Sep 192016
 
Jack-O-Lanterns having a good sense of wellbeing

Jack-O-Lanterns having a good sense of wellbeing

In gender and sexual minority health we’ve focused a lot on the bad things that happen to our communities. Studies about HIV risks, high rates of depression, and discrimination dominant the discussion. For good reason, too. Negative factors cause harm! We want to protect ourselves, our families, and our communities. Research helps us figure out how to stop the badness from happening. But not a lot of research has looked at gender and sexual minority wellbeing. After all, it’s not all doom and gloom. Many in the community are thriving. It would be helpful to know what helps those community members do so well. Today’s study looks at factors associated with wellbeing in transgender and gender non-conforming people.

First, let’s define wellbeing. Wellbeing can be difficult to define. It’s a two-fold concept, including both hedonic and eudemonic approaches. Hedonic wellness is experiencing happiness while avoiding pain. Eudemonic wellness is the sense that one has purpose in life and is living authentically.

Previous studies among lesbian, gay, and bisexual (LGB) communities found that LGB communities had less wellbeing than their heterosexual peers. Social and community support, education, and physical health are all associated with wellbeing. But we don’t know a lot about the transgender community’s wellbeing. At least, not in the literature.

So Stanton et al looked through published data from a large survey, the US Social Justice Sexuality Survey. This survey focused on LGBT people of color. In order to identify all the participants who might be trans, Stanton et al looked at data the participants who did not identify as cisgender.

This study assessed wellbeing by asking participants how often in the past week they felt:

  • Just as good as other people (eudemonic wellness)
  • Hopeful about the future (eudemonic wellness)
  • Happy (hedonic wellness)
  • That they enjoyed life (hedonic wellness)

In addition to those questions about wellbeing, Stanton et al specifically looked at factors they thought might be related, including: health, healthcare provider’s comfort with LGBT issues, family support, and connectedness and engagement with the LGBT community. And as with most other studies, they looked at demographic factors. Demographics included age, income, employment, marital status, and education.

Because OMH is a health-related blog, I’m going to focus in on the results most applicable to health. If you want to read the full study, scroll to the bottom to find a link to the paper!

What did they find?

402 individuals, about 8% of the broader study, did not identify as cisgender. Of those, 32% identified as trans women, 18% as trans men, 21% as men, 21% as women, and 35% as “other.” They were diverse, representing a broad range of ages, races, education levels, and health.

Most (71%) had health insurance. 85% felt their health was “good” or better. Just over half (57%) felt their health care provider was comfortable with their transgender status. 13% thought their health care provider was uncomfortable. 14% said their provider ignored their LGBT status. 16% stayed closeted with their provider.

63%, almost two-thirds, of the participants had high levels of wellbeing!

What factors were associated with wellbeing?

The following factors were associated with more wellbeing:

  • Feeling connected to the local LGBT community
  • Health
  • Family support
  • Heath care provider acceptance.
  • Education
  • Age: the older, the more wellbeing

These factors were not associated with wellbeing:

  • Having access to health insurance
  • Participation in the local LGBT community
  • Race
  • Employment
  • Being single
  • Income

One factor associated with less wellbeing was health care providers who were uncomfortable with or ignorant of their patient’s LGBT status.

What are the limitations of this study?

No study is perfect. The survey that this study pulled data from probably over represents individuals who are active in LGBT communities. Those individuals may not reflect everyone in the community. Health and health insurance levels may also have been higher in this study than in the broader population.

Most limiting is how some of the questions were worded. Gender identity and sexual orientation were mixed together by lumping questions on lesbian/gay/bisexual identity with transgender identity. And they are very, very different experiences. The communities are also different. Questions asking about “sexual identity” may refer to sexual orientation or gender identity or both. It would be good to repeat this study with clarification between sexual orientation and gender identity.

What does all this mean?

Two-thirds of this study’s non-cisgender participants had good wellbeing. Most trans people are doing well, unlike the popular narrative that trans people are broken. Let’s spread that message!

Also, by knowing who has better wellbeing knows we know who has worse wellbeing. We can direct resources toward those who need them! According to this study that would be the young, the less well educated, those without family support, and those who are less physically/psychologically healthy.

Lastly, this study highlights the need for health care providers who are accepting of minorities. Having a provider who knows and accepts GSM patients not only improves health care, it improves the wellbeing of the patient. We need to spread this message.

