Apr 162014
 

One of the premier medical journals, the New England Journal of Medicine, regularly has perspective/opinion pieces. For a pre-med like me, they can be some of the most valuable pages in the journal — they can be windows into medical practice, public policy and the study and practice of medicine. I read them regularly, since my wife got me a subscription to NEJM. Most aren’t related to gender and sexual minority health, so I haven’t addressed them here much. But in the April 10th edition of NEJM, a treasure! Gilbert Gonzales did a good summary of the intersection between same-sex marriage and health.

Many health journals, including NEJM, tend to live behind a pay wall. This particular article, thankfully, is not. But in the interests of public knowledge and discourse, I wanted to summarize some of the interesting points in this article. A heads up: this is a distinctly United States-focused article.

  • Despite recent advances, roughly 60% of the US population lives in a state that prohibits same-sex marriage
  • There are significant health disparities between LGBT and heterosexual/cisgender people, as shown by the 2011 Institute of Medicine report on LGBT health (which I summarized in 3 parts at the time).
  • Discriminatory environments lead to poorer health outcomes. Example: LGBT people in states that ban same-sex marriage have higher rates of depression, anxiety, and alcohol use than straight/cis people in the same states. By the same token, states where same-sex marriage (e.g., MA and CA) was legalized show a drop in mental health care visits for some GLBT people (e.g., gay men).
  • Legalizing same-sex marriage improves access to health insurance for both same-sex spouses and children of same-sex parents.
  • The Affordable Care Act prohibits insurance companies from denying health insurance coverage because of sexual orientation, transgender identity, or pre-existing conditions like HIV.
  • The recent decision on DOMA (United States v Windsor) means couples in a same-sex marriage get taxed like other married couples. This lowers the tax burden of health care costs and health insurance.
  • Health benefits of same-sex marriage should be included in discussion of marriage equality.

All good things to point out, and good to see in such a mainstream medical journal.

We’re lucky enough that the NEJM has decided to have this article be open access. So if you can, read it to form your own opinions!

And as always…  Stay healthy, stay safe, and have fun!

Nov 052013
 

News for the month of October - CC BY 2.0 - flickr user  cygnus921It’s that time of month again! No, not when we try to take over the world… it’s time for the monthly news! In no particular order, then, here we go:

  • Analysis of herbal supplements finds that many are contaminated with species not listed in the ingredients label. Herbs are typically classified as supplements in the United States, and are not regulated by the Food and Drug Administration the way medications are. The FDA website has more on the regulation of herbsSource.
  • One dose of Gardasil may be enough to protect against cervical cancer (but please remember to follow your physician’s instructions about vaccines!). Source. At the same time, the HPV vaccines may be less effective for people of African heritage than for people of European heritage. Source.
  • More evidence that monthly changes in sex hormones in cisgender women are associated with changes in sex drive. Source.
  • Germany’s “indeterminate” birth certificate sex designation law comes into effect. The “Indeterminate” marker is, from what I understand, intended to denote intersex babies, not transgender people. The BBC did a fairly good summary of some community reactions. Source.
  • Low prolactin levels in cisgender men as they age has been correlated with reduced sexuality and sexual functioning. Low prolactin levels were also correlated with general unwellness. Prolactin is a hormone most well known for being involved with lactation in breast-feeding parents, but has other effects too. Source.
  • A new study examining sexual satisfaction in women with complete androgen insensitivity syndrome (CAIS) or Mayer-Rokitansky-Küster-Hauser Syndrome (MRKH Syndrome, aka Müllerian agenesis). Women with CAIS reported less sexual satisfaction and confidence than women with MRKH Syndrome, who mostly reported being satisfied with their sex life. The abstract on this paper is fairly scarce so I’ll try to grab a copy for better examination. Source.
  • A study in Ontario, Canada found that 1/3 of trans people needed emergency medical services in 2012, but only 71% were actually able to receive it. 1/4th of those in the survey reported avoiding the emergency room because they are trans, and just over half needed to educate their provider. Source.
  • Another study has found a decrease in psychopathology (i.e., symptoms of mental illness, such as depression or anxiety) when trans people transition. The biggest drop was just after starting hormone therapy. Source.
  • A study on the changes in sexual desire/activity in trans people was published. In a nutshell, sex drive went down for trans women with hormone therapy but recovered a bit after surgery (compared with those who wanted/planned surgery but hadn’t had it yet). In contrast, trans men generally had their sex drive go up with hormones/surgery. Source.
Feb 102013
 

CC BY-ND 2.0 - TjookAs a group non-heterosexual people have poorer mental health than heterosexuals do. LGB (lesbian, gay, bisexual) folk have higher rates of mood/anxiety disorders, suicidal ideation/attempts, and substance use. Why? The dominant theory is minority stress: simply being a minority is stressful, especially if one is a minority who faces discrimination. Higher levels of stress are associated with poorer mental health. For LGB folk, the fact that their minority status is invisible is an additional factor. Research is conflicted on whether “coming out” improves mental health or not. While coming out in a supportive environment may improve mental health, coming out in a discriminatory environment may do the opposite.

Before I jump into the actual study, a little background on stress. Stress that comes from a psychological or social source is called psychosocial stress. Like all stress, it isn’t just psychological. There’s a biological component too! In the laboratory, there are at least two different ways of measuring stress. The first, and easier, is through cortisol. Cortisol is a stress hormone made from cholesterol that is released by the adrenal glands. It’s a small, non-polar molecule, so it passes right cellular membranes into every cell in the body. Because of this, cortisol can be measured in saliva, making its collection easer, cheaper, and less riskier in research than other measures. Cortisol also has a cyclical pattern; it’s lowest in the morning but rises in concentration through the day. Cortisol measurement is not without its problems. Levels of cortisol, and the reactivity of cortisol concentration to stress, varies between men and women, and between women of varying menstrual cycles and oral contractive use. It’s also worth noting that cross-sex hormones may be a confounding variable for cortisol testing, which is why this study did not include transgender people.

Another way of measuring stress requires a blood sample and lots of blood tests. Stress affects many different body systems. Everything from sex hormones to triglycerides to insulin can be affected, so those levels can be used to help detect stress levels in participants. Non-blood tests such a blood pressure may also be used. These non-cortisol factors were referred to as “allostatic load” (AL) in this study. AL broadly refers to the cumulative biological effects of being ready for “fight or flight“, or in other words, stress.

So what about this study in particular? This study has two goals:

  1. Compare the stress levels of LGB people with heterosexual people
  2. Compare the stress levels of “closeted” LGB people with “out” LGB people.

Participants were 87 people, roughly evenly divided between lesbian/bisexual women, heterosexual women, gay/bisexual men, and heterosexual men. The researchers measured a variety of demographics including age, race, sex, occupational status, socioeconomic status, physical and mental health, substance use, religion, and family. They measured sexual orientation with the Klein scale, and asked about disclosure status (i.e., whether participants were “out” or not). Psychiatric variables included perceived chronic stress, anxiety symptoms, depression symptoms, burnout symptoms, and conscientiousness. Conscientiousness is a personality trait that has been found to be a confounding variable in these kinds of studies. Biological variables were salivary cortisol, measured three times a day to track cortisol’s daily cycle, and allostatic load, as I described above.

And what did they find? There were few statistically significant differences between the groups; only sexual orientation and oral contraceptive use were different. That’s important! Any differences between groups would be a confounding variable. They also verified some expected results. For example, that anxiety symptoms are associated with depression and burnout symptoms, and that elevated cortisol levels were correlated with burnout.

First the researchers reported their results for comparing LGB folk to heterosexual folk (goal #1). They found that gay/bisexual male participants had more depression symptoms than the heterosexual male participants. In contrast, their lesbian/bisexual women participants had fewer depression symptoms than the heterosexual female participants. They also found that allostatic load levels were lower in gay/bisexual men than in heterosexual men. They found no other differences between their LGB participants and their heterosexual participants.

Second the researchers reported their results for comparing out LGB folk to closeted LGB folk (goal #2). In this case, they did not separate by sex or orientation. Out LGB people had fewer anxiety symptoms, depression symptoms, burnout symptoms, and lower cortisol levels than closeted LGB folk did. No other differences were detected.

Every study has its limitations. This study was no different. Limitations and potential confounds included:

  • Combining homosexuals and bisexuals into one group for analysis. While some issues overlap, bisexuals can face different stressors than homosexuals do (e.g., bisexual folk report facing discrimination from both the gay and straight communities where gay folk don’t; ).
  • Relatively small sample size may have made accurately detecting statistical significance difficult.
  • Their sample was from the Montéal area, an area that has been called “one of the most gay-friendly places on Earth.” Results may have been different in a less tolerant area. This means that results from this study can’t necessarily be applied to people in other areas (e.g., Uganda, the American South).
  • Both age and conscientiousness were found to be confounding variables.
  • Variables like gender presentation (e.g., butch vs femme lesbians) were not considered. They could affect how much active discrimination an individual faces and thus might affect their stress load. Other variables, such a family acceptance, were also not considered.

All of this is interesting, but what does this mean? If we interpret these results as true, then there are some interesting dynamics at play. LGB people who are out of the closet have better psychiatric health than closeted LGB people. However, closeted LGB people don’t seem to be at a disadvantage when it comes to the physical effects of stress. As for comparing heterosexuals with non-heterosexuals, gay/bisexual men seem to have poorer mental health than heterosexuals, who have poorer mental health than lesbian/bisexual women. Coming from an American viewpoint, it seems to me that that might be explained by the cultural acceptance of lesbian/bisexual women and rejection of gay/bisexual men. I don’t know how true that is in Canada, though. Do the results support the minority stress hypothesis? Somewhat, but only for the out/closeted comparison. The heterosexual/LGB comparison results partially support minority stress and partially don’t.

I think these results should be interpreted with a large grain of salt. I don’t think it’s justifiable to make conclusions about all LGB people from this one study. These results are curious, certainly. There are factors at play which bear greater examination (e.g., why don’t closeted LGB people show higher cortisol and AL levels?). I’m curious to see what a study replication in a different area and more participants would show.

Abstract. Full text (PDF).

Oct 252012
 

LGBT youth are at elevated risk for suicide. Researchers have been looking into the risk factors for suicide in LGBT youth. Most of the studies so far have been cross-sectional; that means they only studied how things are once, at one point in time. Longitudinal studies, in contrast, measure at multiple points in time. Longitudinal studies are expensive, and risk losing track of participants, but they provide more information.

This year, the first longitudinal study of LGBT youth suicide risk factors was published. The participants were interviewed twice, a year apart. Both times, they were psychiatrically evaluated and asked about suicide attempts. They filled out questionnaires evaluating hopelessness, impulsivity, social support, gender non-conformity, age of same-sex attraction, and LGBT-related victimization.

In this sample, roughly 31.6% of the participants had attempted suicide. This is far higher than the 8% rate reported by the CDC. Seven variables were associated with previous suicide attempts: hopelessness, impulsivity, LGBT-related victimization, low family support, being younger when first feeling same-sex attraction (for LGB youth), and symptoms of either depression or conduct disorder. That is, the more hopeless or impulsive the youth, the more likely it is that they have previously made a suicide attempt. Gender non-conforming behavior and peer support did not seem to affect suicide risk. When it came to predicting future suicide attempts, the best predictor was previous suicide attempts. Youth who had previously attempted suicide had a 10 times greater risk of another attempt compared to those who hadn’t attempted suicide.

