We have our next speaker is Dr. Christopher Flynn. He's an assistant chief psychiatrist for the FAA. As a consultant to the Federal Air Surgeon, he's responsible for the return to flight status recommendations for all classes of airmen and assisting and maintaining the safety of the national airspace. This position relies on Chris's strong clinical psychiatry skills, occupational and military support background, his extensive experience in aerospace medicine and psychiatry. He served in senior senior leadership positions in the Air Force, the VA healthcare system and the US Department of State. He's an author and co author of 10 peer reviewed articles, six aerospace psychiatry focus book chapters. He's earned numerous awards for his service excellence. He's board certified psychiatrist, fellow of the American Psychiatric Association, fellow of the Aerospace Medicine Association, and a member of the American College of Psychiatrists. And today he's going to present on gender experience and aviation mental health standards. Welcome, Dr. Flynn. Thanks very much. So, I hope that I'll be able to give you some insights over the next 45 minutes to an hour. Most of that some of that time is going to be for your questions. I think the first. The first thing that I want to say to prepare you for the talk is that we have professional leaders who are transgender. So I don't want you to wait to the end to wonder about that. That's one of the reasons that we're discussing this today because I don't, you may not know that or, or maybe a question that you've had time. And the second thing that I want to say to you is that I'm not an expert in gender health. I am a psychiatrist and I take care of people, but this is about as complex a topic as you can wander into right now so I'm not going to present myself as a as a great expert, but I'm also trying to help you leave today from this talk feeling like, you know, I know more about that now I think I can understand a bit more about what, what it is we're talking about and why this is a complex topic. Okay, because most of the time right now we don't hear about this except in bits and pieces. So that's my goal for today and we'll see how close I get to it as we move along. I am a physician at the FAA but this is not an FAA sanctioned talk so if you leave from here just say Chris is an idiot, don't say the FAA is. And, and this is just a little bit about my background and thank you for the very kind introduction I think that what's important for you is why should I listen to Chris well I've been an Air Force flight doc, I've taken care of people in the overseas environment as a State Department doc, and so I'm also clinically experienced and so I think those three things together maybe I can offer something that will be practical for you guys because that's really what I'm after is giving you something practical. I hope you were my age, and so you'll remember certain results I hope you won't end up at the end of the talk feeling this way. And I'm going to start with a couple of complicated slides, and then the rest I think will be explanatory to those. Here's the first thing that gets me going right away is like what is, what is the difference between gender, sex, and sexual orientation. I hear those three things, and I get confused almost immediately because I think, I don't know what are you trying to teach me right now about these about this why are we separating these terms out. So, let me help you with this, just to separate out these concepts so gender is an experience where sex is actually phenotype. Right, so that's, that's the difference between these two terms that we're talking about transgender, and then sexual orientation always threw me off. And so I put something in parentheses that you won't usually see but to just to help you understand sexual orientation is really about sexual interest orientation. So, because otherwise it's like well sexual orientation is that what I think I am which is gender. Right, so to try to separate those three things out for you gender is who I think I am. I'm born phenotypically, and then sexual orientation is my sexual interest orientation, who am I attracted to. And those three things I hope will be helpful for you. Then there's these labels that arrive underneath. So gender. For those of us who are straight, that's called sis. And so you'll see that terminology or you'll see the terminology called straight binary means I feel two genders, at the same time, non binary means I feel more than two genders, at the same time. Trans is that terminology that helps us understand that someone is moving from one gender to another. And so that's what trans is telling us. From a gender perspective, for instance, I am phenotypically male, but I feel female, and I'm trans I'm moving from my male phenotype into a female phenotype I'm going to go to get surgery or I'm going to take hormones to match what I believe I am. That's what those terminologies mean you'll remember from medical school training male, female and intersex meaning there are some chromosomal abnormalities that make individuals sexually differentiated in a different way. So sexual orientation or sexual interest orientation has these kinds of words, which end up right here talking about this words this sort of letter salad that you see LB LGBTQIA plus, and oftentimes we, we, I see that and I just I you know I skip right over it like I don't even know what that means. But I'll explain that to you in just a moment but sexual orientation or sexual interest orientation or these kind of terms bisexual means I'm interested in to other genders, gay or homosexual often saying the same thing pansexual again the idea that I recognize in others more than two genders straight is one that you know and asexual which is the A and LGBTQIA is