Published by
Stanford Medicine



Events, Global Health, HIV/AIDS, LGBT, Medicine and Society

Changing the prevailing attitude about AIDS, gender and reproductive health in southern Africa

Changing the prevailing attitude about AIDS, gender and reproductive health in southern Africa

5015384107_517a74d0b5_zDuring the 1990s and early 2000s, HIV/AIDS pummeled through southern Africa killing thousands. Although the epidemic has abated somewhat, the disease is still spreading through certain communities, including the lesbian, gay, bisexual, transgender and intersex (LGBTI) population.

In Zimbabwe, where homosexuality is illegal and President Robert Mugabe has actively spoken out against the LGBTI community, health-care provider Caroline Maposphere works behind the scenes, trying to change the prevailing attitudes and laws without sparking a homophobic backlash like that in Uganda. Maposphere, who serves as a nurse, midwife, chaplain and gender advocate, will visit the Stanford campus this evening to discuss her efforts.

“She tells great stories about how you deal with the kind of social and community issues that lie around HIV prevention and gay and lesbian health issues in a very homophobic and resource-poor environment,” said David Katzenstein, MD, a Stanford infectious disease specialist who met Maposphere in 1992 while working on the Zimbabwe AIDS Prevention Project.

Preventing the spread of HIV in Zimbabwe isn’t as simple as handing out condoms or launching an education campaign, although those are key strategies, said Maposphere. The nation is poor, has few health-care facilities of any kind and LGBTI rights are non-existent. The traditional southern Africa culture view of homosexually, which was sometimes attributed to witchcraft, further complicates the issue.

“It’s very difficult to reach out with services to groups that are not coming out in the open,” Maposphere said. “We try to reach out and remove some of the barriers through discussion rather than being outright confrontational.”

Maposphere often encounters LGBTI individuals who feel they have been shunned by God and have been excluded from their churches in the predominantly Christian nation. In an effort to offer spiritual guidance as well as health care, she earned a college degree in theology and hopes to explore the religious aspects of her work while at Stanford.

In addition, Maposphere is planning to connect with gay-rights activists here and learn effective methods for countering homophobia in her native country. “I’m very hopeful that things will change,” she said.

The free discussion begins at 7:30 PM in the Vaden Education Center on the second floor of the health center on campus.

Previously: Remembering Kenyan statesman and Stanford medical school alumnus Njoroge Mungai, In poorest countries, increase in midwives could save lives of mothers and their babiesSex work in Uganda: Risky business and In Uganda, offering support for those born with indeterminate sex
Photo by Remi Kaupp

Health Disparities, LGBT, Mental Health, Patient Care, Stanford News

Stanford med student discusses his documentary on LGBT vets' health

Stanford med student discusses his documentary on LGBT vets' health

doublelifeWhen Stanford anesthesiologist Audrey Shafer, MD, welcomed attendees to a screening of “The Camouflage Closet” on campus recently, she noted the artistic accomplishments and service work of the film’s director, Michael Nedelman. (And also mentioned he was “a Stanford medical student in his spare time.”) Nedelman, who will be entering his third year here, conducted a project with nine LGBT veterans, all patients at the Veterans Affairs Palo Alto Health Care System, exploring their experiences of trauma and recovery.

Nedelman and his collaborators engaged in a community-based participatory method of film-making, allowing participants to tell their stories through art as a path toward empowerment. The participants were provided with cameras to document their stories; they also had a say in the editing process. And while the project was neither officially sanctioned research nor therapy, many of the participants found the process therapeutic. Christine Stout-Holmes said this in the film about sharing her story:

It’s healing. It makes me feel like, “Hey, I don’t have to be agoraphobic.” “Hey, I don’t have to isolate.”

Of course, I feel fists beating me on my back, but I know that that’s not now. And I know that what I’m doing now is going to benefit clinicians, and vets, and hopefully artists, and young girls to know that every story is important.

Since the film’s premiere last June, it has screened at the National Queer Arts Festival, the 31st annual Gay and Lesbian Medical Association conference, and at universities, film festivals and VA hospitals across the U.S. and in Mexico.

Below, Nedelman answers questions about his work.

You have a BA in film studies from Yale. How did you decide to attend med school, and have your interests in art and medicine always intersected?

It took me a while to understand exactly how my interests in art and medicine intersected, but it turned out they had a common ancestor in my love of story.

