Aug 302014
Image of needle and syringe - click through to see source

Needles and syringes no longer look like this. Isn’t that wonderful?

Testosterone therapy for transgender men, and others who desire testosterone supplementation, typically involves intramuscular injections of testosterone. Intramuscular injections deliver the medication deep within a large muscle — typically a thigh muscle. From there the hormone can slowly work its way into the bloodstream to do its magic. Few other options exist, and those that do are either expensive or less effective (e.g., creams). Testosterone should not be taken as a pill because it’s very bad for the liver in that form. One possible alternative that has been discussed recently is subcutaneous testosterone injections.

Subcutaneous injections go just under the skin. If you’ve ever had a tuberculosis skin test (“PPD”) or been involved in injections for people with Type I diabetes you’ve seen this done. They leave a little “bump” in the skin for a day or two that slowly goes away as the drug is absorbed.

Subcutaneous testosterone has been in sporadic recent use for trans men without any research showing how well it works. But that’s changed now with the publication of the article I’m going to summarize. :) So let’s hop into it!

This was a study involving 36 male-identified trans youth from ages 13-24 (minors had parental consent). None had been exposed to hormones before. Hormone levels and other lab values were measured at the beginning and after six months.

For those interested in the specific technicalities of how the hormone was given, keep reading this paragraph. For those not, skip down to the next one! They were given testosterone cypionate suspended in sesame oil that was made at a local compounding pharmacy. The young men were given the injections by the clinical staff at first, but slowly taught to self-inject. Dosing was biweekly and started at 25mg per week, slowly increasing after that for some with a final dose ranging from 25-75mg.

So what did they find? How did it go? Positively!

About 92% of the young men in this study had testosterone levels in the “male” range at the 6 month check up. Similar goes for estrogen levels — by that 6 month check up their estradiol levels were down in the “male” range too. 85% of the young men who had been menstruating had stopped by that 6 month check up. Most periods stopped roughly around the 3 month mark. Other factors, like hemoglobin (red blood cell concentration) and cholesterol shifted but were not of clinical significance.

Two of the young men had allergic reactions to the sesame oil and were switched to cottonseed oil. This is a pretty well known reaction that happens in intramuscular injections too. Some also noticed small bumps around where they injected for a few days after injection. Those were the only reported side effects. Nobody reported unhappiness with their testosterone treatment method or asked to be switched to a different method.

All in all, a well put together study. Subcutaneous injection of testosterone so far appears to be a possible alternative to intramuscular injection. But it’s worth noting that commercial testosterone is intended for intramuscular injection and that type is not what was tested here. It may not be safe or effective to inject an intramuscular formulation as a subcutaneous one — ask your physician before changing how you use your medications!

As always: this is just one study. More need to be done to confirm these results. Regardless, I think these are good first results and look forward to seeing more.

Study was published in LGBT Health. Abstract is publicly available.

Disclaimer: I have personally met Dr. Olson (lead author of this study), worked with her in a small capacity, and have attended her talks at conferences. My interactions and impressions of her may have biased my interpretation on this study. However, I do my best to keep those preconceptions from affecting my judgment.

Aug 022014
Rural vs Non-rural

Rural vs Non-rural

This study used a convenience sample of transgender individuals and compared mental health factors between trans people living in rural and non-rural areas in the United States.

Why would health and health care differ between rural and suburban or urban trans people? A number of possible factors, including…

  • Transportation issues.
  • Overall difficulty accessing health care. Fewer physicians, fewer hospitals. Few big research or teaching hospitals.
  • Possibly less social support for healthy lifestyles. Depending on the community, support of a healthy lifestyle may be less. Rates of tobacco use, alcohol drinking may be high and access to exercise and a fruit/vegetable-focused diet may be low
  • Less accepting physicians. Rural areas are traditionally more socially conservative, possibly resulting in higher rates of transphobia. Open-minded physicians may not have the resources to learn about transgender health care, and access to specialists is limited in rural areas
  • Smaller minority communities. With a smaller population, and transportation time, it’s much harder to form a supportive LGBT or trans community. Social support and information sharing may be very limited.

The vast majority of transgender health centers are in urban areas including San Francisco, Los Angeles, New York City, Seattle, Boston, Washington DC, and Philadelphia. Resources in places like the middle of rural New Mexico are few. But that doesn’t mean people in such rural places don’t need care too.

This research used the internet, advertising on mailing lists, journals, and forums, to recruit and survey trans people in all areas. They ended up with a very large sample for a trans study: 1,229 people! What determined whether a person lived in a rural or non-rural area? The participants self-selected an option – and if they selected “rural” or “small town” for their location they were classified into “rural”. Other options (suburban and urban) were classified “non-rural”.

What did they measure? Basic demographics, substance use, mental health (including anxiety, depression, somatization, and self-esteem), and sexual risk behaviors. That last one – sexual risk behaviors – was specifically narrow, focusing only on protected vs unprotected penetration with a penis.

