Dec 052016
 

Too often gender and sexual minority health is distilled down to just the Human Immunodeficiency Virus (HIV)…as if that’s the only disease that could possibly be relevant. Some small amount of time might then be dedicated to STD’s like gonorrhea. But really it’s all about HIV. But ignoring all the other aspects of GSM health ignores the diversity of our communities. When I started Open Minded Health I wanted to avoid that topic. I saw so much time and so many resources being dedicated to HIV…I wanted to do something different.

Halfway through my third year of medical school now, I’m beginning to change my mind. We still need to avoid focusing only on HIV. But this one single disease has caused so much devastation, so much individual and cultural harm… I can’t just ignore it here on Open Minded Health. The focus here will still be on non-HIV aspects of GSM health care, but I’ll be sneaking in some articles on HIV too when I think it’s appropriate. Don’t worry, OMH won’t become “All AIDS all the time.”

Which all brings me to today’s article!

Literature Review

Radix, Sevelius, and Deutsch did a literature review looking at HIV in transgender women. Trans women, as a group, have the highest risk for HIV infection of all groups. Although we don’t have great data yet, the best estimate is that 19% of trans women are living with HIV.

Worse, preliminary data show that trans women are less likely to know their HIV status. As a group they’re likely to have higher viral loads. That means their HIV is not suppressed. One study in particular found that among trans women who were diagnosed, only 77% were referred to primary care, 65% were taking anti-retrovirals, and only 55% had suppressed their viral load.

HIV treatment 101
HIV

Diagram of an HIV particle

HIV cannot be cured. It causes harm by destroying part of the immune system. The goal of treatment is to reduce the number of copies of the virus, the “viral load”. The lower the viral load, the better your immune system can work (measured as a “CD4 count”). This has two benefits. First, you live longer. You’re less likely to get an infection or cancer. Second, you’re less likely to spread HIV to others. HAART is the modern gold standard of treatment. HAART stands for “highly active antiretroviral therapy”. Think of it as the new improved ART, or antiretroviral therapy. HAART is a mix of 3+ drugs that work to keep the viral from copying itself.

Trans women and HIV

Why are trans women at such high risk for HIV? Previous studies suggest it comes down to social issues. Trans women are often more visibly “trans” than trans men, and are a easier target for discrimination. They may be more likely to work in the sex industry. In that industry, anal sex is what they likely end up performing, and anal sex is the most likely to spread HIV. In addition, substance use is higher in trans populations. Sharing needles and items used for snorting can also spread HIV.

For whatever reason though trans women are at high risk. Why such a lower rate of treatment? Why are only 65% taking antiretrovirals? First there’s always cost. HAART can cost $10,000 per year and more. Second, some studies suggest that trans women may prioritize hormone therapy over HIV treatment.

HAART and hormones

Lastly, there are some very real concerns about interactions between HAART medications and hormone therapy. Both estrogen and HAART medications are processed by the liver and often by the same enzymes. Estrogen may change the amount of HAART medications that stay in the body, or vice versa.

According to this paper, the only research that’s been done so far on estrogen and HIV therapy has been done with cisgender women on birth control. As long time readers of OMH know, birth control is not hormone therapy. Birth control has both estrogen and progesterone. And the type of estrogen is different between birth control and transgender hormone therapy. Still, it’s what we have to use. These studies showed that some antiretroviral medications do change the blood level of estrogen, and that the levels of some antiretrovirals are changed by estrogen.  However we don’t know if that effect is true with the type of estrogen in transgender hormone therapy…and we don’t know if the differences in the blood levels has a real clinical effect.

I won’t go into detail of which HAART medications did what. Antiretroviral medication names are notoriously difficult to read, pronounce, and remember. Instead, here’s the important part: It is very important for your health care provider to know what you are taking. If you’re taking estrogen, tell your provider. That way they can check for drug-drug interactions and adjust medications appropriately.

What about anti-androgens, like spironolactone, finasteride, and GnRH agonists? Do they interact with antiretrovirals? There are no studies specifically about them and antiretrovirals. No interactions are known. We just don’t know.

The potential effects of transgender hormone therapy on antiretroviral medication blood levels may not even matter in HIV treatment in the end. Why? Well, we don’t just put someone on HAART and never see them again. Physicians check the viral load to see if HAART is working. So they know if doses or medications need to be changed. If there’s an interaction between drugs, they’ll see that the viral load isn’t low and they’ll change the drugs anyway.

Conclusion

In other words: There is no clear reason to avoid HAART while on hormone therapy.

Get tested, know your status, and get treatment if needed. Doing so will allow you to live for many, many years to come.

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

Citation: Radix A et al. Journal of the International AIDS Society 2016, 19(Suppl 2):20810

Nov 212016
 

On October 6, 2016 the National Institutes of Health in the United States designated gender and sexual minorities a disparity population for the purposes of research. This is tremendous news. The NIH is the health research arm of the US government. It gives grants. Scientists working there do crucial research. The NIH provides training and research opportunities for students and professionals alike.

Long time readers of Open Minded Health may remember the many times I’ve said “we need more research.” This is part of how we get that research. Through incentives that can now be provided by the NIH, and through the hard work of all connected with it.

Slowly but surely gender and sexual minority health is becoming better understood. And only through understanding it can we even begin to improve it. Ultimately so that we can all live healthier, longer, happier lives.

Read the full declaration below.

Sexual and Gender Minorities Formally Designated as a Health Disparity Population for Research Purposes

On behalf of many colleagues who have worked together to make today possible, I am proud to announce the formal designation of sexual and gender minorities (SGMs) as a health disparity population for NIH research. The term SGM encompasses lesbian, gay, bisexual, and transgender populations, as well as those whose sexual orientation, gender identity and expressions, or reproductive development varies from traditional, societal, cultural, or physiological norms.

Mounting evidence indicates that SGM populations have less access to health care and higher burdens of certain diseases, such as depression, cancer, and HIV/AIDS. But the extent and causes of health disparities are not fully understood, and research on how to close these gaps is lacking.

In addition, SGM populations have unique health challenges. More research is needed to understand these challenges, such as transgender people taking exogenous hormones.

Progress has been made in recent years, with gains in legal rights and changing social attitudes. However, stigmatization, hate-violence, and discrimination are still major barriers to the health and well-being of SGM populations. Research shows that sexual and gender minorities who live in communities with high levels of anti-SGM prejudice die sooner—12 years on average—than those living in more accepting communities.

The Minority Health and Health Disparities Research and Education Act of 2000 authorizes the Director of the National Institute on Minority Health and Health Disparities (NIMHD), in consultation with the director of the Agency for Healthcare Research and Quality (AHRQ) at the U.S. Department of Health and Human Services, to define health disparity populations. This month, with strong support from AHRQ Director Andrew Bindman, M.D., I formally designate sexual and gender minorities as a disparity population for research purposes.

The designation builds on previous steps by NIH to advance SGM health research. In 2011, the Institute of Medicine (now The National Academies of Sciences, Engineering, and Medicine) published an NIH-commissioned report on LGBT health issues. In response to the report recommendations, NIH extended its research portfolio and created the Sexual and Gender Minority Research Office (SGMRO). The SGMRO, within the Office of the Director, coordinates NIH-supported activities on SGM health issues and provides guidance to researchers within and outside of NIH.

I offer my gratitude to inaugural SGMRO Director Karen L. Parker, Ph.D., M.S.W., and NIH Principal Deputy Director Lawrence A. Tabak, D.D.S., Ph.D., who led the proposal for designation. I also offer my gratitude to colleagues across NIH who served on the NIH-established working group for their careful consideration on this matter.

This designation marks an important and necessary step in realizing NIH’s mission to advance the health of all Americans.

Source

Nov 092016
 

Dearest readers,

The US election may be terrible blow to minority rights throughout the 50 states, DC, and territories. All gender and sexual minorities, along with our Muslim and Black loved ones and many others, may be at risk.

We know how ugly some parts of America can be. We know that every time one of us is murdered. We’ve all had the slurs thrown at us, or our family or friends. Or been quietly denied housing, healthcare, marriage. And last night those ugliest bits won in our political system, a move that jeopardizes our safety and our rights for decades to come.Light in the Darkness

It’s okay to grieve.

It’s okay to be scared.

It’s even okay to be angry.

If you are in crisis right now, stop reading and call one of these hotlines:

For me, I am reminded of Proposition 8. That was the ballot measure in California that took away same sex marriage rights in 2012. My (now) wife and I sat and watched the news unfold with disbelief. The state we’d thought was so progressive, that we’d thought was safe, turned on us. President Trump, and the Republican Senate and House, are far worse. But the emotions I hear echoing throughout our communities are the same: fear, disbelief, despair, a loss of safety. I never thought I’d trust my neighbors again. But we did ultimately gain the right to marry again, and public opinion continues to support us doing so.

Now for me, the emotion that boils to the surface most strongly now is determination. I can’t fix politics. I cannot, by myself, change the views of the country. Nor can I undo what has been done. But there is a lot I can do. I refuse to run and hide. I refuse to sit down and be quiet.

I will be a light in the darkness.

Please, join me.

If you can…

Lastly, remember all that our communities have survived. From the Holocaust to Stonewall to AIDS to now. We did so by working as a community. By looking out for one another and protecting one another. By calling out injustice when we saw it. By protesting when we needed to.

We survived. We will survive. Better yet, we will thrive.

Because, after all, living well is the best victory of all.

Be that light in the darkness.

Oct 312016
 

Comorbidity is a fancy sounding term, but it’s also important phenomenon. Researchers and clinicians historically noticed that some diseases and disorders tend to occur together. A person with one is likely to have the other. The disorders “clump”. That’s comorbidity. Depression and anxiety “clump” together, so they’re considered “co-morbid”. But the disorders or diseases don’t cause each other. They just tend to occur together, for whatever reason. This week’s article looked at two psychological disorders to see if they were potentially co-morbid: borderline personality disorder and sexual masochism disorder.

What is borderline personality disorder (BPD)?
Comorbidities of BPD

Comorbidities of BPD

BPD is a personality disorder. Personality disorders are specific group of disorders in psychology. They are life long patterns of interaction that cause dysfunction in everyday life. There is no treatment for most personality disorders. Personality disorders include narcissism, antisocial personality disorder, and paranoid personality disorder.

BPD specifically is defined in the DSM 5 as a “pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity”. People with BPD rarely have relationships that last for long. Their opinions of people may change drastically from moment to moment. Their opinion of themselves changes too. They fear abandonment. Resorting to suicide attempts or self injury to get others to stay is not uncommon. Their mood can also be very unstable. A constant feeling of hollowness inside is also common.

Most people with BPD are women. It’s one of the few personality disorders that does have a treatment. Dialectical behavior therapy, a modification of cognitive behavior therapy, is helpful.

What is sexual masochism disorder? How does it differ from masochism?

Sexual masochism disorder is not the same thing as masochism!

Masochism is the sexual or emotional enjoyment of receiving pain. Sadism is the opposite. It’s the enjoyment of giving pain. Many people safely practice sadism/masochism as part of their sexual life. Masochism and sadism by themselves are not psychiatric diagnoses. They are normal, healthy parts of human sexuality.

In contact, sexual masochism disorder (SMD) is masochism that causes distress, dysfunction, or nonconsensual harm. For example, deliberately putting yourself in a situation where you could be raped. Or asphyxiating yourself when you’re alone (because it can, and does, kill). Because those are likely to cause serious harm, they might be considered SMD rather than masochism.

The specifics of what counts as SMD vs masochism is, frankly, a hot topic. But key in that difference is whether the individual is distressed or having difficulties because of their interests…and whether they seek treatment. Unfortunately, there is no specific treatment for SMD.

All of which brings us to today’s study…

Frías et al tried to answer several questions, including: Are BPD women more likely to have SMD than women without BPD?

So they interviewed and surveyed 120 women. These women were referred to them by a local adult outpatient mental health center. All had personality disorders. 60 had BPD. 60 had other personality disorders. Frías et al verified those diagnoses and interviewed the participants. They diagnosed SMD based on those interviews.

The surveys asked about:

  • childhood traumas
  • attachment styles
  • self esteem
  • sensation (adventure) seeking
  • perfectionism
  • sexual fantasies
  • sexual satisfaction

And as always, there was a demographic questionnaire.

What did they find?

SMD was 10 times more likely in BPD women than in women without BPD. Which sounds impressive. 6 out of 60 women with BPD had SMD. That means 54 out of 60 women with BPD did not have SMD. None of the 60 control women had SMD.

BPD women with SMD, compared with BPD women without SMD, were more likely to…

  • Have experienced childhood sexual abuse
  • Be sensation seekers
  • Have a dismissing or hostile attachment style

There were no differences in…

  • Demographics
  • Non-sexual childhood trauma
  • Self-esteem
  • Perfectionism
  • Sexual satisfaction

Interesting comments came out of the interviews as well. Some of the SMD women reported that they had previously injured themselves for masochistic reasons. Others intentionally put themselves in places where they were nearly injured or raped. They didn’t tend to involve others in their SMD needs. Instead they preferred to masturbate, self-injure, or asphyxiate themselves. None were involved in the local BDSM community.

What are the limitations of this study?

As I’ve said many times before, no study is perfect. This study in particular ended up being very small. Only 6 women in the BPD group had SMD. It’s very difficult to make generalizations based on 6 people. A bigger study would help clarify the potential relationships. And can you really make a conclusion based on such a small sample size? I would take the conclusions here with a small grain of salt until they’re repeated with a larger sample size.

I also have my doubts about comparing women with BPD to women with other personality disorders. Research needs a “control” group. The control group is usually a group without the disorder. In fact, they’re usually completely healthy. The researchers then have a comparison group.

Comparing women with BPD to women with other personality disorders doesn’t seem like a clear control group to me. What bias was introduced? It’s difficult to say. I’d like to see a study like this done with a control group without psychiatric diagnoses.

Lastly, this study has the usual limitations. It’s not an experimental study. So the results are correlation, not causation. Since they asked participants to remember historical events, there’s a recall bias. As always, their results may not apply to other populations.

What do the results mean?

I find it interesting that none of the women with SMD were active in their local BDSM group. This is evidence that SMD and masochism are not the same thing. Definitely one of the tidbits from this study that we need to share.

The association between childhood sexual abuse, BPD, and SMD is interesting. There have been theories that sexual abuse and BPD may be related. Even theories that abuse may cause BPD. I would hesitate to go quite that far. However, it’d be worth doing more research to find out.

In summary — this is interesting investigational work, but certainly not the last word.

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

Citation: Frías, Á., González, L., Palma, C., & Farriols, N. (2016). Is There a Relationship Between Borderline Personality Disorder and Sexual Masochism in Women?. Archives of Sexual Behavior, 1-8.

Oct 172016
 
Barriers are not always as obvious as a wall

Barriers are not always as obvious as a wall

Although many want to, not all transgender people are able to medically transition. The transgender community has been vocal about their needs and the barriers to medical care. However we still need research literature on the topic. Some research has been done, but not enough. Today’s study looked closer at who is receiving medical transition treatment and who hasn’t, and why they haven’t been able to get treatment.

As a quick reminder, medical transition is the medical treatment transgender people receive to treat gender dysphoria. Medical transition physically changes a person’s body from looking like one sex to looking like another. It usually includes hormone therapy and surgery. For more information, I recommend reading Trans 101 for Trans People.

Back to our study! Sineath et al polled transgender people who attended the Southern Comfort Conference (SCC). SCC is a yearly conference dedicated to education and networking in the transgender community. Of the 453 participants who stared answering the survey, 280 completed it. Participants answered demographic questions. They also answered questions about the medical therapy they had received and wanted to receive. There was a free writing section where participants could detail why they had not received any treatments they wanted.

That’s rather striking change between those who started the survey and those who finished it. And unfortunately there were differences between the group who finished it and the group who did not. Those who finished it were more likely to be college educated and trans women. That means that trans men and less well educated people were under represented in this study. While I don’t think there was much that Sineath et al could have done to prevent it, this does mean that the results should be taken with a grain of salt.

What did Sineath et al find?

Of the 280 participants who completed the survey, the majority (84%) were trans women. The rest (16%) were trans men. In this sample, trans women were more likely to be white, in a relationship, and over the age of 40 than trans men.

59% of participants had used, or were currently taking, hormone therapy. Roughly equal percentages of trans men (63%) and trans women (58%) had ever had hormone therapy. Among those who had never had hormone therapy, 53% of trans women and 76% of trans men planned to have it.

Trans men were far more likely to have gotten chest surgery (26%) or want it (88%) than trans women (5% and 40%, respectively). Of all 280 participants, only 11 (3.9%) had received genital surgery. All 11 were trans women. Roughly equal proportions of trans men and trans women wanted genital surgery.

Interestingly, nonwhite and single participants were more likely to have received hormone therapy than white and partnered participants.

I confess, I would have thought that the white people would have had more hormone therapy than non-white people. White people tend to have more resources. Perhaps there are also more barriers though? There are resources specifically aimed at non-white trans people, and perhaps they’re being especially effective. I am not entirely certain what to make of this. If you have ideas, let me know in the comments!

As for single trans people being more likely to have hormone therapy than partnered, that is more immediately understandable. Married or partnered trans people may be negotiating their transition with their partner. Or they may be waiting for children to grow. Either way, a delay makes sense.

What barriers were keeping people from getting medical transition?

There was also a significant difference in why participants had not received medical care between trans men and trans women. For trans men, lack of qualified care was the most dominant factor. 41% of trans men in this study cited that reason. Another 29% cited cost. A scattering of others cited fear of surgery (6%), employment issues (6%), and “other” (18%).

Trans women had a different distribution of concerns. Cost was the most commonly cited reason for not getting medical transition (23%). Employment issues was second largest, at 19%. Others cited age (9%), readiness (9%), needing a psychiatrist letter (7%), not feeling like they needed surgery (6%), fear of surgery (4%), and inability to access qualified care (2%). 21% cited “other” reasons.

What does all this mean?

This study found that 59% of trans participants use hormone therapy. That’s much lower than other studies. According to Sineath et al, previous studies found rates anywhere from 70% to 93%. Why the discrepancy? Studies with high levels of hormone therapy usually were conducted at clinics. Clinics are where participants actively seek hormone therapy! That explains why 93% of trans people in some studies were on hormone therapy. But why the 70%? That number came from a one-time survey that wasn’t clinic specific. It’s difficult to say how many trans people actually do get hormone therapy across the entire US. The real number may be somewhere between 59% and 70%.

 

This study also found pretty significant differences in the barriers trans people reported. Trans men cited the lack of access to qualified care far more than trans women did. That makes sense. Trans women are far more represented in both popular and medical media. The medical care of trans women is often talked about. I see far more papers and case reports about trans women in the medical literature. More surgeons offer vaginoplasties than metoidioplasties or phalloplasties.

Trans women experienced issues with employment more than trans men. Again, this makes sense. Trans women typically have a harder time “passing” than trans men. Women are subject to employment difficulties and interpersonal violence more because they’re more visible.

I, personally, look at how many trans men are struggling finding qualified care. I’m listening most strongly to that. So much of the talk around transgender care is about trans women. It really is past time that trans men get as much, or more, focus.

Conclusion

Ultimately, this study is a solid contribution to our understanding of medical transition. Thank you to Sineath et al and all the participants at the Southern Comfort Conference!

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

Citation: Sineath, R. C., Woodyatt, C., Sanchez, T., Giammattei, S., Gillespie, T., Hunkeler, E., … & Sullivan, P. S. (2016). Determinants of and Barriers to Hormonal and Surgical Treatment Receipt Among Transgender People.Transgender Health, 1(1), 129-136.