A few years out of college, I was working at Mount Sinai in New York City on both clinical research and documentary film studies. Whether or not there was a camera in the room, I loved hearing people’s stories, and turning those stories into something meaningful. But in a medical context, I also saw the opportunity to get involved in these stories – to reach past the lens and make a tangible difference.

Combining the two wasn’t really a new concept, though. My first major work in college was a photography project addressing preventable blindness in South India. As with “The Camouflage Closet,” I loaned out cameras to rural vision clinic patients who were able to document their restored sight through images that were important to them. But I had no idea that hyphenating doctor-filmmaker was even an option until I discovered, and later met with, filmmakers like Maren Grainger-Monsen, MD, and Gretchen Berland, MD. Something clicked when I figured out that patient care and digital media could go hand-in-hand.

What are some of the issues faced by this population that you’re most interested in exploring through storytelling?

Some of the issues I found most compelling are not just the unique challenges faced by some individuals (e.g. witch hunts of the pre-DADT – “Don’t Ask, Don’t Tell” – era, increased rates of military sexual trauma, barriers to accessing care), but also the creativity and strength that come from their recovery narratives. Alongside some of the heavier moments in the film, there’s some humor, too. I think I personally learned a lot from the veterans’ resilience, and how their pride – for being LGBT, and for being veterans – factors into their personal growth.

What do you hope viewers will take away from your film?

I hope viewers will come out of the film with a desire to learn more about the unique challenges, types of trauma, and sources of resilience among a previously silenced community. I think there’s a lot to identify with in the film, whether or not you identify as LGBT or a veteran, and there’s a lot to be said for turning empathy into action. This is partly why we also created an accompanying educational resource that summarizes previous research, evidence-based suggestions for culturally relevant care, and resources for clinicians and veterans.

The veterans were excited that clinicians and providers would see and learn from their work. But at the end of the day, I wonder if some of them might have answered this question a little differently. Something we often heard among the vets was, “Even if just one other veteran out there sees this and knows they aren’t alone, we’ve accomplished what we came here to do.”

Previously: Documentary on LGBT veterans’ PTSD, trauma and recovery premieres tomorrow and Photography and storytelling may help poor women with HIV cope with their illness
Film still from “The Camoflauge Closet” courtesy of Michael Nedelman

LGBT, NIH, Public Health, Research

Study shows funding for LGBT health research lacking, offers solutions

Lesbian, gay, bisexual and transgender patients often face a unique set of health risks, including higher rates of hepatitis among gay men and increased risk factors for breast cancer among lesbians. Past research conducted at Stanford highlighted the need to better train future physicians on how to care for the LGBT community. Now findings published in the American Journal of Public Health show national funding for LGBT medical research is also lacking, which is contributing to health inequities for patients.

During the study (subscription required), researchers examined studies funded by the the National Institutes of Health between 1989 and 201 and found 628 pertained to LGBT health issues, which accounts for one-half of one percent of all studies supported by the institute. A significant portion of these studies focused on sexual health matters, including HIV/AIDS, and the majority related to health of sexual minority men. Studies unrelated to sexual health matters accounted for one tenth of one percent of all studies during this time period.

In a release, study authors made the following recommendations to boost funding for LGBT studies and reduce inequalities in care:

  • Establish policies that designate LGBT people as priority populations for research that goes beyond HIV/AIDS and sexual health issues.
  • Increase evidence-based intervention research to improve LGBT and reduce health inequities.
  • Explore new strategies to increase the amount of LGBT health research, including support for diversity among researchers.
  • Support efforts to expand the pool of trained researchers prepared to propose LGBT research projects through training grants, fellowships, career awards and the establishment of LGBT Centers of Excellence.

Previously: Study finds ER avoidance in transgender individuals needing careGay, lesbian, bisexual and transgendered health issues not being taught in medical school and A call for more training on LGBT health issues

Emergency Medicine, Health Disparities, LGBT, Patient Care, Research

Study finds ER avoidance in transgender individuals needing care

ER2Past reports have found high levels of postponing medical care in transgender and non-gender-conforming people, owing to experiences including refusal of care, harassment and violence in medical settings, and lack of provider knowledge. A 2011 committee opinion from the American Colleges of Obstetricians and Gynecologists called the consequences of inadequate treatment among this population “staggering.”

Now, Canadian research on an Ontario transgender population shows levels of emergency-room avoidance by trans people. Published online in the Annals of Emergency Medicine, the study (subscription required) examined data from surveys in 408 transgender, transsexual, or transitioned people, many of them young (16-24 years); approximately half were male-to-female and half were female-to-male.

