vicodin online
News Events Profiles Clinical Management Directory

Archive for February, 2018

Dr. Steven J. Morris Selected as Premier Physician of the Year

Thursday, February 22nd, 2018
Members of the Crohn’s & Colitis Foundation Georgia Chapter including Dr. Steven J. Morris, Premier Physician of the Year

Pictured left to right: Mike Weinberg, Past Board President; Roberta Sirzyk, Gala Chair; Steven Morris, MD, Premier Physician of the Year; Barbara Mays, Elvin C. Price Volunteer of the Year; Gina and Sam Shapiro, Citizens of the Year

Dr. Steven J. Morris, managing partner of Atlanta Gastroenterology Associates, was selected as “Premier Physician of the Year” by the Crohn’s & Colitis Foundation Georgia Chapter. He was honored at the organization’s annual Torch Gala on February 3, 2018 at the InterContinental in Buckhead. Proceeds from the event supported critical research to better diagnose, and ultimately cure, inflammatory bowel disease which includes Crohn’s disease and ulcerative colitis.

“This is personal because I have spent almost four decades taking care of patients with ulcerative colitis and Crohn’s disease,” said Morris. “It is rewarding to be recognized for something that is often humbling, challenging and a privilege to do on a daily basis.”

Dr. Morris is a clinical associate professor with the Emory University School of Medicine. He is past president of the Georgia Gastrointestinal Society and previously served as chief of staff at Emory University Hospital Midtown Hospital. He has been with Atlanta Gastroenterology Associates for 40 years.


Survey Finds Misperceptions About Organ Transplant Hinder Donation Decisions

Thursday, February 22nd, 2018

A survey developed by physicians and researchers at Emory University about organ donation and transplantation found that misperceptions about the lifesaving process are the most common deterrents for donating organs. The survey responses and findings were recently published in the Journal of the American College of Surgeons.

Having concerns over getting inadequate medical care following an illness or accident, if registered as a donor, was the strongest independent predictor of willingness to donate overall, the survey found. Some other less concerning factors or myths that impeded willingness in the study included thinking there was an increased cost for the donor family when donating organs and thinking a famous person would get higher priority on the waitlist than others.

The researchers developed the survey addressing attitudes and factual knowledge about organ donation and transplantation. The survey was placed in paper format in four healthcare provider waiting rooms in Georgia and distributed online (Survey Monkey). The survey’s primary purpose was to determine the association between answers to seven specific knowledge-based questions regarding organ donation/transplantation and willingness to (1) be an organ donor and 2) donate a deceased family member’s organ.

“We wanted to look at variables in a multivariate way – ones previously shown to deter donation in a univariate way – to find if there were any that strongly and independently predicted (un)willingness to donate,” says Marty T. Sellers, MD, MPH, assistant professor of surgery, Division of Transplantation, Emory University School of Medicine.

Univariate analysis is the simplest form of data analysis that contains only one predictor variable. Multivariate analysis is the analysis of three or more variables and more accurately identifies the variable(s) that independently predict an outcome by adjusting for other variables.

“The myths chosen to evaluate in our survey were known from prior studies to be reasons people cite that interfere with their willingness to donate,” says Sellers. “These myths were the focus of this publication, since they represent things that are ‘correctable’ through outreach and education.”

Surveys were returned by 772 respondents, with 766 (99.2 percent) answering the primary questions of whether they wanted their organs donated upon death “if doing so would save someone else’s life.” Of the respondents, 84.6 percent were willing to donate, 76.2 percent were female, 79.7 percent were Caucasian and 16.5 percent were African American. The respondents represented 37 states.

Having concerns over getting inadequate medical care from paramedics or physicians if registered as an organ donor was the strongest concern of willingness to donate overall. African Americans were more likely than Caucasians to have this concern (20.2 percent vs. 9.5 percent).

“Medical teams in charge of caring for the sick and/or injured are not part of a transplant team, and their focus is entirely on the person who comes in under their care,” explains Sellers. “People awaiting transplants are completely off their radar screen. It is only when certain clinical ‘triggers’ are met signifying that a potential donor exists in a hospital that the organ procurement organization or OPO — LifeLink of Georgia in our case — is notified by the hospital staff that they have a potential donor.”
The survey also found that willingness to donate a family member’s organs depended on whether a discussion about a donation had previously occurred: 61 percent would donate with no prior discussion, while 95.2 percent would donate if the family member had said “yes” to donation, 11 percent if “no.”

