Lavender Health – LGBTQ Resource Center

On May 30, 2014, the Department Appeals Board at the Department of Health and Human Services issued a ruling that will end the discriminatory Medicare policy excluding transition-related surgeries from Medicare coverage. Transgender people receiving Medicare will no longer be automatically denied coverage for sex reassignment surgeries. The ruling recognizes the procedures as medically necessary for individuals who do not identify with their biological sex.

Like most other medical services under Medicare, patients must still be approved for any procedure by their provider(s). Decisions about coverage for transition-related care will be made on an individual basis. This ruling only affects Medicare. It will not affect private insurance, Medicaid, or Veterans insurance.

Although this change in Medicare will hopefully allow numerous people to finally transition, this ruling brings another issue to light. To qualify for transition-related surgery through private insurance or Medicare, a provider must diagnose a person with Gender Identity Disorder or Gender Dysphoria. These disorders are found in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. Providers use these codes to document a diagnosis, which in turn is used by insurance companies to determine reimbursement for care.

These diagnosis codes denote a disease or condition (a pathology). Thus, a Gender Identity Disorder / Gender Dysphoria diagnosis is double-edged. It is not only required for insurance companies to pay for transition-related health services, but it also shows that the person has a disease/disorder/condition. It pathologizes the individual.

In the meantime, it seems that this ruling will produce the most immediate results. Transgender people who qualify for Medicare will be able to seek transition-related health services. But more advocacy work needs to be done to de-pathologize transgender people, but still provide pathways for insurance companies to pay for their care.

Here are a few related web links:

National Center for Transgender Equality

Fact Sheet on Medicare Coverage of Transition-Related Care

American Psychiatric Association

Gender Dysphoria Fact Sheet

TransgenderASIA

A call for the removal of gender identity variance from the psychiatric diagnostic manuals

Are you a nurse or a friend of nursing?  Do you want to make LGBTQI history in nursing?  Then here is an opportunity for you!  GLMA: Health Professionals Advancing LGBT Equality, is in the process of establishing a Nursing Section!  The invitation is now open to “sign up” to become part of the founding membership of this historic GLMA Nursing Section!  Members of the Section will plan and implement specific actions to advance LGBTQI issues in nursing practice, education, research and policy.  If you want to be part of establishing this Section, please complete our online “Statement of Commitment.”

The initial formal meeting of the Section will be on September 10, 2014, in Baltimore, Maryland, at the time of the 2nd annual GLMA Nursing Summit, with the annual GLMA conference to follow.  We hope you can join us, but if you cannot, never fear – we are implementing a full range of online tools for members of the Nursing Summit to connect and participate.  One of our tools is already in place — the GLMA Google email group.  You can sign up today to be on the email list, regardless of your intention to join the GLMA Nursing Section.  Just visit the google group page, request to join; please include a brief statement letting us know who you are!

The Summit will be a full day of celebration of LGBTQI nurses and allies gathering together, with workgroups organizing to follow through on action goals established last year at the first Nursing Summit.  You do not have to be a nurse, or identified as LGBTQI – you are welcome to join us for the Summit if you are eager to see this work move forward!  Registration for the GLMA conference and the Summit are now open, so visit the GLMA web site today to reserve your spot!

Perhaps because Big Pharma finds its erectile dysfunction medications going into generics, it has recently begun to tell men over 40 that their normal signs of aging are a pathology, the product of low testosterone. In its knack for catchy euphemisms (like “E.D.” for the less savory “impotence”), Big Pharma tells us that “Low T” renders us ghostly shadows of our former selves, for which testosterone supplements will offer the remedy.

Gay, bisexual, and transgender men may be particularly susceptible to this marketing. Our popular queer culture amplifies the youth orientation of American consumerism, extolling sexual prowess and buff physique. Indeed, lower testosterone is associated with increased body fat and reduced sexual drive and energy, as well as lowered muscle and bone mass, and increased erection problems and depression.

What is “normal”?

However, there are problems both with both the diagnosis and the “cure.” First, what is a “normal” measure of testosterone? That range is quite broad, from 300 to 1,200 nanograms per deciliter. Without knowing your baseline testosterone level, what constitutes a deficiency? Moreover, testosterone levels vary across a single day, usually higher in the morning. Unfortunately, many people are prescribed testosterone therapies without diagnostic or follow-up blood tests.

