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UGAPREMED A MAGAZINE FOR STUDENTS INTERESTED IN SCIENCE AND HEALTH GRADY COLLEGE OF JOURNALISM

gender and sexuality abnorm alities

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FIND US ON SOCIAL MEDIA www.premedmag.org

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WELCOME TO OPPORTUNITY The Lake Erie College of Osteopathic Medicine can help students interested in becoming a physician, pharmacist or dentist get an early start! LECOM has developed affiliation agreements and early acceptance programs with over 100 colleges and universities around the country. These affiliation programs give qualified students a provisional early acceptance to LECOM for the College of Osteopathic Medicine, School of Pharmacy or School of Dental Medicine on our campuses in Erie and Greensburg, PA or Bradenton, FL. To learn more about our early acceptance programs, visit us at our booth or online at LECOM.edu.

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staff Faculty Advisors Dr. Leara Rhodes

Executive Editors Annika Carter Selin Odman Sona Rao Galit Deshe Heather Huynh Jesse Hu Lily Wang Hanna Friedlander Writers Anisha Yagnik Emma Burke Hallie Smith Leah Ginn Nikhil Gangasani Nivedha Balaji Saakya Peechara Sarah Caesar Syeda Nausheen

ANNIKA CARTER Editor-In-Chief

SELIN ODMAN Content Editor

SONA RAO Online Editor

HEATHER HUYNH Operations Editor

JESSE HU Treasurer

GALIT DESHE Design Editor

HANNA FRIEDLANDER Photography Editor

LILY WANG Photography Editor

Designers Wayland Yeung Photographers Graham Cain Copy Editors Annika Jonker Christina Najjar Monisha Narayanan Mickey Dao

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a message FROM OUR EDITOR

We have all heard the saying, “Women are from Venus, men are from Mars.” And I think we can all agree that this is, mostly, true — there are behaviors that are typically “feminine” and behaviors that are typically “masculine.” It is strange to think, though, what exactly it is about muscles that make them “manly,” and what it is about emotions that make them “womanly.” Our society, and in fact much of human society, has created strict gender roles. Although these roles in some cultures may be reversed from what we view as the norm, they are ever-apparent. We may not pay attention to it, but our sexuality plays a major role in our day-to-day lives. Historically, the first thing a new mother hears after hours of labor is, “It’s a boy!” or, “It’s a girl!” All through childhood, kids are taught to classify living things as boy or girl. The question that remains: Are the lines between boy and girl, masculine and feminine, really so clear-cut?

Before delving into this issue of PreMed Magazine, I think it is important to clear up the differences between gender and sexuality. Gender is defined as the physical state of being male or female. Sexuality, on the other hand, refers to the group an individual identifies himself or herself with. An individual can, anatomically, be one gender, but identify, psychologically, as the opposing sexuality. Like virtually everything else in nature, our gender and sexuality exist on a spectrum. The idea of a spectral representation of sexuality is not new — I have been using the terms “girly-girl” and “tom-boy” since before I can remember — but there has been recent upheaval surrounding certain issues regarding gender and sexual minorities. In this issue, we do not aim to make a political statement, we simply aim to inform. We hope to inform you, our readers, in how gender and sexuality affect individuals’ access or quality of healthcare, how different genders differ biologically and how sex plays a role in our everyday lives as students, doctors and members of our communities. Enjoy.

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con ten ts

6 TECHNOLOGY AND MEDICINE


14

Sex Abnormality at birth

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Gender Pay Inequality in the Healthcare Industry

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STI: A Rising Concern and How to Dodge It

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Why America is Failing Sex Ed

38

Women are from Venus, Men are from Mars

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Challenges for Sexual and Gender Minority Members

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Behave As Instructed

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Gender ≠Sex

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Synthetic Life

41

DocThoughts: Bringing the Bedside to the Boardroom

18

Undermining the Potential of Women in Medicine

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Dimensions of Gender Identity

30

Book Review: The Checklist Manifesto

36

The Lowdown on Hormone Replacement Therapy

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Gender Identity and Health Disparities

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THE LEARA SCHOLARSHIP WANNA WIN $500? PreMed Magazine will now be offering a scholarship in each issue. Each scholarship will require a submission from you, our readers. This submission can be a piece of writing, or artwork. In each issue, our scholarship will have a different topic for these submissions.

This month's topic is:

If you could change one thing about the world, what would it be?

To enter, please send an email to ugamedmag@gmail.com by April 1st with the following information: - Your Name - Your Email Address - Your Phone Number - Your Local Address - Your Expected Graduation Date - Your Major - Your Current GPA Please attach to this email a file containing your submission. Preferred files are Microsoft Word documents, .jpgs, or PDFs. Remember, this scholarship is open to ALL majors, not just pre-health students! The recipient of this scholarship will be announced in our December 4th issue. He or she will be rewarded with $500 to be spent on furthering his or her education both on and off campus.

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CONGRATULATIONS

SPRING 2017 LEARA SCHOLARSHIP WINNER

PATRICIA DUFFY TURN THE PAGE TO READ HER ENTRY

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WHAT MAKES YOU, YOU? leara scholarship winner PATRICIA DUFFY

If someone prompted me with the question, “What makes you, you?” prior to my starting college in 2014, my response would have been far different from my answer now. Back then, I had a consistent, go-to response. I was third in my high school class, senior class president, editor-in-chief of the yearbook, cheerleading captain, and an all-around active member of the community. I was outgoing to the point of being overwhelming. To the public eye, without trying to sound egotistical, I was that girl. The one who was seemingly woven into her many commitments, like they defined her, and to an extent, they did. That was what made me who I was for that period of time, and the dedication I had to my various commitments was a product of my desire to run away from the moments of my life, up until that point, I felt had defined me. My childhood was rocky. I grew up in an unconventional family. My mom never married my biological father. Instead, when I was three months old, she married the man I have the privilege of calling Dad. I was their first child, and soon after my birth, another little girl came along. Devastatingly, she passed away from SIDS at three months old, right before my dad was preparing to deploy with his military unit. I was only one year old at the time of her passing and don’t hold any memories of her besides the pictures I have of us during the few months we spent with her, but I know that psychologically-jarring moment had some sort of effect on my life. An effect I’ll never truly be able to understand. Furthermore, it’s tough for me to say how that defining moment effected my parents and their

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relationship, but I know it gave way to the roller coaster my family has been on ever since. Two years after my sister’s death, in 1999, Mom and Dad had another little girl, and after struggling with miscarriages and balancing busy jobs (Mom designed fiber optic networks while Dad was an Army Ranger) with their home life, in 2006, my little brother was born. With age differences of threeand-a-half and ten years, respectively, I’ve played differing roles in my sister and brother’s lives. The three of us were no exception to sibling squabbles growing up, more so my sister and I rather than my baby brother, but as we’ve grown, the dislike has turned into adoration. The life events that have taken place in between me and my siblings births are interwoven and innumerable, but the steady thread through it all was the estranged relationship our parents struggled with and still struggle with to this day. Mental and emotional hardships were constant factors I dealt with when at home, and these factors contributed to personal struggles with insecurity, anxiety, and later on, depression. While the anxiety and depression partially stemmed from genetics, my insecurity was a product of the harsh views I had developed of myself. I’m still working on absolving that insecurity now, at age 20. It wasn’t until recent years that I realized moments do define you, but they don’t make you, you. All of life’s moments contribute to the person you are today: a unique, self-aware mental being. Those moments make up the definition of who you are, but the final product is your ever changing reaction


to those moments. You decide what you’re going to make out of those experiences, especially the experiences you can’t control. My childhood wasn’t ideal. It was far from it. But life has gone on. I haven’t let a singular experience define me or make me, me. Rather, I’ve continued to add experiences to my arsenal, using them in my favor and working to continuously create a better version of myself. Despite the overarching theme of familial strife that is still a consistent storyline in my life, age has seemingly lessened the severity of the issues. My family has grown closer and hope and love have prevailed through the darkest of moments. Learning to make peace with all of life’s happenings has also helped. The truth is, I don’t have a solid answer to the question, “what makes you, you?” There are many responses I could give: “My dedication to my family.” “My passion for sports and telling stories.” “My faith in God.” But each of those barely scratch the surface of the authentic me. My identity comprises all of those answers and more. Maybe one day I’ll settle on a singular answer to that question, but until then, I’m comfortable with a fluid, open-ended reply that changes with the day.

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AT BIRTH

SEX ABNORMALITY

Imagine you have just become the proud parent of a newborn. You hear the baby cry just before the doctor whisks your child away for examination. After a few tense moments, the doctor turns around and congratulates you with hesitation. You are told that you baby was born with both female and male genitalia - the diagnosis is intersex.

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Anatomical sex, an issue often taught as being black and white, is a social issue like many others which comes with gray areas. However, scientifically speaking, there are three main types of intersex, which are defined as abnormalities in sexual anatomy that cannot be easily classified as male or female. Those born with true hermaphroditism have male and female internal sex organs, tissue of both the testes and the ovaries, and ambiguous external genitalia. Some people with this condition also have mosaicism of the sex chromosomes, meaning that some cells are

EMMA BURKE


XY (male) while others are XX (female). The second type is gonadal dysgenesis. This type of intersex is characterized by undeveloped sex organs, internal female sex organs, and external genitalia that can fall anywhere on the spectrum from male to female. Sex chromosomes in a person with gonadal dysgenesis can be normal, mosaic, or simply one X chromosome. Finally, pure gonadal dysgenesis is a condition only seen in females. In this variety of intersex, the girls have XY sex chromosomes, female external genitalia, and underdeveloped internal female sex organs. Many of the causes of intersex are genetically linked, resulting from insensitivity to male sex hormones or the dysfunction of enzymes that play a critical role in sex determination. Once it is realized that a child is born with atypical genitalia, doctors try to discover the cause of the condition and help the parents in determining the sex of the child - which has become an extremely controversial issue.

Although searching for an “answer” to a baby’s gender may seem ridiculous, this need stems from a parent’s wish for their baby to live a normal life. Therefore, parents are willing to follow a protocol determined by doctors. This includes inspection of the external and internal sex organs, determination of future fertility, and karyotyping to determine the genetic sex. In most cases, doctors and parents evaluate the testing results to determine what sex the baby will be assigned and raised as. However, there are some patients who are not diagnosed as intersex until puberty or even until they die. In these cases, patients have less severe external presentation of symptoms. They do not realize that something is amiss until they have issues related to infertility or an abnormal progression of events in puberty. While surgery is an option for those born with ambiguous genitalia, the Intersex Society of North America recommends that babies born as intersex are raised as whatever gender the child wants -allowing for him or her to decide at an appropriate age what gender and genitalia to have. However, in some cases, surgery on internal sex organs must be done sooner, forcing the sex of the individual to be determined by doctors. For example, sex organ tumors are common in intersex patients. In these situations, the organs containing the tumor are removed and hormone therapy is implemented. No matter which treatment is chosen for the patient, therapy through counseling and honesty from family members are widely accepted as ways to help intersex patients have the best possible quality of life.

