Jan 092017

Most people today know that cigarette smoking is bad for you. The mantra is drilled into children in school. Tobacco causes COPD and the vast majority of cancers, especially lung cancers. It raises the risk for heart disease. Asthma, diabetes, and osteoporosis are made worse by tobacco. And for pregnant women, tobacco causes birth defects. Children exposed to tobacco are more prone to asthma, ear infectious, and death by Sudden Infant Death Syndrome. (Source)

The negative effects of cigarettes comes from the chemicals in the tobacco plant plus chemicals added by the cigarette manufacturer. It’s not all added by the manufacturer. Hand-made cigarettes, snuff, and cigars still cause disease. Unfortunately tobacco also contains nicotine. Nicotine by itself is relatively harmless, but it is highly addictive. It’s also a stimulant, giving a “high” of its own that many find temporarily helpful as they deal with the stresses of life. Physical and psychological addiction together make it very difficult to quit smoking.

A nicotine patch, one of the main aids in quitting smoking

A nicotine patch, one of the main aids in quitting smoking

Quitting is possible. No matter how many packs a smoker has smoked, their health improves when they quit. For many it can take multiple tries before they’re able to quit for good. And I’m sure you’ve seen the advertisements; there are medications and therapies out there to help those who are interested.

Because smoking is such a huge public health issue, the United States government included tobacco use in its Healthy People 2020 project. Healthy People is a set of goals to improve the health of the US population. In 2008 when the project started 20.8% of US adults smoked. They want to reduce that number to 12% by the year 2020.

Sound ambitious? Perhaps. But on November 11th, 2016 the Centers for Disease Control released new data on smoking rates in the US. This included data from 2005 to the 2015 National Health Interview Survey. So we can see the progress for ourselves!

But wait, why am I talking about smoking on a blog dedicated to gender and sexual minority healthy? Because LGBT people smoke more than our heterosexual and cisgender neighbors. And in this new report, the CDC actually included information on LGB smoking. Let’s take a look!

The Data

Good news, everyone!

Graph of the decline in smoking rate20.9% of adults in the United States smoked in 2005. By 2014, only 16.8% smoked. That fell to 15.1% by 2015! And among those who currently smoke, fewer reported smoking every day; from 80.8% of smokers being daily smokers in 2005 to 75.7% in 2015. And the number of cigarettes smoked per day dropped too; from 16.7 in 2005 to 14.2 in 2015. So not only are fewer people smoking overall, but those who are smokers are smoking less.

Unfortunately smoking is not so low in all groups. When the CDC looked at subgroups, there were some stark differences. Here are the groups who smoked the most in their analysis:

  • Individuals experiencing serious psychological distress: 40.6% vs 14% who did not
  • Those with a GED: 34.1% vs 3.6% of those with a college degree
  • Medicaid enrollees (27.8%) and people without insurance (27.4%), vs those with private insurance (11.1%) or Medicare only (8.9%). A reminder for international audiences — Medicaid is the US public health insurance for the poor. Medicare is the equivalent for those over the age of 65 or with certain health conditions
  • The poor: 26.1% vs 13.9%
  • People with disabilities: 21.5% vs 13.8%
  • Lesbian, gay, and bisexual people: 20.6% vs 14.9%. (Transgender people were not included in this analysis)
  • Men more than women: 16.7% vs 13.6%

In other words: People with poor mental health, the poor, the undereducated, the disabled, and minorities are more likely to be smokers. And lesbian, gay, and bisexual people are more likely to be smokers than their heterosexual neighbors. 1 in 5 LGB people smoke. 1 in 6 heterosexual people smoke.

Unfortunately we can’t see how the percentages have changed for LGB people. The survey in 2005 did not include sexual orientation. But even from this one snippet of data we know that LGB people are indeed at risk.

But why?

Why is there this difference in smoking rates?

The truth is that we don’t know for certain. But here are some possibilities:

  • Stress. Smoking, like other substance use, is something that many people try to use to control the stress in their lives. The brief “high” of the nicotine helps for a short time. Unfortunately it’s not the most effective long-term solution. But being part of a minority is stressful, so we’d expect to see more minorities smoking simply because of that stress.
  • Advertising. The LGBT community has been specifically targeted in some smoking advertisements.
  • Lack of targeted anti-smoking campaigns and resources
  • Lack of health insurance and access to physicians in order to access help in quitting

And likely there are many other reasons.