Causes of reduced testosterone

Second, symptoms of reduced testosterone may have a variety of causes, including medications and illnesses. Measurably reduced testosterone may have one or more causes: tumor, inflammation, or genetic disorder. Excess body fat, type 2 diabetes, as well as use of steroids and analgesic opiates are also associated with reduced testosterone.

Risks of testosterone therapies

Third, taking testosterone supplements is not without its risks. Use of testosterone supplements is associated with an increased risk of cancer of the prostate and breasts. Both of these prospects are important to keep in mind for people born as biological males (i.e., with prostate glands) or as biological females who are transgender female-to-male. Although most males who live long enough will develop prostate cancer, testosterone supplements  can stimulate cancer tumor growth. Moreover, testosterone supplement use has been associated with heart disease. A study published earlier this year in PLOS One identified an increased probability of heart attacks among older men who had used testosterone supplement therapies: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0085805

Conclusions

There are worse things in life than aging and its normal effects. Reduced testosterone later in life may bestow an evolutionary advantage, protecting people born male (with prostates) from the increased probability of prostate cancer. Transgender female-to-male patients should understand and be monitored for the increased risk of breast cancer. As the Institute of Medicine’s 2011 report on sexual minority health observed, threats to transgender health are insufficiently researched and incompletely understood. http://www.iom.edu/Reports/2011/The-Health-of-Lesbian-Gay-Bisexual-and-Transgender-People.aspx

The healthiest prescription you can have for lower testosterone is to manage weight through diet and exercise (both aerobic, which builds stamina, and resistance training, which builds muscle and bone mass). Because alcohol can reduce testosterone, limiting alcoholic beverages may help.

Further information

May Clinic. (2014). Testosterone therapy: Key to male vitality? Healthy Lifestyle, Sexual Health. http://www.mayoclinic.org/healthy-living/sexual-health/in-depth/testosterone-therapy/art-20045728

National Institutes of Health, National Library of Medicine. (2014). Low testosterone tutorial. MedlinePlus. http://www.nlm.nih.gov/medlineplus/tutorials/lowtestosterone/htm/index.htm

During the past 18 months, I have worked on the federally funded Doing It For Ourselves project, targeting older women of size for nutrition, physical activity, and stress reduction activities. It has been an interesting process that has challenged my own assumptions in so many ways. I wrote about my own experiences as a researcher and group facilitator last month, but this month I’d like to talk about a more cognitive “aha” movement I had during the research gathering phase of this study.

One of the first activities we did as a cross-site team was to do a critical review of the literature on weight among sexual minority women. Not surprisingly, of the 35 articles we reviewed, about 65% of them found a statistically significant difference with lesbians and often bisexual women, being heavier than heterosexual women. But the magnitude of the difference was not huge…probably about a 4-5 pound difference overall. I was tasked with lead author on this paper, and I felt that we could not leave the paper as only a review of the weight studies. I needed to know whether that weight difference was associated with any health risks. All the biomedical literature available today tries to convince us that obesity is related to higher rates of diabetes, heart disease, hypertension, and some cancers. I knew that many studies in the past 20 years have reported that lesbians are at high risk for breast cancer. A researcher at a lecture I attended in the past year said lesbians were nine times more likely to get breast cancer, but reported no sources.

So I conducted a review of the literature. Finally, because of the addition of sexual orientation questions to some of the big health surveillance instruments, there is some population-based data on frequency of health problems. Here is what I found:
• Diabetes: 8 studies, none found a significant difference
• Hypertension: 10 studies, none found a significant difference
• Heart Disease: 2 studies found a small difference with lesbians having higher rates; 8 studies found no differences
• Breast Cancer: 2 studies found lesbians with higher rates and 5 studies found no differences.

I got to wondering about what effect the rhetoric about risk might have in our communities and recalled some of the reactions women had at lectures, classes, or conferences I had attended in the past. Some women had seemed to adopt a fatalistic response. They seemed to think that the problem of stigma was too large to address, so they were inevitably going to get some of these disorders. Others seemed to have their heads in the sand…they did not want to hear this information. I wondered if they would also avoid screening tests like mammograms because of this avoidance. I don’t know if there is research on this issue of the unintended consequences of disseminating information about risk factors, and I will look into this when I have some time. But for now, what do you think? Should we be developing materials to alert LGBT people about risks, or should we consider other strategies to promote health?