While solid organ transplantation saves the lives of thousands of people each year, many patients die while waiting on transplant waitlists. According to the Organ Procurement and Transplantation Network (OPTN), in 2017, 34,796 organs were transplanted in the U.S., with 28,587 organs coming from deceased organ donors. A single donor can provide lifesaving organs for up to eight or nine recipients.

With more than 115,000 people on waitlists for a lifesaving organ transplant, better understanding of the common donation myths and misperceptions is crucial.

“Educating the public regarding these and other misperceptions is desperately needed,” says Sellers. “With education, we believe this would convert more eligible donors into actual donors, which would shorten waiting times and allow transplantation earlier in a disease process. It would also lead to less pre- and post-transplant mortality; many living donors would be spared the risks associated with donating; and overall costs associated with transplantation would decrease.”


Mike Mandl and Jack Tillman join Piedmont Healthcare

Thursday, February 22nd, 2018

Mike Mendl

Piedmont Healthcare announced today the founding partners of Atlanta-based business advisory firm Mandl & Co. have joined the health system and both executives are joining Piedmont’s executive leadership team.

Mike Mandl joins Piedmont as the system’s only Executive Vice President, reporting to CEO Kevin Brown and serving as Brown’s second in command. Mandl will partner with Brown in executing the strategic agenda for Piedmont and oversee a broad range of system functions including finance, strategy and planning, supply chain, real estate and philanthropy.

Prior to co-founding Mandl & Co. in 2016, Mandl served in a number of executive roles with Emory University and Emory Healthcare, most recently as Emory University’s Executive Vice President for Business and Administration. While at Emory, Mandl oversaw finance, investments, human resources, campus planning, real estate, IT and other functions. Earlier in his career, Mandl served in executive roles at Duke University, the University of Pennsylvania, Glaxo Pharmaceuticals and KPMG.

Jack Tillman

Jack Tillman is also joining Piedmont from Mandl & Co. as Vice President and Chief of Real Estate. Tillman was co-founder and managing director for Mandl & Co., overseeing the firm’s asset management and real estate development projects for clients across the continent.

“One of the consequences of Piedmont’s recent growth has been the sizable growth in our real estate portfolio, from hospitals and medical office buildings to retail properties and land holdings. On top of that, the largest healthcare development in Georgia history is underway on our Piedmont Atlanta campus. Adding Jack’s experience and expertise to our existing real estate and corporate development team will help us maximize our investments and best manage our large and diverse portfolio,” Brown said.


Northside Hospital Announces Fetal Therapy Program, Partnership with Texas Children’s Fetal Center

Thursday, February 22nd, 2018

Northside Hospital in Atlanta is developing and launching a new Fetal Therapy Program to treat some of Georgia’s sickest unborn babies.

Northside entered into an agreement this month with Texas Children’s Fetal Center, located within Texas Children’s Pavilion for Women in Houston, to train Northside’s maternal-fetal medicine physicians on a procedure to treat twin-to-twin transfusion syndrome (TTTS). Affecting 10 to 15 percent of identical twin pregnancies with a shared placenta, TTTS is a serious complication that, if left untreated, can result in the death of one or both of the babies in more than 90 percent of these pregnancies.

Intrauterine selective fetoscopic laser photocoagulation, or SFLP, is a minimally invasive surgical procedure that uses laser energy to stop the abnormal blood vessel connections that cause twins to share a blood supply, sometimes disproportionately, and often halts the progression of TTTS. Currently, Georgia mothers requiring SFLP are transferred out of state during pregnancy for treatment as no doctors or hospitals in Georgia offer the procedure.

“This new fetal therapy program is the next step in the evolution of our care at Northside and to enhancing the services we already provide to our mothers and babies,” said Dr. Kevin Gomez, Northside Hospital Center for Perinatal Medicine and Georgia Perinatal Consultants.

Northside Hospital’s Fetal Therapy Program will be offered within its Atlanta-campus Women’s Center. Northside hopes to have the program operational by late summer 2018.


Winship names Madhav Dhodapkar as Director of New Center for Cancer Immunology

Thursday, February 22nd, 2018

Madhav Dhodapkar, MBBS

Madhav V. Dhodapkar, MBBS, a world-renowned expert in cancer immunology and translational immunotherapy, will join Winship Cancer Institute of Emory University on March 1, 2018, as the director of the new Winship Center for Cancer Immunology. He will be appointed as the Anise McDaniel Brock Chair and Georgia Research Alliance Eminent Scholar in Cancer Innovation and professor in the Department of Hematology and Medical Oncology in the Emory School of Medicine.

