Aug 312015
 
Psy_II

The Greek letter Psy is often used to symbolize psychology.

The American Psychological Association has released a 55-page document detailing guidelines for psychologists treating transgender and gender non-conforming individuals. To my knowledge, this is the first such document the APA has published. It’s a huge milestone in trans mental health care.

APA guidelines provide standards for both trainees and practicing psychologists on the expected conduct of psychologists. They’re used in both introductory and continuing education.

In this document, the APA lists out the following guidelines (note that TGNC stands for “transgender/gender non-conforming”):

  1. Psychologists understand that gender is a non‐binary construct that allows for a range of gender identities and that a person’s gender identity may not align with sex assigned at birth.
  2. Psychologists understand that gender identity and sexual orientation are distinct but interrelated constructs.
  3. Psychologists seek to understand how gender identity intersects with the other cultural identities of TGNC people.
  4. Psychologists are aware of how their attitudes about and knowledge of gender identity and gender expression may affect the quality of care they provide to TGNC people and their families.
  5. Psychologists recognize how stigma, prejudice, discrimination, and violence affect the health and well‐being of TGNC people.
  6. Psychologists strive to recognize the influence of institutional barriers on the lives of TGNC people and to assist in developing TGNC‐affirmative environments.
  7. Psychologists understand the need to promote social change that reduces the negative effects of stigma on the health and well‐being of TGNC people.
  8. Psychologists working with gender questioning and TGNC youth understand the different developmental needs of children and adolescents and that not all youth will persist in a TGNC identity into adulthood.
  9. Psychologists strive to understand both the particular challenges that TGNC elders experience and the resilience they can develop.
  10. Psychologists strive to understand how mental health concerns may or may not be related to a TGNC person’s gender identity and the psychological effects of minority stress.
  11. Psychologists recognize that TGNC people are more likely to experience positive life outcomes when they receive social support or trans‐affirmative care.
  12. Psychologists strive to understand the effects that changes in gender identity and gender expression have on the romantic and sexual relationships of TGNC people.
  13. Psychologists seek to understand how parenting and family formation among TGNC people take a variety of forms.
  14. Psychologists recognize the potential benefits of an interdisciplinary approach when providing care to TGNC people and strive to work collaboratively with other providers.
  15. Psychologists respect the welfare and rights of TGNC participants in research and strive to represent results accurately and avoid misuse or misrepresentation of findings.
  16. Psychologists seek to prepare trainees in psychology to work competently with TGNC people.
This is all excellent.
There is a history of psychologists attempting to change gender identity through conversion therapy or other coercive means. The APA’s statement, in effect, states very strongly that attempts to change gender identity should not be attempted. Instead, the APA is embracing the ethical treatment of transgender people and of affirming transgender and gender non-conforming people.
Do these guidelines mean anything for you if you’re receiving therapy? Possibly. Talk with your therapist, whether you’re trans or cis, to make sure they’ve seen the updated guidelines. If you’re receiving therapy that is not within these guidelines, consider talking with your therapist about these guidelines or seeking another therapist.
And spread the word! The document itself is publicly available as a PDF.
Aug 242015
 

148px-Orange_ribbon.svgRecent reports have highlighted the frequency of non-suicidal self-injury among gender and sexual minorities. 41.9% of transgender people have self-injured. I was unable to find a percentage for cis lesbian, gay and bisexual people beyond the general report that the rate was “much higher”. Gender and sexual minority (GSM) youth are at particular risk, as are cis women.

So let’s take a quick look at non-suicidal self injury this week. What is it? Why do people do it? And what should those who currently self-injure, and their loved ones, know?

Non-suicidal self injury (NSSI) is a term that refers to deliberate attempts to cause oneself injury without intending suicide. The “without intending suicide” is the important bit there. This is a separate phenomenon from suicidality, though both suicidality and NSSI can come from the same psychological source. NSSI can take many forms, but cutting and burning are the most common. People who have higher levels of stress, such as GSMs, are at higher risk for NSSI. Transgender people may have an additional risk factor because of extreme body dysphoria.

To most who have never participated in NSSI, it can seem baffling. Why would a person do that to themselves? While everyone has different reasons, at core NSSI is about survival. Many use it to defuse overwhelming emotions. Emotional pain is just like physical pain in the brain, causing activation of the same areas. All pain causes the release of morphine-like chemicals in the brain which buffer the pain, causing the sensation of a “high”. By creating physical pain in reaction to emotional pain, the person doing the NSSI can regulate their own emotions and cope. Other people who do NSSI are attempting to focus. When the world seems far away or they feel numb, pain can help them to feel something and give something to concentrate on. Lastly, some people who do NSSI do so as a way to punish themselves, as a way of asserting control in a powerless situation, or to communicate their emotional pain….or for any number of other highly personal reasons.

