Feb 082016
 
Muscular greek statue

We don’t all have to be ready for the Olympics to enjoy the best health we can

The foundation of medicine is the prevention of disease, disability, and death so that everyone has the best quality of life they can. Treating illness once it’s happened is all well and good, but it’s far better to prevent that illness from happening wherever possible. But stigma, discrimination, and ignorance prevent many gender and sexual minority people from getting the preventive medicine they need!

So we begin a new series here on Open Minded Health: Your guide to taking care of your health. Like Trans 101 for Trans People, this is a multiparter that will slowly take the form of a living document.

This week we’ll start with the basics — definitions and health promotion that applies to everyone.

What is health promotion/preventive health? Why should I care?

At its core, health promotion gives you the tools to take care of yourself. Your actions and choices are the core of your health. Doctors, surgeons, and nurses can provide services that help, but the ultimate decision is almost always yours.

Taking care of your health every day won’t stop all bad things from happening. It can’t stop a bad car accident, for example. But it can increase the chances of you surviving the accident and thriving afterwards.

Choosing healthier options can also add years to your lifespan. For example, non-smokers live roughly 10 years longer than smokers. And smokers who quit add years onto their lifespan, no matter when they quit (though earlier is better!)

What can I do on a daily or weekly basis to promote my own health?

This is the nuts and bolts of living well. Little choices every day add to up to a lot! In general, it’s best to make small choices you think you can succeed at rather than huge life changes all at once.

  • Diet: Consider eating more vegetables, less meat, and less sugar. Too much red meat and too little vegetables is associated with heart disease. Too much sugar can lead to obesity and diabetes. So consider replacing beef with chicken, and chicken with lentils or beans. And consider drinking water, seltzer, or diet soda instead of sugared soda. You don’t have to eat kale and quinoa all day to make better choices. The mediterranean diet is another heart-healthy option. MyPlate and the American Heart Association have more details if you’re interested.
  • Exercise: Consider moving more and spending less time sitting down. Park a little further away from work and walk in. Take the stairs. Walk the long way to the bathroom. Go for a walk for part of your lunch break. It all adds up. Consider asking a friend or partner to walk/exercise with you. If your mobility is limited, do what you can. Swimming can be gentle on painful joints, and arm exercises are useful for people who need wheelchairs. Some people find a fitness tracker or pedometer helpful, others don’t. Do what works for you.
  • Tobacco: Avoid tobacco and nicotine products. If you currently use tobacco, make a plan to quit and quit as soon as you can. Many people find a support group, nicotine replacement therapy, and some medications helpful but they’re not necessary for quitting. And remember: relapsing doesn’t mean you’re a failure — you’ve quit before, you can quit again. You have the tools. Also keep in mind that e-cigarettes may not be healthier than regular cigarettes. Early reports show they’re high in formaldehyde, a carcinogen. So it’s best to avoid all tobacco and nicotine. The CDC has resources for those looking to quit.
  • Alcohol: If you drink, drink in moderation. Current recommendations are around 1-2 drinks per day. 1 “drink” is 1 shot worth of alcohol. Limit the times you drink heavily (“binge” drinking). If you do drink heavily occasionally, don’t drink to the point of passing out or vomiting. As always, don’t drink and then drive and avoid drinking when you’re on certain medications. The CDC has more information.
  • Addiction: If you feel that you may have a problem with your use of drugs or other habits, it’s probably worth taking a break from those drugs/habits for a while. If that’s intolerable, it may be time to quit outright. Help for addiction does exist. The best help comes from trained mental health professionals. But if those aren’t available for you, you can consider support groups (online or in person), seeking help from a physician, or working through workbooks on your own. Here’s more information on addiction treatment.
  • Illegal drugs: Most sources say you should always avoid using illegal drugs. And avoiding illegal drugs is best for your health. But that’s simply not reality for everyone. If you choose to use illegal drugs, it’s important to reduce your risks. First — be careful with your sources. As I’m sure you know, contamination isn’t a made up problem. Second — use those drugs as little as possible. This helps avoid addiction and tolerance. Third — use the drugs in the safest way possible. Vaporize, don’t smoke. Avoid injecting drugs, but if you do inject then don’t share needles. Here’s more information.

That’s where I’m going to leave it for this week. But don’t worry! More information is coming. :) And as always — let me know if you have feedback, questions, or concerns. Have a lovely week in the meantime.

Feb 012016
 
Human heart and lungs -- the core of the human cardiovascular system

Human heart and lungs — the core of the human cardiovascular system

Cardiovascular disease (CVD) is the leading cause of death in the United States. And it’s growing, largely because the factors that lead to CVD are growing too: obesity, diabetes, high blood pressure, high cholesterol, diets based on meat, and physical inactivity. We have data on how CVD risk varies depending on sex, ethnicity, and socioeconomic status. But we don’t have strong data on how gay, lesbian, and bisexual peoples risk factors add up to actual CVD risk.

CVD risk is often calculated using data from the Framingham study, a massive multigenerational study started back in 1948. The risk calculators that still come from that study today are some of the most well validated calculators we have. A physician can plug in a few numbers and get a good estimate of your risk of having a cardiovascular-related event over the next few years. The calculators are publicly available, but really do need training to interpret.

Why do I bring up the Framingham study? Because the study I’m examining this week uses those same calculators and other factors to try to estimate the cardiovascular risk of lesbian, gay, and bisexual cisgender people. Let’s take a look at what they did!

This study used data from the National Longitudinal Study of Adolescent to Adult Health. They used data from a whopping 13,427 participants. That’s a lot of people — one of the largest sample sizes covered here on Open Minded Health. The participants were also quite young for a study on heart disease — mostly around 28-29 years old. They looked at social factors like age, ethnicity, educational level, and level of financial stress. They also looked at medical factors, like their diabetes status and hypertension (high blood pressure) status.

The researchers reported sexual orientation on a Kinsey-like 5-point scale, from “heterosexual” to “mostly heterosexual” to “bisexual” to “mostly homosexual” to “homosexual”. I’ll try to stick to that language for clarity. Among the participants, 80% of the women and 93.5% of the men said they were heterosexual. In contrast, .9% of the women and 1.7% of the men said they were homosexual, and 18.7% of women and 4.8% of men were in the middle.

So what about their cardiovascular risk?

The men’s 30 year CVD risk was 17.2%, and the women’s was 9%. What does that mean? It means the men has a 17% chance of having cardiovascular disease in the next 30 years. In other words, a little under 1 in 5 of the men would have CVD by the end of 30 years. By then, they’d be in their late 50’s. Roughly one in five men and one in ten women in the entire study would likely have cardiovascular disease by their late 50’s.

What happens when we look at sexual orientation?

For women: Compared to heterosexual women (9% risk), all other sexual orientations were at higher risk for cardiovascular disease. Mostly heterosexual women had the lowest of non-heterosexual women, at 9.8%. Mostly homosexual women had the highest, at 11.8%.

For men: Compared to heterosexual men (17.2% risk), some sexual orientations were at higher risk and some were at lower risk. Mostly heterosexual and completely homosexual men were at lower risk of cardiovascular disease — 16.3% and 16.6% respectively. In contrast, mostly homosexual men had higher risk, at 20.2%!

What factors other than sexual orientation came into play? Risks were lower with more education. Being a college graduate reduced risk from 3% for women to 5% for men. Being of Asian or Hispanic descent was also protective, though not nearly as much. And the factors that increased risk? Being of African descent (up to 1% higher), being older (up to 1.5% higher), and having financial stress (up to 1.2% higher).

Let’s summarize a bunch of those numbers, shall we?

Overall, men are at twice the risk for cardiovascular disease as women. Non-heterosexual women are at higher risk than heterosexual women. Among men, mostly heterosexual and completely homosexual men were at lowest risk and mostly homosexual men were at the highest risk. Among everyone, poorer black people were at higher risks and richer, more educated hispanics and asians were at lower risks.

Why such a difference?

It’s hard to say. The researchers don’t go into detailed statistics to figure it out. I have some thoughts from looking over the data they published though. For women, it looks like part of that increased risk is from smoking — it looks like a higher percentage of non-heterosexual women smoked. On the male side, it looks like diabetes may play a role. But I haven’t run statistics to see if what I think I’m seeing is real or just by chance.

Regardless — this is valuable information which will help public health officials determine where to put their resources.

What can you do with this information? You can work to reduce your own cardiovascular risk! Here are some things to consider doing (depending on what works for you!):

  • Move more, eat less. Most Americans eat too much and don’t move enough, which leads to obesity and cardiovascular disease.
  • Stop smoking. Much easier said than done, but this is one of the best things you can do for your health
  • If you have diabetes, keep your blood sugar under control as best you can. Aim for the lowest HbA1c you can, but under 7% is a great place to be. If you haven’t spoken with a diabetes nurse educator, they can be great allies.
  • If you have hypertension, keep it under control as best you can. Take your medications, and talk with your doctor about them.
  • Get some healthy stress relief. Whether that’s a long hot bath, a fitness class, a long walk/run in the wilderness, or knitting a scarf — find something that helps you relax every day.

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

Jan 252016
 

800px-Mercury_fig_leafThe metoidioplasty is one of two potential genital surgeries for trans men. It takes advantage of the fact that trans men already have a penis: their clitoris!

With testosterone, the clitoris grows. A metoidioplasty removes tissue around the clitoris. This exposes more of it and helps it to hang in a more male position. That’s why a metoidoplasty is sometimes also called a “clitoral release” or a “free-up”. That’s it — that’s the core of a metoidioplasty.

In addition, the urethra can also be routed through the neopenis. At the same time the vagina can also be removed, and a scrotum made from the labia. A metoidioplasty does not remove the cervix, uterus, or ovaries. That would be a different surgery. However some surgeons will perform a hysterectomy at the same time as a metoidioplasty.

All in all, a metoidioplasty preserves the tissues that are already there. It shuffles them around into a masculine shape. Not everybody will have everything done, and there are many options.

Why would I want a metoidioplasty?

Everyone has their own reasons. Here are some that I have heard:

  • Ability to “pass” in male spaces, such as bathrooms and locker rooms. With genital surgery, the fear of having a towel around the waist slip at an awkward moment is gone.
  • Relieving gender dysphoria. What’s not to like about that?
  • Ability to pee standing up. Only with a urethral lengthening procedure, which carries its own risks.
  • Keeping erections and erogenous sensation. Some men are also able to have penetrative sex after a metoidioplasty.
  • Cheaper, easier to find a surgeon, and fewer surgeries than a phalloplasty with good results.

What is involved in metoidioplasty? What are my options?

Different surgeons will include different specific stages to a metoidioplasty. But the core of a metoidioplasty is clitoral release. The clitoris is freed from its surrounding tissues so it can hang the way a penis hangs.

Others steps are often included, including…

  • Vaginectomy: Removal of the vagina. May be required for some forms of urethral lengthening. Usually combined with a scrotoplasty, which fuses the labia together to make a scrotum. At the same time testicular implants can also be placed.
  • Urethral lengthening: The urethra is routed through the neopenis and lengthened using other tissue. This allows peeing through the penis and while standing.
  • Hysterectomy, oophorectomy: Removal of the uterus, fallopian tubes, and ovaries.

I’ve heard there are different techniques. What are they?

The biggest difference centers around urethral lengthening. Since the urethra is only so long, other tissue is used to lengthen it. That tissue can come from the vagina or inner labia, or it can come from the inside of your cheek (“buccal”).

Surgeons often have their own individual techniques and strategies in addition.

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

It depends on which specific procedures you have done.

For a simple metoidioplasty only without urethral lengthening, vaginectomy/scrotoplasty, or hysterectomy, some surgeons will perform it under “twilight” anesthesia. This is also called conscious sedation. You’ll be relaxed and won’t feel pain but will likely stay awake. This level of sedation is also used by some dentists, so it’s not unique to this procedure. If you’re also having more intense procedures, like urethral lengthening, then you’ll be under general anesthesia.

The surgery itself lasts anywhere from 2-5 hours depending on what procedures you’re having. You’ll likely spend one night in recovery in the hospital. Full recovery time also varies. One surgeon advises bed rest for 24 hours, plus either 7-14 days off work with no heavy lifting for 2-4 weeks. Again — this depends on the intensity of your surgery.

What are the possible risks of metoidioplasty?

The usual risks with surgery apply here: adverse drug reactions, bleeding, infection and the like. Permanent loss/reduction in sensation may occur, as with all surgeries. And pain can persist for a long time.

The penis itself can end up twisted (torqued), which is repairable by surgery. The length may also be less than was hoped.