For the past decade, Dhodapkar has served as chief of hematology, the Arthur H. and Isabel Bunker Professor of Medicine (Hematology), and professor of immunobiology at Yale University School of Medicine. An expert in the treatment of multiple myeloma, he also was co-director of the Cancer Immunology Program within the Yale Cancer Center.

“The arrival of Dr. Dhodapkar at Winship Cancer Institute signals our commitment to the growing cancer immunotherapy research space,” says Walter J. Curran, Jr., MD, Winship’s executive director.

Dhodapkar is credited with helping to define the role of the immune system in controlling early cancer cells. His research focuses on how the immune system regulates the progression from precursor lesions to cancer as well as the mechanisms of treatment sensitivity and resistance to cancer immunotherapy.

Dhodapkar earned his medical degree from the All India Institute of Medical Sciences in New Delhi, India. He completed his residency in internal medicine at St. Louis University and his fellowship in hematology and medical oncology at the Mayo Clinic in Rochester, Minnesota. Prior to Yale, Dhodapkar served on the faculty at Memorial Sloan Kettering Cancer Center and The Rockefeller University in New York.

Dhodapkar has authored more than 100 scientific papers. He is a prior recipient of several awards including the National Institutes of Health Director’s Transformative Research Award and the National Cancer Institute Outstanding Investigator Award in 2016.

Dhodapkar’s wife, Kavita Dhodapkar, MBBS, a leading cancer immunology researcher at Yale, will also join the Emory faculty as an associate professor in pediatrics and director of the Pediatric Immuno-Oncology Program at the Aflac Cancer and Blood Disorders Center at Children’s Healthcare of Atlanta. She will also become an active Winship investigator in cancer immunology.


Children’s Healthcare of Atlanta Expands Town Center Campus With New Outpatient Care Center

Thursday, February 22nd, 2018

Children’s Healthcare of Atlanta opened the doors of the Children’s at Town Center Outpatient Care Center on February 6. The new 48,187-square-foot building, located on the existing Children’s at Town Center campus, provides pediatric specialty care in multiple disciplines to Cobb County and surrounding areas.

The Outpatient Care Center on the Children’s at Town Center campus will be named the Cunningham Family Building in recognition of a generous gift from Cobb resident Jay Cunningham. The facility will offer families access to an expanded sports medicine gym, outpatient rehabilitation, and orthotics and prosthetics, as well as pediatric specialists, including allergy, otolaryngology (ENT), endocrinology, general surgery, nephrology, orthopaedics and pulmonology.

These services join Children’s urgent care and radiology offerings currently available on the Town Center campus. In addition to the new building, the existing facilities at Town Center are currently being renovated and will be completed in summer 2018.

In 2017, Children’s treated 35,000 children who live in Cobb County, from broken bones, ear tube surgeries, sports rehabilitation to cancer. Children’s has five locations in Cobb County and offers families access to more than 2,000 pediatric providers representing more than 60 pediatric specialties and programs within the Children’s system.


Central Corneal Thickness Could Affect Glaucoma Risk

Thursday, February 22nd, 2018

Research led by Emory Eye Center scientist Eldon E. Geisert, PhD, shows that a protein that affects corneal thickness might also be connected to glaucoma risk.

The study, conducted on mice, found that variations in the genes that code for a protein called POU6F2 correlated with corneal thickness. In the developing eye, nerve cells of the retina and cells of the cornea express POU6F2. When the researchers removed the gene that codes for POU6F2, the mice had thinner corneas than normal mice. They also learned that POU6F2 helps regulate the developing cornea and helps keep it healthy by replenishing corneal stems cells in adult mice.

In glaucoma, pressure builds in the eye and damages the optic nerve. If left untreated, glaucoma may ultimately lead to blindness. Thinner corneas are a well-known risk factor for one variation of the disease – primary open angle glaucoma (POAG). Geisert’s group demonstrated that the cells expressing POU6F2 are the most sensitive to injury. In collaboration with other research groups studying the human risk factors for glaucoma, POU6F2 is a good candidate for glaucoma risk in humans.

“We were very surprised by our findings,” Geisert says. “Almost everyone believes that the link between central corneal thickness and glaucoma is due to stiffness of the cornea and sclera – not because of a protein such as POU6F2 which controls gene expression. Thus, the link was not immediately obvious.”

“The specific role many proteins play in our body may differ from tissue to tissue,” he continues. “In the cornea, POU6F2 is involved with tissue development and marks the stem cells that maintain corneal integrity. But it appears to have a completely different role in the retina.”

