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
HIV

Diagram of an HIV particle

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

Trans women and HIV

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

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

HAART and hormones

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

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

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

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

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

Conclusion

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

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

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

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

Oct 312016
 

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

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

Comorbidities of BPD

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

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

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

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

Sexual masochism disorder is not the same thing as masochism!

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

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

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

All of which brings us to today’s study…

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

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

The surveys asked about:

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

And as always, there was a demographic questionnaire.

What did they find?

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

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

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

There were no differences in…

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

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

What are the limitations of this study?

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

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

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

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

What do the results mean?

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

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

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

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

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

Oct 172016
 
Barriers are not always as obvious as a wall

Barriers are not always as obvious as a wall

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

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

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

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

What did Sineath et al find?

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

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

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

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

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

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

What barriers were keeping people from getting medical transition?

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

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

What does all this mean?

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

 

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

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

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

Conclusion

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

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

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

Oct 032016
 

Pain is an interesting phenomenon. It is nearly a human universal. The vast majority of humans have experienced it. Some experience it daily. Yet we all have different relationships with pain. Pain can be the enemy. It can be something to run away from or something to be endured if running doesn’t work. Or it can be something to come to terms with, like an old friend. Physical pain can be a tool too, muting emotional pain. Lastly, pain can be embraced. Some people ride the pain like a wave and find enjoyment in the intensity. They are often called “masochists”.

Masochism is the enjoyment, often sexual in nature, of receiving and experiencing pain. Masochism is typically practiced in a consensual “session”, paired with sadism. Some masochists prefer pain to come with physical restriction (bondage) and/or power exchange (dominance/submission). Yes, this is the same thing as BDSM or “kink.”

Researchers wondered if there was anything different about masochists’ sensation of pain. After all, most people avoid pain. Pain is unpleasant. Why deliberately seek it out? Can the experience of masochists tell us about how humans experience pain? Most importantly — can we learn anything that might help alleviate the suffering associated with chronic pain?

To answer these questions, Defrin et al invited 34 people to participate in a study. Half of those people were masochists involved in the local BDSM scene. The other half was a control group who did not. Both groups filled out surveys about pain. They answered questions on…

  • how much they feared pain
  • their experiences of pain in everyday life
  • how much they catastrophize pain. How terrible is it when they do experience pain? And how do they cope with pain when they do experience it? Different aspects of catastrophizing include rumination on the pain, magnification of that pain, and a feeling of helplessness.
  • the masochists were also surveyed about their BDSM experiences

Defrin et al tested the pain threshold of both groups. They tested the pressure required for the participant to report feeling pain, while the participants were “seated on comfortable armchairs”. (No! Not the Comfy Chair!)

The comfy chair might be a torture beyond what masochists were expecting

The comfy chair might be a torture beyond what masochists were expecting

If you don’t get that reference, stop reading this article right now. Go watch the glory that is Monty Python. Then come back. Don’t worry, I’ll wait.

What did Defrin et al find?

First – what were masochists doing and enjoying? The majority enjoyed whipping on the buttocks. Other areas of the body were also involved. Generally, the more pain and the more areas of the body they experienced pain in, the more they enjoyed the experience. Masochists in this study had weekly to monthly sessions. 

What about everyday pain? When you stub your toe and go “ow!”? As groups, both masochists and non-masochists reported the same amount of pain. Both disliked that kind of sudden, unpredictable pain. However there were some differences. Among masochists, those who had more frequent sessions reported less pain in their every day lives. Interestingly, some people from both groups reported some enjoyment with everyday pain (65% of masochists and 24% controls).

When tested, masochists had a higher pain threshold than non-masochists. For both groups, the more frequently they encountered pain the higher their pain threshold was.

Masochists also reported lower levels of pain catastrophization. They ruminated and magnified pain less and had more of a sense of control surrounding pain than non-masochists did. And the more frequently they had sessions and the more parts of their bodies that were involved, the less fear of pain they had.

So in summary — compared with non-masochists, masochists were better able to cope with everyday pain and had a higher pain threshold. The more the masochist experienced pain in their sessions, the bigger this difference.

Why might there be this difference?

This was a correlational study. So it’s impossible to say for certain why there were these differences between masochists and controls. There are three possibilities:

  • Masochists naturally have a lower pain threshold
  • The experiences of being a masochist and having frequent exposures to pain increases their pain threshold
  • There is a third factor that wasn’t found in this study

To me, the second explanation is most likely. I would expect that if masochists naturally had a lower pain threshold then the number of sessions wouldn’t make a difference. But that wasn’t the case.

Masochistic sessions are highly pleasurable. Rather than attempting to reject or escape the pain, masochists embrace it in a positive, safe environment. That environment matters! The way that we approach pain absolutely affects how much pain we feel and how intense that pain is.

This study does have a number of holes. It has a small sample size. That always limits how applicable the study is. In addition the pain experiences used in the study were predictable, just like the pain in masochistic sessions. Predictable pain is a very different experience from unpredictable pain. If pain is predictable the brain can prepare. Neurotransmitter amounts can change and blunt the feeling of pain. So can we really extrapolate predictable pain thresholds to everyday, nonpredictable, pain thresholds?

I find it interesting too that some of the control group reported everyday pain to be enjoyable. Perhaps there are more people who would participate in masochistic activities given the chance and societal acceptance?

What does this mean for those who suffer with chronic pain?

Well, no one is going to suggest that they all start masochistic sessions. But perhaps borrowing the mindset of masochism would be helpful. Working to help those with chronic pain accept and work positively with their pain may be helpful. It’s hard to say.

What do you think?

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