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Making friends and finding social opportunities can sometimes be difficult, particularly for children with neurodevelopmental disabilities, such as autism spectrum disorder, attention deficit hyperactivity disorder, or an intellectual disability. Here’s what parents can do to help.

Building inclusive communities

Friendships and social connections are an important aspect of our lives. They provide a sense of belonging and allow people to be included in their communities.

People with neurodevelopmental disabilities may communicate, learn, and behave differently. Sometimes these differences make it harder than usual to develop friendships and participate in social activities.

But parents and others can help create more inclusive communities and opportunities to build social relationships, especially for people with neurodiverse abilities.

Below are some tips and strategies to help children learn and develop the social and emotional skills they need to make friends.

Practice at home: Tips for common social situations

Navigating social settings and making friends involve many skills you can practice with children at home.

• Greetings and questions. Make a habit of practicing greetings throughout the day. Model good listening for your child, and take turns asking and answering conversation starters like, “How are you?”
• Calm body movements. Sometimes it can be hard for children with neurodevelopmental disabilities to keep a calm body. Have your child practice giving their body enough room and keeping personal space between themselves and others by using an arm’s-length distance.
• Appropriate level of voice. Encourage your child to listen and match the level of your voice. Imagine your voice has a volume dial and practice turning the volume up and down.
• Eye contact. Looking directly into someone’s eyes can be difficult, so help your child instead look at different parts of your face or practice looking at their own eyes in the mirror.
• Reading and responding to social signals. People regularly communicate using more than just words. Social signals are the variety of ways in which we communicate through body language and facial expressions. Often this can be tricky to detect for children who are neurodiverse. Help your child recognize common social signals by asking what someone’s body or face might be saying.

Rerouting challenging behaviors to help children build friendships

Challenging behaviors may get in the way of making and keeping friends. It is important to address challenging behaviors like impulsivity and aggression through therapies and programming. Additionally, practicing the following fundamental skills can help reduce challenging behaviors.

• Patience. Learning how to wait for a turn to play or a time to speak in a conversation is an important social skill. Practice waiting with a timer, gradually building up from 10 seconds, to one minute, to five minutes.
• Flexibility. Help your child make compromises using first/then statements, such as, “First we play your way, then my way.” Model flexible play and redirect with new toys to show how play can evolve.
• Communicating strong emotions.Handling strong feelings can be difficult sometimes. Practice communicating these feelings effectively either by asking for help, using an emotions board, or taking a break.

How to throw a wide net socially

Encouraging social opportunities is an important part of supporting friendships and social relationships for children with neurodevelopmental disabilities. Social spaces offer chances for children who are neurodiverse to find activities they enjoy. They are able to practice the social and emotional skills they are learning and even meet other children practicing these same skills.

• Structure and organize play dates. Set up the environment before a play date by making a list of activities to do with a friend, then picking out of a hat which activities to do and in what order.
• Make a list of things that are fun to do and invite others to join. Look for free or low-cost programs or events out in the community.
• Connect with other parents of children with disabilities. Set up an activity for your children like an ice cream date, going on a walk, or a game night with adults and kids together. These encounters can give rise to repeat, planned social interactions.
• Check out organizations in the community for children with disabilities, like Special Olympics, or recreational programs that foster inclusive environments through Unified Sports.
• Look into facilitated recreational activities like a Lego club or pizza parties with teachers. Plan to bring a support person if needed.

Your child’s doctor or teacher may be able to suggest additional community or web-based resources designed to help families support friendships for children with neurodiverse abilities.

About the Authors

Sydney Reynders, ScB, Contributor

Sydney Reynders, ScB, is a clinical research coordinator in the Boston Children’s Hospital Down Syndrome Program. She assists in research investigating educational, behavioral, and medical interventions in Down syndrome and other neurodevelopmental disorders. She received her … See Full Bio View all posts by Sydney Reynders, ScB

Nicole Baumer, MD, MEd, Contributor

Nicole Baumer, MD, MEd is a child neurologist/neurodevelopmental disabilities specialist at Boston Children's Hospital, and an instructor in neurology at Harvard Medical School. Dr. Baumer is director of the Boston Children's Hospital Down Syndrome Program. She … See Full Bio View all posts by Nicole Baumer, MD, MEd

We all want our child to have friends. We want them to be happy, and to build the social skills and connections that will help them now and in the future.

Sometimes, and for some children, making friends isn’t easy. This is particularly true after the COVID-19 pandemic. Because of isolation and remote school, many children either didn’t learn the skills they need to make friends — or those skills got rusty.

Here are some ways parents can help.

