Jul 182016

Transgender youth are a special population. Because of the relative novelty of treatment at any age much less for youth, data are scarce. A recent review article examining the published data on transgender youth was published. Let’s take a look at what they found.

First, how about prevalence? How many youth self identify as transgender? There are very, very, few studies that get good numbers on this. One study in New Zealand found that 1.2% of secondary school children identified as transgender, and 2.5% weren’t sure about their gender.

As we well know, being a gender and sexual minority can often be associated with health disparities. And this review reports on that too. Identifying as transgender was associated with negative psychological health. Specifically, being bullied, having symptoms of depression, attempting self harm, and attempting suicide were all more common in transgender youth than in cisgender youth. How much of that was because of discrimination and how much was because of gender dysphoria was not explored.

Researchers have also found that being transgender and having autism appear to go together. No one is quite sure why yet. There’s still a lot of research to be done to figure that out.

One interesting difference in the literature stands out to me, though. It appears that transgender men are more likely to self harm and transgender women are more likely to be autistic. Among cisgender people, cis women are more likely to self harm and cis men are more likely to be autistic. There are theories for why that sex difference exists, but there’s little to no agreement. It could be related to social environments, hormones, the environment in the womb, or any number of other factors. But the observation that transgender men and women more resemble their sex than their gender for self harm and autism is worth investigating further.

What about the effects of hormone therapy for transgender youth? Especially puberty suppression, which is the unique factor for their treatment? As a reminder, the treatment of transgender youth is largely based on the Dutch model. At puberty, children go on puberty suppressing drugs. They then go on hormones (and thus begin puberty) at age 16 and are eligible for surgery at age 18. There are efforts to deliver cross-sex hormones earlier, but the Dutch model is the standard that most of the research is based on. A Dutch study found that the psychological health of transgender youth improved after surgery. Their psychological health even equalled that of their cisgender peers! The researchers also found that youth continued to struggle with body image throughout the time they were on puberty suppression only. But their self-image improved with hormone therapy and surgery. None of the children regretted transitioning. And they said that social transition was “easy”.

One challenge to that particular Dutch study is that the Dutch protocol excludes trans youth who have significant psychiatric issues. A young person with unmanaged schizophrenia, severe depression, or other similar issue wouldn’t be allowed to start hormones. So the research was only on relatively psychologically healthy youth to begin with. It’s difficult to say if that had an effect on the study’s results. It’s also difficult to say whether the psychological health of a trans youth is the cause or the result of their dysphoria. A trans youth with depression might well benefit from hormone therapy, after all.

There are multiple questions still unresolved when it comes to treating transgender children. Does puberty suppression have a long term effect on their bones? Are there long-term physical or psychological health effects of early transition? How should children with serious psychological conditions be treated (besides the obvious answer — with compassion)? And on, and on.

The medical and scientific communities are working on answering these questions. But it will take time. And in the mean time — physicians and families do they best they can with what information we have. If you have, or are, a transgender youth please consider participating in a study so we can do even better for children in the future.

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

Feb 012016
Human heart and lungs -- the core of the human cardiovascular system

Human heart and lungs — the core of the human cardiovascular system

Cardiovascular disease (CVD) is the leading cause of death in the United States. And it’s growing, largely because the factors that lead to CVD are growing too: obesity, diabetes, high blood pressure, high cholesterol, diets based on meat, and physical inactivity. We have data on how CVD risk varies depending on sex, ethnicity, and socioeconomic status. But we don’t have strong data on how gay, lesbian, and bisexual peoples risk factors add up to actual CVD risk.

CVD risk is often calculated using data from the Framingham study, a massive multigenerational study started back in 1948. The risk calculators that still come from that study today are some of the most well validated calculators we have. A physician can plug in a few numbers and get a good estimate of your risk of having a cardiovascular-related event over the next few years. The calculators are publicly available, but really do need training to interpret.

Why do I bring up the Framingham study? Because the study I’m examining this week uses those same calculators and other factors to try to estimate the cardiovascular risk of lesbian, gay, and bisexual cisgender people. Let’s take a look at what they did!

This study used data from the National Longitudinal Study of Adolescent to Adult Health. They used data from a whopping 13,427 participants. That’s a lot of people — one of the largest sample sizes covered here on Open Minded Health. The participants were also quite young for a study on heart disease — mostly around 28-29 years old. They looked at social factors like age, ethnicity, educational level, and level of financial stress. They also looked at medical factors, like their diabetes status and hypertension (high blood pressure) status.

The researchers reported sexual orientation on a Kinsey-like 5-point scale, from “heterosexual” to “mostly heterosexual” to “bisexual” to “mostly homosexual” to “homosexual”. I’ll try to stick to that language for clarity. Among the participants, 80% of the women and 93.5% of the men said they were heterosexual. In contrast, .9% of the women and 1.7% of the men said they were homosexual, and 18.7% of women and 4.8% of men were in the middle.

So what about their cardiovascular risk?

The men’s 30 year CVD risk was 17.2%, and the women’s was 9%. What does that mean? It means the men has a 17% chance of having cardiovascular disease in the next 30 years. In other words, a little under 1 in 5 of the men would have CVD by the end of 30 years. By then, they’d be in their late 50’s. Roughly one in five men and one in ten women in the entire study would likely have cardiovascular disease by their late 50’s.

What happens when we look at sexual orientation?

For women: Compared to heterosexual women (9% risk), all other sexual orientations were at higher risk for cardiovascular disease. Mostly heterosexual women had the lowest of non-heterosexual women, at 9.8%. Mostly homosexual women had the highest, at 11.8%.

For men: Compared to heterosexual men (17.2% risk), some sexual orientations were at higher risk and some were at lower risk. Mostly heterosexual and completely homosexual men were at lower risk of cardiovascular disease — 16.3% and 16.6% respectively. In contrast, mostly homosexual men had higher risk, at 20.2%!

What factors other than sexual orientation came into play? Risks were lower with more education. Being a college graduate reduced risk from 3% for women to 5% for men. Being of Asian or Hispanic descent was also protective, though not nearly as much. And the factors that increased risk? Being of African descent (up to 1% higher), being older (up to 1.5% higher), and having financial stress (up to 1.2% higher).

Let’s summarize a bunch of those numbers, shall we?

Overall, men are at twice the risk for cardiovascular disease as women. Non-heterosexual women are at higher risk than heterosexual women. Among men, mostly heterosexual and completely homosexual men were at lowest risk and mostly homosexual men were at the highest risk. Among everyone, poorer black people were at higher risks and richer, more educated hispanics and asians were at lower risks.

Why such a difference?

It’s hard to say. The researchers don’t go into detailed statistics to figure it out. I have some thoughts from looking over the data they published though. For women, it looks like part of that increased risk is from smoking — it looks like a higher percentage of non-heterosexual women smoked. On the male side, it looks like diabetes may play a role. But I haven’t run statistics to see if what I think I’m seeing is real or just by chance.

Regardless — this is valuable information which will help public health officials determine where to put their resources.

What can you do with this information? You can work to reduce your own cardiovascular risk! Here are some things to consider doing (depending on what works for you!):

  • Move more, eat less. Most Americans eat too much and don’t move enough, which leads to obesity and cardiovascular disease.
  • Stop smoking. Much easier said than done, but this is one of the best things you can do for your health
  • If you have diabetes, keep your blood sugar under control as best you can. Aim for the lowest HbA1c you can, but under 7% is a great place to be. If you haven’t spoken with a diabetes nurse educator, they can be great allies.
  • If you have hypertension, keep it under control as best you can. Take your medications, and talk with your doctor about them.
  • Get some healthy stress relief. Whether that’s a long hot bath, a fitness class, a long walk/run in the wilderness, or knitting a scarf — find something that helps you relax every day.

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

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!

Oct 192012

Data from a University of Maryland School of Medicine survey were just released showing that nearly four out of ten lesbians do not get regular pap smears. Pap smears screen for cervical cancer, among other things. Cervical cancer is usually caused by the human papilloma virus (HPV). HPV can be spread by skin-to-skin contact, so lesbians are just as much at risk for getting HPV as bisexual or heterosexual women. Screening is important to detect precancerous changes and cancer in their earliest stages so that treatment can be done when it’s most effective, preventing deaths.

Why do so few lesbians get their screenings? The primary reasons cited in the survey were: a) not having a physician referral, and b) not having a physician. Together, these two reasons account for 34.8% of study participants. We already know that lack of access to care is a big problem in gender and sexual minority communities. This just helps to confirm it. The survey authors note that lesbians who were open with their physicians about their sexual orientation were more likely to be screened than those who weren’t open.

There has been a recent change to pap smear recommendations. Pap smears are no longer recommended every year for most people. Screening starts at 3 years after first sexual activity, or age 21, whichever is first. From age 21-30, screen every 3 years, then from age 30-65, screen and do an HPV test every 5 years. After 65, no screening is recommended. If a pap smear is abnormal, screenings become more frequent. I should also note that these guidelines apply to everyone with a cervix, regardless of gender identity.

I, personally, think it’s highly advisable for everyone to know their HPV status and get vaccinated if possible, in addition to regular pap smears. HPV vaccines are not a replacement for pap smears because they don’t vaccinate for all HPV strains which cause cervical cancer. However, vaccines do protect against some.

EDIT (10/21/2012): I should also note that during a pap smear, a physician can do other screenings. This includes gonorrhea/chlamydia screening, looking for signs of other STDs or vaginal cancer, and checking the ovaries for lumps.