Just when you thought it was safe…now there is another article in the NewYorkTimes about the pharmaceutical industry pushing hormones for post menopausal women. It is a long and somewhat “shocking” article about how women have been sold a bill of goods regarding estrogen and progesterone after menopause and Wyeth Pharmaceutical paying multimillion dollar claims for women who took hormones and developed breast cancer.
Let me say…don’t believe everything you read. As readers of EverythingHealth know, I am not a shill for big Pharma and have written critiques of their corporate tactics many times. But when it comes to Estrogen replacement it isn’t just doctors and Pharma pushing drugs on unsuspecting women.
The link between breast cancer and endometrial cancer and estrogen (ERT) has been open dialog for decades. The pharmaceutical companies have had it listed in their marketing literature and good physicians make it part of the risk/benefit discussion. I have never felt pushed to prescribe ERT when it was not indicated and good evidence remains about the benefits of female hormones for bone strength and symptom control. Patients should know that for every 10,000 women who take estrogen, 8 more cases of breast cancer are seen. Other factors influence breast cancer like smoking, radiation (excessive chest X-rays, cat scans or mammograms), alcohol etc etc etc. Read more »
Transgender issues have been in the news with the recent announcement that Cher’s daughter, Chaz Bono, is transitioning from female to male. This subject has been plagued by misunderstanding and fear of the unknown. Transgender children are often shamed, bullied, and made to feel totally alone. As adolescents and adults, they face denial of adequate medical coverage and other forms of discrimination – and worse. Just two months ago, a Colorado man was found guilty of murdering an 18 year old transgender woman in what was judged to be a hate crime.
Chaz’s decision to go public with his private struggle is extremely brave. His publicist said,
“It is Chaz’s hope that his choice to transition will open the hearts and minds of the public regarding this issue …”
Step one in reaching the public is defining terms. The terminology surrounding gender issues can be confusing. “Transgender man,”, “transmale,” and “affirmed male” have all been used to refer to a biological female who transitions to a male. I found a glossary of transgender terminology offered by the NCTE to be extremely helpful.
What exactly does transitioning mean? It’s the period during which somebody starts to live as his/her new gender. It can include changing a name or legal documents, taking hormones, and getting surgery. One misconception is that transitioning requires surgery. It doesn’t. As Mara Keisling, the Executive Director for the National Center for Transgender Equality (NCTE) told me, “Most transsexuals don’t get surgery. This is about gender identity, not about genitals.”
There’s a lot of controversy and confusion but experts agree on two crucial concepts:
1) Being transgender is not a choice.
2) Biological sex and gender identity are two different things.
There are people whose external appearance is female but who have felt they were male since they were toddlers – and vice-versa. Norman P. Spack, M.D., an endocrinologist at Children’s Hospital in Boston, Dept. of Pediatrics, Harvard Medical School, has been treating transgender patients since 1985 and significant numbers of teenagers since 1998. Most of his patients have told him “as far back as they can really remember that they were in the wrong body.” Dr. Spack said, “there’s a heavy skew to under 6 years.”
Dr. Spack points out that because transgender has been labeled as a psychiatric illness (“Gender Identity Disorder”) by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), patients are not adequately covered by health insurance. He says that the insurance industry will cover psychiatric costs but denies hormonal and surgical therapy, claiming they are non-covered cosmetic treatments. A step forward came in 2008 when the American Medical Association House of Delegates passed a resolution supporting “public and private health insurance coverage for treatment of gender identity disorder in adolescents and adults” and opposing “categorical exclusions of coverage for treatment of gender identity disorder in adolescents and adults when prescribed by a physician.” But for now, many transgender patients continue to receive inadequate medical coverage and therefore inadequate medical care.
Nobody knows how many transgender people exist. The very definition of transgender can differ from study to study. Some only count people undergoing hormonal/surgical treatment; others rely on self-identification. In the Netherlands and Belgium, estimates based on patients receiving surgery and/or hormones were about 1 in 12-13,000 for transfemales and 1 in 30-34,000 for transmales.