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CHALLENGES FOR SEXUAL AND GENDER MINORITY MEMBERS

HALLIE SMITH

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As the number of individuals identifying as members of the LGBT community is growing, understanding and fulfilling their health needs should be of major importance to those who work in healthcare. They share all of the same physical and mental issues as any other group of society, but many of their problems arise from different origins. Many struggle with hiding their sexuality, living marginalized lives and finding physicians that have the mindset, expertise and skills required to understand their bodies. The insecurity that sexual and gender minorities tend to have bring about challenges to the medical community. Hesitancy to divulge sexual or gender identity when receiving care doesn’t allow the doctor to provide the best care for the patient. Along with the routine checks that must be performed, transgender individuals should follow up with their natal sex issues, such as prostate or breast cancer checks. Prevention services are almost culturally inappropriate, for medical personnel may not always know how to be sensitive to an LGBT member’s feelings.

may have, they might acquire a mental health disorder, such as depression or anxiety. This could be brought about by verbal, emotional or physical abuse from family or community members. Even further, these issues could cause more disorders that negatively affect health. The LGBT population is disproportionately overweight or obese. This unhealthy lifestyle could cause cardiovascular disease, lipid abnormalities or glucose intolerance. While some rely on food as comfort, others turn to substance abuse. Recreational drug use can lead to detrimental choices like unsafe sexual practices or suicide. These threats to the LGBT community are a fact of life. The medical community can help by providing education for physicians and giving minority members a comfortable experience in the office. All members of society should be cognizant of the physical and emotional struggle that LGBT members have or are going through.

Campbell University

Jerry M. Wallace School of Osteopathic Medicine

However, many healthcare providers are not proficient in dealing with LGBT concerns. The lack of data and resources covering minority health makes it difficult for physicians to learn about their patients who are members of the LGBT community. Also, many transgender individuals choose to use exogenous hormones. If a doctor is unaware of this, they may not be able to correctly diagnose a patient’s condition. Financial barriers also prevent minority members from receiving appropriate care. Health insurance limits a minority member’s ability to have transitional therapies, appropriate medication to aid in the transition, or even have the surgery performed. Many insurers refuse to cover these operations or resources because they are not necessary for one to have a healthy body. On top of physical issues that LGBT members

Become a Campbell Physician Teamwork Leadership Professionalism Integrity Diversity

Ethical Treatment of All Humanity campbell.edu/cusom @CampbellUSOM

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UNDERMINING THE POTENTIAL OF WOMEN IN MEDICINE Over the last quarter century, women’s representation, in otherwise male dominated professions such as medicine, has increased significantly. Today, women are entering medical school at roughly the same rate as their male counterparts, yet women encounter a rather subjective medical school experience. Often times, women are criticized and judged for their outward appearances rather than their skills and work ethic. Allyson Herbst, a current resident in internal medicine at Emory University, recalls the time in medical school a resident physician disclaimed “You’re not wearing make-up today. Maybe you should rethink that choice” (Washington Post). Women in the medical field are judged by and held to different standards in comparison to males. During performance evaluations, women are more likely to receive feedback that asks them to “smile more” and “be more approachable” rather than constructive criticism. Female medical students must confront such demeaning comments and sexist banter on a daily basis. Sexism is awfully pervasive and entrenched in the field of medicine, which causes women’s opinion and insight to be considered secondary. Female medical students must also deal with discrimination by the faculty members of medical schools. Women are usually encouraged by faculty members to pursue medical opportunities based solely on an easier, smaller workday so that they can give time to their family. Yet, males are rarely ever advised to pursue a field due to lower number of working hours. While such recommendations are not ill intentioned, they have the potential to contribute to stereotype threat in which negative stereotypes heighten doubt and anxiety within the student. A growing number of research studies show that constant pressure to conform to certain expectations interferes with individuals’ intellectual performance.

SYEDA NAUSHEEN Also, some areas of medicine, such as surgery, has a hostile and unfavorable environment for women. Surgery is a field in medicine in which women are stereotyped to be “the weaker sex [who] are unable to withstand the emotional and physical stressors” (Julia Haskin) that accompany an operating room. This type of mentality is unreasonable and irrational as female medical students undergo the same schooling, training and examinations as male medical students. Therefore, women in the healthcare system are capable of providing equal quality of care as men. In addition to menial treatment, female physicians are often times mistaken for other roles such as nurses. While this mistake is innocuous, it reveals how deeply ingrained the idea that doctors are males is in society. The #ILookLikeASurgeon movement, started by Heather Logghe a surgery resident, works to “shatter the traditional image of a surgeon” (AWS). And in doing so, it celebrates and highlights that idea that a healthcare professional can be from any gender, race, ethnicity, religion and lifestyle.

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GENDER PAY INEQUALITY IN THE HEALTHCARE INDUSTRY SARAH CAESAR Given that women comprise nearly half of the total U.S. labor force, it seems absurdly anachronistic to talk about the existence of a gender pay gap in this day and age. However, despite the enactment of legislation like the Equal Pay Act in 1963 and the Lily Ledbetter Fair Pay Act of 2009 which both prohibit employment discrimination, the disheartening reality still shows women as victims of income inequality in the workforce. In fact, recent reports released by the U.S Congress indicate that American working women typically earn only 79 percent of what men in similar jobs earn. Female physicians, in particular, are dramatically affected by gender pay inequality and often get paid on average $50,000 less annually than their male counterparts when numerous factors, such as number of patients seen, education and experience, have all been taken into account. Dr. Vineet M. Arora, a professor of medicine at University of Chicago and a strong advocate of equal pay for equal work, has spent several years researching the factors that possibly lead to this gender gap. Her research findings indicate that, first and foremost, the main cause of this gender pay disparity is blatant gender discrimination against women, with employers more likely to underpay women than men. Dr. Arora and her fellow researchers found that certain industries and even specific sectors within the healthcare industry, such as radiology, have been successful at adhering to the Equal Pay Act of 1963. They believe that identifying the factors that contribute to successful incorporation of equal pay in these settings could help remedy the problem in fields that undergo the largest pay gaps between genders. What Dr. Arora and her colleagues discovered was that female physicians were often less likely to negotiate for a higher salary due to the stigma women face for making such requests. Hence, they

