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Conference Report: 2013 National Transgender Health Summit (Preliminary)

May 192013

I got back from the 2013 National Transgender Health Summit (NTHS) in Oakland last night. What a fabulous conference! I’m still processing a lot of my notes, but wanted to give a quick report on it before I flood the blog with new resources.

First some basic information. NTHS is cosponsored by UCSF’s Center of Excellence for Transgender Health and the World Professional Association for Transgender Health. It’s designed for medical professionals, mental health professionals, advocates, health administrators, students, and others. I can’t speak for previous years, but this year it was a two-day event. Sessions were broken into various tracks: research, medical, mental health, policy, and special topics. And boy, did we cover quite a lot! And, as always, I wanted to be in five different places all at once.

Aside from the official session topics, though, there were some themes that stood out to me…

There’s a very strong need for cross-cultural trans care. Trans care, like lots of medicine, has been focused on white people. I admit to being guilty of this too! I don’t know how being trans is handled in, for example, an urban latino/a community, and I don’t know how I can best respond to those needs as a future health care provider. I met some folks who were involved in the Trans People of Color Coalition, and I hope to not only educate myself but bring more awareness to my posts here.
There’s a disconnect in some areas between cultural knowledge about medical treatments in trans communities and medical knowledge. I want to give a shout out to Trystan Cotten, author of Hung Jury, for bringing attention to this within trans male communities. One of his examples? Something new for me, certainly: there are anecdotal reports that some trans men can have penetrative sex after metoidioplasty. Sounds like there needs to be a community-level conversation.
It sounds so far like the ICD-11 system will handle both the transgender/transsexual diagnoses and the paraphilia diagnoses much better than the previous ICDs and certainly better than the DSM system. More details when the preliminary criteria are out for comment.
Insurance coverages for trans-related care may improve with the Affordable Care Act. Again, more on this as information becomes more available.
There is a lot of research going on! Yay! I’ll try to link to some of the studies I heard about in a follow up.

Plus so much more! It was really exciting. I hope to post again with more information, links to lots of new resources and shout outs for on-going studies and organizations.

News Roundup for April 2013

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May 022013

Summary of some of the interesting news bits from April 2013.

Researchers in Sweden find that early vaccinations against HPV are more effective than late vaccinations (93% effective before 14 years, 76% after 14 years and before 20 years). Abstract. Open Source Full Text.
Despite low risk of side effects and mild side effects, fewer U.S. parents were less likely to vaccinate against HPV in 2010 than in 2008 (43.9% unwilling to vaccinate in 2010 vs 39.8% unwilling in 2008). Abstract. Open Source Full Text.
Anal cancer rates have dramatically increased since 1973. Abstract.
Roughly 3/4ths of men who show “hypersexual” behavior report being distressed by it or having functional problems. Slightly more than half have relationship problems. Abstract.
Attitudes about female circumcisions have been assessed via Facebook in the “Middle East”. Female circumcision is done by doctors about half of the time, and was more common in rural areas than urban areas. Nearly half of the sample indicated that female circumcision was “necessary” or “very necessary.” Abstract.
Persistant genital arousal disorder may be caused by a mass, according to a recent case study.
In women with menstrual cycles, estrogen may have a delayed positive effect on libido. Progesterone may have a negative effect on libido. News article.
The U.S. Department of Justice has issued new guidelines for medical examinations after a rape. These guidelines now emphasize the survivor’s emotional and physical needs over any forensic needs. News article. Guidelines.
Recent cases of meningitis in gay men raised concerns that gay men may be at risk. After analysis the cases appear not to have been related. Gay men who have been sexually active in or around New York City since September 1st are still advised to get a meningitis vaccine to be on the safe side. News article.

Why the flower picture? It’s a tongue-in-cheek reference to the “flower of the month.” Besides, it’s pretty!

Did I miss anything? Let me know in the comments.

Hope you all had a lovely month!