But Mara Keisling told me those estimates are way too low. “Our best estimate is that one quarter to three quarters of one percent of Americans are transsexuals.” That’s 2.5 to 7.5 in a thousand. Dr. Spack’s estimate is about one in a thousand.
We are not close to understanding all the variables that go into determining why someone feels trapped in the body of the wrong sex. Parents often feel guilty but the wide consensus is that parenting does not cause a child to be become transgender. Research in animals suggests that there are critical periods of development during fetal or neonatal life during which exposure to testosterone influences the sexual differentiation of the brain But we’re far from putting together any sort of unified theory of gender identity that weaves together genes, cell biology, hormones, brain wiring, and nurturing.
Experts stress that transgender is part of a wide continuum of gender identity. As Stephanie Brill and Rachel Pepper say in The Transgender Child: A Handbook for Families and Professionals, “Today, gender can no longer really be considered a two-option category.” They emphasize the importance of patients and families understanding that they are not alone and that there are competent professionals who can help. They say they wrote the book, which I found to be very helpful, to “provide caring families with helpful tools they can use to raise their gender-nonconforming children so they may feel more comfortable both in their bodies and in the world.” The authors quote Dr. Spack who, referring approvingly to the Dutch treatment of adolescents by delaying puberty and giving them hormones, said: “Suicide attempts, so frequent elsewhere, are almost unknown because parents and children know that they will be taken care of and will ultimately join a society known for its tolerance.” Referring to his own patients, Dr. Spack told me “They may be anxious, they may be depressed, but many, many no longer have psychiatric diagnoses after they are treated properly.”
In today’s video segment of CBS Doc Dot Com, I speak to Dr. Ward Carpenter of the Callen-Lorde Community Health Center in NYC, a facility that provides care to patients across the spectrum of gender identity and sexuality. In the segment that follows, Dr. Carpenter explains what surgery and hormones can entail. A warning: it’s a graphic description. Its purpose is not to shock but to educate. Hopefully, better education will lead to less misunderstanding, less fear, and wider acceptance for people like Chaz Bono.
Other Resources:
NCTE: Understanding Transgender Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline
True Selves: Understanding Transsexualism by Mildred L. Brown and Chloe Ann Rounsley
A video synopsis of the report, hosted by Kathleen Sebelius, the Secretary of Health and Human Services, states that women are being left behind when it comes to healthcare and that there are over 21 million uninsured women in the U.S. Young women have much more difficulty finding affordable health insurance than do men and often pay higher premiums – sometimes one and a half times – those of a young man. These facts all add up to women not getting the care they need to stay healthy.
As a primary care provider (PCP) focusing on women’s health, the findings of the report don’t surprise me, not even a little. From my anecdotal studies of the number of women that I have seen over the years, the majority of women struggle to receive the care they need because they cannot afford it. What typically will happen is that these women delay, often for years, any type of check-up or preventive care because of costs. Instead, they wait until they are sick or are having issues, and then they are forced to find the money and the time to seek medical care.
I also have found another factor beyond price that is creating a barrier to healthcare for women, and the word is “convenience.” Many women cannot, or often will not, take the time to seek routine medical care when most doctor’s offices are open, which is nine to five. Frequently these women are working, albeit on jobs that offer them little or no healthcare coverage, and are loathe to take time off of work for a non-emergency medical issues. Women also have the lion’s share of childcare responsibility, and are more likely to put their children’s schedules and family needs well before theirs.
Primary care can be the first place to look for a solution in bringing affordable, convenient care to women so that there are no roadblocks to access. We strive to do just this at our practice. Our Well Women Clinics were spearheaded after much deliberation about cost and convenience. We started last year and have found them to be a great success. For these clinics, we designated specific days during the month for routine well women check-ups. Hours for these check-ups are early morning through lunch one day and mid-afternoon through evening on another days. We offer the clinics two days each month on different days of the week, ideally making times available for each patient’s schedule, whether she is a current patient with us or a new one.
Although the biggest hurdle for women to getting the care may be cost, as the Obama Administration’s report cites, let us not forget the role that convenience in getting this care plays. Healthcare and wellness does not have a nine-to-five schedule. Likewise, most women’s roles beyond possibly those in a regular “office” job are not on such a regimented schedule; their roles as caretakers and mothers have round-the-clock demands. We need to work with women determine and then remove all of the roadblocks to accessing of care, starting first and foremost with cost, moving to convenience and then considering others that may exist.