The results were fairly clear.

For trans women, there was no different in mental health between rural women and non-rural women. But trans men were statistically significantly more likely to have depressive or anxiety symptoms, low self-esteem, and other similar mental health problems if they were rural than if they weren’t rural.

There were no significant differences in substance use for either trans men or trans women. There were no differences in sexual risk behavior either.

Some interesting, and some disturbing, statistics that came out of this:

  • 25-27% of trans women reported a previous suicide attempt vs 38-40% of trans men.
  • 7-10% of all trans people in the study reported binge drinking alcohol in the past 3 months. 7-13% used an illicit substance other than marijuana in that same time frame.
  • 42-45% of trans women reported unprotected penile sex with either a primary or non-primary partner, vs 16-21% of trans men (in the past 3 months)

This study isn’t perfect. It was internet-based and used a convenience sample, so it may not reflect the larger trans population. It also used a broad definition for transgender at times, including those who cross dress for reasons other than gender identity. The fact that it was internet-based means that people who do not use computers or have access to the internet weren’t included. Still, it was the first of its time and its methods were fairly sound given these restrictions.

So what can we conclude?

  • First, something that we knew before: Trans people are in need of compassionate, open-minded mental health care and medical care no matter where they live.
  • Second: That trans men living in rural ares may be faring worse than their urban and suburban brothers.
  • Third: That rates of suicide are still unacceptably high for all trans people
  • Fourth: That trans people, especially trans women, are still at unacceptably high risk for HIV and other STDs via unprotected sexual contact.

What can we do about all of this?

Rural health care is a challenge for both physical and mental health. Telemedicine options continue to be in development. Education and outreach efforts must continue within trans communities. Those who work in physical and mental health, whether rural or urban, must understand that transgender populations face specific stressors and have specific health needs. Efforts to educate all providers, such as WPATH’s mailing list and Trans Line, must continue to be available and probably should expand.

This paper was published in the Journal of Homosexuality and is publicly available.

Jul 282014

Some news months are very quiet. But as it’s said, “It never rains but it pours”. These last two months flooded my inbox. Whew!

Alexandrite for June

Alexandrite for June news

Sexual orientation (LGB) news

  • A meta-analysis of women who identify as lesbian found that roughly 48% had experienced domestic violence of some sort in their lifetimes. 15% of lesbians surveyed were currently experiencing domestic violence. Most of the violence experienced was emotional (43% of lesbians). Source.
  • Even after a cancer diagnosis, gay men report poorer health habits than their heterosexual peers. Such habits include tobacco use, infrequent exercise, high levels of psychological stress, and substance use. Any difference between gay and straight men with regards to cancer diagnosis may be a result of different levels of HIV infection. Source.
  • Women who have sex with women are at higher risk for suicide than heterosexual women. The same was not seen for men. Non-heterosexual men and women did not appear to be at higher risk for death in general than their het peers. Source.
  • Gay and bisexual men appear to be underestimating their chances of acquiring HIV and may be missing out on preventative treatment. Source.
  • A study of ex-ex-gay men found that realizing that sexual orientation change was not possible was the reason for abandoning reparative therapy. Reparative therapy itself resulted in negative mental health and shame for these men. Source.
  • Rates of syphilis are going up among men who have sex with men. Remember to use protection and get tested! Source.

Transgender, gender identity, intersex news

  • A paper was published acknowledging that research on transgender youth was limited at best. This paper advocated for early identification and treatment for the health of the youth. Source.
  • A study of young trans men using subcutaneous testosterone found that subcutaneous testosterone is effective and safe in short-term use. Monthly bleeding stopped within 3 months and most men in the study reached cis male testosterone levels within 6 months. Source.
  • A list of clinics providing care for gender non-conforming and transgender children and youth was published. Source (PDF).
  • A summary article was published summarizing the current state of challenges facing transgender youth within medicine. Source. Another similar article, intended to familiarize a pediatrician with cross-sex hormone treatments, was published. Source.
  • In-person survey results may differ significantly from online survey results within the trans population. An analysis of data from the National Transgender Discrimination Study found that people who took the survey in person were more likely to be young, relatively poorer, trans women who also were more likely to report being HIV positive and use substances. Data from in-person vs online studies should be interpreted accordingly. Source.
  • An open access article was published exploring the lives of several waria, trans feminine people from Indonesia. Most felt that any potential risk in risky transition-related behaviors (e.g., taking hormonal contraception pills, silicone injection) was worth it. Source.
  • Quality of life for intersex people seems to vary widely, depending partially on where they received medical care as children. Source.
  • A review of the care of intersex children concluded that it “requires acceptance of the fact that deviation from the traditional definitions of gender is not necessarily pathologic”. The review also advocated integrated peer support for intersex individuals and the development of skilled and trained teams of professionals to assist families. Source.
  • A case report of a trans woman with BRCA1 was described. BRCA1 is one of the gene mutations that results in a high risk of breast cancer. This woman chose to have medical care as usual, and did not opt for a preventative mastectomy. BRCA1 presents a challenge for all women, but the combination of a BRCA1 gene and estrogen may accelerate a possible breast cancer. Source.
  • A case report of a trans woman developing psychosis when abruptly stopping hormone therapy was reported. Her psychosis resolved when she started hormone therapy again. Source.
  • For relationships between trans women and cis men, both partners may be at risk for increased psychosocial stress because of transphobia. Source.
  • A comparison of rural vs nonrural trans people was published, confirming that rural trans people need medical and mental health services too. Source (full text!)
  • Roughly 16% of trans women in the San Francisco Bay Area were found to have used fillers such as silicone. Please don’t do this! It can, and does, cause death. Source.
Ruby for July

