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.

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!

Sep 192016
Jack-O-Lanterns having a good sense of wellbeing

Jack-O-Lanterns having a good sense of wellbeing

In gender and sexual minority health we’ve focused a lot on the bad things that happen to our communities. Studies about HIV risks, high rates of depression, and discrimination dominant the discussion. For good reason, too. Negative factors cause harm! We want to protect ourselves, our families, and our communities. Research helps us figure out how to stop the badness from happening. But not a lot of research has looked at gender and sexual minority wellbeing. After all, it’s not all doom and gloom. Many in the community are thriving. It would be helpful to know what helps those community members do so well. Today’s study looks at factors associated with wellbeing in transgender and gender non-conforming people.

First, let’s define wellbeing. Wellbeing can be difficult to define. It’s a two-fold concept, including both hedonic and eudemonic approaches. Hedonic wellness is experiencing happiness while avoiding pain. Eudemonic wellness is the sense that one has purpose in life and is living authentically.

Previous studies among lesbian, gay, and bisexual (LGB) communities found that LGB communities had less wellbeing than their heterosexual peers. Social and community support, education, and physical health are all associated with wellbeing. But we don’t know a lot about the transgender community’s wellbeing. At least, not in the literature.

So Stanton et al looked through published data from a large survey, the US Social Justice Sexuality Survey. This survey focused on LGBT people of color. In order to identify all the participants who might be trans, Stanton et al looked at data the participants who did not identify as cisgender.

This study assessed wellbeing by asking participants how often in the past week they felt:

  • Just as good as other people (eudemonic wellness)
  • Hopeful about the future (eudemonic wellness)
  • Happy (hedonic wellness)
  • That they enjoyed life (hedonic wellness)

In addition to those questions about wellbeing, Stanton et al specifically looked at factors they thought might be related, including: health, healthcare provider’s comfort with LGBT issues, family support, and connectedness and engagement with the LGBT community. And as with most other studies, they looked at demographic factors. Demographics included age, income, employment, marital status, and education.

Because OMH is a health-related blog, I’m going to focus in on the results most applicable to health. If you want to read the full study, scroll to the bottom to find a link to the paper!

What did they find?

402 individuals, about 8% of the broader study, did not identify as cisgender. Of those, 32% identified as trans women, 18% as trans men, 21% as men, 21% as women, and 35% as “other.” They were diverse, representing a broad range of ages, races, education levels, and health.

Most (71%) had health insurance. 85% felt their health was “good” or better. Just over half (57%) felt their health care provider was comfortable with their transgender status. 13% thought their health care provider was uncomfortable. 14% said their provider ignored their LGBT status. 16% stayed closeted with their provider.

63%, almost two-thirds, of the participants had high levels of wellbeing!

What factors were associated with wellbeing?

The following factors were associated with more wellbeing:

  • Feeling connected to the local LGBT community
  • Health
  • Family support
  • Heath care provider acceptance.
  • Education
  • Age: the older, the more wellbeing

These factors were not associated with wellbeing:

  • Having access to health insurance
  • Participation in the local LGBT community
  • Race
  • Employment
  • Being single
  • Income

One factor associated with less wellbeing was health care providers who were uncomfortable with or ignorant of their patient’s LGBT status.

What are the limitations of this study?

No study is perfect. The survey that this study pulled data from probably over represents individuals who are active in LGBT communities. Those individuals may not reflect everyone in the community. Health and health insurance levels may also have been higher in this study than in the broader population.

Most limiting is how some of the questions were worded. Gender identity and sexual orientation were mixed together by lumping questions on lesbian/gay/bisexual identity with transgender identity. And they are very, very different experiences. The communities are also different. Questions asking about “sexual identity” may refer to sexual orientation or gender identity or both. It would be good to repeat this study with clarification between sexual orientation and gender identity.

What does all this mean?

Two-thirds of this study’s non-cisgender participants had good wellbeing. Most trans people are doing well, unlike the popular narrative that trans people are broken. Let’s spread that message!

Also, by knowing who has better wellbeing knows we know who has worse wellbeing. We can direct resources toward those who need them! According to this study that would be the young, the less well educated, those without family support, and those who are less physically/psychologically healthy.

Lastly, this study highlights the need for health care providers who are accepting of minorities. Having a provider who knows and accepts GSM patients not only improves health care, it improves the wellbeing of the patient. We need to spread this message.

It’s good to know that it’s not all doom and gloom. Two-thirds of trans and gender nonconforming people are doing well. Let’s expand that number to 100%.

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

Citation: Stanton, M. C., Ali, S., & Chaudhuri, S. (2016). Individual, social and community-level predictors of wellbeing in a US sample of transgender and gender non-conforming individuals. Culture, health & sexuality, 1-18.