What can we do about smoking?

One LGBT-targeted ad to quit smoking

One LGBT-targeted ad to quit smoking

First, and most importantly, is to quit smoking yourself if you smoke. Resources specific to LGBT communities include smokefree.gov and lgbttobacco.org. If you don’t smoke but a loved one does, support them in their efforts to quit.

As a community we can provide smoke-free spaces. Smoke-free bars are important, as are social events that aren’t in bars. We can choose imagery without cigarettes and remove cigarette-including glamour shots from our community spaces.

More broadly, emotional and financial support are important factors involved with smoking. As we saw, people who are emotionally struggling are more likely to be smokers. Supporting each other as a community may help, and with that help preventing smoking and quitting may become more feasible.

Lastly, vote if you can. Policy-level decisions can and do impact smoking rates! For example, raising taxes on cigarettes increases the number of people who quit in a community. And funding for quitting programs often comes from government sources. So make sure you vote (if you can)!

Want to read more on the topic? The original CDC paper is publicly available. Healthy People 2020 also has more information on smoking.

Dec 192016

Given recent events in US politics, today’s study was especially timely. I thought I’d move it up in the queue. Yes, there’s a queue. In today’s study, Owen-Smith et al tried to answer the question “Is there a relationship between depression in transgender people and tolerance of transgender people in their surrounding community?” Logically it makes sense. But we have very little data. Science needs data. So Owen-Smith et al surveyed trans people with the help of a local trans organization.

Dr William' Pink Pills, once marketed as a depression "treatment"

Dr William’ Pink Pills, once marketed as a depression “treatment”

To measure tolerance, they used a simple 1-5 rating scale. They also asked about mistreatment and discrimination in the past 12 months. For depression they used two different scales: the Beck Depression Inventory (BDI) and the Center for Epidemiologic Studies Depression (CESD). The BDI was designed to detect and diagnose Major Depressive Disorder. In contrast, the CESD was designed to detect depressive symptoms, not necessarily the disorder. Between those two scales Owen-Smith et al captured both depressive disorder and depressive symptoms.

As with all studies they also asked about demographics. Age, education, race/ethnicity, and so on. Because this is a study of trans people they asked about hormonal and surgical status. If the participants hadn’t gotten hormones or surgery, Owen-Smith et al asked whether they wanted them.

What did they find?

In total, 399 people completed the study. 70% were trans women. 85% were white. 57% had completed college. 32% were currently receiving hormones and 7% had had surgery.

And 1 in 4 (~24%) said that most people in their area were tolerant of trans people. Roughly half (47%) of the sample had experienced abuse or discrimination. Perhaps surprisingly, there was no difference in abuse based on the tolerance of the participant’s area.

Roughly half of the group were depressed or had depressive symptoms. And this did differ based on the tolerance of the area. Trans people from less tolerant areas were more likely to have depression. In addition, the more abuse they had experienced the more likely it was that they experienced depression. Wanting or receiving hormone therapy was also associated with depression. In contrast, having a college degree was protective. Other factors like surgical status and race had no effect on depression.

What does this mean?

From this study, it seems that being in an area that is perceived to be intolerant of transgender people is associated with depression in trans people. Although this study can only show correlation, not causation we can potentially still make inferences. It may be that as areas become more tolerant, depression rates among trans people go down. Or that as more areas show their tolerance, depression rates will go down. Certainly this study seems to suggest that.

As always, this study has limitations. Its sample was probably not representative of the entire trans community, being mostly white well educated trans women. Results may be different in different groups of trans people.

Depression has serious effects on quality of life. Trans people are at high risk for depression already, with around half having symptoms. Compare that to roughly 4-9% (less than 1 in 10) of the broader population. And the worst outcome of depression, suicide, is high among trans people too. Anything that we can do to decrease suicide, we should do.

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

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

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.


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

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.


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.