Urethral lengthening caries its own risks, including urethral narrowing or blockage, and urethral fistula. Urethral fistula is when a hole forms between the urethra and somewhere it shouldn’t be — so urine may spray from the underside of the penis, for example. Narrowing, blockage, and fistula can be repaired surgically. The stream of urine may also spray or be not what you expect.

What about scars?

The beauty of metoidioplasty is that it doesn’t leave very visible scars.

How will metoidioplasty affect my long-term health?

The metoidioplasty itself (the clitoral extension) doesn’t generally have long-term health implications unless there were complications. The same applies to the urethral lengthening.

Vaginectomy removes your risk for vaginal cancer. If you also had a hysterectomy/oophorectomy, you no longer are at risk for those cancers. However in order to maintain bone health it’s important to stay on sex hormones (testosterone) life-long.

Can I have penetrative sex with my partners after a metoidioplasty?

It depends, but the answer is definitely not “no”. Different people have different results, and different surgeons have different results too. Some surgeons report 4-6cm (1.6-2.4″) long penises, others boast 6-12cm (2.4-4.7″).

If being able to penetrate a partner is the most important thing for you, then you might want to consider a phalloplasty.

More information?

I am not a surgeon, nor an expert on surgeries! Check out some of these other resources and surgeon websites for more information:

Jan 182016
 

There’s been a cluster of publications and news recently that I won’t be able to dig fully into and write a full article on, but still needs mentioned. So this week’s post is a quick summary of a bunch of them!

Several articles came out pointing out that various health care professionals have a role to play in gender/sexual minority health. Articles like this are important in helping the wider medical community understand why learning about gender and sexual minority health issues is important. The articles include…

  • Obstetricians can help screen fetuses for being intersex and help to manage the medical aspect of intersex medical conditions. Gynecologists can help adult intersex people with both medical and social issues associated with being intersex. See the article.
  • Pharmacists can help with the care of trans people above and beyond just filling a prescription. They can help make sure that certain laboratory calculations are done correctly, based on the hormonal status of the patient. They can counsel on the various forms of hormones (e.g., pill vs patch vs injection). See the article.
  • Dermatologists may be able to assist in medical transition by providing hair removal and other noninvasive, aesthetic procedures. See the article.

Asking about sexual orientation and gender identity and recording it in the electronic health record is now a required part of all electronic health records by Medicare/Medicaid. This is part of “meaningful use”, and is part of the larger goal of having electronic health records that actually cooperate with each other and record the same things. Here’s a quick abstract discussing this. This is really the beginning of a change in health care around the United States — there’s now a financial incentive to screen for sexual orientation and gender identity and to handle patients who aren’t cisgender and straight. It’s good stuff.

A study of examined the effectiveness of therapy intended to change same sex sexual attraction as performed within the Church of Jesus Christ of Latter-day Saints. Less than 4% of those surveyed experienced a change. 42% reported that it wasn’t effective, and 37% found it to be moderately to severely harmful. Those who seek to modify their sexual orientation should keep this in mind — therapy intended to change sexual orientation is far more likely to do harm than good. For context, if this therapy was a new drug the FDA would never allow it into the marketplace. It would never get past early clinical trials. In contrast, acceptance therapy (i.e., therapy meant to help one be accepting of one’s orientation) in this study was found not only to reduce depression and improve self esteem but also improved relationships with family. See the abstract.

It’s well known that lesbian, gay, and bisexual cisgender people are at higher risk of suicide than the general public. A study recently clarified some of that risk, finding that bisexual cis women are at nearly 6 times higher risk of suicide than straight cis women (roughly 4-9% of the women). Gay men were 7 times more likely to attempt than straight men (roughly 3.5-13% of gay men). Lesbian and bisexual women were also more likely to attempt suicide at a younger age than straight women — roughly 16 years old vs 19 years old. Sad news. See the abstract.

Gay and bisexual men may be more likely to rely on chosen family for social and economic support than lesbian and bisexual women and heterosexuals, who may rely more on blood relatives. See the abstract.

And very exciting — the FDA has changed their blood donation policy for men who have sex with men! Instead of an “indefinite deferral”, people who quality as “men who have had sex with men” need to wait 12 months after the last sexual encounter to donate. This brings the guidelines for sex who have sex with men roughly equivalent to the guidelines for others who are at higher risk for HIV.

