>> Hello everyone, welcome to session 4A, Treatment Needs of LGBT Populations.
I will go over a few housekeeping items before we get started.
This session is being recorded, you should be hearing the broadcast, the views expressed
in this presentation do not necessarily reflect the views opinions or policies for the Center
of Mental Health Services (CMHS), the Center for Substance Abuse Treatment (CSAT) and the
Substance Abuse of Mental Health Association (SAMHSA), or the Department of Health and
Human Services (HHS).
We are providing live captions, click on the link on this slide, this is also available
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Your line is automatically muted for this session, you will have a lot of opportunities
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>> Some people are giving me Green Checkmark's.
Perfect.
>> I am going to pass things off to today's moderator Ian Lisman, Ian can you verify you
are off mute.
>> Yes.
Thank you everyone.
Welcome to Session 4A.
We have Dr. Thomas Frees, Ph.D. from the UCLA Integrated Substance Abuse Programs.
>> It's nice to be with you today.
It is nice to speak with you about the treatment needs of LGBT populations.
Chat any questions you have the moderators will help me to manage as we go along.
I have about 4 days of information I could present so what I have done today is a survey
across issues, I will talk about these issues related to one specific segment of the population,
really on how they apply to the other segments as well, to cover all issues we need to cover.
>> The Addiction Technology Transfer Center (ATTC) network works really hard to recognize
issues of language and how important it is used correct, this is important and true with
the LGBT population.
So rather than talk about the problems first so rather than saying, an addict, saying a
person that has substance use.
We bring this person first language as much as we can, and I encourage you to listen to
my own language and feel free to chime in if I make any of those mistakes along the
way because we are all learning here.
It is a shift in how we speak about the issues.
The materials we will be talking about were developed through funding from SAMHSA and
allowed us to create the Center of Excellence (CoE) for Racial and Ethnic Minority Young
Men Who Have Sex with Men (YMSM) and other Lesbian, Gay, Bisexual and Transgender (LGBT)
Populations.
This is the name that SAMHSA gave to me.
We claim the alphabet soup in the website, YMSMLGBT.org.
Unfortunately, SAMHSA decided not to refund the CoE but, so the center is not as active,
but we continue to operate as a subprogram within the ATTC.
So, the resources are still available, and we are always happy to engage people through
that.
As we talk about LGBT population we need to look at issues of health disparities.
There are a number of health disparities that are unique to this population, so I want to
survey some of the issues.
And then we'll turn to strategies for reducing them.
One of the reasons why we believe these health disparities
exist are issues of stigma and discrimination heaped on this population.
Very often potential patients and clients are really unsure, as to how they will be
treated in a particular service environment, they are nervous to do so, increasing the
likelihood that they will avoid or delay seeking service or not be fully honest about needs
as they move into the certain service endings.
it's critical that we understand the health issues that our clients may be coming in with.
So that we are comfortable in discussing these issues, even if our client doesn't necessarily
bring them up.
One of the first things that we noticed is that substance use among LGBT people is much
higher than in the heterosexual population.
We do not believe this is indicative of something fundamentally unique or wrong with the LGBT
population, but a coping mechanism to deal with societal discrimination that they experience.
Substances are used to medicate due to family and other conflicts to deal with isolation
and alienation, particularly for those who live in rural areas, it may be very difficult
for them to know where to connect with other areas of communities, and also to take the
risk to reach out to other communities for fear of discrimination.
Substances can help to alleviate that.
We see significant amounts of social anxiety in terms of how to negotiate those issues
as people come into their own with their identities as members of the LGBT community.
Unlike heterosexual people who play with courtship throughout their general upbringing, there
high school situation, and play with dating, many LGBT people feel removed from that, because
of social pressures, and they develop anxiety in those social situations.
Other things that drug and alcohol work really well for they reduce our inhibition, maybe
fear has kept someone reaching out in a social or sexual situation substances use of substances
may lubricate that sort of situation, pun intended, and certain drugs such as methamphetamine
have been shown to increase the pleasure derived once those situations are engaged in.
So, we see significantly higher rates of alcohol use and one class of drugs, when compared
to the heterosexual population.
In one study of gay and bisexual men in four cities it was reported that they had higher
rates of alcohol use, marijuana, poppers, cocaine, ecstasy, downers, and methamphetamine,
in the prior 6 months compared to their heterosexual counterparts.
In another study, gay men and lesbians had significantly higher rates of binge drinking
and heavy alcohol use, although when we look at the diagnostic criteria, for an alcohol
use disorder criteria, we do not see significant differences in those identified as having
a diagnosable problem.
