Apr 162014
 

One of the premier medical journals, the New England Journal of Medicine, regularly has perspective/opinion pieces. For a pre-med like me, they can be some of the most valuable pages in the journal — they can be windows into medical practice, public policy and the study and practice of medicine. I read them regularly, since my wife got me a subscription to NEJM. Most aren’t related to gender and sexual minority health, so I haven’t addressed them here much. But in the April 10th edition of NEJM, a treasure! Gilbert Gonzales did a good summary of the intersection between same-sex marriage and health.

Many health journals, including NEJM, tend to live behind a pay wall. This particular article, thankfully, is not. But in the interests of public knowledge and discourse, I wanted to summarize some of the interesting points in this article. A heads up: this is a distinctly United States-focused article.

  • Despite recent advances, roughly 60% of the US population lives in a state that prohibits same-sex marriage
  • There are significant health disparities between LGBT and heterosexual/cisgender people, as shown by the 2011 Institute of Medicine report on LGBT health (which I summarized in 3 parts at the time).
  • Discriminatory environments lead to poorer health outcomes. Example: LGBT people in states that ban same-sex marriage have higher rates of depression, anxiety, and alcohol use than straight/cis people in the same states. By the same token, states where same-sex marriage (e.g., MA and CA) was legalized show a drop in mental health care visits for some GLBT people (e.g., gay men).
  • Legalizing same-sex marriage improves access to health insurance for both same-sex spouses and children of same-sex parents.
  • The Affordable Care Act prohibits insurance companies from denying health insurance coverage because of sexual orientation, transgender identity, or pre-existing conditions like HIV.
  • The recent decision on DOMA (United States v Windsor) means couples in a same-sex marriage get taxed like other married couples. This lowers the tax burden of health care costs and health insurance.
  • Health benefits of same-sex marriage should be included in discussion of marriage equality.

All good things to point out, and good to see in such a mainstream medical journal.

We’re lucky enough that the NEJM has decided to have this article be open access. So if you can, read it to form your own opinions!

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

Apr 112014
 

A symbol for polyamory: Heart with infinity symbolMonogamy is the practice of having only one sexual, romantic, or intimate partner in one’s life. Non-monogamy, is any practice where more than two people are sexual, romantic, or intimate with each other. Though non-monogamy is an ancient practice which continues to be traditional in many societies and cultures worldwide, in the West it’s a minority behavior. Since the 1970s a particular form of non-monogamy has been emerging: polyamory (lit: “many loves”). Polyamory (“Poly”) is the practice of more than two people involved in a loving, emotionally intimate relationship where sex may or may not be involved.

Outside of that basic definition, polyamory varies widely. Polyamory can involve any number of people in any configuration. Everybody does not have to be involved with everybody else. For example, three people in a polyamorous relationship could be in a V style (i.e., persons A and B are involved, and B and C are involved, but A is not involved with C) or in a triangle relationship (i.e., persons A and B, B and C, and A and C are all in relationships). Polyamory relationships can be “open”, where new partners and relationships are welcomed, or “closed” where they are not. New relationships may be restricted to being only sexual, or not at all sexual. And polyamory relationships may be deemed more or less serious through tags like “primary” and “secondary” relationships.

But how does all this relate to health? Well, it sorta does and it sorta doesn’t.

The factor that likely pops into most minds first is sexually transmitted diseases/infections. How many times have we all been counseled to be monogamous to reduce our risk? I see that message everywhere. But it’s an incomplete message. Research is scarce on poly health, but I’m of the believe that a closed poly relationship is no more risky than a monogamous relationship. Whether a poly relationship is open or closed, safer sex techniques (including the use of barriers and regular STI testing) reduce the risk of STI spread.

More insidious are effects on mental health… but not because of polyamory alone. Polyamory itself, while taking more emotional energy than monogamy, can be incredibly fulfilling and provide abundant psychosocial support. Being poly in a non-accepting environment, however, can be very stressful. And we all know what happens when there’s additional stress. High levels of psychosocial stress are associated with: a) higher levels of depression, anxiety, self-medication via substance use, obesity, eating disorders, non-suicidal self injury, PTSD, and b) lower levels of exercise and healthy eating.

Adding an extra wrinkle: it can be very difficulty for poly-identified people to get mental health support. Finding a poly-friendly therapist (especially one covered by insurance) can be an exercise in frustration. Many mental health care professionals simply don’t understand. Others are downright discriminatory. As one poly person expressed: “I’ve had a mental health ‘professional’ refuse to even try to understand the poly nature of our family and insist that I needed to get out of the relationship before he would ‘treat’ me.” (Source)

So what’s a poly person to do? Take care of yourself. If you’re in an open relationship, be familiar with the various STDs and how they are spread, and practice good safe sex. Do what you can to take care of your mental health — exercise, eat well, get some stress relief in there too. Consider getting in touch with a local poly organization or sex-positive group. They can be invaluable for social support and finding resources when you need them.