NSSI is not an ideal way of coping with life’s stressors. It can be addictive. It’s easy to hurt oneself too much and accidentally attempt suicide or develop infection. Scars and NSSI behavior attract attention, limiting one’s ability to get or maintain a job. Over time it can permanently change a person’s responses to stress and pain.

NSSI is often misunderstood, even in psychology and medicine. Most psychologists and physicians have never experienced NSSI or been close to people who have, so they fail to understand the reasons for NSSI. Until the DSM-V, the only psychological diagnosis that applied was that of borderline personality disorder, which most people who do NSSI do not have.

It can be difficult for a person who self harms to get help. Psychologists and physicians are legally bound to report individuals who are at risk of harming themselves or others to the police. While necessary, it limits confidentiality and can harm trust. Some professionals require that a patient sign a “no self harm contract” before receiving any treatment. Not all patients are willing or able to sign such a contract. Physicians have a limited set of options for treatment: medications (which can take 4-6 weeks to begin to work), referral to a psychologist or psychiatrist, do some level of psychological intervention themselves, or admit the patient to the hospital. And then there’s the question of affordability, especially if you’re unable to hold a job because of the self injury.

Despite these barriers, psychological and medical professionals can be very helpful for people seeking to stop self-injuring. At bare minimum, having a psychologist or physician in the loop can help if a particular incident of self injury goes further than intended. NSSI is a coping strategy, and psychologists and physicians can be very helpful for the issues lying underneath self injury, whether that’s depression, post traumatic stress disorder, or just plain stress.

Lastly, it’s important to know that people can and do learn non-NSSI coping strategies and learn to be self-injury free.

If you want to learn more about non-suicidal self injury, I highly recommend this website. It’s old and the current version is broken, so that links off to the Wayback machine version. It’s still one of the best sites written by people who intimately understand self injury and work to provide information and help others. For a modern alternative, this website also has support forums.

 

 

Aug 172015
 

715px-715px-Sunbedoff_largeA new study finds that gay and bisexual men use tanning beds more frequently than straight men. The use of tanning beds is strongly associated with skin cancers, especially melanoma (the most dead form of skin cancers).

Campaigns to dissuade people from using tanning beds usually target straight women, as they’ve been the most frequent users of tanning beds. These new data show that gay and bisexual men use tanning beds just as frequently as straight women. Lesbian and bisexual women were less likely than straight women to use tanning beds.

Tanning beds should not be used for cosmetic reasons. While many perceive a tan as “healthy” or enjoy the experience of tanning, tanning damages the skin and raises the risk of skin cancer.

Want to read the study for yourself? It’s publicly available!

Aug 102015
 

rainbow-awareness-ribbon-mdGender and sexual minority health isn’t just about HIV/AIDS, sexually transmitted infections, and mental health. It’s also about cancers, and our exposures to risk factors for cancers. Why? Because everyone can get cancer, and we all need both preventative and therapeutic health care.

Cancer is not just one disease, which is why it’s been so difficult to “cure”. Cancer is when a cell mutates and grows out of control. The cells begin to invade other tissues, and can spread throughout the body. Any cell can become cancerous. And different cancers are caused by different things and have different treatments.

A recent paper, published online ahead of print, looked at the data surrounding lesbian, gay, bisexual and transgender/transsexual (LGBT) populations and cancers. They specifically looked at cancers which may be more common in LGBT communities: anal, breast, cervical, colon/rectal, endometrial, lung, and prostate cancers.

Why might these cancers be more common in LGBT communities? Perhaps because of higher levels of risk factors like obesity, smoking, and certain infections. Or perhaps because of lack of preventative health care.

But what do the data say? What data do we even have? So far it looks like we don’t have much information. Most studies about cancers don’t ask about sexual orientation or gender identity. But let’s take the data one cancer type at a time, just as the paper did…

Anal cancer is a rare cancer of the anus. It’s primarily associated with HIV infection and HPV infection. Men who have sex with men, because they are at high risk for HIV and HPV infections, are at higher risk for anal cancer. The risks for women and transgender people are unknown. The best prevention for anal cancer is the HPV vaccine and consistent use of condoms to prevent HPV and HIV infections. Screening, to catch cancers in their most treatable state, can be done through the anal pap test. However there are no guidelines for the anal pap test and its value as a screening tool is uncertain. Treatment for anal cancer can impact not only general quality of life for survivors but sexual quality of life for men who have sex with men. The effects on sexual quality of life may be under appreciated by physicians.

Breast cancer is among the most frequently diagnosed cancers in women. Unlike with anal cancer, there are no obvious risk factors beyond being a cisgender woman. There are no data on how rates of breast cancer differ between heterosexual, bisexual and lesbian women. It is thought that bisexual/lesbian women may be at higher risk of breast cancer because of high rates of smoking, alcohol use, and obesity. Lesbian/bisexual women are also less likely to carry a pregnancy. However, it’s not known if those risk factors are actually associated with higher rates of disease. There are no data on cis or trans male breast cancer. Trans women were thought to potentially be at higher risk because of the hormones they take, but data so far seem to indicate that they’re at low risk. When it comes to screening, the best screenings so far are clinical breast exams and mammography. Women who have sex with women are less likely to receive either. Once they survive a breast cancer, women who have sex with women may be at risk for sexual side effects more than heterosexual women.

Cervical cancer is a cancer that exclusively affects cisgender women, pre-op trans men and others who have a cervix. There are no data describing how the risk for cervical cancer may be different for bisexual/lesbian women and trans men. The biggest risk for cervical cancer is HPV infection. The best prevention of cervical cancer includes the HPV vaccine and the use of barriers to prevent HPV infection. For screening, pelvic exam with pap smear at a regular interval is recommended. Women who have sex with women are less likely to receive the vaccine and less likely to receive regular screenings. Anecdotal evidence suggests that the same is true for trans men. This would leave both bisexual/lesbian women and trans men at higher risk for cervical cancer, and higher risk that if there is cancer it will be discovered at a later stage. No studies have been performed examining how women who have sex with women and trans men fare after a cervical cancer diagnosis.

Colon cancer is the third most common cancer in both men and women. Preliminary studies indicate that lesbian, gay, and bisexual cisgender people are not being diagnosed with colon cancer more frequently than heterosexual people are. There are no data on trans people. However, LGB people are more likely to have risk factors like obesity, smoking, and alcohol use. On the whole, they are also less likely to receive screenings for colon cancer. The exception is gay and bisexual men, who receive colonoscopy and sigmoidoscopy more often than heterosexual men (the authors theorize that this may be because colonoscopy and sigmoidoscopy are used to diagnose difficulties with receptive anal sex). No studies have compared side effects in LGBT survivors. However, clinicians should advise men who have receptive anal sex that treatment may impact their sexual life.

Endometrial cancer is a cancer of the lining of the uterus, which can affect any individual with that lining. There are no data on lesbian, bisexual, or transgender populations nor are there recommendations for prevention and screening for endometrial cancer. Survivor outcomes are similarly murky. However the authors note that lesbian and bisexual women, because of stigma, may seek medical care later than heterosexual women. The authors advocate for a welcoming LGBT environment for patients to facilitate early detection and treatment.

Lung cancer is the leading cause of cancer death worldwide and is primarily caused by tobacco smoke. There are no direct studies of lung cancer in LGBT populations, but LGBT people are far more likely than heterosexual/cisgender people to smoke. LGBT people, as a whole, are thus at higher risk for lung cancer. While an annual screening (via low-dose CT scan) is recommended for some long term smokers, the guidelines were not intended for LGBT patients and may not be appropriate. Outcomes and side effects are unknown for LGBT people.

Prostate cancer is a cancer that exclusively affects cisgender men and transgender women (regardless of surgical status — the prostate is not removed in surgery). HIV+ men may be at lower risk for prostate cancer, though that may be an artifact of testing. The risk of prostate cancer for trans women is unknown, but is not zero. The screening test for prostate cancer, prostate specific antigen (PSA), is of limited value, but it appears that there are no differences in screening based on sexual orientation. Treatment for prostate cancer often has sexual and bowel side effects which may affect men who have sex with men differently (particularly men who prefer receptive anal sex).

Astute readers may have noticed a trend: There are not enough data. This is a huge problem in gender and sexual minority health. We just do not know enough, particularly about topics other than HIV. While some research is going on now to try to tackle these issues, it will be a while before those results come out and get validated.

So in the mean time, what is an LGBT+ person, worried about cancer, to do? You have options! You can…

  • Find a medical provider whom you feel safe and comfortable with, and make sure you come out to them. Ask them about screening schedules for you, given your own set of risk factors. Screenings will not prevent cancer, but they will allow your physician to detect cancer in its earliest, most curable stages and could save your life.
  • Exercise, achieve/maintain as healthy a weight as you can, and eat a varied diet. All of these things will help reduce your risks.
  • Quit smoking, if you currently use tobacco. Don’t start to use tobacco if you currently don’t. All forms of tobacco cause cancer, including chew and snuff.
  • Limit alcohol consumption. Drinking a lot is associated with higher rates of some cancers.
  • Be HPV-aware, and get vaccinated if you can. Use barriers in sexual encounters to prevent both HPV and HIV infection.
  • Be as familiar with your body as you can, so that you can detect changes and notify your physician.

