Feb 202017
 

“Brain tumor” are two words that strike fear into most hearts. They conjure images of thin patients with heads shaved and large fresh scars on their heads, of rapid neurological deterioration, and of sick children. Not all brain tumors are the same, however. Some are aggressive malignant cancer. Those are the bad actors like medullablastoma. They grow and spread quickly, and are very difficult to treat. Others are benign. These grow slowly, and either don’t spread or are very slow to spread. Benign brain tumors include meningioma, which we’re talking about today.

Meningioma is a tumor of the meninges, a thin layer that covers the brain. Meningiomas are benign. They don’t tend to metastasize (spread to other areas of the body). Instead, they grow and can grow enough that they squish parts of the brain. This causes headaches, loss of vision, and changes in thinking and mood.

Brain tumors are rare. So are meningiomas. They affect roughly 97/100,000 people. We don’t yet know exactly what causes them. But by looking are who tends to get them, we have some guesses. Exposure to radiation of the head seems to increase the risk. So does having a condition called Neurofibromatosis II. And meningiomas are more common in cisgender women than in cisgender men. Why? Because of hormones. Like breast cancer, meningioma can grow in response to estrogen or progesterone. Cis men who have been treated for prostate cancer (involving androgen deprivation therapy) are at higher risk. And perhaps trans women are too.

Today’s Paper

And that’s what brings us to today’s paper. We’ve covered meningiomas in trans women once before, but it’s time to take another look now that we have more data.

Today’s paper discusses three new cases of meningioma in trans women. In total now, 8 cases have been discussed in the medical literature. It’s a very small number, but enough to start seeing some patterns.

Of these three new cases, all were over the age of 45, were post-vaginoplasty, and were on cyproterone acetate along with an estrogen. All had surgery to remove the tumor, and they did well. The decision to continue hormone therapy was made on a case-by-case basis.

The authors noted a previous paper that found that cyproterone acetate was associated with meningioma. This was particularly true with doses above 25mg a day. Among the eight cases of meningioma in trans women in the literature, only one was not on cyproterone acetate. Doses ranged from 10mg to 100mg, with most being on 50mg or 100mg. The authors also found reports of higher rates of meningioma among people who use progesterone-like medications. Removing hormone therapy (especially cyproterone acetate) frequently helps to shrink the tumor.

What should you do with this information?

First, don’t panic about meningioma. It’s rare and benign.

There is no screening for meningioma. Instead, if you have any unusual symptoms like changes in your vision or headaches, talk with your doctor.

If you are a trans woman, consider taking the smallest dose of hormones possible. In general, high doses increase side effects and don’t help with transition. If you are diagnosed with a meningioma, have an honest conversation with your doctors about your hormone therapy.

And, of course, be sure to live as healthy a life as you can. Don’t go jumping into volcanos or nuclear power plants. Eat a balanced diet, get some exercise, avoid most drugs, and take care of yourself.

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

Dec 192016
 

Given recent events in US politics, today’s study was especially timely. I thought I’d move it up in the queue. Yes, there’s a queue. In today’s study, Owen-Smith et al tried to answer the question “Is there a relationship between depression in transgender people and tolerance of transgender people in their surrounding community?” Logically it makes sense. But we have very little data. Science needs data. So Owen-Smith et al surveyed trans people with the help of a local trans organization.

Dr William' Pink Pills, once marketed as a depression "treatment"

Dr William’ Pink Pills, once marketed as a depression “treatment”

To measure tolerance, they used a simple 1-5 rating scale. They also asked about mistreatment and discrimination in the past 12 months. For depression they used two different scales: the Beck Depression Inventory (BDI) and the Center for Epidemiologic Studies Depression (CESD). The BDI was designed to detect and diagnose Major Depressive Disorder. In contrast, the CESD was designed to detect depressive symptoms, not necessarily the disorder. Between those two scales Owen-Smith et al captured both depressive disorder and depressive symptoms.

As with all studies they also asked about demographics. Age, education, race/ethnicity, and so on. Because this is a study of trans people they asked about hormonal and surgical status. If the participants hadn’t gotten hormones or surgery, Owen-Smith et al asked whether they wanted them.

