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.

Jun 272016
 

Welcome back to Open Minded Health Promotion! This week is all about how cisgender women who have sex with women, including lesbian and bisexual women, can maximize their health. As a reminder — these are all in addition to health promotion activities that apply to most people, like colon cancer screening at age 50.

Woman-and-woman-icon.svgAll cisgender women who have sex with women should consider…

  • Talk with their physician about their physical and mental health
  • Practice safer sex where possible to prevent pregnancy and sexually transmitted infections. Some sexually transmitted infections can be passed between women. If sexual toys are shared, consider using barriers or cleaning them between uses.
  • If 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 using them in the safest ways possible. For example, consider vaporizing marijuana instead of smoking, or participate in a clean needle program.
  • Maintain a healthy weight. Women who have sex with women are more likely to be overweight than their heterosexual peers. Being overweight is associated with heart disease and a lower quality of life.
  • Exercise regularly. Weight bearing exercise, like walking and running, is best for bone health. But anything that gets your heart rate up and gets you moving is good for your body and mind!
  • Seek help if you’re struggling with self injury, anorexia, or bulimia. These issues are much more common in women than in men, and can be particularly challenging to deal with.
  • Consider taking folic acid supplements if pregnancy is a possibility. Folic acid prevents some birth defects.
  • Discuss their family’s cancer history with their physician.

Your physician may wish to do other tests, including…

  • Cervical cancer screening/Pap smear. All women with a cervix, starting at age 21, should get a pap smear every 3-5 years at minimum. Human papilloma virus (HPV) testing may also be included. More frequent pap smears may be recommended if one comes back positive or abnormal.
  • Pregnancy testing, even if you have not had contact with semen. Emergency situations are where testing is most likely to be urged. Physicians are, to some extent, trained to assume a cisgender woman is pregnant until proven otherwise. If you feel strongly that you do not want to get tested, please discuss this with your physician.
  • BRCA screening to determine your breast cancer risk, if breast cancer runs in your family. They may wish to perform other genetic testing as well, and may refer you to a geneticist.
  • If you’re between the ages of 50 and 74, mammography every other year is recommended. Mammography is a screening test for breast cancer. Breast self exams are no longer recommended.

One note on sexually transmitted infections… some lesbian and bisexual women may feel that they are not at risk for sexually transmitted infections because they don’t have contact with men. This is simply not true. The specific STIs are different, but there are still serious infections that can be spread from cis woman to cis woman. Infections that cis lesbians and bisexual women are at risk for include: chlamydia, herpes, HPV, pubic lice, trichomoniasis, and bacterial vaginosis (Source). Other infections such as gonorrhea, HIV, and syphilis are less likely but could still be spread. Please play safe and seek treatment if you are exposed or having symptoms.

Want more information? You can read more from the CDC, Gay and Lesbian Medical Association, and the United States Preventative Services Task Force.

Oct 052015
 

480px-RGB_LED_Rainbow_from_7th_symmetry_cylindrical_gratingI’ve been saying for years now that the phrase “LGBT community” is insufficient when it comes to health. It’s not one community — it is multiple communities. The social issues and health issues that a gay transgender man faces every day are different from the issues a bisexual cisgender woman faces every day. There are some similarities and grouping the communities together has been politically useful. But it should never be forgotten that L, G, B, and T all face different types of health concerns and have different civil rights battles to face.

A study came out in August that has to be one of my favorites this year. Researchers in Georgia surveyed over three thousand lesbian, gay, bisexual, pansexual, transgender, gender non-conforming, and queer people. They asked about health behaviors of all kinds. And then they did statistical analysis, comparing the various genders (cis male, cis female, trans male, trans female, genderqueer) and sexual orientations (lesbian, gay, bisexual, pansexual, queer, straight). Let’s look at what they found!

  • Diet and exercise: The researchers asked about fatty foods, eating while not hungry, quantity of vegetables and fruits eaten, and about hours and types of exercise. Transgender women had the least healthy diet of all genders. As a group, they were less likely to eat many fruits and vegetables, and more likely to drink sugared drinks and eat when they weren’t hungry. Both cisgender and transgender men were also less likely to eat many vegetables compared with other groups. Genderqueer people and gay cisgender men were most likely to exercise.
  • Substance use: The researchers asked about smoking tobacco and alcohol consumption. Cisgender men were the most likely to drink alcohol, binge drink, and to drink even when they didn’t want to. Participants who identified as queer were also more likely to drink. When it came to tobacco, transgender men and straight participants were the most likely to smoke.
  • Motor vehicle risk: The researchers asked about seatbelt use, speeding, and texting while driving. No clear differences for speeding were noted. Transgender men and straight participants were most likely to drive without a seatbelt. Texting while driving varied considerably; gay and lesbian drivers were most likely to text while driving.
  • Sexual behaviors: The researchers asked about frequency of unprotected sex and sex while intoxicated. Gay men were least likely to have unprotected sex while lesbian women were most likely to have unprotected sex. When it came to sex while intoxicated, only the bisexual participants stood out as being most likely among the groups to have sex while intoxicated.
  • Violence: The researchers asked about self harm and expressing anger at others. Overall rates of interpersonal anger were very low. Transgender men and pansexual people were most likely to self harm.
  • Medical risk taking: The researchers asked about delaying medical care and not following physician advice. Transgender women were least likely to seek care; 1/3 reported that they regularly delayed seeking medical care. Both transgender women and transgender men were more likely to not follow medical advice when it was given. Bisexual people were also more likely to delay seeking medical care compared to lesbian and gay participants.

That’s a mouthful, right? There are a lot of details I left out of this summary and it still threatens to be overwhelming with detail. So how we can break this down even more simply? By talking about the conclusions.

The researchers go into some possible causes for all these different results. Maybe gay men are safer about sex because of HIV risk. Maybe transgender men eat few vegetables because of cultural expectations that “men eat lots of meat and not many vegetables.” Maybe gay and lesbian people text more while driving because of the lack of community-specific messages.

Maybe. And they’re all good thoughts.

I tend to look forward more to what we can do with these data. I’m pretty happy with this study — it’s one of the broadest I’ve seen for inclusion. Few health-oriented pieces of research include pansexual and genderqueer individuals.

It’s important to remember that these results are at the group level. Any individual person who is a gender/sexual minority will have their own health behaviors and risks. They should be evaluated and treated as individuals. From a public health perspective though, this research brings valuable data. Only by knowing what each group faces can prevention, screening, and treatment campaigns be created. Only by knowing, for example, that transgender and bisexual people avoid seeking medical care can we then examine “why?” and act to remove the barriers so that appropriate, respectful medical care is available.

So — can we change the conversation? Instead of talking about “the LGBT community”, let’s talk about “the LGBT communities”. Or, even better, “gender and sexual minority communities” — removing the alphabet soup and expanding the definitions at the same time. This research is only the tip of the iceberg. We have so much more to explore.

The paper is published online ahead of print. 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?