An assumption of my new web show, CBSDOC.COM, is that people are aching for mature discussions about health. This week I went to Central Park in New York City to talk to passersby about their sexuality, hoping to strike the right tone. I brought along two female gynecologists – Dr. Lori Warren and Dr. Rebecca Booth – experts who flew all the way from Louisville, Kentucky to help me out. Dr. Booth has written a book called “The Venus Week: Discover the Powerful Secret of Your Cycle At Any Age” that explains how hormones affect women from adolescence to menopause. Each has an active clinical practice and extensive experience talking to their patients about everything from memory loss following pregnancy (“my memory went out with the placenta”) to plummeting libido. And as luck would have it, total strangers we met at Columbus Circle talked to us quite openly about those very problems, eager to hear some practical advice. I hope we accomplished our goal of talking about a sensitive subject in a grown-up manner.
**Better Health readers: please let us know what you think of this new video series with Dr. LaPook. Leave a comment below. Thanks!**
Not anymore. Today, their front row partner is Coca-Cola. Diet Coke that is.
Dr. Val and I were among a small group of women’s health advocates who met last week to hear the latest on NHLBI’s campaign with Diet Coke and how the fashion industry is bringing an important public health message to women.
Diet Coke’s commitment to the Heart Truth campaign is unprecedented, one of the “largest public awareness initiatives we have ever undertaken,” said Celeste Bottoroff, VP Living Well, Coca-Cola North America.
Leading Diet Coke’s campaign? Endless-legs Heidi Klum and other fashion-conscious women who have revamped the little red dress campaign into a national symbol with guts, curves and most importantly results.
“In 2002, only 34% of the women in this country knew heart disease was the leading cause of death among American women,” Dr. Elizabeth Nabel, NHLBI director, told the group. “But we’re making progress. Today, as a result of the Heart Truth campaign and others like it, 65% of the women now know it’s the number one killer.”
Nabel led a discussion of the common myths associated with women’s heart heath and recalled her own experiences as a cardiology resident when women were caregivers who supported husbands, fathers and other male family members through heart ailments but often ignored or brushed aside their own symptoms for fear that treatment would interfere with domestic chores such as childrearing, cooking, and cleaning. “Even when older women came in with heart problems, they weren’t treated as aggressively as men,” Nabel admitted.
“Most women still need educating,” she remarked. “80% of middle-aged women still have at least one risk factor for heart disease. And just one, doubles your risk of actually having heart disease.”
Joining Nabel were Phyllis Greenberger, President and CEO of the Society for Women’s Health Research, Susan Bennett, MD, Clinical Director of the George Washington University Hospital’s Women’s Heart Program and Robyn Flipse, MS, RD, author and nutrition consultant to discuss the campaign’s most important messages. First, heart disease is not a man’s disease, a point often raised by group’s such as those headed by Greenberger who cited research indicating that only 17% of cardiologists and 8% of primary care physicians know that heart disease is the leading cause of death among women.
And it’s not just for the aged either. “When a 40 year old woman has heart disease it’s worse than a 40 year old man,” said Bennett recalling patients in their 20s and 30s in her practice. “It’s never too late to change your lifestyle,” Flipse added. “The body is very forgiving. Even a 10% drop in weight can have a positive impact on blood pressure, cholesterol and other important risk factors.”
The Heart Truth campaign, thanks to the vision of Dr. Nabel and the willingness of NHLBI to partner with a highly visible, social icon such as Diet Coke is just what’s needed to cut through the feel good messaging that most public health campaigns resort to. Having lived with heart disease my entire adult life (now well into middle age), it’s a welcome boost of energy and the visibility possible with this campaign is unparalleled. Along with it comes some very important information that can save women’s lives.
Look for the heart truth emblem on 6 Billion Diet Coke cans, at community public forms, at American Idol, and fashion shows across the country. Diet Coke, with Heidi’s help, has even designed a new red dress label pin which strongly resembles an hour-glass. And what woman doesn’t want that?
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