Mar 062017

Lesbian, gay and bisexual (LGB) high school students are at higher risk for suicide than their heterosexual peers. The reasons are complex. The facts are simple. In the US in 2015, 29% of LGB youth report attempting suicide in the past year compared to 6% of their heterosexual peers. LGB youth also have higher rates of depression, anxiety, and non-suicidal self injury. Why? One of the main culprits is stigma.

It is still not a “good” or “normal” thing to be LGB in the United States. LGB people are very much in the minority. They are targets for discrimination and violence. All of this is part of stigma. There are different types of stigma. Structural stigma is policy, rule, and law based discrimination. Marriage inequality was one of the most talked-about forms of structural stigma.

If poor mental health outcomes like suicide attempts are partially because of stigma then we would expect changes in those mental health outcomes after a change in stigma. In other words, if marriage inequality is one way that society says “LGB is bad” and drives adolescents toward suicide, then when marriage inequality goes away adolescents should have fewer suicide attempts.

And that’s what the researchers in this week’s study looked at. They asked: Did youth suicide attempts go down after legalization of marriage equality?

The Study

The researchers looked at data from the Youth Risk Behavior Surveillance System (YRBSS). The YRBSS is a survey done by the Centers for Disease Control every 2 years. It’s conducted in 47 of the 50 United States.Among other things, the YRBSS asks about number of suicide attempts in the past 12 months.

They looked at data from 1999-2015. 2015 is before country-wide marriage equality. So instead of looking at national data, they looked state by state. They compared suicide attempts before and after legalization in that state. They also compared suicide attempts in states that legalized and in states that did not legalize in the same year.

In addition they compared straight suicide attempts to LGB suicide attempts. Only 25 states were actually asking about sexual orientation by 2015, so this part of the study was limited.

In total there were data from roughly 760 thousand adolescents. 12.7% of students in states that asked about sexual orientation identified as LGB. 2.3% were gay/lesbian, 6.4% were bisexual, and 4% were uncertain.

8.6% of all students had attempted suicide in the past year before marriage equality. That dropped by 0.6% to 8.0% after same-sex marriage was legalized. If we extrapolate out, that’s roughly 134 thousand adolescents who did not attempt suicide after marriage equality.

For LGB students the difference was even more impressive. Out of 231 thousand adolescents, 28.5% had attempted suicide in the past year prior to legalization. After marriage equality it dropped by 4.0% to 24.5%. That’s a relative reduction of 14%.

And for the statistically nerdy folks among us, those results were statistically significant at the p = 0.05 level.

Nice data, but what does it mean?

Here’s the bottom line. There were fewer suicide attempts in all high school students after marriage equality. This was especially true among LGB youth, but the effect was seen in all youth.

There’s a very important lesson in these results. Legal policies and the message those policies convey have very real effects on health. And it’s not just as simple as policies like mandatory vaccination and the resulting drop in infectious diseases. Denying same sex couples the right to marry and all the legal protections associated with marriage sends the message that LGB people are inferior. And our youth hear that. It has very real effects on their health. It’s behooves us as a society to examine other policies like employment and school protections to see if they send the same message.

From a personal perspective, these results are not surprising. While the Defense of Marriage Act was still law, even as a teenager I was very aware of what that meant for my legal rights. I knew about, and was distressed by, the lack of hospital visitation rights and insurance coverage. As an adult the knowledge that I have the legal right to make medical decisions for my wife without question is immensely comforting. We have a long way to go on other matters, but this one small step makes a difference.

Lastly, never underestimate suicidality. If you or someone you love is in crisis, the Trevor Project is an LGBT friendly suicide hotline for youth. Adults who need assistance can find the right hotline for them here.

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

Feb 202017

“Brain tumor” are two words that strike fear into most hearts. They conjure images of thin patients with heads shaved and large fresh scars on their heads, of rapid neurological deterioration, and of sick children. Not all brain tumors are the same, however. Some are aggressive malignant cancer. Those are the bad actors like medullablastoma. They grow and spread quickly, and are very difficult to treat. Others are benign. These grow slowly, and either don’t spread or are very slow to spread. Benign brain tumors include meningioma, which we’re talking about today.

Meningioma is a tumor of the meninges, a thin layer that covers the brain. Meningiomas are benign. They don’t tend to metastasize (spread to other areas of the body). Instead, they grow and can grow enough that they squish parts of the brain. This causes headaches, loss of vision, and changes in thinking and mood.

Brain tumors are rare. So are meningiomas. They affect roughly 97/100,000 people. We don’t yet know exactly what causes them. But by looking are who tends to get them, we have some guesses. Exposure to radiation of the head seems to increase the risk. So does having a condition called Neurofibromatosis II. And meningiomas are more common in cisgender women than in cisgender men. Why? Because of hormones. Like breast cancer, meningioma can grow in response to estrogen or progesterone. Cis men who have been treated for prostate cancer (involving androgen deprivation therapy) are at higher risk. And perhaps trans women are too.

Today’s Paper

And that’s what brings us to today’s paper. We’ve covered meningiomas in trans women once before, but it’s time to take another look now that we have more data.

Today’s paper discusses three new cases of meningioma in trans women. In total now, 8 cases have been discussed in the medical literature. It’s a very small number, but enough to start seeing some patterns.

Of these three new cases, all were over the age of 45, were post-vaginoplasty, and were on cyproterone acetate along with an estrogen. All had surgery to remove the tumor, and they did well. The decision to continue hormone therapy was made on a case-by-case basis.

The authors noted a previous paper that found that cyproterone acetate was associated with meningioma. This was particularly true with doses above 25mg a day. Among the eight cases of meningioma in trans women in the literature, only one was not on cyproterone acetate. Doses ranged from 10mg to 100mg, with most being on 50mg or 100mg. The authors also found reports of higher rates of meningioma among people who use progesterone-like medications. Removing hormone therapy (especially cyproterone acetate) frequently helps to shrink the tumor.

What should you do with this information?

First, don’t panic about meningioma. It’s rare and benign.

There is no screening for meningioma. Instead, if you have any unusual symptoms like changes in your vision or headaches, talk with your doctor.

If you are a trans woman, consider taking the smallest dose of hormones possible. In general, high doses increase side effects and don’t help with transition. If you are diagnosed with a meningioma, have an honest conversation with your doctors about your hormone therapy.

And, of course, be sure to live as healthy a life as you can. Don’t go jumping into volcanos or nuclear power plants. Eat a balanced diet, get some exercise, avoid most drugs, and take care of yourself.

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

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 and 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