May 292017
 

Medical transition for trans people has only been available in the United States since the 1970’s. Because it’s so new we only have limited data about long term risks and benefits. When I was first learning about trans health I was frustrated by the lack of data. Are trans women protected from heart attacks like cis women are? Do trans men have lower risk for osteoporosis like their cis men peers do? We simply don’t know.

Today’s study is an exploration of the long term morbidity and mortality of trans people who have had surgery. Morbidity and mortality are just fancy words. Morbidity refers to disease or suffering. For example, morbidity may refer to how many people had a heart attack but are alive. Or how many people live with depression, or low back pain. Mortality is how many people died.

Who did they study?

Simonsen et al took advantage of the Denmark health system. In Denmark, there is one national health system. So they were able to look up how many trans people there are in Denmark. They were then able to figure out who had had gender-related surgery. Using medical billing codes, they looked at the diseases and disorders those trans people were diagnosed with. And they used death certificates to determine cause of death. They looked at records from 1970 to April 2014.

In total Simonsen et al looked at the records of 104 trans people. 56 were trans women and 48 were trans men. Surgery was performed between 1978 and 2010. So the patients with the most recent surgery would have been 4 years post surgery.

Most trans women (65%) started hormones age 22-42 and had surgery 9-23 years before the study. Trans men started at similar ages, 21-38 and had surgery 4-1

Beech trees in Denmark, where this study of morbidity and mortality was done

Beech trees in Denmark, where this study of morbidity and mortality was done

6 years before the study.

Their findings

In total, 20 trans people (19%) were diagnosed with a disease/disorder before surgery. That increased to 24 after surgery (23.2%). However, the difference wasn’t statistically significant. That means the difference was likely because of chance.

Diseases seen in this study included cancer, cardiovascular disease, musculoskeletal disease, chronic lung disease, and alcoholic liver disease. Almost all of the diseases were related to behavior and not to hormone therapy or the surgery.

Cardiovascular disease was seen in 10.7% of trans women and 25% of trans men. Compare that to 3.5% of cis women and 4.4% of cis men. The high rate of cardiovascular disease is likely a result of smoking, since high rates of chronic lung disease were also soon. Chronic lung disease includes COPD, which is usually caused by smoking tobacco. Chronic lung disease was seen in 3.8% of trans people. In comparison, 1.3% of cis people had chronic lung disease. There was no difference between before and after surgery in either cardiovascular disease or lung disease.

In contrast, there was a difference seen with alcohol. Alcohol-related diseases were seen in 3.8 of trans people before surgery. After surgery that number dropped to zero.

Musculoskeletal disease was unique. It was found in 10.5% of trans people, compared to 13.9% of the general cis population. So musculoskeletal disease was the only one that trans people, as a population, had less of.

Cancer rates were also higher in trans people. 6.2% of trans men and 3.6% of trans women were diagnosed with cancer. The general population rates are 1.6% of cis men and 2.4% of cis women. The cancer rates seem to be because of increased risk of lung cancer from smoking, however Simonsen et al did not publish the details.

What about deaths?

10 trans people had died in Denmark between 1970 and 2014. That’s 9.4% of all the trans people in Denmark. The average age of death was 53.5 years. The average age of death for the general population in Denmark is 81.9 years for women and 78 years for men. The causes of death were mostly from smoking and alcohol abuse. However, two trans people committed suicide. One was 19 years after surgery, the other was 26 years after surgery.

What do these results mean?

First, that gender-related surgery for trans people does not increase the risk for medical disease. There was no change in disease before and after surgery.

Second, rates of cardiovascular disease, lung disease, cancer, and alcohol-related disease are higher in trans people than in cis people. Smoking tobacco and alcohol seem to be the cause, not hormones. And smoking and alcohol are likely because of stress from discrimination and gender dysphoria.

Third, the average life expectancy for trans people in Denmark is much lower than the general life expectancy. Again, this is because of smoking, alcohol, and suicide.

What are the caveats?

This was a tiny sample. While 104 trans people is a large sample for trans research, it’s a small sample to try to draw large conclusions from. Worse, some of the sub groups were miniscule. It’s near impossible to draw accurate conclusions from only 4 people with lung disease, or 2 suicides.

I was also surprised at the lack of HIV-related diagnoses in this study. HIV is prevalent in trans women in the US for complex reasons. Is the rate lower in Denmark? I don’t know.

