January/February 2019 - The Birds & The Bees Issue by Advocates for Better Health

Jan/February 2019

Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

The

Birds Bees

& Issue

In This Issue: • • • •

A Focus on Sexual Health 2019 TCMS Officers and New Board Members Nancy Guttormson, MD – First a Physician Award Luminary of Twin Cities Medicine

“Your patients will thank you for referring them to Dr. Crutchfield.”

A FAC E O F A M I N N E SOTA DE R M ATOL O GIST Recognized by physicians and nurses as one of the area’s leading dermatologists, Charles E. Crutchfield III MD has received a significant list of honors including the Karis Humanitarian Award from the Mayo Clinic, 100 Most Influential Health Care Leaders in the State of Minnesota (Minnesota Medicine), and the First a Physician Award from the Minnesota Medical Association, for positively impacting both organized medicine and improving the lives of people in our community. He has a private practice in Eagan and is the team dermatologist for the Minnesota Twins, Wild, Vikings and Timberwolves. Dr. Crutchfield is a physician, teacher, author, inventor, entrepreneur, and philanthropist. He has several medical patents, has written a children’s book on sun protection, and writes a weekly newspaper health column. Dr. Crutchfield regularly gives back to the Twin Cities community including sponsoring academic scholarships, camps for children, sponsoring programs for children with dyslexia, mentoring underrepresented students from the University of Minnesota, and establishing a Dermatology lectureship at the University of Minnesota in the names of his parents, Drs. Charles and Susan, both pioneering graduates of the U of M Medical School, class of 1963. As a professor, he teaches students at both Carleton College and the University of Minnesota Medical School. He lives in Mendota Heights with his wife Laurie, three beautiful children and two hairless cats.

AES

THET I C

L OF APPROVA L SEA

CRU TCHFIELD DERMATOLO GY

CRUTCHFIELD DER MATOLOGY Experience counts. Quality matters. Mayo Clinic Medical School Graduate | University of Minnesota Dermatology Trained Top Doctor Minneapolis St. Paul Magazine | Best Doctors for Women Minnesota Monthly Magazine Team Dermatologist for the Minnesota Twins, Vikings, Timberwolves and Wild 1185 Town Centre Drive, Suite 101, Eagan | 651.209.3600 | www.CrutchfieldDermatology.com

CONTENTS VOLUME 21, NO. 1 JANUARY/FEBRUARY 2019

IN THIS ISSUE

Promoting Sexual Health By Thomas E. Kottke, MD

PRESIDENT’S MESSAGE

I’m a Proud Member of This Organization. How About You? By Ryan Greiner, MD

TCMS IN ACTION

By Ruth Parriott, MSW, MPH, CEO Page 14

PROMOTING SEXUAL HEALTH

•

HPV Vaccination: Safe, Effective Cancer Prevention By Pamela Niksich, MD, MPH

•

STDs/HIV in Minnesota and New Tools to End the HIV Epidemic By Mariah Wilberg, Jared Shenk, and Dawn Ginzl

•

SPONSORED CONTENT:

Primary Care Taking Action to Prevent Unintended Adolescent Pregnancies By Shannon Neale, MD, Jamie Lyn Reinschmidt, MD, and Juliana Tillema, MPA, PMP

Page 28

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The Intrauterine Contraceptive Device: The Rising Star of Birth Control By Rebekah Ormsby, MD

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Conversion Therapy: Time for Action By Kevin O’Donnell and James Pathoulas

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Tobacco Marketing to the LGBTQ Community By Adam Kintopf, Gabriel Glissmeyer, Laura Henry, and Betsy Brock

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Environmental Health —Intersections of Reproductive Health and Environmental Justice By Sarah Traxler, MD, MS, FACOG

Page 5

Nancy Guttormson, MD Receives First a Physician Award/ Senior Physicians Association

Physician Advocacy Network: Their Biggest Year Yet

Jan/February 2019

Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

The

Birds Bees

& Issue

Honoring Choices Celebrates a Banner Year!

Page 32 MetroDoctors

Caring Hearts Annual Supply Drive/ In Memoriam

31 32

Career Opportunities LUMINARY OF TWIN CITIES MEDICINE

June LaValleur, MD

The Journal of the Twin Cities Medical Society

In This Issue: • A Focus on Sexual Health • 2019 TCMS Officers and New Board Members • Nancy Guttormson, MD – First a Physician Award • Luminary of Twin Cities Medicine

HPV, STD, HIV, and more. Our authors discuss prevalence, prevention and treatments to keep our patients healthy. Articles begin on page 6. January/February 2019

Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Physician Co-editor Peter J. Dehnel, MD Physician Co-editor Thomas E. Kottke, MD Physician Co-editor Robert R. Neal, Jr., MD Physician Co-editor Marvin S. Segal, MD Physician Co-editor Richard R. Sturgeon, MD Physician Co-editor Charles G. Terzian, MD Medical Student Co-editor Mac Garrett Medical Student Co-editor James Pathoulas Managing Editor Nancy K. Bauer Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Annie Krapek MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, Broadway Place West, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, Broadway Place West, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com. For advertising rates and space reservations, contact: Betsy Pierre phone: (763) 295-5420 e-mail: betsy@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Nancy Bauer at (612) 623-2893.

January/February 2019

January/February Index to Advertisers

TCMS Officers

President: Ryan Greiner, MD President-elect: Sarah Traxler, MD Secretary: Andrea Hillerud, MD Treasurer: Rupa Polam Austria, MD Past President: Thomas E. Kottke, MD At-large: Matthew A. Hunt, MD

Crutchfield Dermatology..................................... Inside Front Cover

TCMS Executive Staff

Entira Family Clinics .......................................31

Ruth Parriott, MSW, MPH, CEO (612) 362-3799; rparriott@metrodoctors.com

Fairview Health Services .................................31

Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com Karen Peterson, Executive Director, Honoring Choices Minnesota (612) 362-3704; kpeterson@metrodoctors.com Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com Trish Greene, Administrative Specialist, Honoring Choices Minnesota (612) 362-3705; tgreene@metrodoctors.com

HealthPartners...................................................... 8 Minnesota Department of Health ...............15 MMA–Achieving Health Equity ..................17 University of Minnesota Health ........................ Outside Back Cover U.S. Army .................................................................

Amber Kerrigan, Project Coordinator, Physician Advocacy Network (612) 362-3706; akerrigan@metrodoctors.com

Inside Back Cover

Annie Krapek, Program Manager, Physician Advocacy Network (612) 362-3715; akrapek@metrodoctors.com

NEED HELP? Feeling overwhelmed and turning to alcohol and/or drugs for relief?

Physicians Serving Physicians is an independent, physician-centric organization that was established in 1981 by a group of physicians in recovery to help other physicians and their families struggling with chemical dependency. The core of PSP’s mission is to provide active help and service to physicians (including residents), medical students and their family members affected by alcohol and drug addiction.

Physicians Serving Physicians can help! For confidential assistance: • Call: (612) 362-3747; email: psp@metrodoctors.com • Jeffrey Morgan, MD, Interim Medical Director, (612) 267-8912 • Psp-mn.com

MetroDoctors

The Journal of the Twin Cities Medical Society

IN THIS ISSUE...

Promoting Sexual Health

lthough the cover art we’ve chosen for this issue is playful and lighthearted, the need to promote sexual health is anything but. In a period when access to sexual health services and accurate sexual health information are at risk, it falls to physicians to ensure that all of our patients — women, men and even children — have access to the information and services which allows them to lead full and productive lives. You say “children”? Yes. In her article on human papilloma virus (HPV), Dr. Pamela Niksich writes that nearly half of all HPV cancers are oropharyngeal cancers in men. HPV cancers can be prevented by immunizing both boys and girls before their first sexual encounter. Start education at 9 years of age and focus on cancer prevention and safety rather than sexual issues. Not too many years ago, intercourse with an HIV-positive partner was a recipe for untimely death. Campaigns like U=U (Undetectable = Untransmittable) made this history. However, as our colleagues from the Minnesota Department of Health remind us, HIV is only one of many STIs, and all require our full attention because they aren’t going away on their own. When I was coming of age, “prep” was a type of school. Now “prep” is Pre-Exposure Prophylaxis (PrEP), a pill taken daily by individuals who engage in high risk behaviors, markedly reducing HIV infections. Julia Stumpf and Dr. Ketzela J. Marsh write about Youth and AIDS Projects (YAP) and other PrEP programs at the University of Minnesota protecting our patients from HIV-AIDS. One attribute of outstanding physicians is an unwavering commitment to patients. Dr. Carol Ball spent her career meeting the needs of women while other physicians stood by. In her Colleague Interview, Carol identifies the many red-flag threats to sexual health services. I believe you’ll be inspired by her interview. Although teen birth and abortion rates are at historic lows, the rates should and could be far lower. HealthPartners has developed a comprehensive program to offer same-day contraception services including long acting reversible contraception (LARC). Drs. Shannon Neale and Jamie Lyn Reinschmidt, By Thomas E. Kottke, MD Member, MetroDoctors Editorial Board

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along with Juliana Tillema, describe the many issues they considered when implementing this very positive program. What do the American Medical Association, American Academy of Pediatrics, American Psychological Association, the American Counseling Association and the Minnesota Medical Association have in common? They’ve all denounced conversion therapy. Read more about this “therapy” in the article by Kevin O’Donnell and James Pathoulas, both University of Minnesota medical students. The LGBTQ+ community has not escaped the attention of the tobacco industry. In a fascinating article on marketing tactics, local advocates describe the tobacco industry’s predatory practices. We cannot, with good conscience, let this targeting continue, and when we have LGBTQ+ patients who use tobacco or nicotine products, we are obligated to offer help. On the whole, US birth outcomes are embarrassingly poor and, African American mothers and their babies fare even worse. Sarah Traxler, TCMS President-elect and Chief Medical Officer of our region’s Planned Parenthood, carefully documents the evidence that environmental toxics may be contributing to African-American preterm birth, low birth weight, and maternal morbidity. We need action. MetroDoctors customarily closes each issue with the biography of a Luminary. Consistent with our theme of promoting sexual health, Dr. June LaValleur is our subject. I first met June about 25 years ago when we both served on a work group addressing breast and cervical cancer screening, but I had no idea that June had contributed so much to our community until I read her biography. I think that you’ll be wowed, too. That’s the issue in a nutshell, but don’t stop with the shorthand version. Read this issue of MetroDoctors cover to cover, and when you are done, recommit yourself to serving the sexual health needs of all members of our community. We will all be better for it. January/February 2019

President’s Message

I’m a Proud Member of This Organization. How About You? RYAN GREINER, MD

As the new president of the Twin Cities Medical Society (TCMS), I am humbled to be joining a long succession of physician leaders who are passionate about organizing for the good of our patients and communities. TCMS is a thriving and vibrant community that values diversity, inclusiveness, community engagement, and advocacy. We had an amazing year under the leadership of outgoing president Dr. Thomas Kottke. Dr. Kottke is a recognized luminary in public health advocacy and his dedication to gun violence prevention, tobacco control, sexual health, and environmental health advocacy has placed the society front and center on important issues that impact the communities we serve. We were proud to see him recognized at the Minnesota Medical Association’s (MMA) Annual Meeting with their distinguished President’s Award. We are grateful for his ongoing commitment to the board of directors and anticipate his continued leadership in shaping the advocacy platform for the medical society. 2018 has been a year of change and progress. We welcomed our new CEO, Ruth Parriott. She brings an extensive repertoire of experience and skills to the position and we have the highest confidence in her capabilities to lead us into the next phase of our growth. The staff at TCMS have been exceptionally welcoming and supportive of Ruth and the board of directors would specifically like to thank Nancy Bauer for her thoughtful and skilled management during the transition. The society is fortunate to have such a dedicated group of professionals supporting the work that has been so impactful to our physicians and communities. Our programmatic offerings continue to engage physicians around the issues that impact the health and wellbeing of their communities. Honoring Choices Minnesota (HCM), our Advance Care Planning program, celebrated its 10th year in 2018. With Ken Kephart, MD as its medical director and Karen Peterson as Executive Director, HCM continues to be one of TCMS’s most recognized and impactful programs. The Physician Advocacy Network (PAN), under the leadership of Peter Dehnel, MD and Annie Krapek, Program Manager, has successfully supported the passage of Tobacco 21 ordinances in 20 (soon to be 21) communities and continues to be a leading partner in the efforts to reduce the impact of e-cigarettes and other tobacco products on the health of our communities. The PAN also kicked off the Dr. Pete Dehnel Public Health Advocacy Fellowship, engaging 11 medical students interested in advocacy opportunities. Finally, the Convenings was developed from a grassroots partnership between Honoring Choices Minnesota, TCMS, and Cathy Wurzer, representing the Bruce H. Kramer Collaborative, to inspire people to think about and discuss their choices for living and dying well. The Convenings was made possible by partnerships with Allina Health, HealthPartners, and KARE-11, and is now launching as an independent nonprofit organization with the new name “End in Mind.” We anticipate ongoing success in advancing these important conversations. Twin Cities Medical Society has an exciting year ahead of us. The society has assumed the management of Physicians Serving Physicians (PSP), a program serving physicians with substance abuse challenges since 1981. We are partnering with local healthcare organizations to expand the services provided under the PSP banner so that a broader range of physicians can access confidential support as they face the stressors of medical practice. The Minnesota Medical Association is refocusing its efforts on engagement through a new task force charged with finding new and better ways to serve Minnesota physicians. TCMS envisions this task force as a way to strengthen our organization through a stronger partnership with them. We also plan to find new and innovative ways to partner with other component medical societies across the state. Our core focus remains on our physician members and the communities in which they work. We need your engagement to be successful. We invite your ideas, your comments, and your leadership. Please reach out to us — we are looking for your voice.