If you are transgender, the guidelines are still unclear. Transgender women who had ever had sex with a man (unclear if cis or trans) used to count as “men who have sex with men” in the FDA’s eyes. Now the FDA advises that transgender people should self report their gender. What this seems to say is that trans women should be counted as women and trans men should be counted as men regardless of hormonal/surgical status. So according to the guidelines, this should be the logic…

  • If you are a cis/trans man who has had sex with another cis/trans man once since 1977, but over 12 months ago: You may donate blood.
  • If you are a cis/trans man who has had sex with another cis/trans man within the past 12 months: Wait until 12 months after that sexual encounter to donate, whether you used a condom/barrier or not.
  • If you are a cis/trans woman who has had sex with a cis/trans man in the past year, and that cis/trans man has had sex with a cis/trans man in the past year: Wait until 12 months after your sexual encounter to donate, whether you used a condom/barrier or not.
  • If you are a cis/trans woman who has not had sex with a cis/trans man in the past year: You may donate blood.
  • If you are a cis/trans woman who has had sex with a cis/trans man in the past year, but that cis/trans man has not had sex with a cis/trans man in the past year: You may donate blood.

Confusing enough? I hope that still helped. Keep in mind that all of the guidelines I attempted to simplify assumes that you’re not HIV+ (no one who is HIV+ may donate). If you’re confused still, take a look at the new guidelines or reach out to your local blood donation center.

And that’s it for this week! I hope this was fun, interesting, and helpful! Have a wonderful week.

Jan 112016
 

Happy new year! I hope everyone had a safe and relaxing holiday season. And welcome back! Thanks, as always, for sticking around while I took care of other business. Let’s get started.

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Vocal cords -- the source of our voice and pitch

Vocal cords — the source of our voice and pitch

This week’s article comes out of Sweden, and asks the question “When we measure voices in the lab, how quickly and how well does testosterone change the voice of trans men?” Testosterone’s effects on voice have been the subject of blessings and curses (by trans men and trans women, respectively) but have received little attention by researchers.

This study was relatively simple — invite 50 trans men to participate, ask them to read into a machine every 3 months as they start testosterone, survey them, and look at their testosterone blood levels.

The men in this study varied in age, from 18 year old men just swapping from puberty blockers to testosterone to 64 year old men. All had never taken testosterone before. Testosterone forms included both intramuscular injection and transdermal (patches/gels/creams). By 3 months into treatment all the men had male testosterone levels in their blood.

So now that we know a bit about who participated…what happened in this study?

Every three months the men came into the lab and were recorded reading. The pitch and force of their voice was analyzed. Most of the study’s details of how they analyzed it is beyond me (I don’t have a foundation in voice analysis), but the results are clear. By 12 months on testosterone their voices had stopped changing. The most change happened in the first 6 months. On average their voices went from a fundamental frequency of 192 Hertz (Hz) at the beginning to 155 Hz after 3 months and finally ended up at 125 Hz. If you want to hear what those sound like, plug those numbers into this website. There was a lot of variation where their voices started out at, and a lot of variation what their voices changed to. Six of the men stayed around 143-170 Hz. Ten men started out lower than 175 Hz.

Fundamental frequency is a fancy term for pitch. On average cis men range from 85 to 155 Hz, and cis women range from 165 to 255 Hz, for reference. The type of testosterone didn’t seem to have a big effect on when voices changed or what they changed to.

What about how the men felt about their voices and whether or not the change was heard by others? The lower the pitch, the more satisfied the men felt about their voice and the more likely they were to report that they were correctly gendered on the phone. By the end of 12 months satisfaction with their voice was higher, with the most change happening between 3 and 6 months.

But it wasn’t all positive for every participant. Twelve men of the 50 also sought voice therapy. Reasons varied from vocal fatigue to the voice not being low enough to instability, strain, or hoarseness. They attended an average of 3 vocal therapy sessions. How well those sessions helped wasn’t measured.

So what’s the important stuff to take away from this study?

  • After 12 months most trans men’s voices have dropped into the male range, but individual results vary.
  • The most significant change in voice happens in the first 6 months of testosterone treatment, but changes continue to 12 months.
  • Some trans men may desire voice therapy during that first year

It’s also worth noting that this was the first published longitudinal study of trans male voices and how they change on testosterone.

What do you think? Do the study results reflect your own experiences or the experiences of your friends and loved ones? Did the researchers miss anything big? Let me know in the comments!

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