Jun 032014
 

6763959_10420a4b6a_mThe biggest news for May of 2014 is really that Medicare lifted the blanket ban on covering genital surgeries for trans people. The National Center for Transgender Equality has a good summary (PDF) of what the decision actually means. If you’re trans and interested in surgery and are a Medicare recipient, I recommend calling the physician who’s prescribing your hormones and consulting with them about next steps. The news was covered in multiple outlets including the NY Times and CNN.

The other piece of news I spotted that is not getting as much traction as I’d like is this: Urine is NOT sterile! For a long time it’s been believed that urine produced by healthy people is sterile – at least until it passes through the urethra. Turns out not to be the case. Something to keep in mind if you have contact with urine. Source

Interested in the other news? Read on!

  • Work continues on the possibility of three-parent babies. While much of the research and reporting talks about preventing mitochondrial diseases, I still think it opens a wonderful door for three-parent poly households. The latest news is fairly political, but supportive.
  • Another study out of Europe indicates that transgender hormone therapy is safe. This was a 1-year study of both men and women, just over 100 people total No deaths or serious adverse reactions were reported. Highly recommend you skim the abstract for yourself! For US readers, please do note though that the hormones used in the study were different formulations than those used in the US. Source.
  • A published case study reminds us that not all “odd” physical things during medical transition are related to transition. This was a case of a trans man who had undiagnosed acromegaly from a benign brain tumor. Eek! He was correctly diagnosed and treated, thankfully. Source.
  • A Swedish review of transgender-related records found a transition regret rate of 2.2%. Other prevalence data, including the usual male:female ratios, are included. Source.
  • A study of gay men found that they have worse outcomes from prostate cancer treatments than straight men. Source.
Aug 152013
 

Rope (often used in BDSM ) smiley face - CC BY 3.0 Rose Lovell

A new psychological study of BDSM practitioners has just been published. This is the first such research to specifically examine the “Big Five” personality characteristics.

For those of you not interested in the nitty-gritty, here’s the digest: As a group, people who practice BDSM report a better sense of well-being and are more open to new experiences, extraverted, conscientious, and less sensitive to rejection than people who don’t practice BDSM. As with all correlations, this does not mean that BDSM activities caused these differences. Rather, people with these characteristics may be more likely to investigate BDSM.

Are you interested in the details? Cool! Let’s break this study down then.

First, some basics on BDSM. As some readers may remember, BDSM is an acronym standing for: Bondage, Dominance/Submission, SadoMasochism… and probably a few others besides. BDSM is considered an “alternative” sexuality and is highly stigmatized here in the United States. BDSM is often misrepresented as a purely sexual practice focused on pain. In truth, it’s often more sensual than sexual or painful. Many forms of BDSM “play” involve no sex or pain at all. Specific practices vary a lot depending on the people involved**.

Within BDSM, a person is typically in one of three roles: dominant (dom/domme), submissive (sub), or switch. The terms are fairly self explanatory. Dominant “has” control, submissive “gives” control, a switch is someone who switches roles*. Sometimes being a dom/sub/switch is referred to as an orientation, sometimes it’s a role for a particular activity (“scene”)***.

What about these personality characteristics? In personality psychology, there’s the concept of the “big five” personality characteristics, OCEAN: Openness, Conscientiousness, Extraversion, Agreeableness, and Neuroticism. Personality characteristics are thought to be innate. You’re born with a certain personality, and it’s relatively unchangeable. Each of the “big five” can be thought of as a line, and each person falls somewhere along that line. To wit….

  • Openness: How open to new experiences are you? Open vs cautious
  • Conscientiousness: How tidy, thorough and responsible are you? Organized vs careless
  • Extraversion: How much do you enjoy being around other people? Extravert vs introvert
  • Agreeableness: How trusting and cooperative are you? Friendly vs cold
  • Neuroticism: How easily do things tip you emotionally off balance? Easily upset vs steady

Some of these traits are associated with greater happiness and resiliency (e.g., Openness, Agreeableness and Extraversion) whereas others are associated with mental instability or illness (e.g., Neuroticism). There are nuances, overlaps, and arguments over these concepts that I won’t address here, but I hope that gives you a good starting place for understanding the study results. Let me know in the comments if it doesn’t and I’ll gladly expand. This study looked at more than just the “big five”. It also included measures of rejection sensitivity, attachment style, and subjective well being.