asexual since I have no interest in sex I have no, I have no motivation for sex. Plus, so L lesbians, G gay, B bisexual, T trans, Q queer which is a term that's old but has continued on to say, I don't like any of the other terms. So queer is saying I may be different than these other LGBTQ. I is intersex, A is asexual plus are some cultural gender related issues for instance Native Americans have some individuals who see themselves as what they call two spirit. And so this plus is really another cultural attempt to say we have to recognize that there are also other ways of describing this feature. So in those Native Americans who are two spirit they feel like they're somewhere in between male and female. And, and so that's what they're trying to talk about you'll see this is almost, and I'll go over for the people online, the pronouns I think are important for you to now begin to recognize for those online I'm just pointing these out. Maybe if you're like me, you know I get a card from somebody and they give me their pronouns right or I get an email and they give you their pronouns and I think come on seriously do I really need to know this. Why am I bringing it up maybe you feel the same way I do, but the second reason I'm bringing it up is because we're doing this now, not because I need to add another step for you to read my email. Because we need to decrease the cultural angst, and the negativity that is going towards people who don't identify just like us so what what that does and you can see it as we get to the end of the talk today. What this does by placing he him his is not telling you I'm, I need to make this a big statement what is really saying is for those people who need to tell me their pronoun is different. I don't want them to feel like they're so different from me. And we'll, I'll help you understand why that's important for us as physicians, we get to the end. Go ahead. When you say they, they. I, I have trouble understanding that. So up there under trans is trans. I guess I thought of trend as someone who dresses like a woman. That's right. They even felt like a woman. I mean, you know, there are some, yes, they don't want to do anything but the male person they are, but they love dressing up as a woman. Trans one, but it was a transition to becoming the gender so thank you for that. Thank you for that question. So, the word trans without writing it all the way out is currently used not to me transvestite was the term that you will you that we used in the past at our age. So that's the trans that you know from age group. Now trans means transsexual. And what that means is I'm a gender that isn't that I'm not a phenotype of. So, so that's that movement now trans is transsexual. Transsexual. Transsexual. Well you can change the genotype. Okay. Changing transgender. Yes, following that. That's true. Go ahead. Thank you for bringing that around. They is for the person who is binary or non binary. In other words, they have more than one gender. And so that's what they are. That's, that's why they is a correct terminology. Because many times when we first saw it in notes. It was a collective noun. Yes, but here it's a singular noun. Yes, it's just, and that's where the confusion lay. When we're trying to clarify the history, because who else are you including in this because there was a name prior to it, and it really got everybody hopelessly messed up. Right. So the question is, it's when do they use it. Only if it's in their pronoun and we consider them then to be either not contradictory but uncertain as to questions which they are identifying. That's why the name could be a he or a she. Yes, and so the correct way is to address the person who is binary or non binary as they, when you're talking to them directly, it's they. Yeah, I don't know how you can respond grammatically, however you want to and our EHRs will do that but I think the main thing for us to understand again what will I'll move through these slides faster than this one but it shows the complexity right, but I think that what we really want to do as physicians is we want to respect the person, and the way that we do that and I'm not going to forget you. The way that we do that is by learning this term, which is what I was trying to say about these pronouns at the bottom. In other words, those pronouns are helping me and you as a physician, connect with the patient correctly right at the start. So somebody's helping me understand that there is a, and it's helped me already I haven't made a misstep that's already separated us. And yes, when you were saying the, you know that you're talking to a person and refer to them. I'm sorry, I still think that the appropriate term is you, because I'm referring to the person individual formula, however they identify as in a third party situation. The other question is, how do you handle the situation where that individual has multiple personality disorder. Are they they or them or whatever so differentiating it. Okay, so we'll jump we'll get for the people online so there's two questions here one is, is it more correct for me to say you or they to a person who is binary or non binary directly from directly in front of me. You is fine, but I, they is where I would try to, I'm trying to, I'm trying to help them. So, so they. So, you would be appropriate way would be appropriate. You know, if you can't know what to do if you don't have that in front of you just simply ask the person, how can I address you so that I can so that we can have a conversation. Like you referred to and that'll, that'll clear that up and then you had a second question. Personality, do not do not confuse these things with multiple personality multiple personality individuals do not have two personalities in front of you at the same time, they may be moving from one