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Opinion and Commentary from TMA

Sexuality and Teens: Talk About It

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For adolescents and young adults, sexual development and health is an especially important area of growth that can have far-reaching impacts into adulthood.

For example, according to the Centers for Disease Control and Prevention (CDC) HIV Surveillance Report 2016, young people ages 15-24 accounted for 21 percent of all new HIV infections, with the majority of those occurring in men who have sex with men (MSM). African-Americans and Latinos are disproportionately affected, accounting for 78 percent of new infections in this age group. 

In addition to rising rates of sexually transmitted infections (STIs), the CDC reports that Texas ranks fifth in the country in births to teens ages 15-19 and has the highest rates of repeat teen pregnancy.

As physicians, what can we do about this? 

We can start by having open, honest, and confidential conversations with our patients about their sexual activity. This includes asking about the number of sexual partners, the gender of their partners, and what sites they use for intercourse (oral, vaginal, anal). 

For patients who are sexually active, we can provide confidential screening for STIs and ask about the use of contraceptives, both barrier and hormonal. For patients who have not yet become sexually active (and for those that have), we can provide counseling on healthy sexual relationships and/or give an appropriate handout. 

It is important for physicians to make themselves available for questions whenever an adolescent patient has any, in addition to encouraging the adolescent to call your office directly.

Besides being an effective clinical advocate for healthy sexual development, physicians have the opportunity to advocate for state policies that promote access to sexual and reproductive services for minors. Currently in Texas, minors cannot confidentially access prescription contraceptives without parental consent unless they are on Medicaid or access care at a Title X clinic. 

In addition, Texas is one of two states in the country that does not allow any state funds to be used to provide confidential contraceptive services to minors. 

Also, under Texas law you are required to report to Child Protective Services any minor who discloses to you that they are sexually active with someone of the same gender. This places physicians in an ethical dilemma in seeking to provide comprehensive care to our patients.  

These state policies hinder a physician’s ability to provide sexual and reproductive health care for adolescents.

Physicians who take care of adolescents are in a unique position to provide accurate sexual and reproductive health information to our patients. 

Because only 16.6 percent of Texas schools provide comprehensive sex education, physicians may be the only source of medically accurate information for adolescents. It is therefore imperative that we continue to advocate for, and provide, our adolescent patients access to confidential STI testing and contraceptive services.

M. Brett Cooper, MD, is a pediatrician in Houston who serves as the Resident & Fellow Section Representative on TMA’s Child and Adolescent Health Committee.   

 

Supporting Transgender and Gender-Diverse Teens

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This week is Global Teen Health Week, and today we are focusing on the health of LGBTQ (lesbian, gay, bisexual, transgender, and queer) youth and young adults, specifically the health of transgender and gender non-conforming (TGNC) youth. 

MongeGender is a core principle of self. Most teenagers identify as the gender that they were assigned at birth (known as “cisgender”), but some do not, and these teens identify as transgender or gender non-conforming (TGNC). 

It is difficult to know the exact numbers of teens who identify as TGNC, though current estimates are about 1 in 137 (0.7 percent) teens are transgender. Texas has the second-highest population of transgender teens in the United States. 

There are many unique needs of TGNC teens, and addressing them in a timely and supportive manner is often a life or death situation, because TGNC teens have much higher rates than other teenagers of depression, self-injury, anxiety, suicidal thoughts, and being the victim of bullying. As a matter of fact, 2 in 3 TGNC teens have seriously thought about suicide compared with only 1-2 in 10 of cisgender teens. 

Creating supportive environments in the home, school, and medical office can go a long way to improve the mental and physical health of TGNC teenagers. Transgender children who are allowed to live as their identified gender have rates of depression and anxiety that are almost identical to cisgender children. 

Transgender teenagers who have the support of their families have remarkably better life satisfaction; self-esteem; mental health, including decreased suicide attempts; and adequate housing, than transgender teens who do not have the support of their families.

Although it is difficult to know exactly what an individual TGNC teen may be struggling with, some common issues include:  

  • Fear of family or friend rejection;
  • Fear of bullying or personal safety;
  • Feelings of shame and guilt;
  • Not understanding what they are feeling or why they are feeling it;
  • Not having words to explain what they are feeling; and
  • Fear that the topic of gender is off-limits with their family or friends.  

Families may be struggling with thoughts such as:  

  • Is my teen safe?
  • What does my teen’s gender diversity mean about my parenting?
  • Is my child normal?  

Many aspects of TGNC teen lives are confusing and challenging for both the teens and their families, and physicians should be able to provide a supportive environment to help. 

Here are some examples of ways that doctor’s offices can be safe and supportive, and what families with TGNC teens should look for: 

  • Doctors, nurses, and staff use a teen’s chosen name and pronouns;
  • Willingness to learn and to be open about not having all the answers;
  • Robust family support to help the families support their TGNC teens;
  • Physical exams, often a big source of stress for TGNC teens, should be explained well in advance, including the exact body parts that need to be examined and the reason for doing the exam. The teen should be given a choice as to when the exam occurs during the visit; and
  • Willingness to advocate for TGNC patients and work with schools to help create supportive environments.  

Maria Monge, MD, is a pediatrician in Austin.


Your Primary Care Practice: Where Everybody Knows Your Name

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Some of you may remember the TV series “Cheers.” While it was essentially a sitcom, I believe that the show had something important to offer. I am referring to the theme song, which goes, “Sometimes you want to go/Where everybody knows your name/And they’re always glad you came.”

Borenstein_mugWhat does this have to do with the primary care medical practice? A lot! 

As medical care becomes more complex, with greater use of specialists and sophisticated testing and technology, having a primary care team committed to each patient’s health is more important than ever before.  

After all, people who have regular contact with their primary care physicians are likely to live longer and be healthier.

A new model of primary care — the patient-centered medical home — was designed to make sure the patient is always at the center of the care team. 

The patient-centered medical home increases patients’ access to the doctor’s office through various means, including longer hours, telephone consultations, electronic visits, and even group visits. 

The model emphasizes better care coordination among health care team members and seeks to avoid unnecessary or redundant testing. It also focuses on helping patients better manage chronic conditions.

For example, a primary care patient-centered medical home can remind patients when it’s time for a critical health screening, such as a mammogram or colonoscopy, and when it’s time for a follow-up appointment.

This new model requires physicians and our teams hone skills such as:   

  • How to create an effective care team; 
  • How to better engage patients in their care; 
  • How to identify and track patients who are at high risk for health problems; 
  • How to improve transitioning patients from the office to the hospital, or hospital to rehab or other setting; and 
  • How primary care can improve care for people with depression and other behavioral health issues.  

If you want to learn more about ways to enhance the care you deliver, plan to attend the upcoming Texas Primary Care and Health Home Summit. The Texas Medical Association is a founding sponsor of the sixth-annual summit, which is dedicated to helping clinicians and their staff incorporate new tools and methods to improve care. 

It’s the only summit of its kind in Texas. Don’t miss out!

Physicians and other members of the primary care team interested in attending the summit on April 5-6 at the Renaissance Hotel at the Arboretum in Austin, visit www.texashealthhomesummit.org

Dr. Bornstein is an internist in Dallas, executive director of the Texas Medical Home Initiative, and a member of the TMA Board of Trustees.


The Battle for the (Pro)Life of the Texas GOP

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Many Texas Catholics who attended mass this past weekend had an up-close look at the ever-widening and ever-nastier split within the state’s antiabortion movement, which itself is a proxy for the fight for control of the Texas Republican Party.

What the parishioners heard or read was a refreshingly candid formal statement from the Texas Catholic Conference of Bishops entitled “Parish Advisory on Texas Right to Life.” The advisory called out Texas Right to Life (TRTL), the state’s largest antiabortion group, over its lobbying and political activities, and encouraged parishes “not to participate in their activities or allow the organization to use parish sites.”

The bishops remain staunchly antiabortion, but they’ve had enough of their erstwhile allies’ antics. Their advisory encourages “all Catholics to engage in pro-life legislative advocacy ... by supporting pro-life groups which engage in respectful legislative advocacy.”

Why is this important to Texas physicians? Here are four reasons:

  • Texas is a solid Republican state, with GOP majorities ensured in both chambers of the Texas Legislature at least through the 2021 session. The real fight is over who will wield the Republican Party’s power in Austin: business conservatives or tea party conservatives – who have been no friend to medicine.
  • The Texas Medical Association has no policy for or against abortion. Our formal policy simply says that TMA “recognizes abortion as a legal medical procedure, and the performance of abortion must be based upon early and accurate diagnosis of pregnancy; informed and nonjudgmental counseling; prompt referral to skillful and understanding personnel working in a good facility; reasonable cost; and professional follow up.” Nevertheless, TMA frequently enters (or gets dragged into) legislative debates on abortion when we oppose state interference with the patient-physician relationship.
  • The state’s main pro-life players, and their funders, are heavily involved in our priority issues as well. For example, TRTL consistently has pushed an agenda that seeks to neutralize physicians’ ability to protect their patients from treatment that imposes unnecessary suffering and pain in their final days.
  • TRTL and its allies (notably Empower Texans and the Texas Home School Coalition) are targeting some of medicine’s legislative champions with misinformation attacks that distort these lawmakers’ voting records.

Some North Texas physicians and political junkies might recall how TRTL knocked out former Sen. Bob Deuell, MD (R-Greenville), in the 2014 primaries by grossly mischaracterizing a bill that he carried. The bill actually enhanced patients’ and families’ legal protections. But that didn’t stop TRTL from twisting it around in order to oust a state senator – a warm and caring family physician -- who didn’t follow their every command.

This election cycle, the nasty action is coming in several House races. The incumbents were all supporters of House Speaker Joe Straus of San Antonio, who is not running for reelection. TRTL, Empower Texans, and a few other groups are working to elect candidates for the House who will toe the line laid out by a handful of rich oil businessmen who want to control the legislature. 

One of their sleight-of-hand tactics is a vote on an amendment to Senate Bill 8 during the 2017 summer special legislative session. SB 8, which passed into law, sets new standards on the disposition of fetal remains and outlaws so-called “partial birth abortion.” All of the pro-medicine candidates who are being targeted by the TRTL campaign voted for SB 8. 

They didn’t, however, vote for the “Schaefer amendment” to the bill, and there’s the rub. The amendment, which was defeated, would have outlawed late-term abortions when the fetus has “a severe fetal abnormality” and would not survive at birth. The amendment was set up as a “scorecard vote,” forcing lawmakers to choose whether to fall in behind TRTL.

As an insightful column in the Amarillo Globe-News noted recently, “‘Severe fetal abnormalities’ [are] those rare instances for an abortion when a baby has no heart, or no brain, or any other vital organ, and will die moments after birth. It did not cover babies with Down’s syndrome, spina bifida, or other non-fatal diseases, but only those catastrophic conditions that define ‘a non-viable fetus.’ Of the 55,287 abortions in Texas in 2015, only 16 fit that category, or 0.03 percent.”

Allowing an abortion in such rare circumstances is the compassionate act, saving the unborn child the agony of trying vainly to survive outside of the womb.

The Texas Alliance for Life, another anti-abortion group, says the amendment “would likely not have saved a single baby from abortion.”

But that’s not the picture TRTL paints. In various commentaries attacking the lawmakers it is trying to oust, TRTL says the Schaefer amendment would “protect preborn children with disabilities from painful abortions after 20 weeks.” A House member’s vote against it, the organization says in its 2017 legislative scorecards (example), meant “demarcating loyalty to the ProLife cause or the anti-Life leadership of the Texas House.”

That scorecard was one of the motivations for the Texas Catholic Conference of Bishops’ advisory.

“We believe this publication is not based on a fair analysis of a legislator’s work, but rather upon whether the legislator has followed voting recommendations of Texas Right to Life,” the bishops wrote. “Unfortunately, a number of legislators who have consistently voted for pro-life and end of life legislation have been opposed by Texas Right to Life.”

Texas Alliance for Life also has sprung to the defense of the targeted legislators, writing letters to the editor like this one for Rep. J.D. Sheffield, DO (R-Gatesville):

“In the race for Texas House District 59, we find it regrettable that State Rep. J.D. Sheffield’s opponent has chosen to attack Dr. Sheffield on the abortion issue, claiming he is not pro-life,” Joe Pojman, the group’s executive director, wrote. “That claim is false.”

“My organization, Texas Alliance for Life, is among the premier pro-life organizations in the state and has worked to pass pro-life bills in the Capitol for 30 years. We can say with certainly that Dr. Sheffield is solidly pro-life. He earned 100 percent on our Legislative Scorecard, and our PAC is proud to endorse him for re-election.”

Other incumbent legislators fighting this uphill battle against the well-funded TRTL attacks include State Reps. Ernest Bailes (R-Shepherd), Travis Clardy (R-Nacogdoches), Sarah Davis (R-West University Place), Charlie Geren (R-Fort Worth), Ken King (R-Canadian), Lyle Larson (R-San Antonio), Four Price (R-Amarillo), Hugh Shine (R-Temple), Jason Villalba (R-Dallas), and Paul Workman (R-Austin). All of these lawmakers, by the way, have earned TEXPAC’s support.

Of course, you have to wonder just how much the TRTL scorecard really means to the group when you consider:

 

  • The organization endorsed the opponents of two incumbent Republican state senators (Craig Estes of Wichita Falls and Kel Seliger of Amarillo) and four GOP House members (Chris Paddie of Marshall, Dan Flynn of Van, Wayne Faircloth of Galveston, and Giovanni Capriglione of Southlake) who compiled 100-percent TRTL voting records in the 2017 legislative session;
  • Two state senators and two representatives with 100-percent scores who are in competitive primaries got no TRTL endorsement; and
  • Four House members with less than 100-percent records received TRTL’s backing.