Current research efforts are attempting to understand how POU6F2 might regulate the eye’s structure and increase a person’s risk of glaucoma. “Things we learn about POU6F2 and retinal ganglion cell susceptibility to injury may provide unique insights into methods to treat early phases of glaucoma,” he says.

“Glaucoma is a complex disease with many genetic and environmental factors influencing the patient population,” Geisert adds. “We hope that defining this link between central corneal thickness and glaucoma – and other aspects of POU6F2 – will aid in early detection of glaucoma and eventually lead to treatments that can halt the progression of this disease.”


Altitude Sickness

Wednesday, February 21st, 2018

By Helen K. Kelley

 Altitude sickness, also called acute mountain sickness, is caused by climbing or walking to a higher and higher altitude too quickly, not giving the enough time to adapt to the lower air pressure and oxygen level in the higher elevation. To understand more about altitude sickness and how to prevent or treat it, we spoke with three Atlanta area physicians who shared their expertise and experience.

Symptoms, prevention and the heart of the matter
At higher altitudes, the barometric pressure decreases, resulting in fewer oxygen molecules available to breathe, ultimately resulting in decreased oxygen delivery to tissues. According to Andrew Smith, M.D., a cardiologist and Medical Director of the Advanced Heart Failure Program at Emory Healthcare, this decreased oxygen availability causes a number of physiological symptoms identified with altitude sickness.

Andrew Smith, M.D.

“With the decreased oxygen availability to the tissues, the result is an increased release of adrenalin, which can cause increase in heart rate and also possibly an increase in pulmonary artery pressures,” he said. “Additionally, what occurs within this is an increase in respiratory rate, and therefore, hyperventilation occurs, at least initially. Resting heart rate increases. Often the humidity tends to be lower at high altitudes, so, along with the increased adrenaline drive, there is a tendency to become dehydrated.”

Along with dehydration, people who are experiencing altitude sickness may have symptoms like mild headaches, nausea, more rapid breathing, fatigue and difficulty sleeping at night. In fact, because the breathing rate tends to be lower when sleeping, the lower level of oxygen delivery to the tissues can put more stress on the body at night.

Smith adds that more serious symptoms can occur at extreme altitudes in both normal people and those with genetic predispositions or health issues.

“For example, high altitude pulmonary edema can happen to anyone. If you develop a bad cough, become short of breath or cough up frothy sputum, that is a sign,” he said. “High altitude cerebral edema, or HACE, can cause a change in mental status, with symptoms like worsening headaches, lethargy, ataxia and confusion. ‘Leaky capillary syndrome,’ in which fluid leaks out of the capillaries in lungs, can also occur in the brain. Symptoms like these indicate you need to get down to a much lower elevation and seek medical attention immediately.”

For those who are traveling to higher elevations, Smith says there are a number of measures they can take to prevent the symptoms.

“Hydrate well and travel slowly to different degrees of elevation, so that some degree of acclimation occurs every few days. If you’re going to be doing something strenuous at a higher elevation, take breaks,” he advised. “Hiking and climbing to higher levels may be fine, but not camping and sleeping there. You can also prepare by getting yourself in better physical condition before you go.”

Most of all, common sense should prevail, especially for people who lead a sedentary lifestyle or who haven’t gotten regular check-ups.

“Travel to a high altitude location can unmask preexisting heart disease. I’d advise anyone planning to do so and who hasn’t been exercising regularly, to see a physician in advance for a cardiac stress test. Chest pain, angina, persistent shortness of breath… those are all warning signs,” Smith said. “Of course, for patients who have known heart disease, travel to high elevations can be extremely risky. It’s important that they recognize that they will be in situations where they don’t have control of their environment; environment will be controlling things like their heart rate response.”

Allen Dollar, M.D.

One physician’s personal experience
Allen Dollar, M.D., Associate Professor at Emory University School of Medicine and Section Chief of Cardiology at Grady Memorial Hospital, has been an avid backpacker since his teens. In recent years, Dollar and two friends have made an annual trip to Colorado to go hiking in the San Juan Mountains. It was there that he experienced altitude sickness for the first time in his life.

“The first year we made the trip I had no problems, but the second year, we ascended more rapidly from the ground level — we went from 6,500 ft. to 13,200 ft. in just two days,” he recalled. “I became sick as a dog. Basically, altitude sickness felt like the worst hangover you could ever have.”

While the treatment is to immediately descend to a safer level, Dollar and his friends were on the far side of a ridge that meant ascending another 500 ft. on a treacherous trail before being able to travel downward. It took an additional 24 hours before Dollar felt well enough to make the ascent and the descent.

He says that he was fortunate not to experience worse symptoms.

“I never developed shortness of breath or high-altitude cerebral edema,” he said. “My friends tested my mental clarity with math problems to be sure I was all right.”

Dollar said that one of his group had been taking Diamox (acetezolomide), a drug that been shown to help in preventing altitude sickness. After seeing his positive results, the others now begin taking Diamox two days prior to starting their climb and the regimen has proved successful.

He adds that there is no way to predict who will experience altitude sickness and who won’t.

“What I can tell you is that altitude sickness doesn’t have anything to do with a person’s fitness level,” he said. “You’re either susceptible or you’re not.”

Abubakr Chaudhry M.D.

Q & A:  Altitude and the lungs
To learn more about how altitude affects the lungs, we asked Abubakr Chaudhry M.D., a pulmonary and critical care physician and specialist in pulmonary vascular diseases with Northside Hospital, to share his insights in a two-part Q & A.

Q. How does altitude affect breathing?
AC: In order to understand how altitude effects breathing, we first have to understand what happens physiologically when we experience rapid changes in barometric pressure, such as during an ascent from sea level (760 mmHg) to the summit of Mount Everest (253 mmHg) per say. It is important to note that there is not a depletion of atmospheric oxygen content at higher altitudes, but rather a change in the driving pressure of the gas in the lungs. The higher you go, the lower the barometric pressure, and thus the lower the driving pressure.

Next, we must understand how gas exchange occurs in the membranes of the lung and how our bodies react to this change in driving pressure. The decreased driving pressure results in tissue hypoxia, decreasing the substrate available for aerobic respiration and stimulating us to hyperventilate. This phenomenon can be quantified by the alveolar-ventilation equation, which demonstrates an inverse relationship between the level of alveolar ventilation and the alveolar PCO2 (if CO2 production is constant). Thus, the more we breathe the less CO2 we retain. Furthermore, at higher altitudes it has been reported that climbers can decrease their PCO2 from a normal value of 40 to a value of 8 ( five-fold!). This change in breathing patterns leads to respiratory alkalosis. Alkalosis has the deleterious effect of increasing hemoglobin’s affinity to oxygen but it also enhances the uptake of oxygen in the pulmonary capillaries, an effect that is highly beneficial in these individuals. With changes in breathing patterns comes the question of need for oxygen.

We used the extreme example of Mount Everest but most normal individuals will not need supplemental oxygen unless they are ascending above 6500 meters.

Q: What are some ways an individual with a lung condition can prepare for travel to a high altitude?
AC: If someone has an underlying lung condition and is preparing for high altitude travel, the best thing to do is see a pulmonologist to assess his or her “hypoxic ventilatory response.” As previously stated, the major physiologic change that occurs with ascent is hyperventilation. If a patient cannot decrease their carbon dioxide levels, it will be unlikely they will have the energy required to oxygenate well, either. Supplemental oxygen can help, but the amount needed will likely change depending on the barometric pressure (the elevation to which the person climbs). If the patient’s hypoxic ventilatory response is poor, I would recommend against high altitude travel.

Preparing for high altitude travel is possible, but not in the way usually advertised. There are a lot of gimmicks out there that promise to “increase your red blood cells” with “hypoxia training.” I do not recommend these even in normal individuals, as the physiologic change is transient. I do recommend safe intensive strength and endurance training with a plan that is doctor supervised. Particularly in patients who have underlying lung disease, not only does training improve mortality, but it also improves the hypoxic ventilatory response by maximizing the body’s utilization of oxygen.

To someone who is planning a climb and has been cleared by their doctor, I recommend remembering the climber’s adage of “climb high and sleep low.” This means you should acclimatize yourself progressively. Once you get above 3000m, try not to climb more than 300m a day and rest every third or fourth day. If you experience symptoms of mountain sickness, you don’t have to run down the mountain, but try to descend at least 500m. In most cases of acute mountain sickness this descent will resolve the symptoms.


Treating the LGBT Patient Population

Wednesday, February 21st, 2018

Approach matters of cultural and gender diversity with “cultural humility” to give all your patients the best access to healthcare.

By Elizabeth Walton, MD

Elizabeth Walton, MD. Photo by Michael A. Schwarz

When it comes to providing demographic information about relationships, the choices facing a new patient have long been the same: Married, Single, Widowed, Divorced.