Article Review: Hormonal Treatment Reduces Psychobiological Distress in Gender Identity Disorder, Independently of the Attachment Style

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May 012013

Summary: Research now indicates that cross-sex hormone therapy is associated with a lower cortisol awakening response in trans people, regardless of attachment style. Many confounding variables, however, were present in this study.

Transgender people have long asserted that gender dysphoria can be extremely distressing and that transition, including hormone therapy, helps relieve that dysphoria. Hormone therapy is known to improve self-reported quality of life, as measured by questionnaire. To my knowledge no other study has looked at stress-related biological factors in trans people. Biological factors are important because self-report is notorious for validity problems. This study looked at one such biological factor, called the cortisol awakening response.

What is the cortisol awakening response? Readers of the blog may remember the last time I spoke about cortisol (paragraph #2). For those who don’t remember…. cortisol is a “stress hormone.” When we’re stressed, whether by speaking in public or running from a lion, cortisol is released. It helps our body be ready for immediate survival by increasing blood sugar and helping with metabolism. High cortisol levels over a long period of time can have many negative effects on health, including weakening the immune system. The cortisol awakening response is part of cortisol’s daily cycle, when cortisol blood levels spike about 20-30 minutes after waking in the morning. The cortisol awakening response is larger in stressed people than in non-stressed people and can be affected by many things, including burn out, fatigue, aspirin, and sleep schedule. Cortisol awakening response is thought to be a good indicator of general stress levels and as a good indicator for stress-related disease risks.

Participants in this study were 70 trans people seen at the Gender Identity Unit of the University of Bari Psychiatric Department, roughly 64% trans women. All the participants had the same hormonal treatment; transdermal estradiol gel and cyproterone acetate (an anti-androgen) for trans women, intramuscular testosterone esters for trans men. They were assessed before hormone therapy and 12 months after starting hormone therapy. There was no significant difference in age, education, or occupation between the two groups.

The researchers measured perceived stress (a self-report of how stressed a person feels) in addition to the cortisol awakening response. The cortisol awakening response was measured by a blood test at 8:00am on three consecutive days, 1 hour after waking.

The results were striking. Before treatment, both perceived stress and cortisol levels were above the ”normal” range. After twelve months of hormone therapy, both were much lower and back within normal ranges. There were no statistically significant differences between trans men and trans women.

However there are a number of confounds for this study. Cortisol levels vary with sex hormones. For example, the cortisol levels of menstrual women will vary depending on which part of the menstrual cycle they’re in. Could cross-sex hormone therapy have caused this change in cortisol levels? Maybe, but then I’d expect there to be a difference between the trans men and trans women in this study and there weren’t.

The researchers also did not appear to attempt to control for other factors which could have impacted the cortisol awakening response. Changes in sleep patterns (e.g., naps) or sleep quality (e.g., a noisy environment) have effects on the cortisol awakening response. As far as I can tell the researchers did not screen for these changes.

Cortisol and stress were not the only things measured in this study. The researchers also looked at attachment styles. Attachment styles are a psychological concept. The idea is that when we are children our interactions with parents, and how they respond to our needs, affects the type of “attachment” we have. Attachment styles are secure or insecure. A secure attachment often results in happy adult relationships. Insecure attachments include avoidant, anxious, and unresolved/disorganized styles. Attachment styles may influence how we respond to stress, so they could have been a confound in this study if not examined.

The researchers determined the attachment style of the participants with a structured interview. They found that trans people are more likely to have an insecure attachment (70%) than the general population with no psychiatric diagnoses (44%). Attachment style did not, however, appear to be correlated with cortisol awakening response or perceived stress.

In other words, the relationship trans people have with their parents did not appear to affect the stress-reducing effects of hormone therapy.

I admit I do not really understand why these researchers chose to examine attachment style in this study. While I think that knowing attachment styles may be useful for therapy, or for the development of effective variations on therapies for trans people, I don’t feel that the inclusion of attachment style was sufficiently justified in this study. Why look at attachment and not, for example, socioeconomic status or social support? I would think either of those would be more likely to have an impact on stress levels than attachment.