January/February 2019

MetroDoctors

The Journal of the Twin Cities Medical Society

TCMS IN ACTION RUTH PARRIOTT, MSW, MPH, CEO

New Leaders Get Right to Work!

At the final board meeting of 2018, the TCMS Board of Directors unanimously approved the nominated slate of officers for 2019. Ryan Greiner, MD, Medical Director-Hospital Medicine at North Memorial Health Hospital, assumed the presidency as Dr. Thomas Kottke, Associate Medical Director, Well-Being, of HealthPartners moved into the immediate past-president position. We are thrilled that Dr. Sarah Traxler, Medical Director of Planned Parenthood Minnesota, North Dakota, South Dakota, accepted the title of president-elect, where she’ll be supported by continuing secretary Dr. Andrea Hillerud, Family Medicine with HealthPartners, and incoming treasurer Dr. Rupa Polam Austria, Pain Medicine specialist at Fairview Ridges Specialty Clinics. Past-president Dr. Matthew Hunt, Associate Professor and Resident Program Director, Department of Neurosurgery at the University of Minnesota, graciously agreed to continue his service on the executive committee as an at-large representative so the new leaders (including this CEO!) can continue to benefit from his experience.

Ryan Greiner, MD

Sarah Traxler, MD

Andrea Hillerud, MD

Rupa Polam Austria, MD

Thomas Kottke, MD

Occupational and Environmental Medicine with HealthPartners, Dr. Kristin Lyerly, Gynecologic Surgery, Maple Grove OB/GYN, and Dr. Matthew Kruse, Forensic Psychiatry at Anoka-Metro Regional Treatment Center. The new directors are moving into a big footprint as Dr. Frank Rhame left the board upon fulfilling his three terms of service as a director. Dr. Rhame’s nationally renowned infectious disease expertise provided a unique perspective and he will continue to offer leadership in other roles. Please join me in congratulating and thanking each of these physicians for their dedication to organized medicine. The board wasted no time in launching into a discussion of recent gun violence mass murders around the country, as well as the daily toll of gun-related injuries, murders, and suicides that plague Minnesota. The board committed to keeping our membership apprised of the ways in which Twin Cities physicians can lend their voice to public discussions and policy debates as community leaders grapple with the challenge of this public health epidemic. One immediate idea is to join the Health Care Coalition to Prevent Gun Violence, administered by Protect Minnesota. Simply text “orange health” to 474747 to add your name and be kept informed of activities targeted to our state. TCMS will also do our best to promote awareness and action through our social media outlets. Follow Twin Cities Medical Society on Facebook and Twitter @TCMSMN. Senior Physicians Association

Matthew Hunt, MD

In addition, three new directors were elected who bring broad experience to the board: Dr. Zeke McKinney, MetroDoctors

The SPA winter meeting will be held January 15, 2019 featuring Dr. Jakob Tolar, Dean, UMN Medical School; see related announcement on page 28.

The Journal of the Twin Cities Medical Society

It’s Not Too Late–Donate Today!

Inspiring the next generation of physician advocates is the theme of the 2018-19 Twin Cities Medical Society Foundation giving campaign while also supporting access to health care. Contributions to TCMSF can be made online through PayPal www.paypal.me/ tcmsf, or send a check directly to TCMS Foundation, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413. Health Careers Program at Roosevelt High School

Last fall, students at Roosevelt High School (Minneapolis) received first-hand information about health careers from five TCMS physicians, each describing their journey through medical school, residency and their specialty experiences.

Thank you to the following speakers: Milton Datta, MD (pictured above); Bruce Gregoire, Medical Student; Ann McIntosh, MD; Carolyn McClain, MD; and Erica Ting, MD. Interested in participating in 2019? Physicians in all specialties are sought; your 50-minute presentation will describe your journey to medicine and why you chose your career path. Contact Nancy Bauer at (612) 623-2893; nbauer@metrodoctors.com for more information. January/February 2019

Promoting Sexual Health

HPV Vaccination: Safe, Effective Cancer Prevention

uman Papillomavirus (HPV) is a group of more than 150 related viruses, spread primarily through vaginal, anal, and oral sex. It is the most common sexually transmitted infection and an estimated six million Americans become infected every year. Those affected are often asymptomatic, or symptoms may develop years after the virus was contracted. Most sexually active individuals will contract HPV at some point in their lifetime, though most of these will be subclinical or unrecognized infections. An increased risk occurs with multiple sexual partners and in men who have sex with men. Condoms, while crucial, provide incomplete protection against HPV transmission. About 75% of the HPV types cause common warts on the skin, while other types are found mainly on the bodyâ&#x20AC;&#x2122;s mucus membranes, including the vagina, anus, mouth, and throat. Papillomas (warts) in these areas are often caused by low-risk HPV types that rarely cause cancer, but HPV types 16 and 18, in particular, are high-risk and can cause cancer in both men and women. In women, cervical cancer is the most common cancer linked to HPV, and 70% of these are due to types 16 and 18. Through a routine Pap smear and HPV testing, cervical dysplasia and cancer can often be found early and addressed. Vulvar and vaginal cancers also occur. In men, the most common HPV-related cancers are oral cancers. Despite a By Pamela Niksich, MD, MPH

January/February 2019

decrease in tobacco use over the past two decades, the incidence of oropharyngeal cancer in men has begun to rise, in large part due to HPV associated cancers. Cohort studies from the 1990s suggested that approximately 50% of oropharyngeal cancers were attributable to HPV, while more recent studies suggest that HPV now accounts for 70 to 80% of cases in North America and Europe. The timing between exposure to HPV and the development of oropharyngeal cancer probably exceeds 10 years. There is no standard screening procedure to find these cancers early, or to look for the presence of HPV on oral mucosa. Many of these oral cancers are found incidentally during routine exam by a doctor, dentist, or dental hygienist. HPV also causes penile cancer, many of which start under the foreskin of the penis and

may be difficult to detect early. It can cause cancer of the anus in both men and women, though it is more common in HIV-positive individuals and in men who have sex with other men. Anal cytology testing, akin to a Pap smear to screen for cervical cancer, may be indicated for these populations. Annually, over 31,500 HPV attributable cancers are diagnosed in the United States, and over one-third of these are diagnosed in men. Approximately 4,100 women will die in 2018 from cervical cancer. Most HPV infections that lead to cancer can be prevented by vaccination before sexual debut. Since introduction of the HPV vaccine 10 years ago, infection with the HPV types that cause most genital warts and cancers have dropped 71% in teen girls. The HPV vaccine was FDA approved for females in 2006 and for males in 2010, and ACIP recommended HPV vaccine as a routine childhood vaccine in 2007 for females and and in 2011 for males. However, vaccine acceptance in the US has been slow, and in 2016, 50% of females and 38% of males had completed the vaccine series. This is well below the Healthy People 2020 goal of 80% vaccine series completion, and the HEDIS goal of two HPV vaccines before age 13 for both boys and girls. Nine-valent HPV vaccine helps to prevent disease caused by HPV types 6, 11, 16, 18, 31, 33, 45, 52, & 58. Two doses of the vaccine, separated by at least five months, are routinely recommended and given at age 11-12 years of age. The

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vaccine is licensed for administration at age 9-26 years, but it is important to note that the immune response to the vaccine is most robust in the preteen population, and the vaccine can only provide protection against the nine included strains if it is given before exposure to those strains. Three doses of HPV vaccine (rather than two) are required if the HPV series is initiated after age 15 years, if the patient is immune compromised, or if dose two was given less than five months after dose one. Common, mild side effects after vaccination include headache, fever, nausea, dizziness, and localized pain or redness. Fainting after any vaccine, not just HPV, is more common among teens, and the patient may be encouraged to use distraction and calming techniques, and to lie down for vaccine administration and remain that way for a few minutes afterward. As with any medication or injection, an allergic reaction is possible but not likely, and patients may be monitored for side effects for 15 minutes after injection before leaving the clinic. Strong, high quality provider recommendation has been shown to be a key factor in acceptance of HPV vaccination. Provider recommendation to receive the vaccine has increased over the years since its introduction, but its endorsement may be affected by assumptions about parent concerns. A study published in the Journal of Adolescent Health in November, 2018 examined the reasons given by parents for not vaccinating children of both genders, age 13-17, from all 50 states and the District of Colombia. In girls, in 2010 when the vaccine was introduced and still in 2018, the top two reasons given for refusing the vaccine were concern over safety and side effects, and a perceived lack of vaccine MetroDoctors

necessity. In boys, the top two concerns were perceived lack of necessity and that the vaccine was not recommended by a provider. Understanding parents’ reasons for lack of HPV vaccination is critical to empowering providers to strongly recommend the vaccine and be open to discussing parents’ concerns. Doing this is likely to improve vaccine uptake at the appropriate age for maximal effectiveness. Pediatricians and general practitioners who feel they must discuss sexuality prior to recommending the vaccine tend to deliver weaker or less frequent recommendations. It’s important to note that a focus on sexuality or sexual debut is not generally congruent with parents’ top concerns (safety and necessity of vaccination), and it may be helpful to shift the discussion to one of cancer prevention and safety rather than sexuality and sexual activity. The Minnesota Department of Health has created a series of short videos for providers regarding HPV vaccine communication. This can be found by entering “MDH HPV video” into any common search engine. Occasionally concerns of vaccine cost are raised by a patient or parent. The HPV vaccine is covered by primary insurers and the VFC program. Merck, the manufacturer of Gardasil, also has a patient assistance program for patients age 19-26 without insurance who cannot afford the vaccine. In summary, HPV infection is the most common sexually transmitted infection and causes significant illness in the form of papillomas and cancer in both genders, and is the leading cause of oropharyngeal cancer in men and cervical cancer in women. HPV education should be part of sexual health education for patients beginning at age

The Journal of the Twin Cities Medical Society

9-10 years, and the vaccine should be strongly endorsed and encouraged as part of routine vaccine administration at age 11-12 years along with TdaP and meningococcal vaccine. The vaccine has been very successful in decreasing the prevalence of cancer-causing strains of HPV, and focusing on cancer prevention and safety of the vaccine can be a very effective way to present this information to parents. Resources are available for providers who would like to become more comfortable discussing this with parents and pre-teens. Pamela Niksich, MD, MPH is a pediatrician with Partners in Pediatrics at the Brooklyn Park clinic. She completed her medical degree and public health degree at the University of Michigan in Ann Arbor, and pediatric residency training and a chief resident year at Washington University in St. Louis. She has been a pediatrician in the Twin Cities since 2003 and has a particular interest in the care of premature infants, developmental and behavioral pediatrics, and adolescent mental health. She can be reached at pamela. niksich@childrensmn.org or in clinic at (763) 425-1211. References: 1. Nadja A. Vielot, Anne M. Butler, et al. Patterns of Use of Human Papillomavirus and Other Adolescent Vaccines in the United States. J Adol Health 61 (2017), p. 281-287. 2. Anna Beavis; Melinda Krakow,, et al. Reasons for Lack of HPV Vaccine Initiation in NIS-Teen Over Time: Shifting the Focus from Gender and Sexuality to Necessity and Safety. J Adol Health 63 (2018), p. 652-656. 3. Joel M. Pafelsky, J. Thomas Cox. UpToDate Patient Education: Human Papillomavirus (HPV) Vaccine, Beyond the Basics. (2018). 4. Centers for Disease Control website. HPV information for Clinicians. Accessed October 2018 at https://www.cdc.gov/hpv/hcp/index. html. 5. Preidt, Robert. The Real Reasons Parents Refuse HPV Vaccination. HealthDay, October 30, 2018.