And as always, this was one study in one country. Every culture and country is different, with different levels of discrimination and different cultural standards. So we can’t make assumptions about other cultures based on this one study.

Despite the limitation, this is an excellent exploratory study. We should continue to look for more data coming out of Denmark to see what more we can learn.

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

Mar 062017
 

Lesbian, gay and bisexual (LGB) high school students are at higher risk for suicide than their heterosexual peers. The reasons are complex. The facts are simple. In the US in 2015, 29% of LGB youth report attempting suicide in the past year compared to 6% of their heterosexual peers. LGB youth also have higher rates of depression, anxiety, and non-suicidal self injury. Why? One of the main culprits is stigma.

It is still not a “good” or “normal” thing to be LGB in the United States. LGB people are very much in the minority. They are targets for discrimination and violence. All of this is part of stigma. There are different types of stigma. Structural stigma is policy, rule, and law based discrimination. Marriage inequality was one of the most talked-about forms of structural stigma.

If poor mental health outcomes like suicide attempts are partially because of stigma then we would expect changes in those mental health outcomes after a change in stigma. In other words, if marriage inequality is one way that society says “LGB is bad” and drives adolescents toward suicide, then when marriage inequality goes away adolescents should have fewer suicide attempts.

And that’s what the researchers in this week’s study looked at. They asked: Did youth suicide attempts go down after legalization of marriage equality?

The Study

The researchers looked at data from the Youth Risk Behavior Surveillance System (YRBSS). The YRBSS is a survey done by the Centers for Disease Control every 2 years. It’s conducted in 47 of the 50 United States.Among other things, the YRBSS asks about number of suicide attempts in the past 12 months.

They looked at data from 1999-2015. 2015 is before country-wide marriage equality. So instead of looking at national data, they looked state by state. They compared suicide attempts before and after legalization in that state. They also compared suicide attempts in states that legalized and in states that did not legalize in the same year.

In addition they compared straight suicide attempts to LGB suicide attempts. Only 25 states were actually asking about sexual orientation by 2015, so this part of the study was limited.

In total there were data from roughly 760 thousand adolescents. 12.7% of students in states that asked about sexual orientation identified as LGB. 2.3% were gay/lesbian, 6.4% were bisexual, and 4% were uncertain.

8.6% of all students had attempted suicide in the past year before marriage equality. That dropped by 0.6% to 8.0% after same-sex marriage was legalized. If we extrapolate out, that’s roughly 134 thousand adolescents who did not attempt suicide after marriage equality.

For LGB students the difference was even more impressive. Out of 231 thousand adolescents, 28.5% had attempted suicide in the past year prior to legalization. After marriage equality it dropped by 4.0% to 24.5%. That’s a relative reduction of 14%.

And for the statistically nerdy folks among us, those results were statistically significant at the p = 0.05 level.

Nice data, but what does it mean?

Here’s the bottom line. There were fewer suicide attempts in all high school students after marriage equality. This was especially true among LGB youth, but the effect was seen in all youth.

There’s a very important lesson in these results. Legal policies and the message those policies convey have very real effects on health. And it’s not just as simple as policies like mandatory vaccination and the resulting drop in infectious diseases. Denying same sex couples the right to marry and all the legal protections associated with marriage sends the message that LGB people are inferior. And our youth hear that. It has very real effects on their health. It’s behooves us as a society to examine other policies like employment and school protections to see if they send the same message.

From a personal perspective, these results are not surprising. While the Defense of Marriage Act was still law, even as a teenager I was very aware of what that meant for my legal rights. I knew about, and was distressed by, the lack of hospital visitation rights and insurance coverage. As an adult the knowledge that I have the legal right to make medical decisions for my wife without question is immensely comforting. We have a long way to go on other matters, but this one small step makes a difference.

Lastly, never underestimate suicidality. If you or someone you love is in crisis, the Trevor Project is an LGBT friendly suicide hotline for youth. Adults who need assistance can find the right hotline for them here.

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

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.

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.

Jan 182016
 

There’s been a cluster of publications and news recently that I won’t be able to dig fully into and write a full article on, but still needs mentioned. So this week’s post is a quick summary of a bunch of them!

Several articles came out pointing out that various health care professionals have a role to play in gender/sexual minority health. Articles like this are important in helping the wider medical community understand why learning about gender and sexual minority health issues is important. The articles include…

  • Obstetricians can help screen fetuses for being intersex and help to manage the medical aspect of intersex medical conditions. Gynecologists can help adult intersex people with both medical and social issues associated with being intersex. See the article.
  • Pharmacists can help with the care of trans people above and beyond just filling a prescription. They can help make sure that certain laboratory calculations are done correctly, based on the hormonal status of the patient. They can counsel on the various forms of hormones (e.g., pill vs patch vs injection). See the article.
  • Dermatologists may be able to assist in medical transition by providing hair removal and other noninvasive, aesthetic procedures. See the article.

Asking about sexual orientation and gender identity and recording it in the electronic health record is now a required part of all electronic health records by Medicare/Medicaid. This is part of “meaningful use”, and is part of the larger goal of having electronic health records that actually cooperate with each other and record the same things. Here’s a quick abstract discussing this. This is really the beginning of a change in health care around the United States — there’s now a financial incentive to screen for sexual orientation and gender identity and to handle patients who aren’t cisgender and straight. It’s good stuff.

A study of examined the effectiveness of therapy intended to change same sex sexual attraction as performed within the Church of Jesus Christ of Latter-day Saints. Less than 4% of those surveyed experienced a change. 42% reported that it wasn’t effective, and 37% found it to be moderately to severely harmful. Those who seek to modify their sexual orientation should keep this in mind — therapy intended to change sexual orientation is far more likely to do harm than good. For context, if this therapy was a new drug the FDA would never allow it into the marketplace. It would never get past early clinical trials. In contrast, acceptance therapy (i.e., therapy meant to help one be accepting of one’s orientation) in this study was found not only to reduce depression and improve self esteem but also improved relationships with family. See the abstract.

It’s well known that lesbian, gay, and bisexual cisgender people are at higher risk of suicide than the general public. A study recently clarified some of that risk, finding that bisexual cis women are at nearly 6 times higher risk of suicide than straight cis women (roughly 4-9% of the women). Gay men were 7 times more likely to attempt than straight men (roughly 3.5-13% of gay men). Lesbian and bisexual women were also more likely to attempt suicide at a younger age than straight women — roughly 16 years old vs 19 years old. Sad news. See the abstract.

Gay and bisexual men may be more likely to rely on chosen family for social and economic support than lesbian and bisexual women and heterosexuals, who may rely more on blood relatives. See the abstract.

And very exciting — the FDA has changed their blood donation policy for men who have sex with men! Instead of an “indefinite deferral”, people who quality as “men who have had sex with men” need to wait 12 months after the last sexual encounter to donate. This brings the guidelines for sex who have sex with men roughly equivalent to the guidelines for others who are at higher risk for HIV.

If you are transgender, the guidelines are still unclear. Transgender women who had ever had sex with a man (unclear if cis or trans) used to count as “men who have sex with men” in the FDA’s eyes. Now the FDA advises that transgender people should self report their gender. What this seems to say is that trans women should be counted as women and trans men should be counted as men regardless of hormonal/surgical status. So according to the guidelines, this should be the logic…

  • If you are a cis/trans man who has had sex with another cis/trans man once since 1977, but over 12 months ago: You may donate blood.
  • If you are a cis/trans man who has had sex with another cis/trans man within the past 12 months: Wait until 12 months after that sexual encounter to donate, whether you used a condom/barrier or not.
  • If you are a cis/trans woman who has had sex with a cis/trans man in the past year, and that cis/trans man has had sex with a cis/trans man in the past year: Wait until 12 months after your sexual encounter to donate, whether you used a condom/barrier or not.
  • If you are a cis/trans woman who has not had sex with a cis/trans man in the past year: You may donate blood.
  • If you are a cis/trans woman who has had sex with a cis/trans man in the past year, but that cis/trans man has not had sex with a cis/trans man in the past year: You may donate blood.

Confusing enough? I hope that still helped. Keep in mind that all of the guidelines I attempted to simplify assumes that you’re not HIV+ (no one who is HIV+ may donate). If you’re confused still, take a look at the new guidelines or reach out to your local blood donation center.

And that’s it for this week! I hope this was fun, interesting, and helpful! Have a wonderful week.