Sep 142015
 

A cluster of studies came out this week looking at different aspects of mental health for gay, lesbian, and bisexual people. Rather than do a deep dive on each one I thought it’d be fun to do a birds eye view of all of them and talk about the results as a group. Ready?

Why look at mental health in lesbian, gay and bisexual (LGB/GLB) people at all, and why might their health be different from their straight peers? Because of minority stress! If you’re a long time reader of the blog that term may sound familiar. Minority stress is the concept that solely by being a minority in a culture you have a higher level of stress. That stress is even worse when you’re a minority that is discriminated against. It’s also worse if you are a member of multiple minorities. Stress is associated with certain mental illnesses, including eating disorders, substance use/abuse, depression, and anxiety. Stress also makes it harder to cope with life’s everyday events.

So what about these studies?

Study #1 looked at disordered eating patterns in young women and compared that eating between gay, bisexual, and straight men and women. The researchers didn’t look at diagnoses or treatments of eating disorders directly. Instead, they screened patients in a primary care clinic for eating patterns and thoughts about eating that are associated with eating disorders. The researchers found that gay and bisexual men were at higher risk for disordered eating than heterosexual men. Among women, bisexual women were at higher risk for disordered eating than both lesbian and straight women.

Study #2 looked at both mental and physical health in LGB and heterosexual people seeking treatment for substance use. They found that gay and bisexual men and women were more likely to have a psychiatric diagnosis (in addition to substance use) than their heterosexual peers. Gay and bisexual men and women were also more likely to have psychiatric prescription medications. Gay/bisexual men and bisexual women, but not lesbian women, were more likely to be receiving psychotherapy and were more likely to have physical health problems and to be using health care services. Anywhere from 1/2 to 3/4 of LGB people seeking substance abuse treatment have had other psychiatric diagnoses, indicating that there is a potential need for additional care beyond substance abuse treatment in LGB people.

Study #3 examined the effects of domestic violence in same sex and opposite sex couples. The researchers found that domestic violence in same sex couples resulted in more symptoms of depression and physical violence than in opposite sex couples.

What does all this mean, and how do we think about this?

First, these studies add to the research that shows that gay, lesbian, and bisexual people are at higher risk for mental health difficulties than their heterosexual peers. However, they add an interesting wrinkle. Gay and bisexual men and bisexual women may be at higher risk than lesbian women. We’ll have to wait for more studies to come out to see if this is a true difference, or just a random quirk of the data. But it’s an interesting thought.

And secondly, that people in same-sex relationships may fare worse when domestic violence happens than people in opposite-sex relationships. This is likely because of the lack of resources and public awareness around domestic violence than anything to do with the relationship itself.

What do you think about these studies?

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!

Feb 202013
 

CC BY-NC-ND 2.0 - Santiago Alvarez

A new study has come out examining the differences between eating disorders and transsexuality. It’s not immediately obvious why those two should be compared. The causes of both are unknown. When you don’t know the cause of a phenomenon it’s often useful to compare it to other phenomena that seems similar. Both eating disorders and transsexuality can be categorized as body-centered phenomena; eating disorders involve weight, transsexuality involves sex characteristics. However there are differences; people with eating disorders are more likely to have other psychiatric diagnoses (e.g., borderline personality disorder) than trans people are. Trans people seem to have psychiatric diagnoses as frequently as the general population, though the data are still tentative.

This Italian study compared three groups, all roughly the same size (100 participants):

  • Trans people, both trans women and trans men. Both pre-op (no sexual reassignment surgery) and post-op folk were included. There were roughly equal numbers of trans men and trans women, and of pre-ops and post-ops. Trans participants had to have a diagnosis of Gender Identity Disorder.
  • People with eating disorders, divided into three groups: anorexia nervosa, bulimia nervosa and binge eating disorder. These participants were mostly female, except in the binge eating group which was half female.
  • Control participants with normal BMI who did not have an eating disorder and were not trans.

What did they measure? The researchers measured demographics, “anthropometric measurements” such as height and weight, psychiatric evaluations to verify diagnoses, psychological symptoms, and body uneasiness. Body uneasiness is multifaceted, including general body/weight dissatisfaction, compulsive self-monitoring (e.g., spending a lot of time in front of the mirror), feeling disconnected from one’s body, and worrying about specific body parts.

What did they find? Results included…

  • Pre-op trans folk had: a) higher levels of body uneasiness than people with eating disorders, b) lower levels of body satisfaction than post-op trans folk, and c) higher levels of depersonalization than all other groups.
  • There was no difference in overall body uneasiness between trans men and trans women. However, there were differences in various aspects of body uneasiness. Trans women were more likely to be concerned about weight gain than trans men. Trans women also self-monitored about as much as people with eating disorders, more than trans men and the control group.
  • Trans participants had lower levels of psychopathology than people with eating disorders. There was no difference between the trans participants and the control group for psychopathology.
  • Pre-op trans women were more likely to have adjustment disorder than all the other groups.

So how do we interpret this? First there’s the difference between trans folk and people with eating disorders. This study confirmed the findings of previous studies. It agrees that trans people are much less likely to have psychiatric diagnoses than people with eating disorders. It also agrees that, in general, trans people are not at elevated risk for psychopathology than the general population. Given the way many psychiatric disorders come in clusters (e.g., mood and anxiety disorders), this may be further evidence that transsexuality is not a psychiatric condition.

The finding that pre-op trans women are more likely to have adjustment disorder requires explanation. Adjustment disorder is not like mood or psychotic disorders. It means that the person is having difficulty adjusting to a life change. For pre-op trans women, the source is obvious: their transition is a major life change and a major stressor. The fear of being “outed” and assaulted or ostracized is very real. Pre-op trans women are also likely o be early in transition and hormone therapy and have a harder time “passing” than trans men.

Why might trans women worry about weight more than trans men? The authors comment, “It could be speculated that [trans women]’s drive for thinness is a way to suppress masculinity and to correspond to a female ideal of attractiveness.” Absolutely! Trans women are women, and so they get all the societal messages encouraging thinness that all Western women receive.

I do, however, feel that one “finding” of theirs must be questioned. As part of demographics, the authors asked about sexual orientation. They then categorized their participants by attraction according to “genotypic sex” (XX, XY, XXY, XO, etc) So when they later reported that their trans participants were more likely to be attracted to the same genotypic sex than their controls and people with eating disorders, they were actually comparing straight trans people to gay cis people. That makes no sense! Of course there were more straight trans people than gay cis people – there are more straight people than gay people overall. Further, “genotypic sex” as a category makes no sense unless you actually check the genotype! Even then, it doesn’t necessarily correspond to phenotypic sex (the sex that the person looks like).The primary limitation to this study is their inclusion of only gender binary trans people who were diagnosed with Gender Identity Disorder. This excludes all genderqueer folk, who may have more difficulty with transition because of societal pressure to be seen as either male or female. Otherwise, I think this study was fairly well put together.

The authors conclude saying that “Our findings suggest that in eating disorder patients [body] uneasiness is primarily linked to general psychopathology, whereas in [transsexuality] this relationship is lacking.” In other words, they suggest that eating disorders come from a general state of psychological illness and that transsexuality does not. The data I have seen, as well as anecdotes from the trans community, agree with this conclusion.

Abstract.

May 262011
 

Welcome back! This part of the IOM report covers adults aged 20 to 60. There are more data available for adults than adolescents, so this part’s broken up a bit different from the last. As a reminder: GLBT (or LGBT – same meaning, different order) stands for gay, lesbian, bisexual, and transgender. I frequently do use GLB separate from T. That is intentional, not a typo. Also, the full report is available here – you can read it online for free.

The best studied aspects of health:

  • Mood/anxiety disorders: There are conflicting data here, but the consensus so far is that GLB people have higher rates of these problems. There’s almost no research on transgender people, but one preliminary study found that around half of transgender people have depression. Yikes!
  • Suicide/Suicidal ideation: LGBT people as a whole appear to be at higher risk. Bisexuals and transgender people appear to be at an even higher risk. Risk also seems to vary by age, sex, race/ethnicity, and how far out of the closet a person is.
  • Cancer: Gay and bisexual men are definitely at a higher risk for anal cancer than heterosexual men. This risk is linked to having anal HPV, which can be spread by anal sex.

Somewhat studied:

  • Eating disorders: May be more common for GLB people than heterosexuals, but we’re not sure. No data on transgender people.
  • Sexual: Gay/bisexual men don’t appear to be at an elevated risk for erectile dysfunction. Transgender people who have had sexual reassignment surgery may be at a higher risk for sexual difficulties…not entirely surprising given the potential for nerve damage from any surgery.
  • Cancer and obesity: Lesbian/bisexual women may be at a higher risk for breast cancer than heterosexual women.
  • Hormone replacement therapy -may- affect cardiovascular health, but it’s unknown.

Essentially not studied: Reproductive health (including the effects of hormone therapy on fertility for transpeople), cancer (especially in transgender patients), and cardiovascular health

Risk factors:

  • Stigma/Discrimination/Victimization: As we all know, LGBT people face these problems all the time.  Stigma is strongly associated with psychological distress. Bisexuals have reported facing discrimination from both the straight and gay communities. One study of transgender people found that 56% had faced verbal harassment, 37% had faced employment discrimination, 19% had faced physical violence.
  • Violence: LGBT people are at an elevated risk for suffering violence. LGBT people do experience intimate partner violence, but the statistics and relative risk are unknown.
  • Substance Use: LGBT people may be more likely to use substances, especially tobacco (read my previous post on this).
  • Childhood abuse: LGB may have higher rates of childhood abuse.

Potential protective factors (LGB): supportive environments, marriage, positive LGB identity, good surgical/hormonal outcomes (T)

As for access/quality of health care? Er…it’s complicated. GLB people get less regular screening (like pap smears and basic physical exams) than heterosexuals and use the emergency room more often. Two biggest obstacles to getting good health care?: problems with the health care providers. This could be perceived discrimination (thinking that someone is acting in a discriminatory way, whether that person is or not), or simply lack of knowledge on the part of the provider. One study found only 20% of physicians had received education about LGBT health issues. That’s only  one in five! I will note that this is improving – medical schools, depending on the school and its location, are starting to teach LGBT cultural competency more than they used to.

Lack of insurance is another barrier, and it especially affects transgender people. The services they need, like hormone therapy and sexual reassignment surgery aren’t covered by insurance. In addition, one study found that a third of transgender people had been treated ill by a physician.

Next time: Older Adults and conclusions…