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

Apr 022014
 

Comparison of male and female skulls

This post is part of an on-going series, Trans 101 for Trans People. If you have additional questions about medical transition, hormones, surgeries, or seeking health care, check out the full page!

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Facial feminization surgery (FFS) is broad term used to refer to many plastic surgeries which modify the face, head and scalp with the aim of feminization. For this article, I’m referring heavily to the work of Dr. Douglas Ousterhout, who literally wrote the book on FFS. Many thanks to him and his staff for their great work. If you want to get into the nitty gritty on each of these surgeries, I highly recommend you pick up a copy of his book. I’ll be doing much more of a summary here.

Facial feminization? Huh? Why would I need that?

The difference between male and female humans is not just in our body fat distribution, pelvis shape and general fuzziness. The presence or absence of testosterone influences our skull shape too, so much so that many adult human skulls can be identified as male or female without resorting to genetic analysis. Some of the more obvious features of a male skull include a brow ridge and wide jaw. Facial feminization surgeries correct some of these effects of testosterone. Other testosterone effects, such as hair loss or the presence of an “Adam’s apple”, can also be corrected surgically.

The #1 goal cited for FFS is the ability to “pass” – to be read by other people as female. Alleviation of dysphoria is also a prominent reason.

Because FFS corrects the masculinization by testosterone, those who did not go through natal puberty likely will not need or want FFS.

Which procedures are core to FFS?

  • Forehead contouring: Bone that makes up the brow ridge is removed and the forehead is re-shaped to a more feminine curve. In most people, the amount of bone that is removed exposes the sinuses in that area, so a bone graft or similar is used. Often combined with scalp advancement.
  • Scalp advancement: To compensate for a higher hair line and/or hair loss, the scalp is repositioned lower down. Often combined with forehead contouring.
  • Rhinoplasty: Reshaping the nose. Male noses tend to be larger than female noses and have different contours. A rhinoplasty can involve all part of the nose, including the tip, the ridge down the center, the size of the nostrils, and back into the nasal septum. Highly recommended to be done with forehead contouring.
  • Lip reshaping: Lips can be feminized by shortening the distance from nose to upper lip and/or adding material to the upper lip to “fill” it out,
  • Sliding genioplasty: Changing the shape and width of the jaw. This is typically done by strategically cutting the jawbone and removing or repositioning segments of it.
  • Jaw tapering/angle reductions: Changing the angle of the point of the jaw. Male jaws are more rectangular, female more pointy. There are three basic ways to accomplish this: grinding away bone in strategic spots, removing sections of bone, and/or reducing the size of the masseter muscle.
  • Thyroid cartilage reduction: The “Adam’s apple” is shaved down to a more feminine size.

Which procedures might be added on, which aren’t necessarily “feminizing”?

  • Temporal fossa augmentation: Filling in the temple with material so it doesn’t look “hollow”
  • Blepharoplasty: An “eyelid lift” – tissue is removed to stop tissue around the eyes from sagging. May not be necessary if you’re having forehead surgeries or scalp-related surgeries.
  • Rhytidectomy: A face-lift. Like blepharoplasty, tissue is removed to “tighten” it up and keep the face from sagging.
  • Otoplasty: Reshaping of the ear
  • Cheek implants: Adding implants to the cheeks to enhance their appearance

Other procedures may be included, depending on what you want and what your surgeon advises.

Will it all be under general anesthesia? How long might my hospital stay be? Recovery time?

Generally speaking, most of these procedures are done under general anesthesia. Some can be done in an outpatient setting (e.g., scalp advance), but most of the time surgeries like these are clustered. That means you typically have more than one procedure done at a time. That clustering helps produce better results and is less risky because you only go under anesthesia once.

The length of your recovery and hospital stay depend on which procedures you have. But generally speaking, if you require a hospital stay at all, it likely won’t be for more than 1-2 days at the most. Most can return to work within a few days, but it may be up to two weeks depending on your procedure. If your procedures involve jaw work, you’ll be on a soft food diet for a period of time.

What risks are involved? Any long-term health risks?

Compared with genital surgeries, the risks in FFS are much less. The work is generally less extensive, and doesn’t enter the abdominal or chest cavity. Still, keep in mind that all surgeries carry risk. Because FFS affects the face, I’d say the biggest risk is of an unsatisfactory result. Do your research and choose your surgeon wisely.

Another risk is that of numbness or sensory problems. Temporary numbness is common after surgery, even a year afterward in the case of scalp advancement. Permanent numbness is a very rare event.

I don’t know of any long-term health risks for facial feminization surgery. Just make sure your primary care provider knows what surgeries you had, just to be on the safe side.

Scars? This is my face after all!

Surgeons who do FFS are usually very good at hiding scars. It’s their job after all – to show no evidence that there was surgery done. One of the most common scars is a small scar along the hairline from a scalp advance – that can be covered by hair transplants at the time of surgery, and it will fade over time. Do talk with your surgeon about the possibility of scars and ask his/her recommendations for scar prevention, but don’t stress over it.

So what’s the downside here? There has to be one!

FFS can be expensive. And it’s even less likely to be covered by insurance than genital surgery – so you’ll need to save up your pennies. There are also very few FFS surgeons in the world, so your options are limited.

Are there any health conditions that mean I can’t get it?

Just the usual prohibitions for surgery. Some surgeons may also have their own requirements, like non-smoking status or low BMI.

Anything else I should know? Resources?

Listen to your surgeon, but be willing to get a second opinion. Also check out…

Apr 012014
 

CC - see linked URLBeen a busy month here. First, let’s have the news!

Transgender

  • A study has failed to find support for the theory that transgender people can be separated into different typologies based on sexual orientation. Source.
  • Gender dysphoria has been found to be correlated with autism/asperger’s and attention deficit disorder. Source.
  • Among trans people seeking care in the emergency department, 52% have at least one negative experience. 32% heard insulting language and 31% were told their provider didn’t know how to provide care. These statistics were gathered in London, Ontario. Source
  • Cross-sex hormones change cortical thickness in the brain. Source.
  • A meta analysis found that the type and dose of estrogen does not impact breast size for trans women. They also did not find an effect, positive or negative, for progestins. Source.
  • A panel lead by a former U.S. surgeon general has urged the US military to eliminate its ban on transgender service members. Source.

Sexuality

  • Pap smears may soon be replaced by HPV-only testing. Source.
  • 43% of young adult and teenaged men report having experienced sexual coercion. 95% of those were initiated by a woman. 18% of those incidents were physical force, 31% verbal, 26% via seduction, and 7% via drugs/alcohol. Tell me again how sexual violence is a woman’s problem. Source.
  • Shout Out Health posted their reminder of how you can find a gay-friendly health care provider

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On an administrative note, I’ll be attending a medical school in Connecticut come the Fall. I don’t know yet what that’ll mean for post frequency here at Open Minded Health, but be warned that things may shake up a little bit.

As always…  Stay healthy, stay safe, and have fun!

Mar 132014
 
Image credit, with thanks, goes to http://ladiesofhysteria.tumblr.com/

One of the many patent medicines, for the “treatment” of hysteria, which was once thought to be the uterus wandering about the body.

This post is part of an on-going series, Trans 101 for Trans People. If you have additional questions about medical transition, hormones, surgeries, or seeking health care, check out the full page!

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For some trans men the very fact that he has ovaries, uretus, cervix and vagina is a source of dysphoria. For trans men who aren’t ready or able to have genital surgery (i.e., metoidioplasty or phalloplasty), there are options similar to orchiectomy for trans women: hysterectomies, oophorectomies, and vaginectomies.

That’s a lot of -ectomies. What exactly are you talking about?

Let’s go through a bunch of the options one by one…

  • A hysterectomy is the removal of the uterus, and only the uterus. There’s a common misperception that a hysterectomy is the same thing as removing all the bits. It’s not. A hysterectomy may or may not involve the removal of the cervix.
  • An oophorectomy is the removal of an ovary. A bilateral oophorectomy is the removal of both ovaries. A bilateral salpingo-oophorectomy is the removal of both ovaries and both fallopian tubes (aka oviducts).
  • A vaginectomy is the removal of the vagina. If a cervix was still present, it would also be removed.

So why get one of these surgeries?

Reasons are of course very personal. Reasons also vary depending on which surgery is involved, but some men have cited the following:

  • Reduction of dysphoria. For some men, just knowing that a uterus and ovaries are present is distressing. Removal can reduce that distress
  • Eliminating the need for pelvic examinations and pap smears (for paps, only if the cervix is removed)
  • Eliminating the risk for some reproductive cancers, including ovarian cancer, cancer of the fallopian tubes, endometrial cancer, and cervical cancer
  • No more menstruation. Ever. Woohoo!

Cis women get these surgeries too, right?

Yup. They can be done for conditions as benign as polycystic ovarian syndrome or fibroids, or for conditions as potentially deadly as cancer. Hysterectomies and oophorectomies are far more common than vaginectomies.

Because these aren’t trans-specific surgeries, finding a surgeon and getting insurance coverage isn’t as difficult as it is for a meta or phallo. It gets even easier if you have a condition (like fibroids) where surgery is recommended in cis women. As your primary care provider for ways you can get the surgery covered. Also note that while many surgeons do perform these, it might be difficult to find one who will treat you in a way that affirms your gender. Be ready to call in your primary care physician or others to support you.

Can these surgeries all be done at once?

Some of them, definitely. So much so that there’s a medical acronym: TAHBSO. Yes, it totally looks like the word “tabasco”. It’s one of my favorite acronyms so far because of that. TAHBSO stands for Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy. It’s the removal of the uterus, oviducts/fallopian tubes, and ovaries all at once through a cut in the abdomen.

I don’t know for sure whether a vaginectomy could be performed at the same time. As your potential surgeon.

What variations in techniques are there?

The biggest variation is in where and how the cuts are made to remove the organs. Vaginectomy is simple – it’s done vaginally.

But hysterectomies and oophorectomies vary. The oldest technique for those is the abdominal incision – a horizontal or vertical cut is made (not too unlike a cesarean section) on the abdomen. This technique is the most traumatic for the body, leaves a scar, and has a longer recovery time.

Two other techniques for hysterectomy and oophorectomy have emerged fairly recently. Laparoscopic surgery is where multiple small cuts are made, and the surgery is performed through those cuts by means of long…uh… sticks basically, with cameras and grasping ends. Lastly, sometimes a hysterectomy can be performed through the vagina, leaving no outward scar at all.

You should discuss the pros/cons of each technique with your potential surgeon to determine which is best for you. A second opinion is important here too.

What should I do if my surgeon says s/he isn’t willing to do a specific technique for me?

Be aware that not all surgeons use all techniques. Some simply have more experience with one over the other. They may well say (or be thinking): “I don’t have a lot of experience doing vaginal hysterectomies, and I don’t want to risk harm, so if you have your hysterectomy with me I want to use the technique I’m best at to minimize your risks.”

Or there could easily be other reasons. Ask your surgeon why!

Can you tell me more about the surgeries? Do they require full anesthesia? How long would I be in the hospital? What kind of recovery time am I looking at?

These surgeries are all “major” surgery, meaning the main body cavity is penetrated. They absolutely will be done under general anesthesia (would you really want to be conscious through that?).

Recovery time will vary depending on what you have done, and how it is performed. It can be as little as two weeks (vaginal hysterectomy) to 6-8 weeks (TAHBSO). Unless you have a complication, even for a TAHBSO you probably won’t spend more than a few days at the most in the hospital.

What are the possible risks?

Risks are mostly the ones associated with any major surgery, including infection, a bad reaction to anesthesia, and the risk of a blood clot. Remember: any surgery can end up resulting in death – the chances may be very small, but still present. There’s also the chance that some of the organs nearby may be accidentally nicked or damaged. Your surgeon will do their best to avoid such damage but it’s a possibility.

If you use your vagina for sex, it may alter some of your sexual responses. Some cis women report pain with intercourse after a hysterectomy, for example.

Your surgeon will go through all the possible risks with you.

What are the possible long-term health effects?

Depends on what was removed.

If you had an oophorectomy, your own biggest source of sex hormones will be gone. You’ll still have a tiny amount from your adrenal glands but not much. This makes it super important to stay on a sex hormone to prevent osteoporosis. There may be other changes too, even if you’re regular with your testosterone – check in with the trans male community/communities to see what else they’ve noticed.

Removal of your ovaries makes you permanently infertile. If having genetic children is important to you, either have them before an oophorectomy or store your eggs. Remember, too, that testosterone is not a contraceptive and also that some trans men can become pregnant and successfully deliver happy healthy babies after being on T for years.

Would these surgeries affect my future ability to have a metoidoplasty or phalloplasty?

They shouldn’t. Some or all of these surgeries may even be the first step in a meta or phallo!

Any health conditions that mean I can’t get any of these surgeries?

As far as I know, only the health conditions which would prevent anyone from having any surgery. As always, to maximize your recovery you’ll want to quit tobacco use and get as fit as you can before your surgery.

Any other thoughts?

As always, communicate with your primary health care provider. He or she will be best able to help you figure out whether a hysterectomy, oophorectomy, or vaginectomy is right for you.