As described in a release:

“Patients who have had trans-specific negative experiences in other parts of the health care system may defer care until they are desperate and need the ER,” said lead study author Greta Bauer, PhD, MPH, of the Schulich School of Medicine & Dentistry in London, Ontario, Canada. “The good news is that nearly three-quarters of those who needed emergency care were able to get it in the ER. The bad news is that so many still were not.”

Almost one-quarter (21 percent) of trans patients reported ever avoiding the ER due to a perception that their trans status would negatively affect such an encounter. Negative experiences specifically related to being transgender were reported by 52 percent of trans patients.

Approximately 54 percent of trans patients reported having to educate their providers “some” or “a lot” regarding trans issues.

Bauer and her colleagues noted in the paper that their work “represents a first contribution on trans experiences within emergency medicine.” More research is needed, they said, “to better understand reasons for ED avoidance and to develop strategies to overcome this.”

Previously: Documentary on LGBT veterans’ PTSD, trauma and recovery premieres tomorrowDistinction with a difference: Transgender neurobiologist picked for National Academy of Science membershipA call for more training on LGBT health issues and Affordable Care Act prohibits discrimination against transgender patients 
Photo by robnguyen01

Health Disparities, LGBT, Public Health, Videos

Documentary on LGBT veterans' PTSD, trauma and recovery premieres tomorrow

Documentary on LGBT veterans' PTSD, trauma and recovery premieres tomorrow

The Camouflage Closet,” a short documentary directed by Stanford medical student Michael Nedelman, offers a snapshot into the lives of nine lesbian, gay, bisexual and transgender (LGBT) veterans and their personal stories involving post-traumatic stress disorder (PTSD), trauma and recovery. The documentary will premiere tomorrow night in San Francisco as part of the National Queer Arts Festival.

Discussing the importance of making the film, Nedelman said, “Many of us rely on two things to cope with traumatic experiences: community and identity. In the military, this was actively suppressed for LGBT service members. Even though [Don’t Ask, Don’t Tell] DADT has ended, we will continue to see the impacts of anti-LGBT policies, and it is becoming clear that there is much that can be done to address it.”

In the brief Q&A below, he talks about the motivation behind the project and what impact he hopes the film will have on the public:

What was the catalyst for creating the film?

The film came about fortuitously, like it was waiting to be shot. There were many things that led us to create the film: I bumped into Andrew V. Ly, now the film’s composer, on my first day as a Californian. We became fast friends, exchanged clips of our own work, and attended an arts workshop together called “Creating Queer Communities,” where we began putting together a proposal for a project that would combine our interests in art and advocacy, as well as my interests in health and medicine. We thought about the LGBT veteran community as something we were very interested in, but there was so little information out there—only 18 empirical studies had ever been published in peer-reviewed journals.

Meanwhile, little did we know that Heliana Ramirez, LISW, was facilitating one of only 15 known LGBT groups at VA hospitals in the country—right here in Menlo Park! Moreover, she had done digital storytelling projects in the past, so I’d say our interests were uncommonly well aligned. Finding the right collaborators, having such a supportive VA, and meeting a group of nine inspiring, artistic LGBT veterans signaled to me that this project was a special one—a unique opportunity that, at least for now, would be difficult to produce anywhere else.

What impact do you hope the film will have on audiences? For example, is the goal to raise awareness, amplify the voice of an underrepresented group, etc?

We think this project has many important audiences, including other people in the LGBT, veteran, and medical communities. We really hope it will foster discussion about opportunities for research, growth, and advocacy in addressing LGBT veteran health issues. This summer, Heliana and I will be working on a teaching guide to accompany clips from the film.

But first and foremost, we used a “video voice” model—which puts cameras into people’s hands—as an empowering tool for participants to share their stories in a structured group setting. At the heart of the methods we used to create this film are the goals of positive change for marginalized communities, and understanding the challenges and strengths of these communities.

Tickets for the premiere can be purchased online.

Previously: A call for more training on LGBT health issues, Medical schools neglect LGBT issues and Gay, lesbian, bisexual and transgendered health issues not being taught in medical school

Behavioral Science, LGBT, Neuroscience, Sexual Health, Stanford News

Distinction with a difference: Transgender neurobiologist picked for National Academy of Science membership

Distinction with a difference: Transgender neurobiologist picked for National Academy of Science membership

The National Academy of Sciences recently celebrated its 150th birthday by, among other things, conferring membership on Ben Barres, MD, PhD. Additional NAS admittees from Stanford were sleep scientist Emmanuel Mignot, MD, PhD, and bioengineer Steve Quake, PhD.

