desk and served it to write my name on the sign and sheet again. The front desk clerk asked what happened, and once I explained she quickly pulled aside another nurse and had her complete the necessary procedures right away. But the already feeble trust had been shattered. My embarrassment and shame threatened to engulf me as I laid on the table, legs spread waiting for the ultrasound to begin. I contemplated stopping the process completely and never going back to avoid further shame. The most upsetting part of that entire encounter was that I believed in my core that the nurse was right. I didn't belong there. I never felt welcome. Prior to that blatantly negative experiences, I was nearly treated. I was never welcomed. Following my egg retrievals, I underwent a complete hysterectomy. On the morning of my procedure, I recalled numerous medical students surrounding my bed to look at me. Some asked questions, others just stared. I assumed they were all helping with this procedure until my surgeon arrived and sent all but one away. It was though I was an animal at the zoo and the kids were pushing to see me. Or more accurately, something to be added to an eager resident's CV. A few days after the surgery, I began experiencing fairly significant bleeding. The on-call doctor told me to come to the labor and delivery emergency room. Now I would like you to picture that same 21-year-old male approaching the front desk of the hospital around 2 a.m. Stating I was told by my doctor to come here. A sleepy eyed male security guard looked at me for a full minute. I watched him struggle to comprehend what was occurring. That's labor and delivery. You know that, right? I stared back and simply said, yes sir, I do. He gave me my ID bracelet and told me where to go. By that point, I was too tired mentally and physically to care about being embarrassed. And I knew this was the last step I needed to complete in order to start my fallop lasty journey with Boston Children's. For every low point and negative experience I've had on this journey, there was a high point with a team at Boston Children's. For my initial consult appointment to this moment right now, I felt supported, heard, valued, and safe with this team. So much so that I wanted to support others in accessing these procedures from the groundbreaking team. I started a fundraiser to support uncovered medical costs for fellow trans individuals. From the moment I met the gasp team, that fear of being judged while under anesthesia left my mind. I will never forget my first surgery here. Wednesday, January 29, 2020. The day and night prior was filled with bowel prep, minimal sleep, and three trips outside with my new puppy. I had to arrive at the hospital at 5.30 and despite this being the biggest day of my transition, a multiple pre-op appointments I had with a surgical team prior, where it was made perfectly clear they were good caring people. I still found myself preoccupied with the thoughts and fears about all the people I had not yet met or vetted. The nurses, the students and training, the anesthesia team. As I sat in the waiting room, I watched families with young children waiting to be called back to pre-op. They stared at my mom and I as respectfully as they could, but were clearly curious as to what this adult was having done. I waited patiently as the admitting nurses became, began coming into the room to call back patients and families one by one. One of the nurses really brought the enthusiasm and an effort to ease some of the young children's and family's fear. She walked into the room and made a big presentation of announces, Mrs. or Mr. come on down. There are multiple nurses, but I had a feeling she would be the one to bring me back. Something in my gut told me she was about to add announce, Mrs. Harper and that feeling was spot on. All eyes were on me as I slowly stood up, waived to her and said, I'm Harper. Her embarrassment with her mistake was only matched by my own. I knew her intentions were not malicious, and since that moment I've been admitted by her multiple times, and she's been incredible, and even as corrected others with making an error in my chart, and ensured that my gender marker was updated in my patient chart. However, that was not the best start to this day. The next hour was full of anxious waiting, countless consent forms medical jargon, and my body being autographed by surgeons. It's an incredibly overwhelming experience, and when I get overwhelmed, I kind of just blank and don't take the time to actually acknowledge how stressed or panicked I am. Then I hear knock knock outside of the curtain, and Nelson emerges. After two minutes of talking to him, I knew I was in good hands. His enthusiasm and passion for the work that he does, and the patient he cares for, was clear. My mom still mentions the time he spent sitting with her while I was in surgery, to give her an update and make sure she knew I was okay. Since that moment, I've never questioned whether people will make fun of me, or even say the slightest potentially negative or judgmental thing, because I know I have a team of people looking out for me. No matter what the surgery is, surgery is an incredibly stressful, invasive, and potentially traumatic experience. For transgender people, we have the added political and social climate to consider when placing our well-being in the hands of medical professionals. Throughout this process, I've had four urologists, each with their own unique technique, ideas and opinions on what was causing my complications. Some surgeons I didn't even meet until the day of surgery. The consistency that the gasp team has provided to me is truly priceless. Knowing infrurge resumed the COVID era, I brought an added level of chaos and stress. I was not allowed to have a support person with me, so I went on alone. But I was never actually alone. I still remember sitting in the pre-op room chatting with Beth, and talking about what Netflix shows I'd been watching to pass the time while recovering. It isn't often that you're able to develop a relationship with your anesthesia team like that. She sat with me while the surgeons came in and went through consent forms, and gave me some much-needed words of encouragement and support when I was feeling particularly frustrated about the process, and worried about a new surgeon. With each encounter, the gasp team continues to make me feel cared for, valued and seen. There's so much hate in this world right now. Ignorance and hatred, demonizing transgender people and calling for the abomination of them. Political figures openly referring to trans people as mutants from another planet. Just this past summer, I had a coworker who clearly was unaware that I'm transgender. Come up to me at work and share his thoughts on me. Share his thoughts with me on the whole gender and pronouns thing. He proceeded to tell me that he follows the rules and calls kids what they want, but he knows it's just a trend from Tumblr. And he'll be over with soon. Just like any other trendy thing. Discriminate Tory ignorant people who hold the power to dictate my right to exist. Make people like Nelson, Beth, Bistra, Alison, Laura, Dr. Crivero, Kristen, Carolyn, and anyone else on the gasp team that I'm forgetting. So incredibly essential in this world. And for the record, me not remembering all the names or aspects of my pre-op journey does not mean each and every one of you has not impacted my life in more ways than I can ever explain. I feel safe in your care, which is not something that comes easily, especially in today's society. You're sick. It's just a trend. You're perverted. You need to be locked up. These are the messages being thrown into the faces of transgender people everywhere at every moment of every day. Young children, just like the young Harper crying himself to sleep begging whatever power was out there to just make me a lesbian. So I wouldn't have to face the world as a transgender person or even better have me wake up as a boy, but I was willing to settle for anything as long as it meant not having to tell the world something was wrong with me. Because that was a message I was given. That's the message transgender individuals are still given today. It feels impossible and exhausting to simply exist as a trans person in this world right now. But people like the gasp team make it better by making every effort possible to make it clear that I exist, I matter, and I deserve quality care just as much as everybody else. At the end of the day, I and many other transgender people just want to live our lives and not constantly question whether or not other people are judging us for doing so. Quality care team specialized in gender diverse needs matter because the kid on the right thought the closest they would ever get to facial hair was that burnt cork beard on Halloween. Because the teen on the right thought a tailored suit teen on the left thought a tailored suit and a buzz cut would never be an option. Because the kid on the left thought of future with a person who loves them for their true self was simply not in the cards. Simply put, this care matters because transgender people matter our safety matters are happiness matters are wellness matters feeling safe comfortable and happy in your own skin should never be a privilege. People should not have to subject themselves to embarrassment and shame and medical settings and hope of finally feeling whole in their body words will never fully explain my immense gratitude to the gasp team for what they have given me. A life I never gave myself permission to imagine as a child a life I still have to pause and pinch myself over but above all they've given me the confidence to pursue moments like this where I can share my story and hopes of connecting with people like you who can then go on to change the lives of gender diverse people everywhere. From a simple hello to the final words you say to someone as they're falling asleep in the operating room your words matter the way you interact with your patients matter. I don't say that to scare you or make you second guess every interaction you have but merely to remind you of the power you hold to impact a person's life an entire sense of worth. I'll close with something my parents said to me as a child when they feared my stubbornness was bound for more world domination this quote feels more important now than it ever has. Use your power for good. Thank you. We're getting close to time I don't know if anybody has the microphones which I'm not sure I find thank you. We are just about at eight o'clock are there any questions that the audience has right now. I'm just going to say a couple quick things Harper thank you so much for sharing your journey and your insights into care and how's impacted you I think it's informative for all of us all the time. And Nelson maybe I'll just bring one question because I love the way that the gas team has really modeled for me what I'd like to see as sort of a service model of care where you've really put some people together to provide a specific level of care study outcome. Develop enhanced recovery protocols and then follows outcomes in doing that has there ever been problems with having to write people present all the time. I mean you said a level of care expectation with that kind of group. Do you ever have people that come in and you did not have the whole team together and that then caused a problem because I think as we look at developing care service lines. That is always a pushback that we get that you know you you have to be able to develop and provide that care all the time. Otherwise you you disappoint people and I guess I'm just interested in how you've organized that. Why don't you come around here. Yeah that has come across a few times you know that this is a topic that we're still learning about we don't know the long term outcomes for some of these procedures and oftentimes people bring their own judgment to the table and you know what we do is we just try to bring it back to the reasons why we're here. We're all here to take care of our patients and our families and provide them with the mutual respect and dignity that they all reserve. Yes it's been a challenge sometimes but oftentimes when you talk to individuals separately and you you approach them you can sometimes break through and then you'll be surprised that they actually often become the champions to help your efforts. Thanks are there any other questions turns. Great it is eight o'clock I'm sorry thank you so much to both Harper and Nelson.
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