advocate establishing programs and workshops that empower women and teach them to negotiate more successfully, in the hopes that this will help promote pay transparency and better salary practices. Numerous organizations, such as the National Committee on Pay Equity (NCPE) and the National Organization for Women, have been created to shed light on the various ways we can reach the goal of pay equity. Equal Pay Day, created by the NCPE, is celebrated on April 12th each year to symbolize “how far into the year women must work to earn what men earned in the previous year.” Although the road to gender pay equality is expected to be bridged only by the year 2050, pay equality advocates like Dr. Arora continue to fervently fight for this cause and hope to make some drastic changes even earlier. Even former President Barak Obama addressed the issue previously in his State of the Union speech, saying, “Today, women make up about half our workforce. But they still make 77 cents for every dollar a man earns. That is wrong. And in 2014, it’s an embarrassment. Women deserve equal pay for equal work.” And it is still an embarrassment here in 2017. While it’s great to see even lead political figures like Obama stand up for income equality, it should be noted that much hard work and dedication will be required on the people’s part to fight the long-held beliefs and misconceptions associated with the causes of this gap. With the dawn of a new era in politics, President-elect Donald Trump and policymakers should continue funding causes that aim to combat gender inequality in the nation-- ideally before 2050.

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behave

SHANNON VOGEL PHOTO BY GRAHAM CAIN

It begins from the moment we are born. “Congrats, It’s a Girl!” balloons are sold exclusively in delicate pastel pinks; baby boys’ bedrooms are painted in light blues. At a young age, little boys are given trucks to crash together during playtime; girls are given Barbie’s instead. Phrases like, “you run like a girl,” and “real men don’t cry,” are thrown around elementary school playgrounds. As puberty blossoms, young boys are taught being assertive is seen as strength, young girls will be instructed not to be too bossy. Young boys will be told they aren’t manly if they express their emotions; young ladies are encouraged to share their feelings. As college arrives, women learn they aren’t taken seriously as competent math and science majors and men learn that being a male art major only invites ridicule. This polarization of genders begins early in life and only increases in consequence as a child grows older. Gender polarization is a concept in sociology by American psychologist Sandra Bem, which states, “societies tend to define femininity and masculinity as polar opposite genders, such that male-acceptable behaviors and attitudes are not seen as appropriate for women, and vice versa”. 22 GENDER AND SEXUALITY

as instructed

Society has taken upon itself the task of putting men and women into different boxes, designating what it believes to be proper behavior and lifestyle choices for each respective gender. The task of raising children is put into one box, responsibility of supporting the family financially put into the other. The delegation of roles and attributes to specific genders is not only harmful, but an antiquated practice. The tired notion that men and women are so fundamentally different is offensive - not only because of the division it creates, but because of its consequences on societal expectations. These expectations are imprinted on virtually every aspect of human existence, including models of dress, social roles, and emotional expression. The stereotypes and polarization of genders is equally harmful in the medical field. Previous research shows that women are far less likely to seek immediate emergency medical treatment than men for similar afflictions, such as heart attacks. In fact, women are far more likely to die from delay of medical treatment for heart attacks. Further


investigation reveals a startling truth, women are afraid they we be told they are ‘over-reacting.’ The toxic figment that women are dramatic or over emotional extends to patient care as well. Masses of women tell tales of inadequate medical care because their concerns were not taken seriously. In these instances, women report their doctors minimizing their reported symptoms, even going as far to say it’s all in their heads. This discrepancy is largely disproportional in the treatment of pain. According to a National Pain Report survey, 90% of women coping with chronic pain felt the healthcare system discriminates against them. Furthermore, found that medical professionals are more likely to tell women that their symptoms are psychosomatic, a term defined as “a physical disorder that is caused by or notably influenced by emotional factors.” Men are affected by gender polarization and societal standards as well. Some studies have found that psychiatrists are less likely to diagnose and medicate men as compared to women for depression, even when they score similarly on standardized diagnostic tests. Researchers hypothesize this results in part from the subconsciously ingrained ideal that men are

emotionally hardier than their female counterparts. Statistics show women are more likely to seek medical treatment for mental illness. This has been thought to contribute to a disproportionate suicide rate for men. According to a similar study, women are 48% more likely to be prescribed psychotropic drugs. Obviously, men face a disadvantage in mental health treatment. All of these disparities are blanketed by the looming shadow of gender polarization. The problem arises when these expectations alter the course of an individual’s life. Polarization and gender specific expectations mold a person to view and experience the world differently. Men grow more likely to be self-centered and career oriented as they are passively molded by societal influence. Similarly, women are subtly instructed to behave more timidly and put family and household above herself. Imagine that each young girl is treated with the respect and expectation to thrive just as boys are. Would this ease the disproportionate rate of poverty, in which 70% of the poor are women? Could the abolition of polarization empower more men to come forward after domestic violence and seek mental health treatment? In all likelihood, the dissolution of gender roles and polarization would have significant positive impacts on society and forward progress. WWW.PREMEDMAG.ORG

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DIMENSIONS OF

GENDER IDENTITY IDENTITY

What you think of yourself as

ORIENTATION

Which gender you are attracted to relative to your own

BIOLOGICAL SEX

Classification based on sexdefining organs & chromosomes

EXPRESSION

How you demonstrate your gender in actions, dress, etc.

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WAYLAND YEUNG

WOMAN

MAN

GENDERQUEER

AGENDER: LACK OF GENDER

HETERO

HOMO

BISEXUAL

ASEXUAL: LACK OF ATTRACTION

FEMALE

MALE

INTERSEX

FTM & MTF: TRANSEXUAL

FEMININE

ANDROGYNOUS

MASCULINE

GENDER NEUTRAL: NOT EXPRESSING EITHER

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NIVEDHA BALAJI

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A RISING CONCERN AND HOW TO DODGE IT

S T I

Sexually Transmitted Infections (STIs) affect individuals of all ages. However, the fact that half of the 20 million people diagnosed with new infections each year, comes from the 15-24 age group is frightening. STIs can be transferred from one individual to another through any means of sexual contact. STIs sometimes also referred to as Sexually Transmitted Diseases (STDs) can rise from bacterial, viral or parasitical pathogens. The most common STI is Human papillomavirus (HPV) with over 14.1 million new infections each year followed by Chlamydia with about 2.9 million cases each year. Some other common infections include Gonorrhea, Genital Herpes and Syphilis. STIs are a larger concern among women than men since women have harsher repercussions and health consequences than men. Maltreated syphilis in pregnant women can lead to infantile death. Untreated Chlamydia and gonorrhea can increase the risk of chronic pelvic pain and ectopic pregnancy, which is an abnormal pregnancy where the fertilized egg settles in places other than the uterus. Additionally, STIs can cause infertility in women. STIs can lead to organ damage, certain types of cancer and death. STIs are common among young women since they are biologically more susceptible to the infections, men who have sexual relationships with other men and young individuals with multiple sex partners. Many STIs have little to no symptoms so it is essential that certain precautions are taken to decrease the number of infections and deaths due to STIs. Vaccinations can help prevent HPV and hepatitis B, the practice of monogamy or reducing the number of sex partners can reduce the chances of encountering infected individuals, disclosure of infections with partners, increased access to prevention services and increased screening can help decrease the high numbers of youth STIs. The use of condoms is also highly effective in reducing the transmission of STIs because they can serve as a barrier that covers any infected parts. That being said, the most dependable way to dodge this bullet would be practicing abstinence and choose a sexual partner who has also practiced abstinence.


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GENDER ≠ SEX SHANNON VOGEL

PHOTO BY HANNA FREIDLANDER

Sex and gender have been historically thought to be interchangeable terms in American culture. Even in present day, many are baffled by the notion that sex and gender are different entities and the general society continuously struggles to grasp the concept. Sex is assigned as male or female at birth, based on reproductive organs and secondary sex characteristics of the individual. While there are some exceptions to male and female assignment, defining sex is far more straightforward than interpreting its distant cousin: gender. Gender is more of an art, than a science; it is experienced differently on a person-to-person basis. It is one’s most intimate concept of themselves, whether it be masculine, feminine, both, or neither. Gender identity is an intangible collage of emotion and expression, perception and

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consciousness, self-awareness and acceptance. “Sex is between the legs, gender is between the ears,” is a phrase commonly used in the LGBT community to simplify the difference between sex and gender. The scientific community recognizes this as generally true as gender is a state of psychological being. Essentially, gender cannot be defined by a set of anatomical traits or genetic expression - it is something felt and expressed more consciously than X and Y chromosomes. It is a deep sense of being, an understanding of who you are in your truest, most raw form. An anonymous, gender-fluid individual shared her personal experience with life outside of traditional gender identity, “To me, the concept of gender fluidity is so natural, but I understand where others get confused. I explain it like this: some mornings


I wake up feeling more like a girl, other mornings, feeling more like a boy; really, that’s how simple it is. This can present itself in how I dress, or carry myself on a given day. It doesn’t change who I am or my core values, which I want to stress to anyone unfamiliar with gender-fluidity.” She continued by explaining the struggles of her gender identity, “When I tell friends I’m genderfluid, I run the risk of alienation. I’ve had people tell me I have a mental illness or that it isn’t natural. I’ve had people tell me that I’m just being dramatic, and that my feelings aren’t valid, which is painful. While the majority of medical professionals treat me with respect, I did once have a doctor recommend therapy when I told

him I was gender-fluid. He acted if my identity was some form of affliction. It felt so outdated and unprofessional.” Those outside the traditional gender spectrum urge others to expand their minds, and consider that traditional “male” or “female” feelings and characteristics are merely a product of outdated gender roles. So while sex is a biologically and genetically determined fate, gender is a label diverged from societal influence of what is “feminine” or “masculine.” Sex and gender are a harmony of anatomy and psychology, still yet to be fully understood, medically and otherwise.

At the state of Georgia’s medical school, our students define us. They are academically excellent and personally altruistic. They consistently rank at or above average on objective measures such as the Medical College Admission Test and United States Medical Licensing Exam. They consistently secure spots in the country’s top residency programs. They volunteer to tutor and mentor local grade-school students. They help build community by providing seasonal fresh fruits and vegetables to our urban neighbors. Students in Augusta recently celebrated the 25th anniversary of their clinic for the underserved. Students in Athens started their own clinic within a year of their arrival. For nearly a half-century now, our students have spent a portion of their summers with high school and college students from underrepresented-in-medicine populations across our vast state, sharing what it really takes to be a doctor and serving as inspirational examples. They’ve even been known to sing a song and dance a step to raise support for children with cancer and their families.

Come change the world with them. The Medical College of Georgia at Augusta University

For more information about the Medical College of Georgia at Augusta University, please visit augusta.edu/mcg.