It’s good to know that it’s not all doom and gloom. Two-thirds of trans and gender nonconforming people are doing well. Let’s expand that number to 100%.

Want to read the article for yourself? The abstract is publicly available!

Citation: Stanton, M. C., Ali, S., & Chaudhuri, S. (2016). Individual, social and community-level predictors of wellbeing in a US sample of transgender and gender non-conforming individuals. Culture, health & sexuality, 1-18.

Aug 152016
 

Welcome back to Open Minded Health Promotion! This week we’re looking at health promotion for transgender women and individuals assigned male at birth. Depending on your history some of these tips will apply more or less to you.

TransgenderPlease remember that these are specific aspects of health in addition to the standard recommendations for everyone (e.g., colonoscopy at age 50). Based on your health and your history, your doctor may have different recommendations for you. Listen to them.

All transgender women should consider…
  • Talk with their doctor about their physical and mental health
  • Practice safer sex where possible. Sexually transmitted infections can be prevented with condoms, dental dams, and other barriers. If you share sexual toys consider using condoms/barriers or cleaning them between uses.
  • Consider using birth control methods if applicable. Hormone therapy is not birth control. Orchiectomy and vasectomy are permanent birth control options. You can still have vaginoplasty after those procedures if you desire. Alternatively, you can use condoms and asking your partner to use hormonal birth control.
  • Store sperm before starting hormone therapy if you want genetic children. Estrogen and anti-androgens definitely affect fertility. You may never be able to have genetic children after hormone therapy.
  • If you’re under the age of 26, get the HPV vaccine. This will reduce the chance for anal, oral, and penile cancers. Theoretically it may also reduce your risk for (neo) vaginal cancers.
  • Protect yourself from HIV. Consider using pre-exposure prophylaxis in addition to condoms in sexual encounters that are higher risk. Avoid selling sex if you can.
  • Avoid tobacco, limit alcohol, and limit/avoid other drugs. If you choose to use substances and are unwilling to stop, consider strategies to limit your risk. For example, consider participating in a clean needle program. Vaporize instead of smoke. And use as little of the drug as you can.
  • Maintain a healthy weight. While being heavy sometimes helps to hide unwanted physical features, it’s also associated with heart disease and a lower quality of life.
  • Limit high-potassium foods while on spironolactone if possible.
  • Exercise regularly. Anything that gets your heart rate up and gets you moving is good for your body and mind! Weight bearing exercise, like walking and running, is best for bone health. If you’re looking to avoid “bulking” up your muscles, cardio exercises are probably your best bet. Staying physically active is especially important if you have a family or personal history of cardiovascular disease.
  • Avoid buying hormones from online stores or on the street. There is no guarantee that you’re getting what you think you’re getting. Even if you do there is no guarantee that the drug was created in a safe lab or was stored properly. Drugs made in the US are guaranteed to contain what they said they do. They are also made in clean facilities and stored correctly so they don’t degrade. Additionally buying hormones online is far more expensive than getting a prescription and going to a pharmacy (especially with discount plans many pharmacies provide). Thus if you can get a prescription, doing so is less risky and far cheaper. For more information, see the FDA.
  • Do not inject silicone. It not only disfigures, it kills. Additionally unsafe needle practices risk spreading HIV and Hepatitis C.
  • If you’ve had genital surgery and you’re all healed from surgery, remember to continue to dilate and take care of your vagina. Keep in touch with your doctor as you need to. Call your surgeon if something specific to the surgery is concerning. Continue to practice safe sex. And enjoy!
Your doctor may wish to do other tests, including…
  • Prostate cancer screening. Vaginoplasty does not remove the prostate. Testosterone is one of the major drivers of prostate cancer. Therefore trans women are at a lower risk for prostate cancer. However, that risk may still exist. Your doctor may recommend a blood test or a digital rectal exam. They should discuss with you the benefits and potential harms of screening.
  • Breast examination for potential detection of breast cancer. We really don’t know yet how much risk trans women are at for breast cancer. Current data suggest that trans women are at low risk. However your doctor may wish to perform a breast examination as part of a physical exam. The goal of the exam is to detect lumps and/or bumps that may need further investigation. They may also teach you how to do a self-exam.
  • Mammography. Again, this is for potential detection of breast cancer. Some doctors recommend following the typical recommendations for cis women. However even those recommendations vary depending on the organization recommending them. Most recommendations include a mammography every 1-2 years starting around age 50. Thus once you turn 50, consider talking with your doctor about the need for mammography.
  • Vaginal examination. For post-op trans women, the vagina is either (penile) skin or intestine. Either way, it can still develop cancer. Some doctors recommend a visual inspection of the vagina to detect such cancers. Others do not.
  • Testicular/penile examination. As long as you have a penis and testes, your doctor may recommend examination. They look for potential cancer as well as hernias (the “turn your head and cough” test).