January/February 2019

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STDs/HIV in Minnesota and New Tools to End the HIV Epidemic Healthcare providers play a vital role in responding to HIV and STDs in Minnesota. This article describes the incidence, prevalence and prevention strategies and ways in which you can help. A New Era of HIV Prevention There are more options for preventing HIV than ever before. Two recent advancements are using HIV treatment to prevent sexual transmission of HIV and pre-exposure prophylaxis (PrEP), a daily pill that prevents HIV. When taken as prescribed, HIV medications reduce the amount of HIV in blood, or viral load, to undetectable levels. This allows people living with HIV to live long and healthy lives, and we now have evidence that being undetectable prevents sexual HIV transmission. Several large studies among couples showed zero HIV transmissions from a person with undetectable HIV to their HIV-negative sex partner. These results led to the creation of the Undetectable = Untransmittable (U=U) campaign, which convey the consensus that people living with HIV who get and stay undetectable have effectively no risk of sexually transmitting HIV. Minnesota was the third state to join the U=U campaign in October 2017, just weeks after the CDC issued a Dear Colleague Letter1 endorsing the effectiveness of HIV treatment as prevention. For more By Mariah Wilberg, Jared Shenk and Dawn Ginzl MetroDoctors

Mariah Wilberg

Jared Shenk

information see HIV Undetectable = Untransmittable (U=U) Information for Providers (www1.nyc.gov/site/doh/ providers/health-topics/hiv-u-u.page). PrEP is another new HIV prevention strategy where HIV-negative people take HIV medication daily to prevent HIV from establishing an infection after exposure. Currently, Truvada© is the only FDA-approved medication for PrEP. Any healthcare provider with prescribing privileges can prescribe PrEP. It is indicated for people with an increased risk of acquiring HIV, including men who have sex with men, people whose sex partner(s) are living with HIV, people with a recent bacterial STD, people who exchange sex for money or goods, people who inject drugs, and people living in communities with high rates of HIV. For more information, see HIV PrEP for the Primary Care Provider (https:// denverptc.org/hivprepvideo.html). How You Can Help You can make a difference by educating

The Journal of the Twin Cities Medical Society

Dawn Ginzl

all patients about sexual health, talking about sexual risks, completing sexual health histories, providing the necessary screenings and treatments per CDC guidelines, getting infected patient’s partners in for testing, and prescribing PrEP when indicated. Please be sure to report all lab-confirmed cases of chancroid, chlamydia, gonorrhea, and syphilis; presumptive and confirmed cases of HIV; and any reportable disease during pregnancy (even if the patient has been previously reported) to the Minnesota Department of Health as required by state statute.2 HIV Infection in Minnesota HIV incidence and prevalence remain moderately low in Minnesota. In 2016, Minnesota’s HIV infection rate was 6.2 per 100,000; slightly less than the Midwest HIV infection rate of 7.5 per 100,000.

(Continued on page 10)

January/February 2019

Promoting Sexual Health STDs/HIV in Minnesota (Continued from page 9)

Figure 1

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Number of Persons Living w/ HIV/AIDS

As of December 31, 2017, a cumulative 11,598 HIV cases had been reported in Minnesota since 1985, and 8,789 people were living in Minnesota with a diagnosed and reported HIV infection. Since the introduction of Highly Active Antiretroviral Therapy (HAART) in 1996, deaths among people living with HIV have significantly decreased, from a high of 318 in 1994 to 73 in 2017. In general, HIV prevalence increases more than incidence per year in Minnesota, because more people living with HIV move to Minnesota than leave for other states or die. Figure 1 shows cumulative HIV/AIDS diagnoses, numbers of people living with diagnosed HIV infections, and deaths from 1996-2017 in Minnesota. HIV infection disproportionately affects some populations in Minnesota. In 2017, Minnesotans of color made up 66% of new diagnoses, but accounted for only 17% of the state’s population in the 2010 census. African-American and African-born Minnesotans were particularly impacted, making up 27% and 21% of new infections in 2017, respectively, while both groups made up 5% of Minnesota’s total population. Male-to-male sexual contact (MSM) remains the predominant mode of exposure to HIV reported since 1985. In 2017, MSM accounted for 47% of new HIV infections with an incident rate of 150.0 per 100,000, compared to a statewide rate of 5.3 per 100,000. HIV incidence also disproportionately affects younger populations, with nearly 40% of new diagnoses in 2017 among Minnesotans under 30 years old. For more information, see HIV/

Number of New HIV/AIDS Cases and Deaths

New HIV Diagnoses, Deaths and Prevalent Cases by Year, 1996-2017

Year **

Includes all new cases HIV infection (non-AIDS) and AIDS at first diagnosis) diagnosed within a given calendar year. Includes allofnew cases(both of HIV HIV infection (both HIV (non-AIDS) and AIDS at first ^ Deaths in Minnesota among people with HIV/AIDS, regardless of location of diagnosis and cause.

diagnosis) diagnosed within a given calendar year. Deaths in Minnesota among people with HIV/AIDS, regardless of location of diagnosis and cause.

AIDS Surveillance (www.health.state. mn.us/divs/idepc/diseases/hiv/stats/index.html). Sexually Transmitted Diseases (STDs) in Minnesota Although overall incidence rates for STDs in Minnesota are lower than in many other areas of the United States, certain population subgroups in Minnesota have very high STD rates. Specifically, STDs disproportionately affect adolescents, young adults, and people of color. STD rates are highest in the cities of Minneapolis and Saint Paul. However, chlamydia and gonorrhea cases in the Twin Cities suburbs and Greater Minnesota account for 62% of the reported cases in 2017. Figure 2 shows rates of chlamydia, gonorrhea, and primary and secondary syphilis in Minnesota from 2007-2017.

population) were reported, representing a 4% increase from 2016. Adolescents and young adults are at highest risk for acquiring a chlamydia infection. The chlamydia rate is highest among 20 to 24-year-olds (2,424 per 100,000). The chlamydia rate among females (574 per 100,000) is nearly twice the rate among males (311 per 100,000), a difference most likely due to more frequent screening among females. Chlamydia infection incidence is highest in communities of color. The rate among blacks is 10 times higher than the rate among whites. Although blacks comprise approximately 5% of Minnesota’s population, they account for 24% of reported chlamydia cases. Rates among Asian/Pacific Islanders, Hispanics, and American Indians are over two to five times higher than the rate among whites.

Chlamydia Chlamydia trachomatis infection is the most commonly reported infectious disease in Minnesota. In 2017, 23,528 chlamydia cases (444 per 100,000

Gonorrhea Gonorrhea is the second most commonly reported STD in Minnesota. In 2017, 6,519 cases (123 per 100,000 population) were reported. This is the highest

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Figure 2

For more information, see STD Statistics and Reports (www.health.state. mn.us/divs/idepc/dtopics/stds/stats/ index.html). Mariah Wilberg is a Communication Specialist for the Minnesota Department of Health and has worked in HIV education and prevention for over five years. She holds an undergraduate degree in Individualized Studies focusing on Social Welfare and is currently pursuing a Master of Public Administration from Metropolitan State University. reported rate of gonorrhea in the last decade. Adolescents and young adults are at greatest risk for gonorrhea with rates of 491 per 100,000 among 20 to 24-year olds. Gonorrhea rates for males (136 per 100,000) were higher than females (110 per 100,000). Communities of color are disproportionately affected by gonorrhea. The incidence of gonorrhea among blacks is 20 times higher than the rate among whites. Rates among Asian/ Pacific Islanders, Hispanics, and American Indians are up to 13 times higher than among whites. Syphilis Surveillance data for primary and secondary syphilis are used to monitor morbidity trends because these represent recently acquired infections. Data for early syphilis includes primary, secondary, and early latent stages of disease.

Primary and Secondary Syphilis In 2017, there were 292 cases of primary/secondary syphilis in Minnesota (5.5 cases per 100,000 persons). This MetroDoctors

represents a 5% decrease compared to the 306 cases (5.8 per 100,000) reported in 2016. Primary and secondary syphilis rates are highest in communities of color. The rate among blacks is six times higher than the rate among whites. Rates among Asian/Pacific Islanders, Hispanics, and American Indians are two to 14 times higher than the rate among whites. Early Syphilis In 2017, the number of early syphilis cases increased by 8%, with 605 cases, compared to 557 cases in 2016. The incidence remains highly concentrated among men who have sex with men (MSM). Of the early syphilis cases in 2017, 511 (84%) occurred among men; 426 (70%) of these were MSM; 46% of the MSM diagnosed with early syphilis were co-infected with HIV. However, the number of women reported has continued to increase from 2012.

Jared Shenk is an HIV Epidemiologist at the Minnesota Department of Health and has worked in various areas of the HIV field since 2004. He holds undergraduate degrees in Health Sciences and Finance from James Madison University and a Master of Public Health in Epidemiology from the University of Minnesota. Dawn Ginzl is an STD Epidemiologist at the Minnesota Department of Health and has 17 years of experience in infectious disease and STD epidemiology. She holds an undergraduate degree in Business Administration and a Master of Public Health in Epidemiology and Biostatistics from the University of Southern California. (Endnotes) 1. Centers for Disease Control and Prevention. (2017, September 27). Dear colleague: September 27, 2017. Retrieved from https://www.cdc. gov/hiv/library/dcl/dcl/092717.html. 2. Minnesota Department of Health. (n.d.) Frequently asked questions about STD and HIV reporting. Retrieved from http://www.health. state.mn.us/divs/idepc/dtopics/stds/frequentlyasked.html.

Congenital Syphilis Two congenital syphilis cases were reported in 2017.

The Journal of the Twin Cities Medical Society

January/February 2019

Sponsored Content

A Comprehensive PrEP Program for Youth Contributed by Julia Stumpf and Ketzela J. Marsh, MD, MS

According to the Centers for Disease Control (CDC), an estimated 1.1 million individuals in the United States (US) were living with HIV in 2015.1 Furthermore, about 1 in 7 was not aware of their infection. Despite rapid advances in anti-retroviral therapy (ART) and a focused effort on using treatment as a prevention tool, annual new HIV transmission rates are not declining fast enough. Between 2011 and 2015, the CDC reports, the US experienced only a 5% rate decrease. Therefore, HIV prevention programming remains a major priority. In this article, we highlight youth as a group that is particularly HIV-vulnerable, describe pre-exposure prophylaxis (PrEP), and explain why a youth-focused comprehensive program is needed. The University of Minnesota-affiliated Youth and AIDS Projects (YAP) has partnered with the University of Minnesota Health Delaware Infectious Disease Clinic to offer a comprehensive HIV prevention program for youth that includes PrEP. We offer a description of the PrEP Program as an example of an integrated care approach that targets youth. Youth Are a Key Population

In the US, certain key populations are disproportionately affected by HIV. Notably, gay, bisexual, and other men who have sex with men (MSM) represented 67% of new infections reported in the US from 20112016.1 In that same period, injection drug users represented 9%, and youth (ages 12

January/February 2019

has been shown to reduce the risk of HIV infection in high-risk populations, lowering it by up to 92% for those at risk via sexual transmission and by 70% for injection drug users.3 In May 2018, the FDA approved a revision to the Truvada labeling to expand the indications for PrEP to include adolescents weighing at least 35 kg. Despite the proven efficacy of Ketzela J. Marsh, MD, MS Julia Stumpf PrEP, the most HIV-vulnerable populations are not accessing it. In 2017, for instance, only about 12% of current 13-24) accounted for 22% of all new infecPrEP users were under the age of 25.4 Retions. Within the latter group, young men searchers and community programs alike who have sex with men (YMSM) of color have identified a variety of factors that were at the highest risk. Between the years may be interfering with key populationsâ&#x20AC;&#x2122; of 2015-2017, the Minnesota Department access to PrEP. These individuals may be of Health reported 152 cases of new HIV concerned about HIV stigma and what diagnoses in young men. Of these, 44% people will think if they know they are were Black and 12% were Hispanic. Taken taking PrEP. They may not want family together, these cases represented a total of or friends to become aware of their risk 18% of the new diagnoses in Minnesota.2 behaviors nor draw more attention to Pre-Exposure Prophylaxis (PrEP) their HIV risk. Identifying the appropriWhile clinics and health initiatives have ate healthcare setting may be challenging, implemented many educational and beespecially for those experiencing homelesshavioral interventions, curtailing high-risk ness. There may be financial and logistical sexual behavior and needle sharing among barriers, such as lack of health insurance injection drug users remains challenging. or transportation. Youth who have health Biomedical HIV prevention represents a insurance may be reluctant to use it when novel modality to stop HIV transmission. a parent is the primary beneficiary, fearing In 2012, the Food and Drug Administrathat their HIV risk or PrEP use might be tion (FDA) approved an indication for revealed through an explanation-of-benthe ART combination tablet TruvadaÂŠ efits document or similar communication (tenofovir disoproxil fumarate/emtricitfrom the health insurance company. Even abine) for PrEP use. This tablet is to be if youth are able to access PrEP, programs taken once daily to prevent the acquisition report that it is more challenging for this of HIV. When taken consistently, PrEP age group to remain adherent to Truvada MetroDoctors

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medication regimens and to stay engaged in PrEP care. A Comprehensive HIV Prevention Program for Youth