I’m a lesbian with a long-term partner. We have two children together. For years, I never knew which box to check because none applied to me.

More recently, practices began including “Partner” as one of the categories. I finally felt included, although the term still didn’t quite feel like it adequately characterized my relationship. As a result, I never felt as if I would be completely safe or even welcome at that practice.

When the federal marriage laws were expanded to include same-sex couples, my partner and I got married. I can now check a box on the form that correctly labels my relationship status, but it still leaves some gaps. More often than not, healthcare providers will assume I am married to a man.

My experience isn’t unique. Those first forms a patient fills out are essential indicators that telegraph what kind of care a patient might receive. For patients who are gay, lesbian, bisexual or transgender, practices that limit the categories to metronormative categories immediately impact the nature of the relationship between patient and doctor. If you don’t even exist on a form, it can be very scary to reveal this information about yourself to your doctor.

To illustrate the point, consider an experience I had as a college sophomore. I was hospitalized for severe abdominal pain. The surgeon asked me if I was sexually active. I said I was. She then asked if I was trying to get pregnant since I wasn’t using contraception. When I told her I wasn’t, the surgeon asked, “Then what are you using? A hope and a prayer?” I had to explain to her that I was not having sex with men. The trust between me and the doctor who was about to operate on me was greatly diminished.

Health equity is the attainment of the highest level of health for all people, and as physicians, we have made a commitment to provide excellent care to the person sitting across from us. When inequities exist, they result in health disparities for individuals, communities and global societies.

The increasing cultural, racial and ethnic diversity of the United States provides challenges and opportunities to physicians in all specialties. As physicians in the United States, we are hardwired to master a theoretically finite body of knowledge and completely “get it right.” This cultural norm among doctors doesn’t serve us well when it comes to issues of diversity and making our care appropriate for people from all walks of life.

It is time to allow us to approach matters of cultural and gender diversity with “cultural humility” as opposed to “cultural competence.” This opens the door for a lifelong commitment to self-evaluation and self-critique that, ultimately, will lead to a more inclusive practice and better healthcare.

Cultural humility does require the constant seeking of more information, especially among issues of gender and sexuality, which are rapidly evolving, especially among younger populations. In the U.S., about 9 million people (3.5 percent) identify as lesbian, gay or bisexual, but about 19 million (8.2 percent) have acknowledged engaging in same-sex behavior. Estimates about the transgender population range from 0.1 percent to 0.5 percent.

Intersectionality and Terminology
LGBTQ individuals are not part of just one community. Many people carry multiple identities, and often they may have to choose one over another at different times, such as being African American or lesbian. Transgender people are very diverse and use many different terms to describe themselves. Language is being created while experiences develop and is changing over time. Some common terms include:

Sex refers to the presence of specific anatomy. It also may be referred to as “sex assigned at birth.”

Gender refers to attitudes, feelings and behaviors that a culture typically associates with masculinity or femininity.

Gender identity is a person’s internal sense of their gender as man, woman, a mix of both or neither. It is often a spectrum. It begins to develop by age 3 and may remain stable over time, change or be fluid. Since gender identity is internal, it may not be visible to others.

Sexual orientation is completely unrelated to gender identity. Sexual orientation is how a person identifies their physical and emotional attraction to others. It encompasses attraction, behavior and identity. It may fluctuate and shift over time. Gender expression is how one externally presents their gender identity through their behavior, mannerisms, speech patterns, dress, hairstyles, etc.

Gender variant/non-conforming refers to people whose gender expression is different from traditional expectations of their gender.

Transgender is an adjective used to describe people whose gender identity differs from their sex assigned at birth and can include male, female, neither or some combination.

Cisgender or cis is a person who is not transgender.

Transsexual may be considered an out-of-date term by some. It historically referred to individuals who had undergone medical/surgical treatment to transition to the opposite gender. This term may be used by some as a self-affirming description of themselves.

Genderqueer, gender fluid refers to someone who rejects distinct categories of male or female. They view gender as a spectrum that fluctuates.

Gender dysphoria is a DSM-5 diagnosis for individuals who have a strong and persistent cross-gender identification and a persistent discomfort with his or her sex, or sense of inappropriateness in the gender role of that sex.