personality to another, but there's only one person personality it's quite difficult to know who which of the personalities, it is, and that's the challenge of treating those Yes, I don't want to drag out. Yeah. One thing that's always confusing to me is when you say somebody is trans. Yes, male or trans female right. Can you. Yes, so so trans male I have become male and trans female I have become female. So the person in front of you may have been born as hearing to be a phenotypically male that are trans female they're now standing in front of you as a female. This slide is only to help address the complexity of what we're talking about I'm not going to go through this slide. I just wanted for you, because I made this slide for me, because as I was chart starting to talk. I said you know how does this work how does gender separate out from phenotypic sex. The sex phenotype, and where in the brain, do these things occur. Well, the reality is we don't know a whole lot about that we can tell you a good bit about the mouse brain. So, but there's not a whole lot to tell you exactly how is it that we as human beings differentiate into these groups because as a, as a psychiatrist if I have someone who's in distress over their gender. The question would be well is that an illness, or have I have we just now begun to understand and accept what has already been there or has always been there but it's been a small number. So, the number of the slide before that I kind of glanced over is that it's about 1% of the population who do not feel that their gender is their sexual phenotype. That's not a small number. And so that means we're gonna meet these people and we need to try to understand that. I wanted just to remind myself, and so I'm hoping to remind you, that we have a very complex system. We have multiple hormones that interact, which affects sexual behavior, sexual change in our physical features as we advance in maturity and cycles of fertility and genealogenesis. So these hormones are very active. There's multiple receptor sites where the hormones operate, and they operate in a variety of locations in the brain as well. And some of these areas of the brain are also differentiated hormonally as the embryo develops. So that these are different, there's different features that become part of the brain, depending on which hormones are more present or not. But no one at this point is saying, oh, we understand exactly how gender expression becomes different from sexual expression. We just know that it happens in about 1% of people. That's the main point, the take-home point here. And I also added on this slide, because the complexity of the sexual response started out with us simply thinking about desire, arousal, orgasm. Those are the three primary concepts of sexuality just from the physiological concepts. And so I wanted to share with you on this slide where those areas of the brain are that operate in those three aspects, desire, arousal, and orgasm. And then inhibition. The prefrontal cortex is the primary area of inhibition of sexual response. And so you remember that because people who have frontal strokes or have frontal trauma often lose that inability to inhibit their behaviors. And so that's, again, just trying to help you understand from a brain perspective, there's a lot going on. The next slide is to try to set us into a context, because I feel like right now the conversation about gender has become the idea that it only started five years ago, that there was some concept of transgender. Well, that's not true, actually. In the Indian culture, transgender has been around since the 1200s. And so the Hindra males that you see here are very alarming to see, because when I was serving in New Delhi, they would come up and tap on your window and they'd ask for money. And that's what they look like. And you're just like, what in the world is going on here? And then it becomes important to say, well, these people have been living in this transgender, this transgender state, and that this has been present for centuries. Similarly, the concept of female warriors, which is not exactly trying to show yourself as the opposite gender, I'm not suggesting that. I'm suggesting, though, that gender roles actually have not always been the gender roles that we think right now. In cultures, for instance, the Dahomey warriors of Benin in West Africa were female warriors, very fierce female warriors. They were present in the 1800s. And so I'm not, again, please don't misunderstand me. I'm not saying that they were transgender. I'm saying that women operating in a different gender concept, in other words, they're taking on a masculine gender role, has been around since the 1800s. When you think about female athletes, that is something that's kind of dramatic. I mean, when you think about it, I wrote here about Dana and Patrick, because, I mean, that is a male-dominated sport, you know, the Indy racing. How did a woman end up winning the Indy 500? How did that happen? That happened because she didn't apply as a normal gender role of a female, right? I mean, I'm not saying that she's sexually interested in somebody else, that's not sexual orientation. I'm just saying she adopted a different gender concept because she was completely different from the people that she was competing. I think that's powerful if you can keep that in mind, right? The idea I'm trying to portray here is that gender has culture related to it, whereas phenotypic sex does not. But gender is cultural as well as psychological. And then male beauty pros, that's something that I think you can understand, that there are men who are particularly good at makeup and makeup artists, and that they can be selected over women. And that's not a gender-related issue, right? It's sort of gender different. Most guys