LONDON (Thomson Reuters Foundation) – U.S. legislators would do better relying on medical evidence, not opinion, as they consider a spate of new proposals that would ban transgender children from treatments such as puberty blockers and cross-sex hormones, expert doctors say.

A measure newly introduced in South Carolina would revoke licenses of doctors who treat trans children, while other lawmakers proposed banning gender reassignment for minors after a Texas father tried to stop his ex-wife from raising their child as a girl instead of a boy.

“These legal efforts could not be more archaic,” said Scott Leibowitz, associate professor of psychiatry at the Ohio State University College of Medicine who works with trans youth.

“The absence of access to beneficial, evidence-based care, which does exist, is very harmful and quite frankly puts youth in the middle of political battles when lives are at stake,” said Leibowitz.

Trans issues are politically contentious in the United States, where the administration of President Donald Trump has banned most trans people from serving in the military. State-level battles have been waged over whether they can use restrooms of their choice.

Leibowitz recently co-wrote a statement condemning “efforts to ban evidence-based care” issued by the American Academy of Child & Adolescent Psychiatry, with nearly 10,000 members.

“This is no place for a legislators to lay in on what their opinion is,” he said.

An estimated 150,000 U.S. teens are trans, according to The Williams Institute, a research group at the University of California, Los Angeles, School of Law.

No public data was readily available on the numbers of younger trans children nor on patients at the nation’s nearly 50 clinics that treat trans youth.

Clinics in other countries have reported increases in referrals, which along with the greater visibility of trans people in the media, has prompted fierce debate over whether children who identify as trans may change their minds.

In the United States, Republican legislators in Texas, Georgia and Kentucky proposed banning gender reassignment treatment for minors following the court battle of a Texas father over how he and his ex-wife raise their 7-year-old child.

The parents disagree over whether the child can have long hair, wear girl’s clothes and go by a female name and pronouns.

Conservative politicians and commentators have sided with the father, and the Texas attorney general has asked for an investigation into possible child abuse.

Legislation to ban gender reassignment “would essentially be going against what is thought in the medical community to be best practice,” said Jennifer Abbott, a family doctor in North Carolina, who has treated trans youth.

“The evidence shows decreases in depression and anxiety in people who receive gender-affirming care,” she said.

Stewart Jones, the lawmaker behind the South Carolina bill, acknowledged that mental illness issues need to be addressed.

“However, to have a person under 18 go forth with that kind of life-altering decision while they’re still developing is a dangerous thing,” he said.

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It is well-known that blood pressure measured in the doctor’s office does not reflect a person’s regular blood pressure levels.

For this reason, about half of American adults are recommended to have their blood pressure measured outside of a clinical setting, according to a new study led by Paul Muntner, Ph.D., professor of epidemiology in the School of Public Health at the University of Alabama at Birmingham. The study found that approximately 104 million Americans should routinely use a blood pressure machine at home to provide backup for—or a contrast with—the results from their visit to the doctor’s office.

According to the study, nearly 93 percent of in adults the United States who have high blood pressure when measured in their doctor’s office and do not take blood pressure medicine should be screened for “white coat hypertension,” a condition where blood pressure spikes when measured at the doctor’s office, but is normal when measured outside of a medical setting. If someone has white coat hypertension, they may not benefit from starting antihypertensive medication.

Researchers also discovered that a third of U.S. adults should be screened for “masked hypertension,” which occurs when individuals do not have high blood pressure based on readings measured in their doctor’s office but do have high blood pressure readings when measured outside of the clinic.

“For some people, a doctor’s office is a place they’re relaxed,” Muntner said. “They are away from job stress, traffic and family issues. Others get anxious they are about to get bad news about their blood pressure—or something worse. Their readings in the doctor’s office cause concern, whereas measuring in a more familiar setting would cause less stress.”

Under the American College of Cardiology and American Heart Association guidelines, people are considered to have high blood pressure if their systolic, or top number, is 130 or higher and their diastolic, or bottom number, is 80 or higher.

In order to ensure people are accurately diagnosed with hypertension, Muntner says, at-home monitoring should be used. While it may seem expensive or tedious to take one’s blood pressure at home, it does not have to be.

Many pharmacies or grocery stores have blood pressure machines customers may use free. Home versions with an electronic inflatable cuff are also available at local drug stores for less than $50.

“The most important thing is to make sure the device has been validated,” Muntner said. “You should also talk to a doctor or a nurse about buying a device and have them teach you how to accurately measure your blood pressure at home.”

Muntner says you should take your blood pressure two times in the morning and two times in the evening for a week at a time. It is best to use a device that records the readings so you do not have to write the results down, and your doctor can see the data at your next appointment.

Ultimately, the most important objective of having people measure their blood pressure at home is to make sure doctors are treating people appropriately.

“Home blood pressure monitoring will better inform the physicians, as well as the patients,” Muntner explained. “That means physicians aren’t starting a patient on medication when they may not have high blood pressure. It also ensures doctors are starting treatment on patients who do have hypertension or are at risk for cardiovascular disease.”

The study was published in Hypertension, the journal of the American Heart Association.

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Some people go to the doctor and find the intake so nerve-wracking their blood pressure spikes. Others find the routine relaxing, as they’re asked to rest for a moment and breathe easy before a blood pressure cuff is wrapped around their arm.

People with borderline hypertension in both categories should confirm the readings by measuring their blood pressure outside their health care provider’s office, according to new research published Monday in the American Heart Association journal Hypertension.

Nearly 93 percent of U.S. adults who have high blood pressure when measured in their doctor’s office and don’t take blood pressure medicine meet the criteria for “white coat hypertension” because their blood pressure is in an acceptable range when re-measured outside a medical setting. Meanwhile, about a third of U.S. adults experience “masked hypertension” because their blood pressure levels measured outside of the doctor’s office are more problematic than measurements at the doctor’s office.

“For some people, a doctor’s office is a place they’re relaxed,” said Paul Muntner, an epidemiologist at the University of Alabama at Birmingham and the study’s senior author. “They are away from job stress, traffic and family issues.”

Others, he said, get anxious they are about to get bad news about their blood pressure – or something worse. Their readings in the doctor’s office cause concern whereas measuring in a more familiar setting would cause less stress.

In either case, the study used the American College of Cardiology and American Heart Association guidelines to determine that as many as 104 million Americans routinely should use a blood pressure machine at home to provide backup for – or a contrast with – the results from their visit to the doctor’s office. People are considered to have high blood pressure if their systolic, or top number, is 130 or higher and their diastolic, or bottom number, is 80 or higher.

Measuring blood pressure outside of a medical setting doesn’t have to be expensive or difficult.

Many pharmacies or grocery stores have blood pressure machines customers can use for free. Reliable home versions with an electronic inflatable cuff can be found at local drug stores for less than $50, and Muntner said the device should be one that already has been tested and validated.

Other options, such as ambulatory blood pressure machines, can be more involved. Those provide readings throughout the day and night and can flag hypertension while people are asleep.

But the sheer size of the population the study suggests should be measuring their blood pressure at home could make it a daunting task to achieve, said Dr. Raymond R. Townsend, who was not associated with the study.

“How many people would be well served by out-of-office blood pressure monitoring? My answer would be virtually anybody,” said Townsend, who heads up the high blood pressure program at the Hospital of the University of Pennsylvania in Philadelphia. “I think that’s a little ambitious.”

The study concedes there are barriers to widespread blood pressure monitoring at home: patient compliance, accuracy of the results, out-of-pocket costs of the device and the time needed to instruct patients on how to take their blood pressure.

What is not subject to debate is the importance of controlling hypertension. The consequences of unmanaged high blood pressure can include heart disease, stroke and organ damage.

And, Muntner said, the study makes a case that there is a benefit to getting more people to check their blood pressure on their own.

“For individual patients, hopefully it means people will be more engaged with their own health care and not just when they go to the doctor’s office.”

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In high-income countries like the U.S., the standard of care for people infected with HIV is to provide antiretroviral pills when the virus is found, even when there are no symptoms of AIDS. The strategy staves off the disease and has a second — big — benefit. It has been shown to prevent the spread of HIV in sexual encounters. It’s called “treatment as prevention” (TasP in medical jargon), or “test and treat.”

But in low-income countries, “test and treat” is not the typical approach to prevention. There has been no research to support it.

So 10 years ago, researchers began planning a massive study of treatment as prevention in South Africa and Zambia. The team came from the London School of Hygiene and Tropical Medicine, Imperial College and from several other institutions in the U.S., Zambia and South Africa.

When they started, they said, there was some doubt in the AIDS research community about whether the effort would be successful. “People didn’t think we could provide antiretroviral therapy in sub-Saharan Africa at all,” says study co-leader Richard Hayes of the London School of Hygiene and Tropical Medicine. “There was a lot of skepticism.”

Helen Ayles, from the same institution and a Zambian research organization called Zambart, hit the same resistance. “People said you’ll never get communities to test, and you’ll never get communities to want to start treatment early and if you do they’ll never stay on the treatment.” That attitude sprang partly from past struggles to get people to follow a regimen of daily drugs, in both developed and developing countries — and from local mistrust when foreigners arrive in low-income countries to carry out a health mission.

The study provided “test and treat” to communities containing a total of about 1 million people in South Africa and Zambia from 2013 to 2018. The $130 million project is called PopART (Population Effects of Antiretroviral Therapy to Reduce HIV Transmission).

The findings show that the practice could play a crucial role in controlling the AIDS epidemic.

“The results are fantastic,” says Ayles. “We managed to demonstrate you can reduce HIV incidence by 30 percent. That’s an amazing thing.”

“This is a landmark study,” says Judith Wasserheit, a longtime AIDS researcher and head of the Department of Global Health at the University of Washington, who was not involved in the research. “Getting communities to adopt an intervention and sustain it is one of the great challenges of global health.”

Details of the new trial were revealed at the Conference on Retroviruses and Opportunistic Infections in Seattle this spring and will be published soon. The findings are likely to be a big source of discussion at the global AIDS and HIV conference in Mexico City in July.

The scale of the trial was immense. Researchers began annual HIV testing in 14 communities of 50,000 or so people each in urban neighborhoods and towns in South Africa and Zambia. Community health workers went to people’s homes, talked to them about HIV and HIV prevention, distributed condoms and offered on-the-spot testing. Those who tested positive were offered free antiretroviral therapy. Another 300,000 or so were in the control group, which did not offer “test and treat.”

The study was funded by the U.S. government and the International Initiative for Impact Evaluation with support from the Bill and Melinda Gates Foundation (which is also a funder of NPR and this blog).

In half of the 14 communities where “test and treat” was the protocol, anyone found to be HIV-positive was offered treatment immediately. The results from these communities were not that impressive: a 7 percent drop in new HIV infections compared to communities in the control arm, where testing and treatment were sometimes available but not with the concerted, door-to-door outreach of the PopART approach.

In the other half of communities where “test and treat” took place, for the first few years treatment didn’t begin until an individual’s white blood cell counts fell below a certain level. (Partway through the study, those communities were switched to immediate treatment when national guidelines changed.)

In those seven “test and treat” communities, whose combined population was about 330,000, the incidence of new infections was 30 percent lower than in the control group communities.

“We showed it’s feasible and acceptable to deliver this kind of intervention in towns in sub-Saharan Africa,” says Hayes.

The new study does leave one major question — why was the drop only 7 percent in the group in which HIV-positive people received treatment right away as opposed to 30 percent in the other treated communities where treatment was initially delayed?

“My first reaction was that the statisticians had got it the wrong way around,” says Hayes. But four different statisticians repeated the analysis and got the same results. The PopART researchers are mining the data to try and understand the difference.

There are other findings to consider from the study. Its designers believed that community buy-in would be key to getting people to accept testing and treatment. So at the start of PopART, the researchers solicited community leaders to serve on advisory boards to oversee the project and help the researchers find and train 700-plus community members to serve as health care workers. The process, says Hayes, “was like mobilizing an army.”

The idea was that these community health workers, who understood their patients’ lives and languages, could make a difference. “What PopART has shown is how important local health workers can be,” says Maryam Shahmanesh, an associate professor at University College London and an HIV prevention and sexual health expert.

Rosemary Phiri, a Zambian with no medical training, found a listing for health workers while looking for a job in her local newspaper. She wound up overseeing 112 workers in the program and went out on community visits.

“It was an amazing experience for me,” says Phiri, now 34 years old. “At first people were not sure what was going on.” Testing centers existed in some of the towns already, but this was a door-to-door effort. “When people realized we were there to help them stop this terrible infection, they became so receptive,” she says. “They saw we were there for their own good.”

Myron Cohen, a professor at the University of North Carolina, calls the new study “a road map.” Cohen is a principal investigator in a worldwide collaboration of researchers who run clinical trials on AIDS interventions, including this one. Cohen had headed the study that in 2011 showed that intensive attention — frequent visits to the health center and counseling on risk reduction and the use of condoms — and antiretroviral drugs can stop transmission between partners when one is known to be HIV-positive.

PopART builds on Cohen’s findings and other efforts, including a major study in South Africa. That study showed that HIV transmission is less frequent in communities where treatment is available compared to similar communities where it is not, suggesting that HIV transmission could be controlled on a population level.

And in early June, a study of a single community in KwaZulu-Natal done by Doctors Without Borders showed that engaging patient groups, local health workers and political leaders encourages people to be tested and treated. The study provided preliminary evidence that widespread outreach could decrease the spread of HIV in a poor area.

The U.N. has set eliminating the public health threat of HIV as a goal for the year 2030. Is that possible? Cohen quickly says yes, if an adequate effort is made — if every HIV infected person can be found, started on treatment and persuaded to stay on treatment. PopART co-leader Richard Hayes hesitates before answering. “I think it can be done,” he finally says. “But I think it will be a real challenge.”

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