A distinguished scientist by anybody’s yardstick, as well as the chair of Stanford’s ironically named neurobiology department, Barres is a leading light in the study of glial cells (collectively known as glia), the 90 percent of all the cells in the brain that aren’t nerve cells.

The term “glia” is derived from the Greek word for glue. Like Rodney Dangerfield, glial cells once got no respect. They were thought of, in fact, as not much more than “brain glue”: mere structural scaffolds for the organ’s much more revered nerve cells.

Barres’ research has proved that hypothesis incorrect, to say the least. (For details, click here.) Discoveries coming out of his lab include, to name one example, glial cells’ crucial role in determining exactly when and where nerve-cell connections in the brain are made, tweaked to strengthen or weaken them, or destroyed.

You don’t get much more respectable than that: Those connections pretty much define the thoughts we have, the emotions and sensations we experience and the actions we take.

The man who, as much as anyone, has brought a set of unsung cells a newly elevated  status would like to see another group get more respect: the estimated 0.3 percent of Americans who are transgender.

“I’m the first transgender scientist to make it into the National Academy of Science,” says Barres, who began life under another first name: Barbara.

“We don’t know if other members past or present are or were transgender,” demurs an NAS representative. And after all, how would they? What kind of statistics could be compiled by an organization that doesn’t ask or track the sexual orientations, much less the gender identities, of its membership? Who would have even considered asking such a question 20 or 30 years ago, much less running sex-chromosome tests on cheek swabs from prospective, current or posthumous members?

But it’s a pretty safe bet that if any previously admitted NAS member were openly transgender, we’d have heard about it. (Transgender computer scientist Lynn Conway was admitted to the National Academy of Engineering in 1989.)

One is tempted to compare Barres to Jackie Robinson, who broke the Major League Baseball’s color barrier in 1947 – except that the latter had to put up with a whole lot more grief from his fellow major-league ballplayers than Barres is likely to encounter from his peers.

“We heartily congratulate Prof. Barres on his election,” says NAS spokesperson Bill Skane.

In science, if anywhere, diverse perspectives drive innovation. “Don’t ever let anyone make you feel bad about being different,” Barres tells young scientists. “Your difference is your greatest advantage.”

Previously: Malfunctioning glia – brains cells that aren’t nerve cells – may contribute big time to ALS and other neurological disorders, Neuroinflammation, microglia, and brain health in the balance and Unsung brain-cell population implicated in variety of autism

In the News, LGBT, Medical Education, Medical Schools

A call for more training on LGBT health issues

A call for more training on LGBT health issues

The need to better train future physicians on how to care for lesbian, gay, bisexual and transgender patients is the subject of an American Medical News story today. Citing research showing that medical schools spend on average just five hours on LGBT health issues, writer Carolyne Krupa includes the thoughts of a Stanford expert:

LGBT patients face numerous disparities, such as limited access to employer-based health care, lower rates of screening for common health conditions and higher rates of mental health issues, said Gabriel Garcia, MD, a gastroenterologist/ hepatologist and professor at Stanford University School of Medicine in California. He is faculty adviser to the school’s LGBT Medical Education Research Group.

Lack of training in LGBT health perpetuates inequities in health outcomes through continued stereotyping and stigmatization, he said. A 2007 survey of 736 California physicians found that at least one in six felt uncomfortable providing care to gay patients.

“Quality patient-provider relationships are the foundation for good health outcomes,” Dr. Garcia said. “LGBT people, as all others, need health care providers they can trust and with whom they can develop genuine, respectful and mutually beneficial relationships.”

Previously: Medical schools neglect LGBT issues and Gay, lesbian, bisexual and transgendered health issues not being taught in medical school

Health Disparities, Health Policy, In the News, LGBT, Stanford News

Affordable Care Act prohibits discrimination against transgender patients

Obtaining appropriate health care –  including adequate medical insurance coverage – has often proved challenging for patients who may identify with one gender, yet still have body parts of another gender. A trans man who still has breasts may not get coverage for a mammogram, for example.

But that may now change: The Department of Health and Human Services has confirmed that the Affordable Care Act prohibits federally funded health-care programs from discriminating against transgender people. ABC News reports on this today and highlights the case of Jay Kallio, who faced discrimination when he sought treatment for breast cancer:

At the age of 50, Kallio transitioned from female to male, but never had gender reassignment surgery, only hormone treatment. ‘I accept my body as I was born,’ he said. But when a suspicious lump was found in his breast and tested positive for cancer, the surgeon was so shocked that Kallio’s body didn’t match his gender identification — not knowing whether to address him as ‘he’ or ‘she’ — that he couldn’t bring himself to tell his patient the grim biopsy results.