Want to read the study for yourself? It’s publicly available!

Jul 132015
 
CDC_edamame

Soybeans, a common source of phytoestrogens

Have you heard that some herbs and foods contain chemicals called “phytoestrogens” that work like estrogen in the body? Ever seen products being sold over the counter advertised to “feminize naturally” or “prevent hot flashes during menopause”? Or read conversations online about using over the counter products to feminize instead of prescribed hormones? Did you stop and wonder if there was truth to the claims? Let’s do a quick overview and do some debunking!

What are phytoestrogens?

Phytoestrogens are estrogen-like chemicals made by plants. Just like how the tobacco plant makes nicotine to defend itself against insects, phytoestrogens are thought to have a protective effect for the plant. One of the most commonly known phytoestrogen is soy isoflavone, which is found in soy beans and soy products. However other plants produce this compounds too. Red clover is another commonly found herb in herbal products.

As a side note: There are three forms of estrogen in the human body that are commonly talked about. Estradiol is the strongest. The type of estrogen used in modern-day hormone therapy is estradiol. So when you see estradiol in the rest of the article, feel free to mentally substitute “estrogen”.

Is it possible that phytoestrogens can feminize?

All things are possible.

First, let’s talk about dose. Phytoestrogens are found in very small doses in foods, or in slightly higher doses in supplements.

Medical transition requires high doses of hormones. A typical dose of estrogen today, when combined with an anti-androgen is around 4mg a day. Before antiandrogens were introduced, doses equivalent to 12mg of estradiol a day were used*. That’s a lot of hormone.

Phytoestrogen products do not come with an anti-androgen. Is it possible that they’re reaching the equivalent dose of 12mg of estradiol a day? Doses found in Canadian products ranged from 1mg to 35mg of phytoestrogens. So if phytoestrogens are equal in strength to estradiol, perhaps.

But that’s a big assumption. The body absorbs different drugs from the digestive tract in different amounts. Then that drug goes through the liver, where some portion may be activated or deactivated. And then it has to circulate around in the blood stream, find its way into the tissues of the body, and find its target. Pharmaceutical drugs have all these factors measured and calculated, so that the dose you’re given should ensure a certain dose is delivered into your tissues in the end. These herbs have not been studied in that way — so until more research is done, it’s difficult to know how much actually gets to the tissues. And it’s known that phytoestrogens bind to estrogen receptors only weakly, so they’re likely to have a weaker effect than estradiol.

In the doses that are being taken, do they have any effect?

As far as I can tell from the evidence, no. Phytoestrogens are marketed to cis women for relief from hot flashes. A study from 2003 published in JAMA found that they do not provide significant relief from hot flashes. Most of the clinical evidence that I’ve seen agrees with that study.

In cis men, phytoestrogens do not affect testosterone levels and does not feminize.

Worse, one study found that among cis women, those who were taking phytoestrogens had lower levels of estrogen in their blood than women who were not taking phytoestrogens.

While in theory phytoestrogens may possibly help with feminization, I see no medical evidence to suggest that they actually do.

Do phytoestrogens provide a consistent dose? Do the pills contain what they say they contain? Is there any regulation?

No. The dose ranges from company to company, pill to pill, season to season. Companies all have their own special formulations with different sources and types of phytoestrogens.

In the United States, supplements are not regulated by the FDA like drugs are. They’re in a special category. There are no independent checks to make sure the supplement is safe before it goes to market. There are no guarantees that the bottle actually has what it says it has. A Canadian study found wide variation in the amounts of phytoestrogens in various products.

Summary

Phytoestrogen supplements may seem to offer an accessible, easy way to feminize. However, there’s little to no evidence behind their use. And since they’re supplements, you’re never sure of what you’ll be getting. If you want to eat foods that are high in phytoestrogen, they’re not likely to do you harm. But from what I can tell of the literature, you’re better off saving that $20 to pay for an estrogen prescription.

If you’re having difficulty finding a physician who’s will prescribe hormone therapy, I urge you to call your local transgender or LGBT center, or visit the WPATH or GLMA website for provider listings.

*: These formulations were often from conjugated estrogens, which use a slightly different dosing. Doses of conjugated estrogens ranged from 7.5 to 10mg/day, and .625mg of conjugated estrogens is roughly equivalent to 1mg of oral estradiol. My figure of 12 mg of estrogen was using the “low” dosage of 7.5mg.