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‘If you don’t ask, then you won’t know’: family doctors guided on care for transgender teens

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A growing number of young people identify as transgender, but many miss out on vital care from a family doctor. The authors of a new Canadian review aim to change that.

Gender dysphoria is the distress an individual may experience when their gender identity doesn’t match the one assigned at birth. Studies from other countries suggest between 1.2 per cent to 4.1 per cent of adolescents identify as transgender.

Monday’s issue of the Canadian Medical Association Journal is devoted to the health of transgender people, who the editors call a vulnerable population. While small studies show the mental health of teens with gender dysphoria improves when they receive supportive medical care, primary care physicians themselves may lack experience to offer it.

“In many cases, I think primary care providers aren’t asking these important questions, let alone romantic and sexual orientations,” said Dr. Joseph Bonifacio, a pediatrician at St. Michael’s Hospital in Toronto and one of the authors of the new review.

“When they do mention, for example, that they may be transgender, they are referred to a gender specialist. And many times the wait list … is one to two years. They can come into my practice with anxiety or depression or other mental health illness.”

In some cases, the teens aren’t attending school. “If you don’t ask, then you won’t know,” Bonifacio said.

In the review, the authors said primary care providers can support teens with gender dysphoria and their families. To help, the researchers provided quick-reference boxes of definitions, as well as recommendations on suppressing hormones to delay puberty.

The “affirming model” means supporting the child, said Dr. Carys Massarella who runs the transgender clinic at Quest Community Health Centre in St. Catharines, Ont. 

‘Nothing magical’

“You don’t have to make any dramatic decisions,” said Massarella, a trans woman. “Make sure the child is safe … at school and with their community, and really just be supportive. You know there’s nothing more magical about it than that.”

The wait list to see a gender specialist can reach two years, said Dr. Joseph Bonifacio. (Craig Chivers/CBC)

Anyone in healthcare who works with children or teens with gender dysphoria recognizes it takes time — not weeks or months but years — to get to know these kids and their families, Massarella said.  

Sydney Tam is a family doctor in Toronto who has worked with the transgender community for nearly 20 years. She wasn’t involved in the review.

“We’re making slow progress,” Tam said. “Trans people continue to call them problematic interactions with health providers and institutions. I think that’s because of people’s values and a certain amount of judgment. The problems are based on a lot of social ignorance … not so much a reflection of what physicians, nurses and other health providers want to do for their patient.”

Tam hopes the publication, which she called well researched and balanced, will help primary care providers to bridge the gap with patients.

Blair Curtis, 18, of Corner Brook, N.L., and his mother found a St. John’s-based support group for parents and families of transgender teens so helpful that they’ve brought it to western Newfoundland.

“Everyone saw me as a girl, I was always she and her,” Curtis recalled. “But inside I knew.”

Initially, Curtis struggled to tell his mother, a health-care worker.

“There wasn’t anything that prepared me, as a nurse, to look after someone or know what transgender really meant,” said his mother, Gerri-Lynn Curtis.

Blair said he feels fortunate to have good medical support. “I have a doctor here who prescribed me testosterone. She’s really accepting, pushing my family to see this was something that I needed.”

The journal’s special issue also includes practical information on transgender-inclusive care, such as the need for physicians to conduct Pap tests on transgender men with cervixes as they are less likely to undergo regular cervical cancer screening, and the need to discuss fertility screening with people before starting hormone therapy.

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Frostbite: What it is and how to identify, treat it

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Manitoba’s temperature has plummeted to its coldest level this season, triggering warnings about the extreme risk of frostbite.

Oh, we know it’s cold. We can feel Jack Frost nipping at our noses. But what about when he gnaws a little harder — what exactly does “frostbite” mean?

People tend to underestimate the potential for severe injuries in the cold, says the Winnipeg Regional Health Authority. We laugh off the sting of the deep freeze, rub our hands back from the brink of numbness and wear our survival proudly like a badge.

That’s because, in most cases, frostbite can be treated fairly easily, with no long-term effects.

But it can also lead to serious injury, including permanent numbness or tingling, joint stiffness, or muscle weakness. In extreme cases, it can lead to amputation.

Bitter cold can cause frostbite in just minutes. Here’s how to recognize the warning signs and treat them. 0:59

Here’s a guide to identifying the first signs, how to treat them, and when to seek medical help.

What is frostbite and frostnip?

Frostbite is defined as bodily injury caused by freezing that results in loss of feeling and colour in affected areas. It most often affects the nose, ears, cheeks, chin, fingers or toes — those areas most often exposed to the air.

Cooling of the body causes a narrowing of the blood vessels, slowing blood flow. In temperatures below –4 C, ice crystals can form in the skin and the tissue just below it.

Frostnip most commonly affects the hands and feet. It initially causes cold, burning pain, with the area affected becoming blanched. It is easy to treat and with rewarming, the area becomes reddened.

Frostbite is the acute version of frostnip, when the soft tissue actually freezes. The risk is particularly dangerous on days with a high wind chill factor. If not quickly and properly treated, it can lead to the loss of tissues or even limbs. 

Signs of frostbite

Health officials call them the four P’s:

  • Pink: Skin appears reddish in colour, and this is usually the first sign.
  • Pain: The cold becomes painful on skin.
  • Patches: White, waxy-feeling patches show when skin is dying.
  • Prickles: Affected areas feel numb or have reduced sensation.

Symptoms can also include:

  • Reduced body temperature.
  • Swelling.
  • Blisters.
  • Areas that are initially cold, hard to the touch.

Take quick action

If you do get frostbite, it is important to take quick action.

  • Most cases of frostbite can be treated by heating the exposed area in warm (not hot) water.
  • Immersion in warm water should continue for 20-30 minutes until the exposed area starts to turn pink, indicating the return of blood circulation.
  • Use a warm, wet washcloth on frostbitten nose or earlobes.
  • If you don’t have access to warm water, underarms are a good place to warm frostbitten fingers. For feet, put them against a warm person’s skin.
  • Drink hot fluids such as hot chocolate, coffee or tea when warming.
  • Rest affected limbs and avoid irritation to the skin.
  • E​levate the affected limb once it is rewarmed.

Rewarming can take up to an hour and can be painful, especially near the end of the process as circulation returns. Acetaminophen or ibuprofen may help with the discomfort.

Do not …

There are a number of things you should avoid:

  • Do not warm the area with dry heat, such as a heating pad, heat lamp or electric heater, because frostbitten skin is easily burned.
  • Do not rub or massage affected areas. This can cause more damage.
  • Do not drink alcohol.
  • Do not walk on your feet or toes if they are frozen.
  • Do not break blisters.

Seek immediate medical attention

While you can treat frostbite yourself if the symptoms are minor — the skin is red, there is tingling — you should seek immediate medical attention at an emergency department if:

  • The exposed skin is blackened.
  • You see white-coloured or grey-coloured patches.
  • There is severe pain or the area is completely numb.
  • The skin feels unusually firm and is not sensitive to touch after one hour of rewarming.
  • There are large areas of blistering.
  • There is a bluish discolouration that does not resolve with rewarming.

Be prepared

The best way to avoid frostbite is to be prepared for the weather in the first place.

Wear several loose layers of clothing rather than a single, thick layer to provide good insulation and keep moisture away from your skin.

The outer garment should breathe but be waterproof and windproof, with an inner thermal layer. Retain body heat with a hat and scarf. Mittens are warmer than gloves because they keep the fingers together.

Be sure your clothing protects your head, ears, nose, hands and feet, especially for children.

Wind chill and frostbite rates

Wind chill: 0 to –9.
Frostbite risk: Low.

Wind chill: –28 to –39.
Frostbite risk: Moderate.

Exposed skin can freeze in 10-30 minutes

Wind chill: –40 to –47.
Frostbite risk: High.

Exposed skin can freeze in five to 10 minutes.

Wind chill: –48 to –54.
Frostbite risk: Very High.

Exposed skin can freeze in two to five minutes.

Wind chill: –55 and lower.
Frostbite risk: Extremely High.

Exposed skin can freeze in less than two minutes.
 

NOTE: In sustained winds over 50 km/h, frostbite can occur faster than indicated.

Source: Environment Canada

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Awkward Flu Jabs Attempted at Golden Globes

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In what can only be described as a new level of propaganda, hosts Andy Samberg and Sandra Oh featured a flu shot stunt during the 76th Golden Globe Awards ceremony. They told the audience to roll up their sleeves, as they would all be getting flu shots, while people in white coats stormed down the aisles, syringes in hand.

Most of the audience looked thoroughly uneasy at the prospect of having a stranger stick them with a needle in the middle of an awards show. But perhaps the worst part of the scene was when Samberg added that anti-vaxxers could put a napkin over their head if they wanted to be skipped, basically suggesting that anyone opposed to a flu shot deserved to be branded with a proverbial scarlet letter.

The flu shots, for the record, were reportedly fake,1 nothing more than a bizarre gag that left many people stunned by the Globe’s poor taste in turning a serious medical choice into a publicity gimmick.

Flu Shot Stunt Reeks of Desperation

Whoever came up with the idea to turn the Golden Globes into a platform for a public health message probably thought it was ingenious, but the stunt only serves as a seemingly desperate attempt to make flu shots relevant and in vogue. During the 2017 to 2018 flu season, only 37 percent of U.S. adults received a flu shot, a 6 percent drop from the prior season.2

“To improve flu vaccination coverage for the 2018-19 flu season, health care providers are encouraged to strongly recommend and offer flu vaccination to all of their patients,” the U.S. Centers for Disease Control and Prevention (CDC) wrote. “People not visiting a provider during the flu season have many convenient places they can go for a flu vaccination.”3

Yet, perhaps the decline in people choosing to get vaccinated has nothing to do with convenience and everything to do with their dismal rates of efficacy. In the decade between 2005 and 2015, the influenza vaccine was less than 50 percent effective more than half of the time.4

The 2017/2018 flu vaccine was a perfect example of this trend. The overall adjusted vaccine effectiveness against influenza A and B virus infection was just 36 percent.5

Health officials blamed the flu season’s severity on the dip in vaccination rates, but as Dr. Paul Auwaerter, clinical director of the division of infectious diseases at Johns Hopkins University School of Medicine, told USA Today, “[I]t is also true that the vaccine was not as well matched against the strains that circulated.”6

But bringing flu shots to the Golden Globes, and calling out “anti-vaxxers,” is nothing more than “medical care, by shame,” noted Dr. Don Harte, a chiropractic activist in California. “But it was entertaining, in a very weird way, including the shock and disgust of some of the intended victims, notably [Willem Dafoe],” he said, adding:7

“This Hollywood publicity stunt for the flu vaccine is one of the stupidest things I’ve ever seen from celebrities. But it does go with the flu shot itself, which is, perhaps, the stupidest of all the vaccines available.”

Did 80,000 People Really Die From the Flu Last Year?

The CDC reported that 79,400 people died from influenza during the 2017/2018 season, which they said “serves as a reminder of how severe seasonal influenza can be.”8 It’s important to remember, however, that the 80,000 deaths figure being widely reported in the media is not actually all “flu deaths.”

According to the CDC, “We look at death certificates that have pneumonia or influenza causes (P&I), other respiratory and circulatory causes (R&C), or other nonrespiratory, noncirculatory causes of death, because deaths related to flu may not have influenza listed as a cause of death.”9

As for why the CDC doesn’t base flu mortality estimates only on death certificates that list influenza, they noted, “Seasonal influenza may lead to death from other causes, such as pneumonia, congestive heart failure or chronic obstructive pulmonary disease … Additionally, some deaths — particularly among the elderly — are associated with secondary complications of seasonal influenza (including bacterial pneumonias).”10

In other words, “flu deaths” are not just deaths directly caused by the influenza virus, but also secondary infections such as pneumonia and other respiratory diseases, as well as sepsis.11

According to the CDC, most of the deaths occurred among those aged 65 years and over, a population that may already have preexisting conditions that makes them more susceptible to infectious diseases. As Harte said of annual flu deaths, “[M]ost if not all, I would assume, are of people who are already in very bad shape.12

CDC Claims Flu Vaccine Reduces Flu Deaths in the Elderly — But Does It?

Since people aged 65 and over are those most at risk from flu complications and death, the CDC has been vocal in their claims that the flu shot significantly reduces flu-related deaths among this population. The research, however, says otherwise.

Research published in 2005 found no correlation between increased vaccination rates among the elderly and reduced mortality. According to the authors, “Because fewer than 10 percent of all winter deaths were attributable to influenza in any season, we conclude that observational studies substantially overestimate vaccination benefit.”13

A 2006 study also showed that even though seniors vaccinated against influenza had a 44 percent reduced risk of dying during flu season than unvaccinated seniors, those who were vaccinated were also 61 percent less like to die before the flu season ever started.14

This finding has since been attributed to a “healthy user effect,” which suggests that older people who get vaccinated against influenza are already healthier and, therefore, less likely to die anyway, whereas those who do not get the shot have suffered a decline in health in recent months.

Journalist Jeremy Hammond summed up the CDC’s continued spreading of misinformation regarding the flu vaccine’s effectiveness in the elderly, as they continue to claim it’s the best way to prevent the flu:15

[T]here is no good scientific evidence to support the CDC’s claim that the influenza vaccine reduces hospitalizations or deaths among the elderly.

The types of studies the CDC has relied on to support this claim have been thoroughly discredited due to their systemic ‘healthy user’ selection bias, and the mortality rate has observably increased along with the increase in vaccine uptake — which the CDC has encouraged with its unevidenced claims about the vaccine’s benefits, downplaying of its risks, and a marketing strategy of trying to frighten people into getting the flu shot for themselves and their family.”

Death of Vaccinated Child Blamed on Not Getting Second Dose

In January 2019, the state of Colorado reported the first child flu death of the 2018/2019 flu season — a child who had received influenza vaccination. But instead of highlighting the vaccine’s failure and clear limitations, the Colorado Department of Public Health and Environment blamed the death on the child being only “partially vaccinated.”

“It’s an unfortunate but important reminder of the importance of two doses of influenza vaccine for young children who are receiving influenza vaccine for the first time,” Dr. Rachel Herlihy, who is the state communicable disease epidemiologist, said in a news release.16 For those who aren’t aware, the CDC notes that one dose of flu shot may not be enough to protect against the flu. Instead, they state:17

“Children 6 months through 8 years getting vaccinated for the first time, and those who have only previously gotten one dose of vaccine, should get two doses of vaccine this season …

The first dose ‘primes’ the immune system; the second dose provides immune protection. Children who only get one dose but need two doses can have reduced or no protection from a single dose of flu vaccine.”

Not only may the flu vaccine fail to provide protection against the flu, but many people are not aware that other types of viruses are responsible for about 80 percent of all respiratory infections during any given flu season.18 The flu vaccine does not protect against or prevent any of these other types of respiratory infections causing influenza-like illness (ILI) symptoms.

The chance of contracting actual type A or B influenza, caused by one of the three or four influenza virus strains included in the vaccine, is much lower compared to getting sick with another type of viral or bacterial infection during the flu season.

Does Flu Vaccine Increase the Risk of Influenza Infection, Contribute to Vaccine Shedding?

There are serious adverse effects that can come along with annual flu vaccination, including potentially lifelong side effects such as Guillain Barré syndrome and chronic shoulder injury related to vaccine administration (SIRVA). They may also increase your risk of contracting more serious flu infections, as research suggests those who have been vaccinated annually may be less protected than those with no prior flu vaccination history.19

Research presented at the 105th International Conference of the American Thoracic Society in San Diego also revealed that children who get seasonal flu shots are more at risk of hospitalization than children who do not. Children who had received the flu vaccine had three times the risk of hospitalization as children who had not. Among children with asthma, the risk was even higher.20

There’s also the potential for vaccine shedding, which has taken on renewed importance with the reintroduction of the live virus vaccine FluMist during the 2018/2019 season. While the CDC states that the live flu virus in FluMist is too weak to actually give recipients the flu, research has raised some serious doubts that this is the case.

One recent study revealed not only that influenza virus may be spread via simple breathing (i.e., no sneezing or coughing required) but also that repeated vaccination increases the amount of virus released into the air.21

MedImmune, the company that developed FluMist, is aware that the vaccine sheds vaccine-strain virus. In its prescribing information, they describe a study on the transmission of vaccine-strain viruses from vaccinated children to nonvaccinated children in a day care setting.

In 80 percent of the FluMist recipients, at least one vaccine-strain virus was isolated anywhere from one to 21 days following vaccination. They further noted, “One placebo subject had mild symptomatic Type B virus infection confirmed as a transmitted vaccine virus by a FluMist recipient in the same playgroup.”22

Are There Other Ways to Stay Healthy During Flu Season?

Contrary to the CDC’s and Golden Globe’s claims that flu vaccinations are a great way to prevent flu, other methods exist to help you stay healthy during the flu season and all year, and they’re far safer than annual flu vaccination. Vitamin D testing and optimization have been shown to cut your risk of respiratory infections, including colds and flu, in half if you are vitamin D deficient, for instance.23,24

In my view, optimizing your vitamin D levels is one of the absolute best respiratory illness prevention and optimal health strategies available. Influenza has also been treated with high-dose vitamin C,25 and taking zinc lozenges at the first sign of respiratory illness can also be helpful.

Following other basic tenets of health, like eating right, getting sound sleep, exercising and addressing stress are also important, as is regularly washing your hands.

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Homemade Miso Soup With Vegetables

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homemade miso soup

Sometimes when the weather is chilly or you’re simply feeling under the weather, there is nothing better than a warm brothy soup. This miso soup combines nutrient-rich bone broth with the probiotic benefits of miso. And you get the benefits of vitamins and minerals from vegetables too. Make a big batch for the whole family or just one bowl for you!

What Is Miso?

Miso is a potent paste made out of fermented soybeans. But isn’t soy bad for you, you ask? Yes and no. Soy beans, like any legume, contain a large amount of phytic acid which interferes with nutrient absorption. They also contain phytoestrogens, which have their own negative side effects.

However, miso is fermented soy. Fermented foods contain bacteria which has eaten the sugars and starches present in the food. This process preserves the food and also gives it probiotics, enzymes, and additional vitamins. It makes the food more easily digested and the nutrients easier for the body to use.

There are several different colors of miso available, and all of them are just fine for soup making. Generally, the darker colored the miso, the stronger the flavor. I can usually find miso in the ethnic food section of my grocery store, but there are also some good organic options available online.

How to Make a Quick Miso Soup

To make miso soup, add a few teaspoons of miso paste is to a broth with spices and vegetables. Traditionally, dashi, the broth used for miso soup, is made with dried bonito (a type of fish) flakes and kelp. While you are welcome to do it this way, you can also use a good chicken bone broth like the one sold at Kettle and Fire.

Then, just top with additional seasonings, some vegetables, the miso, and sometimes a hard-boiled egg.

One note on adding the miso — it works best if you remove about ¼ cup of the warm broth from the pan and whisk in the miso paste with a fork before returning it to the rest of the soup. Once you add the miso, just warm the soup gently. Don’t boil it or you’ll destroy all the gut healthy bacteria in the miso!

If you’d like to try your hand at making dashi, the traditional fish and kelp broth for miso soup, this video is a good one.

No Time to Make From Scratch?

If you want to make life even simpler, Kettle and Fire also sells a delicious miso soup that’s all ready to go. Just heat it up and add any vegetables you like.

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Homemade Miso Soup Recipe

It’s easy to make miso soup at home using a good chicken bone broth, miso paste, and vegetables.

Ingredients

  • cup chicken broth
  • 1 clove garlic (minced)
  • ¼ tsp onion powder
  • ½ tsp ginger (grated)
  • 3 mushrooms (sliced)
  • 1 TBSP miso paste
  • ½ cup fresh spinach
  • 1 green onion (chopped)
  • 1 egg (optional)

Instructions

  • In a small saucepan, combine the broth, minced garlic, onion powder, grated ginger, and sliced mushrooms.

  • Bring it to a boil, then reduce the heat and simmer 5 minutes.

  • Allow the broth to cool slightly.

  • Remove ¼ cup of the warm broth to a small bowl and whisk in the miso paste.

  • Return the broth/miso mixture to the pan with the rest of the broth.

  • Turn the heat on low and add the spinach, heating just until warmed.

  • Top with the green onion and hard boiled egg if desired.

Notes

Other vegetables you can add: baby bok choy, daikon, cabbage, kale, chard

Nutrition

Serving: 1.5cups | Calories: 181kcal | Carbohydrates: 14g | Protein: 17g | Fat: 7g | Saturated Fat: 2g | Cholesterol: 163mg | Sodium: 820mg | Potassium: 675mg | Fiber: 2g | Sugar: 3g | Vitamin A: 35.3% | Vitamin C: 10.5% | Calcium: 5.4% | Iron: 14.7%

Have you ever used miso? What do you do with it?

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