are not gonna be doing that work, but there are some that are, and they can be so good at it that they can be identified for that talent. Gotta figure out which way is first. So here's the intersecting circles that I hope is a concept, which for me was helpful, and I hope it's helpful for you, which is gender is somehow this mixture of overlapping circles of physiology, culture, and psychology. There's something individual about me that's psychological, and that relates to my attraction. There's physiologic factors, and there's cultural factors. But the bottom line here, what I'm trying to teach you, and teach myself, is that when I look in the mirror, I do not see what I am phenotypically looking like. I look in the mirror, and I see myself as a woman, not as a man, if I'm the person who's gonna become trans-female. And the only way I can say this to you is perhaps what you experience as being a physician. I wake up every day, and I look in the mirror. I don't think of myself like the first thing, though I'm not weird enough to do that, but I don't think of myself like, oh, there's a doctor in the mirror. But not too long after I'm on my way to work, I think of myself as a doctor all day long, every minute of the day. And sometimes I don't wanna think about myself as a physician, and I'm getting calls and texts from people who remind me I'm a physician. And I'd just like for you for a moment to say how powerful, if you're like me, how powerful that influence is on how I think and how I feel, and what it would be like if tomorrow you said, Chris, you can't be a doctor anymore. Sorry, we're taking your license away. I mean, I would be in trouble psychologically, right? I would be empty all of a sudden. I would be certainly conflicted. I might be angry. I may be all sorts of things. But something very deep inside of me, I would have to no longer have. If that is a piece of what that transgender person is experiencing, maybe you can get a percentage of it. I am operating not as who I am. I am operating, I am trying to be something that I am not. I look like a man. That's not who I feel like I am. And I'm having to operate as a kind of a man when that's not what I want to be. It's not who I am. How do we differentiate, in terms of terminology, the person who now presents as the opposite, normal gender, if you will, in looking at it, versus the person who has already made that full commitment and has actually transitioned surgically, a la, you know, a Jenner or a Jorgensen, Chris Jorgensen from 1953 era. So the question, if I understand it correctly, is I have a person that's, Chris is standing in front of you, and I'm asking you to call me Christine. Is that the question? Okay, and that's fine. Yeah, and how do you differentiate between them? We say that that's a trans person. But how do we differentiate between that level of trans person and the person who, like Katie Jenner, who has gone through a complete transition and has made that full commitment this summer? So that is what you're going to experience with the patient, how far they are willing to go, because have you had that experience? If you want to say, can you speak to that? Well, I mean, it happened. I'm in a university, so the whole university's made a commitment to pronouns. Yes. Thank you, Chris. University's made a commitment not only to pronouns, but it's also a lot of counseling for individuals who are considering, and then the degree to which they wish to move. And then the other situation is we have a series of physicians who are quite skilled in aiding that, and that's beyond the scope, generally speaking, of family physicians or internists and even endocrinologists. So to that standpoint, what we're doing is basically on the fundamental, we just say, how would we like him to be referred? And in my practice, we had a lot of gay and lesbian, and what I did was take the lesbian, I had two of them, I took them to dinner, and I said, look, how can I screw this up? Right. And they told me what pronouns to use, how to do it, what to look for, and what not to look for, which to me is just as important. It was an indication, I mean, that's how I ended up doing it. And the notion was, how would you like to be called? And then we treated them as to what they identified with, which means you brought somebody else into the room, you go to the misgendered population, we entered on a gown and then sort of things that what we normally do for a female patient, given that they were male and given that they were gender-wise a female. They were gender-wise a female. So I've not dealt with genuine non-binary individuals or binary individuals, that to me was more of a guessing game for me. It's complicated. So I wanted you, thank you so much for talking directly to that. So the point of that is, I am still conflicted, I may feel that I'm female, but I may have so many constraints, my employer, my spouse, my children, that I am not gonna make any of those next steps for some period of time. And we'll talk about that before the end here. But the complexity of all of those steps are challenging. And so when I sit with you as my physician, man, if I can talk to you and you can address me as she, I'm gonna breathe a big sigh of relief because at least for these 15 minutes, I'm talking to you as who I am. And then as I leave from here, I may now go right back to he, him, because that's what I need to be in society. Oh, and by the way, where the other example you used with regard to Chris, being a lot older than Chris, I can tell you that I don't worry about the issue of medicine or not being a doctor, et cetera, because medicine is what I do, it's not who I am. Well, then you are ahead of me, that's really good. On my best day, I can agree with you, but on my worst day, it's a pillar in me that keeps me going. So what