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.

Sep 072015
 

In its August 27th issue, the New England Journal of Medicine (NEJM) published a paper reviewing primary health care needs of men who have sex with men. NEJM is one of the most prestigious American medical journals. It was home to the first paper detailing HIV infection in gay men. It’s one of the two major medical journals that my class has been urged to read weekly — part of our professional development as medical students.

What kinds of things does this review article recommend? And was it complete? Let’s take a look…

First is the recommendation to discuss a comprehensive and open sexual history. This should not stop at the classic “Are you sexually active?” question, but ask how the patient self identifies (gay, bisexual, etc), the kinds of sexual activity, the forms of protection used and the consistency with which they are used. Why? Because of HIV. Other sexually transmitted infections are a concern as well, but the big fear is HIV. Of all new infections in the United States each year, just under 2/3 are among men who have sex with men.

Other infections to be wary of include gonorrhea and chlamydia, Hepatitis A/B/C, and HPV. There has also been a rise in meningitis infections among gay men, caused by the bacterium Neisseria meningitidis. Of these infections, hepatitis A, hepatitis B, HPV, and meningitis all have vaccines. Where possible, men who have sex with men should be vaccinated against these diseases. HIV and hepatitis C have no vaccine. To prevent them, barriers such as condoms and gloves can be used in sexual encounters and screening tests should be performed. Pre-exposure prophylaxis and antiretroviral therapy for HIV+ individuals can also be helpful for preventing HIV spread, but cannot and should not replace barriers.

Thankfully, this article was not all about the sex lives of men who have sex with men. Too often the lives of gay and bisexual men are distilled down to just their sex lives, particularly because of HIV. The author points out that men who have sex with men should be screened for substance use, depression and anxiety. However, they stop there. While asking about tobacco, alcohol and illicit drugs is very important, there are other important aspects of the lives of gay and bisexual men that should be addressed. In particular, I would ask about…

  • Social support and living situation, particularly among young gay/bi men and older gay/bi men. Young men are at higher risk for being homeless because of family discrimination. Bullying also happens frequently among young gay/bi men. Older men may have lost their support group during the 1980s-1990s and may be facing the challenge of growing old alone. LGBT elders may face the prospect of going “back into the closet” to receive nursing home care.
  • Domestic violence. Same-sex domestic violence is under reported and specific resources are scarce.
  • History of assault or violence. Violence against men perceived to be gay/bi can have lifelong health consequences, including post traumatic stress disorder.
  • Attempts to self harm or suicide. These must never be ignored, no matter who one is talking to.
  • Diet and exercise. Eating disorders are known to occur in gay/bi men. Diet may be poor and exercise may be too low or too high, depending on the individual and his situation.

Yes, screening for HIV and other sexually transmitted diseases is important. And this article did bring some specific health issues to a large audience. However it’s important not to distill men who have sex with men down to a cluster of diseases. Let this article be a spark for discussion, and not the be-all and end-all of primary care for men who have sex with men.

What do you think? Did I miss anything important in the things I would add?

A preview of the paper is publicly available.

Jan 092015
 

This is the start of a new series of posts here on Open Minded Health: Quickies! I often run into items in the medical literature that are too short to do a fully post on, but for whatever reason I think it’s worth covering it anyway.

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This week’s quickie is a case report, which was presented as a poster at a medical conference.

7170317810_f25026d624_mA trans woman in her thirties showed up at the emergency room with gastrointestinal problems. She had nausea, pain, and bleeding. No significant medical history was noted in the report, and she was on a normal dose of hormone therapy.

When they took her blood to run some lab tests, the sample appeared “as white and turbid as milk.”

Her lab work revealed a triglyceride level of 30,000 mg/dl. For reference, a normal triglyceride level is less than 150. Above 500 is considered “very high.”

She was immediately transferred to the intensive care unit for treatment. Triglycerides that high can cause inflammation of the pancreas. Thankfully all her pancreatic lab values were normal. After a week of treatment, which managed to get her triglycerides down to 3,000, she was sent home. She was instructed to stop estrogen treatment, take new prescribed triglyceride-lowering medications, and to follow up with her physician.

Why did the hospital physicians recommend that this patient stop her estrogen? Because estrogen treatment is known to increase triglyceride levels. Triglyceride levels that high are extremely rare. A much more mild version can, however, happen to anyone who has high estrogen levels. It can happen to cis women in pregnancy or receiving hormone replacement therapy for menopause. It can also happen to trans women on estrogen treatment.

High triglyceride levels are usually “silent” — there are no symptoms. That’s part of the reason it’s important to see a physician regularly for screening, especially if you’re at higher risk. High triglyceride levels are more likely if you…

  • are overweight
  • don’t exercise
  • eat a high-carbohydrate, high-fat diet
  • have other cardiovascular issues
  • are on certain medications
  • or if it runs in your family

Mild elevations in triglyceride levels may be controllable with diet, exercise, and weight control. If those don’t help, your physician may prescribe medications to lower your triglycerides.

For more information on triglycerides, including what they are, normal levels, and how to control them…check out this article by WebMD or ask your primary care provider.

The case report inspiring this post was “Hypertriglyceridemia up to thirty thousand due to estrogen: Conservative Management” and was published in Critical Care Medicine.