What did they find?

In total, 399 people completed the study. 70% were trans women. 85% were white. 57% had completed college. 32% were currently receiving hormones and 7% had had surgery.

And 1 in 4 (~24%) said that most people in their area were tolerant of trans people. Roughly half (47%) of the sample had experienced abuse or discrimination. Perhaps surprisingly, there was no difference in abuse based on the tolerance of the participant’s area.

Roughly half of the group were depressed or had depressive symptoms. And this did differ based on the tolerance of the area. Trans people from less tolerant areas were more likely to have depression. In addition, the more abuse they had experienced the more likely it was that they experienced depression. Wanting or receiving hormone therapy was also associated with depression. In contrast, having a college degree was protective. Other factors like surgical status and race had no effect on depression.

What does this mean?

From this study, it seems that being in an area that is perceived to be intolerant of transgender people is associated with depression in trans people. Although this study can only show correlation, not causation we can potentially still make inferences. It may be that as areas become more tolerant, depression rates among trans people go down. Or that as more areas show their tolerance, depression rates will go down. Certainly this study seems to suggest that.

As always, this study has limitations. Its sample was probably not representative of the entire trans community, being mostly white well educated trans women. Results may be different in different groups of trans people.

Depression has serious effects on quality of life. Trans people are at high risk for depression already, with around half having symptoms. Compare that to roughly 4-9% (less than 1 in 10) of the broader population. And the worst outcome of depression, suicide, is high among trans people too. Anything that we can do to decrease suicide, we should do.

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

Dec 052016
 

Too often gender and sexual minority health is distilled down to just the Human Immunodeficiency Virus (HIV)…as if that’s the only disease that could possibly be relevant. Some small amount of time might then be dedicated to STD’s like gonorrhea. But really it’s all about HIV. But ignoring all the other aspects of GSM health ignores the diversity of our communities. When I started Open Minded Health I wanted to avoid that topic. I saw so much time and so many resources being dedicated to HIV…I wanted to do something different.

Halfway through my third year of medical school now, I’m beginning to change my mind. We still need to avoid focusing only on HIV. But this one single disease has caused so much devastation, so much individual and cultural harm… I can’t just ignore it here on Open Minded Health. The focus here will still be on non-HIV aspects of GSM health care, but I’ll be sneaking in some articles on HIV too when I think it’s appropriate. Don’t worry, OMH won’t become “All AIDS all the time.”

Which all brings me to today’s article!

Literature Review

Radix, Sevelius, and Deutsch did a literature review looking at HIV in transgender women. Trans women, as a group, have the highest risk for HIV infection of all groups. Although we don’t have great data yet, the best estimate is that 19% of trans women are living with HIV.

Worse, preliminary data show that trans women are less likely to know their HIV status. As a group they’re likely to have higher viral loads. That means their HIV is not suppressed. One study in particular found that among trans women who were diagnosed, only 77% were referred to primary care, 65% were taking anti-retrovirals, and only 55% had suppressed their viral load.

HIV treatment 101
HIV

Diagram of an HIV particle

HIV cannot be cured. It causes harm by destroying part of the immune system. The goal of treatment is to reduce the number of copies of the virus, the “viral load”. The lower the viral load, the better your immune system can work (measured as a “CD4 count”). This has two benefits. First, you live longer. You’re less likely to get an infection or cancer. Second, you’re less likely to spread HIV to others. HAART is the modern gold standard of treatment. HAART stands for “highly active antiretroviral therapy”. Think of it as the new improved ART, or antiretroviral therapy. HAART is a mix of 3+ drugs that work to keep the viral from copying itself.

Trans women and HIV

Why are trans women at such high risk for HIV? Previous studies suggest it comes down to social issues. Trans women are often more visibly “trans” than trans men, and are a easier target for discrimination. They may be more likely to work in the sex industry. In that industry, anal sex is what they likely end up performing, and anal sex is the most likely to spread HIV. In addition, substance use is higher in trans populations. Sharing needles and items used for snorting can also spread HIV.