And most importantly: Take care of your mental health. We lose far too many people every year to suicide. Perhaps worse, far more struggle with depression and anxiety. Do what you need to do to take care of you. If your normal strategies aren’t working then reach out. There is help.

Want more information? You can read more from UCSF’s Primary Care Protocols and the Gay and Lesbian Medical Association.

Aug 012016
 

Welcome back to Open Minded Health Promotion! This week we’re looking at health promotion for transgender men and individuals assigned female at birth. Depending on your history some of these tips will apply more or less to you.

TransgenderPlease remember that these are specific aspects of health in addition to the standard recommendations for everyone (e.g., colonoscopy at age 50). Based on your health and your history, your doctor may have different recommendations for you. Listen to them.

All transgender men should consider…
  • Talk with their doctor about their physical and mental health
  • Practice safer sex where possible. Sexually transmitted infections can be prevented with condoms, dental dams, and other barriers. If you share sexual toys consider using condoms/barriers or cleaning them between uses.
  • Consider using birth control methods if applicable. Testosterone is not an effective method of birth control. In fact, testosterone is bad for fetuses and masculinizes them too. Non-hormonal options for birth control include condoms, copper IUDs, diaphragms and spermicidal jellies.
  • If you’re under the age of 26, get the HPV vaccine. This will reduce the chance for cervical, vaginal, anal, and oral cancers.
  • Avoid tobacco, limit alcohol, and limit/avoid other drugs. If you choose to use substances and are unwilling to stop, consider strategies to limit your risk. For example, consider participating in a clean needle program. Vaporize instead of smoke. And use as little of the drug as you can.
  • Maintain a healthy weight. While being heavy sometimes helps to hide unwanted curves, it’s also associated with heart disease and a lower quality of life.
  • Exercise regularly. Anything that gets your heart rate up and gets you moving is good for your body and mind! Weight bearing exercise, like walking and running, is best for bone health.
  • Be careful when weight lifting if you’re newly taking testosterone. Muscles grow faster than tendon, thus tendons are at risk for damage when you’re lifting until they catch up.
  • Consider storing eggs before starting testosterone if you want genetic children. Testosterone may affect your fertility. Consult a fertility expert if you need advising.
  • Seek help if you’re struggling with self injury, anorexia, or bulimia. Trans men are at higher risk than cis men for these aspects of mental health.
  • If you have unexplained vaginal bleeding, are on testosterone, and have not had a hysterectomy notify your doctor immediately. Some “breakthrough” bleeding is expected in the first few months of testosterone treatment. Once your dose is stable and your body has adapted to the testosterone you should not be bleeding. Bleeding may be benign but it may also be a sign that something more serious is going on. Contact your doctor.
  • In addition, talk with your doctor if you have pain in the pelvic area that doesn’t go away. This may also need some investigation. And s/he may be able to help relieve the pain.
  • Be as gentle as you can with binding. Make sure you allow your chest to air out because the binding may weaken that skin and put you at risk for infection. Be especially careful if you have a history of lung disease or asthma because tight binding can make it harder to breathe. You may need your inhaler more frequently if you have asthma and you’re binding. If this is the case, talk with your doctor.
  • If you’ve had genital surgery and you’re all healed from surgery: there are no specific published recommendations for caring for yourself at this point. So keep in touch with your doctor as you need to. Call your surgeon if something specific to the surgery is concerning. Continue to practice safe sex. And enjoy!
Your doctor may wish to do other tests, including…
  • Cervical cancer screening (if you have a cervix). The recommendation is every 3-5 years minimum, starting at age 21. Even with testosterone, this exam should not be painful. Talk with your doctor about your needs and concerns. Your doctor may offer a self-administered test as an alternative. Not every doctor offers a self-administered test.
  • Mammography even if you’ve had chest reconstruction. We simply don’t know what the risk of breast cancer is after top surgery because breast tissue does remain after top surgery. Once you turn 50, consider talking with your doctor about the need for mammography. In addition, if you’re feeling dysphoric discussing breast cancer then it may be helpful to remember that cis men get breast cancer too.
  • If you have not had any bottom surgery you may be asked to take a pregnancy test. This may not be intended as a transphobic question. Some medications are extremely harmful to fetuses. Hence doctors often check whether someone who can become pregnant is pregnant before prescribing. Cisgender lesbians get this question too, even if they’ve never had contact with cisgender men.

And most importantly: Take care of your mental health. We lose far too many people every year to suicide. Perhaps worse, far more struggle with depression and anxiety. Do what you need to do to take care of you. If your normal strategies aren’t working then reach out. There is help.

Want more information? You can read more from UCSF’s Primary Care Protocols and the Gay and Lesbian Medical Association.

Jul 182016
 

Transgender youth are a special population. Because of the relative novelty of treatment at any age much less for youth, data are scarce. A recent review article examining the published data on transgender youth was published. Let’s take a look at what they found.

First, how about prevalence? How many youth self identify as transgender? There are very, very, few studies that get good numbers on this. One study in New Zealand found that 1.2% of secondary school children identified as transgender, and 2.5% weren’t sure about their gender.

As we well know, being a gender and sexual minority can often be associated with health disparities. And this review reports on that too. Identifying as transgender was associated with negative psychological health. Specifically, being bullied, having symptoms of depression, attempting self harm, and attempting suicide were all more common in transgender youth than in cisgender youth. How much of that was because of discrimination and how much was because of gender dysphoria was not explored.

Researchers have also found that being transgender and having autism appear to go together. No one is quite sure why yet. There’s still a lot of research to be done to figure that out.

One interesting difference in the literature stands out to me, though. It appears that transgender men are more likely to self harm and transgender women are more likely to be autistic. Among cisgender people, cis women are more likely to self harm and cis men are more likely to be autistic. There are theories for why that sex difference exists, but there’s little to no agreement. It could be related to social environments, hormones, the environment in the womb, or any number of other factors. But the observation that transgender men and women more resemble their sex than their gender for self harm and autism is worth investigating further.

What about the effects of hormone therapy for transgender youth? Especially puberty suppression, which is the unique factor for their treatment? As a reminder, the treatment of transgender youth is largely based on the Dutch model. At puberty, children go on puberty suppressing drugs. They then go on hormones (and thus begin puberty) at age 16 and are eligible for surgery at age 18. There are efforts to deliver cross-sex hormones earlier, but the Dutch model is the standard that most of the research is based on. A Dutch study found that the psychological health of transgender youth improved after surgery. Their psychological health even equalled that of their cisgender peers! The researchers also found that youth continued to struggle with body image throughout the time they were on puberty suppression only. But their self-image improved with hormone therapy and surgery. None of the children regretted transitioning. And they said that social transition was “easy”.

One challenge to that particular Dutch study is that the Dutch protocol excludes trans youth who have significant psychiatric issues. A young person with unmanaged schizophrenia, severe depression, or other similar issue wouldn’t be allowed to start hormones. So the research was only on relatively psychologically healthy youth to begin with. It’s difficult to say if that had an effect on the study’s results. It’s also difficult to say whether the psychological health of a trans youth is the cause or the result of their dysphoria. A trans youth with depression might well benefit from hormone therapy, after all.

There are multiple questions still unresolved when it comes to treating transgender children. Does puberty suppression have a long term effect on their bones? Are there long-term physical or psychological health effects of early transition? How should children with serious psychological conditions be treated (besides the obvious answer — with compassion)? And on, and on.

The medical and scientific communities are working on answering these questions. But it will take time. And in the mean time — physicians and families do they best they can with what information we have. If you have, or are, a transgender youth please consider participating in a study so we can do even better for children in the future.

Want to read the review for yourself? The abstract is publicly available.

Jul 042016
 

On June 17, 2016 The Lancet, one of the UK’s most prestigious medical journals, published an entire series dedicated to global transgender health.

The World Professional Association for Transgender Health biennial conference happened over the weekend of June 17-21. I wasn’t able to go this time around, so I can’t report on it directly. But! It looks like it was a fabulous conference. Topics ranged from surgical techniques to cancer prevention to health and psychological care for transgender youth. You can see the schedule yourself.

The Pentagon has announced that it will begin allowing transgender people to openly serve in the US military next month. No details on what that means for veterans or formal military who were dismissed from service because of that status have yet been revealed. Source.

President Obama has declared Stonewall a national monument.