Month: September 2021

As a cisgender woman with long hair and a closet full of dresses, I can count on one hand the number of times I’ve been misgendered by being called “he” or “sir.” Cisgender means I was assigned female at birth and identify as a woman. For people who are transgender and/or nonbinary (TNB), with a different gender identity than their assigned sex at birth, being misgendered may be a daily occurrence.

Why does misgendering matter?

Imagine a scenario in which you are called the wrong pronoun or honorific — for example Mr., Ms., or Mrs. — multiple times a day. It might happen in person, over the phone, or via email. Each time it happens, you must decide whether it is worth it to correct that person or easier to let it go. Imagine that you are repeatedly confronted with this experience and the decision of whether or not to correct it throughout the day — every day. As we know from research, and as I’ve also heard from the TNB people I know, this is both exhausting and demoralizing. When people are misgendered, they feel invalidated and unseen. When this happens daily, it becomes a burden that can negatively impact their mental health and their ability to function in the world.

If you are a cisgender person, you can lighten this burden for TNB people by using the right names, pronouns, and honorifics to refer to them, apologizing when you misgender someone, and correcting other people when they misgender someone.

How do you use the correct name, pronouns, and honorifics?

It’s simple: follow the person’s lead, or ask them. The name, pronouns, and honorifics that a person chooses to use for themselves communicate to others how they want to be seen and acknowledged. Using the correct terms for someone is a sign of respect and recognition that you see them as they see themselves.

If you knew someone previously as one gender and now they use a different name, pronouns, or honorifics, it can be hard to remember to use the right terms, especially if the person is gender-fluid and changes their pronouns more often. It can also be challenging to adjust to using gender-neutral pronouns like they and them, neopronouns like ze and zir, and unfamiliar honorifics, such as Mx (pronounced “mix”). But using the right terms is critically important for supporting and respecting TNB people.

A few tips and tools

• Try not to make assumptions about a person’s name, pronouns, or honorifics based on how they look. The only way to know for sure what terms a person uses is to ask them in private (“What pronouns do you use?”). Asking someone in front of other people may unintentionally put them on the spot to disclose their identity to new people. You can ask anyone — cisgender or TNB — their name, pronouns, or honorifics.
• Once you know what terms a person uses, the best way to make sure that you use the correct ones is to practice (this tool can help). Practice when they are in the room and when they are not in the room. Practice before you know you will see someone. Practice with others in your life: your cisgender friends, your spouse, your pet, your child. In our household, my wife and I try to use gender-neutral pronouns to refer to our preschooler’s toys and dolls so that we can practice using them ourselves. We even change the pronouns of characters in books that we read as another way to practice.
• Another tip for remembering to use the correct name, pronouns, and honorifics is to pause before you speak. When we are stressed or busy, we are more likely to misgender people. Try to pause for a beat before you speak to make sure you are using the right terms to refer to someone. Similarly, reread emails before you send them to make sure you are not misgendering someone.
• Be patient as you learn to use new terms and pronouns. It gets easier with practice and may become second nature over time.

How to apologize for misgendering someone

Misgendering will happen. What’s most important is how you handle it when it does. The best way to handle misgendering someone who is present is to apologize and try harder next time (“I’m sorry, I meant [correct name/pronoun/honorific]”). Keep your apology brief so that it doesn’t become about you and your mistake.

If you are corrected by someone else, try not to be defensive. Instead, simply respond with a thank you and a correction (“Oh, thank you — I’ll email [correct name/pronoun] about that”). This is an important step, even if the misgendered person is not present, so you can practice and so others can learn from your example. Any time you misgender someone, practice so you can do better next time.

How to correct misgendering when you hear or see it

As a cisgender colleague and supervisor to numerous TNB people, many of whom are nonbinary and use they/them pronouns, I often find myself in situations where I need to correct misgendering. I might say something like “I noticed you used she to refer to that person. Just to let you know, they use they/them pronouns.” Or I might write a note in a Zoom chat or in an email, “Just a friendly reminder that this person uses they/them pronouns.” Stepping forward this way lessens the burden of correcting misgendering for TNB people. It also models to others that a correction can be done in a friendly way, and is important for respecting and including TNB people.

How to use gender-neutral language and normalize pronouns

One way to avoid misgendering is to use gender neutral language. Here are some examples:

• Instead of “boys and girls” or “ladies and gentlemen,” say “everyone.”
• Instead of “fireman” or “policeman,” say “firefighter” or “police officer.”
• Instead of “hey guys,” say “hey everyone” or “hey all.”

