Alicia Ault

It’s not a new drug – it’s been available in topical form for hair loss since 1988 and was approved as an antihypertensive in 1979 – but a low-dose oral form of minoxidil is gaining new currency – and a growing public profile – as an adjunctive therapy for hair loss.

The number of scholarly publications examining its use for hair loss has grown dramatically in the last 2 years: There were 2 in 2019, and that jumped to 17 in 2020 and 20 in 2021, with another 16 published so far this year, according to a PubMed search. An August article in The New York Times touting it as a potential cheap magic bullet is likely to drum up even more interest, said dermatologists.

The low-dose formulation is especially exciting for women, as there have been few great oral options for them, clinicians said.

Female hair loss “is devastating,” said Lily Talakoub, MD, adding that topical minoxidil (Rogaine), topical serums, and supplements “really do not provide the considerable growth that women really want to see.” Oral minoxidil is not approved by the U.S. Food and Drug Administration for hair loss, but “it has been shown in studies to cause the hairs to grow,” and has become a “lifeline” for women, said Dr. Talakoub, a dermatologist who is in private practice in McLean, Va.

“For many years we haven’t had anything new to tell patients medically,” said Lynne J. Goldberg, MD, professor of dermatology and pathology at Boston University School of Medicine. “Now, all of the sudden there’s a cheap, widely available efficacious medicine. That’s huge for female-pattern hair loss,” said Dr. Goldberg, who is also the director of the Boston Medical Center’s Hair Clinic.

“I’ve been using oral minoxidil for about 4 years with great success,” said dermatologist Eva Simmons-O’Brien, MD, who is in private practice in Towson, Md. She has used it primarily in women, mainly because she sees more women than men for hair loss.

Dr. Simmons-O’Brien said the excitement about low-dose oral minoxidil follows an increasing recognition in the medical and scientific community that hair loss is more than just a cosmetic issue.
 

Mechanism not fully understood

When minoxidil was first brought to market as an antihypertensive, clinicians noted hair growth in “balding patients,” which led to the development of the topical form. Even though it has been used for hair growth for decades, its mechanism of action is not fully understood. It is known that minoxidil is a vasodilator; it may also increase DNA synthesis and enhance cell proliferation, according to a review published in 2019.

“The positive effect of minoxidil on hair growth is mainly due to its metabolite, minoxidil sulfate, and the enzyme responsible for this conversion is sulfotransferase, which is located in hair follicles and varies in production among individuals,” write the authors, all affiliated with Mahidol University in Bangkok, Thailand.

Writing in the American Academy of Dermatology’s Dermatology World Insights and Inquiries, Warren R. Heymann, MD, observed that “even after decades of use,” how minoxidil improves alopecia is still not completely understood. He noted that a 2020 review found that minoxidil’s vasodilatory effects “are propagated by upregulation of vascular endothelial growth factor (VEGF), increasing cutaneous blood flow with resultant increase in oxygen and growth factor delivery to the hair follicle.” The medication prolongs the anagen phase and shortens the telogen phase, added Dr. Heymann, head of dermatology at Rowan University, Camden, N.J.

As an antihypertensive, minoxidil is given at 5-40 mg daily. Those doses have produced serious side effects such as sodium and fluid retention, ischemic heart disease, pericardial effusion, and pulmonary hypertension, according to the Thai researchers.

Those side effects have appeared to be rare with low-dose oral minoxidil. However, in JAAD Case Reports, South African researchers reported a case in which low-dose oral minoxidil may have led to cardiac side effects. A healthy 40-year-old woman, who after 3 weeks of treatment with 5% topical minoxidil, tacrolimus ointment 0.1%, clobetasol propionate ointment, 100 mg of doxycycline twice daily, and 0.25 mg of oral minoxidil daily, was hospitalized with full-body edema. An ultrasound showed fluid collections in the pericardium, pleural space, and abdomen. She also had a pleural effusion. The patient was given 40 mg of intravenous furosemide daily for 4 days, and the edema resolved.

“Having excluded other causes of pericardial effusion and anasarca in the previously healthy, young woman, we concluded that LDOM [low-dose oral minoxidil] was responsible for her clinical presentation,” write the authors.

A review of 17 studies published on-line in 2020 in the Journal of the American Academy of Dermatology found low-dose minoxidil to be safe and effective. Androgenetic alopecia was the most commonly studied, with doses of 0.25-1.25 mg proving to be effective and safe. It was also safe and effective for female-pattern hair loss, traction alopecia, chronic telogen effluvium, lichen planopilaris, alopecia areata, and permanent chemotherapy-induced alopecia.

The most common adverse effect was hypertrichosis. Other adverse events included postural hypotension and dizziness, lower-limb edema, and mild blood pressure changes.

In another multicenter, 1,404-patient safety study published in 2021 in JAAD, the authors found that hypertrichosis was the most frequent adverse event, reported by 15% of patients. Systemic adverse events included lightheadedness (1.7% of patients), fluid retention (1.3%), tachycardia (0.9%), headache (0.4%), periorbital edema (0.3%), and insomnia (0.2%). Only 29 patients (1.2%) withdrew because of these side effects.

“It definitely helps, and it’s relatively safe,” said Adam Friedman, MD, professor and chair of dermatology at George Washington University in Washington. “But I wouldn’t want to call it a game-changer,” he said, adding that it works best when used in combination with other therapies. He often uses it with a 5-alpha reductase inhibitor – finasteride (Propecia) or dutasteride (Avodart) – “rather than as a monotherapy,” said Dr. Friedman.
 

From Australia to around the globe

The first publication on low-dose oral minoxidil for hair loss was in December 2017. The pilot study in female-pattern hair loss was published in the International Journal of Dermatology by Rodney Sinclair, MBBS, MD, a Melbourne, Australia–based dermatologist.

Amy McMichael, MD, professor of dermatology at Wake Forest University, Winston-Salem, N.C., said she first heard Dr. Sinclair present his findings at an alopecia research meeting in Japan shortly before his initial publication.

“After that, I think all of us said, ‘Huh, this is interesting, and let’s try it, because we’re always looking for something more to help our patients,’” Dr. McMichael said, adding that she’s been prescribing low-dose minoxidil to her patients for 5 years.

She and colleagues at Wake Forest, along with Jerry Cooley, MD, a dermatologist in private practice in Charlotte, published a retrospective case series in March, looking at 105 adult patients – 80 women (ages 24-80) and 25 men (ages 19-63) – who were treated for androgenetic alopecia and/or telogen effluvium with oral minoxidil (dose range of 0.625–2.5 mg) once daily for a year, matched to 105 case controls.

Efficacy was based on the clinician’s assessment of clinical response and clinical photographic evaluation using a 3-point scale (worsening, stabilization, and improvement). Half of those treated demonstrated clinical improvement and 43% demonstrated stabilization. There was a significant difference (P < .001) in clinical response between those who received minoxidil and the controls.

Ideal patients?

Given its ease of use and low cost – $4-$12 for a 30-day supply of 2.5 mg tablets, according to GoodRX – low-dose minoxidil is a good fit for many patients, said dermatologists.

The best candidate is “a woman who’s perimenopausal or menopausal who’s got what we would say is moderate to severe loss of hair that’s kind of just starting,” said Dr. Simmons-O’Brien. The medication is not likely to grow hair where there is scarring already, however, she said.

“I tend to use it in people who either don’t want to do the topical minoxidil or have used it and have a lot of potential side effects from it,” like itching and irritation, said Dr. McMichael. She said oral minoxidil can also be helpful as an adjunct in patients with alopecia areata and that it can be used after anti-inflammatory treatments in central centrifugal cicatricial alopecia.

Dr. Goldberg said low-dose minoxidil would not be her first choice for female-pattern hair loss but that it’s “a great alternative” for people who can’t tolerate the topical form. Most of the women she has prescribed it to “have been pretty happy,” she added.

“I would be a little cautious in patients on a number of other medications,” Dr. Goldberg said, noting minoxidil’s potential systemic side effects.

Clinicians said they generally consult with a patient’s internist when they are starting them on oral minoxidil. “I always want to touch base with the primary care physician first,” said Dr. Friedman.

“If they’re on oral antihypertensive medications already, then I would ask them to talk to either their primary care physician or their cardiologist to make sure it’s okay to give this low dose,” said Dr. McMichael.

At the low doses, minoxidil rarely has any blood pressure–lowering effects, dermatologists said.

Women are usually started on 1.25 mg, while men can start at a higher, 2.5-mg dose, said clinicians.

Dr. Goldberg and Dr. Simmons-O’Brien said that recent additional warnings for finasteride about sexual side effects and the potential for suicide have changed the way they approach its use in young men, and that it has highlighted the potential for oral minoxidil as an alternative.

Oral minoxidil is rarely used as a monotherapy. “It takes a village” to address hair loss, said Dr. Simmons-O’Brien, noting that she likes to evaluate nutrition, vitamin D levels, and whether a patient is anemic or has thyroid disease when determining a course of action.

Dermatologists said they use oral minoxidil in combination with spironolactone, topical minoxidil, finasteride, or dutasteride. If patients are already on antihypertensives or at risk for excessive blood pressure–lowering effects of a combination that includes spironolactone, the dermatologists said again they will consult with a patient’s primary care physician first.

For women, the main limiting factor with oral minoxidil may be unwanted hair growth, usually on the face. Most of the clinicians interviewed for this story said they did not use spironolactone to counteract that hypertrichosis.

Dr. McMichael said she cautions African American women or women of African descent – who tend to have more body hair at baseline – that they should be aware of the potential for excess hair growth associated with low-dose minoxidil. She and other dermatologists interviewed for this story said they urge patients who are bothered by the excess hair to shave or wax or use other nonpharmacologic approaches.

The excess hair growth is less bothersome for men, they said.
 

Not a magic wand

Despite the increased profile and interest, oral minoxidil is not a cure-all, clinicians said.

“It’s important for patients to realize that hair loss can be complicated and there is no one magic wand,” said Dr. Simmons-O’Brien. Clinicians typically “are using several things to help encourage these follicular units to not miniaturize and disappear and create scars,” she said.

Dr. Friedman said he finds that patients have a hard time hearing that to continue to maintain growth, they have to take a medication for the rest of their life. “If you stop, you will have to start again,” he said. 

Oral minoxidil, when used in combination with other therapies, will improve hair growth, said Dr. Goldberg. But it will not take someone back a decade, she said. “I try to temper expectations – promise a little and achieve more,” Dr. Goldberg said.

The study was independently supported. Dr. Smith and Dr. Jones report no relevant financial relationships. Dr. Simmons-O’Brien reports that she has received speaking fees from Isdin. Dr. McMichael disclosed relationships with Eli Lilly, Pfizer, Nutrafol, Revian, and UCB Pharma. Dr. Friedman, Dr. Goldberg, and Dr. Talakoub reported no disclosures.

A version of this article first appeared on Medscape.com.

It’s not a new drug – it’s been available in topical form for hair loss since 1988 and was approved as an antihypertensive in 1979 – but a low-dose oral form of minoxidil is gaining new currency – and a growing public profile – as an adjunctive therapy for hair loss.

The number of scholarly publications examining its use for hair loss has grown dramatically in the last 2 years: There were 2 in 2019, and that jumped to 17 in 2020 and 20 in 2021, with another 16 published so far this year, according to a PubMed search. An August article in The New York Times touting it as a potential cheap magic bullet is likely to drum up even more interest, said dermatologists.

The low-dose formulation is especially exciting for women, as there have been few great oral options for them, clinicians said.

Female hair loss “is devastating,” said Lily Talakoub, MD, adding that topical minoxidil (Rogaine), topical serums, and supplements “really do not provide the considerable growth that women really want to see.” Oral minoxidil is not approved by the U.S. Food and Drug Administration for hair loss, but “it has been shown in studies to cause the hairs to grow,” and has become a “lifeline” for women, said Dr. Talakoub, a dermatologist who is in private practice in McLean, Va.

“For many years we haven’t had anything new to tell patients medically,” said Lynne J. Goldberg, MD, professor of dermatology and pathology at Boston University School of Medicine. “Now, all of the sudden there’s a cheap, widely available efficacious medicine. That’s huge for female-pattern hair loss,” said Dr. Goldberg, who is also the director of the Boston Medical Center’s Hair Clinic.

“I’ve been using oral minoxidil for about 4 years with great success,” said dermatologist Eva Simmons-O’Brien, MD, who is in private practice in Towson, Md. She has used it primarily in women, mainly because she sees more women than men for hair loss.

Dr. Simmons-O’Brien said the excitement about low-dose oral minoxidil follows an increasing recognition in the medical and scientific community that hair loss is more than just a cosmetic issue.
 

Mechanism not fully understood

When minoxidil was first brought to market as an antihypertensive, clinicians noted hair growth in “balding patients,” which led to the development of the topical form. Even though it has been used for hair growth for decades, its mechanism of action is not fully understood. It is known that minoxidil is a vasodilator; it may also increase DNA synthesis and enhance cell proliferation, according to a review published in 2019.

“The positive effect of minoxidil on hair growth is mainly due to its metabolite, minoxidil sulfate, and the enzyme responsible for this conversion is sulfotransferase, which is located in hair follicles and varies in production among individuals,” write the authors, all affiliated with Mahidol University in Bangkok, Thailand.

Writing in the American Academy of Dermatology’s Dermatology World Insights and Inquiries, Warren R. Heymann, MD, observed that “even after decades of use,” how minoxidil improves alopecia is still not completely understood. He noted that a 2020 review found that minoxidil’s vasodilatory effects “are propagated by upregulation of vascular endothelial growth factor (VEGF), increasing cutaneous blood flow with resultant increase in oxygen and growth factor delivery to the hair follicle.” The medication prolongs the anagen phase and shortens the telogen phase, added Dr. Heymann, head of dermatology at Rowan University, Camden, N.J.

As an antihypertensive, minoxidil is given at 5-40 mg daily. Those doses have produced serious side effects such as sodium and fluid retention, ischemic heart disease, pericardial effusion, and pulmonary hypertension, according to the Thai researchers.

Those side effects have appeared to be rare with low-dose oral minoxidil. However, in JAAD Case Reports, South African researchers reported a case in which low-dose oral minoxidil may have led to cardiac side effects. A healthy 40-year-old woman, who after 3 weeks of treatment with 5% topical minoxidil, tacrolimus ointment 0.1%, clobetasol propionate ointment, 100 mg of doxycycline twice daily, and 0.25 mg of oral minoxidil daily, was hospitalized with full-body edema. An ultrasound showed fluid collections in the pericardium, pleural space, and abdomen. She also had a pleural effusion. The patient was given 40 mg of intravenous furosemide daily for 4 days, and the edema resolved.

“Having excluded other causes of pericardial effusion and anasarca in the previously healthy, young woman, we concluded that LDOM [low-dose oral minoxidil] was responsible for her clinical presentation,” write the authors.

A review of 17 studies published on-line in 2020 in the Journal of the American Academy of Dermatology found low-dose minoxidil to be safe and effective. Androgenetic alopecia was the most commonly studied, with doses of 0.25-1.25 mg proving to be effective and safe. It was also safe and effective for female-pattern hair loss, traction alopecia, chronic telogen effluvium, lichen planopilaris, alopecia areata, and permanent chemotherapy-induced alopecia.

The most common adverse effect was hypertrichosis. Other adverse events included postural hypotension and dizziness, lower-limb edema, and mild blood pressure changes.

In another multicenter, 1,404-patient safety study published in 2021 in JAAD, the authors found that hypertrichosis was the most frequent adverse event, reported by 15% of patients. Systemic adverse events included lightheadedness (1.7% of patients), fluid retention (1.3%), tachycardia (0.9%), headache (0.4%), periorbital edema (0.3%), and insomnia (0.2%). Only 29 patients (1.2%) withdrew because of these side effects.

“It definitely helps, and it’s relatively safe,” said Adam Friedman, MD, professor and chair of dermatology at George Washington University in Washington. “But I wouldn’t want to call it a game-changer,” he said, adding that it works best when used in combination with other therapies. He often uses it with a 5-alpha reductase inhibitor – finasteride (Propecia) or dutasteride (Avodart) – “rather than as a monotherapy,” said Dr. Friedman.
 

From Australia to around the globe

The first publication on low-dose oral minoxidil for hair loss was in December 2017. The pilot study in female-pattern hair loss was published in the International Journal of Dermatology by Rodney Sinclair, MBBS, MD, a Melbourne, Australia–based dermatologist.

Amy McMichael, MD, professor of dermatology at Wake Forest University, Winston-Salem, N.C., said she first heard Dr. Sinclair present his findings at an alopecia research meeting in Japan shortly before his initial publication.

“After that, I think all of us said, ‘Huh, this is interesting, and let’s try it, because we’re always looking for something more to help our patients,’” Dr. McMichael said, adding that she’s been prescribing low-dose minoxidil to her patients for 5 years.

She and colleagues at Wake Forest, along with Jerry Cooley, MD, a dermatologist in private practice in Charlotte, published a retrospective case series in March, looking at 105 adult patients – 80 women (ages 24-80) and 25 men (ages 19-63) – who were treated for androgenetic alopecia and/or telogen effluvium with oral minoxidil (dose range of 0.625–2.5 mg) once daily for a year, matched to 105 case controls.

Efficacy was based on the clinician’s assessment of clinical response and clinical photographic evaluation using a 3-point scale (worsening, stabilization, and improvement). Half of those treated demonstrated clinical improvement and 43% demonstrated stabilization. There was a significant difference (P < .001) in clinical response between those who received minoxidil and the controls.

Ideal patients?

Given its ease of use and low cost – $4-$12 for a 30-day supply of 2.5 mg tablets, according to GoodRX – low-dose minoxidil is a good fit for many patients, said dermatologists.

The best candidate is “a woman who’s perimenopausal or menopausal who’s got what we would say is moderate to severe loss of hair that’s kind of just starting,” said Dr. Simmons-O’Brien. The medication is not likely to grow hair where there is scarring already, however, she said.

“I tend to use it in people who either don’t want to do the topical minoxidil or have used it and have a lot of potential side effects from it,” like itching and irritation, said Dr. McMichael. She said oral minoxidil can also be helpful as an adjunct in patients with alopecia areata and that it can be used after anti-inflammatory treatments in central centrifugal cicatricial alopecia.

Dr. Goldberg said low-dose minoxidil would not be her first choice for female-pattern hair loss but that it’s “a great alternative” for people who can’t tolerate the topical form. Most of the women she has prescribed it to “have been pretty happy,” she added.

“I would be a little cautious in patients on a number of other medications,” Dr. Goldberg said, noting minoxidil’s potential systemic side effects.

Clinicians said they generally consult with a patient’s internist when they are starting them on oral minoxidil. “I always want to touch base with the primary care physician first,” said Dr. Friedman.

“If they’re on oral antihypertensive medications already, then I would ask them to talk to either their primary care physician or their cardiologist to make sure it’s okay to give this low dose,” said Dr. McMichael.

At the low doses, minoxidil rarely has any blood pressure–lowering effects, dermatologists said.

Women are usually started on 1.25 mg, while men can start at a higher, 2.5-mg dose, said clinicians.

Dr. Goldberg and Dr. Simmons-O’Brien said that recent additional warnings for finasteride about sexual side effects and the potential for suicide have changed the way they approach its use in young men, and that it has highlighted the potential for oral minoxidil as an alternative.

Oral minoxidil is rarely used as a monotherapy. “It takes a village” to address hair loss, said Dr. Simmons-O’Brien, noting that she likes to evaluate nutrition, vitamin D levels, and whether a patient is anemic or has thyroid disease when determining a course of action.

Dermatologists said they use oral minoxidil in combination with spironolactone, topical minoxidil, finasteride, or dutasteride. If patients are already on antihypertensives or at risk for excessive blood pressure–lowering effects of a combination that includes spironolactone, the dermatologists said again they will consult with a patient’s primary care physician first.

For women, the main limiting factor with oral minoxidil may be unwanted hair growth, usually on the face. Most of the clinicians interviewed for this story said they did not use spironolactone to counteract that hypertrichosis.

Dr. McMichael said she cautions African American women or women of African descent – who tend to have more body hair at baseline – that they should be aware of the potential for excess hair growth associated with low-dose minoxidil. She and other dermatologists interviewed for this story said they urge patients who are bothered by the excess hair to shave or wax or use other nonpharmacologic approaches.

The excess hair growth is less bothersome for men, they said.
 

Not a magic wand

Despite the increased profile and interest, oral minoxidil is not a cure-all, clinicians said.

“It’s important for patients to realize that hair loss can be complicated and there is no one magic wand,” said Dr. Simmons-O’Brien. Clinicians typically “are using several things to help encourage these follicular units to not miniaturize and disappear and create scars,” she said.

Dr. Friedman said he finds that patients have a hard time hearing that to continue to maintain growth, they have to take a medication for the rest of their life. “If you stop, you will have to start again,” he said. 

Oral minoxidil, when used in combination with other therapies, will improve hair growth, said Dr. Goldberg. But it will not take someone back a decade, she said. “I try to temper expectations – promise a little and achieve more,” Dr. Goldberg said.

The study was independently supported. Dr. Smith and Dr. Jones report no relevant financial relationships. Dr. Simmons-O’Brien reports that she has received speaking fees from Isdin. Dr. McMichael disclosed relationships with Eli Lilly, Pfizer, Nutrafol, Revian, and UCB Pharma. Dr. Friedman, Dr. Goldberg, and Dr. Talakoub reported no disclosures.

A version of this article first appeared on Medscape.com.

It’s not a new drug – it’s been available in topical form for hair loss since 1988 and was approved as an antihypertensive in 1979 – but a low-dose oral form of minoxidil is gaining new currency – and a growing public profile – as an adjunctive therapy for hair loss.

The number of scholarly publications examining its use for hair loss has grown dramatically in the last 2 years: There were 2 in 2019, and that jumped to 17 in 2020 and 20 in 2021, with another 16 published so far this year, according to a PubMed search. An August article in The New York Times touting it as a potential cheap magic bullet is likely to drum up even more interest, said dermatologists.

The low-dose formulation is especially exciting for women, as there have been few great oral options for them, clinicians said.

Female hair loss “is devastating,” said Lily Talakoub, MD, adding that topical minoxidil (Rogaine), topical serums, and supplements “really do not provide the considerable growth that women really want to see.” Oral minoxidil is not approved by the U.S. Food and Drug Administration for hair loss, but “it has been shown in studies to cause the hairs to grow,” and has become a “lifeline” for women, said Dr. Talakoub, a dermatologist who is in private practice in McLean, Va.

“For many years we haven’t had anything new to tell patients medically,” said Lynne J. Goldberg, MD, professor of dermatology and pathology at Boston University School of Medicine. “Now, all of the sudden there’s a cheap, widely available efficacious medicine. That’s huge for female-pattern hair loss,” said Dr. Goldberg, who is also the director of the Boston Medical Center’s Hair Clinic.

“I’ve been using oral minoxidil for about 4 years with great success,” said dermatologist Eva Simmons-O’Brien, MD, who is in private practice in Towson, Md. She has used it primarily in women, mainly because she sees more women than men for hair loss.

Dr. Simmons-O’Brien said the excitement about low-dose oral minoxidil follows an increasing recognition in the medical and scientific community that hair loss is more than just a cosmetic issue.
 

Mechanism not fully understood

When minoxidil was first brought to market as an antihypertensive, clinicians noted hair growth in “balding patients,” which led to the development of the topical form. Even though it has been used for hair growth for decades, its mechanism of action is not fully understood. It is known that minoxidil is a vasodilator; it may also increase DNA synthesis and enhance cell proliferation, according to a review published in 2019.

“The positive effect of minoxidil on hair growth is mainly due to its metabolite, minoxidil sulfate, and the enzyme responsible for this conversion is sulfotransferase, which is located in hair follicles and varies in production among individuals,” write the authors, all affiliated with Mahidol University in Bangkok, Thailand.

Writing in the American Academy of Dermatology’s Dermatology World Insights and Inquiries, Warren R. Heymann, MD, observed that “even after decades of use,” how minoxidil improves alopecia is still not completely understood. He noted that a 2020 review found that minoxidil’s vasodilatory effects “are propagated by upregulation of vascular endothelial growth factor (VEGF), increasing cutaneous blood flow with resultant increase in oxygen and growth factor delivery to the hair follicle.” The medication prolongs the anagen phase and shortens the telogen phase, added Dr. Heymann, head of dermatology at Rowan University, Camden, N.J.

As an antihypertensive, minoxidil is given at 5-40 mg daily. Those doses have produced serious side effects such as sodium and fluid retention, ischemic heart disease, pericardial effusion, and pulmonary hypertension, according to the Thai researchers.

Those side effects have appeared to be rare with low-dose oral minoxidil. However, in JAAD Case Reports, South African researchers reported a case in which low-dose oral minoxidil may have led to cardiac side effects. A healthy 40-year-old woman, who after 3 weeks of treatment with 5% topical minoxidil, tacrolimus ointment 0.1%, clobetasol propionate ointment, 100 mg of doxycycline twice daily, and 0.25 mg of oral minoxidil daily, was hospitalized with full-body edema. An ultrasound showed fluid collections in the pericardium, pleural space, and abdomen. She also had a pleural effusion. The patient was given 40 mg of intravenous furosemide daily for 4 days, and the edema resolved.

“Having excluded other causes of pericardial effusion and anasarca in the previously healthy, young woman, we concluded that LDOM [low-dose oral minoxidil] was responsible for her clinical presentation,” write the authors.

A review of 17 studies published on-line in 2020 in the Journal of the American Academy of Dermatology found low-dose minoxidil to be safe and effective. Androgenetic alopecia was the most commonly studied, with doses of 0.25-1.25 mg proving to be effective and safe. It was also safe and effective for female-pattern hair loss, traction alopecia, chronic telogen effluvium, lichen planopilaris, alopecia areata, and permanent chemotherapy-induced alopecia.

The most common adverse effect was hypertrichosis. Other adverse events included postural hypotension and dizziness, lower-limb edema, and mild blood pressure changes.

In another multicenter, 1,404-patient safety study published in 2021 in JAAD, the authors found that hypertrichosis was the most frequent adverse event, reported by 15% of patients. Systemic adverse events included lightheadedness (1.7% of patients), fluid retention (1.3%), tachycardia (0.9%), headache (0.4%), periorbital edema (0.3%), and insomnia (0.2%). Only 29 patients (1.2%) withdrew because of these side effects.

“It definitely helps, and it’s relatively safe,” said Adam Friedman, MD, professor and chair of dermatology at George Washington University in Washington. “But I wouldn’t want to call it a game-changer,” he said, adding that it works best when used in combination with other therapies. He often uses it with a 5-alpha reductase inhibitor – finasteride (Propecia) or dutasteride (Avodart) – “rather than as a monotherapy,” said Dr. Friedman.
 

From Australia to around the globe

The first publication on low-dose oral minoxidil for hair loss was in December 2017. The pilot study in female-pattern hair loss was published in the International Journal of Dermatology by Rodney Sinclair, MBBS, MD, a Melbourne, Australia–based dermatologist.

Amy McMichael, MD, professor of dermatology at Wake Forest University, Winston-Salem, N.C., said she first heard Dr. Sinclair present his findings at an alopecia research meeting in Japan shortly before his initial publication.

“After that, I think all of us said, ‘Huh, this is interesting, and let’s try it, because we’re always looking for something more to help our patients,’” Dr. McMichael said, adding that she’s been prescribing low-dose minoxidil to her patients for 5 years.

She and colleagues at Wake Forest, along with Jerry Cooley, MD, a dermatologist in private practice in Charlotte, published a retrospective case series in March, looking at 105 adult patients – 80 women (ages 24-80) and 25 men (ages 19-63) – who were treated for androgenetic alopecia and/or telogen effluvium with oral minoxidil (dose range of 0.625–2.5 mg) once daily for a year, matched to 105 case controls.

Efficacy was based on the clinician’s assessment of clinical response and clinical photographic evaluation using a 3-point scale (worsening, stabilization, and improvement). Half of those treated demonstrated clinical improvement and 43% demonstrated stabilization. There was a significant difference (P < .001) in clinical response between those who received minoxidil and the controls.

Ideal patients?

Given its ease of use and low cost – $4-$12 for a 30-day supply of 2.5 mg tablets, according to GoodRX – low-dose minoxidil is a good fit for many patients, said dermatologists.

The best candidate is “a woman who’s perimenopausal or menopausal who’s got what we would say is moderate to severe loss of hair that’s kind of just starting,” said Dr. Simmons-O’Brien. The medication is not likely to grow hair where there is scarring already, however, she said.

“I tend to use it in people who either don’t want to do the topical minoxidil or have used it and have a lot of potential side effects from it,” like itching and irritation, said Dr. McMichael. She said oral minoxidil can also be helpful as an adjunct in patients with alopecia areata and that it can be used after anti-inflammatory treatments in central centrifugal cicatricial alopecia.

Dr. Goldberg said low-dose minoxidil would not be her first choice for female-pattern hair loss but that it’s “a great alternative” for people who can’t tolerate the topical form. Most of the women she has prescribed it to “have been pretty happy,” she added.

“I would be a little cautious in patients on a number of other medications,” Dr. Goldberg said, noting minoxidil’s potential systemic side effects.

Clinicians said they generally consult with a patient’s internist when they are starting them on oral minoxidil. “I always want to touch base with the primary care physician first,” said Dr. Friedman.

“If they’re on oral antihypertensive medications already, then I would ask them to talk to either their primary care physician or their cardiologist to make sure it’s okay to give this low dose,” said Dr. McMichael.

At the low doses, minoxidil rarely has any blood pressure–lowering effects, dermatologists said.

Women are usually started on 1.25 mg, while men can start at a higher, 2.5-mg dose, said clinicians.

Dr. Goldberg and Dr. Simmons-O’Brien said that recent additional warnings for finasteride about sexual side effects and the potential for suicide have changed the way they approach its use in young men, and that it has highlighted the potential for oral minoxidil as an alternative.

Oral minoxidil is rarely used as a monotherapy. “It takes a village” to address hair loss, said Dr. Simmons-O’Brien, noting that she likes to evaluate nutrition, vitamin D levels, and whether a patient is anemic or has thyroid disease when determining a course of action.

Dermatologists said they use oral minoxidil in combination with spironolactone, topical minoxidil, finasteride, or dutasteride. If patients are already on antihypertensives or at risk for excessive blood pressure–lowering effects of a combination that includes spironolactone, the dermatologists said again they will consult with a patient’s primary care physician first.

For women, the main limiting factor with oral minoxidil may be unwanted hair growth, usually on the face. Most of the clinicians interviewed for this story said they did not use spironolactone to counteract that hypertrichosis.

Dr. McMichael said she cautions African American women or women of African descent – who tend to have more body hair at baseline – that they should be aware of the potential for excess hair growth associated with low-dose minoxidil. She and other dermatologists interviewed for this story said they urge patients who are bothered by the excess hair to shave or wax or use other nonpharmacologic approaches.

The excess hair growth is less bothersome for men, they said.
 

Not a magic wand

Despite the increased profile and interest, oral minoxidil is not a cure-all, clinicians said.

“It’s important for patients to realize that hair loss can be complicated and there is no one magic wand,” said Dr. Simmons-O’Brien. Clinicians typically “are using several things to help encourage these follicular units to not miniaturize and disappear and create scars,” she said.

Dr. Friedman said he finds that patients have a hard time hearing that to continue to maintain growth, they have to take a medication for the rest of their life. “If you stop, you will have to start again,” he said. 

Oral minoxidil, when used in combination with other therapies, will improve hair growth, said Dr. Goldberg. But it will not take someone back a decade, she said. “I try to temper expectations – promise a little and achieve more,” Dr. Goldberg said.

The study was independently supported. Dr. Smith and Dr. Jones report no relevant financial relationships. Dr. Simmons-O’Brien reports that she has received speaking fees from Isdin. Dr. McMichael disclosed relationships with Eli Lilly, Pfizer, Nutrafol, Revian, and UCB Pharma. Dr. Friedman, Dr. Goldberg, and Dr. Talakoub reported no disclosures.

A version of this article first appeared on Medscape.com.

A New York psychiatrist who has been suspended from practicing pending an investigation by state licensing authorities has been sentenced to 11 years in state prison for her role in the attempted murder of her child’s father, who is also a psychiatrist.

Pamela Buchbinder pled guilty to first-degree burglary and assault on September 7, almost exactly 10 years after the November 2012 attack on Michael Weiss, MD. Weiss was beaten with a sledgehammer and stabbed multiple times but survived the attack.

The September plea deal was announced by the Manhattan district attorney, who said that Ms. Buchbinder acknowledged she had enlisted the help of her then-19-year-old cousin Jacob Nolan to kill Dr. Weiss. Ms. Buchbinder was in a custody battle with Dr. Weiss over their then-5-year-old child.

At the Oct. 11 sentencing, Ms. Buchbinder and her defense attorney attempted to withdraw that plea. NBC4 New York reported that Buchbinder claimed she was not in her right mind on the day of the plea because she had received a “contact high” from others in her holding cell who were using synthetic marijuana and that she had not taken her prescribed medications that day.

The judge did not entertain the request and proceeded with the sentencing.

Ms. Buchbinder has been held at Rikers Island prison, in East Elmhurst, N.Y., since she was arrested in 2017, so has already served 5 years of her 11-year sentence. She must also serve 5 years of postrelease probation.
 

Insurance policy beneficiary

Ms. Buchbinder’s cousin was convicted of second-degree attempted murder in 2016 and was sentenced to 9.5 years in prison.

In a 2017 interview with CBS News, Mr. Nolan, who said he was “bipolar,” claimed Ms. Buchbinder had manipulated him into trying to kill her child’s father by telling him “horror stories” about Weiss. Soon after the interview, Ms. Buchbinder was arrested.

In 2022, the New York Post reported that Ms. Buchbinder had been named a beneficiary of Dr. Weiss’ $1.5 million life insurance policy several days before the attack.

Prosecutors had surveillance footage of Ms. Buchbinder with Nolan at a Manhattan hardware store purchasing the sledgehammer. According to the CBS report, at the time of her arrest, she also was apparently preparing to flee.

She was denied bail and has been held at Rikers Island since her arrest.

Ms. Buchbinder was licensed to practice in New York in 1999. In April 2018, the New York State Board for Professional Medical Conduct issued an interim order that precluded her from practicing medicine in New York.

The interim order will be in effect until the board completes its investigation. As of press time, the board had not updated its files.

A version of this article first appeared on Medscape.com.

A New York psychiatrist who has been suspended from practicing pending an investigation by state licensing authorities has been sentenced to 11 years in state prison for her role in the attempted murder of her child’s father, who is also a psychiatrist.

Pamela Buchbinder pled guilty to first-degree burglary and assault on September 7, almost exactly 10 years after the November 2012 attack on Michael Weiss, MD. Weiss was beaten with a sledgehammer and stabbed multiple times but survived the attack.

The September plea deal was announced by the Manhattan district attorney, who said that Ms. Buchbinder acknowledged she had enlisted the help of her then-19-year-old cousin Jacob Nolan to kill Dr. Weiss. Ms. Buchbinder was in a custody battle with Dr. Weiss over their then-5-year-old child.

At the Oct. 11 sentencing, Ms. Buchbinder and her defense attorney attempted to withdraw that plea. NBC4 New York reported that Buchbinder claimed she was not in her right mind on the day of the plea because she had received a “contact high” from others in her holding cell who were using synthetic marijuana and that she had not taken her prescribed medications that day.

The judge did not entertain the request and proceeded with the sentencing.

Ms. Buchbinder has been held at Rikers Island prison, in East Elmhurst, N.Y., since she was arrested in 2017, so has already served 5 years of her 11-year sentence. She must also serve 5 years of postrelease probation.
 

Insurance policy beneficiary

Ms. Buchbinder’s cousin was convicted of second-degree attempted murder in 2016 and was sentenced to 9.5 years in prison.

In a 2017 interview with CBS News, Mr. Nolan, who said he was “bipolar,” claimed Ms. Buchbinder had manipulated him into trying to kill her child’s father by telling him “horror stories” about Weiss. Soon after the interview, Ms. Buchbinder was arrested.

In 2022, the New York Post reported that Ms. Buchbinder had been named a beneficiary of Dr. Weiss’ $1.5 million life insurance policy several days before the attack.

Prosecutors had surveillance footage of Ms. Buchbinder with Nolan at a Manhattan hardware store purchasing the sledgehammer. According to the CBS report, at the time of her arrest, she also was apparently preparing to flee.

She was denied bail and has been held at Rikers Island since her arrest.

Ms. Buchbinder was licensed to practice in New York in 1999. In April 2018, the New York State Board for Professional Medical Conduct issued an interim order that precluded her from practicing medicine in New York.

The interim order will be in effect until the board completes its investigation. As of press time, the board had not updated its files.

A version of this article first appeared on Medscape.com.

A New York psychiatrist who has been suspended from practicing pending an investigation by state licensing authorities has been sentenced to 11 years in state prison for her role in the attempted murder of her child’s father, who is also a psychiatrist.

Pamela Buchbinder pled guilty to first-degree burglary and assault on September 7, almost exactly 10 years after the November 2012 attack on Michael Weiss, MD. Weiss was beaten with a sledgehammer and stabbed multiple times but survived the attack.

The September plea deal was announced by the Manhattan district attorney, who said that Ms. Buchbinder acknowledged she had enlisted the help of her then-19-year-old cousin Jacob Nolan to kill Dr. Weiss. Ms. Buchbinder was in a custody battle with Dr. Weiss over their then-5-year-old child.

At the Oct. 11 sentencing, Ms. Buchbinder and her defense attorney attempted to withdraw that plea. NBC4 New York reported that Buchbinder claimed she was not in her right mind on the day of the plea because she had received a “contact high” from others in her holding cell who were using synthetic marijuana and that she had not taken her prescribed medications that day.

The judge did not entertain the request and proceeded with the sentencing.

Ms. Buchbinder has been held at Rikers Island prison, in East Elmhurst, N.Y., since she was arrested in 2017, so has already served 5 years of her 11-year sentence. She must also serve 5 years of postrelease probation.
 

Insurance policy beneficiary

Ms. Buchbinder’s cousin was convicted of second-degree attempted murder in 2016 and was sentenced to 9.5 years in prison.

In a 2017 interview with CBS News, Mr. Nolan, who said he was “bipolar,” claimed Ms. Buchbinder had manipulated him into trying to kill her child’s father by telling him “horror stories” about Weiss. Soon after the interview, Ms. Buchbinder was arrested.

In 2022, the New York Post reported that Ms. Buchbinder had been named a beneficiary of Dr. Weiss’ $1.5 million life insurance policy several days before the attack.

Prosecutors had surveillance footage of Ms. Buchbinder with Nolan at a Manhattan hardware store purchasing the sledgehammer. According to the CBS report, at the time of her arrest, she also was apparently preparing to flee.

She was denied bail and has been held at Rikers Island since her arrest.

Ms. Buchbinder was licensed to practice in New York in 1999. In April 2018, the New York State Board for Professional Medical Conduct issued an interim order that precluded her from practicing medicine in New York.

The interim order will be in effect until the board completes its investigation. As of press time, the board had not updated its files.

A version of this article first appeared on Medscape.com.

Some members of the American Academy of Pediatrics say its association leadership is blocking discussion about a resolution asking for a “rigorous systematic review” of gender-affirming care guidelines.

At issue is 2018 guidance that states children can undergo hormonal therapy after they are deemed appropriate candidates following a thorough mental health evaluation.

Critics say minors under age 18 may be getting “fast-tracked” to hormonal treatment too quickly or inappropriately and can end up regretting the decision and facing medical conditions like sterility.

Five AAP members, which has a total membership of around 67,000 pediatricians in the United States and Canada, this year penned Resolution 27, calling for a possible update of the guidelines following consultation with stakeholders that include mental health and medical clinicians, parents, and patients “with diverse views and experiences.”

Those members and others in written comments on a members-only website accuse the AAP of deliberately silencing debate on the issue and changing resolution rules. Any AAP member can submit a resolution for consideration by the group’s leadership at its annual policy meeting.

This year, the AAP sent an email to members stating it would not allow comments on resolutions that had not been “sponsored” by one of the group’s 66 chapters or 88 internal committees, councils, or sections.

That’s why comments were not allowed on Resolution 27, said Mark Del Monte, the AAP’s CEO. A second attempt to get sponsorship during the annual leadership forum, held earlier this month in Chicago, also failed, he noted. Mr. Del Monte told this news organization that changes to the resolution process are made every year and that no rule changes were directly associated with Resolution 27.

But one of the resolution’s authors said there was sponsorship when members first drafted the suggestion. Julia Mason, MD, a board member for the Society for Evidence-based Gender Medicine and a pediatrician in private practice in Gresham, Ore., says an AAP chapter president agreed to second Resolution 27 but backed off after attending a different AAP meeting. Dr. Mason did not name the member.

On Aug. 10, AAP President Moira Szilagyi, MD, PhD, wrote in a blog on the AAP website – after the AAP leadership meeting in Chicago – that the lack of sponsorship “meant no one was willing to support their proposal.”

The AAP Leadership Council’s 154 voting entities approved 48 resolutions at the meeting, all of which will be referred to the AAP Board of Directors for potential, but not definite, action as the Board only takes resolutions under advisement, Mr. Del Monte notes.

In an email allowing members to comment on a resolution (number 28) regarding education support for caring for transgender patients, 23 chose to support Resolution 27 instead.

“I am wholeheartedly in support of Resolution 27, which interestingly has been removed from the list of resolutions for member comment,” one comment read. “I can no longer trust the AAP to provide medical evidence-based education with regard to care for transgender individuals.” 

“We don’t need a formal resolution to look at the evidence around the care of transgender young people. Evaluating the evidence behind our recommendations, which the unsponsored resolution called for, is a routine part of the Academy’s policy-writing process,” wrote Dr. Szilagyi in her blog.

Mr. Del Monte says that “the 2018 policy is under review now.”

So far, “the evidence that we have seen reinforces our policy that gender-affirming care is the correct approach,” Mr. Del Monte stresses. “It is supported by every mainstream medical society in the world and is the standard of care,” he maintains.

Among those societies is the World Professional Association for Transgender Health, which in the draft of its latest Standards of Care (SOC8) – the first new guidance on the issue for 10 years – reportedly lowers the age for “top surgery” to 15 years.

The final SOC8 will most likely be published to coincide with WPATH’s annual meeting in September in Montreal.

Opponents plan to protest outside the AAP’s annual meeting, in Anaheim in October, Dr. Mason says.

“I’m concerned that kids with a transient gender identity are being funneled into medicalization that does not serve them,” Dr. Mason says. “I am worried that the trans identity is valued over the possibility of desistance,” she adds, admitting that her goal is to have fewer children transition gender.

Last summer, AAP found itself in hot water on the same topic when it barred SEGM from having a booth at the AAP annual meeting in 2021, as reported by this news organization.

A version of this article first appeared on Medscape.com.

Some members of the American Academy of Pediatrics say its association leadership is blocking discussion about a resolution asking for a “rigorous systematic review” of gender-affirming care guidelines.

At issue is 2018 guidance that states children can undergo hormonal therapy after they are deemed appropriate candidates following a thorough mental health evaluation.

Critics say minors under age 18 may be getting “fast-tracked” to hormonal treatment too quickly or inappropriately and can end up regretting the decision and facing medical conditions like sterility.

Five AAP members, which has a total membership of around 67,000 pediatricians in the United States and Canada, this year penned Resolution 27, calling for a possible update of the guidelines following consultation with stakeholders that include mental health and medical clinicians, parents, and patients “with diverse views and experiences.”

Those members and others in written comments on a members-only website accuse the AAP of deliberately silencing debate on the issue and changing resolution rules. Any AAP member can submit a resolution for consideration by the group’s leadership at its annual policy meeting.

This year, the AAP sent an email to members stating it would not allow comments on resolutions that had not been “sponsored” by one of the group’s 66 chapters or 88 internal committees, councils, or sections.

That’s why comments were not allowed on Resolution 27, said Mark Del Monte, the AAP’s CEO. A second attempt to get sponsorship during the annual leadership forum, held earlier this month in Chicago, also failed, he noted. Mr. Del Monte told this news organization that changes to the resolution process are made every year and that no rule changes were directly associated with Resolution 27.

But one of the resolution’s authors said there was sponsorship when members first drafted the suggestion. Julia Mason, MD, a board member for the Society for Evidence-based Gender Medicine and a pediatrician in private practice in Gresham, Ore., says an AAP chapter president agreed to second Resolution 27 but backed off after attending a different AAP meeting. Dr. Mason did not name the member.

On Aug. 10, AAP President Moira Szilagyi, MD, PhD, wrote in a blog on the AAP website – after the AAP leadership meeting in Chicago – that the lack of sponsorship “meant no one was willing to support their proposal.”

The AAP Leadership Council’s 154 voting entities approved 48 resolutions at the meeting, all of which will be referred to the AAP Board of Directors for potential, but not definite, action as the Board only takes resolutions under advisement, Mr. Del Monte notes.

In an email allowing members to comment on a resolution (number 28) regarding education support for caring for transgender patients, 23 chose to support Resolution 27 instead.

“I am wholeheartedly in support of Resolution 27, which interestingly has been removed from the list of resolutions for member comment,” one comment read. “I can no longer trust the AAP to provide medical evidence-based education with regard to care for transgender individuals.” 

“We don’t need a formal resolution to look at the evidence around the care of transgender young people. Evaluating the evidence behind our recommendations, which the unsponsored resolution called for, is a routine part of the Academy’s policy-writing process,” wrote Dr. Szilagyi in her blog.

Mr. Del Monte says that “the 2018 policy is under review now.”

So far, “the evidence that we have seen reinforces our policy that gender-affirming care is the correct approach,” Mr. Del Monte stresses. “It is supported by every mainstream medical society in the world and is the standard of care,” he maintains.

Among those societies is the World Professional Association for Transgender Health, which in the draft of its latest Standards of Care (SOC8) – the first new guidance on the issue for 10 years – reportedly lowers the age for “top surgery” to 15 years.

The final SOC8 will most likely be published to coincide with WPATH’s annual meeting in September in Montreal.

Opponents plan to protest outside the AAP’s annual meeting, in Anaheim in October, Dr. Mason says.

“I’m concerned that kids with a transient gender identity are being funneled into medicalization that does not serve them,” Dr. Mason says. “I am worried that the trans identity is valued over the possibility of desistance,” she adds, admitting that her goal is to have fewer children transition gender.

Last summer, AAP found itself in hot water on the same topic when it barred SEGM from having a booth at the AAP annual meeting in 2021, as reported by this news organization.

A version of this article first appeared on Medscape.com.

Some members of the American Academy of Pediatrics say its association leadership is blocking discussion about a resolution asking for a “rigorous systematic review” of gender-affirming care guidelines.

At issue is 2018 guidance that states children can undergo hormonal therapy after they are deemed appropriate candidates following a thorough mental health evaluation.

Critics say minors under age 18 may be getting “fast-tracked” to hormonal treatment too quickly or inappropriately and can end up regretting the decision and facing medical conditions like sterility.

Five AAP members, which has a total membership of around 67,000 pediatricians in the United States and Canada, this year penned Resolution 27, calling for a possible update of the guidelines following consultation with stakeholders that include mental health and medical clinicians, parents, and patients “with diverse views and experiences.”

Those members and others in written comments on a members-only website accuse the AAP of deliberately silencing debate on the issue and changing resolution rules. Any AAP member can submit a resolution for consideration by the group’s leadership at its annual policy meeting.

This year, the AAP sent an email to members stating it would not allow comments on resolutions that had not been “sponsored” by one of the group’s 66 chapters or 88 internal committees, councils, or sections.

That’s why comments were not allowed on Resolution 27, said Mark Del Monte, the AAP’s CEO. A second attempt to get sponsorship during the annual leadership forum, held earlier this month in Chicago, also failed, he noted. Mr. Del Monte told this news organization that changes to the resolution process are made every year and that no rule changes were directly associated with Resolution 27.

But one of the resolution’s authors said there was sponsorship when members first drafted the suggestion. Julia Mason, MD, a board member for the Society for Evidence-based Gender Medicine and a pediatrician in private practice in Gresham, Ore., says an AAP chapter president agreed to second Resolution 27 but backed off after attending a different AAP meeting. Dr. Mason did not name the member.

On Aug. 10, AAP President Moira Szilagyi, MD, PhD, wrote in a blog on the AAP website – after the AAP leadership meeting in Chicago – that the lack of sponsorship “meant no one was willing to support their proposal.”

The AAP Leadership Council’s 154 voting entities approved 48 resolutions at the meeting, all of which will be referred to the AAP Board of Directors for potential, but not definite, action as the Board only takes resolutions under advisement, Mr. Del Monte notes.

In an email allowing members to comment on a resolution (number 28) regarding education support for caring for transgender patients, 23 chose to support Resolution 27 instead.

“I am wholeheartedly in support of Resolution 27, which interestingly has been removed from the list of resolutions for member comment,” one comment read. “I can no longer trust the AAP to provide medical evidence-based education with regard to care for transgender individuals.” 

“We don’t need a formal resolution to look at the evidence around the care of transgender young people. Evaluating the evidence behind our recommendations, which the unsponsored resolution called for, is a routine part of the Academy’s policy-writing process,” wrote Dr. Szilagyi in her blog.

Mr. Del Monte says that “the 2018 policy is under review now.”

So far, “the evidence that we have seen reinforces our policy that gender-affirming care is the correct approach,” Mr. Del Monte stresses. “It is supported by every mainstream medical society in the world and is the standard of care,” he maintains.

Among those societies is the World Professional Association for Transgender Health, which in the draft of its latest Standards of Care (SOC8) – the first new guidance on the issue for 10 years – reportedly lowers the age for “top surgery” to 15 years.

The final SOC8 will most likely be published to coincide with WPATH’s annual meeting in September in Montreal.

Opponents plan to protest outside the AAP’s annual meeting, in Anaheim in October, Dr. Mason says.

“I’m concerned that kids with a transient gender identity are being funneled into medicalization that does not serve them,” Dr. Mason says. “I am worried that the trans identity is valued over the possibility of desistance,” she adds, admitting that her goal is to have fewer children transition gender.

Last summer, AAP found itself in hot water on the same topic when it barred SEGM from having a booth at the AAP annual meeting in 2021, as reported by this news organization.

A version of this article first appeared on Medscape.com.

When Spencer Siedlecki got COVID-19 in March 2021, he was sick for weeks with extreme fatigue, fevers, a sore throat, bad headaches, nausea, and eventually, pneumonia.

That was scary enough for the then-13-year-old and his parents, who live in Ohio. More than a year later, Spencer still had many of the symptoms and, more alarming, the once-healthy teen had postural orthostatic tachycardia syndrome, a condition that has caused dizziness, a racing heart when he stands, and fainting. Spencer missed most of the last few months of eighth grade because of long COVID.

“He gets sick very easily,” said his mother, Melissa Siedlecki, who works in technology sales. “The common cold that he would shake off in a few days takes weeks for him to feel better.”

The transformation from regular teen life to someone with a chronic illness “sucked,” said Spencer, who will turn 15 in August. “I felt like I was never going to get better.” Fortunately, after some therapy at a specialized clinic, Spencer is back to playing baseball and golf.

Spencer’s journey to better health was difficult; his regular pediatrician told the family at first that there were no treatments to help him – a reaction that is not uncommon. “I still get a lot of parents who heard of me through the grapevine,” said Amy Edwards, MD, director of the pediatric COVID clinic at University Hospitals Rainbow Babies & Children’s and an assistant professor of pediatrics at Case Western Reserve University, both in Cleveland. “The pediatricians either are unsure of what is wrong, or worse, tell children ‘there is nothing wrong with you. Stop faking it.’ ” Dr. Edwards treated Spencer after his mother found the clinic through an internet search.

Alexandra Yonts, MD, a pediatric infectious diseases doctor and director of the post-COVID program clinic at Children’s National Medical Center in Washington, has seen this too. They’ve had “a lot of kids coming in and saying we’ve been passed around from doctor to doctor, and some of them don’t even believe long COVID exists,” she said.

But those who do get attention tend to be White and affluent, something Dr. Yonts said “doesn’t jibe with the epidemiologic data of who COVID has affected the most.” Black, Latino, and American Indian and Alaska Native children are more likely to be infected with COVID than White children, and have higher rates of hospitalization and death than White children.

It’s not clear whether these children have a particular risk factor, or if they are just the ones who have the resources to get to the clinics. But Dr. Yonts and Dr. Edwards believe many children are not getting the help they need. High-performing kids are coming in “because they are the ones whose symptoms are most obvious,” said Dr. Edwards. “I think there are kids out there who are getting missed because they’re already struggling because of socioeconomic reasons.”

Spencer is one of 14 million children who have tested positive for SARS-CoV-2 since the start of the pandemic. Many pediatricians are still grappling with how to address cases like Spencer’s. The American Academy of Pediatrics has issued only brief guidance on long COVID in children, in part because there have been so few studies to use as a basis for guidance.

The federal government is aiming to change that with a newly launched National Research Action Plan on Long COVID that includes speeding up research on how the condition affects children and youths, including their ability to learn and thrive.

A CDC study found children with COVID were significantly more likely to have smell and taste disturbances, circulatory system problems, fatigue and malaise, and pain. Those who had been infected had higher rates of acute blockage of a lung artery, myocarditis and weakening of the heart, kidney failure, and type 1 diabetes.
 

Difficult to diagnose

Even with increased media attention and more published studies on pediatric long COVID, it’s still hard for a busy primary care doctor “to sort through what could just be a cold or what could be a series of colds and trying to look at the bigger picture of what’s been going on in a 1- to 3-month period with a kid,” Dr. Yonts said.

Most children with potential or definite long COVID are still being seen by individual pediatricians, not in a specialized clinic with easy access to an army of specialists. It’s not clear how many of those pediatric clinics exist. Survivor Corps, an advocacy group for people with long COVID, has posted a map of locations providing care, but few are specialized or focus on pediatric long COVID.

Long COVID is different from multisystem inflammatory syndrome in children (MIS-C), which occurs within a month or so of infection, triggers high fevers and severe symptoms in the gut, and often results in hospitalization. MIS-C “is not subtle,” said Dr. Edwards.

The long COVID clinic doctors said most of their patients were not very sick at first. “Anecdotally, of the 83 kids that we’ve seen, most have had mild, very mild, or even asymptomatic infections initially,” and then went on to have long COVID, said Dr. Yonts.

“We see it even in children who have very mild disease or even are asymptomatic,” agreed Allison Eckard, MD, director of pediatric infectious diseases at the Medical University of South Carolina, Charleston.
 

Fatigue, mood problems

Dr. Yonts said 90% of her patients have fatigue, and many also have severe symptoms in their gut. Those and other long COVID symptoms will be looked at more closely in a 3-year study the Children’s National Medical Center is doing along with the National Institute of Allergy and Infectious Diseases.

There are no treatments for long COVID itself.

“Management is probably more the correct term for what we do in our clinic at this point,” said Dr. Yonts. That means dealing with fatigue and managing headache and digestive symptoms with medications or coping strategies. Guidelines from the American Academy of Physical Medicine and Rehabilitation help inform how to help kids safely resume exercise.

At the Children’s National Medical Center clinic, children will typically meet with a team of specialists including infectious diseases doctors on the same day, said Dr. Yonts. Psychologists help children with coping skills. Dr. Yonts is careful not to imply that long COVID is a psychological illness. Parents “will just shut down, because for so long, they’ve been told this is all a mental thing.”

In about a third of children, symptoms get better on their own, and most kids get better over time. But many still struggle. “We don’t talk about cure, because we don’t know what cure looks like,” said Dr. Edwards.
 

Vaccination may be best protection

Vaccination seems to help reduce the risk of long COVID, perhaps by as much as half. But parents have been slow to vaccinate children, especially the very young. The AAP reported that, as of Aug. 3, just 5% of children under age 5, 37% of those ages 5-11, and 69% of 12- to 17-year-olds have received at least one dose of a COVID-19 vaccine.

“We have tried to really push vaccine as one of the ways to help prevent some of these long COVID syndromes,” said Dr. Eckard. But that advice is not always welcome. Dr. Eckard told the story of a mother who refused to have her autistic son vaccinated, even as she tearfully pleaded for help with his long COVID symptoms, which had also worsened his autism. The woman told Dr. Eckard: “Nothing you can say will convince me to get him vaccinated.” She thought a vaccine could make his symptoms even worse.

The best prevention is to avoid being infected in the first place.

“The more times you get COVID, the more you increase your risk of getting long COVID,” said Dr. Yonts. “The more times you roll the dice, eventually your number could come up.

A version of this article first appeared on WebMD.com.

When Spencer Siedlecki got COVID-19 in March 2021, he was sick for weeks with extreme fatigue, fevers, a sore throat, bad headaches, nausea, and eventually, pneumonia.

That was scary enough for the then-13-year-old and his parents, who live in Ohio. More than a year later, Spencer still had many of the symptoms and, more alarming, the once-healthy teen had postural orthostatic tachycardia syndrome, a condition that has caused dizziness, a racing heart when he stands, and fainting. Spencer missed most of the last few months of eighth grade because of long COVID.

“He gets sick very easily,” said his mother, Melissa Siedlecki, who works in technology sales. “The common cold that he would shake off in a few days takes weeks for him to feel better.”

The transformation from regular teen life to someone with a chronic illness “sucked,” said Spencer, who will turn 15 in August. “I felt like I was never going to get better.” Fortunately, after some therapy at a specialized clinic, Spencer is back to playing baseball and golf.

Spencer’s journey to better health was difficult; his regular pediatrician told the family at first that there were no treatments to help him – a reaction that is not uncommon. “I still get a lot of parents who heard of me through the grapevine,” said Amy Edwards, MD, director of the pediatric COVID clinic at University Hospitals Rainbow Babies & Children’s and an assistant professor of pediatrics at Case Western Reserve University, both in Cleveland. “The pediatricians either are unsure of what is wrong, or worse, tell children ‘there is nothing wrong with you. Stop faking it.’ ” Dr. Edwards treated Spencer after his mother found the clinic through an internet search.

Alexandra Yonts, MD, a pediatric infectious diseases doctor and director of the post-COVID program clinic at Children’s National Medical Center in Washington, has seen this too. They’ve had “a lot of kids coming in and saying we’ve been passed around from doctor to doctor, and some of them don’t even believe long COVID exists,” she said.

But those who do get attention tend to be White and affluent, something Dr. Yonts said “doesn’t jibe with the epidemiologic data of who COVID has affected the most.” Black, Latino, and American Indian and Alaska Native children are more likely to be infected with COVID than White children, and have higher rates of hospitalization and death than White children.

It’s not clear whether these children have a particular risk factor, or if they are just the ones who have the resources to get to the clinics. But Dr. Yonts and Dr. Edwards believe many children are not getting the help they need. High-performing kids are coming in “because they are the ones whose symptoms are most obvious,” said Dr. Edwards. “I think there are kids out there who are getting missed because they’re already struggling because of socioeconomic reasons.”

Spencer is one of 14 million children who have tested positive for SARS-CoV-2 since the start of the pandemic. Many pediatricians are still grappling with how to address cases like Spencer’s. The American Academy of Pediatrics has issued only brief guidance on long COVID in children, in part because there have been so few studies to use as a basis for guidance.

The federal government is aiming to change that with a newly launched National Research Action Plan on Long COVID that includes speeding up research on how the condition affects children and youths, including their ability to learn and thrive.

A CDC study found children with COVID were significantly more likely to have smell and taste disturbances, circulatory system problems, fatigue and malaise, and pain. Those who had been infected had higher rates of acute blockage of a lung artery, myocarditis and weakening of the heart, kidney failure, and type 1 diabetes.
 

Difficult to diagnose

Even with increased media attention and more published studies on pediatric long COVID, it’s still hard for a busy primary care doctor “to sort through what could just be a cold or what could be a series of colds and trying to look at the bigger picture of what’s been going on in a 1- to 3-month period with a kid,” Dr. Yonts said.

Most children with potential or definite long COVID are still being seen by individual pediatricians, not in a specialized clinic with easy access to an army of specialists. It’s not clear how many of those pediatric clinics exist. Survivor Corps, an advocacy group for people with long COVID, has posted a map of locations providing care, but few are specialized or focus on pediatric long COVID.

Long COVID is different from multisystem inflammatory syndrome in children (MIS-C), which occurs within a month or so of infection, triggers high fevers and severe symptoms in the gut, and often results in hospitalization. MIS-C “is not subtle,” said Dr. Edwards.

The long COVID clinic doctors said most of their patients were not very sick at first. “Anecdotally, of the 83 kids that we’ve seen, most have had mild, very mild, or even asymptomatic infections initially,” and then went on to have long COVID, said Dr. Yonts.

“We see it even in children who have very mild disease or even are asymptomatic,” agreed Allison Eckard, MD, director of pediatric infectious diseases at the Medical University of South Carolina, Charleston.
 

Fatigue, mood problems

Dr. Yonts said 90% of her patients have fatigue, and many also have severe symptoms in their gut. Those and other long COVID symptoms will be looked at more closely in a 3-year study the Children’s National Medical Center is doing along with the National Institute of Allergy and Infectious Diseases.

There are no treatments for long COVID itself.

“Management is probably more the correct term for what we do in our clinic at this point,” said Dr. Yonts. That means dealing with fatigue and managing headache and digestive symptoms with medications or coping strategies. Guidelines from the American Academy of Physical Medicine and Rehabilitation help inform how to help kids safely resume exercise.

At the Children’s National Medical Center clinic, children will typically meet with a team of specialists including infectious diseases doctors on the same day, said Dr. Yonts. Psychologists help children with coping skills. Dr. Yonts is careful not to imply that long COVID is a psychological illness. Parents “will just shut down, because for so long, they’ve been told this is all a mental thing.”

In about a third of children, symptoms get better on their own, and most kids get better over time. But many still struggle. “We don’t talk about cure, because we don’t know what cure looks like,” said Dr. Edwards.
 

Vaccination may be best protection

Vaccination seems to help reduce the risk of long COVID, perhaps by as much as half. But parents have been slow to vaccinate children, especially the very young. The AAP reported that, as of Aug. 3, just 5% of children under age 5, 37% of those ages 5-11, and 69% of 12- to 17-year-olds have received at least one dose of a COVID-19 vaccine.

“We have tried to really push vaccine as one of the ways to help prevent some of these long COVID syndromes,” said Dr. Eckard. But that advice is not always welcome. Dr. Eckard told the story of a mother who refused to have her autistic son vaccinated, even as she tearfully pleaded for help with his long COVID symptoms, which had also worsened his autism. The woman told Dr. Eckard: “Nothing you can say will convince me to get him vaccinated.” She thought a vaccine could make his symptoms even worse.

The best prevention is to avoid being infected in the first place.

“The more times you get COVID, the more you increase your risk of getting long COVID,” said Dr. Yonts. “The more times you roll the dice, eventually your number could come up.

A version of this article first appeared on WebMD.com.

When Spencer Siedlecki got COVID-19 in March 2021, he was sick for weeks with extreme fatigue, fevers, a sore throat, bad headaches, nausea, and eventually, pneumonia.

That was scary enough for the then-13-year-old and his parents, who live in Ohio. More than a year later, Spencer still had many of the symptoms and, more alarming, the once-healthy teen had postural orthostatic tachycardia syndrome, a condition that has caused dizziness, a racing heart when he stands, and fainting. Spencer missed most of the last few months of eighth grade because of long COVID.

“He gets sick very easily,” said his mother, Melissa Siedlecki, who works in technology sales. “The common cold that he would shake off in a few days takes weeks for him to feel better.”

The transformation from regular teen life to someone with a chronic illness “sucked,” said Spencer, who will turn 15 in August. “I felt like I was never going to get better.” Fortunately, after some therapy at a specialized clinic, Spencer is back to playing baseball and golf.

Spencer’s journey to better health was difficult; his regular pediatrician told the family at first that there were no treatments to help him – a reaction that is not uncommon. “I still get a lot of parents who heard of me through the grapevine,” said Amy Edwards, MD, director of the pediatric COVID clinic at University Hospitals Rainbow Babies & Children’s and an assistant professor of pediatrics at Case Western Reserve University, both in Cleveland. “The pediatricians either are unsure of what is wrong, or worse, tell children ‘there is nothing wrong with you. Stop faking it.’ ” Dr. Edwards treated Spencer after his mother found the clinic through an internet search.

Alexandra Yonts, MD, a pediatric infectious diseases doctor and director of the post-COVID program clinic at Children’s National Medical Center in Washington, has seen this too. They’ve had “a lot of kids coming in and saying we’ve been passed around from doctor to doctor, and some of them don’t even believe long COVID exists,” she said.

But those who do get attention tend to be White and affluent, something Dr. Yonts said “doesn’t jibe with the epidemiologic data of who COVID has affected the most.” Black, Latino, and American Indian and Alaska Native children are more likely to be infected with COVID than White children, and have higher rates of hospitalization and death than White children.

It’s not clear whether these children have a particular risk factor, or if they are just the ones who have the resources to get to the clinics. But Dr. Yonts and Dr. Edwards believe many children are not getting the help they need. High-performing kids are coming in “because they are the ones whose symptoms are most obvious,” said Dr. Edwards. “I think there are kids out there who are getting missed because they’re already struggling because of socioeconomic reasons.”

Spencer is one of 14 million children who have tested positive for SARS-CoV-2 since the start of the pandemic. Many pediatricians are still grappling with how to address cases like Spencer’s. The American Academy of Pediatrics has issued only brief guidance on long COVID in children, in part because there have been so few studies to use as a basis for guidance.

The federal government is aiming to change that with a newly launched National Research Action Plan on Long COVID that includes speeding up research on how the condition affects children and youths, including their ability to learn and thrive.

A CDC study found children with COVID were significantly more likely to have smell and taste disturbances, circulatory system problems, fatigue and malaise, and pain. Those who had been infected had higher rates of acute blockage of a lung artery, myocarditis and weakening of the heart, kidney failure, and type 1 diabetes.
 

Difficult to diagnose

Even with increased media attention and more published studies on pediatric long COVID, it’s still hard for a busy primary care doctor “to sort through what could just be a cold or what could be a series of colds and trying to look at the bigger picture of what’s been going on in a 1- to 3-month period with a kid,” Dr. Yonts said.

Most children with potential or definite long COVID are still being seen by individual pediatricians, not in a specialized clinic with easy access to an army of specialists. It’s not clear how many of those pediatric clinics exist. Survivor Corps, an advocacy group for people with long COVID, has posted a map of locations providing care, but few are specialized or focus on pediatric long COVID.

Long COVID is different from multisystem inflammatory syndrome in children (MIS-C), which occurs within a month or so of infection, triggers high fevers and severe symptoms in the gut, and often results in hospitalization. MIS-C “is not subtle,” said Dr. Edwards.

The long COVID clinic doctors said most of their patients were not very sick at first. “Anecdotally, of the 83 kids that we’ve seen, most have had mild, very mild, or even asymptomatic infections initially,” and then went on to have long COVID, said Dr. Yonts.

“We see it even in children who have very mild disease or even are asymptomatic,” agreed Allison Eckard, MD, director of pediatric infectious diseases at the Medical University of South Carolina, Charleston.
 

Fatigue, mood problems

Dr. Yonts said 90% of her patients have fatigue, and many also have severe symptoms in their gut. Those and other long COVID symptoms will be looked at more closely in a 3-year study the Children’s National Medical Center is doing along with the National Institute of Allergy and Infectious Diseases.

There are no treatments for long COVID itself.

“Management is probably more the correct term for what we do in our clinic at this point,” said Dr. Yonts. That means dealing with fatigue and managing headache and digestive symptoms with medications or coping strategies. Guidelines from the American Academy of Physical Medicine and Rehabilitation help inform how to help kids safely resume exercise.

At the Children’s National Medical Center clinic, children will typically meet with a team of specialists including infectious diseases doctors on the same day, said Dr. Yonts. Psychologists help children with coping skills. Dr. Yonts is careful not to imply that long COVID is a psychological illness. Parents “will just shut down, because for so long, they’ve been told this is all a mental thing.”

In about a third of children, symptoms get better on their own, and most kids get better over time. But many still struggle. “We don’t talk about cure, because we don’t know what cure looks like,” said Dr. Edwards.
 

Vaccination may be best protection

Vaccination seems to help reduce the risk of long COVID, perhaps by as much as half. But parents have been slow to vaccinate children, especially the very young. The AAP reported that, as of Aug. 3, just 5% of children under age 5, 37% of those ages 5-11, and 69% of 12- to 17-year-olds have received at least one dose of a COVID-19 vaccine.

“We have tried to really push vaccine as one of the ways to help prevent some of these long COVID syndromes,” said Dr. Eckard. But that advice is not always welcome. Dr. Eckard told the story of a mother who refused to have her autistic son vaccinated, even as she tearfully pleaded for help with his long COVID symptoms, which had also worsened his autism. The woman told Dr. Eckard: “Nothing you can say will convince me to get him vaccinated.” She thought a vaccine could make his symptoms even worse.

The best prevention is to avoid being infected in the first place.

“The more times you get COVID, the more you increase your risk of getting long COVID,” said Dr. Yonts. “The more times you roll the dice, eventually your number could come up.

A version of this article first appeared on WebMD.com.

It is a story that has quickly gone viral around the world: A Mission Viejo, Calif.-based dermatologist has been arrested for allegedly poisoning her husband.

Yue Yu, MD, aged 45, was booked into the Orange County Jail on Aug. 4, after Irvine Police had been called to her residence that day by her husband, Jack Chen, MD, 53, a radiologist. Dr. Chen provided the police with video evidence that he said showed Dr. Yu pouring a drain-opening chemical into his hot lemonade drink.

“The victim sustained significant internal injuries but is expected to recover,” the Irvine police department said in a statement.

Dr. Yu was released after paying a $30,000 bond and has not been formally charged, according to the New York Post.

In a statement to the court on Aug. 5, Dr. Chen said he and the couple’s two children had long suffered verbal abuse from his wife and her mother, according to the Post. Multiple news organizations reported that Dr. Chen filed for divorce and also for a restraining order against Dr. Yu on that day.

After feeling ill for months – and being diagnosed with ulcers and esophageal inflammation – Dr. Chen reportedly set up video cameras in the couple’s house. He said he caught Dr. Yu on camera pouring something into his drink on several occasions in July.

According to NBC News, Dr. Yu’s attorney, David E. Wohl, said that Dr. Yu “vehemently and unequivocally denies ever attempting to poison her husband or anyone else.”

Dr. Yu received her medical degree from Washington University in St. Louis in 2006 and has no disciplinary actions against her, according to the Medical Board of California. She was head of dermatology at Mission Heritage Medical Group, but her name and information have been scrubbed from that group’s website. Mission Heritage is affiliated with Providence Mission Hospital. A spokesperson for the hospital told NBC News that it is cooperating with the police investigation and that no patients are in danger.

The dermatologist is due to report back to court in November, NBC News said.

A version of this article first appeared on Medscape.com.

It is a story that has quickly gone viral around the world: A Mission Viejo, Calif.-based dermatologist has been arrested for allegedly poisoning her husband.

Yue Yu, MD, aged 45, was booked into the Orange County Jail on Aug. 4, after Irvine Police had been called to her residence that day by her husband, Jack Chen, MD, 53, a radiologist. Dr. Chen provided the police with video evidence that he said showed Dr. Yu pouring a drain-opening chemical into his hot lemonade drink.

“The victim sustained significant internal injuries but is expected to recover,” the Irvine police department said in a statement.

Dr. Yu was released after paying a $30,000 bond and has not been formally charged, according to the New York Post.

In a statement to the court on Aug. 5, Dr. Chen said he and the couple’s two children had long suffered verbal abuse from his wife and her mother, according to the Post. Multiple news organizations reported that Dr. Chen filed for divorce and also for a restraining order against Dr. Yu on that day.

After feeling ill for months – and being diagnosed with ulcers and esophageal inflammation – Dr. Chen reportedly set up video cameras in the couple’s house. He said he caught Dr. Yu on camera pouring something into his drink on several occasions in July.

According to NBC News, Dr. Yu’s attorney, David E. Wohl, said that Dr. Yu “vehemently and unequivocally denies ever attempting to poison her husband or anyone else.”

Dr. Yu received her medical degree from Washington University in St. Louis in 2006 and has no disciplinary actions against her, according to the Medical Board of California. She was head of dermatology at Mission Heritage Medical Group, but her name and information have been scrubbed from that group’s website. Mission Heritage is affiliated with Providence Mission Hospital. A spokesperson for the hospital told NBC News that it is cooperating with the police investigation and that no patients are in danger.

The dermatologist is due to report back to court in November, NBC News said.

A version of this article first appeared on Medscape.com.

It is a story that has quickly gone viral around the world: A Mission Viejo, Calif.-based dermatologist has been arrested for allegedly poisoning her husband.

Yue Yu, MD, aged 45, was booked into the Orange County Jail on Aug. 4, after Irvine Police had been called to her residence that day by her husband, Jack Chen, MD, 53, a radiologist. Dr. Chen provided the police with video evidence that he said showed Dr. Yu pouring a drain-opening chemical into his hot lemonade drink.

“The victim sustained significant internal injuries but is expected to recover,” the Irvine police department said in a statement.

Dr. Yu was released after paying a $30,000 bond and has not been formally charged, according to the New York Post.

In a statement to the court on Aug. 5, Dr. Chen said he and the couple’s two children had long suffered verbal abuse from his wife and her mother, according to the Post. Multiple news organizations reported that Dr. Chen filed for divorce and also for a restraining order against Dr. Yu on that day.

After feeling ill for months – and being diagnosed with ulcers and esophageal inflammation – Dr. Chen reportedly set up video cameras in the couple’s house. He said he caught Dr. Yu on camera pouring something into his drink on several occasions in July.

According to NBC News, Dr. Yu’s attorney, David E. Wohl, said that Dr. Yu “vehemently and unequivocally denies ever attempting to poison her husband or anyone else.”

Dr. Yu received her medical degree from Washington University in St. Louis in 2006 and has no disciplinary actions against her, according to the Medical Board of California. She was head of dermatology at Mission Heritage Medical Group, but her name and information have been scrubbed from that group’s website. Mission Heritage is affiliated with Providence Mission Hospital. A spokesperson for the hospital told NBC News that it is cooperating with the police investigation and that no patients are in danger.

The dermatologist is due to report back to court in November, NBC News said.

A version of this article first appeared on Medscape.com.

In September 2022, the University of California, Berkeley, will start training its first class of “trip facilitators,” who will learn how to guide individuals through therapeutic psychedelic experiences aimed at addressing a variety of mental health problems.

The UC Berkeley Center for the Science of Psychedelics (BCSP) training program aims to create a cadre of facilitators who will be ready to help if, and when, substances such as psilocybin, MDMA, and LSD are approved in the United States, Tina Trujillo, PhD, an associate professor at UC Berkeley’s School of Education, told reporters at a press briefing.

Hallucinogenic drugs are on the Drug Enforcement Administration’s (DEA) Schedule I list because they are considered to have no currently accepted medical use and high abuse potential. But there has been an explosion of research into psychedelics – combined with therapy – as treatment for severe depression, posttraumatic stress disorder, substance-use disorder, and other mental health conditions. Some 100 clinical trials are underway.

“The estimates are that we’re going to need 100,000 trained psychedelic facilitators once psilocybin and MDMA are approved by the [U.S. Food and Drug Administration] FDA, which is expected to happen within the next 5 years or so,” said Michael Pollan, co-founder of the BCSP. He is author of “How to Change Your Mind,” a 2018 book about psychedelics, which has been adapted into a four-part docuseries currently streaming on Netflix.

Courtesy Alia Malley

Nine-month program

The first 24 trainees – a mix of physicians, nurses, psychotherapists, and social workers – will undergo 9 months of education and preparation in “the technical, the cultural, the mystical, and the ethical dimensions of psychedelic facilitation,” said Dr. Trujillo.

The BCSP’s Certificate Program in Psychedelic Facilitation will have “an emphasis on both western science and spiritual care traditions,” she said.

Trainees will receive 150 instructional hours and a 25-hour practicum and will take part in a final 5-day retreat. The program will initially focus only on psilocybin, in part because the BCSP is involved in several FDA-approved trials testing the drug.

In one study – which aims to enroll participants in the fall – researchers will use functional MRI to examine the neural correlates of the psychedelic experience in individuals receiving low-dose psilocybin.

Eligible trainees will have an opportunity to participate in the Berkeley psilocybin trials and “increase their first-hand knowledge,” Dr. Trujillo said.

At the conclusion of the training, students will receive a certificate, “not a license or sanction to go off and practice,” she said. She noted that eventually, when facilitation is legal, certificate holders will be able to practice in clinical research settings or in health care settings.
 

Growing acceptance in psychiatry

Mr. Pollan said there has been a radical change in acceptance of psychedelics as potential therapies.

“The shift from destroyer of young minds in the ‘60s to effective medicine in the 2020s is as sudden as it is confusing for many people,” he said. He noted that the Berkeley center hopes to provide evidence-based information for journalists, the public, and clinicians.

He said that after his book was released, he expected pushback from “mainstream psychiatry.” Instead, he was invited to give grand rounds talks. Psychiatrists are “very open to the potential of psychedelics,” Mr. Pollan said.

“The reason for that, quite frankly, is because they are desperate,” he said. “The tools of conventional psychiatry to deal with things like depression and anxiety and addiction are not very good, and some of them are failing,” he said.

Mr. Pollan cited some other indicators of acceptance. In Oregon, beginning in 2023, psilocybin will be available to anyone older than 21 years but only for use in licensed facilities with licensed facilitators, and the substance must be produced by a licensed manufacturer.

In November, Colorado will ask voters whether they want to follow the Oregon model and legalize psilocybin. If approved, another Colorado ballot initiative would decriminalize possession.

Mr. Pollan noted that Cory Booker, the Democratic Senator from New Jersey, and Rand Paul, a conservative Republican Senator from Kentucky, have found a common cause, introducing legislation to let select terminally ill patients have access to psychedelics and other Schedule I drugs.

Some 400 companies are conducting research on psychedelics. Researchers must have a license from the DEA to obtain and study the substances, Andrea Gomez, assistant professor of neurobiology at UC Berkeley, told reporters.

She said growing interest in the potential of these drugs might lead more researchers to “jump through the hoops” to get the licenses. The floodgates would truly open if the National Institutes of Health started funding studies, she said.

A version of this article first appeared on Medscape.com.

In September 2022, the University of California, Berkeley, will start training its first class of “trip facilitators,” who will learn how to guide individuals through therapeutic psychedelic experiences aimed at addressing a variety of mental health problems.

The UC Berkeley Center for the Science of Psychedelics (BCSP) training program aims to create a cadre of facilitators who will be ready to help if, and when, substances such as psilocybin, MDMA, and LSD are approved in the United States, Tina Trujillo, PhD, an associate professor at UC Berkeley’s School of Education, told reporters at a press briefing.

Hallucinogenic drugs are on the Drug Enforcement Administration’s (DEA) Schedule I list because they are considered to have no currently accepted medical use and high abuse potential. But there has been an explosion of research into psychedelics – combined with therapy – as treatment for severe depression, posttraumatic stress disorder, substance-use disorder, and other mental health conditions. Some 100 clinical trials are underway.

“The estimates are that we’re going to need 100,000 trained psychedelic facilitators once psilocybin and MDMA are approved by the [U.S. Food and Drug Administration] FDA, which is expected to happen within the next 5 years or so,” said Michael Pollan, co-founder of the BCSP. He is author of “How to Change Your Mind,” a 2018 book about psychedelics, which has been adapted into a four-part docuseries currently streaming on Netflix.

Courtesy Alia Malley

Nine-month program

The first 24 trainees – a mix of physicians, nurses, psychotherapists, and social workers – will undergo 9 months of education and preparation in “the technical, the cultural, the mystical, and the ethical dimensions of psychedelic facilitation,” said Dr. Trujillo.

The BCSP’s Certificate Program in Psychedelic Facilitation will have “an emphasis on both western science and spiritual care traditions,” she said.

Trainees will receive 150 instructional hours and a 25-hour practicum and will take part in a final 5-day retreat. The program will initially focus only on psilocybin, in part because the BCSP is involved in several FDA-approved trials testing the drug.

In one study – which aims to enroll participants in the fall – researchers will use functional MRI to examine the neural correlates of the psychedelic experience in individuals receiving low-dose psilocybin.

Eligible trainees will have an opportunity to participate in the Berkeley psilocybin trials and “increase their first-hand knowledge,” Dr. Trujillo said.

At the conclusion of the training, students will receive a certificate, “not a license or sanction to go off and practice,” she said. She noted that eventually, when facilitation is legal, certificate holders will be able to practice in clinical research settings or in health care settings.
 

Growing acceptance in psychiatry

Mr. Pollan said there has been a radical change in acceptance of psychedelics as potential therapies.

“The shift from destroyer of young minds in the ‘60s to effective medicine in the 2020s is as sudden as it is confusing for many people,” he said. He noted that the Berkeley center hopes to provide evidence-based information for journalists, the public, and clinicians.

He said that after his book was released, he expected pushback from “mainstream psychiatry.” Instead, he was invited to give grand rounds talks. Psychiatrists are “very open to the potential of psychedelics,” Mr. Pollan said.

“The reason for that, quite frankly, is because they are desperate,” he said. “The tools of conventional psychiatry to deal with things like depression and anxiety and addiction are not very good, and some of them are failing,” he said.

Mr. Pollan cited some other indicators of acceptance. In Oregon, beginning in 2023, psilocybin will be available to anyone older than 21 years but only for use in licensed facilities with licensed facilitators, and the substance must be produced by a licensed manufacturer.

In November, Colorado will ask voters whether they want to follow the Oregon model and legalize psilocybin. If approved, another Colorado ballot initiative would decriminalize possession.

Mr. Pollan noted that Cory Booker, the Democratic Senator from New Jersey, and Rand Paul, a conservative Republican Senator from Kentucky, have found a common cause, introducing legislation to let select terminally ill patients have access to psychedelics and other Schedule I drugs.

Some 400 companies are conducting research on psychedelics. Researchers must have a license from the DEA to obtain and study the substances, Andrea Gomez, assistant professor of neurobiology at UC Berkeley, told reporters.

She said growing interest in the potential of these drugs might lead more researchers to “jump through the hoops” to get the licenses. The floodgates would truly open if the National Institutes of Health started funding studies, she said.

A version of this article first appeared on Medscape.com.

In September 2022, the University of California, Berkeley, will start training its first class of “trip facilitators,” who will learn how to guide individuals through therapeutic psychedelic experiences aimed at addressing a variety of mental health problems.

The UC Berkeley Center for the Science of Psychedelics (BCSP) training program aims to create a cadre of facilitators who will be ready to help if, and when, substances such as psilocybin, MDMA, and LSD are approved in the United States, Tina Trujillo, PhD, an associate professor at UC Berkeley’s School of Education, told reporters at a press briefing.

Hallucinogenic drugs are on the Drug Enforcement Administration’s (DEA) Schedule I list because they are considered to have no currently accepted medical use and high abuse potential. But there has been an explosion of research into psychedelics – combined with therapy – as treatment for severe depression, posttraumatic stress disorder, substance-use disorder, and other mental health conditions. Some 100 clinical trials are underway.

“The estimates are that we’re going to need 100,000 trained psychedelic facilitators once psilocybin and MDMA are approved by the [U.S. Food and Drug Administration] FDA, which is expected to happen within the next 5 years or so,” said Michael Pollan, co-founder of the BCSP. He is author of “How to Change Your Mind,” a 2018 book about psychedelics, which has been adapted into a four-part docuseries currently streaming on Netflix.

Courtesy Alia Malley

Nine-month program

The first 24 trainees – a mix of physicians, nurses, psychotherapists, and social workers – will undergo 9 months of education and preparation in “the technical, the cultural, the mystical, and the ethical dimensions of psychedelic facilitation,” said Dr. Trujillo.

The BCSP’s Certificate Program in Psychedelic Facilitation will have “an emphasis on both western science and spiritual care traditions,” she said.

Trainees will receive 150 instructional hours and a 25-hour practicum and will take part in a final 5-day retreat. The program will initially focus only on psilocybin, in part because the BCSP is involved in several FDA-approved trials testing the drug.

In one study – which aims to enroll participants in the fall – researchers will use functional MRI to examine the neural correlates of the psychedelic experience in individuals receiving low-dose psilocybin.

Eligible trainees will have an opportunity to participate in the Berkeley psilocybin trials and “increase their first-hand knowledge,” Dr. Trujillo said.

At the conclusion of the training, students will receive a certificate, “not a license or sanction to go off and practice,” she said. She noted that eventually, when facilitation is legal, certificate holders will be able to practice in clinical research settings or in health care settings.
 

Growing acceptance in psychiatry

Mr. Pollan said there has been a radical change in acceptance of psychedelics as potential therapies.

“The shift from destroyer of young minds in the ‘60s to effective medicine in the 2020s is as sudden as it is confusing for many people,” he said. He noted that the Berkeley center hopes to provide evidence-based information for journalists, the public, and clinicians.

He said that after his book was released, he expected pushback from “mainstream psychiatry.” Instead, he was invited to give grand rounds talks. Psychiatrists are “very open to the potential of psychedelics,” Mr. Pollan said.

“The reason for that, quite frankly, is because they are desperate,” he said. “The tools of conventional psychiatry to deal with things like depression and anxiety and addiction are not very good, and some of them are failing,” he said.

Mr. Pollan cited some other indicators of acceptance. In Oregon, beginning in 2023, psilocybin will be available to anyone older than 21 years but only for use in licensed facilities with licensed facilitators, and the substance must be produced by a licensed manufacturer.

In November, Colorado will ask voters whether they want to follow the Oregon model and legalize psilocybin. If approved, another Colorado ballot initiative would decriminalize possession.

Mr. Pollan noted that Cory Booker, the Democratic Senator from New Jersey, and Rand Paul, a conservative Republican Senator from Kentucky, have found a common cause, introducing legislation to let select terminally ill patients have access to psychedelics and other Schedule I drugs.

Some 400 companies are conducting research on psychedelics. Researchers must have a license from the DEA to obtain and study the substances, Andrea Gomez, assistant professor of neurobiology at UC Berkeley, told reporters.

She said growing interest in the potential of these drugs might lead more researchers to “jump through the hoops” to get the licenses. The floodgates would truly open if the National Institutes of Health started funding studies, she said.

A version of this article first appeared on Medscape.com.

Transgender people who medically detransition – those who stop or switch gender-affirming hormone therapy or who undergo a reversal of a surgical reconstruction – report feeling stigmatized by clinicians and receiving inadequate professional support, researchers have found. As a result, such patients often avoid health care at the time they stop undergoing medical interventions, and many consider their overall care to be “suboptimal.”

“Clinicians providing gender-affirming care must be careful to avoid shaming patients who are pursuing hormonal cessation or switching or surgical reversals and instead strive to address current mental and physical health needs,” wrote the authors of the new study, which was published  in JAMA Network Open.

In a commentary accompanying the journal article, Jack L. Turban, MD, a psychiatrist at the University of California, San Francisco, argues that discontinuation of gender-affirming care is rare and is “woefully politicized”.

Dr. Turban wrote, “clinical protocols should be in place to support patients who have dynamic needs surrounding these interventions.” He added that “gender-affirming care should encompass the entirety of an individual’s embodiment goals, even when those goals may have pivoted over time.”

For the study, Kinnon R. MacKinnon, PhD, of York University, Toronto, and colleagues conducted video interviews with 28 Canadian individuals older than 18 years. All identified as “detransitioning, retransitioning, detrans, retrans, reidentifying, [experiencing] a shift in gender identity after initiating transition, or having stopped transition.”

Eighteen (64%) were assigned female sex at birth, and 10 (36%) were assigned male sex at birth. Twenty (71%) were aged 20-29; six were aged 30-39, and two were older than 40. Twenty-one were White. One participant who only socially transitioned was removed from the analysis of medical transitions. About half who medically transitioned did so between the ages of 18 and 24.

Reasons for stopping a medical transition included concerns about physical or mental health, surgical complications, postoperative pain, unsupportive parents or romantic partners, discrimination in the workplace, and difficulty accessing clinical care or gender-affirming surgery.

One participant, who had been assigned female sex at birth and who now identifies as female, said the transition did not help. The process was “a hot mess,” she said. Because she’d known people who had experienced improvements in mental and physical health as a result of transitioning, especially after initiating hormone therapy, she kept going. But, she said, “the farther I got into transition, the worse my [borderline personality disorder] symptoms and my presentation was.”
 

Lack of clinician support – going ‘cold turkey’

Many individuals reported that they stopped taking hormones “cold turkey,” without the support of a therapist or a clinician, because they did not trust health care providers or had had bad interactions with the medical system.

Most of those who had undergone gender-affirming surgical removal of testes or ovaries in their initial transition said the care they received when they decided to detransition was “bad.” Clinicians were judgmental or had inadequate knowledge about the process, the researchers reported. Some detransitioners said such encounters with clinicians added to their feelings of shame.

One participant who was born female and transitioned to male said she had good relationships with her clinicians and therapist, but she still felt “guilt and shame” about detransitioning back to female. She also worried that those clinicians would view her initial decision as a “mistake” or “through a lens of ‘regret,’ which was inauthentic to her feelings,” the researchers reported.

Another individual who had been assigned female sex at birth said that when she wanted to detransition, she consulted a physician about switching back to estrogen. “She wasn’t very tactful,” the person, who now identifies as female, recalled. “She made comments about how I should have thought about [my initial transition] harder.”

Participants said clinicians lacked sufficient information on detransitioning.

Dr. Turban noted that data are limited on the physiologic and psychological effects of discontinuing exogenous hormone therapy, “because it is such a rare occurrence.” He acknowledged that “more research is needed on the effects of discontinuation so that clinicians can better educate patients.”

The researchers found that most who sought to detransition consulted online forums and networks. The r/detrans discussion group on Reddit, for instance, now has 36,400 members.

Some reported regret that they had transitioned, while others – especially those who identify now as nonbinary or gender-fluid – said they were happy with their initial choice.

Eighteen of the 27 had no regrets and/or had positive feelings about the gender-affirming medications or procedures they had received in the past. Six (22%) had regret, and three were ambivalent. The rate of regret in the relatively small sample is higher than that observed in several other studies. Trans advocates also point out that detransitioning does not necessarily equate with regret.

When asked whether she regretted having undergone a double mastectomy, an individual who had been assigned female sex at birth and who now identifies as female said, “Some days I do, some days I don’t.” She also said she is not considering breast augmentation. “I’m just going to leave myself alone,” she said, adding that “it’s part of my journey.”

A participant who had been assigned female sex at birth and who now identifies as a cisgender woman said that she is mostly regarded by others as a trans person now, although she does not identify that way. But she said taking testosterone in the past was the right decision. “At the time, that was absolutely what I knew I had to do,” she said. “I’m actually not upset about any of the permanent changes it had on my body.”

The researchers noted that some participants said that “their parents or family circumstances explicitly forced, or implicitly encouraged detransition.”

Dr. Turban encouraged clinicians to consider how such external factors might “exacerbate internal factors,” such as internalized transphobia, which could lead to a discontinuation of gender-affirming care.

The study received funding from the Social Sciences and Humanities Research Council (SSHRC) Insight Development Program and a York University SSHRC Explore grant. Travis Salway, MD, a coauthor, has received grants from Canadian Institutes of Health Research, Michael Smith Health Research BC, BC SUPPORT Unit Fraser Centre, Simon Fraser University’s Community-Engaged Research Initiative, and the Social Sciences and Humanities Research Council outside the submitted work. The other authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

This article was been updated on 8/5/22 to include additional information about detransitioning.

Transgender people who medically detransition – those who stop or switch gender-affirming hormone therapy or who undergo a reversal of a surgical reconstruction – report feeling stigmatized by clinicians and receiving inadequate professional support, researchers have found. As a result, such patients often avoid health care at the time they stop undergoing medical interventions, and many consider their overall care to be “suboptimal.”

“Clinicians providing gender-affirming care must be careful to avoid shaming patients who are pursuing hormonal cessation or switching or surgical reversals and instead strive to address current mental and physical health needs,” wrote the authors of the new study, which was published  in JAMA Network Open.

In a commentary accompanying the journal article, Jack L. Turban, MD, a psychiatrist at the University of California, San Francisco, argues that discontinuation of gender-affirming care is rare and is “woefully politicized”.

Dr. Turban wrote, “clinical protocols should be in place to support patients who have dynamic needs surrounding these interventions.” He added that “gender-affirming care should encompass the entirety of an individual’s embodiment goals, even when those goals may have pivoted over time.”

For the study, Kinnon R. MacKinnon, PhD, of York University, Toronto, and colleagues conducted video interviews with 28 Canadian individuals older than 18 years. All identified as “detransitioning, retransitioning, detrans, retrans, reidentifying, [experiencing] a shift in gender identity after initiating transition, or having stopped transition.”

Eighteen (64%) were assigned female sex at birth, and 10 (36%) were assigned male sex at birth. Twenty (71%) were aged 20-29; six were aged 30-39, and two were older than 40. Twenty-one were White. One participant who only socially transitioned was removed from the analysis of medical transitions. About half who medically transitioned did so between the ages of 18 and 24.

Reasons for stopping a medical transition included concerns about physical or mental health, surgical complications, postoperative pain, unsupportive parents or romantic partners, discrimination in the workplace, and difficulty accessing clinical care or gender-affirming surgery.

One participant, who had been assigned female sex at birth and who now identifies as female, said the transition did not help. The process was “a hot mess,” she said. Because she’d known people who had experienced improvements in mental and physical health as a result of transitioning, especially after initiating hormone therapy, she kept going. But, she said, “the farther I got into transition, the worse my [borderline personality disorder] symptoms and my presentation was.”
 

Lack of clinician support – going ‘cold turkey’

Many individuals reported that they stopped taking hormones “cold turkey,” without the support of a therapist or a clinician, because they did not trust health care providers or had had bad interactions with the medical system.

Most of those who had undergone gender-affirming surgical removal of testes or ovaries in their initial transition said the care they received when they decided to detransition was “bad.” Clinicians were judgmental or had inadequate knowledge about the process, the researchers reported. Some detransitioners said such encounters with clinicians added to their feelings of shame.

One participant who was born female and transitioned to male said she had good relationships with her clinicians and therapist, but she still felt “guilt and shame” about detransitioning back to female. She also worried that those clinicians would view her initial decision as a “mistake” or “through a lens of ‘regret,’ which was inauthentic to her feelings,” the researchers reported.

Another individual who had been assigned female sex at birth said that when she wanted to detransition, she consulted a physician about switching back to estrogen. “She wasn’t very tactful,” the person, who now identifies as female, recalled. “She made comments about how I should have thought about [my initial transition] harder.”

Participants said clinicians lacked sufficient information on detransitioning.

Dr. Turban noted that data are limited on the physiologic and psychological effects of discontinuing exogenous hormone therapy, “because it is such a rare occurrence.” He acknowledged that “more research is needed on the effects of discontinuation so that clinicians can better educate patients.”

The researchers found that most who sought to detransition consulted online forums and networks. The r/detrans discussion group on Reddit, for instance, now has 36,400 members.

Some reported regret that they had transitioned, while others – especially those who identify now as nonbinary or gender-fluid – said they were happy with their initial choice.

Eighteen of the 27 had no regrets and/or had positive feelings about the gender-affirming medications or procedures they had received in the past. Six (22%) had regret, and three were ambivalent. The rate of regret in the relatively small sample is higher than that observed in several other studies. Trans advocates also point out that detransitioning does not necessarily equate with regret.

When asked whether she regretted having undergone a double mastectomy, an individual who had been assigned female sex at birth and who now identifies as female said, “Some days I do, some days I don’t.” She also said she is not considering breast augmentation. “I’m just going to leave myself alone,” she said, adding that “it’s part of my journey.”

A participant who had been assigned female sex at birth and who now identifies as a cisgender woman said that she is mostly regarded by others as a trans person now, although she does not identify that way. But she said taking testosterone in the past was the right decision. “At the time, that was absolutely what I knew I had to do,” she said. “I’m actually not upset about any of the permanent changes it had on my body.”

The researchers noted that some participants said that “their parents or family circumstances explicitly forced, or implicitly encouraged detransition.”

Dr. Turban encouraged clinicians to consider how such external factors might “exacerbate internal factors,” such as internalized transphobia, which could lead to a discontinuation of gender-affirming care.

The study received funding from the Social Sciences and Humanities Research Council (SSHRC) Insight Development Program and a York University SSHRC Explore grant. Travis Salway, MD, a coauthor, has received grants from Canadian Institutes of Health Research, Michael Smith Health Research BC, BC SUPPORT Unit Fraser Centre, Simon Fraser University’s Community-Engaged Research Initiative, and the Social Sciences and Humanities Research Council outside the submitted work. The other authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

This article was been updated on 8/5/22 to include additional information about detransitioning.

Transgender people who medically detransition – those who stop or switch gender-affirming hormone therapy or who undergo a reversal of a surgical reconstruction – report feeling stigmatized by clinicians and receiving inadequate professional support, researchers have found. As a result, such patients often avoid health care at the time they stop undergoing medical interventions, and many consider their overall care to be “suboptimal.”

“Clinicians providing gender-affirming care must be careful to avoid shaming patients who are pursuing hormonal cessation or switching or surgical reversals and instead strive to address current mental and physical health needs,” wrote the authors of the new study, which was published  in JAMA Network Open.

In a commentary accompanying the journal article, Jack L. Turban, MD, a psychiatrist at the University of California, San Francisco, argues that discontinuation of gender-affirming care is rare and is “woefully politicized”.

Dr. Turban wrote, “clinical protocols should be in place to support patients who have dynamic needs surrounding these interventions.” He added that “gender-affirming care should encompass the entirety of an individual’s embodiment goals, even when those goals may have pivoted over time.”

For the study, Kinnon R. MacKinnon, PhD, of York University, Toronto, and colleagues conducted video interviews with 28 Canadian individuals older than 18 years. All identified as “detransitioning, retransitioning, detrans, retrans, reidentifying, [experiencing] a shift in gender identity after initiating transition, or having stopped transition.”

Eighteen (64%) were assigned female sex at birth, and 10 (36%) were assigned male sex at birth. Twenty (71%) were aged 20-29; six were aged 30-39, and two were older than 40. Twenty-one were White. One participant who only socially transitioned was removed from the analysis of medical transitions. About half who medically transitioned did so between the ages of 18 and 24.

Reasons for stopping a medical transition included concerns about physical or mental health, surgical complications, postoperative pain, unsupportive parents or romantic partners, discrimination in the workplace, and difficulty accessing clinical care or gender-affirming surgery.

One participant, who had been assigned female sex at birth and who now identifies as female, said the transition did not help. The process was “a hot mess,” she said. Because she’d known people who had experienced improvements in mental and physical health as a result of transitioning, especially after initiating hormone therapy, she kept going. But, she said, “the farther I got into transition, the worse my [borderline personality disorder] symptoms and my presentation was.”
 

Lack of clinician support – going ‘cold turkey’

Many individuals reported that they stopped taking hormones “cold turkey,” without the support of a therapist or a clinician, because they did not trust health care providers or had had bad interactions with the medical system.

Most of those who had undergone gender-affirming surgical removal of testes or ovaries in their initial transition said the care they received when they decided to detransition was “bad.” Clinicians were judgmental or had inadequate knowledge about the process, the researchers reported. Some detransitioners said such encounters with clinicians added to their feelings of shame.

One participant who was born female and transitioned to male said she had good relationships with her clinicians and therapist, but she still felt “guilt and shame” about detransitioning back to female. She also worried that those clinicians would view her initial decision as a “mistake” or “through a lens of ‘regret,’ which was inauthentic to her feelings,” the researchers reported.

Another individual who had been assigned female sex at birth said that when she wanted to detransition, she consulted a physician about switching back to estrogen. “She wasn’t very tactful,” the person, who now identifies as female, recalled. “She made comments about how I should have thought about [my initial transition] harder.”

Participants said clinicians lacked sufficient information on detransitioning.

Dr. Turban noted that data are limited on the physiologic and psychological effects of discontinuing exogenous hormone therapy, “because it is such a rare occurrence.” He acknowledged that “more research is needed on the effects of discontinuation so that clinicians can better educate patients.”

The researchers found that most who sought to detransition consulted online forums and networks. The r/detrans discussion group on Reddit, for instance, now has 36,400 members.

Some reported regret that they had transitioned, while others – especially those who identify now as nonbinary or gender-fluid – said they were happy with their initial choice.

Eighteen of the 27 had no regrets and/or had positive feelings about the gender-affirming medications or procedures they had received in the past. Six (22%) had regret, and three were ambivalent. The rate of regret in the relatively small sample is higher than that observed in several other studies. Trans advocates also point out that detransitioning does not necessarily equate with regret.

When asked whether she regretted having undergone a double mastectomy, an individual who had been assigned female sex at birth and who now identifies as female said, “Some days I do, some days I don’t.” She also said she is not considering breast augmentation. “I’m just going to leave myself alone,” she said, adding that “it’s part of my journey.”

A participant who had been assigned female sex at birth and who now identifies as a cisgender woman said that she is mostly regarded by others as a trans person now, although she does not identify that way. But she said taking testosterone in the past was the right decision. “At the time, that was absolutely what I knew I had to do,” she said. “I’m actually not upset about any of the permanent changes it had on my body.”

The researchers noted that some participants said that “their parents or family circumstances explicitly forced, or implicitly encouraged detransition.”

Dr. Turban encouraged clinicians to consider how such external factors might “exacerbate internal factors,” such as internalized transphobia, which could lead to a discontinuation of gender-affirming care.

The study received funding from the Social Sciences and Humanities Research Council (SSHRC) Insight Development Program and a York University SSHRC Explore grant. Travis Salway, MD, a coauthor, has received grants from Canadian Institutes of Health Research, Michael Smith Health Research BC, BC SUPPORT Unit Fraser Centre, Simon Fraser University’s Community-Engaged Research Initiative, and the Social Sciences and Humanities Research Council outside the submitted work. The other authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

This article was been updated on 8/5/22 to include additional information about detransitioning.

A woman wearing purple surgical scrubs stares into a camera, looking frustrated, but doesn’t speak. Superimposed over her head is the text “just realized I only get to Yeet 4 Teets next week,” and a crying emoji. Rain appears to drip down over her while “Stan” by Eminem plays in the background.

That October 2020 TikTok by Sidhbh Gallagher, MD, a Miami-based plastic surgeon known as @gendersurgeon, had almost 10,000 likes and was tagged #topsurgery, #masculoplasty, #ftm, and #transman, among other hashtags.

“What health check do I have to get in preparation for teetus deletus?” is the question in another Dr. Gallagher TikTok. Dr. Gallagher is a prolific user of social media with over 268K TikTok followers and over 44K Instagram followers. Another Dr. Gallagher TikTok account, @thevagicianmd, has some 7K followers.

Another cosmetic surgeon, Tony Mangubat, MD, known as @Tikdoctony to his more than 200K followers, uses similar hashtags – like #teetusdeleetus – in his TikToks.

Clearly not medical terms, hashtags like #yeettheteet and #teetusdeletus are often used by the transgender community. The posts by Dr. Gallagher and Dr. Mangubat are part of an ever-growing wave of social media activity by medical professionals.  

Plastic surgeons have never been shy about advertising their work – and many have taken to social media to do so, including showing before and after photos. A 2020 study published in Plastic and Reconstructive Surgery found that the majority of such surgeons, especially those in private practice, use social media.

But the use of TikTok, Instagram, and other social media platforms by surgeons who specialize in gender reassignment raises questions about the appropriateness of promoting such procedures, especially to a younger-skewing audience.

Because of the limits on pornography and nudity of social media platforms, most social media posts by gender surgeons are about female-to-male (FTM) mastectomies, the fastest-growing transgender procedure.

The American Society of Plastic Surgeons (ASPS) started separately tracking gender-affirmation procedures in 2015. That year, members reported doing 1,360 FTM procedures.

In 2020, the ASPS further separated procedures into additional categories. That year – when many surgeries were postponed because of the COVID-19 pandemic – FTM mastectomies grew by 15%, with 8,548 procedures performed, a far greater number than for any other transgender surgery, and a sixfold increase in the number of procedures done in 2015.
 

‘Gimmicky,’ but building community

Surgeons interviewed for this article said they use social media primarily to connect with patients and to educate in a light-hearted way.

While Dr. Gallagher acknowledges that using #teetusdeletus is “kind of gimmicky,” she said she doesn’t view it as unprofessional because she is “using the words of the community I serve.” Many of her patients have seen a medical professional “who just didn’t understand what it is to have gender dysphoria, didn’t understand what it is to be trans, so going from that experience to somebody who uses the same language as the community uses can be quite a comfortable experience,” she said in an interview.

Dr. Mangubat, a Seattle-area plastic surgeon who has been doing mastectomies for trans male patients since 1988, said he tailors his TikToks to that group. He likes TikTok – which he started using in early 2021 – because it has rules against bullying, swearing, and pornography, he told this news organization.

“It’s really not ... advertising ... it’s a community-building platform,” said Dr. Mangubat. “If you build community, people will trust you, and if you provide good accurate information, then people will be safer,” he said. 

But, “I’m not telling them to come to me,” he stressed.

He always appears in scrubs and doesn’t do music, doesn’t dance, and doesn’t post before and after photos, but he still gets thousands – or sometimes hundreds of thousands – of likes.

His mission, he said, is to answer the community’s questions. “We’re reaching patients that have had their top surgery, that are going to have their top surgery, that are looking for how to get top surgery, that are just starting on testosterone, that haven’t started on testosterone – it’s the whole spectrum of patients,” said Dr. Mangubat.
 

Risks downplayed?

Other surgeons have expressed concern about ethical boundaries and the tendency of social media posts to downplay risks of what are life-changing procedures.

A 2020 study of YouTube videos on top surgery, for instance, concluded that “there were no unbiased videos by board-certified plastic surgeons explaining the risks, benefits, treatment options, and alternatives to surgery.”

Alison Clayton, MBBS, an Australian psychiatrist, said that social media posts can create false expectations because they emphasize style over substance, omit risks, and can create an unwarranted sense of trust in the doctor that can spill over into the physician-patient relationship.

Dr. Clayton also believes that “the gender-affirming surgical procedures being offered to these youth have a scant empirical evidence base for benefits to psychological health and well-being.”

It is known that a number of those who transition, using either opposite sex hormones and/or surgical procedures, later have regret and “detransition,” but statistics are lacking. It is also a controversial area, with many detransitioners saying they didn’t get appropriate care and weren’t properly assessed before being given hormones or heading to surgery.

Most of the gender surgeons interviewed for this article said they see almost “zero” regret if proper mental health evaluations are performed before surgery, and they added, the procedures can relieve dysphoria.

Nevertheless, posts should not be “all fun and games,” said Josef Hadeed, MD, chair of the ASPS Patient Safety Committee and Public Education Committee and a member of its Social Media Subcommittee.

“When someone makes a decision to undergo a surgical procedure, they should be very aware there are some risks and potentially serious risks involved,” he told this news organization.

The ASPS “wants members to use social media in a judicious manner” in a way that educates the public and encourages patients to learn about a procedure and to consult with board-certified plastic surgeons, said Dr. Hadeed.

The Beverly Hills, Calif.–based surgeon does gender-affirmation procedures himself and uses Instagram, on which he has 53.4K followers, to educate patients and highlight his work using before and after photos.

“I like to think I do it in a very tasteful way,” Dr. Hadeed said. “It’s not in a way that’s sort of suggestive to patients, including minors, that this is something they need to get done, because if they are thinking about getting it done there is a lengthy process that they have to go through before they even set foot in our office.”

And he said “it may be inappropriate” to use certain hashtags or terminology, “even if it does ‘speak’ to the patients. Professionally, plastic surgeons should maintain a higher standard and maintain that even with their social media.”

Marci Bowers, MD, a gynecologic surgeon who performs gender-affirming procedures, and who is transgender herself, agreed.

“Some of the posts out there seem sensational, distasteful, and risk compromising patient confidentiality,” Dr. Bowers said in an interview.

“Much of this seemed to cross the line of good taste and appropriateness,” added Dr. Bowers, who is the incoming president of the World Professional Association for Transgender Health (WPATH). “Creating an idealized video without addressing risk is inappropriate and misleading,” she stressed.

“These surgeons would perhaps better serve their clients by focusing on and improving their clinical care,” she added.  

Dr. Bowers said that although WPATH has not addressed social media use in the past, its ethics committee will be taking on the topic this year.

Social media posts about gender-affirming procedures “don’t usually talk about the barriers, they don’t talk about bad outcomes, they tend to just focus on success stories,” said Gwendolyn P. Quinn, MD, a bioethicist, and Livia S. Wan, MD, professor of obstetrics and gynecology at the NYU Grossman School of Medicine.

But she also sees some positives. The posts can help normalize gender-affirming surgery, and post-procedure photos might “help people realize that they can’t just have everything exactly the way they want it to be,” said Dr. Quinn.
 

Does social media influence or educate?

Studies have documented the power of social media to influence desire and decisionmaking, especially when it comes to cosmetic surgery.

“The use of social media creates a vague area between patient confidentiality and entertainment,” writes Nisha Gupta and colleagues of the UCLA David Geffen School of Medicine in a review published in the Aesthetic Surgery Journal.

While social media use is on the rise by plastic surgeons and has the potential to educate, it has also “compromised the integrity of the doctor-patient relationship,” they add.

Surgeons can use tools to place themselves higher in searches, and patients might assume that those who have hundreds of thousands of followers “are the most qualified or trusted, although this is not always the case,” they note.

Markus Rach, PhD, a researcher with the University of Applied Sciences and Arts Northwestern Switzerland, analyzed the impact of TikTok’s plastic surgery content on how adolescents perceived themselves and how it influenced their decision to have a procedure.

Most TikTok users are under age 24, and #plasticsurgery has a huge viewership with some 3.8 billion views at the time of publication, said Dr. Rach. He found that influencers tended to make adolescents feel bad and want surgery but that plastic surgeons had a moderating effect on both negative feelings and the intent to get surgery.

Dr. Bowers said that, despite her concerns, she does not “believe social media influences like TikTok and Facebook create artificial demand.”

However, Dr. Mangubat said social media can make plastic surgery seem enticing. “It can happen, and it does happen,” he said, but he added that’s true for any cosmetic procedure, not just gender-affirming surgery.

The pitfall with social media is that “patients are being sold a vision of themselves that may or may not be possible,” he observed.

Dr. Quinn worries less about people being talked into a procedure and more about those who don’t want surgery.

“There are people who identify as transgender but do not feel the need to change any parts of their body,” she said. “And that should be okay.”
 

Concerns about minors

New guidance from WPATH, their Standards of Care (SOC) 8 – the first update in 10 years – are due to be published this month. As reported by this news organization, and as stated in the draft of the SOC 8 published for comment in December 2021, the organization has recommended lowering the age for “top” surgery from 18 to 15 years.

Dr. Clayton has concerns about young people with gender dysphoria, who she says are “often vulnerable youth, many of whom have comorbid psychiatric and neurodevelopmental disorders.”

“This may contribute to a greater vulnerability of this population to undue influence,” added Dr. Clayton.

Sean Devitt, MD, and Jeffrey M. Kenkel, MD, of the University of Texas Southwestern Medical Center, Dallas, expressed concern that social media posts by plastic surgeons could be especially dangerous for young people.

“Given that the prefrontal cortex, which is largely responsible for impulse control, is not fully developed until the age of 25, is it ethical to allow younger patients to make life-lasting decisions under the guise of education?” they ask in a commentary on the review by Ms. Gupta and colleagues about plastic surgeons’ use of social media. The review did not focus on gender-affirmation procedures.

Many surgeons – but not all – steer clear of genital (“bottom”) surgeries in minors. However, bilateral mastectomies are being performed in those as young as age 13 based on surgeons’ risk-benefit calculus for the patient.

A study, published in May in the Annals of Plastic Surgery, showed there was a 13-fold increase in the number of bilateral mastectomies performed on under-18s between January 2013 and the end of July 2020. Of the 209 minors (age 12-17) who had the surgery, two (0.95%) expressed regret by the time of follow-up, at 3 and 7 years post-operatively, but neither had reversal surgery.

A small 2018 study, published in JAMA Pediatrics, among trans males who had top surgery found high rates of satisfaction, though one of the 68 patients reported experiencing regret “sometimes.” The mean age of patients in the surgical group was 19 years and the youngest patient was 14.

“Most of us who practice heavily in this field will make exceptions, not for genital surgery but typically for top surgery,” said Dr. Gallagher, who added that she operates on one minor [under 18] a month, while doing some 400-500 gender-affirmative surgeries a year. For some patients, “doing nothing isn’t necessarily a no-harm option,” said Dr. Gallagher.

“Arbitrarily picking the age of 18 and sentencing that patient to another year of dysphoria” might not be the best risk-benefit calculus, she said.  

Dr. Mangubat agrees, especially if, for example, a trans man develops double D breasts by age 14. “You’ve sentenced them to 4 years of misery” before they can get insurance coverage, he said. His youngest top surgery patient was age 15. He said the person’s family, mental health professional, and primary care physician were all in favor of the procedure.

Dr. Mangubat also noted that some insurers, such as Kaiser Permanente, now cover bilateral mastectomy starting at age 16.

Dr. Quinn, the bioethicist, said not every minor or young adult is equipped to make the best long-term decisions.

She works with younger patients who have cancer, for example, and said her suggestions that they consider fertility preservation are often met with protestations “that they will never have children.”

The same issue arises with transgender patients. They may not want to think about having children or issues such as breast feeding while in their teens or early 20s. “But you know from your experience that they may feel differently in 10 years, but they’re just not in the mind frame to think about it,” said Dr. Quinn.

Some young people may accurately never want children, said Dr. Quinn, “but there is a lack of maturity shown when a person just shuts down a conversation and won’t even listen to infertility threats and potential preservation options.”  
 

Concerns about regret?

Dr. Gallagher said she follows the WPATH standards, which require mental health evaluations, and as a result, “the risk of regret is incredibly low.”

However, one of Dr. Gallagher’s patients who detransitioned, Grace, who goes by @HormoneHangover on social media, said she has taken umbrage at some of the Miami surgeon’s TikToks, including one, “Why might some patients feel sad after surgery ... despite wanting it for so long??”

“This is actually not uncommon with ANY kind of surgery, but it’s temporary!” said the TikTok text. Dr. Gallagher is wearing a red dress and heels and flips her hair while the text scrolls above her.

But to Grace, the TikTok “really bothered me, because sometimes there is regret, and I think that sort of advertising paints a falsely rosy picture,” she said in an interview.

And it is emblematic of what she feels was Dr. Gallagher’s “breezy” approach to explaining the procedure to her. “The surgery itself was a shocking experience for me,” she said. “The physical experience was very jarring. It was very disturbing in a way I hadn’t anticipated or understood in advance,” said Grace.

Dr. Mangubat, who does 100 bilateral mastectomies in trans patients a year, said he goes to great lengths to ensure his patients are good candidates. Everyone – even those who self-pay – must have counseling, and if the individual seems to be considering the surgery because it’s “trendy,” he steers clear.

“If they’re not serious about it, I don’t want to operate on them,” said Dr. Mangubat. “There have been maybe two patients who have come back” to detransition, he said. 

Dr. Hadeed also said he has not seen regret. He attributes this to his vetting process, which includes investigating the background of the mental health professionals who write support letters.

“We’ve turned away a lot of patients from our office either because of inadequate letters or because the person writing the letter just doesn’t really have any proper credentials,” he said.
 

Is social media use by plastic surgeons the new normal?

With so many plastic surgeons – including those who perform transgender procedures – using social media, it may increasingly be just part of doing business.

“Undoubtedly gender surgery teams will have a greater presence on social media in the future,” write Alireza Hamidian Jahromi, MD, and a colleague of the plastic surgery department at Rush University Medical Center, Chicago, in a letter published in Plastic and Reconstructive Surgery.  

Kyle R. Latack, MD, and colleagues at the University of Southern California and the University of Michigan, have studied the use of social media by the transgender community and write that they believe “there should be an increased effort to develop high-quality and unbiased resources for patient education that can be made [available] on social media.”

Dr. Gallagher said TikTok helped her erase fear. “A bilateral mastectomy is a scary surgery for an 18-year-old or a 20-year-old,” she said, “but they have to do it for their well-being.”

“That is a criticism I’ve heard – that I seek to minimize it or that I’m flippant about it,” said Dr. Gallagher.

For “top surgery the risk profile is pretty low,” she said, “so what I try to do is educate people that it’s maybe not as scary a procedure as they think.”

Dr. Mangubat, however, is concerned about some of what he sees, especially the explosion of surgeons offering gender-affirming procedures. “Now everybody wants a piece of it,” he said.

“Let’s face it, it’s money now. You get paid for doing this surgery. Hospitals get paid a lot of money for their operating rooms for doing the surgery,” said Dr. Mangubat. “There are some surgeons who believe the transgender community is just another market.”

A version of this article first appeared on Medscape.com.

A woman wearing purple surgical scrubs stares into a camera, looking frustrated, but doesn’t speak. Superimposed over her head is the text “just realized I only get to Yeet 4 Teets next week,” and a crying emoji. Rain appears to drip down over her while “Stan” by Eminem plays in the background.

That October 2020 TikTok by Sidhbh Gallagher, MD, a Miami-based plastic surgeon known as @gendersurgeon, had almost 10,000 likes and was tagged #topsurgery, #masculoplasty, #ftm, and #transman, among other hashtags.

“What health check do I have to get in preparation for teetus deletus?” is the question in another Dr. Gallagher TikTok. Dr. Gallagher is a prolific user of social media with over 268K TikTok followers and over 44K Instagram followers. Another Dr. Gallagher TikTok account, @thevagicianmd, has some 7K followers.

Another cosmetic surgeon, Tony Mangubat, MD, known as @Tikdoctony to his more than 200K followers, uses similar hashtags – like #teetusdeleetus – in his TikToks.

Clearly not medical terms, hashtags like #yeettheteet and #teetusdeletus are often used by the transgender community. The posts by Dr. Gallagher and Dr. Mangubat are part of an ever-growing wave of social media activity by medical professionals.  

Plastic surgeons have never been shy about advertising their work – and many have taken to social media to do so, including showing before and after photos. A 2020 study published in Plastic and Reconstructive Surgery found that the majority of such surgeons, especially those in private practice, use social media.

But the use of TikTok, Instagram, and other social media platforms by surgeons who specialize in gender reassignment raises questions about the appropriateness of promoting such procedures, especially to a younger-skewing audience.

Because of the limits on pornography and nudity of social media platforms, most social media posts by gender surgeons are about female-to-male (FTM) mastectomies, the fastest-growing transgender procedure.

The American Society of Plastic Surgeons (ASPS) started separately tracking gender-affirmation procedures in 2015. That year, members reported doing 1,360 FTM procedures.

In 2020, the ASPS further separated procedures into additional categories. That year – when many surgeries were postponed because of the COVID-19 pandemic – FTM mastectomies grew by 15%, with 8,548 procedures performed, a far greater number than for any other transgender surgery, and a sixfold increase in the number of procedures done in 2015.
 

‘Gimmicky,’ but building community

Surgeons interviewed for this article said they use social media primarily to connect with patients and to educate in a light-hearted way.

While Dr. Gallagher acknowledges that using #teetusdeletus is “kind of gimmicky,” she said she doesn’t view it as unprofessional because she is “using the words of the community I serve.” Many of her patients have seen a medical professional “who just didn’t understand what it is to have gender dysphoria, didn’t understand what it is to be trans, so going from that experience to somebody who uses the same language as the community uses can be quite a comfortable experience,” she said in an interview.

Dr. Mangubat, a Seattle-area plastic surgeon who has been doing mastectomies for trans male patients since 1988, said he tailors his TikToks to that group. He likes TikTok – which he started using in early 2021 – because it has rules against bullying, swearing, and pornography, he told this news organization.

“It’s really not ... advertising ... it’s a community-building platform,” said Dr. Mangubat. “If you build community, people will trust you, and if you provide good accurate information, then people will be safer,” he said. 

But, “I’m not telling them to come to me,” he stressed.

He always appears in scrubs and doesn’t do music, doesn’t dance, and doesn’t post before and after photos, but he still gets thousands – or sometimes hundreds of thousands – of likes.

His mission, he said, is to answer the community’s questions. “We’re reaching patients that have had their top surgery, that are going to have their top surgery, that are looking for how to get top surgery, that are just starting on testosterone, that haven’t started on testosterone – it’s the whole spectrum of patients,” said Dr. Mangubat.
 

Risks downplayed?

Other surgeons have expressed concern about ethical boundaries and the tendency of social media posts to downplay risks of what are life-changing procedures.

A 2020 study of YouTube videos on top surgery, for instance, concluded that “there were no unbiased videos by board-certified plastic surgeons explaining the risks, benefits, treatment options, and alternatives to surgery.”

Alison Clayton, MBBS, an Australian psychiatrist, said that social media posts can create false expectations because they emphasize style over substance, omit risks, and can create an unwarranted sense of trust in the doctor that can spill over into the physician-patient relationship.

Dr. Clayton also believes that “the gender-affirming surgical procedures being offered to these youth have a scant empirical evidence base for benefits to psychological health and well-being.”

It is known that a number of those who transition, using either opposite sex hormones and/or surgical procedures, later have regret and “detransition,” but statistics are lacking. It is also a controversial area, with many detransitioners saying they didn’t get appropriate care and weren’t properly assessed before being given hormones or heading to surgery.

Most of the gender surgeons interviewed for this article said they see almost “zero” regret if proper mental health evaluations are performed before surgery, and they added, the procedures can relieve dysphoria.

Nevertheless, posts should not be “all fun and games,” said Josef Hadeed, MD, chair of the ASPS Patient Safety Committee and Public Education Committee and a member of its Social Media Subcommittee.

“When someone makes a decision to undergo a surgical procedure, they should be very aware there are some risks and potentially serious risks involved,” he told this news organization.

The ASPS “wants members to use social media in a judicious manner” in a way that educates the public and encourages patients to learn about a procedure and to consult with board-certified plastic surgeons, said Dr. Hadeed.

The Beverly Hills, Calif.–based surgeon does gender-affirmation procedures himself and uses Instagram, on which he has 53.4K followers, to educate patients and highlight his work using before and after photos.

“I like to think I do it in a very tasteful way,” Dr. Hadeed said. “It’s not in a way that’s sort of suggestive to patients, including minors, that this is something they need to get done, because if they are thinking about getting it done there is a lengthy process that they have to go through before they even set foot in our office.”

And he said “it may be inappropriate” to use certain hashtags or terminology, “even if it does ‘speak’ to the patients. Professionally, plastic surgeons should maintain a higher standard and maintain that even with their social media.”

Marci Bowers, MD, a gynecologic surgeon who performs gender-affirming procedures, and who is transgender herself, agreed.

“Some of the posts out there seem sensational, distasteful, and risk compromising patient confidentiality,” Dr. Bowers said in an interview.

“Much of this seemed to cross the line of good taste and appropriateness,” added Dr. Bowers, who is the incoming president of the World Professional Association for Transgender Health (WPATH). “Creating an idealized video without addressing risk is inappropriate and misleading,” she stressed.

“These surgeons would perhaps better serve their clients by focusing on and improving their clinical care,” she added.  

Dr. Bowers said that although WPATH has not addressed social media use in the past, its ethics committee will be taking on the topic this year.

Social media posts about gender-affirming procedures “don’t usually talk about the barriers, they don’t talk about bad outcomes, they tend to just focus on success stories,” said Gwendolyn P. Quinn, MD, a bioethicist, and Livia S. Wan, MD, professor of obstetrics and gynecology at the NYU Grossman School of Medicine.

But she also sees some positives. The posts can help normalize gender-affirming surgery, and post-procedure photos might “help people realize that they can’t just have everything exactly the way they want it to be,” said Dr. Quinn.
 

Does social media influence or educate?

Studies have documented the power of social media to influence desire and decisionmaking, especially when it comes to cosmetic surgery.

“The use of social media creates a vague area between patient confidentiality and entertainment,” writes Nisha Gupta and colleagues of the UCLA David Geffen School of Medicine in a review published in the Aesthetic Surgery Journal.

While social media use is on the rise by plastic surgeons and has the potential to educate, it has also “compromised the integrity of the doctor-patient relationship,” they add.

Surgeons can use tools to place themselves higher in searches, and patients might assume that those who have hundreds of thousands of followers “are the most qualified or trusted, although this is not always the case,” they note.

Markus Rach, PhD, a researcher with the University of Applied Sciences and Arts Northwestern Switzerland, analyzed the impact of TikTok’s plastic surgery content on how adolescents perceived themselves and how it influenced their decision to have a procedure.

Most TikTok users are under age 24, and #plasticsurgery has a huge viewership with some 3.8 billion views at the time of publication, said Dr. Rach. He found that influencers tended to make adolescents feel bad and want surgery but that plastic surgeons had a moderating effect on both negative feelings and the intent to get surgery.

Dr. Bowers said that, despite her concerns, she does not “believe social media influences like TikTok and Facebook create artificial demand.”

However, Dr. Mangubat said social media can make plastic surgery seem enticing. “It can happen, and it does happen,” he said, but he added that’s true for any cosmetic procedure, not just gender-affirming surgery.

The pitfall with social media is that “patients are being sold a vision of themselves that may or may not be possible,” he observed.

Dr. Quinn worries less about people being talked into a procedure and more about those who don’t want surgery.

“There are people who identify as transgender but do not feel the need to change any parts of their body,” she said. “And that should be okay.”
 

Concerns about minors

New guidance from WPATH, their Standards of Care (SOC) 8 – the first update in 10 years – are due to be published this month. As reported by this news organization, and as stated in the draft of the SOC 8 published for comment in December 2021, the organization has recommended lowering the age for “top” surgery from 18 to 15 years.

Dr. Clayton has concerns about young people with gender dysphoria, who she says are “often vulnerable youth, many of whom have comorbid psychiatric and neurodevelopmental disorders.”

“This may contribute to a greater vulnerability of this population to undue influence,” added Dr. Clayton.

Sean Devitt, MD, and Jeffrey M. Kenkel, MD, of the University of Texas Southwestern Medical Center, Dallas, expressed concern that social media posts by plastic surgeons could be especially dangerous for young people.

“Given that the prefrontal cortex, which is largely responsible for impulse control, is not fully developed until the age of 25, is it ethical to allow younger patients to make life-lasting decisions under the guise of education?” they ask in a commentary on the review by Ms. Gupta and colleagues about plastic surgeons’ use of social media. The review did not focus on gender-affirmation procedures.

Many surgeons – but not all – steer clear of genital (“bottom”) surgeries in minors. However, bilateral mastectomies are being performed in those as young as age 13 based on surgeons’ risk-benefit calculus for the patient.

A study, published in May in the Annals of Plastic Surgery, showed there was a 13-fold increase in the number of bilateral mastectomies performed on under-18s between January 2013 and the end of July 2020. Of the 209 minors (age 12-17) who had the surgery, two (0.95%) expressed regret by the time of follow-up, at 3 and 7 years post-operatively, but neither had reversal surgery.

A small 2018 study, published in JAMA Pediatrics, among trans males who had top surgery found high rates of satisfaction, though one of the 68 patients reported experiencing regret “sometimes.” The mean age of patients in the surgical group was 19 years and the youngest patient was 14.

“Most of us who practice heavily in this field will make exceptions, not for genital surgery but typically for top surgery,” said Dr. Gallagher, who added that she operates on one minor [under 18] a month, while doing some 400-500 gender-affirmative surgeries a year. For some patients, “doing nothing isn’t necessarily a no-harm option,” said Dr. Gallagher.

“Arbitrarily picking the age of 18 and sentencing that patient to another year of dysphoria” might not be the best risk-benefit calculus, she said.  

Dr. Mangubat agrees, especially if, for example, a trans man develops double D breasts by age 14. “You’ve sentenced them to 4 years of misery” before they can get insurance coverage, he said. His youngest top surgery patient was age 15. He said the person’s family, mental health professional, and primary care physician were all in favor of the procedure.

Dr. Mangubat also noted that some insurers, such as Kaiser Permanente, now cover bilateral mastectomy starting at age 16.

Dr. Quinn, the bioethicist, said not every minor or young adult is equipped to make the best long-term decisions.

She works with younger patients who have cancer, for example, and said her suggestions that they consider fertility preservation are often met with protestations “that they will never have children.”

The same issue arises with transgender patients. They may not want to think about having children or issues such as breast feeding while in their teens or early 20s. “But you know from your experience that they may feel differently in 10 years, but they’re just not in the mind frame to think about it,” said Dr. Quinn.

Some young people may accurately never want children, said Dr. Quinn, “but there is a lack of maturity shown when a person just shuts down a conversation and won’t even listen to infertility threats and potential preservation options.”  
 

Concerns about regret?

Dr. Gallagher said she follows the WPATH standards, which require mental health evaluations, and as a result, “the risk of regret is incredibly low.”

However, one of Dr. Gallagher’s patients who detransitioned, Grace, who goes by @HormoneHangover on social media, said she has taken umbrage at some of the Miami surgeon’s TikToks, including one, “Why might some patients feel sad after surgery ... despite wanting it for so long??”

“This is actually not uncommon with ANY kind of surgery, but it’s temporary!” said the TikTok text. Dr. Gallagher is wearing a red dress and heels and flips her hair while the text scrolls above her.

But to Grace, the TikTok “really bothered me, because sometimes there is regret, and I think that sort of advertising paints a falsely rosy picture,” she said in an interview.

And it is emblematic of what she feels was Dr. Gallagher’s “breezy” approach to explaining the procedure to her. “The surgery itself was a shocking experience for me,” she said. “The physical experience was very jarring. It was very disturbing in a way I hadn’t anticipated or understood in advance,” said Grace.

Dr. Mangubat, who does 100 bilateral mastectomies in trans patients a year, said he goes to great lengths to ensure his patients are good candidates. Everyone – even those who self-pay – must have counseling, and if the individual seems to be considering the surgery because it’s “trendy,” he steers clear.

“If they’re not serious about it, I don’t want to operate on them,” said Dr. Mangubat. “There have been maybe two patients who have come back” to detransition, he said. 

Dr. Hadeed also said he has not seen regret. He attributes this to his vetting process, which includes investigating the background of the mental health professionals who write support letters.

“We’ve turned away a lot of patients from our office either because of inadequate letters or because the person writing the letter just doesn’t really have any proper credentials,” he said.
 

Is social media use by plastic surgeons the new normal?

With so many plastic surgeons – including those who perform transgender procedures – using social media, it may increasingly be just part of doing business.

“Undoubtedly gender surgery teams will have a greater presence on social media in the future,” write Alireza Hamidian Jahromi, MD, and a colleague of the plastic surgery department at Rush University Medical Center, Chicago, in a letter published in Plastic and Reconstructive Surgery.  

Kyle R. Latack, MD, and colleagues at the University of Southern California and the University of Michigan, have studied the use of social media by the transgender community and write that they believe “there should be an increased effort to develop high-quality and unbiased resources for patient education that can be made [available] on social media.”

Dr. Gallagher said TikTok helped her erase fear. “A bilateral mastectomy is a scary surgery for an 18-year-old or a 20-year-old,” she said, “but they have to do it for their well-being.”

“That is a criticism I’ve heard – that I seek to minimize it or that I’m flippant about it,” said Dr. Gallagher.

For “top surgery the risk profile is pretty low,” she said, “so what I try to do is educate people that it’s maybe not as scary a procedure as they think.”

Dr. Mangubat, however, is concerned about some of what he sees, especially the explosion of surgeons offering gender-affirming procedures. “Now everybody wants a piece of it,” he said.

“Let’s face it, it’s money now. You get paid for doing this surgery. Hospitals get paid a lot of money for their operating rooms for doing the surgery,” said Dr. Mangubat. “There are some surgeons who believe the transgender community is just another market.”

A version of this article first appeared on Medscape.com.

A woman wearing purple surgical scrubs stares into a camera, looking frustrated, but doesn’t speak. Superimposed over her head is the text “just realized I only get to Yeet 4 Teets next week,” and a crying emoji. Rain appears to drip down over her while “Stan” by Eminem plays in the background.

That October 2020 TikTok by Sidhbh Gallagher, MD, a Miami-based plastic surgeon known as @gendersurgeon, had almost 10,000 likes and was tagged #topsurgery, #masculoplasty, #ftm, and #transman, among other hashtags.

“What health check do I have to get in preparation for teetus deletus?” is the question in another Dr. Gallagher TikTok. Dr. Gallagher is a prolific user of social media with over 268K TikTok followers and over 44K Instagram followers. Another Dr. Gallagher TikTok account, @thevagicianmd, has some 7K followers.

Another cosmetic surgeon, Tony Mangubat, MD, known as @Tikdoctony to his more than 200K followers, uses similar hashtags – like #teetusdeleetus – in his TikToks.

Clearly not medical terms, hashtags like #yeettheteet and #teetusdeletus are often used by the transgender community. The posts by Dr. Gallagher and Dr. Mangubat are part of an ever-growing wave of social media activity by medical professionals.  

Plastic surgeons have never been shy about advertising their work – and many have taken to social media to do so, including showing before and after photos. A 2020 study published in Plastic and Reconstructive Surgery found that the majority of such surgeons, especially those in private practice, use social media.

But the use of TikTok, Instagram, and other social media platforms by surgeons who specialize in gender reassignment raises questions about the appropriateness of promoting such procedures, especially to a younger-skewing audience.

Because of the limits on pornography and nudity of social media platforms, most social media posts by gender surgeons are about female-to-male (FTM) mastectomies, the fastest-growing transgender procedure.

The American Society of Plastic Surgeons (ASPS) started separately tracking gender-affirmation procedures in 2015. That year, members reported doing 1,360 FTM procedures.

In 2020, the ASPS further separated procedures into additional categories. That year – when many surgeries were postponed because of the COVID-19 pandemic – FTM mastectomies grew by 15%, with 8,548 procedures performed, a far greater number than for any other transgender surgery, and a sixfold increase in the number of procedures done in 2015.
 

‘Gimmicky,’ but building community

Surgeons interviewed for this article said they use social media primarily to connect with patients and to educate in a light-hearted way.

While Dr. Gallagher acknowledges that using #teetusdeletus is “kind of gimmicky,” she said she doesn’t view it as unprofessional because she is “using the words of the community I serve.” Many of her patients have seen a medical professional “who just didn’t understand what it is to have gender dysphoria, didn’t understand what it is to be trans, so going from that experience to somebody who uses the same language as the community uses can be quite a comfortable experience,” she said in an interview.

Dr. Mangubat, a Seattle-area plastic surgeon who has been doing mastectomies for trans male patients since 1988, said he tailors his TikToks to that group. He likes TikTok – which he started using in early 2021 – because it has rules against bullying, swearing, and pornography, he told this news organization.

“It’s really not ... advertising ... it’s a community-building platform,” said Dr. Mangubat. “If you build community, people will trust you, and if you provide good accurate information, then people will be safer,” he said. 

But, “I’m not telling them to come to me,” he stressed.

He always appears in scrubs and doesn’t do music, doesn’t dance, and doesn’t post before and after photos, but he still gets thousands – or sometimes hundreds of thousands – of likes.

His mission, he said, is to answer the community’s questions. “We’re reaching patients that have had their top surgery, that are going to have their top surgery, that are looking for how to get top surgery, that are just starting on testosterone, that haven’t started on testosterone – it’s the whole spectrum of patients,” said Dr. Mangubat.
 

Risks downplayed?

Other surgeons have expressed concern about ethical boundaries and the tendency of social media posts to downplay risks of what are life-changing procedures.

A 2020 study of YouTube videos on top surgery, for instance, concluded that “there were no unbiased videos by board-certified plastic surgeons explaining the risks, benefits, treatment options, and alternatives to surgery.”

Alison Clayton, MBBS, an Australian psychiatrist, said that social media posts can create false expectations because they emphasize style over substance, omit risks, and can create an unwarranted sense of trust in the doctor that can spill over into the physician-patient relationship.

Dr. Clayton also believes that “the gender-affirming surgical procedures being offered to these youth have a scant empirical evidence base for benefits to psychological health and well-being.”

It is known that a number of those who transition, using either opposite sex hormones and/or surgical procedures, later have regret and “detransition,” but statistics are lacking. It is also a controversial area, with many detransitioners saying they didn’t get appropriate care and weren’t properly assessed before being given hormones or heading to surgery.

Most of the gender surgeons interviewed for this article said they see almost “zero” regret if proper mental health evaluations are performed before surgery, and they added, the procedures can relieve dysphoria.

Nevertheless, posts should not be “all fun and games,” said Josef Hadeed, MD, chair of the ASPS Patient Safety Committee and Public Education Committee and a member of its Social Media Subcommittee.

“When someone makes a decision to undergo a surgical procedure, they should be very aware there are some risks and potentially serious risks involved,” he told this news organization.

The ASPS “wants members to use social media in a judicious manner” in a way that educates the public and encourages patients to learn about a procedure and to consult with board-certified plastic surgeons, said Dr. Hadeed.

The Beverly Hills, Calif.–based surgeon does gender-affirmation procedures himself and uses Instagram, on which he has 53.4K followers, to educate patients and highlight his work using before and after photos.

“I like to think I do it in a very tasteful way,” Dr. Hadeed said. “It’s not in a way that’s sort of suggestive to patients, including minors, that this is something they need to get done, because if they are thinking about getting it done there is a lengthy process that they have to go through before they even set foot in our office.”

And he said “it may be inappropriate” to use certain hashtags or terminology, “even if it does ‘speak’ to the patients. Professionally, plastic surgeons should maintain a higher standard and maintain that even with their social media.”

Marci Bowers, MD, a gynecologic surgeon who performs gender-affirming procedures, and who is transgender herself, agreed.

“Some of the posts out there seem sensational, distasteful, and risk compromising patient confidentiality,” Dr. Bowers said in an interview.

“Much of this seemed to cross the line of good taste and appropriateness,” added Dr. Bowers, who is the incoming president of the World Professional Association for Transgender Health (WPATH). “Creating an idealized video without addressing risk is inappropriate and misleading,” she stressed.

“These surgeons would perhaps better serve their clients by focusing on and improving their clinical care,” she added.  

Dr. Bowers said that although WPATH has not addressed social media use in the past, its ethics committee will be taking on the topic this year.

Social media posts about gender-affirming procedures “don’t usually talk about the barriers, they don’t talk about bad outcomes, they tend to just focus on success stories,” said Gwendolyn P. Quinn, MD, a bioethicist, and Livia S. Wan, MD, professor of obstetrics and gynecology at the NYU Grossman School of Medicine.

But she also sees some positives. The posts can help normalize gender-affirming surgery, and post-procedure photos might “help people realize that they can’t just have everything exactly the way they want it to be,” said Dr. Quinn.
 

Does social media influence or educate?

Studies have documented the power of social media to influence desire and decisionmaking, especially when it comes to cosmetic surgery.

“The use of social media creates a vague area between patient confidentiality and entertainment,” writes Nisha Gupta and colleagues of the UCLA David Geffen School of Medicine in a review published in the Aesthetic Surgery Journal.

While social media use is on the rise by plastic surgeons and has the potential to educate, it has also “compromised the integrity of the doctor-patient relationship,” they add.

Surgeons can use tools to place themselves higher in searches, and patients might assume that those who have hundreds of thousands of followers “are the most qualified or trusted, although this is not always the case,” they note.

Markus Rach, PhD, a researcher with the University of Applied Sciences and Arts Northwestern Switzerland, analyzed the impact of TikTok’s plastic surgery content on how adolescents perceived themselves and how it influenced their decision to have a procedure.

Most TikTok users are under age 24, and #plasticsurgery has a huge viewership with some 3.8 billion views at the time of publication, said Dr. Rach. He found that influencers tended to make adolescents feel bad and want surgery but that plastic surgeons had a moderating effect on both negative feelings and the intent to get surgery.

Dr. Bowers said that, despite her concerns, she does not “believe social media influences like TikTok and Facebook create artificial demand.”

However, Dr. Mangubat said social media can make plastic surgery seem enticing. “It can happen, and it does happen,” he said, but he added that’s true for any cosmetic procedure, not just gender-affirming surgery.

The pitfall with social media is that “patients are being sold a vision of themselves that may or may not be possible,” he observed.

Dr. Quinn worries less about people being talked into a procedure and more about those who don’t want surgery.

“There are people who identify as transgender but do not feel the need to change any parts of their body,” she said. “And that should be okay.”
 

Concerns about minors

New guidance from WPATH, their Standards of Care (SOC) 8 – the first update in 10 years – are due to be published this month. As reported by this news organization, and as stated in the draft of the SOC 8 published for comment in December 2021, the organization has recommended lowering the age for “top” surgery from 18 to 15 years.

Dr. Clayton has concerns about young people with gender dysphoria, who she says are “often vulnerable youth, many of whom have comorbid psychiatric and neurodevelopmental disorders.”

“This may contribute to a greater vulnerability of this population to undue influence,” added Dr. Clayton.

Sean Devitt, MD, and Jeffrey M. Kenkel, MD, of the University of Texas Southwestern Medical Center, Dallas, expressed concern that social media posts by plastic surgeons could be especially dangerous for young people.

“Given that the prefrontal cortex, which is largely responsible for impulse control, is not fully developed until the age of 25, is it ethical to allow younger patients to make life-lasting decisions under the guise of education?” they ask in a commentary on the review by Ms. Gupta and colleagues about plastic surgeons’ use of social media. The review did not focus on gender-affirmation procedures.

Many surgeons – but not all – steer clear of genital (“bottom”) surgeries in minors. However, bilateral mastectomies are being performed in those as young as age 13 based on surgeons’ risk-benefit calculus for the patient.

A study, published in May in the Annals of Plastic Surgery, showed there was a 13-fold increase in the number of bilateral mastectomies performed on under-18s between January 2013 and the end of July 2020. Of the 209 minors (age 12-17) who had the surgery, two (0.95%) expressed regret by the time of follow-up, at 3 and 7 years post-operatively, but neither had reversal surgery.

A small 2018 study, published in JAMA Pediatrics, among trans males who had top surgery found high rates of satisfaction, though one of the 68 patients reported experiencing regret “sometimes.” The mean age of patients in the surgical group was 19 years and the youngest patient was 14.

“Most of us who practice heavily in this field will make exceptions, not for genital surgery but typically for top surgery,” said Dr. Gallagher, who added that she operates on one minor [under 18] a month, while doing some 400-500 gender-affirmative surgeries a year. For some patients, “doing nothing isn’t necessarily a no-harm option,” said Dr. Gallagher.

“Arbitrarily picking the age of 18 and sentencing that patient to another year of dysphoria” might not be the best risk-benefit calculus, she said.  

Dr. Mangubat agrees, especially if, for example, a trans man develops double D breasts by age 14. “You’ve sentenced them to 4 years of misery” before they can get insurance coverage, he said. His youngest top surgery patient was age 15. He said the person’s family, mental health professional, and primary care physician were all in favor of the procedure.

Dr. Mangubat also noted that some insurers, such as Kaiser Permanente, now cover bilateral mastectomy starting at age 16.

Dr. Quinn, the bioethicist, said not every minor or young adult is equipped to make the best long-term decisions.

She works with younger patients who have cancer, for example, and said her suggestions that they consider fertility preservation are often met with protestations “that they will never have children.”

The same issue arises with transgender patients. They may not want to think about having children or issues such as breast feeding while in their teens or early 20s. “But you know from your experience that they may feel differently in 10 years, but they’re just not in the mind frame to think about it,” said Dr. Quinn.

Some young people may accurately never want children, said Dr. Quinn, “but there is a lack of maturity shown when a person just shuts down a conversation and won’t even listen to infertility threats and potential preservation options.”  
 

Concerns about regret?

Dr. Gallagher said she follows the WPATH standards, which require mental health evaluations, and as a result, “the risk of regret is incredibly low.”

However, one of Dr. Gallagher’s patients who detransitioned, Grace, who goes by @HormoneHangover on social media, said she has taken umbrage at some of the Miami surgeon’s TikToks, including one, “Why might some patients feel sad after surgery ... despite wanting it for so long??”

“This is actually not uncommon with ANY kind of surgery, but it’s temporary!” said the TikTok text. Dr. Gallagher is wearing a red dress and heels and flips her hair while the text scrolls above her.

But to Grace, the TikTok “really bothered me, because sometimes there is regret, and I think that sort of advertising paints a falsely rosy picture,” she said in an interview.

And it is emblematic of what she feels was Dr. Gallagher’s “breezy” approach to explaining the procedure to her. “The surgery itself was a shocking experience for me,” she said. “The physical experience was very jarring. It was very disturbing in a way I hadn’t anticipated or understood in advance,” said Grace.

Dr. Mangubat, who does 100 bilateral mastectomies in trans patients a year, said he goes to great lengths to ensure his patients are good candidates. Everyone – even those who self-pay – must have counseling, and if the individual seems to be considering the surgery because it’s “trendy,” he steers clear.

“If they’re not serious about it, I don’t want to operate on them,” said Dr. Mangubat. “There have been maybe two patients who have come back” to detransition, he said. 

Dr. Hadeed also said he has not seen regret. He attributes this to his vetting process, which includes investigating the background of the mental health professionals who write support letters.

“We’ve turned away a lot of patients from our office either because of inadequate letters or because the person writing the letter just doesn’t really have any proper credentials,” he said.
 

Is social media use by plastic surgeons the new normal?

With so many plastic surgeons – including those who perform transgender procedures – using social media, it may increasingly be just part of doing business.

“Undoubtedly gender surgery teams will have a greater presence on social media in the future,” write Alireza Hamidian Jahromi, MD, and a colleague of the plastic surgery department at Rush University Medical Center, Chicago, in a letter published in Plastic and Reconstructive Surgery.  

Kyle R. Latack, MD, and colleagues at the University of Southern California and the University of Michigan, have studied the use of social media by the transgender community and write that they believe “there should be an increased effort to develop high-quality and unbiased resources for patient education that can be made [available] on social media.”

Dr. Gallagher said TikTok helped her erase fear. “A bilateral mastectomy is a scary surgery for an 18-year-old or a 20-year-old,” she said, “but they have to do it for their well-being.”

“That is a criticism I’ve heard – that I seek to minimize it or that I’m flippant about it,” said Dr. Gallagher.

For “top surgery the risk profile is pretty low,” she said, “so what I try to do is educate people that it’s maybe not as scary a procedure as they think.”

Dr. Mangubat, however, is concerned about some of what he sees, especially the explosion of surgeons offering gender-affirming procedures. “Now everybody wants a piece of it,” he said.

“Let’s face it, it’s money now. You get paid for doing this surgery. Hospitals get paid a lot of money for their operating rooms for doing the surgery,” said Dr. Mangubat. “There are some surgeons who believe the transgender community is just another market.”

A version of this article first appeared on Medscape.com.

A large Danish study has found that cancer increases the risk of new-onset type 2 diabetes, especially certain types of cancer, most notably pancreatic malignancies.

“Our study demonstrates that there is an elevated risk of developing diabetes if a person is affected by lung, pancreatic, breast, brain, urinary tract, or uterine cancers,” said Lykke Sylow, PhD, associate professor in the Molecular Metabolism in Cancer and Ageing Group at the University of Copenhagen, in a statement.

“It is great to see such a large, well-designed study confirm the findings of previous smaller studies and observations,” said Elias S. Siraj, MD, the David L. Bernd Distinguished Chair for EVMS-Sentara Cardiovascular Diabetes Program at Eastern Virginia Medical School in Norfolk, when asked for comment by this news organization. Dr. Siraj also noted that “in clinical care we do observe that many patients develop diabetes after being diagnosed with cancer although one needs a well-designed study to confirm that observation.”
 

Diabetes risk highest with pancreatic cancer

Type 2 diabetes at the time of cancer diagnosis is known to increase cancer-specific and all-cause mortality, but not much is known about whether cancer is a risk factor for type 2 diabetes, the researchers state in their study, published in Diabetes Care.

Dr. Sylow and colleagues from the Steno Diabetes Center Copenhagen, Rigshospitalet, analyzed a database consisting of 112 million blood samples from 1.3 million Danes from 2000 to 2015. They looked at cancer cases with an incidence of more than 1,000 and excluded individuals with diabetes prior to cancer diagnosis. 

They found an increased risk of new-onset type 2 diabetes for all cancers (hazard ratio, 1.09; 95% confidence interval, 1.03-1.14). For pancreatic cancer, the hazard ratio rose to 5.0 (95% CI, 3.62-6.90), for brain and nervous system cancers the hazard ratio was 1.54 (95% CI, 1.22-1.95), and for uterine cancer the hazard ratio was 1.41 (95% CI, 1.10-1.84).

The link with pancreatic cancer was not surprising, said Dr. Sylow.

Dr. Siraj agreed, noting that a few studies have shown a strong association. “It has also been observed for years that many patients with pancreatic cancer may present with new-onset diabetes,” he said. “The mechanism is not clearly understood but could include a direct damage of the beta cells by the pancreatic cancer or could be due to a paraneoplastic secretion of special factors by the cancer that can affect beta-cell function or insulin resistance,” said Dr. Siraj, who is also professor and chief of endocrinology and director of the Strelitz Diabetes Center at Eastern Virginia Medical School.

The higher diabetes risk associated with brain and nervous system cancers has not been previously described and is “an intriguing finding,” he said.

In their statement, the Danish investigators said there is nothing in their research to suggest why some cancers are associated with a higher risk of new-onset type 2 diabetes, but they offered some theories, including that chemotherapeutics and perhaps the cancer, itself, may contribute.

“We know that cancer cells are able to secrete substances that can affect organs and possibility contribute to an increased incidence of diabetes,” said Dr. Sylow in the statement.
 

Increased mortality risk in those with cancer and type 2 diabetes

Dr. Sylow and colleagues also analyzed mortality in a subset of 28,308 patients with cancer who were still alive 2 years after diagnosis. They documented a 21% higher rate of all-cause mortality in these patients compared with those who did not have new-onset type 2 diabetes.

“We do not know enough about the patients who were diagnosed with type 2 diabetes, but we think our findings illustrate a potential new area of intervention in the cancer clinic,” Dr. Sylow said. However, the findings still require replication before drawing any definite conclusions, she added.

Christoffer Johansen, MD, PhD, DMSc, of Rigshospitalet, said in the statement that it might be prudent to screen patients with lung, breast, brain, uterine, and urinary tract cancers for diabetes. “Early intervention could have an impact on certain cancer patients,” said Dr. Johansen.

Dr. Siraj said he would urge oncologists to routinely monitor blood glucose levels during cancer treatment and as part of long-term surveillance, and to consider the potential risk of new-onset diabetes when choosing a cancer therapy. If diabetes is diagnosed, clinicians should be sure that it’s managed by a primary care physician or endocrinologist, “as proper treatment may contribute to better outcomes of the cancer,” said Dr. Siraj.

Endocrinologists should consider the possibility of pancreatic cancer if someone with few risk factors for type 2 diabetes has a new-onset diagnosis, he said. And they should aim for good glycemic control in those with new-onset type 2 diabetes, as it may lead to better cancer outcomes, he said.

Dr. Sylow has reported grant support from the Novo Nordisk Foundation and Independent Research Fund Denmark. Dr. Johansen has reported serving as an educator for Janssen and Pfizer. Coauthors have received grant support from the Danish Cancer Society and served as consultants, on advisory boards, or as educators for Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Incyte, GSK, MSD, Mundipharma, Novartis, Novo Nordisk, Pfizer, and Sanofi.

A version of this article first appeared on Medscape.com.

A large Danish study has found that cancer increases the risk of new-onset type 2 diabetes, especially certain types of cancer, most notably pancreatic malignancies.

“Our study demonstrates that there is an elevated risk of developing diabetes if a person is affected by lung, pancreatic, breast, brain, urinary tract, or uterine cancers,” said Lykke Sylow, PhD, associate professor in the Molecular Metabolism in Cancer and Ageing Group at the University of Copenhagen, in a statement.

“It is great to see such a large, well-designed study confirm the findings of previous smaller studies and observations,” said Elias S. Siraj, MD, the David L. Bernd Distinguished Chair for EVMS-Sentara Cardiovascular Diabetes Program at Eastern Virginia Medical School in Norfolk, when asked for comment by this news organization. Dr. Siraj also noted that “in clinical care we do observe that many patients develop diabetes after being diagnosed with cancer although one needs a well-designed study to confirm that observation.”
 

Diabetes risk highest with pancreatic cancer

Type 2 diabetes at the time of cancer diagnosis is known to increase cancer-specific and all-cause mortality, but not much is known about whether cancer is a risk factor for type 2 diabetes, the researchers state in their study, published in Diabetes Care.

Dr. Sylow and colleagues from the Steno Diabetes Center Copenhagen, Rigshospitalet, analyzed a database consisting of 112 million blood samples from 1.3 million Danes from 2000 to 2015. They looked at cancer cases with an incidence of more than 1,000 and excluded individuals with diabetes prior to cancer diagnosis. 

They found an increased risk of new-onset type 2 diabetes for all cancers (hazard ratio, 1.09; 95% confidence interval, 1.03-1.14). For pancreatic cancer, the hazard ratio rose to 5.0 (95% CI, 3.62-6.90), for brain and nervous system cancers the hazard ratio was 1.54 (95% CI, 1.22-1.95), and for uterine cancer the hazard ratio was 1.41 (95% CI, 1.10-1.84).

The link with pancreatic cancer was not surprising, said Dr. Sylow.

Dr. Siraj agreed, noting that a few studies have shown a strong association. “It has also been observed for years that many patients with pancreatic cancer may present with new-onset diabetes,” he said. “The mechanism is not clearly understood but could include a direct damage of the beta cells by the pancreatic cancer or could be due to a paraneoplastic secretion of special factors by the cancer that can affect beta-cell function or insulin resistance,” said Dr. Siraj, who is also professor and chief of endocrinology and director of the Strelitz Diabetes Center at Eastern Virginia Medical School.

The higher diabetes risk associated with brain and nervous system cancers has not been previously described and is “an intriguing finding,” he said.

In their statement, the Danish investigators said there is nothing in their research to suggest why some cancers are associated with a higher risk of new-onset type 2 diabetes, but they offered some theories, including that chemotherapeutics and perhaps the cancer, itself, may contribute.

“We know that cancer cells are able to secrete substances that can affect organs and possibility contribute to an increased incidence of diabetes,” said Dr. Sylow in the statement.
 

Increased mortality risk in those with cancer and type 2 diabetes

Dr. Sylow and colleagues also analyzed mortality in a subset of 28,308 patients with cancer who were still alive 2 years after diagnosis. They documented a 21% higher rate of all-cause mortality in these patients compared with those who did not have new-onset type 2 diabetes.

“We do not know enough about the patients who were diagnosed with type 2 diabetes, but we think our findings illustrate a potential new area of intervention in the cancer clinic,” Dr. Sylow said. However, the findings still require replication before drawing any definite conclusions, she added.

Christoffer Johansen, MD, PhD, DMSc, of Rigshospitalet, said in the statement that it might be prudent to screen patients with lung, breast, brain, uterine, and urinary tract cancers for diabetes. “Early intervention could have an impact on certain cancer patients,” said Dr. Johansen.

Dr. Siraj said he would urge oncologists to routinely monitor blood glucose levels during cancer treatment and as part of long-term surveillance, and to consider the potential risk of new-onset diabetes when choosing a cancer therapy. If diabetes is diagnosed, clinicians should be sure that it’s managed by a primary care physician or endocrinologist, “as proper treatment may contribute to better outcomes of the cancer,” said Dr. Siraj.

Endocrinologists should consider the possibility of pancreatic cancer if someone with few risk factors for type 2 diabetes has a new-onset diagnosis, he said. And they should aim for good glycemic control in those with new-onset type 2 diabetes, as it may lead to better cancer outcomes, he said.

Dr. Sylow has reported grant support from the Novo Nordisk Foundation and Independent Research Fund Denmark. Dr. Johansen has reported serving as an educator for Janssen and Pfizer. Coauthors have received grant support from the Danish Cancer Society and served as consultants, on advisory boards, or as educators for Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Incyte, GSK, MSD, Mundipharma, Novartis, Novo Nordisk, Pfizer, and Sanofi.

A version of this article first appeared on Medscape.com.

A large Danish study has found that cancer increases the risk of new-onset type 2 diabetes, especially certain types of cancer, most notably pancreatic malignancies.

“Our study demonstrates that there is an elevated risk of developing diabetes if a person is affected by lung, pancreatic, breast, brain, urinary tract, or uterine cancers,” said Lykke Sylow, PhD, associate professor in the Molecular Metabolism in Cancer and Ageing Group at the University of Copenhagen, in a statement.

“It is great to see such a large, well-designed study confirm the findings of previous smaller studies and observations,” said Elias S. Siraj, MD, the David L. Bernd Distinguished Chair for EVMS-Sentara Cardiovascular Diabetes Program at Eastern Virginia Medical School in Norfolk, when asked for comment by this news organization. Dr. Siraj also noted that “in clinical care we do observe that many patients develop diabetes after being diagnosed with cancer although one needs a well-designed study to confirm that observation.”
 

Diabetes risk highest with pancreatic cancer

Type 2 diabetes at the time of cancer diagnosis is known to increase cancer-specific and all-cause mortality, but not much is known about whether cancer is a risk factor for type 2 diabetes, the researchers state in their study, published in Diabetes Care.

Dr. Sylow and colleagues from the Steno Diabetes Center Copenhagen, Rigshospitalet, analyzed a database consisting of 112 million blood samples from 1.3 million Danes from 2000 to 2015. They looked at cancer cases with an incidence of more than 1,000 and excluded individuals with diabetes prior to cancer diagnosis. 

They found an increased risk of new-onset type 2 diabetes for all cancers (hazard ratio, 1.09; 95% confidence interval, 1.03-1.14). For pancreatic cancer, the hazard ratio rose to 5.0 (95% CI, 3.62-6.90), for brain and nervous system cancers the hazard ratio was 1.54 (95% CI, 1.22-1.95), and for uterine cancer the hazard ratio was 1.41 (95% CI, 1.10-1.84).

The link with pancreatic cancer was not surprising, said Dr. Sylow.

Dr. Siraj agreed, noting that a few studies have shown a strong association. “It has also been observed for years that many patients with pancreatic cancer may present with new-onset diabetes,” he said. “The mechanism is not clearly understood but could include a direct damage of the beta cells by the pancreatic cancer or could be due to a paraneoplastic secretion of special factors by the cancer that can affect beta-cell function or insulin resistance,” said Dr. Siraj, who is also professor and chief of endocrinology and director of the Strelitz Diabetes Center at Eastern Virginia Medical School.

The higher diabetes risk associated with brain and nervous system cancers has not been previously described and is “an intriguing finding,” he said.

In their statement, the Danish investigators said there is nothing in their research to suggest why some cancers are associated with a higher risk of new-onset type 2 diabetes, but they offered some theories, including that chemotherapeutics and perhaps the cancer, itself, may contribute.

“We know that cancer cells are able to secrete substances that can affect organs and possibility contribute to an increased incidence of diabetes,” said Dr. Sylow in the statement.
 

Increased mortality risk in those with cancer and type 2 diabetes

Dr. Sylow and colleagues also analyzed mortality in a subset of 28,308 patients with cancer who were still alive 2 years after diagnosis. They documented a 21% higher rate of all-cause mortality in these patients compared with those who did not have new-onset type 2 diabetes.

“We do not know enough about the patients who were diagnosed with type 2 diabetes, but we think our findings illustrate a potential new area of intervention in the cancer clinic,” Dr. Sylow said. However, the findings still require replication before drawing any definite conclusions, she added.

Christoffer Johansen, MD, PhD, DMSc, of Rigshospitalet, said in the statement that it might be prudent to screen patients with lung, breast, brain, uterine, and urinary tract cancers for diabetes. “Early intervention could have an impact on certain cancer patients,” said Dr. Johansen.

Dr. Siraj said he would urge oncologists to routinely monitor blood glucose levels during cancer treatment and as part of long-term surveillance, and to consider the potential risk of new-onset diabetes when choosing a cancer therapy. If diabetes is diagnosed, clinicians should be sure that it’s managed by a primary care physician or endocrinologist, “as proper treatment may contribute to better outcomes of the cancer,” said Dr. Siraj.

Endocrinologists should consider the possibility of pancreatic cancer if someone with few risk factors for type 2 diabetes has a new-onset diagnosis, he said. And they should aim for good glycemic control in those with new-onset type 2 diabetes, as it may lead to better cancer outcomes, he said.

Dr. Sylow has reported grant support from the Novo Nordisk Foundation and Independent Research Fund Denmark. Dr. Johansen has reported serving as an educator for Janssen and Pfizer. Coauthors have received grant support from the Danish Cancer Society and served as consultants, on advisory boards, or as educators for Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Incyte, GSK, MSD, Mundipharma, Novartis, Novo Nordisk, Pfizer, and Sanofi.

A version of this article first appeared on Medscape.com.

The U.S. Supreme Court has voted to overturn the federal constitutional right to abortion, which will now leave the issue to be decided on a state-by-state basis.

According to some estimates, about 25 million women of reproductive age will now live in states that ban or severely restrict abortion. Twenty-six states are “certain or likely” to ban abortion, according to the Guttmacher Institute, which supports abortion rights.

Thirteen states have so-called trigger laws that will ban abortion almost immediately, while nine other states are now likely to try to enforce near-total bans or severe restrictions that have been blocked by courts pending the outcome of the just-issued decision in Dobbs v. Jackson Women’s Health Organization. Four states also have a history or have shown a recent desire to prohibit abortion, according to the Guttmacher Institute.

Doctors and others who provide abortion services, or in some states “aid or abet” an abortion, could be fined thousands of dollars or sent to prison.

The court voted in favor of Mississippi and its 2018 law that outlawed abortion after 15 weeks. Jackson Women’s Health, the state’s sole remaining abortion provider, sued to block the law soon after it passed.

The Supreme Court decision is not a surprise, as the justices indicated they were leaning that way during oral arguments in December. The majority’s thoughts were further revealed when a draft of the opinion was leaked to the news outlet Politico on May 2. 

In the final opinion, Justice Samuel Alito, writing for the majority, “It is time to heed the Constitution and return the issue of abortion to the people’s elected representatives.”

The decision strikes down both precedent-setting rulings that established a right to abortion until the point of viability, long considered to be 24 weeks: Roe v. Wade (1973) and Planned Parenthood v. Casey (1992).

Twenty-five medical professional societies – representing OB/GYNs, family medicine doctors, fertility specialists, geneticists, hospitalists, internists, pediatricians, psychiatrists, nurses, nurse practitioners, and midwives – had urged the court to throw out the Mississippi law. And more than 2,500 medical professionals signed on to a petition in June, urging the court to uphold the right to abortion.

The number of abortions has recently increased from what had been a long decline. The Guttmacher Institute estimates there were there were 930,160 abortion procedures in 2020 (compared to 3.6 million births), an 8% increase from 2017. The number does not include self-managed abortions. The organization said the increase was potentially due to expanded Medicaid coverage and reduced access to contraception due to Trump administration policies.
 

Trigger laws and bans

When trigger laws and new restrictions go into effect, women in the South, Midwest, and Inter-Mountain West will likely have to drive hundreds of miles for an abortion, according to Guttmacher. Women in Louisiana, for instance, would have to drive 660 miles to get to the nearest provider in Illinois.

University of Utah researchers estimated that almost half of women will see a big increase in the distance to abortion care, from a median distance of 39 miles to 113 miles. State bans will disproportionately impact women of color, those living in poverty, and people with less education, they said.

The CDC has reported that Black women are three times more likely to die from a pregnancy-related cause than white women.

Doctors and other abortion providers could face serious penalties. The maximum penalty in Texas is life in prison, and the sentence could be 10 to 15 years in 11 other states, according to an article in the medical journal JAMA by attorneys Rebecca B. Reingold and Lawrence O. Gostin.

“Threats of prosecution undermine clinicians’ ability to provide safe, evidence-based care and to counsel patients honestly, impeding the patient-physician relationship,” they wrote. “Given harsh penalties, physicians may cease treating pregnancy loss, with no clear line between treating miscarriages and abortions.”

In preparing for these attacks on patients and doctors, New York Gov. Kathy Hochul on June 13 signed a bill that immediately protects anyone who has an abortion and medical professionals in the state who provide them from legal retaliation by states that restrict or prohibit abortion.

Even while Roe was still the law, Mississippi had banned most abortions after 20 weeks, and 16 states prohibited abortion after 22 weeks. A Texas ban on abortion after 6 weeks – which also allows private citizens to sue abortion providers – was allowed to stay in place while it was being challenged.

On May 26, Oklahoma Gov. Kevin Stitt signed  a bill banning abortion from the moment of conception. Just as in Texas, the Oklahoma law allows what critics have called “bounty hunting” of abortion providers.

Four states have a constitutional amendment declaring that the state constitution does not secure or protect the right to abortion or allow the use of public funds for abortion: Alabama, Louisiana, Tennessee, and West Virginia.
 

Some states protecting rights

At least 16 states have proactively protected a right to an abortion, according to Guttmacher, while The New York Times reports that Washington, DC, has laws that protect abortion, along with 20 states: Alaska, Colorado, Illinois, Maine, Massachusetts, Minnesota, Nevada, New Hampshire, New Mexico, Rhode Island, California, Connecticut, Delaware, Hawaii, Maryland, New Jersey, New York, Oregon, Vermont, and Washington.

Some of these states are gearing up for a potential influx of patients. Washington Gov. Jay Inslee signed a law that authorizes physician assistants, advanced registered nurse practitioners, and other providers acting within their scope of practice to perform abortions. And the Maryland Legislature overrode a veto by Gov. Larry Hogan of a law that expands who can perform abortions.

Wisconsin Gov. Tony Evers in early June called a special legislative session to repeal the state’s 173-year-old dormant ban on abortion. But the majority Republican legislature vowed to take no action.

B. Jessie Hill, JD, associate dean for academic affairs and a professor at the Case Western Reserve University School of Law, says she expects anti-abortion groups to challenge these protective laws, “by saying that fetuses are persons under the Constitution with a right to life and therefore that the state has to protect them.”

But, she says, “there’s going to be big, big challenges with those lawsuits,” and they will not be “winners off the bat.”
 

Medication abortions, travel next battle

Some states are also trying to outlaw or severely restrict the use of RU-486, the abortion pill. A Tennessee law that goes into effect in 2023 would ban delivery of pills by mail and require a patient to have two doctor visits – one consultation and one to pick up the pills.

Mississippi has also enacted restrictions including the requirement that women meet with a doctor  first – and is being sued by pill maker GenBioPro.

Guttmacher estimates that medication abortion accounted for 39% of all abortions in the U.S. in 2017 and 60% of all abortions that occurred before 10 weeks’ gestation.

Some states have floated the idea of prohibiting anyone from traveling to another state for an abortion.

George Mason University law professor Ilya Somin, JD, has written that such a law would likely violate the Dormant Commerce Clause, “which forbids state regulations that specifically restrict interstate commerce or discriminate against it.”

He also wrote that states lack the authority to regulate activity that takes place beyond their borders and that such bans “are open to challenge because they violate the constitutional right to travel.”

Hill also said a travel ban would be problematic, noting that it might be difficult to prosecute someone for “something you did completely in another state.”

A version of this article first appeared on Medscape.com.

The U.S. Supreme Court has voted to overturn the federal constitutional right to abortion, which will now leave the issue to be decided on a state-by-state basis.

According to some estimates, about 25 million women of reproductive age will now live in states that ban or severely restrict abortion. Twenty-six states are “certain or likely” to ban abortion, according to the Guttmacher Institute, which supports abortion rights.

Thirteen states have so-called trigger laws that will ban abortion almost immediately, while nine other states are now likely to try to enforce near-total bans or severe restrictions that have been blocked by courts pending the outcome of the just-issued decision in Dobbs v. Jackson Women’s Health Organization. Four states also have a history or have shown a recent desire to prohibit abortion, according to the Guttmacher Institute.

Doctors and others who provide abortion services, or in some states “aid or abet” an abortion, could be fined thousands of dollars or sent to prison.

The court voted in favor of Mississippi and its 2018 law that outlawed abortion after 15 weeks. Jackson Women’s Health, the state’s sole remaining abortion provider, sued to block the law soon after it passed.

The Supreme Court decision is not a surprise, as the justices indicated they were leaning that way during oral arguments in December. The majority’s thoughts were further revealed when a draft of the opinion was leaked to the news outlet Politico on May 2. 

In the final opinion, Justice Samuel Alito, writing for the majority, “It is time to heed the Constitution and return the issue of abortion to the people’s elected representatives.”

The decision strikes down both precedent-setting rulings that established a right to abortion until the point of viability, long considered to be 24 weeks: Roe v. Wade (1973) and Planned Parenthood v. Casey (1992).

Twenty-five medical professional societies – representing OB/GYNs, family medicine doctors, fertility specialists, geneticists, hospitalists, internists, pediatricians, psychiatrists, nurses, nurse practitioners, and midwives – had urged the court to throw out the Mississippi law. And more than 2,500 medical professionals signed on to a petition in June, urging the court to uphold the right to abortion.

The number of abortions has recently increased from what had been a long decline. The Guttmacher Institute estimates there were there were 930,160 abortion procedures in 2020 (compared to 3.6 million births), an 8% increase from 2017. The number does not include self-managed abortions. The organization said the increase was potentially due to expanded Medicaid coverage and reduced access to contraception due to Trump administration policies.
 

Trigger laws and bans

When trigger laws and new restrictions go into effect, women in the South, Midwest, and Inter-Mountain West will likely have to drive hundreds of miles for an abortion, according to Guttmacher. Women in Louisiana, for instance, would have to drive 660 miles to get to the nearest provider in Illinois.

University of Utah researchers estimated that almost half of women will see a big increase in the distance to abortion care, from a median distance of 39 miles to 113 miles. State bans will disproportionately impact women of color, those living in poverty, and people with less education, they said.

The CDC has reported that Black women are three times more likely to die from a pregnancy-related cause than white women.

Doctors and other abortion providers could face serious penalties. The maximum penalty in Texas is life in prison, and the sentence could be 10 to 15 years in 11 other states, according to an article in the medical journal JAMA by attorneys Rebecca B. Reingold and Lawrence O. Gostin.

“Threats of prosecution undermine clinicians’ ability to provide safe, evidence-based care and to counsel patients honestly, impeding the patient-physician relationship,” they wrote. “Given harsh penalties, physicians may cease treating pregnancy loss, with no clear line between treating miscarriages and abortions.”

In preparing for these attacks on patients and doctors, New York Gov. Kathy Hochul on June 13 signed a bill that immediately protects anyone who has an abortion and medical professionals in the state who provide them from legal retaliation by states that restrict or prohibit abortion.

Even while Roe was still the law, Mississippi had banned most abortions after 20 weeks, and 16 states prohibited abortion after 22 weeks. A Texas ban on abortion after 6 weeks – which also allows private citizens to sue abortion providers – was allowed to stay in place while it was being challenged.

On May 26, Oklahoma Gov. Kevin Stitt signed  a bill banning abortion from the moment of conception. Just as in Texas, the Oklahoma law allows what critics have called “bounty hunting” of abortion providers.

Four states have a constitutional amendment declaring that the state constitution does not secure or protect the right to abortion or allow the use of public funds for abortion: Alabama, Louisiana, Tennessee, and West Virginia.
 

Some states protecting rights

At least 16 states have proactively protected a right to an abortion, according to Guttmacher, while The New York Times reports that Washington, DC, has laws that protect abortion, along with 20 states: Alaska, Colorado, Illinois, Maine, Massachusetts, Minnesota, Nevada, New Hampshire, New Mexico, Rhode Island, California, Connecticut, Delaware, Hawaii, Maryland, New Jersey, New York, Oregon, Vermont, and Washington.

Some of these states are gearing up for a potential influx of patients. Washington Gov. Jay Inslee signed a law that authorizes physician assistants, advanced registered nurse practitioners, and other providers acting within their scope of practice to perform abortions. And the Maryland Legislature overrode a veto by Gov. Larry Hogan of a law that expands who can perform abortions.

Wisconsin Gov. Tony Evers in early June called a special legislative session to repeal the state’s 173-year-old dormant ban on abortion. But the majority Republican legislature vowed to take no action.

B. Jessie Hill, JD, associate dean for academic affairs and a professor at the Case Western Reserve University School of Law, says she expects anti-abortion groups to challenge these protective laws, “by saying that fetuses are persons under the Constitution with a right to life and therefore that the state has to protect them.”

But, she says, “there’s going to be big, big challenges with those lawsuits,” and they will not be “winners off the bat.”
 

Medication abortions, travel next battle

Some states are also trying to outlaw or severely restrict the use of RU-486, the abortion pill. A Tennessee law that goes into effect in 2023 would ban delivery of pills by mail and require a patient to have two doctor visits – one consultation and one to pick up the pills.

Mississippi has also enacted restrictions including the requirement that women meet with a doctor  first – and is being sued by pill maker GenBioPro.

Guttmacher estimates that medication abortion accounted for 39% of all abortions in the U.S. in 2017 and 60% of all abortions that occurred before 10 weeks’ gestation.

Some states have floated the idea of prohibiting anyone from traveling to another state for an abortion.

George Mason University law professor Ilya Somin, JD, has written that such a law would likely violate the Dormant Commerce Clause, “which forbids state regulations that specifically restrict interstate commerce or discriminate against it.”

He also wrote that states lack the authority to regulate activity that takes place beyond their borders and that such bans “are open to challenge because they violate the constitutional right to travel.”

Hill also said a travel ban would be problematic, noting that it might be difficult to prosecute someone for “something you did completely in another state.”

A version of this article first appeared on Medscape.com.

The U.S. Supreme Court has voted to overturn the federal constitutional right to abortion, which will now leave the issue to be decided on a state-by-state basis.

According to some estimates, about 25 million women of reproductive age will now live in states that ban or severely restrict abortion. Twenty-six states are “certain or likely” to ban abortion, according to the Guttmacher Institute, which supports abortion rights.

Thirteen states have so-called trigger laws that will ban abortion almost immediately, while nine other states are now likely to try to enforce near-total bans or severe restrictions that have been blocked by courts pending the outcome of the just-issued decision in Dobbs v. Jackson Women’s Health Organization. Four states also have a history or have shown a recent desire to prohibit abortion, according to the Guttmacher Institute.

Doctors and others who provide abortion services, or in some states “aid or abet” an abortion, could be fined thousands of dollars or sent to prison.

The court voted in favor of Mississippi and its 2018 law that outlawed abortion after 15 weeks. Jackson Women’s Health, the state’s sole remaining abortion provider, sued to block the law soon after it passed.

The Supreme Court decision is not a surprise, as the justices indicated they were leaning that way during oral arguments in December. The majority’s thoughts were further revealed when a draft of the opinion was leaked to the news outlet Politico on May 2. 

In the final opinion, Justice Samuel Alito, writing for the majority, “It is time to heed the Constitution and return the issue of abortion to the people’s elected representatives.”

The decision strikes down both precedent-setting rulings that established a right to abortion until the point of viability, long considered to be 24 weeks: Roe v. Wade (1973) and Planned Parenthood v. Casey (1992).

Twenty-five medical professional societies – representing OB/GYNs, family medicine doctors, fertility specialists, geneticists, hospitalists, internists, pediatricians, psychiatrists, nurses, nurse practitioners, and midwives – had urged the court to throw out the Mississippi law. And more than 2,500 medical professionals signed on to a petition in June, urging the court to uphold the right to abortion.

The number of abortions has recently increased from what had been a long decline. The Guttmacher Institute estimates there were there were 930,160 abortion procedures in 2020 (compared to 3.6 million births), an 8% increase from 2017. The number does not include self-managed abortions. The organization said the increase was potentially due to expanded Medicaid coverage and reduced access to contraception due to Trump administration policies.
 

Trigger laws and bans

When trigger laws and new restrictions go into effect, women in the South, Midwest, and Inter-Mountain West will likely have to drive hundreds of miles for an abortion, according to Guttmacher. Women in Louisiana, for instance, would have to drive 660 miles to get to the nearest provider in Illinois.

University of Utah researchers estimated that almost half of women will see a big increase in the distance to abortion care, from a median distance of 39 miles to 113 miles. State bans will disproportionately impact women of color, those living in poverty, and people with less education, they said.

The CDC has reported that Black women are three times more likely to die from a pregnancy-related cause than white women.

Doctors and other abortion providers could face serious penalties. The maximum penalty in Texas is life in prison, and the sentence could be 10 to 15 years in 11 other states, according to an article in the medical journal JAMA by attorneys Rebecca B. Reingold and Lawrence O. Gostin.

“Threats of prosecution undermine clinicians’ ability to provide safe, evidence-based care and to counsel patients honestly, impeding the patient-physician relationship,” they wrote. “Given harsh penalties, physicians may cease treating pregnancy loss, with no clear line between treating miscarriages and abortions.”

In preparing for these attacks on patients and doctors, New York Gov. Kathy Hochul on June 13 signed a bill that immediately protects anyone who has an abortion and medical professionals in the state who provide them from legal retaliation by states that restrict or prohibit abortion.

Even while Roe was still the law, Mississippi had banned most abortions after 20 weeks, and 16 states prohibited abortion after 22 weeks. A Texas ban on abortion after 6 weeks – which also allows private citizens to sue abortion providers – was allowed to stay in place while it was being challenged.

On May 26, Oklahoma Gov. Kevin Stitt signed  a bill banning abortion from the moment of conception. Just as in Texas, the Oklahoma law allows what critics have called “bounty hunting” of abortion providers.

Four states have a constitutional amendment declaring that the state constitution does not secure or protect the right to abortion or allow the use of public funds for abortion: Alabama, Louisiana, Tennessee, and West Virginia.
 

Some states protecting rights

At least 16 states have proactively protected a right to an abortion, according to Guttmacher, while The New York Times reports that Washington, DC, has laws that protect abortion, along with 20 states: Alaska, Colorado, Illinois, Maine, Massachusetts, Minnesota, Nevada, New Hampshire, New Mexico, Rhode Island, California, Connecticut, Delaware, Hawaii, Maryland, New Jersey, New York, Oregon, Vermont, and Washington.

Some of these states are gearing up for a potential influx of patients. Washington Gov. Jay Inslee signed a law that authorizes physician assistants, advanced registered nurse practitioners, and other providers acting within their scope of practice to perform abortions. And the Maryland Legislature overrode a veto by Gov. Larry Hogan of a law that expands who can perform abortions.

Wisconsin Gov. Tony Evers in early June called a special legislative session to repeal the state’s 173-year-old dormant ban on abortion. But the majority Republican legislature vowed to take no action.

B. Jessie Hill, JD, associate dean for academic affairs and a professor at the Case Western Reserve University School of Law, says she expects anti-abortion groups to challenge these protective laws, “by saying that fetuses are persons under the Constitution with a right to life and therefore that the state has to protect them.”

But, she says, “there’s going to be big, big challenges with those lawsuits,” and they will not be “winners off the bat.”
 

Medication abortions, travel next battle

Some states are also trying to outlaw or severely restrict the use of RU-486, the abortion pill. A Tennessee law that goes into effect in 2023 would ban delivery of pills by mail and require a patient to have two doctor visits – one consultation and one to pick up the pills.

Mississippi has also enacted restrictions including the requirement that women meet with a doctor  first – and is being sued by pill maker GenBioPro.

Guttmacher estimates that medication abortion accounted for 39% of all abortions in the U.S. in 2017 and 60% of all abortions that occurred before 10 weeks’ gestation.

Some states have floated the idea of prohibiting anyone from traveling to another state for an abortion.

George Mason University law professor Ilya Somin, JD, has written that such a law would likely violate the Dormant Commerce Clause, “which forbids state regulations that specifically restrict interstate commerce or discriminate against it.”

He also wrote that states lack the authority to regulate activity that takes place beyond their borders and that such bans “are open to challenge because they violate the constitutional right to travel.”

Hill also said a travel ban would be problematic, noting that it might be difficult to prosecute someone for “something you did completely in another state.”

A version of this article first appeared on Medscape.com.