For whatever reason though trans women are at high risk. Why such a lower rate of treatment? Why are only 65% taking antiretrovirals? First there’s always cost. HAART can cost $10,000 per year and more. Second, some studies suggest that trans women may prioritize hormone therapy over HIV treatment.

HAART and hormones

Lastly, there are some very real concerns about interactions between HAART medications and hormone therapy. Both estrogen and HAART medications are processed by the liver and often by the same enzymes. Estrogen may change the amount of HAART medications that stay in the body, or vice versa.

According to this paper, the only research that’s been done so far on estrogen and HIV therapy has been done with cisgender women on birth control. As long time readers of OMH know, birth control is not hormone therapy. Birth control has both estrogen and progesterone. And the type of estrogen is different between birth control and transgender hormone therapy. Still, it’s what we have to use. These studies showed that some antiretroviral medications do change the blood level of estrogen, and that the levels of some antiretrovirals are changed by estrogen.  However we don’t know if that effect is true with the type of estrogen in transgender hormone therapy…and we don’t know if the differences in the blood levels has a real clinical effect.

I won’t go into detail of which HAART medications did what. Antiretroviral medication names are notoriously difficult to read, pronounce, and remember. Instead, here’s the important part: It is very important for your health care provider to know what you are taking. If you’re taking estrogen, tell your provider. That way they can check for drug-drug interactions and adjust medications appropriately.

What about anti-androgens, like spironolactone, finasteride, and GnRH agonists? Do they interact with antiretrovirals? There are no studies specifically about them and antiretrovirals. No interactions are known. We just don’t know.

The potential effects of transgender hormone therapy on antiretroviral medication blood levels may not even matter in HIV treatment in the end. Why? Well, we don’t just put someone on HAART and never see them again. Physicians check the viral load to see if HAART is working. So they know if doses or medications need to be changed. If there’s an interaction between drugs, they’ll see that the viral load isn’t low and they’ll change the drugs anyway.

Conclusion

In other words: There is no clear reason to avoid HAART while on hormone therapy.

Get tested, know your status, and get treatment if needed. Doing so will allow you to live for many, many years to come.

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

Citation: Radix A et al. Journal of the International AIDS Society 2016, 19(Suppl 2):20810

Oct 172016
 
Barriers are not always as obvious as a wall

Barriers are not always as obvious as a wall

Although many want to, not all transgender people are able to medically transition. The transgender community has been vocal about their needs and the barriers to medical care. However we still need research literature on the topic. Some research has been done, but not enough. Today’s study looked closer at who is receiving medical transition treatment and who hasn’t, and why they haven’t been able to get treatment.

As a quick reminder, medical transition is the medical treatment transgender people receive to treat gender dysphoria. Medical transition physically changes a person’s body from looking like one sex to looking like another. It usually includes hormone therapy and surgery. For more information, I recommend reading Trans 101 for Trans People.

Back to our study! Sineath et al polled transgender people who attended the Southern Comfort Conference (SCC). SCC is a yearly conference dedicated to education and networking in the transgender community. Of the 453 participants who stared answering the survey, 280 completed it. Participants answered demographic questions. They also answered questions about the medical therapy they had received and wanted to receive. There was a free writing section where participants could detail why they had not received any treatments they wanted.

That’s rather striking change between those who started the survey and those who finished it. And unfortunately there were differences between the group who finished it and the group who did not. Those who finished it were more likely to be college educated and trans women. That means that trans men and less well educated people were under represented in this study. While I don’t think there was much that Sineath et al could have done to prevent it, this does mean that the results should be taken with a grain of salt.

What did Sineath et al find?

Of the 280 participants who completed the survey, the majority (84%) were trans women. The rest (16%) were trans men. In this sample, trans women were more likely to be white, in a relationship, and over the age of 40 than trans men.

59% of participants had used, or were currently taking, hormone therapy. Roughly equal percentages of trans men (63%) and trans women (58%) had ever had hormone therapy. Among those who had never had hormone therapy, 53% of trans women and 76% of trans men planned to have it.