On the whole, I think that the cortisol results of this study are decent validation of the anecdotal evidence from trans people themselves, but that the exploration of attachment style in this context is a red herring.

The abstract is publicly available.

Article Review: Long-Term Evaluation of Donor-Site Morbidity after Radial Forearm Flap Phalloplasty for Transsexual Men

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Apr 182013

The first study of long-term effects of radial forearm flap phalloplasty was published just this month. The aesthetics, functionality, and health status of the donor site on the forearm was examined. This study was reported by researchers at the Center for Sexology and Gender Problems at Ghent University Hospital in Belgium.

Does “radial forearm flap phalloplasty” sound like gibberish? Let’s break it down. Phalloplasty is one of the genital procedures available for trans men (the other is metoidioplasty, which we’ve previously covered). In a phalloplasty, tissue from elsewhere on the body is used to make a penis. ”Radial forearm” refers to the part of the body used: a section of forearm, including blood vessels and nerves. “Flap” means the tissue from the forearm is removed completely from the body then put on in another location. “Flap” is in contrast to “pedicle”, where the tissue remains connected in one spot. So a radial forearm flap phalloplasty, essentially, is where tissue from the forearm is used to make a penis. At the same time, hysterectomy and bilateral oophorectomy are done.

As with any surgery involving a graft, both the donor and receiver tissues are damaged. This procedure leaves a scar on the forearm where The researchers report that scarring, reduced bone density, limited range of motion, decreased finger/hand strength, loss of graft, delayed healing, and sensory changes have all been reported. But how common are they? Enter the current research.

Who participated in this research? 44 trans men who had had the procedure. They were an average of 9 years post-surgery, with a range from 9 months to 22 years. Six had a metoidioplasty before their phalloplasty. The median age at surgery was 28. All participants were on hormone therapy, and had been for an average of 10 years; most on a mix of testosterone esters delivered intramuscularly (which is fairly standard practice). The trans male participants were compared to a control group of cis women. There was no weight difference (BMI) between the two groups, but there were more tobacco smokers in the experimental (trans men) group than in the control group (cis women). The control group was not on any metabolic or hormonal altering treatment. In addition to general questions (e.g., tobacco use, medications, medical conditions), the forearm scars of participants were assessed. Questions relating to scar pain, stiffness, and sensation were included. Bone density and body mass were also measured.

The results are very clear. The researchers found no differences in physical activity, lean mass (muscle and bone) of the forearm, or bone health between trans men and cis women. No bone breaks in the donor forearm were reported. In other words, there were no functional problems with the donor forearm. Most (70%) scars had enough blood flow. No itching or pain was reported. The age of the trans man at the time of surgery did not appear to be associated with any negative outcomes.

Best of all, most trans men were satisfied with the way their forearm scar looked. Here’s the breakdown:

26% satisfied
21% very satisfied
30% neutral
19% unsatisfied
5% very unsatisfied

None of the trans men reported regretting their surgery because of their forearm scars. The threat of damage to the forearm itself from this procedure appears to be less than previously thought, though as always it’s not risk-free.

I have to object, however, to using only cis women as controls for a group of trans men. Trans men are not women. The trans men in this study had been post-op for as much as 22 years, meaning no ovaries, so very low levels of “female” sex hormones. Combined with testosterone therapy, their hormone levels much more closely resemble that of males than females. It just doesn’t make any scientific sense. Worse, it carries the subtext that trans men are women, not men. Brain evidence and anecdotal evidence from trans people themselves indicate otherwise, and that such attitudes are extremely harmful.

This research was published in the Journal of Sexual Medicine.

Article Review: Sexual Orientation and Disclosure in Relation to Psychiatric Symptoms, Diurnal Cortisol, and Allostatic Load

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Feb 102013

As 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:

Compare the stress levels of LGB people with heterosexual people
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).

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