As always, these results should be accepted with caution. For example, this study did not find that gender non-conforming behavior was associated with suicidality. This is in contrast to other studies which did find an association. This study’s participants may not be representative of the population. They also had a small (ish) sample: 237 participants; 21 were transgender, and 13 had attempted suicide. Small sample sizes can limit a study’s ability to detect statistical significance. Gender non-conforming behavior may actually be associated with suicidality, but this study may not have had a large enough sample to detect it.

For me, this study brings up the question: How do we prevent suicide attempts in our LGBT youth who have already attempted suicide? They’re the most at risk for future attempts, according to this study. I don’t have a solid answer; neither do the researchers. But they do say that “The current findings underscore the need for increased prevention efforts and specifically point to the value of targeting youth who have made a prior attempt and who acknowledge their same-sex attractions at younger ages.”

Study Abstract – Full Text – Archives of Sexual Behavior

Jun 012011
 

For “older” adults, the IOM uses retirement age (around 60) as their starting age. For this group, there are no well-studied areas of health (beyond HIV/AIDS, which I don’t cover here). I’ve decided to leave the conclusion portion for another post – the last in this series.

  • Depression: Definitely more frequent in LGB elders than heterosexual elders. A very significant mental stress for this group is surviving the start of the HIV/AIDS epidemic. One study of elder gay/bisexual men found that 93% of them had known others who were HIV+ or had died of AIDS. There is no empirical data on rates of depression in elder transgender people, but it’s thought to be high.
  • Suicide/suicidal ideation: Empirical data suggest the rates of suicide are higher in LGB elders. No data on transgender elders.
  • Sexual/reproductive health: This is a rarely studied area. PCOS and its related risks may be an issue in some transgender elders. There is some indication that gay/bisexual men may be at the same risk as heterosexual men for prostate cancer. Early research implies that “lesbian bed death” may be a real phenomenon, but it’s a controversial topic. All cis-gendered women (bisexual, heterosexual, or lesbian) appear to have the same rate of hysterectomies. Sexual violence was reported on for transgender elders and it appears to be high. One study found about half of transgender elders had experienced “unwanted touch” in the past fifteen years.
  • Cancers: There are no data on cancers and transgender elders. Elder gay/bisexual men are at a higher risk of developing anal cancer (which is linked to receiving anal sex and HPV). Non-heterosexual women also appear to be at a higher risk for reproductive cancers (due to risk factors like smoking and obesity).
  • Cardiovascular health: Data appear to be conflicted. Transwomen using estrogen may be at a higher risk for venous thromboembolism (this may be because of the specific forms of estrogen used). There’s an association between transgender people getting their hormones from someone other than a doctor and poor health outcomes (e.g., osteoporosis, cardiovascular disease). The relevant transition hormones may cause long-term health problems at high doses, but no studies have really looked at this.

Risk factors include those for the younger age groups. Ageism within the LGBT communities may be an additional challenge for LGBT elders. Elders may also feel they need to hide their orientation if they move into a retirement home. Some retirement homes may also be discriminatory.  Transgender elders especially face very high threats of violence.

Some studies have found that elders felt more prepared for the aging process by being LGBT. Why? They’d already overcome huge difficulties. They’d already done a lot of personal growth. LGBT people are also more likely to have education beyond high school, and education is a well-known protective factor for the negative effects of aging. Conversely, some LGBT elders reported fewer relationship and social opportunities, being afraid of double discrimination, and problems with health care providers.

As for elder interactions with the health care system, again there’s a lot in common with younger age groups. One out of four transgender elders report being denied health care solely because they were transgender. Elders in general face problems if they need to enter assisted living homes, as some homes are discriminatory. It’s also worth noting that LGBT elder social structure is different from heterosexual social structure. LGBT elders rely much more on close friends than relatives (and/or adult children). Their chosen families are less likely to be recognized by the medical community, especially without legal paperwork.

So that’s it for what I’ll summarize from the report. Thanks for sticking around for it… this is hefty stuff.