Aug 152016

Welcome back to Open Minded Health Promotion! This week we’re looking at health promotion for transgender women and individuals assigned male at birth. Depending on your history some of these tips will apply more or less to you.

TransgenderPlease remember that these are specific aspects of health in addition to the standard recommendations for everyone (e.g., colonoscopy at age 50). Based on your health and your history, your doctor may have different recommendations for you. Listen to them.

All transgender women should consider…
  • Talk with their doctor about their physical and mental health
  • Practice safer sex where possible. Sexually transmitted infections can be prevented with condoms, dental dams, and other barriers. If you share sexual toys consider using condoms/barriers or cleaning them between uses.
  • Consider using birth control methods if applicable. Hormone therapy is not birth control. Orchiectomy and vasectomy are permanent birth control options. You can still have vaginoplasty after those procedures if you desire. Alternatively, you can use condoms and asking your partner to use hormonal birth control.
  • Store sperm before starting hormone therapy if you want genetic children. Estrogen and anti-androgens definitely affect fertility. You may never be able to have genetic children after hormone therapy.
  • If you’re under the age of 26, get the HPV vaccine. This will reduce the chance for anal, oral, and penile cancers. Theoretically it may also reduce your risk for (neo) vaginal cancers.
  • Protect yourself from HIV. Consider using pre-exposure prophylaxis in addition to condoms in sexual encounters that are higher risk. Avoid selling sex if you can.
  • Avoid tobacco, limit alcohol, and limit/avoid other drugs. If you choose to use substances and are unwilling to stop, consider strategies to limit your risk. For example, consider participating in a clean needle program. Vaporize instead of smoke. And use as little of the drug as you can.
  • Maintain a healthy weight. While being heavy sometimes helps to hide unwanted physical features, it’s also associated with heart disease and a lower quality of life.
  • Limit high-potassium foods while on spironolactone if possible.
  • Exercise regularly. Anything that gets your heart rate up and gets you moving is good for your body and mind! Weight bearing exercise, like walking and running, is best for bone health. If you’re looking to avoid “bulking” up your muscles, cardio exercises are probably your best bet. Staying physically active is especially important if you have a family or personal history of cardiovascular disease.
  • Avoid buying hormones from online stores or on the street. There is no guarantee that you’re getting what you think you’re getting. Even if you do there is no guarantee that the drug was created in a safe lab or was stored properly. Drugs made in the US are guaranteed to contain what they said they do. They are also made in clean facilities and stored correctly so they don’t degrade. Additionally buying hormones online is far more expensive than getting a prescription and going to a pharmacy (especially with discount plans many pharmacies provide). Thus if you can get a prescription, doing so is less risky and far cheaper. For more information, see the FDA.
  • Do not inject silicone. It not only disfigures, it kills. Additionally unsafe needle practices risk spreading HIV and Hepatitis C.
  • If you’ve had genital surgery and you’re all healed from surgery, remember to continue to dilate and take care of your vagina. Keep in touch with your doctor as you need to. Call your surgeon if something specific to the surgery is concerning. Continue to practice safe sex. And enjoy!
Your doctor may wish to do other tests, including…
  • Prostate cancer screening. Vaginoplasty does not remove the prostate. Testosterone is one of the major drivers of prostate cancer. Therefore trans women are at a lower risk for prostate cancer. However, that risk may still exist. Your doctor may recommend a blood test or a digital rectal exam. They should discuss with you the benefits and potential harms of screening.
  • Breast examination for potential detection of breast cancer. We really don’t know yet how much risk trans women are at for breast cancer. Current data suggest that trans women are at low risk. However your doctor may wish to perform a breast examination as part of a physical exam. The goal of the exam is to detect lumps and/or bumps that may need further investigation. They may also teach you how to do a self-exam.
  • Mammography. Again, this is for potential detection of breast cancer. Some doctors recommend following the typical recommendations for cis women. However even those recommendations vary depending on the organization recommending them. Most recommendations include a mammography every 1-2 years starting around age 50. Thus once you turn 50, consider talking with your doctor about the need for mammography.
  • Vaginal examination. For post-op trans women, the vagina is either (penile) skin or intestine. Either way, it can still develop cancer. Some doctors recommend a visual inspection of the vagina to detect such cancers. Others do not.
  • Testicular/penile examination. As long as you have a penis and testes, your doctor may recommend examination. They look for potential cancer as well as hernias (the “turn your head and cough” test).

And most importantly: Take care of your mental health. We lose far too many people every year to suicide. Perhaps worse, far more struggle with depression and anxiety. Do what you need to do to take care of you. If your normal strategies aren’t working then reach out. There is help.

Want more information? You can read more from UCSF’s Primary Care Protocols and the Gay and Lesbian Medical Association.