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BOOK REVIEW OF THE CHECKLIST MANIFESTO

NIKHIL GANGASANI

Title: The Checklist Manifesto Author: Atul Gawande Price: $12.34 Paperback, $9.99 Kindle As the worlds of medicine and virtually all professions become increasingly complex, how can we become better at preventing mistakes and complications? Gone are the days when one individual possesses all the know-how in a particular field to run everything smoothly.Also, how can individuals efficiently work together? The answer to both of these questions may be simpler than you think…... checklists. In The Checklist Manifesto, author Dr. Atul Gawande compellingly advocates for the use of checklists in minimizing human error amidst increasingly complex situations. An outstanding surgeon and public health official, Gawande illustrates his journey of both discovering the power of checklists and putting together and testing a checklist to minimize error in surgery. Interestingly, this journey takes the reader through the historically important use of checklists in fields including construction, aviation, and finance. Flavorful anecdotes keep the reader engaged while clearly presenting how checklists have not only brought success and saved the day, but also how an absence of checklists has brought about catastrophe. Throughout the book, Gawande acknowledges arguments against checklists and successfully counters with, in addition to anec-

30 GENDER AND SEXUALITY

dotes, his own study on the effectiveness of checklists employed at eight surgical units around the world and with coherent explanations for common reasons people resist checklists. In brief, Gawande argues that checklists serve two main purposes: 1) To remind experts and experienced individuals of the simple but critical steps of a process that can easily be overlooked among more complicated actions 2) To facilitate proper discussion and teamwork among experienced individuals approaching an a complex issue from different angles Personally, I find this book to be one of a kind in the field of medicine. Before reading The Checklist Manifesto, I assumed solving and preventing errors and issues in the medical field always involved mind numbingly complex planning and strategy and number crunching ad nauseum. Gawande proved me wrong. By investigating the impact of a simple tool in multiple fields outside of medicine, Gawande shows how applying observations from outside the “medical box” can bring new, lasting benefits to the field of medicine. He proves how a simple 19 item checklist aimed at preventing “stupid” mistakes in surgery and improving communication between members of the operating room has significantly decreased rates of error in the OR and increased perceptions of teamwork among surgical staff. What makes this book a standout is the effort of Atul Gawande to look beyond medicine for guidance and the simple yet powerful structure of the solution Gawande presents. The argument for checklists in this book provides valuable insight on preparation, organization and communication for future leaders in any profession or field. Gawande even provides examples of checklists - and even better - a checklist for creating checklists! Pre-meds should read The Checklist Manifesto to not only to grasp the concept that alleviating issues in medicine sometimes solely requires simple solutions found outside of medicine, but also to learn how checklists can make their lives more efficient and error-free.

E T H

G pr O of en th w

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31


WHY AMERICA IS FAILING SEX ED NIKHIL GANGASANI

PHOTO BY HANNA FREIDLANDER Sex education is a fiercely debated topic in the United States. Some believe it shouldn’t be offered in public schools, while others think that current teaching methods are ineffective. No matter which side you stand on, teen sex statistics tell an interesting story. Almost half of all high school students in the U.S. have had sex at least once according to a survey conducted by the Centers for Disease Control and Prevention. Of students that had sex within the three months leading up to the survey, 14% did not use any form of contraception (HIV Surveillance Report, 2016). In 2014, almost one in four new diagnoses of HIV in the U.S. were adolescents ages 13-24, and about half of all new STDs reported in 2014 were in those ages 1524 (Morbidity and Mortality, 2016 and Sexually Transmitted, 2015). Whether parents like it or not, their kids are having sex -- and they aren’t being as safe about it as they should be. Of the 88% of U.S. high schools who held mandatory health classes in 2014, only 61% instructed students on the methods of contraception. However, three-quarters of these classes taught that abstinence was the best way to prevent pregnancy and STD transmission (Teen Pregnancy Prevention, 2015). With so many schools offering sex education courses, why does the United States have one of the highest teen pregnancy and STD rates of the developed world (Hauser)? The answer lies in the way sexual health education is approached. While every state has some form of sex education, only 20 states have legislation in place that mandates public school sex education information must be accurate. The majority of states have an “optout” system for sexual health courses in public

32 GENDER AND SEXUALITY

schools, allowing for parents to choose for their child to not participate -- this in turn allows for students, the majority of whom will engage in sexual relationships during high school, not to be provided with the information they need to stay safe. In addition, four states have “opt-in” systems, meaning parents must elect for their child to even participate in the course (National Conference, 2016). For those students who do end up taking a class about sexual health, the vast majority are told that abstinence is the best way to avoid the unintended consequences of sex. And it’s true -- avoiding all types of sex is 100% effective at preventing pregnancy and STDs. However, telling a room full of curious, hormonal teenagers not to engage in sex is akin to handing pizza to somebody on a diet and telling them not to eat it. The abstinenceuntil-marriage program that most schools promote is ineffective - almost 25% of girls will become pregnant at least once before they are 20 years old (National Conference, 2016). With only 13% of women being married by the time they turn 20, it is clear that adolescents are not waiting until marriage to have sex (Copen et al., 2012). A study conducted by Advocates for Youth found that abstinence based programs have little, if any, long-term effect on changing the sexual behavior of teens despite having some short-term impact (Hauser). Some states have gone as far as providing adolescents with inaccurate information to dissuade them from engaging in sexual acts. Illinois is one such state, making claims that those who rely on condoms for birth control have a 15% chance of getting pregnant and cannot protect themselves from the transmission of Human Papillomavirus. Despite


using these scare tactics, the rate of pregnancy remained steady and STD rates rose for Illinois teens (Advocates for Youth). Abstinence-until-marriage programs should be abandoned in classrooms across the United States in favor of a model similar to that used across Europe. Dutch, French and German school systems, where adolescents become sexually active one to two years later, on average, than their American counterparts. Access to and a positive attitude towards sexual education are part of what has made these countries so successful at keeping STD and teen pregnancy rates low. In the U.S., about one in every five sexually active teen girls takes oral birth control, a rate three times lower than that in the Netherlands and Germany. Europeans promote responsible sex education instead of the abstinence-until-marriage approach, investing more

of their resources into providing their citizens with the free contraception and STD screenings that will help teens make informed and safe decisions (Berne, L., and Huberman, B., 1999). It is time that we take control of sex education in our public schools. Only 7% of parents with children in grades seven through twelve believe that sex education should not be taught in schools at all. Two-thirds of parents with students in that same age group prefer movement away from the abstinence-until-marriage philosophy of teaching (National Public Radio, 2004). We have let the minority control the fate of our youth by hindering the quality and availability of sexual health classes in our public schools. The reality is, kids all grow up and have sex -- some at a younger age than others. To ensure their safety and well-being, it is time that we lead a sex education revolution.

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An artifical genome is designed based on the hypothesized minimum requirements for life. The designer genome is chemically synthesized as tiny overlapping fragments of the full genome.

A C G T

Using PCR assembly, larger 1.4 kbp fragments are formed based on overlapping regions. Five corresponding 1.4 kbp fragments are further assembled in vitro into 7 kbp casettes.

SYNTHETIC

LIFE

34 GENDER AND SEXUALITY

Researchers led by Craig Venter successfully created a synthetic unicellular bacteria dubbed JCVI-syn3.0 with only 473 genes: the smallest of any autonomous organism.


Casettes are cloned using E. coli and sequence-verified for integrity. The casettes are further assembled into one-eighth genomes using yeast cells. The one-eighth genomes are rolling circle amplified.

Yeast cells are once again used to assemble the one-eighth genomes into the full genome.

WAYLAND YEUNG

3

Hours

JCVI-syn3.0 replicates in only

Gene expression Gene preservation

GENOME CONTENT

Unknown Cytosolic metabolism Cell membrane

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35


THE LOWDOWN ON HORMONE REPLACEMENT THERAPY

LEAH GINN

It has long been known that men and women are biologically different. Women carry the baby and men thank their stars that they don’t have to turn into a hormonal balloon for nine months. However, it is important to note that although everyone is aware of the reproductive differences, male and female bodies differ in so many other less-acknowledged yet very important ways. Most people know about the established field of women’s health, which focuses on the reproductive system. Trying to distinguish itself from women’s health and make itself heard is another distinct field called sex-specific medicine. This is a medical practice that considers how male and female physiologies respond differently to diseases and treatment. Scientists and physicians that advocate for and practice sex-specific medicine will take into account their patients’ biological sex when making clinical decisions. Research on cardiovascular disease is among the most studied sex-specific literature in recent years that has been applied clinically and shared with the public. Literature shows that men and women are at risk for cardiovascular disease at different ages, from different causes and via different physiological mechanisms. Heart attack symptoms are typically described as a chest pain or pressure, shortness of breath and sharp pain in

36 GENDER AND SEXUALITY

the arm and shoulder, but these are actually the typical symptoms experienced by men. Women, on the other hand, may be less likely to realize that they are having a heart attack, due to the small vessel heart disease—blockage of the smaller vessels rather than the main artery—that is more common among women. The symptoms, which include fatigue, nausea and lightheadedness, are less alarming and can occur weeks before the actual heart attack. This knowledge has become well-known in the medical community but is not yet common knowledge among the populace. In a 2012 National Survey taken by the American Heart Association, it was found that only 18% of women answered that nausea was a sign of a heart attack, compared to 56% of women who answered “chest pain” and 60% who answered “pain that spreads to shoulders, neck, or arm”. Understanding the sexspecific differences in cardiovascular health also gives insight for women to prevent a heart attack. The causes for heart attacks in men are typically related to heavy exercise, whereas the causes for women are more often social and psychological. Dr. Vera Regitz-Zagrosek of The International Society for Gender Medicine suggested in 2012 that factors such as job stress —as a result of social inequality in the workplace—can increase risk of cardiovascular disease for women.


Although sex-specific literature is available and fairly well-known in the medical communities, it is often ignored in laboratories as well in the doctor’s office. Until a few decades ago, most clinical trials —using both humans and animals—were conducted using male subjects and the results were applied to women, under the assumption that the female physiology would perform the same way as the male physiology. This practice can lead to adverse effects when faced with the reality that the patient’s biological sex can change their response to drugs and other treatments. Some sleep-aid drugs are a key example of the differences in male and female physiology. Alyson McGregor, an emergency medicine doctor and women’s health advocate who gave a TED Talk in 2014 entitled, “Why medicine often has dangerous side effects for women,” said that many women who took sleep-aid drugs ended up in car accidents because the suggested dosage is metabolized slower in their bodies than in men. These incidents could have been prevented if the drug had been tested on women as well as men when it was being produced. She also pointed out that in the ER, the same treatments are routinely given to

patients regardless of their sex. Not only were the drugs tested on mostly men, but they were also administered as if all patients were men. Scientists in the research field are much at fault for not practicing sex-specific medicine, but the doctors play an equally vital role, as they decide the ultimate diagnosis and treatment. Today, many doctors don’t practice sex-specific medicine. However, we are constantly training the next generation of doctors. The problem can be fixed at the root. Medical school curricula need to differentiate between women’s health and sex-specific medicine, and emphasize the equal importance of the latter. A survey and study conducted by Jenkins and colleagues in the journal Biology of Sex Differences in 2016, most medical students nationwide felt that they were not properly educated on sex-specific medicine, and that, based on their education, they would not feel prepared to treat their patients using that technique. The literature is available and convincing. Practicing sex-specific medicine is essential for ensuring accurate diagnosis and it cannot be ignored.

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37


MEN ARE FROM MARS Males store fat among organs, while females store fat in a ring around the abdomen. That’s why you can

typically tell gender from an MRI and why liposuction is easier on women.

Female registered nurses make on average 5% less than their male counterparts, even though 90% of nurses are females.

Males are more likely than females to suffer from almost all diseases. Of the few exceptions are osteoporosis, multiple sclerosis and breast cancer.

The skulls of men and women can be distinguished by the male’s heavier mandible, rounder and broader brow bone and larger occipital protuberance.

There are many different gene differences between men and women in the liver. This is why men and women metabolize drugs like Tylenol or alcohol so differently.

Males tend to have more muscle above the torso, while females tend to have more muscle below the torso. The difference is about 15%.

ANNIKA CARTER, WAYLAND YEUNG GALIT DESHE

38 GENDER AND SEXUALITY


Male doctors are 2x more likely to be sued Men have more standard deviation in IQ than women...In both directions!

On average, women live 7 years longer than men.

Male brains are typically better at spatial cognition.

On average, females have a higher body fat percentage, at 26% compared to males at 13%.

TOP 10 LEADING CAUSES OF DEATH 1

HEART DISEASE

1

2

CANCER (ANY TYPE)

2

6

UNINTENTIONAL INJURIES

3

3

CEREBROVASCULAR DISEASES

4

4

CHRONIC LOWER RESPIRATORY DISEASES

5

7

DIABETES MELLITUS

6

8

INFLUENZA AND PNEUMONIA

7

SUICIDE

8

9

NEPHRITIS, NEPHROTIC SYNDROME, OR NEPHROSIS 9

5

ALZHEIMER’S DISEASE

10

SEPTICEMIA

10

WOMEN ARE FROM VENUS WWW.PREMEDMAG.ORG

39


bedside

bringing the

to the

DOCTHOUGHTS

BOARDROOM

What does the term “patient advocate” mean to you? As doctors it is important that we support our patients beyond just the clinical setting. Our patients’ stories and our experiences as leaders in healthcare give us the power to influence policy change on a local or even national level. In this interview with Dr. Jay Bhatt, CMO of the American Hospital Association, CEO and president of the Health Research and Education Trust (HRET), and practicing physician, we are urged as future medical students and physicians to get involved in shaping the nation’s policy. Getting involved in policy change as a practicing physician or even as a medical student will get us closer to achieving better healthcare outcomes for our patients -current or future.

not part of the policy conversation but over the last ten years we’re seeing significant clinical voices. Medical students are working in government at the state, local, federal level or physicians are having dual roles, like myself, seeing patients but also working in policy and bringing the story that I see on the front lines in caring for patients to the conversations that I am having...We are in the best position as physicians and medical students to bring the bedside to the boardroom and, you know, there is really no one else positioned effectively to do that.

What role do physicians play in shaping the public policy?

Medicine is not just the clinical. The clinical understanding and the practice of medicine gets influenced by the environment. We want to make sure that that environment helps us take care of patients in the best way that we can. I think what we are seeing that’s missing in the policy world is real front line stories, you know that voice of the patient being treated for sepsis or that voice and experience of a patient dealing with end of life and

Policy should be something that...amplifies our ability to take care of patients and their families. It helps us create the kind of healthcare ecosystem we can be proud of, that our patients can be proud of, that our families can be proud of. In the early 1900s...the physician and medical student voice was

40 GENDER AND SEXUALITY

Why is it important that physicians and medical students get involved in public policy and advocacy work?


the challenges they go through and the potential for mistakes, the potential for sharing successes. [The real-world experiences] get lost in policy if the clinicians and the students aren’t bringing those stories forward...If we don’t, as physicians, contribute our voice and our action to shaping health policy for our patients and their families and for the many stakeholders that work in healthcare then someone else is going to do it for us and that voice that’s going to do it for us isn’t going to be as informed as the frontline voice we can bring. What are the steps that doctors and students can take to become more involved in policy and advocacy work? So if you don’t have that much time I think reading the perspective pieces in these journals will give you really a great background on...what’s happening. Again, the foundation is being a great doctor and so you have to make sure you are learning the material you need to learn to be a good

doctor and...if you have exposed yourself to these experiences and perspectives then you’ll be in a better position to say, “I can engage in it and make a difference.” If you do have some more time, then you can get really involved in a campaign...Getting involved in these campaigns allows you to not only feel like you are contributing to a larger story and making a difference, but you get to see how certain things work. And if you have just a little bit of time, think about an issue you care about, learn a little about it, and send an email to your legislator or make a phone call or Tweet a perspective or shoot an Instagram photo of people sharing their voice...I think social media is a very easy way to be getting involved in advocacy and policy. And you can also consume information through there. There’s a lot of Hashtags and Thunderclaps and LinkedIn profiles that you can follow to learn about key policy issues and what people are doing to address them. Want to see the full interview or interviews like it? Find DocThoughts at DocThoughtsMed.com.

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41


Gender Identity & Health Disparities SAAKYA PEECHARA, WAYLAND YEUNG

What is gender identity? Gender identity refers to a person’s internal sense of being male, female, or something else. The term transgender is an umbrella term for persons whose gender expression or behavior does not conform to that typically associated with the sex to which they were assigned to at birth.

65% 65% 65% 65% 18

of transgender individuals have reported discrimination in public accommodation settings in the past 12 months

of transgender individuals have reported discrimination in public accommodation settings in the past 12 months

of transgender individuals have reported discrimination in public accommodation settings in the past 12 months

of transgender individuals have reported discrimination in public accommodation settings in the past 12 months

65% 65% 65% 65%

of transgender individuals have reported discrimination in public accommodation settings in the past 12 months

of transgender individuals have reported discrimination in public accommodation settings in the past 12 months

of transgender individuals have reported discrimination in public accommodation settings in the past 12 months

of transgender individuals have reported discrimination in public accommodation settings in the past 12 months

states

& Washington DC

have laws that prohibit discrimination based on gender identity

42 GENDER AND SEXUALITY


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99%

OR 638 out of 644 2014-2015

Ross graduates who passed their USMLE exams on the first attempt attained a residency by April 2016.

YOUR ROAD TO RESIDENCY. LEARN MORE AT: ROSSU.EDU

Important information about the educational debt, earnings, and completion rates of students who attended this program can be found at http://medical.rossu.edu/ medical-school/gainful-employment.htm. Š2016 Ross University School of Medicine. All rights reserved.

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