Aug 012016
 

Welcome back to Open Minded Health Promotion! This week we’re looking at health promotion for transgender men and individuals assigned female 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 men 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. Testosterone is not an effective method of birth control. In fact, testosterone is bad for fetuses and masculinizes them too. Non-hormonal options for birth control include condoms, copper IUDs, diaphragms and spermicidal jellies.
  • If you’re under the age of 26, get the HPV vaccine. This will reduce the chance for cervical, vaginal, anal, and oral cancers.
  • 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 curves, it’s also associated with heart disease and a lower quality of life.
  • 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.
  • Be careful when weight lifting if you’re newly taking testosterone. Muscles grow faster than tendon, thus tendons are at risk for damage when you’re lifting until they catch up.
  • Consider storing eggs before starting testosterone if you want genetic children. Testosterone may affect your fertility. Consult a fertility expert if you need advising.
  • Seek help if you’re struggling with self injury, anorexia, or bulimia. Trans men are at higher risk than cis men for these aspects of mental health.
  • If you have unexplained vaginal bleeding, are on testosterone, and have not had a hysterectomy notify your doctor immediately. Some “breakthrough” bleeding is expected in the first few months of testosterone treatment. Once your dose is stable and your body has adapted to the testosterone you should not be bleeding. Bleeding may be benign but it may also be a sign that something more serious is going on. Contact your doctor.
  • In addition, talk with your doctor if you have pain in the pelvic area that doesn’t go away. This may also need some investigation. And s/he may be able to help relieve the pain.
  • Be as gentle as you can with binding. Make sure you allow your chest to air out because the binding may weaken that skin and put you at risk for infection. Be especially careful if you have a history of lung disease or asthma because tight binding can make it harder to breathe. You may need your inhaler more frequently if you have asthma and you’re binding. If this is the case, talk with your doctor.
  • If you’ve had genital surgery and you’re all healed from surgery: there are no specific published recommendations for caring for yourself at this point. So 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…
  • Cervical cancer screening (if you have a cervix). The recommendation is every 3-5 years minimum, starting at age 21. Even with testosterone, this exam should not be painful. Talk with your doctor about your needs and concerns. Your doctor may offer a self-administered test as an alternative. Not every doctor offers a self-administered test.
  • Mammography even if you’ve had chest reconstruction. We simply don’t know what the risk of breast cancer is after top surgery because breast tissue does remain after top surgery. Once you turn 50, consider talking with your doctor about the need for mammography. In addition, if you’re feeling dysphoric discussing breast cancer then it may be helpful to remember that cis men get breast cancer too.
  • If you have not had any bottom surgery you may be asked to take a pregnancy test. This may not be intended as a transphobic question. Some medications are extremely harmful to fetuses. Hence doctors often check whether someone who can become pregnant is pregnant before prescribing. Cisgender lesbians get this question too, even if they’ve never had contact with cisgender men.

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.

Mar 142016
 
Baby shower items! by Ana Fuji

Baby shower items! by Ana Fuji

A recent review of fertility preservation in trans and intersex people was published in the new journal Transgender Health. It’s a topic only briefly addressed previously on Open Minded Health (in trans 101 for trans people). Using the review as inspiration then, this week I’ll cover options and factors to consider when it comes to having biological children.

The basic technique in fertility treatments is the harvesting of sperm or eggs. Those sperm or eggs can then be frozen for later use or used for fertility treatments such as in vitro fertilization. For this to work, ovaries or testes have to be producing those eggs and sperm. This means the person has to be past their natal puberty and produce enough viable eggs and sperm that they can be harvested.

For transgender adults, sperm/eggs are best harvested before any hormones are taken. Hormones do reduce fertility, although they are not considered reliable enough to be used as birth control. The amount of estrogens or testosterone needed to have an impact on fertility is currently unknown, but it seems to be different for everyone. So your safest bet is to store egg/sperm before beginning hormones if you can afford it and if having a biological child in the future is important to you. Surgical removal of ovaries/uterus/testes does, of course, make a person sterile and unable to have future biological children.

Trans men who still have a uterus can carry a child but need to be off testosterone to do so as testosterone is harmful to fetal growth. Transgender women cannot carry children with current medicine.

Flowchart

A flowchart for fertility possibilities for trans youth — click to enlarge

For transgender youth it’s more complex. If the youth hasn’t gone through their natal puberty (e.g., for someone assigned female at birth that would be a female puberty) enough to have fertile sperm/eggs, then they have no sperm/eggs to harvest. Going from pre-puberty to puberty blockers to gender-appropriate hormone therapy means that, with today’s technology, there is no future fertility for the youth. If the youth has been on puberty blockers only, the blockers can be removed and the youth allowed to go far enough into natal puberty so that sperm/eggs can be harvested, and then transition. However going through natal puberty is often traumatic for trans youth, and may not be worth it for the youth. There are experimental options currently being used for children with cancer — taking ovarian or testicular tissue from the child and freezing it for future use. However it’s very experimental and I don’t know of anyone doing it for trans youth at this time.

With trans youth there is the added concern of ethical decision making. Children and adolescents cannot give informed consent. That’s the job of the parents or legal guardians. But their desires may clash with that of the youth, possibly causing harm. Depending on the family the question of fertility may or may not be problematic.

For intersex people or people with differences of sexual development, the effect on fertility depends on the specifics of the medical condition. But there are some larger concepts we can talk about. First — being intersex does not automatically mean a person has no fertility. Many of the intersex medical conditions do result in lower fertility. The potential treatment depends on what’s actually causing the low fertility.

  • If the ovary/testis itself is considered “abnormal” (e.g., a mosaic ovary), the effect on fertility is often failure of the ovary/testis. In this case, there’s little that modern medicine can do. The person can try the experimental preservation technique of harvesting and freezing ovarian/testicular tissue, but that’s an experimental technique.
  • If the root cause is hormonal (e.g., congenital adrenal hyperplasia), then it’s possible that sperm/eggs can be harvested. Hormonal treatment may also help fertility.
  • If the root cause is a higher risk of ovarian/testicular cancer, fertility preservation depends on whether the person is pre- or post- puberty. Treatment for an ovary/testicle that has a high risk of becoming cancerous is removal of that ovary/testicle. So if the person has already gone through puberty and is about to have the organ removed, sperm/eggs can be harvested before. If they are pre-pubertal, they can try the experimental technique of freezing the tissue.

Genetic counseling may also be useful for intersex people, as some differences of sexual development conditions are genetic and can be passed down to biological children. Intersex people should receive fertility counseling from physicians knowledgeable in their particular condition at as young an age as possible to maximize their options.

Lastly — never forget that having biological children isn’t the only way to have children. Adoption, fostering, and co-parenting are all wonderful things and are not any less valid ways to have children than having a biological one. If the laws in your state allow, consider adopting, fostering, or co-parenting.

Sep 242013
 

This post is a legacy page, and was part of an on-going series, Trans 101 for Trans People. It covers questions about medical transition, hormones, surgeries, or seeking health care for transgender people.

For the material that once lived on this page, please see this page.

Please update your links to the full Trans 101.

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…