Ruby for July news

Sexuality, minority sexual behavior news

  • A pair of case reports of urethral sounding came out, this time from Korea. As a reminder: electrical cables and magnets do not make for good sounding instruments. No matter how embarrassing, remember to get medical care when you need it! Thankfully for these two men the objects were removed, though one removal did require surgery. Source (NSFW images).
  • A review of changes to the paraphilia section of the DSM-V found that some of the changes make it more likely that someone will be falsely diagnosed with a paraphilia. Source.
  • Another study on personality traits of people diagnosable with paraphilias was published. The abstract isn’t really detailed enough to really see what the results were, but this is one to keep an eye on… Source.
  • An exploration of the psychological and sexual sides to apotemnophilia (desire to have an amputation of a healthy limb) was published. Source.
  • Comparison of self-identified swingers and self-identified polyamorous people found that both groups were more likely to seek psychological care when they needed it than the general population. Poly folk and swingers were also more likely to report that they were satisfied with life. Source (full text!).
  • Debates continue on the definition of paraphilias, and their inclusion in the DSM. Source.
  • A study of some in the Adult Baby/Diaper Love communities found that few in those communities have problems with their interests. Source.
  • A case of inability to urinate was presented. The cause? A sex toy that had been accidentally left in her vagina 10 years previously. Retained objects like that can cause fistulas (holes – either between the rectum and the vagina or the bladder and the vagina). The woman in the case had surgery. Source.
  • Among opposite-sex couples vasectomy was found to increase sexual satisfaction for both partners. Source.

Miscellaneous and general news

  • A number of Hispanic medical organizations came out in support of LGBT health. Source.
  • Almost half of LGBT people living in Nebraska had considered suicide in their lifetime. Source.
  • Some 80% of German medical students express interest in learning about human sexuality. Despite efforts to increase education for decades, only half of those students were able to correctly answer questions on human sexuality. Source.
Jun 032014

6763959_10420a4b6a_mThe biggest news for May of 2014 is really that Medicare lifted the blanket ban on covering genital surgeries for trans people. The National Center for Transgender Equality has a good summary (PDF) of what the decision actually means. If you’re trans and interested in surgery and are a Medicare recipient, I recommend calling the physician who’s prescribing your hormones and consulting with them about next steps. The news was covered in multiple outlets including the NY Times and CNN.

The other piece of news I spotted that is not getting as much traction as I’d like is this: Urine is NOT sterile! For a long time it’s been believed that urine produced by healthy people is sterile – at least until it passes through the urethra. Turns out not to be the case. Something to keep in mind if you have contact with urine. Source

Interested in the other news? Read on!

  • Work continues on the possibility of three-parent babies. While much of the research and reporting talks about preventing mitochondrial diseases, I still think it opens a wonderful door for three-parent poly households. The latest news is fairly political, but supportive.
  • Another study out of Europe indicates that transgender hormone therapy is safe. This was a 1-year study of both men and women, just over 100 people total No deaths or serious adverse reactions were reported. Highly recommend you skim the abstract for yourself! For US readers, please do note though that the hormones used in the study were different formulations than those used in the US. Source.
  • A published case study reminds us that not all “odd” physical things during medical transition are related to transition. This was a case of a trans man who had undiagnosed acromegaly from a benign brain tumor. Eek! He was correctly diagnosed and treated, thankfully. Source.
  • A Swedish review of transgender-related records found a transition regret rate of 2.2%. Other prevalence data, including the usual male:female ratios, are included. Source.
  • A study of gay men found that they have worse outcomes from prostate cancer treatments than straight men. Source.
May 282014

Hey folks!

I’m deep in the middle of planning my move into medical school. So until early August, posts are going to be a bit scarce here at Open Minded Health. I’ll still be doing monthly news roundups and responding to comments and e-mails, but I’m delaying content posts until I’m settled. Hope you all understand.

For now – go out and enjoy that lovely summer weather.

And as always…  Stay healthy, stay safe, and have fun!