So why look at the “big five” and all those others in the context of BDSM? The arguments of the researchers make some sense. While BDSM and the “big five” have not been directly compared before, there is some evidence that the “big five” is associated with certain sexual attitudes. The more open you are, the more permissive your attitudes around sex. The more neurotic you are, the less stable your relationships, thus impacting your sexual life. And so on. Similarly, people with secure attachment styles are more likely to have a wide variety of sexual behaviors and better trust with partner(s) than people with insecure attachment styles.

So we have our variables: the “big five”, rejection sensitivity, attachment style, subjective well-being. What about our participants?

BDSM participants were 902 Dutch people, 464 male and 438 female (no mention of trans or genderqueer folks), recruited from one Dutch BDSM forum. Control participants were 434 Dutch people screened for BDSM behavior, 129 male and 305 female, recruited from magazine ads or websites having to do with “secrets”. Men in the study were older than women. I’m really not sure this control is an adequate control for this study because of the recruitment methods… but I’m not sure it’s not either. Differences between the groups? There certainly were some other than the practice of BDSM. There were significantly more women in the control group than the BDSM group. The control group was younger and less well educated than the BDSM group, although both were more well educated than the average Dutch citizen. Whether these differences affected the study results is unknown, but a possibility.

The researchers also note a gender difference between roles in the BDSM group. Men were 33.4% submissive, 18.3% switch, and 48.3% dominant identified. Women, on the other hand, were 75.6% submissive, 16.4% switch, and 8% dominant. This is certainly reflected in the stereotypes associated with BDSM activities.

Results included:

  • People who practice BDSM were more Open, Extraverted, and Conscientious than the control participants.
  • People who practice BDSM were less Neurotic and Agreeable than the control participants
  • People who practice BDSM were less sensitive to rejection than people who didn’t practice BDSM. Within the BDSM participants, submissives were more sensitive to rejection than dominants
  • People who practice BDSM had a greater sense of well-being than control participants. Dominants scored the highest on well-being.
  • Relatively few differences between BDSM participants and control participants was found when attachment styles were examined. When there was a difference, BDSM participants had a more secure attachment than control participants.

Effect sizes were small to medium. That is about average for a psychological study.

The OCEAN results make sense within the context of BDSM. In order to even try BDSM activities, you’d need to be open to new experiences. Conscientiousness is also valued, in order to be safe. Extraversion is helpful within a community setting. The rejection sensitivity results also make sense to me – a timid person may not continue to explore BDSM after one or two rejections. But this is all after-the-fact reasoning, and not particularly predictive or scientific.

The authors note that these results contradict the long-standing assumption that women who participate in BDSM so do because they were abused as children. But they didn’t ask directly about childhood sexual abuse. Rather, they draw this conclusion from the established relationship between attachment styles and abuse history. Childhood abuse is associated with insecure attachment. But in this study, BDSM folk were more likely to have a secure attachment than the control group. I think this logic is fairly sound, though a definitive answer will need to wait for a study where childhood abuse is specifically asked about.

The most obvious limitations to this study are the participants. The BDSM and control participants were not necessarily comparable, and there were significant known differences between the groups. Those differences could have affected the study’s results. Also, as usual, this study’s results may not be generalizable to BDSM communities in other countries (e.g., the United States).

Despite the limitations, these results are a delightful breath of fresh air, when so much of the literature treats BDSM as psychopathology. People who practice BDSM has long argued that there is nothing inherently “wrong”, “sick” or “dangerous” about their sexuality. These results absolutely support their assertion. The study authors state “We therefore conclude that these results favor the view […] that BDSM may be thought of as a recreational leisure, rather than the expression of psychopathological processes.” Yes, yes and yes.

The study was published in the Journal of Sexual Medicine. The abstract is publicly available.

* This is a highly simplified description. Power, and the exchange of power, is complex.

** It’s important to note, though, that for many people who participate in BDSM pain is very important, if not the central experience.

*** In addition to Dom/Sub/Switch, there’s also the idea of “topping” and “bottoming”. Topping and bottoming are much more transitory than Dom/Sub/Switch. In any particular activity, the Top is the “do-er” and the Bottom is the “do-ee”. But being Top or Bottom is activity specific and not as much of an orientation as Dom/Sub/Switch.

May 012013
 

One way to reduce stress and cortisol - CC BY 2.0 - flickr user eamoncurry123Summary: 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 the daily cycle, when 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. 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 do not really understand why these researchers chose to examine attachment style in this study. I think that knowing attachment styles may be useful for therapy or for the development of effective variations on therapies for trans people. But 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.

