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The National Center for Transgender Equality, NCTE, and the Human Rights Campaign gather on Pennsylvania Avenue in front of the White House in Washington, Monday, Oct. 22, 2018, for a #WontBeErased rally. Anatomy at birth may prompt a check in the "male" or "female" box on the birth certificate _ but to doctors and scientists, sex and gender aren't always the same thing. The Trump administration purportedly is considering defining gender as determined by sex organs at birth, which if adopted could deny certain civil rights protections to an estimated 1.4 million transgender Americans. (AP Photo/Carolyn Kaster)

The National Center for Transgender Equality, NCTE, and the Human Rights Campaign gather on Pennsylvania Avenue in front of the White House in Washington, Monday, Oct. 22, 2018, for a #WontBeErased rally. Anatomy at birth may prompt a check in the "male" or "female" box on the birth certificate _ but to doctors and scientists, sex and gender aren't always the same thing. The Trump administration purportedly is considering defining gender as determined by sex organs at birth, which if adopted could deny certain civil rights protections to an estimated 1.4 million transgender Americans. (AP Photo/Carolyn Kaster)


Science Says: Sex and gender aren’t the same

By LAURAN NEERGAARD

AP Medical Writer

Tuesday, October 23

WASHINGTON (AP) — Anatomy at birth may prompt a check in the “male” or “female” box on the birth certificate — but to doctors and scientists, sex and gender aren’t always the same thing.

The Trump administration purportedly is considering defining gender as determined by sex organs at birth, which if adopted could deny certain civil rights protections to an estimated 1.4 million transgender Americans.

But variation in gender identity is a normal part of human diversity, the American Academy of Pediatrics, or AAP, stresses in a new policy that outlines how to provide supportive medical care for transgender youth.

Here are some questions and answers about what can be sometimes blurry lines.

Q: Aren’t sex and gender interchangeable terms?

A: Sex typically refers to anatomy while “gender goes beyond biology,” says Dr. Jason Rafferty, a pediatrician and child psychiatrist at Hasbro Children’s Hospital in Rhode Island, and lead author of the AAP’s transgender policy.

Gender identity is more an inner sense of being male, female or somewhere in between — regardless of physical anatomy, he explained. It may be influenced by genetics and other factors, but it’s more about the brain than the sex organs.

And transgender is a term accepted across science and medical groups to mean people whose gender identity doesn’t match what Rafferty calls their “sex assigned at birth.”

Q: How early can people tell if they’re transgender?

A: It’s normal for children to explore in ways that ignore stereotypes of masculinity and femininity. Rafferty says it’s whether those feelings and actions remain consistent over time that tells. Sometimes that happens at a young age, while for others it may be adolescence or beyond.

Regardless, the pediatricians’ policy calls for “gender-affirmative” care so that children have a safe, nonjudgmental and supportive avenue to explore their gender questions.

Q: What kind of care might they need?

A: Transgender people of all ages are more likely to be bullied and stigmatized, which can spur anxiety and depression and put them at increased risk for suicide attempts.

For children, medicine to suppress puberty may be considered, to buy time as the youth grapples with questions of gender identity.

Q: Can’t a genetic test settle if someone’s male or female?

A: “It’s not like we’re going to find a magic transgender gene,” Rafferty says, noting that a mix of genes, chemicals and other factors contribute but is not well understood.

Generally, people are born with two sex chromosomes that determine anatomical sex — XY for males and XX for females.

But even here there are exceptions that would confound any either-or political definition. People who are “intersex” are born with a mix of female and male anatomy, internally and externally. Sometimes they have an unusual chromosome combination, such as men who harbor an extra X or women who physically appear female but carry a Y chromosome. This is different than being transgender.

The Associated Press Health & Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education. The AP is solely responsible for all content.

The Conversation

Transgender and non-binary people face health care discrimination every day in the US

October 23, 2018

Author: Shanna K. Kattari, Assistant Professor of Social Work, University of Michigan

Disclosure statement: Shanna K. Kattari receives funding from University of Michigan – Michigan Institute for Clinical and Health Research.

Partners: University of Michigan provides funding as a founding partner of The Conversation US.

Many people may experience anxiety when seeking medical treatment. They might worry about wait times, insurance coverage or how far they must travel to access care.

Transgender and non-binary individuals have an added fear: gender-related discrimination. This can involve being outed due to a name or gender mismatch on an insurance card, being completely denied care or even being left to die.

Most recently, the White House has begun to seriously weigh removing transgender and intersex individuals from definitions of gender completely. If enacted, such a change would almost certainly lead to problems for transgender and non-binary people as they seek a variety of health services. Growing scientific evidence shows that this population faces significant hurdles in many domains, including when seeking medical and mental health care.