Intersex refers to individuals whose physical bodies are not easily categorized as male or female (previously referred to as hermaphrodite). The number of intersex individuals is estimated between one in 1,000 to 4,500 newborns each year in the U.S. The DSM-V classifies these as Disorders of Sex Development. Since the term ‘disorder’ is used, it is considered pejorative by many and not used in the Intersex community. Intersex people are sometimes grouped with transgender people, but they are not the same. Some intersex individuals see themselves as part of the LGBTQ community; others don’t.

Queer is often used as a self-affirming and inclusive umbrella term for LGBT people, but can be considered an offensive term when used to cause harm.

Best Practices for the Best Healthcare
The LGBTQ community has unique health issues. Although many healthcare providers have developed practices specific to the healthcare needs of gay men, lesbians and bisexuals, fewer have had experience with transgender patients. As transgender people become more visible and are telling their healthcare providers, it’s important for us to develop some rudimentary procedures and best practices to help provide the best possible healthcare.

Trans patients often fear the medical community and delay seeking help for a problem. Many have been met with hostility from healthcare providers, sometimes being called the dehumanizing pronoun “it.” Others may have had physicians refuse to use their preferred name or pronoun.

A friend who is a psychiatrist told me about her experience with her trans son, who was born with female genitalia and raised as a girl until fourteen when he came out to his parents. My friend trained with her son’s pediatrician in residency. This doctor had treated him since birth. At their first appointment as a trans male, mother and son were met with extreme hostility. The doctor asked him inappropriate questions, such as whether he had sex with girls and whether he liked it.

The experience was very traumatic for both people. The mother later called a longtime friend and pediatrician to share this traumatic event. Her friend’s response was “Well, we don’t have those kinds of people in South Carolina.” Not surprisingly, it is not uncommon for patients to have to drive four or five hours to find a therapist or doctor capable and willing to treat trans patients in smaller cities and towns.

Clinicians have differing views on whether gender nonconformity should be regarded as a normal variation of gender expression, a medical condition or a psychiatric disorder. An alternate perspective views gender as a continuum from male to female, permitting a spectrum of gender identities with varying proportions of maleness and femaleness.

Nonconformity and Identity
It is impossible to predict with certainty whether gender nonconformity in an individual child will persist into adolescence or adulthood. Review of the evidence from prospective and retrospective follow-up studies suggests that gender dysphoria in prepubertal children persists into adolescence/ adulthood in a minority of children.

Children with consistent, persistent and insistent nonconforming behaviors and expression are more likely to maintain nonconforming gender identity in the long term. Demonstration of gender-nonconforming behaviors and expression reflects an innate preference of the child. Young children who are gender non-conforming generally are not gender dysphoric because they lack a clear understanding that their internal gender identity does not match their genitals.

The physical changes of puberty usually are exceptionally difficult for gender-nonconforming youth. The development of unwanted secondary sexual characteristics is described by many as a betrayal of one’s body, the final confirmation that they must live in an adult version of a body that is not reflective of their true self. Gender dysphoria that intensifies with the onset of puberty rarely subsides.

Trans people experience very high rates of stigma and discrimination that can lead to health disparities. It is legal in 28 states to fire an employee or deny housing because they are gay or transgender. The U.S. Department of Justice recently argued in front of an appeals court in New York that Title VII (of the Civil Rights Act of 1964 prohibiting discrimination on the basis of sex, race, color, national origin, and religion) did not provide protections to gay, lesbian or transgender workers.

Not surprisingly, LGBT people experience higher rates of substance abuse, HIV/STDs, tobacco use, violence, depression, suicidality and self harm. Forty one percent of trans people have attempted suicide (compared to 5.6-14.3 percent of U.S. adults). Trans women are murdered at a much higher rate than the general population. Trans women of color experience the highest.

Gender identity is not obvious by looking at someone. We should ask the same questions of all patients and not assume that people are heterosexual or cisgender, regardless of how they look.

1) Ask about current gender identity (preferably with a blank, instead of boxes to check)
2) Ask about sex assigned at birth
3) Ask what pronoun they use
4) Ask legal name
5) Ask preferred name

Clinical care should be based on an up-to-date anatomical inventory: Breasts, cervix, ovaries, penis, prostate, testes, uterus, vagina. Trans men still need pap smears if they have not had a hysterectomy. Trans women need prostate exams. The majority of trans individuals have not had surgery.

There is an abundance of erroneous information on the internet about trans people.

Physicians have an opportunity to provide more reliable information. For example, there are numerous reports about high rates of regret in patients who have had gender affirming surgery. More recent studies suggest that less than four percent of people who have gender-reassignment surgery regret it. Researchers have also found that the surgery dramatically reduces suicide rates among trans people.

For trans youth, family non-acceptance is a very strong risk factor for mental health issues. These youth are at a much higher risk of verbal and physical victimization, social isolation and peer rejection, school problems, depression and anxiety, self harm and suicidality, homelessness and sexual exploitation. Conversely, a recent article published in the journal Pediatrics presented a study that showed no difference in depression and only a small increase in anxiety in trans youth who are supported by their family compared to the general youth population.

In addition to conveying the strong evidence that family nonsupport is a very big risk factor for negative health impacts, the physician should address safety and bullying. It is very important to help the family advocate for the the child/ adolescent in the school system. It may be helpful or even necessary for you as the physician to write a letter of support and medical necessity for the child to express his/her gender identity. This can also be helpful to educate staff and students.

Make sure that referrals you make to other physicians are safe for the patient by doing your research. If you know that a physician has ethical or religious issues with LGBT individuals, you should not refer them to these people. Similarly, if you do not feel comfortable taking care of an LGBT individual, you should recognize your bias and refer to someone who is.

If in doubt, you can never go wrong using the ‘Golden Rule.’ Do unto others as you would have them do unto you.

Resources and Reading Materials

Make sure to have adequate resources for treating the LGBT community. Here is a list for yourself, your patients and their families.

LGBT Resources
• Human Rights Campaign:
• Georgia Equality:
• Family Acceptance Project:
• Gay and Lesbian Medical Association:
• PFLAG (Parent/Friend/LGBT Support):
• The Health Initiative:
• The Trevor Project:

Trans-specific Resources
• Trans Youth Support Network:
• Trans Youth Equality Foundation:
• I Am: Trans People Speak:
• Trans Student Educational
• National Center for Transgender Equality:
• Trans Family Support Services:
• Trans Active:
• Queer Med:

Teacher, Parent and Other Supportive Adult Titles
• 50 Ways of Saying Fabulous, Graeme Aitken, 2015 (20th anniversary edition)
• BALLS: It Takes Some to Get Some, Chris Edwards, 2016.
• Becoming Nicole: The Transformation of an American Family, Amy Ellis Nutt, 2016.
• Circle of Change (ebook), Laney Cairo, 2016.
• Helping Your Transgender Child, Irwin Krieger, 2011.
• Gender Born, Gender Made: Raising Healthy, Gender-Nonconforming Children, Diane Ehrensaft, 2011.
• Gender Dysphoria: An Essential Guide for Understanding and Dealing with Gender Identity Disorder. Eleanor Nye, 2015.
• Gender Outlaws: The Next Generation, Katie Bornstein, 2010.
• My Child is Transgender: 10 Tips for Parents of Adult Trans Children, Matt Kailey, 2012.
• My Daughter He: Transitioning with our Transgender Children, Candace Waldron, 2014.
• Principles of Transgender Medicine and Surgery, Randi Ettner, Stan Monstrey, & Eli Coleman, 2016.
• Rainbow Family Collection: Selecting and Using Children’s Books with Lesbian, Gay, Bisexual, Transgender, and Queer Content, Jamie Campbell Naidoo, 2012.
• Raising Ryland. Hillary Whittington, 2016.
• Safe Spaces: Making Schools and Communities Welcoming to LGBT Youth. Annemarie Vaccaro, Gerri August, & Megan S. Kennedy, 2011.
• Second Son: Transitioning Toward My Destiny, Love, and Life, Ryan K. Sallans, 2012.
• The Gender Creative Child, Diane Ehrensaft 2016.
• The Lives of Transgender People, Genny Beemyn & Susan Rankin, 2011.
• The Transgender Child: A Handbook for Families and Professionals.
• Stephanie Brill & Rachel Pepper, 2008.
• The Transgender Teen, Stephanie A. Brill & Lisa Kenney, 2016.
• Trans/Portraits: Voices from Transgender Communities. Jackson Wright.
• Shultz, 2015.
• Transgender Family Law: A Guide to Effective Advocacy, Jennifer L. Levi (Editor), 2012.
• Transgender Transition: Quick Start Guidebook, Sky Logan, 2016.
• Transitions of the Heart: Stories of Love, Struggle, and Acceptance by Mothers of Transgender and Gender Variant Children, Rachel Pepper, Ed., 2012


Buckhead CME Dinner

Thursday, February 15th, 2018

February 15, 2018. Maggiano’s Little Italy, Buckhead. For more information, visit



Malcare WordPress Security
Resources F T L Subscription Advertising About Us Past Issues Contact