While PrEP is an effective biomedical tool, it makes up only one component of a comprehensive HIV prevention program, which may also include promoting condom use, routine sexually transmitted infection (STI) testing and treatment, routine HIV testing, and risk-reduction counseling. With the goal of addressing the unique barriers that youth face, YAP partnered with the University of Minnesota Health Delaware Infectious Disease Clinic to launch the PrEP Program. YAP is an academic and community-based organization affiliated with the University of Minnesota founded in 1989 with the mission to prevent transmission of HIV to and from high-risk youth and to provide care to youth and families living with HIV infection. YAP offers a variety of additional programs, including Medical Case Management, Treatment Adherence, and HIV Testing. Housed within the University of Minnesota Health Clinics and Surgery Center, the Delaware Infectious Disease Clinic has over 40 years of experience in patient care, research, and teaching and is a community leader in the treatment and prevention of HIV. The clinic offers a variety of patient services designed to meet the unique needs of each patient. There are more than 10 Infectious Disease physician specialists that staff the clinic, and every PrEP provider is an HIV expert. Together, YAP and the Delaware Infectious Disease Clinic offer the comprehensive PrEP Program to anyone between the ages of 13 to 30 years, but the Program is specifically designed to reach youth who are particularly high-risk. YAP has dedicated outreach services to identify and engage HIV-vulnerable youth, especially those youth involved in sex work, injection drug use, or experiencing homelessness. Once identified, a PrEP Navigator offers to meet with interested youth to identify any barriers in their accessing PrEP and provides them with general HIV education, an individualized risk assessment, and rapid HIV testing. If a youth meets MetroDoctors

the eligibility criteria for PrEP, the Navigator offers additional services, including health insurance review and/or enrollment, financial assistance referrals, and ultimately, linkage to care. Once participants are linked to the Delaware Infectious Disease Clinic, they have access to the Medication Therapy Management program with the clinic pharmacist, as well as the HIV Clinic Pharmacy program, which provides medication tracking, refill reminders, and medication mailing. Additionally, a social worker and RNs with HIV expertise are available for psychosocial support and resource management. Each PrEP provider visit includes HIV testing and offers STI testing and treatment. After successfully engaging a participant with the Delaware Infectious Disease Clinic, the PrEP Navigator remains in close communication with the participant and in collaboration with the clinic team. The Navigator also provides monthly check-in phone calls to monitor for medication side effects, to track the patient’s overall tolerance of Truvada, and to assist with coordinating follow-up appointments and lab orders. These monthly interactions are also key opportunities to encourage condom use and to provide further risk-reduction counseling. If a participant is struggling with medication adherence or with engagement in the PrEP Program, the Navigator and the clinic staff work together to provide support and troubleshoot factors identified as barriers to care. HIV transmission rates remain high among key populations in the US, including YMSM of color and young injection drug users. PrEP is a biomedical prevention tool that can prevent HIV transmission regardless of high-risk behavior when individuals have consistent adherence. However, youth struggle with access, medication adherence, and engagement in PrEP care. The PrEP Program offers a comprehensive approach to HIV prevention while addressing the unique barriers that youth face in the fight against HIV. While PrEP intake has improved overall since 2012, youth remain a small subset of users. YAP and the Delaware Infectious Disease Clinic call on our community providers to identify HIV-vulnerable youth

The Journal of the Twin Cities Medical Society

and to direct them to the PrEP Program’s targeted services. For more information or to refer a patient: Youth and AIDS Projects yap@umn.edu (612) 301-6675 Delaware Street Clinic Jeff Strowbridge, LICSW (612) 676-4050 Julia Stumpf is a Medical Case Manager and PrEP Navigator for the Youth and AIDS Projects. She completed her BA at the University of San Francisco. She has worked in harm reduction and HIV programs globally and with the Youth and AIDS Projects since 2015. Ketzela J. Marsh, MD, MS is an Infectious Disease physician and PrEP provider at the University of Minnesota Health Delaware Infectious Disease Clinic. She completed an Internal Medicine/Pediatrics Residency at the University of Miami and a combined Adult and Pediatric Infectious Diseases Fellowship at the University of Minnesota. Her research and clinical interests center around HIV prevention and treatment for youth. References 1. Centers for Disease Control and Prevention. Diagnoses of HIV infection among adults aged 50 years and older in the United States and dependent areas, 2011–2016. Supplemental Report 2018; 23(5). https://www.cdc.gov/hiv/pdf/ library/reports/surveillance/cdc-hiv-surveillance-supplemental-report-vol-23-5. pdf. Accessed October 2018. 2. Minnesota Department of Health. HIV/ AIDS annual data release 2017. HIV/AIDS Surveillance Reports. http://www.health. state.mn.us/divs/idepc/diseases/hiv/ stats/2017/index.html. Accessed October 2018. 3. Centers for Disease Control and Prevention: U.S. Public Health Service. Preexposure prophylaxis for the prevention of HIV infection in the United States–2014: A Clinical practice guideline. Atlanta, GA: Centers for Disease Control and Prevention, 2014. 4. Sullivan PS, Giler RM, Mouhanna F, et al. Trends in the use of oral emtricitabine/tenofovir disoproxil fumarate for pre-exposure prophylaxis against HIV infection, United States, 2012-2017. Ann Epidemiol.22 June 2018. [Epub ahead of print] doi.org/10.1016/j.annepidem.2018.06.009.

January/February 2019

Promoting Sexual Health

Colleague Interview: A Conversation with Carol E. Ball, MD

arol E. Ball, MD is Medical Director Emeritus and Director of Abortion Services, Planned Parenthood of Minnesota, North Dakota, South Dakota and an Assistant Professor, Department of Obstetrics, Gynecology and Women’s Health, University of Minnesota. In addition, Dr. Ball serves as Medical Director, Women’s Health Programs, Ramsey County and the City of St. Paul Public Health Department, and is also a member of the Medical Committee of the Board of Directors, Women’s Health Center, Duluth, Minnesota. Dr. Ball received her medical degree at the Mayo Medical School, Rochester, MN; completed a Flexible Internship at USPHS Hospital, San Francisco, CA, and residency in Obstetrics and Gynecology at St. Paul Ramsey Medical Center.

What motivated you to dedicate your career to sexual, reproductive health, and abortion care? First of all, I am a feminist and I now realize that my feminist framework has influenced nearly every decision I have made in my career, as well as in my personal life. It therefore, makes sense that I chose an area of medicine that specifically deals with the health of women and the medical issues that most affect women. After my internship, I began working in the Indian Health Service in Cass Lake on the Leech Lake Reservation in northern Minnesota very close to Bemidji. I learned that there was a Planned Parenthood Clinic in Bemidji. I have always been a big supporter of Planned Parenthood, so I offered to work there a few times a month. I found that I really enjoyed my interaction with patients and working with them to choose the best method of contraception for them. I also became very aware during this time of the importance of contraception in allowing women to have control of their lives and their futures. Though I had always been pro-choice, this was also the time when the importance of access to safe, legal abortion became very clear to me. I knew from my experience at Planned Parenthood in Bemidji that I wanted to make women’s health care and, especially family planning and abortion care, a focus of my career. A few years later the Women’s Health Center opened in Duluth to provide abortions for the women of northern Minnesota and surrounding area. I called the director there to ask if 14

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I could learn how to do abortions and “the rest is history.” That was in 1981 which means that I have been an abortion provider for 37 years. Several years after beginning to work at the Women’s Health Center, I decided that I wanted to increase my knowledge and training in women’s medicine. I was fortunate to be accepted into the Obstetrics and Gynecology residency program at what was then St. Paul-Ramsey Medical Center and I completed that training in 1992.

How do we further reduce the very high teen pregnancy rate in the US? The teen pregnancy rate in the US is higher than in many other developed countries, but it has been decreasing steadily over the past couple of decades for white teenagers. Teens of color experience teen pregnancy at disproportionate rates compared to their white counterparts and this health disparity is due to a combination of systemic and institutional racism that leads to a lack of access to healthcare services, information and education. The overall decline in teen pregnancy has been shown to be mainly attributable to increasing use of reliable contraception by teenagers. In order to continue this trend we need to continue to improve access to the most effective methods of contraception, especially intrauterine contraceptives (IUCs) and implants. One very effective way of doing that is by providing contraception at low or no cost to the patient. This is something that the Affordable MetroDoctors

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Care Act (ACA) did and is also a part of the ACA that is under constant threat. In addition, more education is needed for those healthcare providers who deal with adolescent patients, so they are more comfortable talking to these patients about their sexual and reproductive lives and needs. There continues to be a misconception that IUCs are not a good choice for an adolescent and that needs to change. We need to educate providers so they know that an IUC or implant can be a first line method for the adolescent patient. Finally, I believe that comprehensive, age-appropriate education regarding healthy relationships, healthy sexuality, making healthy decisions about sexual activity, and contraception should be a routine part of school curriculums and should begin at a very early age. It will take some time, but this will go a long way to bringing our teen pregnancy rate in line with that of the rest of the developed world.

Please offer your insight about why pregnancy outcomes are getting worse in the United States. Maternal morbidity and mortality in the US is higher than in most, if not all, other developed countries and is getting higher. I believe that one of the main reasons for this dismal fact is the lack of universal healthcare coverage in our country. Many women cannot afford the cost of medical care so they delay getting the care that they need when they become pregnant, or they get

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fragmented and more expensive care in the emergency room. This means they get far along in their pregnancies or actually go into labor before getting the care they need. At that point it is too late to diagnose and treat problems that could have been mitigated earlier in the pregnancy. The ACA and expansion of Medicaid in some states has helped with access to care, but those provisions in the ACA that provide for care during pregnancy are threatened and not all states have expanded Medicaid eligibility. The increase in the rate of Cesarean delivery over the past several decades also contributes to poor pregnancy outcomes. Not only is morbidity and mortality higher for Cesarean than for vaginal delivery, but Cesarean delivery also can have detrimental effects on subsequent pregnancies. I see women who have had four, five or more deliveries by Cesarean section. The risk of placental abnormalities increases with the number of prior Cesareans as does the risk of a Cesarean scar ectopic pregnancy. The latter is a condition that for the first several decades of my career I knew about theoretically but had never seen a case. Now we see a case of a Cesarean section scar ectopic almost every 3-4 months. If not diagnosed early, these pregnancies are a very high-risk situation for the woman, often requiring hysterectomy and resulting in massive hemorrhage. We also have an epidemic of obesity in this country. Obesity results in higher risk to both the woman and her fetus during the pregnancy and delivery. In addition, obesity puts the woman (Continued on page 16)

January/February 2019

Promoting Sexual Health Colleague Interview (Continued from page 15)

at risk for developing hypertension, diabetes, and other medical conditions that can result in significant pregnancy complications. I’m sure there are other factors resulting in the increase in maternal mortality in the US. These are just some that come immediately to my mind and those that I see in my own practice.

Where are we falling short in providing services to LGBTQ+ patients? How can we make their experience better? Just as people of color experience structural and institutional racism within the medical system, the LGBTQ+ community experiences homophobia, heterosexism, and entrenched binary attitudes about gender. As soon as they walk into a medical care facility, they most often will find restrooms designated for men and women rather than all gender restrooms. They are handed forms that do not have answer choices that fit them, and they can experience insensitive and rude attitudes from support staff and even medical providers they have come to for care. Not surprisingly, many LGBTQ+ people are very hesitant to attempt to access even the most basic health care. We, as a medical community, need to address these issues, change the physical environment of our facilities, make sure that our forms are inclusive, and train both our support staff and our providers so this community can get their medical needs met in a welcoming and respectful environment.

What do you envision for the future of contraception and abortion care in the United States? In Minnesota? What battles do you see ahead? Victories on the horizon? The appointment of Brett Kavanaugh to the Supreme Court puts Roe v Wade in jeopardy of being overturned. If that happens, there are 20+ states that have laws in place that could be used to restrict or ban abortion if Roe is overturned. Four of those states have a “trigger” law which would automatically ban abortion if Roe were to be overturned. Even if Roe v Wade is not overturned, there are now five justices who are hostile to access to abortion and could support laws that make it increasingly difficult for women to access abortion. Under those circumstances the fight for access to safe abortion will be fought at the state level with some states passing more restrictive laws that might lead to closing many or all the abortion providers in their states, and other states resisting passage of those restrictions. We will, essentially, return to the conditions that were in place prior to Roe v Wade where women had to travel even longer distances than they do now to access abortion in a less restrictive state. Fortunately, Minnesota is not one of those states that has a hostile law in place. In fact, there is a Minnesota Supreme Court opinion stating that access to abortion is a constitutional right. As a result of the last election, the Minnesota House will have a 16

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pro-choice majority and all of our state constitutional offices are held by people with records that are very supportive of abortion rights. Not only is Minnesota unlikely to pass further restrictions on abortion, but there may be some opportunities to remove some of the restrictions that are already in place. If further restrictions to abortion access are upheld by the Supreme Court in the future, Minnesota may become one of the few states in our region with continued access to safe, legal abortion. Unbelievably, access to contraception is also under attack at the federal level. The Trump-Pence administration would like to overturn the birth control mandate in the ACA and expand the ability of employers to deny coverage for birth control due to religious or moral objections. In addition, they are threatening to impose a gag rule on Title X, the program that provides federal dollars for low income patients to access contraception and other reproductive health care. This would prevent providers from giving full information to their pregnant patients. Specifically, providers would not be able to discuss abortion as an option or provide information about resources that might provide abortion. This is, obviously, a gross interference in the physician-patient relationship and mandates unethical behavior on the part of providers by requiring that we withhold information from our patients. Planned Parenthood is the largest provider of Title X services in the state of Minnesota. If the “gag rule” is implemented birth control access for 53,000 Minnesotans will be at risk. Other providers in Minnesota do not have the capacity to absorb all the patients that are currently being seen by Planned Parenthood, resulting in a huge gap in the ability of these patients to access that care.

What areas of sexual and reproductive health deserve most of our attention from a policy/ advocacy initiative point of view? I have always been keenly aware of the impact that politics, legislation, and policymaking can have on my ability to offer the full range of sexual and reproductive medical care to my patients. I have paid close attention to politics, have donated to individual supportive candidates and been supportive in other ways, and have occasionally spoken with legislators and given testimony. I have, however, been careful to not let political activity interfere with my clinical responsibilities. During the decades that I have been an abortion provider there have been few other physicians who have been willing to provide that care, so patient care has been my first priority. Fortunately, there have always been supportive physicians in more traditional practices who understand how the politics of abortion and contraception can adversely affect their ability to best care for their patients. These physicians have been willing to work within organized medicine to bring the powerful voice of physicians into the political arena. Sexual and reproductive care is basic health care. Over 99% of women use contraception and one in three women have at least MetroDoctors

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one abortion in their lifetime. Restricting access to this care by imposing waiting periods, mandating that false and misleading information be given to patients, requiring parental consent or notification, and all the other various government-imposed requirements in place today are an unacceptable interference in the physician-patient relationship and interfere in our ability to provide our patients with the highest quality and safest care. Preserving the physician-patient relationship is something that all physicians can agree on and is an important area of advocacy for organized medicine. In addition, I would like to see organized medicine advocate strongly for universal healthcare coverage, whether that be by fixing the problems with the Affordable Care Act that have become evident since its implementation to make it more affordable and expand its coverage to more people, by working on putting in place a single payer system, or by any other means.

What do you believe the future holds for Planned Parenthood? Planned Parenthood has now been in existence for over 100 years. Though the organization has always had an organized opposition, it has not only survived, but thrived. We will not only survive these difficult political times, but we will become stronger and more resilient. I’m sure you have seen the signs and heard the slogan — “Planned Parenthood is here for GOOD!”

The vast majority of the public see Planned Parenthood in a very favorable light and are supportive of the medical services and education that we provide. More and more of our supporters are being activated by the current political climate. This has meant an increase in donors, volunteers and supporters.

As you move closer to retirement, what sort of role will you continue to play in the sexual and reproductive health community? I plan to continue to provide abortions and other reproductive health services for another few years. I still enjoy caring for patients and feel that I can still make a contribution. I just joined the Board of Directors of Physicians for Reproductive Health and have been on the Advisory Council for the Program on Human Sexuality for the past several years, and I’d like to continue that work. As I decrease my clinical hours and have a bit more free time, I would like to work more on the issue of universal healthcare coverage both here in Minnesota and on a national level. I believe that the way we pay for health care in this country is a travesty. I think that you can tell from some of my answers to these questions that I think that universal health care can be a large part of the solution to the many problems we have with health disparities and poor health outcomes. I would like to be a part of moving that solution forward and seeing it become a reality.

Join the MMA on Facebook Live

as we discuss how the medical community can unite to achieve health equity in Minnesota. The two-part series is presented by the MMA, the Minnesota Chapter of the American Academy of Pediatrics (MNAAP) and the Minnesota Academy of Family Physicians (MAFP).

Achieving Health Equity MetroDoctors

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JOIN US! www.facebook.com/mnmed January 22 (Noon to 1)

Addressing health disparities within the Native American community

February 20 (Noon to 1)

Structural racism and other barriers to health equity

January/February 2019

Sponsored Content

Primary Care Taking Action to Prevent Unintended Adolescent Pregnancies Contributed by Shannon Neale, MD, Jamie Lyn Reinschmidt, MD, Juliana Tillema, MPA, PMP

Although the US birth rate first-line contraceptive methods among adolescents and young for adolescents, yet only 5% of women age 15-24 are using adults reached a historic low in 2015 (22.3 per 1,000 women), them.6 This suggests patients unplanned pregnancies remain simply aren’t getting the right stubbornly persistent, challenginformation from their cliniing the social and economic cians. Unsurprisingly, a recent well-being of our nation’s young survey of midwestern pediatriwomen. Eighty-two percent of Shannon Neale, MD cians found that many did not Jamie Lyn Juliana Tillema, discuss LARC, especially IUDs, teen pregnancies are unintendReinschmidt, MD MPA, PMP ed.1 Furthermore, the US has in their counseling of adolessignificant racial and ethnic disparities. cents. The reasons were primarily the result by HealthPartners Institute and analyzed Nationally, black and Hispanic girls are of poor and outdated knowledge of IUDs. pregnancy data from HealthPartners clintwice as likely to give birth as white girls. Many pediatricians in the survey erroneics — also found that 57% of these teens This disparity is greater in Minnesota, ously believed IUDs were dangerous to had no documentation of sexual activity where black and Hispanic girls are around future fertility. They also had the percepin their medical record and 47% had no three times more likely to give birth than tion that adolescents wouldn’t want IUDs. documentation of reproductive health white girls. Worse yet, American Indian However, once educated about IUDs, the counseling. Only 35% had contraception girls are almost five times more likely to clinicians’ opinions changed.7 prescribed within 12 months of becoming 2 When educating about contracepgive birth than white girls. pregnant, and only one had a long acting tion options, it is a best-practice to use This matters because teen pregnancy contraceptive prescribed. As a result of is not just associated with premature birth a structured counseling tool. These tools this gap in care, HealthPartners began a 3 and higher mortality rates, it is also assoare used by the clinician to provide inforproject to improve sexual health care for ciated with adverse social and economic mation consistently, accurately, and in a adolescents and young adults. standardized manner. Data show that 70% outcomes. Only about half of all teenage LARC is Recommended mothers will earn a high school diploma by of adolescents will choose a LARC method as First Line age 22 compared to 90% of teenagers who when counseled on effectiveness and proSafe and effective options for contracepare not mothers. This disparity in educavided the method at no cost. Eighty-one tion are long acting reversible contraceppercent of those who start a LARC will tion is linked to lower wages throughout tives (LARCs). These include intrauterine continue with their chosen method.8 adulthood, and poorer outcomes in adult devices (IUDs) — both the copper IUD mental health, longevity, relationship forThere are many structured counsel4 and the four levonorgestril IUDs — as well mation, and public service. ing tools available, including ones offered as Nexplanon, the levonorgestril implant. by the Centers for Disease Control and Missed Opportunities One of the biggest barriers to providPrevention (CDC)9 and Bedsider.org.10 A 2014 study published in JAMA Pediing access to LARC appear to be clinicians HealthPartners Patient Education Deatrics found that on average teens who themselves. partment combined features from existgave birth had three visits to primary care The American College of Gynecoloing tools with patient-friendly clinical in the 12-month period preceding their gists (ACOG) and the American Academy information to create our own tools. They pregnancy. 5 The study — which was led of Pediatrics (AAP) recommend LARC as include pictures, summaries of methods, 18

January/February 2019

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risks and benefits for the patients, along with prompts for the counseling clinician. Some clinicians may feel uncomfortable having conversations about birth control and sexuality with their adolescent patients, so clinician education may be warranted. We created a video in partnership with the Annex Teen Clinic to educate clinicians about why these conversations are important and how to have them. It’s now mandatory that our clinicians watch it if they see adolescent patients. In addition, we’ve modified and implemented a Teen Questionnaire made available by the Minnesota Department of Health. The questionnaire helps identify and prioritize high-risk behaviors so clinicians can address them in the primary care setting. Private Time with Adolescents is Important

It’s critically important that clinicians create private time to discuss sexual health and contraception with their adolescent patients. Private time allows the adolescent to take ownership of their own health as they transition into adulthood. This helps the clinician build a relationship with the patient while creating a safe space to discuss important topics like sexuality. Some clinicians fear that parents may be offended when asked to step out of the exam room. In reality, most parents welcome the opportunity for their children and expect it when educated that it is part of age-appropriate care. To help support parents during this time of transition, HealthPartners developed letters that are given to parents at the 10- and 11-year well visits. The letters remind parents that clinicians will start having private conversations with their kids at the 12- or 13-year well visits. Then, at the 12- or 13-year well visit, they’ll receive another letter about private discussions and risk assessments that their child will be receiving, as well as why these are important. Similarly, teens also receive letters at check-in describing what will happen at the visit and outlining their rights to confidentiality. We have received extremely positive feedback from families about this process.

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Confidentiality

Minnesota minor consent laws provide protection to adolescents who are seeking sexual health care. These laws allow adolescents to receive confidential care without parental involvement for contraceptive care, pregnancy testing and obstetrical health care, sexually transmitted disease testing and treatment, and Hepatitis B immunization. While minors have the right to confidentiality, the reality is that confidentiality may be difficult to ensure if their parents’ insurance is billed. The amount of information available to parents is variable depending on the insurer and the circumstances. Teens who want complete confidentiality and are unable to self-pay for sexual health services may best be referred to a clinic that receives federal or state funding toward family planning programs.* Take Action

The most efficient and effective way to improve adolescent sexual health in primary care is to create standardized processes that promote these best practices during child and adolescent well visits. This includes leveraging and embedding contraceptive counseling tools in the clinic, administering a teen questionnaire and social-emotional screen, providing letters to parents and teens at check in, and facilitating oneon-one time for the patient and clinician. It may seem daunting, but it’s not impossible. In 2014, HealthPartners launched its Children’s Health Initiative to improve care for children. Among other things, this large improvement project included all of these elements, making adolescent sexual health a priority. While we don’t know yet how this effort will impact pregnancy rates, we are confident that taking these steps to address adolescent sexual health will help prevent teen pregnancy, promote healthy sexual practices and help young patients grow into healthy, responsible adults. Shannon Neale, MD, is a Family Medicine physician and chair of the Family Medicine Department at Park Nicollet. She is also an assistant professor at the University of Minnesota Department of Family Medicine and Community Health and faculty at the

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Methodist Hospital Family Medicine Residency Program. Jamie Lyn Reinschmidt, MD, co-leads HealthPartners’ adolescent sexual health work group under the health system’s Children’s Health Initiative. She has been a Family Medicine provider at HealthPartners Roseville/North Suburban Family Physicians for more than 20 years. Reinschmidt has also has been involved in care improvement projects related to postpartum depression and ADHD among children. Juliana Tillema, MPA, PMP, is the project manager for the HealthPartners Children’s Health Initiative, focusing on adolescent sexual health. She is also active in community adolescent sexual health practitioner groups and manages other strategic projects for HealthPartners. She holds a bachelors degree from the University of Wisconsin–Madison and a masters of public affairs from New York University’s Wagner Graduate School of Public Service. *Find a directory of family planning clinics here: http://www.health.state.mn.us/ divs/cfh/program/familyplanning/directory.cfm. (Endnotes) 1. Finer LB and Zolna MR, “Declines in unintended pregnancy in the United States, 2008–2011,” New England Journal of Medicine, 2016, 374(9):843–852. 2. Farris, J., Austin, J., & Brown, C. (2018). 2018 Adolescent Sexual Health Report. Minneapolis, MN: University of Minnesota Healthy Youth Development • Prevention Research Center. 3. Ganchimeg et al, “Pregnancy and childbirth outcomes among adolescent mothers: a World Health Organization multicountry study.” BJOG. 2014 Mar;121 Suppl 1:40-8. doi: 10.1111/1471-0528.12630. 4. Needham BL, Crosnoe R, Muller C. Academic Failure in Secondary School: The Inter-Related Role of Health Problems and Educational Context. Social problems. 2004;51(4):569-586. 5. Kharbanda, EO, Stuck, L, Molitor B, Nordin J. Missed Opportunities for Pregnancy Prevention Among Insured Adolescents. JAMA Pediatrics, 2014;168(12):e142809. doi:10.1001/ jamapediatrics.2014.2809. 6. Branum AM, Jones J. Trends in long-acting reversible contraception use among U.S. women aged 15–44. NCHS data brief, no 188. Hyattsville, MD: National Center for Health Statistics. 2015. 7. E.D. Berlan et al. / J Pediatr Adolesc Gynecol 30 (2017): 47-52. 8. Secura, et al, “Provision of no-cost, long-acting contraception and teenage pregnancy,” N Engl J Med 2014;371:1316-23. 9. https://www.cdc.gov/reproductivehealth/ contraception/unintendedpregnancy/pdf/ Contraceptive_methods_508.pdf. 10. https://beyondthepill.ucsf.edu/sites/beyondthepill.ucsf.edu/files/Tiers_Chart_ENGLISH.pdf. January/February 2019

Promoting Sexual Health

The Intrauterine Contraceptive Device: The Rising Star of Birth Control

ver the past decade, more and more women are requesting intrauterine contraceptive devices for birth control. The convenience, cost effectiveness, and efficacy rates of over 99% make these long-acting reversible contraceptive devices a great option for reproductive-aged women. The most frequently requested devices remain the Paragard Intrauterine Copper Contraceptive and the Mirena 52 mg Levonorgestrel-Releasing Intrauterine System. The Paragard offers 10 years of reliable contraception and appeals to women who prefer a hormone-free product. It is a T-shaped plastic device with a copper filament wrapped around the main shaft. The copper filament releases copper ions, creating a sterile inflammatory reaction within the uterus which is toxic to sperm. Another benefit of the Paragard is that it can be inserted up to five days after unprotected intercourse to provide post coital contraception. It is 99% effective at preventing pregnancy within 120 hours of intercourse, and can then be left in place for an additional 10 years of ongoing birth control. One downside of the Paragard is that it tends to make the menses a little heavier and a little more painful, so it is not a good option for women who suffer from menorrhagia or dysmenorrhea. The Mirena is a soft flexible plastic T-shaped device which releases levonorgestrel, a progestin, at a rate of 20 mcg per day initially and falls to about 50% By Rebekah Ormsby, MD

January/February 2019

of that at the five year mark. The benefit of this progestin is that it thins the lining of the uterus, resulting in lighter menses or amenorrhea. Amenorrhea is attained in about 20% of Mirena users after one year. This effect on menstruation makes the Mirena an ideal choice for women who have heavy periods. The Mirena is an especially good option for women with polycystic ovarian syndrome, obesity, or who are otherwise at increased risk for endometrial cancer, as the constant dose of levonorgestrel protects against endometrial hyperplasia. The effect on menses has also helped the Mirena gain traction among active young women who want to minimize the inconvenience of menstruation. It has also been shown to be effective in reducing pain in women who suffer from endometriosis. Patients interested in the Mirena need to be aware of the high rate for unscheduled bleeding and spotting within the first 3-6 months after

placement while the endometrium thins out. Although the levonorgestrel is mainly released into the uterine environment, there is some systemic absorption resulting in hormonal side effects in a small percentage of Mirena users. The most common systemic complaints are acne, melasma, headaches, depressed mood, and breast pain. That being said, most Mirena users are pleased with this form of contraception and it is the most popular intrauterine contraceptive device in the United States. The market has responded to the success of the Mirena by releasing a number of new progestin-containing IUD products. Kyleena is a 19.5 mg levonorgestrel-releasing intrauterine system which provides five years of contraception, and Skyla is a 13.5 mg levonergestrel-releasing system which is approved for three years. And finally, the Liletta is very similar to the Mirena in that it contains 52 mg of levonorgestrel and releases it at a rate of about 19 mcg per day. Liletta is approved for five years of contraception. All of the progestin-containing IUDs lighten menses and can result in amenorrhea. The amenorrhea rates after one year are 12%, 6%, and 20% for the Kyleena, Skyla, and Liletta respectively. A large part of the popularity of the intrauterine contraceptive device is that there are very few contraindications to their use. Some contraindications include uterine cavity-distorting anatomic abnormalities such as cavity-distorting uterine fibroids, uterine septa, and unicornuate or bicornuate uteri. Progestin-containing IUDs should not be used

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in patients with active liver disease or progestin-sensitive breast cancers. Uterine or cervical neoplasms as well as active gynecologic infections are all contraindications to IUDs. IUDs should be used with caution in women who are at high risk for STDs as these women have a greater risk of developing pelvic inflammatory disease. Consistent condom use and/or frequent screening for sexually transmitted infections should be strongly encouraged in this group to reduce the risk of infectious complications. Advanced HIV is also considered a contraindication to intrauterine contraceptive devices according to the World Health Organization. Wilson’s Disease is a contraindication to the Paragard IUD due to the copper ions that are released. Unlike combined oral contraceptive pills, intrauterine devices are considered safe to use in the setting of poorly-controlled hypertension and in most clotting disorders. In fact, the levonorgestrel-containing devices are often used to combat menorrhagia brought on by anticoagulation therapy for women with clotting disorders. All IUDs can be safely used in lactating women and are very popular for this particular group since the demanding schedule of nursing an infant may make it difficult to adhere to daily pill use. Intrauterine contraceptive devices have very high satisfaction rates. However, there are a few mechanical problems that can occur such as malposition, perforation, migration, expulsion, or embedment of the device into the uterus. Women who present with ongoing cramping or bleeding, or inability to locate IUD strings should have the placement of the IUD checked by ultrasound. If the device is not correctly positioned, it should be removed. If the patient desires another intrauterine contraceptive device, her gynecologist may choose to place the new one under ultrasound guidance to be sure that the insertion is correct. A busy gynecology practice can expect to see a few cases a year of IUDs that have migrated into the pelvis and have to be retrieved laparoscopically. MetroDoctors

This is typically the result of an undiagnosed perforation, often at the time of IUD placement. Expulsion occurs when the uterus contracts and pushes the device out of the uterine fundus. Expulsion of one IUD is not a contraindication to getting another IUD, but the patient should be counseled on a one in three risk of recurrence. Embedment of a device into the endometrium usually goes unnoticed until it is time for the IUD to be removed. Most embedded IUDs can be safely removed in the office although sometimes hysteroscopy is necessary. Perhaps the most common nuisance event with intrauterine contraceptive devices is “lost strings.” Usually when the IUD strings cannot be found at the cervix, they are lurking in the endocervical canal and can be found and grasped with some effort. Other times, the strings completely retract into the endometrial cavity, and ultrasound guided or hysteroscopic removal of the device may be necessary. As more and more women are choosing IUDs, more complications are seen in a typical gynecology practice, however the overall rate of mechanical IUD complications is very low. Another intrauterine contraceptive device complication that should not be overlooked is pregnancy. The risk of pregnancy with any type of IUD is less than 1%. If pregnancy occurs with an IUD in place, there is an increased risk of a miscarriage or ectopic pregnancy; however a normal term delivery is entirely possible. If an intrauterine pregnancy is diagnosed with an intrauterine contraceptive device in place, the device should be removed if the strings are visible. If the strings are not visible, the device should be left in place. The relationship between IUDs and ectopic pregnancies is somewhat complicated. A pregnancy diagnosed with an IUD in place has a high likelihood of being ectopic. However, because IUDs reduce the overall risk of pregnancy, they also substantially decrease the absolute risk of ectopic pregnancy. When the Paragard hit the US market in 1988, there was initially little

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interest in it due to the IUD’s checkered past. There was a sentiment of distrust of IUDs in the wake of the Dalkon Shield debacle in the 1970s. The ill-fated legacy of the Dalkon Shield was due in part to its multifilamentous string which was ideal for bacterial proliferation, and in part to population factors and sexual practices prior to the widespread use of condoms. The end result was that thousands of Dalkon Shield users developed pelvic inflammatory disease, often resulting in infertility. Many women required hysterectomies and 18 women in the United States died due to septic miscarriages. Eventually the Dalkon Shield was removed from the market, but not before the reputation of the IUD was tarnished. When the Paragard and, as of 2001, the Mirena entered the US market, they were up against a two decades-old grudge against IUDs. The burden of proof was on the IUD companies to end the maligned belief that all IUDs cause pelvic inflammatory disease and infertility. Over time and with copious safety data, the Paragard and the Mirena were able to reverse these fears and gain the trust of the next generation of reproductive-aged women. Within a decade, that tenuous trust turned to outright enthusiasm as more women requested intrauterine contraceptive devices. The recent expansion of the IUD market to include three other products (Skyla, Kyleena, and Liletta) has broadened the appeal to an even wider audience of women. Rebekah Ormsby, MD is a shareholder at Associates in Women’s Health, P.A. and sees patients in both their Edina and Downtown Minneapolis offices. Dr. Ormsby received her bachelor’s degree in Chemistry and History from Augsburg College, and in 2001, she received her medical degree from the University of Minnesota. Dr. Ormsby then completed a residency in Obstetrics and Gynecology at the University of Minnesota in 2005. She is board certified by the American College of Obstetrics and Gynecology.

January/February 2019

Promoting Sexual Health

Conversion Therapy: Time for Action

onversion therapy, also known as reparative therapy or sexual orientation change efforts (SOCE), is a discredited medical practice aimed at changing a patient’s sexual orientation, gender identity, or gender expression. An estimated 698,000 adults ages 18-59 have received conversion therapy in the US with 350,000 experiencing conversion therapy as children or adolescents.(1) An estimated 77,000 youth ages 13-17 will receive some form of conversion therapy by the time they reach the age of 18.(1) Mental health professionals in Minnesota still practice conversion therapy where it remains legal.(2,3) It is time for Minnesota to leave this dangerous and illegitimate practice in the past. Conversion therapy is rooted in the belief being Lesbian, Gay, Bisexual, Transgender, or Queer (LGBTQ) is a disorder and propagates a narrative of intolerance leading to worse health outcomes for LGBTQ populations. LGBTQ youth are vulnerable to these practices as parental pressure may force this therapy on them. Parents may seek conversion therapy services for their child on the misguided premise their child’s sexual orientation or gender identity are a mental disorder. Youth who report being rejected for their sexuality or gender expression are 3.4 times more likely to use illicit drugs, 5.9 times more likely to face depression, and 8.4 times By Kevin O’Donnell and James Pathoulas

January/February 2019

Kevin O’Donnell

James Pathoulas

more likely to entertain suicidal ideation compared to reaffirmed LGBTQ youth.(4) Over the past several years, the American Medical Association, American Academy of Pediatrics, American Psychological Association, and American Counseling Association all issued statements denouncing this practice as ineffective and harmful.(1) Despite the Diagnostic and Statistical Manual removing homosexuality as a mental disorder in 1973, many mental health providers continue to treat homosexuality as a disorder. A study of mental health providers found 4% would offer conversion therapy services if requested by the patient.(5) Mental health providers who believe conversion therapy is ethical are significantly more likely to hold negative attitudes of LGBTQ people.(6) Conversion therapy received increased national attention in the past few years. After Obergefell v. Hodges, the 2015 landmark Supreme Court

case granting marriage equality, many LGBTQ advocacy organizations began to shift focus to conversion therapy. The Obama administration issued a report condemning the practice and called for federal legislative action in 2015.(7) A federal bill, the Therapeutic Fraud Prevention Act, was introduced in 2017 to classify conversion therapy as consumer fraud. This would allow the Federal Trade Commission and state attorneys general to act against individuals providing these services for a fee.(7) Beyond legislation, two movies in 2018 focused on the harms on LGBTQ youth. The Miseducation of Cameron Post and Boy Erased displayed the plight of LGBTQ youth who are forced into these camps. Boy Erased, based on a book by the same name by Garrard Conley, describes the author’s personal experience going through a conversion therapy camp in 2004. Garrard, then 19 years old, was told by his parents they would no longer

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Percent of the state population protected from conversion therapy

Percent of the state population protected from conversion therapy by local ordinances

MAP Citation: Movement Advancement Project. “Equality Maps: Conversion Therapy Laws.” http://www. lgbtmap.org/equality-maps/conversion_therapy (10/31/2018).

pay for his college or let him remain part of the family unless he attended the camp. His harrowing experience only ended when he told his mother he was contemplating suicide. The organizations running these camps prey on the misguided fears of parents with little accountability or empirical evidence of success or improving health. Exodus International, the umbrella organization running the camp Garrard attended, closed down in 2013 and admitted in a statement from the CEO “...I am sorry that some of you spent years working through the shame and guilt you felt when your attractions didn’t change. I am sorry we promoted sexual orientation change efforts and reparative theories about sexual orientation that stigmatized parents....”.(8) Many states and municipalities have banned conversion therapy using different legal approaches. States efforts have mostly focused on licensing MetroDoctors

bodies which govern licensed mental health providers. This was the method enacted by California in 2012. In 2017, a legal challenge to this method of regulating conversion therapy was taken to the United States Supreme Court in Welch v. Brown. Opponents argued state regulation of licensed providers in a religious setting was a breach of religious freedom. The Supreme Court ruled the law was constitutional and not a violation of religious freedom. The Supreme Court also denied a 2014 petition that claimed the California ban was a violation of free speech, affirming the Ninth Circuit decision the California ban was not a violation of the First Amendment. These legal precedents are important considerations for states considering their own legislation. Unfortunately, bans only addressing licensed mental health providers do not address the many unlicensed therapists who still practice conversion therapy. Some states and

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municipalities instead label conversion therapy as a fraudulent business practice and therefore subject to regulation. In 2015, a court case in New Jersey hinged on this argument. The religious affiliated non-profit organization offering these services was found to be violating the New Jersey’s Consumer Fraud Act. The ruling forced the organization to pay restitution to the plaintiffs and close within 30 days.(9) As an effective legal measure, bans, which include legal language focused on the fraudulent business practice of conversion therapy, can regulate both licensed and unlicensed mental health providers. Milwaukee, Madison and Eau Claire have all passed their own municipal ordinances applying fines of $500-$1,000 per violation.(10,11,12) These ordinances do not affect religious leaders providing spiritual counseling for free. Ordinances regulating the business of (Continued on page 24)

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Promoting Sexual Health Conversion Therapy (Continued from page 23)

conversion therapy provide more encompassing protection for LGBTQ youth compared to regulation solely of licensing bodies. Laws regulating the fraudulent and harmful practice of conversion therapy on minors have passed in 14 states and the District of Columbia. Forty-seven municipalities have passed their own ordinances regulating conversion therapy on minors in places without statewide regulation. Legislation has historically been bipartisan with six of the 14 statewide bans signed by Republican governors. Bills in both bodies of the Minnesota State legislature have failed over the past several years despite increasing advocacy efforts. No cities in Minnesota have passed municipal ordinances. Before 2018, the Minnesota Medical Association (MMA) had no policies regarding conversion therapy. At the 2018 MMA Policy Forum, we submitted a policy proposal, with the endorsement of the MMA–Medical Student Section, advocating for a ban on conversion therapy for minors and vulnerable adults in the State of Minnesota. The discussion from fellow Minnesota physicians was encouraging and the policy proposal had broad support. The MMA Policy Council convened a month later and recommended an expanded policy to include a ban across all ages. The MMA Board of Trustees voted to adopt this policy at their November meeting. As medical providers, it is our ethical duty to advocate against dangerous and unethical medical practices; even when these practices take place under 24

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religious pretense. Decades ago, medical providers legitimized conversion therapy to the detriment of countless individuals. While this discredited practice is declining, vulnerable LGBTQ patients, both minors and adults, continue to be actively harmed. We need to report colleagues practicing conversion therapy to the respective licensing bodies. We need to stop referring our patients for treatment at clinics known to be offering conversion therapy. Finally, we need to use our unique and privileged positions within society to encourage lawmakers at the local, state, and federal level to enact bans on conversion therapy services. Together, we can ensure LGBTQ patients receive affirming, ethical and medically appropriate mental health care.

Kevin O’Donnell is a fourth-year medical student at the University of Minnesota Medical School. He is a 2018-2019 TCMS Dr. Pete Dehnel Public Health Advocacy Fellow. He is applying to Internal Medicine Residencies.

James Pathoulas is a second-year medical student at the University of Minnesota Medical School and is a medical student co-editor of MetroDoctors.

10.

11.

12. Bibliography 1. The Williams Institute, UCLA. “CONVERSION THERAPY AND LGBT YOUTH.” 2018. https://williamsinstitute.law.ucla.edu/ wp-content/uploads/Conversion-Therapy-LGBT-Youth-Jan-2018.pdf. 2. Serres, Chris. “Marcus Bachmann’s Counseling Center Sanctioned for Violating State Rules.” Star Tribune, 2017.http://www. startribune.com/mental-clinic-owned-bymarcus-bachmann-sanctioned-for-violatingstate-rules/416879364/.

Voices, Queer. “Michele And Marcus Bachmann’s ‘Ex-Gay’ Clinic’s Practices Described By Undercover Lesbian Filmmaker.” Huffington Post , 2 Feb. 2016. https://www.huffingtonpost. com/2012/04/12/michele-and-marcus-bachmann-ex-gay-clinic_n_1420752.html. Ryan, Caitlin, et al. “Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults.” Pediatrics 123.1 (2009): 346352. http://pediatrics.aappublications.org/ content/123/1/346. Bartlett, Annie, Glenn Smith, and Michael King. “The response of mental health professionals to clients seeking help to change or redirect same-sex sexual orientation.” BMC psychiatry 9.1 (2009): 11. McGeorge, Christi R., Thomas Stone Carlson, and Russell B. Toomey. “An exploration of family therapists’ beliefs about the ethics of conversion therapy: The influence of negative beliefs and clinical competence with lesbian, gay, and bisexual clients.” Journal of marital and family therapy 41.1 (2015): 42-56. President Obama White House. “FACT SHEET: Obama Administration’s Record and the LGBT Community.” https://obamawhitehouse. archives.gov/the-press-office/2016/06/09/ fact-sheet-obama-administrations-record-and-lgbt-community. (11/4/2018). “Exodus International to Shut Down. I am Sorry.” Speak Love, 2013, web.archive.org/ web/20140102085752/http://wespeaklove.org/ exodus/. New Jersey Supreme Court. MICHAEL FERGUSON, ET AL., V. JONAH, ET AL. 2015. https:// www.splcenter.org/sites/default/files/d6_legacy_files/downloads/case/jonahopinion.pdf. Milwaukee City Council. (11/4/2018) https:// milwaukee.legistar.com/LegislationDetail. aspx?ID=3357011&GUID=67C62217-450C4E3B-BBC5-8A9792F911C1. City of Madison Ordiance 23.60 https:// m a d i s o n . l e g i s t a r. c o m / V i e w . a s h x ?M=F&ID=6300907&GUID=9D03A719-EC8A4B87-8ADC-E9198BE1134C. Wisconsin Public Radio. “Eau Claire Becomes Third Wisconsin City To Ban Conversion Therapy” (11/4/2018) https://www.wpr.org/ eau-claire-becomes-third-wisconsin-city-banconversion-therapy.

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Tobacco Marketing to the LGBTQ Community

he tobacco industry has a long history of targeting specific communities with its advertising. Some examples are well known: Virginia Slims’ “You’ve Come a Long Way, Baby” ads aimed at women, or Newport using African American models to attract black smokers to menthol cigarettes. But one group that has been targeted is less well known: the LGBTQ community. Long before it became common in the American mainstream to directly market to LGBTQ individuals, the tobacco industry had its sights set on this demographic . . . and the results are tragic. We know about LGBTQ tobacco marketing because of Minnesota’s lawsuit against the cigarette companies in the 1990s, which exposed millions of pages of documents they had kept secret from the public.1 These documents revealed how deliberately and unfeelingly the industry targeted minority communities . . . including LGBTQ Americans. Throughout the 20th Century, major advertisers rarely put images of LGBTQ people in their ads. It was considered too risky, since companies feared such images would offend mainstream Americans and turn them away from their brands.2 But in the 1980s, cigarette companies looked at the LGBTQ community and saw an untapped market. Philip Morris was one of the first to explore By Adam Kintopf, Gabriel Glissmeyer, Laura Henry, and Betsy Brock MetroDoctors

From Left: Adam Kintopf, Laura Henry, Gabriel Glissmeyer, and Betsy Brock.

the idea. A company memo from 1985 reads: It seems to me that homosexuals have made enormous progress in changing their image in this country. . . . A few years back they were considered damaging, bad and immoral, but today they have become acceptable members of society. . . . We should research this material and perhaps learn from it.3 By the 1990s, cigarette companies were routinely advertising in publications aimed at gay men, including The Advocate, Out and Genre. Health concerns about smoking were well known by this time, and some gay publications were skeptical of the industry’s targeting. But most of them went along with it. Jeff Yarbough, editor of The Advocate, noted that gay magazines were “in a beggar’s position, rather than a chooser’s

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position,” and needed any ad revenue they could get to stay afloat.4 In fact, many LGBTQ individuals saw such tobacco marketing to them as very positive, because it acknowledged their existence in a way barely seen in ads for other products and services.5 The companies researched and planned their campaigns. Philip Morris found that gay men responded to the “masculinity/sexuality” of the Marlboro Man image, so they placed Marlboro ads in gay publications.6 They used a technique called “gay vague,” which combines male and female figures in images that would not raise the eyebrows of heterosexual viewers, but could be construed as homoerotic by the LGBTQ community.7 R.J. Reynolds, the maker of (Continued on page 26)

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Promoting Sexual Health Tobacco Marketing to the LGBTQ Community (Continued from page 25)

Camel cigarettes, used offensive language to describe its intended customers in a marketing plan internally called “Project SCUM” (for “sub-cultural urban marketing”), which targeted gays and “street people.” Today, there are more restrictions around tobacco advertising, and yet greater cultural awareness and acceptance of LGBTQ individuals means these ads are still targeting them. Camel has sought to associate its products with individuality and being true to oneself — important values to many LGBTQ people — and continues advertising in gay publications such as Out and Instinct.8 And a 2016 campaign for the Big Tobacco-owned blu e-cigarettes used images of a drag performer to directly appeal to the LGBTQ market.9 The result of this long history of targeting and relationship-building is devastating. The smoking rate among LGBTQ people in Minnesota is 26%10 — much higher than the general population’s 14%11 — and they suffer disproportionately from tobacco-related diseases. In 2017, new research found that more HIV-positive patients die of illness related to tobacco use than die of AIDS.12 The tobacco industry has now spent decades convincing people that smoking is a symbol of LGBTQ style, empowerment and pride. But cigarettes aren’t a positive part of LGBTQ communities; they are in fact harming those communities by addicting people to products that cause disease and death. 26

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Healthcare providers can help their LGBTQ patients by always asking about tobacco use and referring them to available cessation resources.13 Adam Kintopf is Senior Communications Manager at ClearWay Minnesota. He has published on health disparities in Indian Country and LGBTQ communities, presented at national conferences, and served on the production team for Reclaiming Sacred Tobacco, an Emmy-winning documentary on the tobacco practices of American Indian tribes. Laura Henry is passionate about creating healthier LGBTQ communities. She works as the Volunteer Manager at The Aliveness Project, a nonprofit that links people living with HIV to resources. Laura attended Goucher College and received a BA in sociology. She lives in Minneapolis, Minnesota. Gabriel Glissmeyer is a senior at Augsburg University studying Exercise Science. He has worked in tobacco prevention and cessation in high-risk youth population and LGBTQ people for a decade in Utah, Minnesota, and on a national level. Betsy Brock is the Director of Research at the Association for Nonsmokers-Minnesota. In this role, she focuses on gathering and disseminating research findings that can be put into action to both make meaningful policy change and evaluate the impact of existing tobacco control policies. Brock is an expert in tobacco industry marketing tactics, particularly direct marketing,

point-of-sale marketing, and new tobacco products. She is knowledgeable about the ways that the tobacco companies market their products to youth and young adults. Brock received her MPH from the University of Minnesota and her BA from Macalester College. She has publications in various peer-reviewed journals including Tobacco Control. (Endnotes) 1. Campaign for Tobacco-Free Kids. New studies of tobacco industry documents show how industry manipulates products and underscore need for FDA authority over tobacco. 2002. 2. Adams M. Promophobia: Many companies still feel skittish about marketing to the gay community. Incentive. 1999. 3. Philip Morris International. Smoking and health initiatives. Industry Documents Library. 1985. 4. Smith EA and Malone RE. The outing of Philip Morris: Advertising tobacco to gay men. American Journal of Public Health. 2003. 5. Smith EA et al. “If you know you exist, it’s just marketing poison”: Meanings of tobacco industry tactics in the Lesbian, Gay, Bisexual and Transgender community. American Journal of Public Health. 2008. 6. Benson & Hedges. Exploratory qualitative research: Benson & Hedges in the gay market. Industry Documents Library. 2009. 7. Alsop R. Cracking the gay market code: Marketers plant symbols in ads. The Wall Street Journal. 1999. 8. Glissmeyer G et al. Glitter, smoke and mirrors: Tobacco marketing in LGBTQ spaces. The Routledge Handbook of LGBTQIA Administration and Policy. 2018. 9. blu eCigs. She’s being herself in this photo, and she’s absolutely stunning. Twitter. 2016. 10. CDC. Behavioral Risk Factor Surveillance System, Minnesota data. 2015. 11. ClearWay Minnesota and the Minnesota Department of Health. Minnesota Adult Tobacco Survey. 2014. 12. Reddy KP et al. Lung cancer mortality associated with smoking and smoking cessation among people living with HIV in the United States. JAMA. 2017. 13. All Minnesota tobacco users have access to free cessation help through QUITPLAN Services (quitplan.com or 1-888-354-PLAN).

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Environmental Health — Intersections of Reproductive Health and Environmental Justice

n our complex society exposure to environmental toxins is inevitable. These include airborne microparticulates from fossil fuel processing and combustion, toxic wastes containing carcinogenic organics, and heavy metals released into our waters and soils. Additionally, hazardous chemicals are used in everyday products like food packaging, cosmetics, cleaning supplies, and clothing. As one of the social determinants of health, our chemical environment clearly affects the health of our patients and communities. Certain populations and communities are at higher risk of harm from environmental toxics. For example, discriminatory housing policies, racism, and socioeconomic inequities have meant that lower income communities and communities of color locate in more highly polluted areas near industrial sites, incinerators, superfund sites, landfills, and congested highways.1 Recent research into environmental pollutants has implicated specific chemicals in adverse effects on endocrine homeostasis, especially during vulnerable times of development (e.g. pregnancy or puberty).2 New data suggest that a disproportionate burden of toxic exposures experienced by disadvantaged communities may explain some of the reproductive health disparities experienced

By Sarah Traxler, MD, MS, FACOG MetroDoctors

by women of color such as higher rates of preterm birth, low birth weight, and maternal morbidity.3 Endocrine disrupting compounds, a class of chemicals including bisphenols, phthalates, and parabens (used in food packaging, plastic bottles, cosmetics, etc.), can interfere with normal estrogen, androgen, thyroid, neurotransmitter, and glucocorticoid pathways, in turn altering normal development of the reproductive, cardiovascular, skeletal, and central nervous systems. These chemicals have been implicated in fetal anomalies, infertility, subfertility, miscarriage, stillbirth, polycystic ovary syndrome, endometriosis, low birth weight, and some reproductive cancers. In men, exposure is associated with increased incidence of testicular dysgenesis syndrome, hypospadias, cryptorchidism, poor semen quality, and testicular germ cell cancers.4 Reproductive health, social policies, and environmental health are integral to the health outcomes of the families and communities we serve. The Reproductive Justice movement encompasses the ideas that women maintain bodily autonomy — the right to have children or not to have children — and espouses an idea that, to many of us, seems intuitive — that parents have the right to raise children in safe and sustainable communities. The right to have and raise children in safe environments demonstrates one of the intersections of the Reproductive Justice and Environmental

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Justice movements. Efforts by physicians to address reproductive health disparities through clinical care must include advocacy for policies directed at reducing environmental pollution and correcting disparities that imperil our most vulnerable communities. Sarah Traxler, MD, Medical Director, Planned Parenthood Minnesota, North Dakota, South Dakota. References 1. Bullard RD, et al. “Toxic Wastes and Race at Twenty: 1987-2007.” March 2007. 2. Pollack AZ, et al. “Exposure to bisphenol A, chlorophenols, benzophenones, and parabens in relation to reproductive hormones in healthy women: A chemical mixture approach,” Environment International. 2018;120:137-144. 3. Huang H, et al. “Investigation of association between environmental and socioeconomic factors and preterm birth in California,” Environment International. 2018. https://doi. org/10.1016/j.envint.2018.07.027. 4. Gore AC, et al. “Executive Summary to ECD-2: The Endocrine Society’s Second Scientific Statement on Endocrine-Disrupting Chemicals,” Endocrine Reviews. 2015;36:593-602.

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January/February 2019

Nancy Guttormson, MD Receives First a Physician Award On December 6, 2018, Nancy Guttormson, MD, surrounded by colleagues and friends at Fairview Ridges Hospital, was presented with the First a Physician Award by TCMS President, Thomas Kottke, MD. The First a Physician Award was established in 2007, to recognize a member of the medical society who selflessly gives of his/her time and energy to improve the health of their patients, has made a positive impact on organized medicine and the medical community’s ability to practice medicine, and/or has been instrumental in improving the lives of others in our community. The nomination of Dr. Nancy

Guttormson met all of these criteria. She is described as a highly skilled head and neck endocrine and breast surgeon, doing more head and neck endocrine cases than any other surgeon within the Fairview system. Dr. Guttormson From left: Dr. John Houghland, Chief of Staff, Fairview Ridges is focused on atten- Hospital; Dr. Thomas Kottke, 2018 TCMS President; Dr. Nancy Guttormson, recipient; Dr. Sabeen Askari, nominator; Dr. Paul tion to detail with a Kettler, VPMA. commitment to foltogether experts from outside the system low-up on case findings, often bringing and throughout the Twin Cities to collaborate on best treatment plans; she’s humble, genuine and caring. Senior Physicians Association She is a leader — serving as Chief of Winter Meeting Staff, Chair of the Credentials Committee and served on many other medical staff Tuesday, January 15, 2019 committees; she pioneered the thyroid Join your friends and colleagues for lunch, conversation and an interesting presencancer program, helped establish the Breast tation by Jakob Tolar, MD, PhD, Dean, University of Minnesota Medical School, Center at Fairview Ridges Hospital, and a on Tuesday, January 15, 2019. breast multidisciplinary tumor board. And, a teacher — educating and in“The Current State of the Medical School spiring medical students and the nursing and Vision for the Future” staff, as well as hosting forums on breast 11:30 a.m. – Social Hour cancer for members of the community. 12 noon – Lunch This quote is taken from the nomi12:20 p.m. – Business Meeting; Update from Ruth Parriott, nation letter: TCMS CEO “In today’s business of health care where 12:30 p.m. – Guest Presentation by Jakob Tolar, MD, PhD the focus is on specialty care, Dr. Guttormson has somehow managed to Location: Broadway Ridge NE 3001 Broadway Street NE provide quality, specialized care in the Lower Level Conference Room D good-old family physician style where Minneapolis, MN 55413 the patient comes first.” The Twin Cities Medical Society Board Cost: $25; Invite a guest to join you! of Directors is honored to recognize this Register online at: www.metrodoctors.com/spa-winter-2019 unsung hero for her dedicated and untirQuestions? Contact Nancy Bauer at (612) 623-2893; nbauer@metrodoctors.com ing service to the profession of medicine. Congratulations, Dr. Guttorsom.

January/February 2019

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The Journal of the Twin Cities Medical Society

Physician Advocacy Network: Their Biggest Year Yet

he Physician Advocacy Network (PAN) is celebrating a successful 2018 as we come to the close of the program’s fourth year. This year we educated over 1,800 physicians, teachers and other health professionals from across the state about e-cigarettes and tobacco cessation. We continued to work to reduce tobacco-related health inequities by partnering with the American Lung Association in Minnesota on ways to reduce tobacco use among people with mental health and substance use conditions, and with the Institute for Clinical Systems Improvement to share best practices in cessation with FQHCs and community-based clinics. The PAN also supported the work of 17 communities as they passed policies By Annie Krapek, PAN Project Manager

like Tobacco 21 and restricting flavored tobacco products this year. These successes would not have been possible if not for the 300 physicians, residents and medical students who advocated on behalf of these life-saving policies. We will continue to fight to reduce the harm of tobacco in Minnesota in the new year, but we need your help. Young people continue to vape at alarming rates. It is more urgent than ever that we raise the tobacco age to 21 and restrict flavored tobacco products at the state level. Minnesota’s largest tobacco cessation resource, QUITPLAN Services, will close in 2020 when its funding from the tobacco lawsuit settlement expires. The Minnesota legislature must act now to establish a new cessation program, or Minnesota smokers will be left without this critical resource. We see time and time again that when

physicians speak out, lawmakers listen. I hope you will join us in advocating for these essential policies in 2019. To get involved you can sign up for action alerts at www.panmn.org/action-alerts or contact Annie Krapek at akrapek@metrodoctors. com. Thank you for all you do to make Minnesota a healthier state.

PAN staff (from left): Annie Krapek, Program Manager; Amber Kerrigan, Program Coordinator; and Kate Feuling Porter, Intern.

Honoring Choices Celebrates a Banner Year!

onoring Choices had a successful year in 2018, continuing to grow awareness of Advance Care Planning (ACP) in Minnesota. The program works in two realms: educating and informing the general public, and training healthcare professionals and advising healthcare sites on ACP best practices. Coordinating a team of trained volunteers, Honoring Choices led 34 public presentations, presented at three conferences, and participated in eight health fairs last year. This meant over 2,000 Minnesotans heard about the importance of ACP. Many of them were given the opportunity for a follow-up individualized meeting to talk through their goals and values related to By Karen Peterson, Honoring Choices Executive Director

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future healthcare decisions, as well as complete a health care directive. Working in the professional world, Honoring Choices supported ongoing ACP efforts and held 11 classes to train 150 practicing physicians, nurses, social workers and chaplains to hone their ACP skills. Future practitioners also received instruction from Honoring Choices. ACP orientation efforts are increasing at the University of Minnesota Schools of Medicine, Nursing, and Healthcare Administration. ACP is now a regular part of first year medical students’ clerkship program, and fourth year medical students’ ICU orientation. This means we reach every medical student twice during their fouryear educational pathway. In addition, guest lecturing in the nursing program has

The Journal of the Twin Cities Medical Society

allowed Honoring Choices to lead every nursing student in both the bachelors and masters programs to a better understanding of their role in ACP. All together, over 700 future healthcare professionals are learning about ACP, helping them enter their careers with an understanding of this important topic.

Honoring Choices Executive Director Karen Peterson presents at the North Suburban Evening Lions Club.

January/February 2019

You (Your Organization) Can Make a Difference Caring Hearts Supply Drive for Homeless People is an annual event to collect personal hygiene items, over-the counter and prescription medications for adults experiencing homelessness in the St Paul area. During the month of February, clinics and hospitals simply put out a collection box and encourage staff and/ or patients to donate an item(s). At the end of the month, all donations can be brought to either St. Josephâ&#x20AC;&#x2122;s Hospital in St. Paul or to the Twin Cities Medical Society office in Minneapolis. Have your site representative contact Nancy Bauer, Twin Cities Medical Society Foundation at (612) 6232893 or NBauer@metrodoctors.com to express your interest. Materials will be sent to you in January, including shopping lists and flyers to advertise the drive.

All donated items are distributed to the homeless through the following two programs: West Sideâ&#x20AC;&#x2122;s Health Care for the Homeless, providing primary and behavioral health care, and Continuum Care, providing substance abuse case management, care coordination and peer support. Sponsored by HealthEast Care System and Twin Cities Medical Society Foundation.

26th Annual Supply Drive February 2019

In Memoriam MALCOLM BLUMENTHAL, MD, passed away on November 14, 2018. Dr. Blumenthal practiced Allergy and Immunology in downtown Minneapolis, was a professor in this field at the University of Minnesota, and an internationally recognized expert. Dr. Blumenthal joined the medical society in 2010. REINHOLD GOEHL, MD, passed away on September 16, 2018. He was an OB-GYN practicing at OB-GYN Associates, Ltd. and HealthPartners/Group Health. Dr. Goehl joined the medical society in 1968. PAUL HARTIG, MD, passed away on September 3, 2018. Dr. Hartig had a urology practice in Minneapolis and was a charter member of the Fairview Southdale Medical Staff. He served as President and Chairman of the (former) Hennepin County Medical Society. Dr. Hartig became a member of the medical society in 1964. LESLIE JACOBSON, MD, passed away on September 17, 2018. Dr. Jacobson was an ophthalmologist practicing at Southdale Eye Clinic. He joined the medical society in 1965.

January/February 2019

LOWELL KLEVEN, MD, passed away on October 2, 2018. Dr. Kleven was a partner at Northwest Orthopedics, specializing in hand surgery. He joined the medical society in 1966. CHARLES MARVIN, JR., MD, passed away on October 7, 2018. Dr. Marvin was a plastic and reconstructive surgeon. He joined the medical society in 2017. S. SCOTT NICHOLAS, MD, passed away on October 17, 2018. An allergist, Dr. Nicholas was a Senior Partner at Eisenstadt Allergy & Asthma until 2018. He was a Clinical Professor at the University of Minnesota Medical School. Dr. Nicholas joined the medical society in 1969. JOSEPH SPRAFKA, MD, passed away on October 14, 2018. He practiced surgery at St. Paul Surgeons, Ltd. Dr. Sprafka joined the medical society in 1950. BARBARA SUBAK, MD, passed away on October 29, 2018. One of four women in her medical school class of 1956, she was a founder of Parkside Clinic, a women-run, private, family practice clinic. Dr. Subak joined the medical society in 1957.

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| January/February 2019

LUMINARY of Twin Cities Medicine By Marvin S. Segal, MD

JUNE LAVALLEUR, MD Could it have been the early agrarian background of our Luminary that encouraged her to somehow gather the “seeds of knowledge” and then to widely “disseminate and plant” them? Ashby, a farm town of <450 souls in West Central Minnesota, was the childhood home of Dr. June LaValleur in the 1950s. Her long, circuitous and unconventional pathway to and through the world of medicine began after first becoming her high school’s valedictorian and then a wife and mother of three sons. Her scientific interest and aptitude led this working mom to become a laboratory technician for 10 years until she was accepted to the physician assistant (PA) program at St. Cloud State University — eventually, and after working six years as a PA, earning her bachelor’s degree with Magna Cum Laude honors. And, as interesting as this history was, here’s where it really becomes fascinating . . . June, at the age of 41 became a student at our U of M Medical School (then, the oldest person ever accepted)! The “balancing act” required between her homemaker responsibilities and her studies was not easy. Dr. June modestly now states, “Something was driving me to accomplish my goals; ya do what ya have to do!” Her med school years were successful as evidenced by the bestowing of the Minnesota Medical Foundation Outstanding Student Award and upon graduation her acceptance to the four-year residency in Ob/ Gyn at her alma mater where she was further honored with a Resident of the Year Award. She chose Ob/Gyn as a specialty because of her positive surgical experience as a PA, though during her residency as a peri-menapausal woman, she became particularly interested in learning more about menopause and related challenges of aging women. Dr. LaValleur noted that little time and emphasis was spent on those topics during the training of young physicians, and — with her usual energetic gusto — she set out to correct that deficit as an academic gynecologic physician on the faculty of her medical school. June’s next nearly 20 years of teaching and meaningful clinical research were spent enriching her already significant fund of knowledge and sharing that wisdom with students, residents, colleagues, patients and — more recently with — the lay public. She was the Director of the Division 32

January/February 2019

of General Gynecology and the long-standing Director of the Mature Women’s Center. Numerous recognitions were awarded along the way for her remarkable contributions. Her interest in issues of aging have more recently evolved into matters of sexuality, a subject which is all-too-often not volunteered by patients nor triggered by clinicians. Her more recent formal education in sexual medicine has resulted in an even greater appreciation of its importance and resulted in her sub-specialty certification in this field. Meaningful “pearls of wisdom” that the good doctor holds dear and shares in her hundreds of teaching encounters include: “We must pay attention to the ‘whole’ person;” “Don’t be reluctant to speak, I’ll be there to listen;” “Build trust by being non-judgmental;” “These problems aren’t so unique, rather are as usual as encountered with other health difficulties;” “Touching is an important element in the psychology of sexual health.” Dr. June LaValleur’s thirst for knowledge continues, even in her semi-retired state. Her interest in the development of medical school Chairs in Sexual Health Education and continuing numerous presentations on this subject have occupied much of her recent time as she searches out “my next career, where I might have an even bigger effect.” Yes, we are pleased that our Luminary continues to “gather and plant important seeds of knowledge” in much the same fashion as that small town girl began over a half century ago. This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine. Please forward names of physicians you would like considered for this recognition to Nancy Bauer, Managing Editor, nbauer@metrodoctors.com.

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PRACTICE YOUR PASSION AS A U.S. ARMY PHYSICIAN

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