creates mental health problems then? There's gender dysphoria, right? If I feel like I'm a female in a male's body, then what is it that, how can I help you understand what happens next? What happens next is this conflict, this internal conflict that I have to try to live with. I either subvert it, I suppress it, I repress it, right? Those are all those terms from psychiatry that you remember back in school. None of those end up with good outcomes. So I'm either repressing or suppressing, denying, I'm trying to not have it happen that I feel different than what I am. I'm trying to fit in with what I'm supposed to be in my culture. But in fact, that ends up leading to problems in of itself. Then there are these problems of how do I actually, and I'm gonna walk over here for the people online. How can I actually, let's just say I wanna change my name. Well, in order to do that, I have to get approvals from the state or the county. So now I have to go deal with people who may be aggressively against what I'm doing, who may make me feel incredibly uncomfortable for what I'm asking. And so those approvals become a burden. And then if I change my gender, what happens to my insurance? How does my medical insurance change? These things are all again, very problematic. Is someone going to try to force me to change by going to conversion therapy? Is that what my parents want me to do or whatever? So I think that the complexity of this just starts to get into a really big ball of wax when you start to think about it. It's not so simple just to say, oh, well, why don't you just call yourself a woman? Well, there's a lot of complexity about what's gonna happen to them. So consequently, the more open you become, then the more, especially in this day and age, the more social media allows you to be attacked and be labeled as bad or to be rejected or to lose relationships because you were trying to live a different gender than your phenotype. And I'd have to very quickly say that the mental health community was not at the forefront of understandings. We've been kind of behind the whole time. And so believe me, as a psychiatrist, I can't stand up in front of you and say, look what a great job we did. We pathologized this from the very beginning. And so we're trying to catch up. The example that's a tragic example, but I wanna make clear to you is a person who in his community was very upstanding. He led a church, he led a community, and yet he internally was transgender and he was outed on the social media. Somebody decided they found some photographs of him living in that alternate gender. He would do that only at home or in certain experiences, but those were found and placed in the wild, so to speak, on the social media. And tragically, he killed himself. This is not something that has no consequences to it. The person who did that thinking they were going to gain points or do something that they thought was morally outstanding for them to do is not where you want to be as far as I'm concerned. So it's a very tragic outcome when that happens, but being outed and emotionally outed is one problem, but that's not all that happens. In fact, in different communities, if you're identified as different, you'll be physically attacked. Matthew Shepard was killed in Wyoming back in 1998 because he was gay and the individuals around him decided that they couldn't live with that anymore. And so they attacked him one night and left him dying on a fence in Wyoming. New York doesn't happen just in the middle states. In New York on the East Coast, transgender Rita Esner was killed in 1998. Why, Chris, am I picking out 1998 to say this has been around for decades? Maybe some of us are thinking, oh, this just came up this election cycle. Transgender has been around for centuries and it's been around in the United States for decades. Right now it's very hotly politicized, but I'm trying to help you as a provider. Like me, I'm trying to help me as a provider to understand where do I fit in all of this. The Pulse nightclub, about 49 killed at one time. Somebody who was tragically, you know, deranged to do that. And then they, so this is they, Max Benedict, who just was attacked last month at her school in Oklahoma and she committed suicide the next day. So these have consequences, right? Consequences in the way that we think about individuals who are different. So what happens if you're in this bind? Thank you. But, but it's, so it's, it's a, it's a good, it's a good question. And you actually made the dividing line, right? Because what they said was, well, what's the difference between these two things? And the difference is that one person is dealing with non-reality, right? The person who is delusional. So we don't want to think about, this is not a delusional problem. This is a problem that is, that is internal, but not delusional. Delusional means there's no basis in reality for what the person is experiencing. So if I experienced myself as female, but I'm male, the challenge for us in medicine is to understand how does that work? Now let's just say I'm schizophrenic and I'm experiencing that. That would create quite a challenge, right? For me as a psychiatrist, because I'd have to be thinking, is this transgender or is this delusional thinking for some other reason? But I do believe those are two different things. One is, one is an experience that is detached from reality and the other is not detached from reality. It is the challenge of experiencing yourself internally is different from your phenotype. Well, I mean, I understand. And I don't have, I'm still, I'm not trying to be argumentative. But prove to me that I'm not Jesus Christ. Within my mindset, within me, within my me, I am Jesus Christ the same as you are she, if you will. Right. So, so I'd say I can't, I can't, at least today that I'm aware, there's not a blood test I can do. There's not a a genotype, a DNA testing there that says, okay, yeah, Murray's trans female, but John is not. I mean, other than Murray says, I'm trans. Okay. So it seems to me we're being arbitrary. I'm not trying to be argumentative. And I don't want to belabor this. Yeah. I think, I think I'll try to make one more point about that. Then I'll move on because I don't think they're the same thing. And I want to make clear that in my view, they're not the same. Yeah. And I, I agree with that. I think. Yeah. So, so, you know, when I have a patient who tells me that they're Jesus Christ, you know, I don't really wonder too much about that. You got to ask them whether or not the prophet has inferred. I don't too much wonder about, right. I mean, that that's the difference between delusions and something like this. That's the, when somebody is telling me they feel like they're a female I'm also putting this into context, right? If you said, oh, Chris, this is a new thing. It just started three years ago. Nobody's ever seen it before. And so what I'm also trying to help you understand is, you know, maybe somebody in the 12th century thought they were Jesus Christ, but it didn't start a movement with them, right? Oh, the second Jesus Christ was Paul or Harry. Second Jesus Christ was Harry in 12th century and everybody's following him. People pretty much can understand that that's a delusion, whereas this is not. So I don't want you to get infused about the difference between delusions and transgender. So gender experience, because of this difference that people are dealing with day in and day out, that leads to, as you might expect, depression, anxiety, self-medication with substance abuse. And then if you're attacked emotionally or physically, you're going to end up with trauma related disorders. And so those are present. The worst case scenario is that people move in desperation into suicidal thinking and suicidal behavior. And that's where we're trying to avoid this outcome. Well, Chris, what makes that more likely and what makes that less likely? Because I think for you, if you're seeing a patient like this, you'd like to know. The more victimization they have, the more history of self-injury the individual has, and the more substance misuse increases the risk for suicide. Whereas the opposite is true with social support, gender affirming care. So if a person is moving in the direction or they just feel supported by their community, if you go back to Bubba Copeland, who was not living his true gender, he was living his male gender. He had a lot of emotional support in his community, right? But he had no emotional support for his true, his experience gender. But this is where I think things become so important for us in medicine and why I appreciate what your college is doing. Where I work at, when I moonlight MedStar in Washington, DC, it's very much the same way. We're really focusing on how to help people feel non-threatened and support. I'm not going to teach you how to be a psychiatrist, but the point of the DSM-5 slide is just to say it is there. Gender dysphoria is in the DSM-5. There's a debate right now within psychiatry about whether this even needs to be a disorder. Because what we need to do from a psychiatric perspective is help the person live the gender that they're in, not pathologize why they're not living the gender, right, if you follow me. But that's where we're at right now. Gender dysphoria is in the DSM-5 and it generally follows that three circle concept that we've talked about. The psychology, so one's experience, the physiology, they believe that they have the feelings of the other gender, and they want socially to be treated as the other gender. So culture, psychology, and physiology kind of in the DSM-5, just to let you know that it exists and why then it becomes an aeromedical concern is because we have aviators with a diagnosis of gender dysphoria, and we have to decide what should we do. Should we be concerned about that? Should we be not concerned? Well, we approach this problem the same as we would with any other mental health or medical problem. So we look at are the symptoms in stable remission, as you can see, and I'll go to try to help the people online. So the general principles are the same. Is there symptom remission of whatever the mental health disorder is, and are there co-occurring mental health conditions? So those are the two big top line questions, right? How big is the burden of illness? Well, I've already told you that we can expect to see anxiety, depression, substance abuse, suicidal behaviors. So then when we're looking at an aviator's case, we can't be too surprised if we see that, because this is the history that the person has come through to where they are right now. So we look for those as we're talking about here, what kind of treatment has the person utilized? And we use an expert to help us evaluate, and this is the World Professional Association for Transgender Health. You'll see the acronym WPATH at times, but we require that at the FAA based on a decision grid of how we're going to look over the case. And so we want to see an evaluation from a WPATH trained professional, because they know enough about the patients to help us understand, is this person on the right trajectory? Are they in trouble? What more should we do for them? So for those who are AMEs, you'll know in the AME guide there is that, and you can look at it to help you submit a package. Of course you know this. I mean, and can we hold course? I want to make sure Dr. Flynn can get through slides. Okay. I'll pass the microphone around to everybody once we get through. Okay. Yeah, we're almost there too. Thank you for that. So I wanted to take this from the notional, right, and now