Sep 212012
 

Because hormone therapy is known to slow and eventually stop sperm production, trans women who wish to have biological children must store their sperm before starting hormones. It is not known whether sperm production will resume if hormones are discontinued. Both the WPATH and Endocrine Society guidelines recommend considering sperm storage before starting hormone therapy.

Those recommendations aren’t without conflict. Some in the medical field have expressed concerns about the welfare of children born to trans parents. There are no empirical data available on those kids, but the authors of this study comment that “the lack of reassuring evidence cannot be used as a barrier against reproduction after gender transition.” I think they’re absolutely right. Further, the data on same-sex parenting help reinforce that it’s not the gender of the parent(s) that’s important for a child’s well-being. Factors like cooperation and stability are far more influential.

The authors note that there is little research surrounding reproduction in trans women, and that the research world has little understanding of the motivations and concerns affecting trans women’s reproductive decisions. Several issues they mention seeing in their clinic include cost, desire to transition quickly, and difficulty producing sperm for freezing. They also call for more research, so that clinicians better understand what trans women are facing and can improve health care.

I was really glad to see this article published. There was a lot of discussion of reproductive options for young trans people at the latest Gender Spectrum conference. It’s good to see it being discussed respectfully in the literature.

Link (Archives of Sexual Behavior)

EDIT: Yes, that title does look weird, doesn’t it? It really is the title of the article that was published.

Jun 012011
 

For “older” adults, the IOM uses retirement age (around 60) as their starting age. For this group, there are no well-studied areas of health (beyond HIV/AIDS, which I don’t cover here). I’ve decided to leave the conclusion portion for another post – the last in this series.

  • Depression: Definitely more frequent in LGB elders than heterosexual elders. A very significant mental stress for this group is surviving the start of the HIV/AIDS epidemic. One study of elder gay/bisexual men found that 93% of them had known others who were HIV+ or had died of AIDS. There is no empirical data on rates of depression in elder transgender people, but it’s thought to be high.
  • Suicide/suicidal ideation: Empirical data suggest the rates of suicide are higher in LGB elders. No data on transgender elders.
  • Sexual/reproductive health: This is a rarely studied area. PCOS and its related risks may be an issue in some transgender elders. There is some indication that gay/bisexual men may be at the same risk as heterosexual men for prostate cancer. Early research implies that “lesbian bed death” may be a real phenomenon, but it’s a controversial topic. All cis-gendered women (bisexual, heterosexual, or lesbian) appear to have the same rate of hysterectomies. Sexual violence was reported on for transgender elders and it appears to be high. One study found about half of transgender elders had experienced “unwanted touch” in the past fifteen years.
  • Cancers: There are no data on cancers and transgender elders. Elder gay/bisexual men are at a higher risk of developing anal cancer (which is linked to receiving anal sex and HPV). Non-heterosexual women also appear to be at a higher risk for reproductive cancers (due to risk factors like smoking and obesity).
  • Cardiovascular health: Data appear to be conflicted. Transwomen using estrogen may be at a higher risk for venous thromboembolism (this may be because of the specific forms of estrogen used). There’s an association between transgender people getting their hormones from someone other than a doctor and poor health outcomes (e.g., osteoporosis, cardiovascular disease). The relevant transition hormones may cause long-term health problems at high doses, but no studies have really looked at this.

Risk factors include those for the younger age groups. Ageism within the LGBT communities may be an additional challenge for LGBT elders. Elders may also feel they need to hide their orientation if they move into a retirement home. Some retirement homes may also be discriminatory.  Transgender elders especially face very high threats of violence.

Some studies have found that elders felt more prepared for the aging process by being LGBT. Why? They’d already overcome huge difficulties. They’d already done a lot of personal growth. LGBT people are also more likely to have education beyond high school, and education is a well-known protective factor for the negative effects of aging. Conversely, some LGBT elders reported fewer relationship and social opportunities, being afraid of double discrimination, and problems with health care providers.

As for elder interactions with the health care system, again there’s a lot in common with younger age groups. One out of four transgender elders report being denied health care solely because they were transgender. Elders in general face problems if they need to enter assisted living homes, as some homes are discriminatory. It’s also worth noting that LGBT elder social structure is different from heterosexual social structure. LGBT elders rely much more on close friends than relatives (and/or adult children). Their chosen families are less likely to be recognized by the medical community, especially without legal paperwork.

So that’s it for what I’ll summarize from the report. Thanks for sticking around for it… this is hefty stuff.