Mar 162015
 

170px-Rod_of_Asclepius2.svgBeing a gender or sexual minority (GSM) is not only difficulty and tricky for patients — it can also be a challenge for medical providers. Medicine can be a particularly conservative field, depending on location and specialty. Lives are, after all, often at stake.

Despite recent advances it appears that some 40% of lesbian, gay and bisexual medical students are hiding their sexual minority status in medical school. Among transgender medical students, 70% were hiding their identity. All because of fear of discrimination.

That fear has been, and still is, warranted. From medical providers transitioning and losing their practices, to medical students losing their residency slots, to LGBT health student organizations fighting to exist, LGBT providers face similar discrimination as our patients.  Similar happens for other gender and sexual minority health care providers, though we lack statistics. At a meeting of kink-identified mental health care providers, one attendee noted a high level of vulnerability for the clinicians. Being “outed” could lose them their jobs or even trigger legal action.

To some extent, discretion among health care providers is warranted. Most people don’t want to know about their clinician’s (or coworker’s) personal lives. And most GSM providers don’t actually want to share those most intimate details. It’s where the line is that can be distressing — how much information is too much? Can I discuss my wife when other women clinicians are discussing their husbands? How exactly do you notify your fellow clinicians or patients about a change in gender pronouns or name? How can a clinician use information gained from intimate encounters to help patients, without revealing too much? It’s a balance we constantly seek. Sometimes mentors are there and can help. Other times we figure it out as we go along.

Yet we bring a lot to the table, as minorities. Like many racial and ethnic minorities, there are pressures and issues that affect GSM people more than the majorities. We bring that knowledge with us to the research we choose to perform, the communities we participate in, and each and every patient encounter.

We as clinicians and future clinicians need to have the support in order to be appropriately open about our gender and sexual minority status. Our patients and clients must know they can be safe and honest with us so they can receive the most complete and respectful care possible.

Some progress has been made already. There’s an association for LGBT medical professionals. There’s an association for kink psychological research. There’s an association for transgender health. All of which allow student members and provide mentoring. Many other organizations exist too. Some US medical schools are working with their students to provide a safe and welcoming environment where these issues can be explored. The American Association of Medical Colleges recently launched a program to enhance education surrounding LGBT and intersex health care. The American Medical Association also has an LGBT Advisory committee.

I’m proud to say that my medical school has been accepting and supportive of its gender and sexual minority patients, and that clinics in the area of my medical school are seeking to expand their care to be more inclusive of LGBT patients. Support exists for both those seeking medical care, and those seeking to provide that care. It’s only the beginning.

Jan 092015
 

This is the start of a new series of posts here on Open Minded Health: Quickies! I often run into items in the medical literature that are too short to do a fully post on, but for whatever reason I think it’s worth covering it anyway.

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This week’s quickie is a case report, which was presented as a poster at a medical conference.

7170317810_f25026d624_mA trans woman in her thirties showed up at the emergency room with gastrointestinal problems. She had nausea, pain, and bleeding. No significant medical history was noted in the report, and she was on a normal dose of hormone therapy.

When they took her blood to run some lab tests, the sample appeared “as white and turbid as milk.”

Her lab work revealed a triglyceride level of 30,000 mg/dl. For reference, a normal triglyceride level is less than 150. Above 500 is considered “very high.”

She was immediately transferred to the intensive care unit for treatment. Triglycerides that high can cause inflammation of the pancreas. Thankfully all her pancreatic lab values were normal. After a week of treatment, which managed to get her triglycerides down to 3,000, she was sent home. She was instructed to stop estrogen treatment, take new prescribed triglyceride-lowering medications, and to follow up with her physician.

Why did the hospital physicians recommend that this patient stop her estrogen? Because estrogen treatment is known to increase triglyceride levels. Triglyceride levels that high are extremely rare. A much more mild version can, however, happen to anyone who has high estrogen levels. It can happen to cis women in pregnancy or receiving hormone replacement therapy for menopause. It can also happen to trans women on estrogen treatment.