bring it back down to the practical for those of you who are seeing it. Are there transgender aviators? Yes, there are. I'm going to review with you a convenience sample of 15 cases that I reviewed personally so that we can put this into context and you can try to see what is it that I'm trying to help you leave with today. So all outcomes are possible. We have 50, about half of those cases are flying with what we call a special issue. It's what you might call a waiver if you're in the military. But some of them have no restriction at all. They have an unrestricted certificate and they're new gender because they have completely, as you were asking me, they've completely moved into that new gender role. They are not having any dysphoria or any difficulties and we don't think there's any reason to follow them up. They no longer have that condition and there's nothing else that we need to follow. And then some are not yet ready to fly because they still have difficulties that need to be treated. So I think that would make sense to all of you. We have trans male, and again, answering that question, how does that work? Trans male means they became male, right? So these are now females who are male, who were females, now male, were male, now female. And then we have one binding, a person who identifies as they, as we've been talking about. All therapies are represented. So we have some individuals who have neither hormone therapy nor surgery. In other words, they live their gender phenotypically looking like the other. So again, to answer that question that you asked me about, that person who sits in front of you appears to be male, but wants to be addressed as she. And so that happens. And then we have some who have had surgery and some who have used hormone therapy. And we've had a wide range of the diagnoses that you would have expected, right? By the slide, a couple of slides ago, depression, we've seen anxiety, substance use, and then a smattering of other diagnoses that I knew. So I hope that's helpful to you in sort of putting this into perspective that we have professional aviators who are doing a good job as we would expect them to do once they're fitting into how they view themselves and believe themselves to be. What are the principles of gender dysphoria treatment? This is what's helpful for me. And basically you want to provide the right treatment at the right time. So one of the questions, and there's been good questions from a lot of people, but one of the questions is like, when does this happen? Everybody's not on the same timeline. Some people are going to wait. Some people may never transition all the way through surgery. Some people may use hormonal therapy, but in general, delay in treatment is problematic. Conversion therapy does not work. It tends to lead to worse outcomes. Biological therapies are effective. And so for individuals who are trying to suppress puberty, what that basically does is allow this to be thought through longer before the actual opposite gender phenotype becomes present or more present. And gender affirming hormone therapy is what is used throughout life if the person is living in that opposite body. And gender affirming surgery may or may not be used. Psychological therapies are helpful to help people work through it. And social approaches, which I think is one of the most important things, this was very powerful to me. The risk for suicide attempt, when you can practice your faith with your gender that you feel, reduces. So if you're rejected by your faith, your risk for suicide goes up. People just really, these folks want to be part of the community. So case example, this will get you, this will get you what a person looks like, has experienced gender incongruence since childhood. That's typically when the individual knows that they don't fit. They suffer in silence. They usually try to fit in their life to be culturally normal. So they get married, they have children, and then somewhere around the mid thirties, they can't hold it anymore. They just can't continue in that way. And they begin to have the discussion with their spouse that eventually leads to divorce. Then the children have to be managed. The legal process to get all these things done becomes problematic. They fear, for instance, if they're a professional aviator, whether the FAA will allow them to fly or not. You can all leave from here today, spread that news. And they will, if possible, go to psychotherapy to talk about it, start on a medication for their anxiety or depression. They stop flying, they begin hormone therapy, they create a new system of support, emotional support in their new gender, and they reapply to fly. And as you can see, 70% of the time they go back to fly. And that's what, that's what we want them to be able to do. Okay. U.S. Navy, first trans-female pilot. So yay to the Navy. She is a EA-18 pilot and continues to fly actively now. So if you walk away today, if I've done a good job, what I hope I've been able to do is help you put this into context, reduce some of the confusion, still a little confusing, but reduce some of the confusion. Recall that we're in a moment of time that's been going on for many centuries. The first, and many decades when you consider the first trans-feminine surgery was in 1931. The first trans-masculine surgery was in 1946. So we're in the flow, but how we respond to that now, I think is important. And I hope we can keep, we can live up to our own expectations of how to help people feel safe and supported, because that's typically what gets them across the finish line, no matter where they're at in that process.

aviation mental health

gender experience

transgender leadership

gender identity

transgender challenges

FAA psychological evaluations

gender-affirming therapy

transgender aviators