Trans men were far more likely to have gotten chest surgery (26%) or want it (88%) than trans women (5% and 40%, respectively). Of all 280 participants, only 11 (3.9%) had received genital surgery. All 11 were trans women. Roughly equal proportions of trans men and trans women wanted genital surgery.

Interestingly, nonwhite and single participants were more likely to have received hormone therapy than white and partnered participants.

I confess, I would have thought that the white people would have had more hormone therapy than non-white people. White people tend to have more resources. Perhaps there are also more barriers though? There are resources specifically aimed at non-white trans people, and perhaps they’re being especially effective. I am not entirely certain what to make of this. If you have ideas, let me know in the comments!

As for single trans people being more likely to have hormone therapy than partnered, that is more immediately understandable. Married or partnered trans people may be negotiating their transition with their partner. Or they may be waiting for children to grow. Either way, a delay makes sense.

What barriers were keeping people from getting medical transition?

There was also a significant difference in why participants had not received medical care between trans men and trans women. For trans men, lack of qualified care was the most dominant factor. 41% of trans men in this study cited that reason. Another 29% cited cost. A scattering of others cited fear of surgery (6%), employment issues (6%), and “other” (18%).

Trans women had a different distribution of concerns. Cost was the most commonly cited reason for not getting medical transition (23%). Employment issues was second largest, at 19%. Others cited age (9%), readiness (9%), needing a psychiatrist letter (7%), not feeling like they needed surgery (6%), fear of surgery (4%), and inability to access qualified care (2%). 21% cited “other” reasons.

What does all this mean?

This study found that 59% of trans participants use hormone therapy. That’s much lower than other studies. According to Sineath et al, previous studies found rates anywhere from 70% to 93%. Why the discrepancy? Studies with high levels of hormone therapy usually were conducted at clinics. Clinics are where participants actively seek hormone therapy! That explains why 93% of trans people in some studies were on hormone therapy. But why the 70%? That number came from a one-time survey that wasn’t clinic specific. It’s difficult to say how many trans people actually do get hormone therapy across the entire US. The real number may be somewhere between 59% and 70%.

 

This study also found pretty significant differences in the barriers trans people reported. Trans men cited the lack of access to qualified care far more than trans women did. That makes sense. Trans women are far more represented in both popular and medical media. The medical care of trans women is often talked about. I see far more papers and case reports about trans women in the medical literature. More surgeons offer vaginoplasties than metoidioplasties or phalloplasties.

Trans women experienced issues with employment more than trans men. Again, this makes sense. Trans women typically have a harder time “passing” than trans men. Women are subject to employment difficulties and interpersonal violence more because they’re more visible.

I, personally, look at how many trans men are struggling finding qualified care. I’m listening most strongly to that. So much of the talk around transgender care is about trans women. It really is past time that trans men get as much, or more, focus.

Conclusion

Ultimately, this study is a solid contribution to our understanding of medical transition. Thank you to Sineath et al and all the participants at the Southern Comfort Conference!

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

Citation: Sineath, R. C., Woodyatt, C., Sanchez, T., Giammattei, S., Gillespie, T., Hunkeler, E., … & Sullivan, P. S. (2016). Determinants of and Barriers to Hormonal and Surgical Treatment Receipt Among Transgender People.Transgender Health, 1(1), 129-136.

Sep 192016
 
Jack-O-Lanterns having a good sense of wellbeing

Jack-O-Lanterns having a good sense of wellbeing

In gender and sexual minority health we’ve focused a lot on the bad things that happen to our communities. Studies about HIV risks, high rates of depression, and discrimination dominant the discussion. For good reason, too. Negative factors cause harm! We want to protect ourselves, our families, and our communities. Research helps us figure out how to stop the badness from happening. But not a lot of research has looked at gender and sexual minority wellbeing. After all, it’s not all doom and gloom. Many in the community are thriving. It would be helpful to know what helps those community members do so well. Today’s study looks at factors associated with wellbeing in transgender and gender non-conforming people.