Try to pay attention to your language and find ways to switch to gender-neutral terms.

You can be mindful of your own pronouns and help other people be mindful by normalizing displays of pronouns. Here are some ways that I make my own pronouns (she/her) visible to others:

• I list my pronouns in my email signature, in my Zoom name, and on the title page of presentations.
• I wear a pronoun pin at work.
• I introduce myself with my pronouns.

These actions signal to others that I am thinking about pronouns,  and am aware that people may use different pronouns than might be expected from their appearance.

You may still make mistakes, but it’s important to keep practicing and trying to use the right terms! By using the correct names, pronouns, and honorifics to refer to people, apologizing when you misgender someone, and correcting other people when they misgender, you can support and respect the TNB people around you. This helps create a more inclusive world for everyone.

About the Author

Sabra L. Katz-Wise, PhD, Contributor

Sabra L. Katz-Wise, PhD (she/her) is an assistant professor in adolescent/young adult medicine at Boston Children’s Hospital, in pediatrics at Harvard Medical School, and in social and behavioral sciences at the Harvard T.H. Chan School of … See Full Bio View all posts by Sabra L. Katz-Wise, PhD

Active surveillance for prostate cancer has its tradeoffs. Available to men with low- and intermediate-risk prostate cancer, the process entails monitoring a man’s tumor with periodic biopsies and prostate-specific antigen (PSA) tests, and treating only when — or if — the disease shows signs of progression.

Active surveillance allows men to avoid (at least for a while) the side effects of invasive therapies such as surgery or radiation, but men often feel anxious wondering about the state of their cancer as they spend more time untreated. Is there a middle path between not treating the cancer at all and aggressive therapies that might have lasting side effects? Emerging evidence suggests the answer might be yes.

During a newly-published phase 2 clinical trial, researchers evaluated whether a drug called enzalutamide might delay cancer progression among men on active surveillance. Enzalutamide interferes with testosterone, a hormone that drives prostate tumors to grow and spread. Unlike other therapies that block synthesis of the hormone, enzalutamide prevents testosterone from interacting with its cellular receptor.

A total of 227 men were enrolled in the study. The investigators randomized half of them to a year of daily enzalutamide treatment plus active surveillance, and the other half to active surveillance only. After approximately two years of follow-up, the investigators compared findings from the two groups.

The results showed benefits from enzalutamide treatment. Specifically, tumor biopsies revealed evidence of cancer progression in 32 of the treated men, compared to 42 men who did not get the drug. The odds of finding no cancer in at least some biopsy samples were 3.5 times higher in the enzalutamide-treated men. And it took six months longer for PSA levels to rise (suggesting the cancer is growing) in the treated men, compared to men who stayed on active surveillance only.

Enzalutamide was generally well tolerated. The most common side effects were fatigue and breast enlargement, both of which are reversible when men go off treatment.

In an accompanying editorial, Susan Halabi, a statistician who specializes in prostate cancer at Duke University, described the data as encouraging. But Halabi also sounded a cautionary note. Importantly, differences between the two groups were evident only during the first year of follow-up. By the end of the second year, signs of progression in the treated and untreated groups “tended to be very similar,” she wrote, suggesting that enzalutamide is beneficial only for as long as men stay on the drug. Longer studies lasting a decade or more, Halabi added, may be necessary to determine if early enzalutamide therapy changes the course of the disease, such that the need for more invasive treatments among some men can be delayed or prevented.

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, editor of the Harvard Health Publishing Annual Report on Prostate Diseases, and editor in chief of HarvardProstateKnowledge.org, said the study points to a new way of approaching active surveillance, either with enzalutamide or perhaps other drugs. “An option that further decreases the likelihood that men on active surveillance will need radiation or surgery is important to consider,” he says. “This was a pilot study, and now we need longer-term research.”

About the Author

Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Charlie Schmidt is an award-winning freelance science writer based in Portland, Maine. In addition to writing for Harvard Health Publishing, Charlie has written for Science magazine, the Journal of the National Cancer Institute, Environmental Health Perspectives, … See Full Bio View all posts by Charlie Schmidt

If you’re in your 80s or 70s and you’ve noticed that you’re having some memory loss, it might be reasonable to be concerned that you could be developing Alzheimer’s disease or another form of dementia. But what if you’re in your 60s, 50s, or 40s… surely those ages would be too young for Alzheimer’s disease or dementia, right?

About 10% of Alzheimer’s disease is young onset, starting before age 65

Not necessarily. Of the more that 55 million people living with dementia worldwide, approximately 60% to 70% of them have Alzheimer’s disease. And of those 33 to 38.5 million people with Alzheimer’s disease, memory loss or other symptoms began before age 65 in 10% of them. Alzheimer’s is, in fact, the most common cause of young onset dementia. A recent study from the Netherlands found that of those with a known classification of their young onset dementia, 55% had Alzheimer’s disease, 11% vascular dementia, 3% frontotemporal dementia, 3% Parkinson’s disease dementia, 2% dementia with Lewy bodies, and 2% primary progressive aphasia.

Young onset dementia is uncommon

To be clear, young onset dementia (by definition starting prior to age 65, and sometimes called early onset dementia) is uncommon. One study in Norway found that young onset dementia occurred in 163 out of every 100,000 individuals; that’s in less than 0.5% of the population. So, if you’re younger than 65 and you’ve noticed some trouble with your memory, you have a 99.5% chance of there being a cause other than dementia. (Whew!)

There are a few exceptions to this statement. Because they have an extra copy of the chromosome that carries the gene for the amyloid found in Alzheimer’s plaques, more than half of people with Down syndrome develop Alzheimer’s disease, typically in their 40s and 50s. Other genetic abnormalities that run in families can also cause Alzheimer’s disease to start in people’s 50s, 40s, or even 30s — but you would know if you are at risk because one of your parents would have had young onset Alzheimer’s disease.

How does young onset Alzheimer’s disease differ from late onset disease?

The first thing that should be clearly stated is that, just as no two people are the same, no two individuals with Alzheimer’s disease show the same symptoms, even if the disease started at the same age. Nevertheless, there are some differences between young onset and late onset Alzheimer’s disease.

People with typical, late onset Alzheimer’s disease starting at age 65 or older show the combination of changes in thinking and memory due to Alzheimer’s disease plus those changes that are part of normal aging. The parts of the brain that change the most in normal aging are the frontal lobes. The frontal lobes are responsible for many different cognitive functions, including working memory — the ability to keep information in one’s head and manipulate it — and insight into the problems that one is having.

This means that, in relation to cognitive function, people with young onset Alzheimer’s disease may show relatively isolated problems with their episodic memory — the ability to form new memories to remember the recent episodes of their lives. People with late onset Alzheimer’s disease show problems with episodic memory, working memory, and insight. So, you would imagine that life is tougher for those with late onset Alzheimer’s disease, right?

Depression and anxiety are more common in young onset Alzheimer’s disease

People with late onset Alzheimer’s disease do show more impairment, on average, in their cognition and daily function than those with young onset Alzheimer’s disease, at least when the disease starts. However, because their insight is also impaired, those with late onset disease don’t notice these difficulties that much. Most of my patients with late onset Alzheimer’s disease will tell me either that their memory problems are quite mild, or that they don’t have any memory problems at all!

By contrast, because they have more insight, patients with young onset Alzheimer’s disease are often depressed about their situation and anxious about the future, a finding that was recently confirmed by a group of researchers in Canada. And as if having Alzheimer’s disease at a young age wasn’t enough to cause depression and anxiety, recent evidence suggests that in those with young onset Alzheimer’s disease, the pathology progresses more quickly.

Another tragic aspect of young onset Alzheimer’s disease is that, by affecting individuals in the prime of life, it tends to disrupt families more than late onset disease. Teenage and young adult children are no longer able to look to their parent for guidance. Individuals who may be caring for children in the home now need to care for their spouse as well — perhaps in addition to caring for an aging parent and working a full-time job.

What should you do if you’re younger than 65 and having memory problems?

As I’ve discussed, if you’re younger than 65 and you’re having memory problems, it’s very unlikely to be Alzheimer’s disease. But if it is, there are resources available from the National Institute on Aging that can help.

What else could be causing memory problems at a young age? The most common cause of memory problems below age 65 is poor sleep. Other causes of young onset memory problems include perimenopause, medication side effects, depression, anxiety, illegal drugs, alcohol, cannabis, head injuries, vitamin deficiencies, thyroid disorders, chemotherapy, strokes, and other neurological disorders.

Here are some things that everyone at any age can do to improve their memory and reduce their risk of dementia:

• Perform aerobic exercise.
• Eat Mediterranean-style meals.
• Avoid alcohol, cannabis, and drugs.
• Sleep well.
• Participate in social activities.
• Pursue novel, cognitively stimulating activities, listen to music, practice mindfulness, and keep a positive mental attitude.

About the Author

Andrew E. Budson, MD, Contributor

Dr. Andrew E. Budson is chief of cognitive & behavioral neurology at the Veterans Affairs Boston Healthcare System, lecturer in neurology at Harvard Medical School, and chair of the Science of Learning Innovation Group at the … See Full Bio View all posts by Andrew E. Budson, MD

A new study shows something we’ve always figured was true: our health and habits as children and teens affect our health as adults. And not just our health, but how long we live.

What did the study measure and find?

The International Childhood Cardiovascular Cohorts Consortium Outcomes Study has been collecting data on almost 40,000 people from the United States, Finland, and Australia. They started enrolling them as children in the 1970s through the 1990s, and have been following them ever since.

The researchers have been looking at the effects of five risk factors:

• body mass index, or BMI, a calculation that shows if a person is within a healthy weight range
• systolic blood pressure, which is the top number in a blood pressure reading and is a measure of how much pressure is exerted on the arteries when the heart beats
• total cholesterol value, a measure of how much of the waxy substance is in your blood. While cholesterol is important for doing things like building cells and hormones, having too much of it can lead to heart disease and stroke.
• triglyceride level, a measure of how much of this fatty substance is in the blood. As with cholesterol, too much of it increases the risk of heart disease and stroke.
• smoking in youth.

From 2015 to 2019, the researchers followed up on all of these people, who were 46 on average, which is not very old. They found that almost 800 of them had had cardiovascular events (like a heart attack or stroke), of which more than 300 were fatal.

When the researchers matched outcomes to values for the five factors, they found that they were indeed risk factors:

• People who had higher than normal values for all of the risk factors had almost triple the risk of cardiovascular disease.
• Smoking was the biggest risk factor, followed by BMI, systolic blood pressure, triglycerides, and cholesterol.
• You didn’t need to have all five factors to be at risk; for example, people who were obese as children were more than three times more likely to have cardiovascular disease — and those whose blood pressure was either high or close to high had double the risk.

None of this is a surprise, but seeing it so clearly should be a wake-up call, especially to parents.

What can parents do to help steer a course toward healthy adulthood?

Parents can take these four important steps:

1. Know if your child is at risk. Understandably, many parents don’t pay close attention to the numbers at their child’s checkup, or the results of blood tests. But those numbers are important.

• Make sure you know your child’s BMI — and if it is healthy or not. In adults, we say that a BMI of 19 to 25 is healthy. In children and teens, it’s a bit more complicated; we look at the BMI percentile based on age and gender. If the percentile is between 85 and 95, the child is overweight; if it’s over 95, the child is obese. The Centers for Disease Control and Prevention has a calculator you can use to get the BMI and percentile.
• Know your child’s blood pressure — and whether it is healthy or not. Again, this depends on age, gender, and height. Sadly, many pediatricians miss abnormal blood pressures because numbers that seem normal can be unhealthy for some children, so it’s important to ask your doctor to be sure. Your child’s blood pressure should be measured at every checkup starting at age 3.
• Ask about checking your child’s cholesterol and triglyceride levels. This is generally done in adolescence, but may be done earlier if a child is overweight, or if there is a family history of elevated levels. If you or a close family member has high cholesterol or triglycerides, make sure your child’s pediatrician is aware.
• Ask your child about smoking (and other substance use). Don’t assume you know.

2. Take what you learn — and this study — seriously. An “it’s just baby fat” or “they have plenty of time to get healthy” approach can be dangerous.

• If your child has an elevated BMI, blood pressure, cholesterol level, or triglyceride level, talk with your doctor about what you can do — and do it. 
• No matter what your child’s numbers are, make sure they have a healthy diet, rich in fruits, vegetables, whole grains, healthy fats, and lean protein. Limit added sugar (especially in beverages), processed foods, and unhealthy fats.
• Same goes for exercise: children should be exercising for an hour a day. That doesn’t have to be a team sport, if your child is not a team sports kind of person (or your life doesn’t lend itself to team sports); active play, going for walks, doing exercise videos, or even just dancing in the living room is fine.

3. Talk to your kids about not smoking. Start early — well before adolescence, when peer pressure becomes powerful. Make sure they know the facts, and help them learn and practice ways to say no.
4. See your doctor regularly. Children should see their doctor at least yearly, and if your child has one of the five risk factors, they will need more frequent visits. Make these visits a priority — your child’s life might literally depend on it.

Follow me on Twitter @drClaire

About the Author

Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD