Jun 292015
 

Two_golden_wedding_ringsAs I’m sure you know by now, the United State Supreme Court has declared that same-sex marriage is legal in all of the United States. Why was marriage so important, anyway? And what’s next?

Marriage is a legal institution in the United States. There are legal rights and responsibilities for spouses. Marriage proponents were not arguing for the religious right to have a marriage ceremony. Anyone who wants to can have a ceremony. What mattered, and why they found so hard for so long, were the legal rights. Many of these rights have to do with taxes, estates, the right to adopt, and so on — areas that are somewhat outside the realm of this blog. There are some important medical-related rights that are covered by marriage, including…

  • The right to hospital visitation. If one spouse is in a restricted area of a hospital (such as an intensive care unit), the other spouse has the legal right to visit. While President Obama did issue an executive order ordering hospitals to allow visitation for same-sex couples, it only applies to hospitals that accept Medicare/Medicaid. Most hospitals do, but it isn’t all.
  • The right to make medical decisions
  • Giving consent for autopsies and burial arrangements
  • Medical insurance coverage for spouses
  • Family leave to take care of a sick or injured spouse

Individual institutions can and have granted some or all of these rights before. For example, Google is well-known for its equitable treatment of employees in same-sex relationships. And some hospitals have accepted medical power of attorney documents with no question for same-sex partners. But it wasn’t universal.

For a long time now people in same-sex relationships have been in a legal gray zone. They may be legally married in one state. But cross a state line and suddenly that state may not consider them to be married anymore. This was because of the Defense of Marriage act, which is now null thanks to the US Supreme Court.

The US Supreme Court not only ensured that all same-sex marriages be considered legal marriages at the Federal level, it ordered all states to issue same-sex marriage licenses and honor the same-sex marriages performed in other states.

This should ensure equal marriage rights for both same-sex and opposite sex couples.

As the Onion and Boing Boing jointly pointed out, there are many many more rights that LGBT people lack that they need. It’s not just marriage. Many states still do not allow same-sex couples to adopt. Others allow discrimination based on sexual orientation or gender identity in employment, schools, or housing. Men who have sex with men are still barred from giving blood at the federal level. In some states, transgender people lack access to legal name changes, protection from violence, health care coverage, and equal access to employment. There’s still a lot of legal work to be done.

And everybody needs access to knowledgeable, compassionate health care. No matter who they are, what they do, or who they do it with.

If you’re interested in medical organizations seeking to advance health care for all people, check these groups out:

  • GLMA: Gay and Lesbian Medical Association. Despite the name, covers all of “LGBT”. They are the premier medical advocacy group, and maintain a list of LGBT and LGBT-friendly providers.
  • WPATH: World Professional Association for Transgender Health. Creators of the Standard of Care, which give providers guidelines on best medical practices for transgender people around the world. Also has a list of providers.
  • TASHRA: The Alternative Sexualities Health Research Alliance​. A newer, smaller group “working to create a world where all kinksters have equal access to culturally competent, non-judgmental, and knowledgeable healthcare”.

And have a lovely rest of Pride month. We truly do have something to celebrate this year.

Jun 262015
 

800px-Phaedriel's-orchidVaginoplasties for transgender women have been performed for a little over 80 years. The first known surgery was in 1931. Those early surgeries (link includes surgical images) were a little crude by modern standards. The patients in question already had penectomy (removal of the penis) and orchiectomy (removal of the testes) performed so most erogenous sensation was lost. No labia were formed as far as I can tell, and the vagina was made of skin from the inner thigh.

In the 80-some-odd years that have followed those first surgeries, the techniques have improved tremendously. However there’s little evidence to suggest which techniques are the best. Studies have been small and inconsistent in the factors they examine. Study results may be inaccurate. Without more data, and more consistent measures, nothing can be said for certain. Still, a recent meta analysis pulled what data we do have together into one document. And today I’ll translate and summarize their summary.

There are three basic techniques for vaginoplasty for trans women:

  • Penile inversion. The tissue of the penis itself is used to line the vagina and labia. Parts of the scrotum and/or urethra may also be used.
  • Intestinal graft, either from the ileum (part of the small intestine) or rectosigmoid region (end of the large intestine). This is less common among US surgeons than among non-US surgeons.
  • Non-penile skin graft. This is an older technique, primarily used before 2000. Grafts were often taken from the inner thigh or abdomen.