First, let’s define wellbeing. Wellbeing can be difficult to define. It’s a two-fold concept, including both hedonic and eudemonic approaches. Hedonic wellness is experiencing happiness while avoiding pain. Eudemonic wellness is the sense that one has purpose in life and is living authentically.

Previous studies among lesbian, gay, and bisexual (LGB) communities found that LGB communities had less wellbeing than their heterosexual peers. Social and community support, education, and physical health are all associated with wellbeing. But we don’t know a lot about the transgender community’s wellbeing. At least, not in the literature.

So Stanton et al looked through published data from a large survey, the US Social Justice Sexuality Survey. This survey focused on LGBT people of color. In order to identify all the participants who might be trans, Stanton et al looked at data the participants who did not identify as cisgender.

This study assessed wellbeing by asking participants how often in the past week they felt:

  • Just as good as other people (eudemonic wellness)
  • Hopeful about the future (eudemonic wellness)
  • Happy (hedonic wellness)
  • That they enjoyed life (hedonic wellness)

In addition to those questions about wellbeing, Stanton et al specifically looked at factors they thought might be related, including: health, healthcare provider’s comfort with LGBT issues, family support, and connectedness and engagement with the LGBT community. And as with most other studies, they looked at demographic factors. Demographics included age, income, employment, marital status, and education.

Because OMH is a health-related blog, I’m going to focus in on the results most applicable to health. If you want to read the full study, scroll to the bottom to find a link to the paper!

What did they find?

402 individuals, about 8% of the broader study, did not identify as cisgender. Of those, 32% identified as trans women, 18% as trans men, 21% as men, 21% as women, and 35% as “other.” They were diverse, representing a broad range of ages, races, education levels, and health.

Most (71%) had health insurance. 85% felt their health was “good” or better. Just over half (57%) felt their health care provider was comfortable with their transgender status. 13% thought their health care provider was uncomfortable. 14% said their provider ignored their LGBT status. 16% stayed closeted with their provider.

63%, almost two-thirds, of the participants had high levels of wellbeing!

What factors were associated with wellbeing?

The following factors were associated with more wellbeing:

  • Feeling connected to the local LGBT community
  • Health
  • Family support
  • Heath care provider acceptance.
  • Education
  • Age: the older, the more wellbeing

These factors were not associated with wellbeing:

  • Having access to health insurance
  • Participation in the local LGBT community
  • Race
  • Employment
  • Being single
  • Income

One factor associated with less wellbeing was health care providers who were uncomfortable with or ignorant of their patient’s LGBT status.

What are the limitations of this study?

No study is perfect. The survey that this study pulled data from probably over represents individuals who are active in LGBT communities. Those individuals may not reflect everyone in the community. Health and health insurance levels may also have been higher in this study than in the broader population.

Most limiting is how some of the questions were worded. Gender identity and sexual orientation were mixed together by lumping questions on lesbian/gay/bisexual identity with transgender identity. And they are very, very different experiences. The communities are also different. Questions asking about “sexual identity” may refer to sexual orientation or gender identity or both. It would be good to repeat this study with clarification between sexual orientation and gender identity.

What does all this mean?

Two-thirds of this study’s non-cisgender participants had good wellbeing. Most trans people are doing well, unlike the popular narrative that trans people are broken. Let’s spread that message!

Also, by knowing who has better wellbeing knows we know who has worse wellbeing. We can direct resources toward those who need them! According to this study that would be the young, the less well educated, those without family support, and those who are less physically/psychologically healthy.

Lastly, this study highlights the need for health care providers who are accepting of minorities. Having a provider who knows and accepts GSM patients not only improves health care, it improves the wellbeing of the patient. We need to spread this message.

It’s good to know that it’s not all doom and gloom. Two-thirds of trans and gender nonconforming people are doing well. Let’s expand that number to 100%.

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

Citation: Stanton, M. C., Ali, S., & Chaudhuri, S. (2016). Individual, social and community-level predictors of wellbeing in a US sample of transgender and gender non-conforming individuals. Culture, health & sexuality, 1-18.