Rates of discrimination

Transgender and non-binary individuals are those whose gender does not align with the social expectations connected to the sex they were assigned at birth. Sex, usually assigned male or female at birth, is based on genitalia, while gender is a complete sense of who one knows themselves to be.

It’s difficult to estimate what percent of the population is transgender or non-binary. Gender identity is not included in the U.S. census or on most national or statewide data collection efforts. However, research shows that approximately 0.6 percent of U.S. adults identify with a gender expansive identity, such as transgender, non-binary, genderqueer or agender.

Younger people are more likely to have one of these identities compared to adults. Somewhere between 0.7 and 3.8 percent of high school-aged youth report that they identify as transgender, non-binary or another identity besides the sex they were assigned at birth.

This population has many challenging experiences when compared to individuals who are not transgender. Some problems include employment and housing discrimination, as well as higher rates of partner violence. Many of these experiences are connected to transphobia, or discrimination against transgender and non-binary individuals.

Health researchers such as myself have been working to better understand the discrimination that this group faces in medical settings. For example, approximately one-fifth of transgender and non-binary individuals have been denied equal treatment when trying to access doctors or hospitals.

Discrimination can come in many different forms. Medical providers might assume that all health issues are correlated with one’s gender identity – for example, assuming that pneumonia is somehow connected to hormone use, or that all anxiety must be due to being transgender. These and other such issues are often referred to as broken arm syndrome. Others might be refused care, or experience harmful language or harassment.

These experiences of discrimination are elevated for transgender and non-binary people of color and people with disabilities. This is true not only in medical settings, but in places like mental health centers, domestic violence centers, drug treatment programs and rape crisis centers. In fact, those with multiple types of disabilities – whether physical, socioemotional or learning-related – are over three times more likely to experience discrimination in all four settings as compared to non-disabled people.

Making health care more inclusive

Societal stigma and bias can leave transgender and non-binary people feeling marginalized. But there are steps that medical providers can take to promote resiliency and well-being among this population.

Transgender and non-binary individuals have higher rates of depression and thoughts about suicide. They are also significantly more likely to attempt suicide. These increased rates are not due to being transgender, but from dealing with stigma, lack of acceptance and abuse.

One study showed that, when transgender and non-binary individuals had a primary care provider that they considered to be inclusive, they had lower rates of depression and suicidal thoughts. About 54 percent of those without an inclusive provider reported current depression, compared to only 38 percent of those with such a provider.

I believe that medical and nursing schools, social work, counseling and psychology training programs, and community organizations should make a tangible effort to better train all health providers and social service professionals. Staff should have more comfort treating members of this community, especially those who hold multiple marginalized identities, like transgender people of color.

This training could include information on different language used by this community; guidance on how to correctly use a variety of pronouns; or best health care practices for working with members of this community. It could even simply start by providing a basic understanding of the difference between gender and sex.

Training could help reduce these alarming rates of discrimination faced by this community – as well as bolster their overall health and well-being.

The Conversation

Why did the flu kill 80,000 Americans last year?

October 23, 2018

Author: Patricia L. Foster, Professor Emerita of Biology, Indiana University

Disclosure statement: Patricia L. Foster receives funding from the US Army Research Office. She is affiliated with Union of Concerned Scientists and Concerned Scientists at Indiana University.

Partners: Indiana University provides funding as a member of The Conversation US.

The 2017-2018 flu season was historically severe. Public health officials estimate that 900,000 Americans were hospitalized and 80,000 died from the flu and its complications. For comparison, the previous worst season from the past decade, 2010-2011, saw 56,000 deaths. In a typical season, 30,000 Americans die.

So why was the 2017-2018 season such a bad year for flu? There were two big factors.

First, one of the circulating strains of the influenza virus, A(H3N2), is particularly virulent, and vaccines targeting it are less effective than those aimed at other strains. In addition, most of the vaccine produced was mismatched to the circulating A(H3N2) subtype.

These problems reflect the special biology of the influenza virus and the methods by which vaccines are produced.

Flu virus is a quick change artist

Influenza is not a single, static virus. There are three species – A, B and C – that can infect people. A is the most serious and C is rare, producing only mild symptoms. Flu is further divided into various subtypes and strains, based on the viral properties.

Viruses consist of protein packages surrounding the viral genome, which, in the influenza virus, consists of RNA divided into eight separate segments. The influenza virus is enveloped by a membrane layer derived from the host cell. Sticking through this membrane are spikes made up of the proteins haemagglutinin (HA) and neuraminidase (NA), both of which are required for the virus to successfully cause an infection.

Your immune system reacts first to these two proteins. Their properties determine the H and N designations of various viral strains – for instance, the H1N1 “swine flu” that swept the globe in 2009.

Both HA and NA proteins are constantly changing. The process that copies the viral RNA genome is inherently sloppy, plus these two proteins are under strong pressure to evolve so they can evade attack by the immune system. This evolution of the HA and NA proteins, called antigenic drift, prevents people from developing lasting immunity to the virus. Although the immune system may be prepared to shutdown previously encountered strains, even slight changes can require the development of a completely new immune response before the infected person becomes resistant. Thus we have seasonal flu outbreaks.

In addition, various subtypes of influenza A infect animals, the most important of which, for humans, are domestic birds and pigs. If an animal is simultaneously infected with two different subtypes, the segments of their genomes can be scrambled together. Any resulting virus may have new properties, to which humans may have little or no immune defense. This process, called antigenic shift, is responsible for the major pandemics that have swept the world in the last century.

Forecasting flu, producing vaccine

Against this background of antigenic change, every year the World Health Organization predicts which strains of flu virus will be circulating during the next flu season, and vaccines are formulated based on this information.

In 2017-2018 the vaccine was directed against specific subtypes of A(H1N1), A(H3N2) and B. The Centers for Disease Control and Prevention estimates that this vaccine was 40 percent effective in preventing influenza overall. But, significantly, it was only 25 percent effective against the especially dangerous A(H3N2) strain. This mismatch probably reflects the way most of the vaccines are produced.

The common way of producing influenza vaccine starts by growing the virus in fertilized chicken eggs. After several days, the viruses are harvested, purified and inactivated, leaving the surface proteins, HA and NA, intact. But, when the virus is grown in eggs, individual viruses with changes in the HA protein that increase its ability to bind to chicken cells can grow better and thus become more common.

When people receive vaccines produced from these egg-adapted viruses, their immune system learns to target the egg-influenced HA proteins and may not react to the HA proteins on the viruses actually circulating in humans. Thus, the virus used to produce much of the 2017-2018 vaccine provoked an immune response that did not fully protect against the A(H3N2) virus circulating in the population – although it may have lessened the severity of the flu.

Small improvements and a universal vaccine

Scientists are on the hunt for a better way to protect the world’s population from influenza.

Two new vaccines that do not use egg-grown viruses are currently available. One, a vaccine made from viruses grown in mammalian cells, proved in preliminary studies to be only 20 percent more effective against A(H3N2) than egg-produced vaccine. The other, a “recombinant” vaccine consisting of only the HA proteins, is produced in insect cells, and its effectiveness is still being evaluated.

The ideal solution is a “universal” vaccine that would protect against all influenza viruses, no matter how the strains mutate and evolve. One effort relies on the fact that flu’s HA protein “stalk” is less variable than the “head” that interacts with the host cell surface; but vaccines made from a cocktail of HA protein “stalks” have proved disappointing so far. A vaccine composed of two proteins internal to the virus, M1 and NP, which are much less variable than surface-exposed proteins, is in clinical trials, as is another vaccine made up of a proprietary mixture of pieces of viral proteins. These vaccines are designed to stimulate the “memory” immune cells that persist after an infection, possibly providing lasting immunity.

Will the 2018-2019 flu season be as bad?

Based mainly on the recent flu season in South America, the World Health Organization recommended changing the A(H3N2) subtype in the vaccine to one that better matches last year’s circulating A(H3N2). They also recommended changing the B subtype to one that appeared in the U.S. late in the 2017-2018 season and became increasingly common elsewhere. The WHO anticipated that the circulating A(H1N1) subtype will be the same as last year and so no change was necessary on that front. So, although the same strains will most likely be circulating, epidemiologists expect the vaccines to provide better protection.

The CDC recommends that everyone 6 months and older get a flu shot every year, but, typically, fewer than half of Americans do so. Flu and its complications can be life-threatening, particularly for the young, the old and the otherwise debilitated. Most years the vaccine is well matched to the circulating virus strain, and even a poorly matched vaccine offers protection. Plus, wide-spread vaccination stops the virus from spreading and protects the vulnerable.

The first flu death of the 2018-2019 season has already occurred – a healthy but unvaccinated child died in Florida – affirming the importance of getting the flu shot.

Opinion: CAFE Standards Vs. Economics

By Arthur R. Wardle and William F. Shughart II

InsideSources.com

The announcement of plans to ease the nation’s fuel economy standards (known as Corporate Average Fuel Economy standards, or CAFE) triggered numerous defenses of the regulation.

CAFE, which began as a program to reduce oil consumption, is now almost always justified on environmental grounds. Fuel economy standards do succeed in reducing greenhouse gas emissions, but market responses to fuel efficiency hikes make the policies less effective. The costs of high fuel economy standards simply do not make sense given the diversity of viable alternatives for reducing greenhouse gases.

First, the greenhouse gas benefits of tougher fuel efficiency rules are mitigated by consumer behavior. When people buy new, more efficient cars, they don’t maintain their old travel habits. Taking advantage of their ability to drive more miles per gallon of fuel, they tend to travel more. In the long term, the “rebound effect,” as that behavior often is called, eliminates 32 percent of the fuel savings that would occur if drivers kept distances travelled unchanged.

Worse, the higher costs of new vehicles manufactured to meet stricter fuel efficiency standards encourages consumers to hold on to old gas-guzzling clunkers. Since tougher CAFE rules discourage carmakers from selling large, powerful vehicles, older trucks and SUVs tend to stick around the longest. This “scrappage effect,” by keeping older, less efficient vehicles on the road, eliminates an additional 13 percent to 16 percent of fuel savings.

Carmakers themselves mitigate the efficacy of CAFE standards. To alleviate some of the standard’s strain on producers of larger vehicles like trucks and SUVs, the standards vary based on a vehicle’s wheelbase. Therefore, manufacturers can meet the standards either by making their cars more fuel efficient or just by expanding their footprints — an option that is sometimes cheaper but does nothing to help the environment.

The EPA, in its Midterm Evaluation report intended to evaluate the success of the CAFE program, basically ignored these problems. In calculating the benefits of efficiency standards, the agency estimated the rebound effect as offsetting only 10 percent of projected fuel savings, and left the effects of scrappage and larger wheelbases out of the calculations entirely.

The National Highway Traffic Safety Administration issued a range of estimates for both the costs of CAFE standards and carbon-dioxide emissions the rules would eliminate. Using the NHTSA’s best-case scenarios for cost and greenhouse gas mitigation, the program manages to improve air quality at a cost of $87 per ton of carbon. That figure exceeds the EPA’s old estimate of the social cost of carbon of $46 in 2025 — a number that has since been rescinded by the Trump administration — as well as most academic calculations of carbon’s social cost.

That’s just the best-case scenario. Using more realistic estimates of CAFE’s costs and carbon-reduction benefits yields an eye-popping implicit cost of $1,000 per ton of carbon.

Keep in mind that many other proposals for mitigating vehicle emissions are available. Raising gas taxes, or, better yet, imposing a tax on vehicle miles travelled, would discourage travel and help with pollution, congestion and road maintenance costs simultaneously. Those policies do not suffer from rebound, scrappage, or wheelbase expansion effects.

The Trump administration is not proposing to repeal the fuel efficiency requirements currently in effect or even to halt the standards’ upward climb immediately. The proposal merely freezes the standards as of 2021, five years earlier than the Obama administration’s version of the rules. Many of the cost-effective ways of improving fuel efficiency have already been implemented by the auto industry, meaning that future changes to lower fuel usage must be, on average, costlier. Pausing the standards in 2021 prevents those costs from spiraling out of control.

The fight against greenhouse gas emissions should at least seek to defend the environment using least-cost policies whenever possible. CAFE standards turn out to be an expensive method of cutting emissions compared to alternative climate policy options, even within the transportation sector.

ABOUT THE WRITERS

Arthur R. Wardle is a graduate student in economics at Utah State University. William F. Shughart II is research director of the Independent Institute and is J. Fish Smith Professor in Public Choice at Utah State’s Huntsman School of Business and senior editor for the Center for Growth and Opportunity. They wrote this for InsideSources.com.

The National Center for Transgender Equality, NCTE, and the Human Rights Campaign gather on Pennsylvania Avenue in front of the White House in Washington, Monday, Oct. 22, 2018, for a #WontBeErased rally. Anatomy at birth may prompt a check in the "male" or "female" box on the birth certificate _ but to doctors and scientists, sex and gender aren’t always the same thing. The Trump administration purportedly is considering defining gender as determined by sex organs at birth, which if adopted could deny certain civil rights protections to an estimated 1.4 million transgender Americans. (AP Photo/Carolyn Kaster)
https://www.sunburynews.com/wp-content/uploads/sites/48/2018/10/web1_121625270-c3ddf25cd1dc45c68f669fc7d8582759.jpgThe National Center for Transgender Equality, NCTE, and the Human Rights Campaign gather on Pennsylvania Avenue in front of the White House in Washington, Monday, Oct. 22, 2018, for a #WontBeErased rally. Anatomy at birth may prompt a check in the "male" or "female" box on the birth certificate _ but to doctors and scientists, sex and gender aren’t always the same thing. The Trump administration purportedly is considering defining gender as determined by sex organs at birth, which if adopted could deny certain civil rights protections to an estimated 1.4 million transgender Americans. (AP Photo/Carolyn Kaster)
News & Views

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