Penile inversion is the most common technique in the United States today. It’s also the most well researched. In contrast, intestinal grafts are rarely performed by surgeons who specialized in transgender vaginoplasty in the United States today. Intestinal grafts are more commonly performed by non-US surgeons or for individuals who do not have a penis to invert. Lastly, the non-penile skin graft is an older technique that does not appear to be used much anymore.

All three techniques appears to produce overall satisfactory results. The average depth was around 10cm to 13.5 cm, and the vast majority of trans women were satisfied with their depth. The majority of women were also able to have vaginal intercourse (75%) and obtain orgasm (70%+). A majority were also aesthetically pleased by their results (90%) and had an improvement in their quality of life.

All techniques had their own levels of complications. Overall the most common complication was narrowing of the vagina (anywhere from 12%-43% of patients depending on technique). Urine stream changes and increases in risk of urethral infection were also fairly common, affecting 1 in 3 women. Rare serious complications included tissue death, rectal injuries, fistulas, deep vein thrombosis, and pulmonary embolism.

Comparisons between techniques was difficult because the details of each technique differed and the outcome measurements differed too. It does seem that, as far as the researchers could tell, there were fewer complications for intestinal graft vaginoplasties than for penile inversion vaginoplasties.However abdominal discomfort and “foul” vaginal secretions during intercourse have been reported for intestinal graft vaginoplasties, largely with rectosigmoid vaginoplasty. For penile inversion vaginoplasties, using urethral or scrotal skin in addition to penile skin was associated with more complications as well.

More research in general, and more standardized research, is crucial to understanding the best surgical techniques. Patients deserve the best results and the safest surgeries possible. Surgeons have already made great strides. Time to make more!

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

Jun 222015
 
Fruit made of marzipan

Fruit made of marzipan

If you find yourself feeling confused by the many and contradictory messages about food and diet and supplements, you’re not alone. It’s a maze!

Believe it or not, medical students do get training in nutrition. Here are some general guidelines to help you figure out the weird and wacky world of food and supplements today!

1. Eat as broad a variety as you can. Include as many vegetables and fruit as you can. It doesn’t need to be fresh vegetables. They can be frozen or canned, or even processed. But the variety helps you get vitamins and minerals, and is tasty too.

2. Don’t bother with organic. There’s no nutritional difference or health benefit. You’re better off saving the money and using it to buy more vegetables.

3. Be reasonable with salt and fat. Don’t go on a very low salt/fat or very high salt/fat diet. Your body needs both, but too much of either may increase your risk of heart disease.

4. Unless you’ve been told otherwise by your doctor, don’t take multivitamins, vitamins, or supplements. Not even antioxidants! They don’t do healthy people much if any good, and may cause harm. Exceptions to this rule include calcium for women who don’t get enough calcium in their diet and iron/folic supplements for pregnant women to prevent anemia and birth defects.

5. Eat less and move more. You don’t need to run a marathon unless you want to. But moderate exercise is definitely good. So is being a “normal” (not overweight, obese, or underweight) weight.

6. Try eating less meat. Eating lots of meat is associated with cardiac disease. Try eating a little less and getting your protein from lentils, beans, tofu, nuts, dairy, or plain ol’ whole wheat. Besides, meat is expensive.

7. Ignore fads. Yes, this includes low-carb, high-carb, low-fat, high-fat, no-gluten, many food intolerances…and the list goes on!

8. Tell your doctor about your nutrition and if you take any supplements, including herbs. Some foods may interact with your medications (grapefruit is notorious for this). If you’re trying to change a habit for the better, consider mentioning it to them. They may know some resources that would help.

Got any more? Let me know your thoughts in the comments!!

Jun 192015
 
One symbol for DSD

One symbol for DSD

The medical care of people with differences of sexual development (DSD) has changed significantly over recent decades. A difference of sexual development, also called disorder of sexual development or intersex condition, is a medical condition where there is some difference in the sexual development of the baby. The gonads and genitals of a baby may develop in a way that is different from the stereotypically male and female gonads and genitals (“ambiguous genitalia”, for example). Or the baby may have chromosomes other than XX or XY. Or they may be physically female but be XY. There are a large number of conditions that are folded under the title of “Differences of sexual development.”

So how did children used to be treated with DSD? The policy was one of secrecy and surgery. In order not to “confuse” the child about whether they were a boy or a girl, corrective surgery was used at a very early age. Children were often not told that they had a DSD. They took medications without knowing why they took them, or had surgeries without knowing why.

This was standard treatment until intersex people themselves started to speak up. They spoke of being taught to feel shame about their genitals. They spoke of pain and discomfort with sexual activities because of the genital surgeries. They spoke of being assigned the wrong sex. They spoke of the psychological distress of never having been told they had a DSD.

And slowly medicine listened. Today, surgery is not recommended unless the life of an infant is at risk. Open communication is encouraged, and organizations such as the Accord Alliance exist now to support people with DSD.

All of this history brings us to today’s study. D’Alberton et al investigated the quality of life and psychological health of women with DSD in Italy. They compared women with DSD to women without DSD, and they also compared older women with DSD to younger women with DSD to look for effects of the change in the way they were medically treated.

Who did they survey? 43 adult women with DSD, all of whom were genetically XY. Most (79%) had complete androgen insensitivity syndrome. By “women”, the authors mean people who were identified as female at birth and who have female gender identities. They were compared to 43 women without medical conditions, recruited from medical and nursing fields.

What did they measure? They used standardized surveys to measure psychosocial adjustment, quality of life, and depression/anxiety symptoms. They also asked demographic questions and medical questions.

What did they find?

Women with DSD had higher levels of employment and education than women without DSD. Women with DSD were also less likely to have a partner or children and more likely to be living with a parent than women without DSD. Overall quality of life was good for women with DSD. However women with DSD had higher levels of psychological distress (depression, anxiety) than women without DSD.

Younger women with DSD had lower levels of psychological distress than older women with DSD. The younger women were also told their diagnosis at an earlier age than the older women (11.6 vs 15). This suggests that the change in management has indeed made a difference.

Many women with DSD had a surgery. 74% of women with DSD had a gonadectomy (removal of the gonads). Some had additional surgeries, such as vaginal reconstruction. All the women who had gonadectomy were on hormone replacement therapy. There appears to be little standardization of hormone replacement for women with DSD. All the women with DSD in this study reported that they were comfortable with their female gender identity.

What were the limitations of the study? Mostly small sample size. And the sample was a bit of a convenience sample — they were drawn from support groups. The comparison sample was not representative of the average population either, being mostly nurses and medical students. However the authors did make an effort to compare to data from the average population where possible.

What does all this mean?

Overall, women with DSD are doing fairly well. There wasn’t a lot of suicidality or low education or extremely high levels of distress in this group. But it does seem like there’s still work to be done. The finding that women with DSD had higher levels of psychological distress than women without DSD is concerning. The authors recommend that all people with DSD, and their families, be offered psychological support and counseling. It’s a good place to start.

Interested in reading the study for yourself? The abstract is publicly available!

Jun 152015
 

Mortier_PillonTestosterone replacement therapy has become nearly common place recently. Marketing of testosterone creams is everywhere. In addition to the big pharmaceutical companies, compounding pharmacies are now making and selling testosterone creams too. Compounding pharmacies are typically small local pharmacies where the medications are made and mixed on site. A compounded medication can be helpful to someone who, for example, is allergic to a filler used in a commercial product. Compounded products are often cheaper than commercial non-generic products. Compounded products are supposed to be standardized just like commercial products are. But are they?

The Federal Food and Drug Administration (United States) produced a report back in 2006 that showed that somewhere around 33% of compounding pharmacies were not making or selling standardized products.

Now a Canadian study confirms that compounding pharmacies may not be well standardized either. The researches took samples at two different times from ten randomly selected compounding pharmacies in Toronto. The samples were then analyzed and compared to two different commercial forms.

The commercial forms were consistently within 20% of the prescribed dose. Only 50% of the compounded forms in the first batch were within those limits. Worse, only 30%  of the second compounded batch were within that limit. Yikes! One pharmacy even had no testosterone in its product at all. The consistency within a pharmacy’s products also varied wildly. One pharmacy had 91% of the of the testosterone it was supposed to have in one sample, and only 8% in another sample.

The compounded testosterone was generally cheaper than the commercial testosterone. Compounded testosterone ranged from $57-161 for a 30-day supply, averaging around $105. The commercial stuff was $140-150 for 30-days.

This has very serious concerns for patients. Wild swings in testosterone level are not safe. For their safety and health, a patient should receive the dose that was prescribed. Not “half the dose one month” and “double the dose the next”. The lower price of the compounded products could easily lure a lower income patient into purchasing the compound instead of the commercial.

What can you do as a patient? Make sure that you get your prescriptions from a non-compounding pharmacy. If cost is an issue, talk with your pharmacist about using a generic. Generics are held to the same standards are brand-name drugs and are often made by the same company. Alternatively, consider discussing medication options with your physician and/or pharmacist.

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