But just that increase in heavy drinking days even if it doesn't rise to the level of substance
abuse, can cause increase in gastrointestinal distress and blood pressure, breast cancer,
and a variety of other issues.
That we also known to be seen inn higher rates the LGBT population.
Among trans-women, studies have shown higher rates again, illicit drug use, alcohol and
marijuana use, and trans-women also report higher rates of drug injection, although the
stereotype is about Street drug, is misplaced only about 12% admitted to injections, were
using them specifically for street drugs, the majority of those people were using them
for hormones, or other kind of body modification issues like silicone, that helps their body
conform to their gender identity.
>> The good news is relatively few trans-women reported needle sharing, and the more needle
exchange, and free needles that are available to people, the more likely it will be true.
Fewer studies have been done of trans-men, the little data that is available estimates
significant issues with drug and alcohol as well, at a higher rate than the general population.
Most of the research done on these issues related to LGBT community, has been reflected
funded on the back of HIV so we have a lot of information on those groups highly impacted
by HIV, gay men and trans women, but much less on trans-men, lesbians and trans-men
and bisexuals across the board.
I am sorry about the coughing, -- I have a spring cold, -- If I disappear it's because
I'm coughing.
>> Assault is an ongoing issue among the LGBT community, in a study of trans-people, called
Injustice at Every Turn, they surveyed over 6000 transgender and gender nonconforming
people, they found high rate of people over 70% had experienced bullying sexual harassment,
sexual assault, harassment of all forms.
Even expulsion from school as a result of their gender expression.
>> Comparing the different kinds of abuse across geographical areas, they found a range
of people reporting assault kind of experience, even the lower numbers in that regard was
significantly higher that we see in the general population.
Sexually transmitted infections are something that needs to be addressed.
Often, we see people delaying both screening and treatment for sexually transmitted infections
(STI).
This slide is focused specifically on lesbians, there is assumption made among providers that
lesbians cannot get sexually transmitted infections, I don't know where that assumption comes from.
Anytime you're touching sex organs, or mucosa contact, there is the potential for sexually
transmitted infections, not to mention vaginal fluids and menstrual blood.
Lesbians are just as likely to be infected and having any type of sexual interactions,
with someone who is infected.
It is important to remember, appropriate screening for sexually transmitted infections, also
gender related cancer, sex-related cancers, are really critical.
Regular Pap smears, HPV tests for all people with a vagina regardless of gender identity,
screening for testicular cancer, screening for breast cancer become important.
This becomes important for many trans-people who do not want to out themselves to their
doctor for fear of discrimination from providers.
They may delay the appropriate screenings.
The other thing that is important to state out loud is for anyone that has ever had anal
intercourse, screening for HPV anally through Pap Smears are recommended.
A lot of the medical providers do not know and do not routinely screen for those issues.
And so, we see higher rates of anal cancers particularly in gay men.
The
bisexual population generally has the most extreme health disparities.
Worse outcomes in every health indicators, often because of their unwillingness to disclose
to their providers.
Even in their own communities' bisexuals can fall through the cracks.
Heterosexuals assume Bisexuals are experimenting and will come back to claim heterosexual identity,
many in the gay community will assume, bisexual individuals are on a step along the way to
a gay or lesbian identity, while that is true for some people.
It is more the case that bisexual orientation is a true orientation that needs to be acknowledged
by providers as such their patients will be more open and honest.
About who they are what they may be facing.
>> It is important to remember regardless of the individual is, the gender identity,
sexual orientation doesn't necessarily say who they may or may not be engaged in sex
with.
Someone may identify as being a gay man but may have a regular sexual partner who is a
woman.
It is important when screening that we understand who they are in terms of gender identity and
sexual orientation but our screening for sexual risks, be as broad as possible and do not
make assumptions who they are having sex with based on those labels as they apply themselves.
>> As I indicated earlier.
For MSM and transwomen in one study-- the rates vary quite a bit-- in one study, the
average self-report of about 12% among trans-women across the US being HIV positive.
56% black trans-women.
In a global meta-analysis of studies, 22% of trans-women were shown to be HIV positive
throughout the US.
Very little known about rates among transmen.
The best studies have been done like Philadelphia, Washington and San Francisco range from zero
to 0% -3% of trans-men reporting that they are HIV positive.
The issue of racial disparity in HIV diagnosis cannot be overlooked.
In 2016 CDC report, it was estimated that one and 11 white MSM will be diagnosed with
HIV in a lifetime, the number jumps to one in four Latino MSM, and one in two black MSM
are likely to be diagnosed with HIV during their lifetime.
I see this as an issue of stigma and discrimination with information not getting to people.
We need to pay attention to agencies, and how are we sending messages.
Not too long ago I was in an agency which specifically targets black MSM but all of
the literature in the agency with -- no criticism to the agency showed images of white men.
This is probably because that was what was available.
We need to find a way to overcome that and to make sure that we are getting this information
out.
It is unacceptable, when we know one into black men and one in four Latino men who are
MSM will be HIV infected during their lifetime.
Someone said wow, that states it entirely.
>> When we look at the younger version of those, young men who have sex with men, are
the most at risk for new infections at this particular point.
We see a significant amount of the burden is on the backs of minority of young men that
have sex with men.
In 2014 they accounted for 80%, of new HIV infections among 13-24-year-olds in the US.
When we look deeper into that data, between 2005 and 2015.
What we are looking at is an increase of 87% of diagnosis in minority men who have sex
with men.
Significantly higher than white men.
Again, the importance of getting this information out is really critical.
An Infection that is much easier to catch is hepatitis.
Significant rates of Hepatitis are found among LGBT populations as well.
Hepatitis A, 10% of new HIV infections are among gayer bisexual men, 20% of Hep C infections,
WE know that HCV is transmitted at higher rates among MSM populations.
It can be transmitted by injection, also by sexual behavior particularly if there happens
to be tearing of the skin during that contact so that there is blood to blood, semen to
blood contact along the way.
The most at-risk group are those who are HIV-positive, and co-infection with HCV needs to be addressed,
in order to keep people as healthy as possible.
One of the things that we look at, health disparities among this population is intersectionality.
It is not just the case being a member of LGBT community, is responsible of disparities,
LGBT people also have race and ethnicity issues, and gender stigma issues, socio-economic issues
that come up.
As we look at all of the different categories, or identities of people that they carry with
them, moving through the world, the more of these disenfranchised groups that they are
with, it is not just an added phenomena, but this multiplicative phenomenon so that if
you have compounding effect of multiple stigmatize identities, being carried by a single individual,
so the impact of any in particular health disparity is greater if you have many identities
rather than if you have none or one.
>> That is critical in legal protections for the LGBT communities.
This map shows where there are state laws that protect and include nondiscrimination
laws, based on sexual orientation and gender identity.
All of the states marked in purple have both protected sexual orientation and gender identity.
Those in orange have only protections based on sexual orientation.
There are no specific laws protecting against discrimination based on gender identity.
This means, while LGBT people can get married in all 50 states, you can meet your landlord
at the door and be told you are evicted because they are told they do not want gay people
living in the environment, or a trans person looking for work, you cannot say we do not
want to hire you because of a particular race, you can say out loud in all of those states
not colored in he can say out loud, we do not want your kind of people here.
And will not have anybody who doesn't express gender in the way that we expect them to,
there is no legal protections associated in the states.
There's a lot of advocacy and works that needs to be done in those arenas.
It begins to make sense, why people are so cautious.
In terms of disclosing their sexual identity or gender identity because they really don't
know when there might be legal ramifications.
>> It is important to highlight we can do a lot in terms of helping people protect themselves.
I will switch gears and walk through the specific things that we can do to help, to make sure
LGBT people feel safe and comfortable in accessing services.
In order to do that--before I do that.
Zach if it's okay, why don't we open it up to questions, see if there are any questions
in the health disparities that we have covered so far?
>> I'm sorry I didn't tell you I was going to do that.
>> That's okay.
>> We do have one question.
A couple of questions and comments in the chat box.
I will get to those.
There is one question, who says where we can find the stats for trans men, have there ever
been grouped with women due to their gender of birth.
>> Really good questions -- I don't know is the answer, there are few stats there.
Most of the information that we have, it is very small localized study, that may not be
generalizable to the entire trans male community.
Because we don't ask about sexual orientation or gender identity on the census.
>> We cannot make any forecast along the way.
While we are used to doing that with other segments with the population, the studies
have been even more localized on trans-men.
The center of excellence on transgender health at UCSF keeps a repository of information
across all communities but even if you look there, the trans men information is really
sparse.
In terms of them being lumped in with women because of the gender they were assigned at
birth, I think that absolutely does happen.
Most of the governmental forms, with criticism intended including those distributed by SAMHSA,
do not ask about gender, really it depends on the person and how they answer that question
as to which group they would be lumped into as they aggregate the data across the communities.
We have a lot of information hidden, but there is no way to pull out that information because
of how data is collected.
>> These are all the questions we have now.
Please put your questions in the box, don't be shy we will have questions at the end.
Now is your time to ask the expert.
Thank you.
>> Thank you very much.
If we are going to make safe spaces.
We really need to look not at a single structure.
But at five different structures.
We need to look at the individual.
We need to evaluate each individual client in terms of their own self-esteem.
Their sense of affirming their own gender identity, in terms of their sexual orientation.
How comfortable or positive or negative do they feel about that.
What kind of internal stereotypes do they carry about themselves.
What messages does that send to them.
Look at the interpersonal.
How does the person experience the world among their friendship groups, and their family?
How accepting have their family been.
What social support do they have.
Also, we need to look at our impact on interpersonal communications and what kind of bias, unconsciously
that we are sharing with our clients that we are not aware of.
>> I heard a provider talking about a trans client, who came in, the provider said wow,
she's really beautiful, I couldn't even tell she was trans.
What kind of message does that say how important is that to pass within the world, according
to heteronormative, and gender normative stereotypes we have.
What does this say about the person who doesn't, according to those gender normative stereotypes.
We can say a whole lot accidentally, and never realize that we are displaying bias along
the way.
Paying attention to our own communication is critical to identifying our colleagues
and our friends' feedback on the areas where we need to grow.
We need to look at the institutional setting, what does your agency look like?
How competent are the providers in terms of providing LBGT space, and what kind of educational
policies are required to ensure that the providers have the information they need to adequately
address the health, mental health and substance abuse needs of their LGBT clients.
Look at the larger community.
Identify how involved in the community they are and how accepting of the LGBT population.
West Hollywood for instance in Southern California has a reputation in being a gay friendly city.
But how has the individual experience the community, because it is also is the case,
it is a significant numbers of Gay bashing, that happens within the confines of the city
for instance.
Then the policy issues.
We look at one policy in terms of nondiscrimination and how they roll out across the country.
What kind of policies are there in terms of housing and public accommodation, what are
the policies in terms of incarceration, and how members in the community are treated and
housed within the institutional settings.
Looking at their own policies, crossing back to the individual institutions, in terms of
housing and group participation for instance among people who have gender expression.
Or discussions outside of the norm for those particular settings.
How do we handle those and make sure that there are safe spaces for them?
There is study done that demonstrated that LGBT clients experience more stigma from treatment
programs and staff, then they do from the other clients within the staff.
I truly believe that staff are generally well-meaning, a lot of times unconscious biases that are
coming out.
So, ensuring adequate training becomes really important.
Many programs never train to address trans issues.
And they just say we do not have those kinds of clients, my response to that, that has
to be BS.
Gay, trans clients, other members of LGBT community are coming in, and they are working
as hard as possible to pass within the setting or they are not coming in because it has been
recognized as not a safe space for them.
How do you as agencies deal with these sleeping situations or showering situations how does
that relate to the current identity of your patient population.
Having clear policies and training staff so that the client isn't having to advocate for
themselves in that regard.
The policies are in place to protect them, this becomes really critical.
>> The question that becomes, what do service situations look like?
If you have gender segregated facilities, what do you do if it is a female only setting,
and you have a trans only woman come in.
How do you handle that?
If you have a mixed setting how do you handle that.
>> How do you handle identity documents?
A lot of times they are required in order to receive services to give their government
issued ID, which may have a name and sex listed then that different, then the one they use
and/or gender identity.
It is critical that we honor the person in front of us, not the government ID by figuring
out how to enact policies.
That takes some thought.
What does assessment look like?
How do you deal with people who don't fit into groups?
>> How do you deal with bullying and victimization within your agency.
How do you keep records to make sure while the record is identified according to the
ID, the individual is respected accordingly?
>> By the way, it is bullying and victimizing, to use inappropriate language.
It is completely unacceptable to use racial epithets within a program and no one will
tolerate that, but as recently as two months ago, I was in a program where they were throwing
the F word around as if it was nothing.
By F word, I mean fag, which is violent and demeaning word.
If you do not know the history, I encourage you to do an internet search.
Even if you do not know the history you should know that the word carries the weight of weapons,
it is inappropriate and unacceptable to use those epithets.
>> Agencies can be divided into one that is not on here, LGBT nonresponsive.
First generally they become tolerant, they are aware, that they use their services, there
may not be specific program and set up for that particular population.
As we move to sensitive, organizations are aware of and knowledgeable and accepting of
LGBT people, although they tend to be mainstream within standard program services.
Within a much more knowledgeable staff along the way.
Then we get to affirmative, actively promotes self-acceptance as a key part of recovery
both within and outside of the organization.
I would like to ask you a question doing this as a Poll.
How would you rate your organization in terms of responsiveness to the issues, is it tolerant,
sensitive or affirmative?
I will give you few seconds just to answer.
>> Great thank you very much.
I think significant when the conference that we are on is about HIV and HIV care, we know
LGBT people or over representative among service needs, it is fantastic that almost 50% of
you work in agencies, that are affirmative, another third working agencies that are in
LGBT sensitive.
It continues to boggle my mind, that we live in a world where 16% of you are still working
in agencies that are LGBT tolerant, that tolerance is phenomenal, it is a phenomenal place to
start.
But looking both at whatever role within the organization and certainly the higher up in
management the more critical it is.
To look at the tolerant agencies and move towards LGBT sensitive issues.
How do make the sensitive agencies truly make those affirmative and affirming of LGBT people
as they seek services within your organization.
Thank you very much for answering that poll.
>> Creating an LGBT affirming setting requires a number of steps.
It involves helping the staff recognize the vulnerable nature of this population and how
that leads to the health disparities we talked about in the opening part of the presentation.
>> Studies have shown that LGBT affirming organizations or known allies are the preferred
providers of LGBT clients.
Even if you are an agency, working in an agency, that is non-re-sponsoring, you putting a rainbow
sticker on that computer to give an indication that it is a safer space here than it might
be elsewhere, may go a long way as the bridge to someone who needs your help.
>> A question for the chat, if providers lack inclusive information about sexual orientation,
or they have heterosexist beliefs what impact does this have on people who are not like
them in regard to gender and sexual orientation?
Type your responses, if you would.
Just looking at the conversation recognizing the training along the way is critical yes
that's right it leads to feeling invisible, lack of respect, service utilization and low
self-esteem, alienate, this is likely to drive them from treatment, it is likely to make
them feel isolated-- great thank you very much,
They may feel misunderstood and left out-- experience discrimination.
Valerie your comment is powerful, -- death.
>> Treatment saves lives.
Treatment for mental health, substance and medical issues saves lives.
If your care is unacceptable it may lead to death.
>> The predictors of treatment success on the mental health side all relate to rapport
with providers.
I have not seen studies specifically, but I think because the number one predict there
on the substance abuse side, the length and treatment pick the longer we keep someone
in treatment the longer they are to have positive outcomes that they are receiving.
We know that if the organization isn't responsive they are likely to feel discriminated, retraumatized,
not to get or seek services in those organizations and likely to drop out of treatment early
increasing the likelihood of negative outcomes.
Thank you for responding to that chat.
>> Practical suggestions are around creating policies that are inclusive to everyone.
Procedures that help prevent discrimination and harassment.
Give really clear information to clients and staff on how to file grievances and complaints
if they do experience inequitable or unfair treatment in the services that they are receiving.
>> It is critical that we look at all aspects of the process of taking someone into the
program and getting them through the program.
What is the initial contact like?
Are they responsive to the people who present themselves with different expressions of gender
for instance, how does the phone inquiry work?
what kind of questions are asked?
What does the intake look like, does it have a Heterosexist slant, does it only ask if
they're married or partnering in other ways?
What does program participation look like and what does this look like pick what are
the elements of the program that they have access to?
And those that are denied to them based on how they present themselves.
In other words, they get shuffled to the converted broom closet down the hall because fear of
rooming a transwoman with other women.
>> Finally, what does referral to services look like?
What do discharge procedure and the aftercare issues, how do we deal with these?
>> Paying attention to all of those issues becomes really critical if we are going to
adequately care for that well-being of the individual.
We need to look specifically at what our procedures are one of the big issues that come up?
Very often how do we deal with people who are different in terms of housing, bathrooms
and showers.
The answer is men should be housed with men and women should be housed with women.
It doesn't necessarily say you need to make that determination on sex, if a trans-client
comes in, they should be offered another room with the woman, you should have a conversation
with the people who are roomed together and asked for concerns about this.
If someone says, I do not want to room, that person should be converted broom closet down
the hall, because they are the person with the problem.
Girls should be in girl places, boys should be in boys' places, wherever possible, there
should be an everyone bathroom that is a single seater that could be made available to everyone.
>> In doing it that way, we decrease the likelihood that the person will experience discrimination
reduce the likelihood that they are going to feel rejected by the program and we take
care of any issues by dealing with the person that has a problem.
I want to make one final point.
Most of our intake forms ask about male and female, they ask about sex and not gender.
The recommendation is a more inclusive set of questions asking the person on what their
current gender identity is, and if you place for people to fill in their own.
And another to ask the the sex I was assigned at birth.
And you know from those answers that you are dealing with a trans man who wants to be identified
that way but may have some health or other issues that need to be taken care of or addressed.
>> With that.
I will close my formal presentation.
You all are welcome to download the slides, there are a few other recommendations along
the way.
I will turn it over to Zach to help us walk through any questions.
>> This is Ian.
We have some questions.
>> Are co-infections higher in MSM of color populations?
>> What specific co-infections are you talking about?
While you are doing that maybe you can type that into the chat.
While you are doing that.
The risk of infection with HIV is partly determined by the race/ethnicity of that particular individual.
Again, having to do with the lack of access on how to adequately care for their health.
When we think about these co-infections with HCV other disease and communicable disease
processes, we compound the impact.
Based on the reality, that they do not know how to protect themselves from HIV infection
and are at risk for other infections.
In truth, I have never seen data separated out, so I can't see specifically but I can
say given the increased risk of all MSM of color and YMSM particularly the risk of co-infection,
and multiple infections, is also significantly higher because it is many of the same behaviors
that lead to infections across-the-board, to my knowledge.
we do not have more information on that.
Can you speak more to implicit bias and its impact on LGBT communities and health specifically
communities of color?
>> I think a topic we can spend a day on.
There are structural elements and internally held perceptions, that leak out into our service
interactions.
That we do not recognize is problematic.
Looking at how bias plays out is really critical.
I truly believe health disparities among people of color in these communities is really about
the biases that are built into our systems.
We see an increase in health disparities across the board for LGBT people, and significantly
more for LGBT people of color.
One way that this plays out.
One example.
That you may see in yourself.
A number of years ago I've had an opportunity to go to one of the first national summit
on transgender health put on by the Center of excellence at UCSF.
I was excited, about the opportunity to learn.
I walked into the room.
My first reaction was not to simply look at the presentation on the board, but to take
a gasp, there were a lot of trans people here.
I did a double take on myself, saying where did that come from?
Recognizing my visceral reaction in walking into that room, allowed me to learn more at
that event, than I had at any conference.
Not only did I have the opportunity to learn the information, the content I went to learn,
but every interaction with every individual, looking for signs of that unconscious reaction
I expressed when I first walked into the room, looking at where it came from.
What assumptions I was making.
And how I can work to not allow that to impact the reactions with the provider or clients
I have along the way.
That is what you need to do to adequately address implicit bias as it comes through
in unconscious communications that we have in the world.
I hope this is pointing us in the right direction.
>> We only have a couple of minutes left.
There are a whole bunch of questions.
If we didn't get your questions we will follow-up.
We have Dr. Freese contact information.
We have a dozen questions.
We will not get to them all.
>> -- Ian -- If you can just send them out to me I can address them as well pick
>> Ok.
We only have a couple of minutes left and we have a survey.
One question, because of the lack of education within communities is the reason for the high
infection rate and how do we create more programs for young adults?
>> Really good question.
I will be brief.
Number of recommendations in working with YMSM people of color in the presentation so
download the slides, there is an article published in this I will include the reference specifically
on that.
In a nutshell we need to upturn our educational purpose, and ask the clients we are seeking
to serve, how best we can get information out to them.
When we did this for a particular summit on this particular issue.
It was really about making services comprehensive.
Using social media appropriately.
And stop being so boring.
Getting out the information to provide.
Looking at making our services attractive the to the populations that we were ready
to serve, this is the most critical element of this, I'm sorry we did not have more time
to discuss it in further detail.
>> I will send it over to Zach.
I want to thank you Dr. Freese thank you so much, thank you to all of our attendees and
participants, this has been a really great session.
>> Thank you very much.
>> Thank you, Ian, I will bring up a couple of survey poll questions, we would greatly
appreciate your feedback.
You will find the link at your top left screen, to the closing plenary session.
If you will take a moment to save that link so that you can join us after the break, in
that session as well, thank you for joining have a great day.
>> [Event Concluded]
For more infomation >> A new treatment for uterine disorder endometriosis - Duration: 3:28. 
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