High triglyceride levels are usually “silent” — there are no symptoms. That’s part of the reason it’s important to see a physician regularly for screening, especially if you’re at higher risk. High triglyceride levels are more likely if you…

  • are overweight
  • don’t exercise
  • eat a high-carbohydrate, high-fat diet
  • have other cardiovascular issues
  • are on certain medications
  • or if it runs in your family

Mild elevations in triglyceride levels may be controllable with diet, exercise, and weight control. If those don’t help, your physician may prescribe medications to lower your triglycerides.

For more information on triglycerides, including what they are, normal levels, and how to control them…check out this article by WebMD or ask your primary care provider.

The case report inspiring this post was “Hypertriglyceridemia up to thirty thousand due to estrogen: Conservative Management” and was published in Critical Care Medicine.

Jan 042015
 

8787343055_a2a6eb06bf_mIt’s a new year here at Open Minded Health. I hope you all had a safe, fabulous, and fun new years celebration. Here at OMH it’s time for the yearly questions and answers post.

For the unfamiliar — once a year I take a deep look at all the search queries that bring people here. Often, they’re questions that I didn’t completely answer or that need answering. So in case anyone else has these questions — there are answers here now that Google can find. The questions are anonymous and I reword them to further anonymize them.

This year is all questions about transgender health issues. There’s been a lot published and a lot in the news about trans health issues lately. This next year I’ll try to find other articles to post about too, though. :)

Questions!

What are the healthier estrogens that a transgender woman can take?

In order from least risk to most risk: estrogen patch, estrogen injection sublingual/oral estradiol, oral ethinyl estradiol, oral premarin.

But note that that’s an incomplete picture. The estrogen patch isn’t the best for initial transition and is very expensive. Injectable estrogen means sticking yourself with a needle every 1-2 weeks and needing a special letter to fly with medications. By far the cheapest of these options is oral estradiol.

Ethinyl estradiol is the form of estrogen used in birth control. Premarin is conjugated equine estrogens, meaning they’re the estrogens from a pregnant horse. Neither should be the first choice for transition. They’re both higher risk than estradiol.

For transgender women, how long does it take to see the benefits of taking spironolactone?

The rule of thumb is 3 months before changes on hormone therapy.

Where is the incision placed in an orchiectomy for transgender women?

That depends on the surgeon. But I’m know you can find images and personal stories on /r/transhealth and transbucket.

Does a trans man have to stop taking hormones to give birth?

Yes. Trans men and others who can become pregnant who are taking testosterone must stop testosterone treatment before becoming pregnant. Testosterone can cross the placenta and cause serious problems for the fetus. Once the child is delivered and no longer breast feeding testosterone can be resumed.

Once you’re on female hormones, how long does it take to get hair down to your shoulders?

My understanding is that the speed that hair grows doesn’t change. It grows at roughly 1/2 an inch a month. Expect growing it out to shoulder length to take 2-3 years.

As a trans woman on estrogen, are there foods I should avoid?

If you’re on estrogen only, there are no foods you should avoid. Instead eat a healthy varied diet.

If you’re on spironolactone you may need to avoid foods that are high in potassium. Potato skins, sweet potatoes, bananas, and sports supplements are foods you may need to limit or avoid. Ask your physician if you need to avoid these foods.

Is there a special diet that can help me transition?

In general, no. Any effect that food may have is, in general, too subtle to make a difference. The possible exception is foods that are very high in phytoestrogens — like soy. Phytoestrogens are chemicals in plants that act a little like estrogen in the body. There are a few case reports in the medical literature of people developing breasts when they eat a lot (and I do mean a lot) of soy. But they’re unusual. Ask your physician before you make radical changes in your diet. In general — just eat a healthy, varied diet.

I’m a trans guy taking testosterone and having shortness of breath. Do I need to worry?

See a physician as soon as you can. Shortness of breath may be a sign of something serious. Taking testosterone raises your risk for polycythemia (too many red blood cells in the blood), which can manifest as shortness of breath.

How often do trans women get injections of estrogen?

Most women have their injection every week to two weeks.

Can I still masturbate while I’m on estrogen?

Yes. Many trans women have difficulty getting or maintaining an erection though.

Can I get a vaginoplasty before coming out as transgender or transitioning?

Generally speaking, no. Surgeons follow the WPATH standards of care which require hormone therapy and letters of recommendation from physicians and therapists before vaginoplasty.

Are there risks to having deep penetrative sex if you’re a trans woman?

I’m assuming you’re referring to vaginal sex post-vaginoplasty. The vagina after a vaginoplasty is not as stretchy or as sturdy as most cis vaginas. It’s possible to cause some tearing if the sex is vigorous or if there are sharp edges (e.g., a piercing or rough fingernails).

Things you can do that might help prevent injury: Make sure you’re well healed after surgery. Dilate regularly as recommended by your surgeon. Use lots of lubrication, and try to go gently at first. Topical estrogen creams may also be helpful for lubrication and flexibility.

Is it safe to be on trans hormone therapy if you have a high red blood count?

Depends. If you’re a trans man looking for testosterone, you may need treatment first to control the high red blood cell count. Testosterone encourages the body to make more red blood cells, which would make the problem worse.

What kinds of injection-free hormone therapy are available to trans men?

Topical testosterone is available for trans men. It’s a slower transition and it’s expensive, but it exists and it works. Oral testosterone should never be used because of the risk of liver damage.

What can cause cloudy vision in trans women on hormone therapy?

Seek medical care. It could be unrelated, but changes to vision are not a good sign.

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And that’s it for this year! Next week we’ll be back to normal posts. :)

Aug 302014
 
Image of needle and syringe - click through to see source

Needles and syringes no longer look like this. Isn’t that wonderful?

Testosterone therapy for transgender men, and others who desire testosterone supplementation, typically involves intramuscular injections of testosterone. Intramuscular injections deliver the medication deep within a large muscle — typically a thigh muscle. From there the hormone can slowly work its way into the bloodstream to do its magic. Few other options exist, and those that do are either expensive or less effective (e.g., creams). Testosterone should not be taken as a pill because it’s very bad for the liver in that form. One possible alternative that has been discussed recently is subcutaneous testosterone injections.

Subcutaneous injections go just under the skin. If you’ve ever had a tuberculosis skin test (“PPD”) or been involved in injections for people with Type I diabetes you’ve seen this done. They leave a little “bump” in the skin for a day or two that slowly goes away as the drug is absorbed.

Subcutaneous testosterone has been in sporadic recent use for trans men without any research showing how well it works. But that’s changed now with the publication of the article I’m going to summarize. :) So let’s hop into it!

This was a study involving 36 male-identified trans youth from ages 13-24 (minors had parental consent). None had been exposed to hormones before. Hormone levels and other lab values were measured at the beginning and after six months.

For those interested in the specific technicalities of how the hormone was given, keep reading this paragraph. For those not, skip down to the next one! They were given testosterone cypionate suspended in sesame oil that was made at a local compounding pharmacy. The young men were given the injections by the clinical staff at first, but slowly taught to self-inject. Dosing was biweekly and started at 25mg per week, slowly increasing after that for some with a final dose ranging from 25-75mg.

So what did they find? How did it go? Positively!

About 92% of the young men in this study had testosterone levels in the “male” range at the 6 month check up. Similar goes for estrogen levels — by that 6 month check up their estradiol levels were down in the “male” range too. 85% of the young men who had been menstruating had stopped by that 6 month check up. Most periods stopped roughly around the 3 month mark. Other factors, like hemoglobin (red blood cell concentration) and cholesterol shifted but were not of clinical significance.

Two of the young men had allergic reactions to the sesame oil and were switched to cottonseed oil. This is a pretty well known reaction that happens in intramuscular injections too. Some also noticed small bumps around where they injected for a few days after injection. Those were the only reported side effects. Nobody reported unhappiness with their testosterone treatment method or asked to be switched to a different method.

All in all, a well put together study. Subcutaneous injection of testosterone so far appears to be a possible alternative to intramuscular injection. But it’s worth noting that commercial testosterone is intended for intramuscular injection and that type is not what was tested here. It may not be safe or effective to inject an intramuscular formulation as a subcutaneous one — ask your physician before changing how you use your medications!

As always: this is just one study. More need to be done to confirm these results. Regardless, I think these are good first results and look forward to seeing more.