Due to the doctor’s mistake, Kallio was late in receiving treatment.

In a story on transgender health care for the recent issue of Stanford Medicine, I highlight the barriers facing the patients and the importance of doctors providing prejudice-free care. A Stanford physician also emphasizes the unique needs of transgender patients:

Physicians should be cognizant that sex-change surgery patients often still carry reproductive organs from before, and these may need continuing medical attention. That’s something that can be easily missed, says Nelson Teng, MD, associate professor of obstetrics and gynecology at Stanford, who has treated several female-to-male transsexuals for endometrial cancer — cancer of the lining of the uterus. “Many male transgender patients still have a uterus and still should see gynecologists.”

Previously: Gay, lesbian, bisexual and transgendered health issues not being taught in medical school
Via ThinkProgress

Global Health, HIV/AIDS, LGBT

A call for safe sex awareness to combat HIV in China

So far, the spread of HIV in China has remained at levels less than one-fifth that of Europe and the United States, but now researchers warn that discomfort over discussing sex is a major problem. According to the Chinese Ministry of Public Health, the transmission of HIV between homosexuals has risen (.pdf) from 0.3 percent before 2005 to 13.7 percent in 2011.

In a comment published online today in Nature a consortium of Chinese researchers compare attitudes toward sexuality in China today to those in Western countries a quarter of a century ago. They write:

Chinese people aren’t uncomfortable just in discussing homosexuality — sex in general is still considered extremely personal and is rarely addressed openly or directly, irrespective of orientation. This discomfort has resulted in a pervasive stigma against people with HIV, a lack of general sex education for young people and poor epidemiological data about the spread of HIV in some populations around the country.

The result is a hidden population of individuals who are afraid to seek out HIV information resources or testing and counselling centres. Poorly educated, unaware of their HIV status and under pressure to conceal their sexual encounters, these men often engage in high-risk behaviour. And once one man hiding his activity becomes infected, the disease will spread among his partners, in an ongoing cycle. It is therefore no surprise that incidence of HIV has skyrocketed in this population.

Although cases of HIV among homosexual men represent a much smaller portion of those infected, (just 13.7 percent compared to 50 percent in the U.S.) the researchers say there is cause for concern. They call for more testing and public programs as well as better social and media awareness:

Leading by example is one of the most powerful ways to combat stigma … In 2003, a man stood up during an AIDS summit with former US President Bill Clinton at Tsinghua University in Beijing, and in doing so became one of the first Chinese people to publicly reveal his HIV status. Clinton embraced the man, named Peng-fei Song, bringing him positive media attention. Song later became a strong advocate for HIV awareness and prevention. China needs to encourage more individuals affected by HIV/AIDS to step up and help to change people’s perception of the disease.

History, LGBT, Medical Education

A Harvard professor's words on being gay and in medicine

Ready to be moved? Take a few minutes to read this touching essay, which CommonHealth posted today, on being gay in the medical field. Written by Mark Schuster, MD, PhD, the William Berenberg Professor of Pediatrics at Harvard Medical School and chief of general pediatrics at Children’s Hospital Boston, the text is based on a speech the author gave in 2010 at the Children’s Hospital Boston GLBT & Friends Celebration.

Schuster records incidents of discrimination he faced or observed during his medical education in the 1980s and in his early career. He also remarks on how the field has progressed in its treatment of gays and lesbians and brings to light issues that still need addressing. From the piece:

It may seem odd that I didn’t complain to anyone, but there was no one at the medical school or the hospital to whom I or my gay classmates thought it was safe to complain. There were no policies to protect us; no grievance boards; no mechanisms in place. Times have changed, but I still have undergrads ask me if they can come out in their medical school applications and medical students ask if they can come out in their residency applications. Yes, times have changed, but they have not changed enough.

I could not believe that in a mere two decades we had gone from “I’ve decided not to write you a recommendation” to “Your job is to get this guy’s partner a fellowship.”

It’s easy for me to think that my experiences two decades ago are ancient history. For me, they are. I’ve been lucky enough to construct a life that does not involve a daily fear of being outed, of being beaten, of being fired, or of having my children taken away from me. But many people still live with such fears. My experiences wouldn’t sound so quaint to them.

Stanford Medicine Resources: