The sun rises over the San Joaquin Valley, California, today is May 29, 2020.
Did you know that educational attainment has been demonstrated to be a strong predictor of health outcomes, including obesity and age of death?(1) That should be a motivation to continue educating yourself, for instance, you can listen to this podcast while you go for a walk around your block… what a great combination! If increasing your health is not enough to motivate you to listen, what if we offer you money? You’ll be surprised at the end of this episode.
Summer is now in full swing. Many of our patients continue to work, or even may have more work, during this season.
According to Mayo Clinic nephrologist William Haley, heat and lack of proper hydration lead to a higher prevalence of nephrolithiasis in the summer. It’s good to remember that kidney stones between 5-10 mm have a higher passing rate, and tamsulosin may facilitate this process. You would need to treat five patients with kidney stones 5-10 mm to get one stone passage. Stones larger than 10 mm are less likely to pass and may require urology consult. So, this summer, remind your patients to stay well hydrated.
Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.
The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve.
Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971.[Music continues and fades…]
“My mission in life is not merely to survive, but to thrive; and to do so with some passion, some compassion, some humor, and some style.” –Maya Angelou.
Passion, compassion, humor, and style(4) —that sounds like a good combination to thrive. Residency is a very special time of your life. Enjoy it! We have a very special resident today. Claudia Carranza was interviewed in Episode 11 “Chlamydia with Clau”, so you probably remember her. That’s why I will change the first question.
My husband and I have a dog, we bought a house in Bakersfield, and I love dancing hip-hop, merengue, and zumba.
This week I learned about what gender identity truly means. I am embarrassed to admit it but although I
think of myself as a very open minded and respectful person, I did not really understand the difference
between gender expression, gender identity, etc.
I was watching “Becoming”, Michelle Obama’s documentary. At the very end they had young adults introducing themselves and one person said “I’m non-binary”, and then it hit me. Do I, a resident physician, really understand how I would address or refer to a nonbinary patient? And the answer was NO.
Today I will introduce these concepts in a simple way so we better understand them.
Definition of gender and more
Gender is assigned at birth based on genitalia and chromosomes; male and female which would be the “assigned gender” at birth.
Gender identity is the innate sense of feeling male, female, neither or a bit of both. There is research
with regards to gender identity and how the main drive of it is in the brain. I did have a professor in
medical school who had done research for many years in mice; he studied the brain and different
components. One of his research topics focused on how sex genes/hormones change during
development of an embryo/fetus and, to put it in simple terms, the amount of X and Y did not always
necessarily match the chromosomal make up or genitalia of the fetus. I wish I could find some of his research to share it but after so many moves during med school I do not actually have any of the info, but I promise to upload to our website it when I get a chance to find it.
One research article I did find that was published on Nature is called “Sex Chromosomes and Brain Gender”(5). In a nutshell it states that hormones not only have specific changes in the brain as a whole but also differentiate the “XX” and “XY” brain SEX cells. This is not to say that there is a “female” or “male” brain, which is something I have read on the internet; these types of research from my understanding is attempting to explain that there are many components playing a role in gender identity determination, and that it is not black or white.
Gender expression is the way gender is presented to others; and this can vary depending on cultures, religion, time. How we chose to express our gender in public in terms of clothing, haircut, voice, behavior.
Gender diversity is a terminology replacing the prior “gender non-conformity” which includes any variation from the cultural norm.
Transgender is an ADJECTIVE for a person whose gender identity differs from the assigned gender at
birth.
A Transgender man/transman/transmasculine individual is a person with a masculine gender identity who was assigned female sex at birth.
A Transgender woman/transwoman/transfeminine individual is a person with a feminine gender identity who was assigned male sex at birth.
Cisgender is person whose gender identity matches their genital anatomy. For example, I identify myself as cisgender.
Nonbinary gender identity which is a person of any assigned gender sex at birth who has a gender identity that is neither feminine or masculine, or it could be a combination of both.
Meaning of LGBT
We have all probably heard about LGBT, but since 1996 there was a Q added to LGBT → LGBTQ for those who identify as queer or are questioning. There is another variant LGBTI or LGBTIQ where the I includes intersex people to LGBT groups. LGBT + encompasses spectrums of sexuality and gender.
For those of us who are unfamiliar, intersex refers to individuals born with any variation in sex characteristics such as chromosomes, gonads, sex hormones or genitals that do not fit the typical definition of male/female bodies; for example, you might have heard of the previously used term “hermaphrodite”. This word is no longer appropriate for use of humans as it can be misleading.
Comment: There is more about gender than we currently know. We have patients who were raised as boys and later on they realized they had uterus and ovaries. We know there are medical conditions in which sex is not black and white. In those cases, we have to be very sensitive to our patients, and provide the care they need and deserve in a respectful and effective way.
I think understanding and respecting patients and their gender identity is important for any physician. We are here to treat, help and improve the health of our patients. As family physicians or primary care
physicians we are sometimes going to be the first step in a parent understanding a child’s gender
identity. We should support a gender-affirmative model which would include allowing or encouraging
children to express their perceived gender in a supportive and safe environment; this would include not
only in the office but also in their home, school, etc.
It’s important for us to understand that it is a normal part of growing up for children to explore gender
expression and gender roles. Children do assume gender stereotypes for themselves, this usually starts
in preschool and later is more defined in school aged children. One thing to note is that the gender
behavior and expression becomes more persistent with age.
In a cohort study by Gulgoz S and others “Similarity in transgender and cisgender children’s gender development,”(6) it was found that the persistency of gender expression was coherent between both groups, meaning that transgender and cisgender children began to affirm their gender expression at about the same pace and time.
For all physicians out there, if you do not know enough or are not comfortable with talking to parents or
patients about gender diversity then PLEASE make sure to refer them to someone who is
knowledgeable! Parents and patients will need lots of guidance especially as they go through
adolescence when gender diverse patients will undergo likely unwanted pubertal changes.
Some may experience gender dysphoria which is discomfort or distress by a mismatch between gender identity and the gender sex assigned at birth. This can develop into depression or anxiety which can lead patients to participate in risky behaviors.
Comment: I agree with you, we should educate ourselves on the treatment of this diverse population. You can choose what to believe, you can raise your family the way you want, teach your family values you consider right for you and your family, but at the same time educate yourself how to treat this population, and if you decide to refer to another provider, it is also acceptable.
My go-to is always UpToDate, but I have to admit I did use Wikipedia this time and Google to have a
better understanding on when abbreviations changed, or to read about the opinion of the general
population on gender identity issues and just to see what other sources I could find.
Comment: Yes, UpToDate is an excellent source, but in a topic like this, you can expand your search to many other resources. And you also mentioned that a documentary motivated you to do more research about a topic which you ignored.
Besides UpToDate “Gender development and clinical presentation of gender diversity in children and
adolescents”(7) and Wikipedia “LGBT”(8), I read planned parenthood “Sex and Gender Identity”(9), the TREVOR project “Trans + Gender Identity”(10), I also read an article in Nature Neurology “Sex Chromosomes and Brain Gender”, and a Pubmed article “Similarity in Transgender and Cisgender Children’s gender development”.
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Speaking Medical (Medical word of the Week):
by Dr Gregory Fernandez
The medical term for this week is Anosognosia. Anosognosia is an inability or refusal to recognize a defect or disorder that is clinically evident. It’s like denying it’s sunny when you are out in Bakersfield at noon in mid-July. Anosognosia is the result of damage to the brain structures, typically to the parietal lobe or a diffuse lesion on the fronto-temporal-parietal area in the right hemisphere. Anosognosia can present as a sign of Alzheimer’s disease, traumatic brain injury, stroke, or mental illness such as anorexia nervosa or schizophrenia. Anosognosia is very similar to denial, but denial is a defense mechanism. When you don’t want to admit that you’ve gained weight, even when your jeans don’t fit you anymore, you don’t have Anosognosia, you are just in denial.
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Espanish Por Favor (Spanish Word of the Week): Pecho
by Dr Claudia Carranza
Hi this is Dr Carranza on our section Espanish por favor. This week’s word is pecho. Pecho means chest or breast and pechos mean breasts. This word comes from Latin root “pectus” which means chest. Patients can come to you with the complaint: “Doctor, me duele el pecho” which means “Doctor, I have chest pain”- take a minute, take a deep breath, this does not necessarily mean you have to start an ACS work up; remember the other etiologies such as costochondritis or muscle pain. Also remember it could mean that their breast hurts; think of this especially in lactating mothers or if the patient says: “Doctor, me duelen los pechos” which means “Doctor, my breasts hurt”. At that point, switch gears and focus on breast pain instead of chest pain. For example, inquire about lactation, relations to menstrual cycle, triggers, or dig for red flags if you suspect cancer. Now you know the Spanish word of the week, pecho. See you next time!
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For your In-sanity
by Dr Steven Saito
Send your answers to RBresidency@clinicasierravista.org.
This podcast was created for family medicine residents, but we have listeners of all walks of life in different parts of the world. So, this week, we want to reward your loyalty to medical education whoever you are. We are going to give you three questions about topics covered in this podcast, and the first listener to give us the correct answers to the three questions will be awarded an Amazon gift card. The three questions are:
If you want a clue about these questions, a key number would be 3-6-9.
Now we conclude our episode number 14 “Gender Diversity”. Dr Carranza taught us what “non-binary” means and gave us an introduction to the terminology LGBTIQ. Is it chest pain or breast pain? That’s the question you should ask when a patient tells you in Spanish they have pain on their pechos. Anosognosia is the inability to recognize a sign of disease even when it is grossly evident. For your IN-sanity this week, we asked three questions: 1. In what nostril should you apply intranasal triptans to treat an acute cluster headache? 2. What’s another term for wet-to-dry dressing? and 3. Why do we use single-dose vaccine vials? The first listener who answers correctly to the three questions will get a prize. Getting pay to keep learning –It cannot get any better than that. Send your answers to RBresidency@clinicasierravista.org.
This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.
If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice.
Our podcast team is Hector Arreaza, Steven Saito, Claudia Carranza, Terrance McGill, and Gregory Fernandez. Audio edition: Suraj Amrutia. See you soon!
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