Study was published in LGBT Health. Abstract is publicly available.

Disclaimer: I have personally met Dr. Olson (lead author of this study), worked with her in a small capacity, and have attended her talks at conferences. My interactions and impressions of her may have biased my interpretation on this study. However, I do my best to keep those preconceptions from affecting my judgment.

Aug 022014
 
Rural vs Non-rural

Rural vs Non-rural

This study used a convenience sample of transgender individuals and compared mental health factors between trans people living in rural and non-rural areas in the United States.

Why would health and health care differ between rural and suburban or urban trans people? A number of possible factors, including…

  • Transportation issues.
  • Overall difficulty accessing health care. Fewer physicians, fewer hospitals. Few big research or teaching hospitals.
  • Possibly less social support for healthy lifestyles. Depending on the community, support of a healthy lifestyle may be less. Rates of tobacco use, alcohol drinking may be high and access to exercise and a fruit/vegetable-focused diet may be low
  • Less accepting physicians. Rural areas are traditionally more socially conservative, possibly resulting in higher rates of transphobia. Open-minded physicians may not have the resources to learn about transgender health care, and access to specialists is limited in rural areas
  • Smaller minority communities. With a smaller population, and transportation time, it’s much harder to form a supportive LGBT or trans community. Social support and information sharing may be very limited.

The vast majority of transgender health centers are in urban areas including San Francisco, Los Angeles, New York City, Seattle, Boston, Washington DC, and Philadelphia. Resources in places like the middle of rural New Mexico are few. But that doesn’t mean people in such rural places don’t need care too.

This research used the internet, advertising on mailing lists, journals, and forums, to recruit and survey trans people in all areas. They ended up with a very large sample for a trans study: 1,229 people! What determined whether a person lived in a rural or non-rural area? The participants self-selected an option – and if they selected “rural” or “small town” for their location they were classified into “rural”. Other options (suburban and urban) were classified “non-rural”.

What did they measure? Basic demographics, substance use, mental health (including anxiety, depression, somatization, and self-esteem), and sexual risk behaviors. That last one – sexual risk behaviors – was specifically narrow, focusing only on protected vs unprotected penetration with a penis.

The results were fairly clear.

For trans women, there was no different in mental health between rural women and non-rural women. But trans men were statistically significantly more likely to have depressive or anxiety symptoms, low self-esteem, and other similar mental health problems if they were rural than if they weren’t rural.

There were no significant differences in substance use for either trans men or trans women. There were no differences in sexual risk behavior either.

Some interesting, and some disturbing, statistics that came out of this:

  • 25-27% of trans women reported a previous suicide attempt vs 38-40% of trans men.
  • 7-10% of all trans people in the study reported binge drinking alcohol in the past 3 months. 7-13% used an illicit substance other than marijuana in that same time frame.
  • 42-45% of trans women reported unprotected penile sex with either a primary or non-primary partner, vs 16-21% of trans men (in the past 3 months)

This study isn’t perfect. It was internet-based and used a convenience sample, so it may not reflect the larger trans population. It also used a broad definition for transgender at times, including those who cross dress for reasons other than gender identity. The fact that it was internet-based means that people who do not use computers or have access to the internet weren’t included. Still, it was the first of its time and its methods were fairly sound given these restrictions.

So what can we conclude?

  • First, something that we knew before: Trans people are in need of compassionate, open-minded mental health care and medical care no matter where they live.
  • Second: That trans men living in rural ares may be faring worse than their urban and suburban brothers.
  • Third: That rates of suicide are still unacceptably high for all trans people
  • Fourth: That trans people, especially trans women, are still at unacceptably high risk for HIV and other STDs via unprotected sexual contact.

What can we do about all of this?

Rural health care is a challenge for both physical and mental health. Telemedicine options continue to be in development. Education and outreach efforts must continue within trans communities. Those who work in physical and mental health, whether rural or urban, must understand that transgender populations face specific stressors and have specific health needs. Efforts to educate all providers, such as WPATH’s mailing list and Trans Line, must continue to be available and probably should expand.

This paper was published in the Journal of Homosexuality and is publicly available.