Start at home: Learning relationship skills

Making and keeping friends involves skills that are best learned at home with your family. Some of them include:

• Empathy. Make sure that everyone in the family treats each other fairly and with kindness. Sometimes we turn a blind eye to sibling fights, or feel justified in snapping at our partner when we have had a long day. No matter what we say, our children pay attention to what we do.
• Curiosity about others. Make a family habit of asking each other about their day, their interests, their thoughts.
• Communication skills. These days, devices endanger the development of those skills. Shut off the devices. Have family dinners. Talk with each other.
• Cooperation. Do projects, play games, and do chores as a family. Work together. Help your child learn about taking turns and valuing the input of others.
• Regulating emotions. It’s normal to have strong feelings. When your child does, help them find ways to understand big emotions and manage them.
• Knowing when and how to apologize — and forgive. This really comes under empathy, but teach your child how to apologize for their mistakes, make amends, and forgive the mistakes of others.

All of these apply also to how you and your partner talk about — or with — other people in front of your children, too!

Be a good role model outside the home, too

When you are outside your home, be friendly! Strike up conversations, ask questions of people around you. Help your child learn confidence and strategies for talking to people they don’t know.

Make interactions easier

Conversations and interactions can be easier if they are organized around a common interest or activity. Here are some ways parents can help:

• Sign your child up for sports or other activities that involve their peers. Make sure it’s something they have at least some interest in doing.
• Get to know the parents of some of your child’s peers — and invite them all to an outing or meal. It could allow the children to get to know each other while taking some of the pressure off.
• When planning playdates, think about fun, cooperative activities — like baking cookies, or going to a park or museum.

Keep an eye on your child — but don’t hover

Ultimately, your child needs to learn to do this — and you don’t want to embarrass them, either. The two exceptions might be:

• If the children aren’t interacting at all, you might want to suggest some options for activities. Facilitate as necessary, and step back out again.
• If there is fighting or meanness on either side, you should step in and make it clear that such behavior isn’t okay.

Keep an open line of communication, and be supportive

Talk with your child regularly about their day, about their interactions, and how things made them feel. Listen more than you talk. Be positive and supportive. Remember that part of being supportive is understanding your child’s personality and seeing the world from their eyes. You can’t make your child someone they are not.

If your child keeps struggling with making friends, talk to your doctor

All parents need help sometimes — and sometimes there is more to the problem than meets the eye. This is particularly true if your child has ADHD or another diagnosis that could make interactions more challenging.

For information on supporting friendships at different ages, check out the advice from the American Academy of Pediatrics.

Follow me on Twitter @drClaire

About the Author

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

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

Low energy, brain fog, and lung problems are a few of the lingering aftereffects reported by some people who have had COVID-19. Could gut troubles also fall among the constellation of chronic symptoms that people with long-haul COVID experience? And if so, what do experts suggest to help ease this?

What happens to the gut during a COVID infection?

As we head into the fourth year since COVID-19 became a global health emergency, hundreds of millions of people around the globe have been infected with the virus that causes it. Since 2020, we’ve known that the virus particles that cause lung illness also infect the gastrointestinal (GI) tract: the esophagus, stomach, small intestines, and colon. This can trigger abdominal pain and diarrhea, which often — but not always — clear up as people recover.

We know chronic gut problems such as irritable bowel syndrome (IBS) sometimes occur even after illness caused by microorganisms like Campylobacter and Salmonella are cured. Could this happen with COVID-19?

What is long COVID?

While most people who get COVID-19 will survive, medical science is becoming aware of a group of people suffering from lasting declines in health. Well-reported long COVID aftereffects include tiredness, breathing difficulty, heart rhythm changes, and muscle pain. But few people, even in the medical field, are aware that long COVID symptoms may include chronic diarrhea and abdominal pain.

Why might the gut be involved in long COVID?

It is not clear why chronic gut symptoms might occur after a COVID-19 infection. One possible insight is a well-known syndrome called post-infectious irritable bowel syndrome (IBS) that may occur after a stomach flu (gastroenteritis).

Long after the bug causing the illness is gone, a change in gut-brain signaling may occur. A complex network of nerves connects the gut and the brain, and controls communication between different parts of the gut. These nerves tell body organs to produce digestive juices, alert you to the need to go to the bathroom, or prevent you from having another serving of stuffing at the Thanksgiving table.

The nerve network of the gut is so complicated that it is sometimes called the second brain. When the nerves are working well, you won’t notice a thing: you eat without pain, you move your bowels with ease, you have no GI worries. But what if the nerves are not working well? Then, even if the process of digestion remains normal, you may frequently have symptoms like pain or a distressing change in your bowel movements, such as diarrhea or constipation.

Once known as functional GI disorders, these health problems are now called disordered gut-brain interactions (DGBIs). When viruses and bacteria infect the gut, experts believe they may prompt a change in gut-brain signaling that can cause a DGBI like IBS to develop.

What to do if you’re noticing long-lasting gut problems after COVID-19 infection

We still do not know conclusively if COVID-19 can cause a long-term change in gut-brain messaging that leads to IBS or other disordered gut-brain interactions. But increasing evidence suggests that GI distress lasting six months or longer might be a symptom of long COVID. While we wait for more evidence, some GI specialists, including myself, recommend trying approaches that help relieve irritable bowel syndrome and other DGBIs.

If you are suffering from chronic abdominal pain and a change in your bowel movements after having had COVID-19, talk to your primary care doctor. Many health conditions have similar symptoms, including viral or bacterial infections, inflammation, or even cancers. A thorough exam can help to rule out certain conditions.

If the problem persists, do not suffer alone or feel embarrassed to act! Seek help if severe pain or changes in bowel movements are harming your quality of life or affecting daily activities. Talk with your doctor about the possibility that your chronic gut symptoms might be a form of long COVID. Find out if they can recommend helpful treatments or suggest a referral to a GI specialist. As research continues, new information may be available.

About the Author

Christopher D. Vélez, MD, Contributor

Dr. Christopher Vélez is an attending gastroenterologist in the Center for Neurointestinal Health of Massachusetts General Hospital's division of gastroenterology and the MGH department of medicine. He focuses on neurogastroenterology and motility disorders of the esophagus, … See Full Bio View all posts by Christopher D. Vélez, MD

When I worked at Greenpeace for five years before I attended medical school, a popular slogan was, “Think globally, act locally.” As I write this blog about climate change and hay fever, I wonder if wiping off my computer that I’ve just sneezed all over due to my seasonal allergies counts as abiding by this aphorism? (Can you clean a computer screen with a tissue?)

Come to think of it, my allergies do seem to be worse in recent years. So do those of my patients. It seems as if I’m prescribing nasal steroids and antihistamines, recommending over-the-counter eye drops, and discussing ways to avoid allergens much more frequently than in the past. Are people more stressed out, working harder, sleeping less, and thus more susceptible to allergies? Or, are the allergies themselves actually worse? Could the worsening of climate change explain why the rates of allergies and asthma have been climbing steadily over the last several decades?

There’s more pollen and a longer pollen season

Seasonal allergies tend to be caused disproportionately by trees in the spring, grasses in the summer, and ragweed in the fall. The lengthening interval of “frost-free days” (the time from the last frost in the spring to the first frost in the fall) allows more time for people to become sensitized to the pollen — the first stage in developing allergies — as well as to then become allergic to it. No wonder so many more of my patients have been complaining of itchy eyes, runny nose, and wheezing.

In many places in the United States, due to climate change, spring is now starting earlier and fall is ending later, which, yearly, allows more time for plants and trees to grow, flower, and produce pollen. This leads to a longer allergy season. According to a study at Rutgers University, from the 1990s until 2010, pollen season started in the contiguous United States on average three days earlier, and there was a 40% increase in the annual total of daily airborne pollen. More recent research in North America shows rising concentrations of sneeze-inducing pollens and lengthening pollen seasons from 1990 to 2018, largely driven by climate change.

Climate change is increasing the potency of pollen

In addition to longer allergy seasons, allergy sufferers have other things to fret about with climate change. When exposed to increased levels of carbon dioxide, plants grow to a larger size and produce more pollen. Some studies have shown that ragweed pollen, a main culprit of allergies for many people, becomes up to 1.7 times more potent under conditions of higher carbon dioxide. With warming climates, the geographic distribution of pollen-producing plants is expanding as well; for example, due to warmer temperatures, ragweed species can now inhabit climates that were formerly inhospitable.

Other unfortunate consequences of climate change, which we are already witnessing, include coastal flooding as the arctic ice sheets melt, causing the sea levels to rise; and more extreme weather, such as storms and droughts. With the increased coastal flooding, mold outbreaks are more common, which can trigger or worsen allergic reactions and asthma. More extreme weather events, such as thunderstorms, are associated with an increase in emergency department visits for asthma attacks. (It is unclear why this is the case, but one theory suggests that the winds associated with thunderstorms kick up a tremendous amount of pollen.) Allergies and asthma are closely associated, with many people, this author included, having “allergic asthma” that is likely to worsen as climate change progresses.

So what can an allergy sufferer do?

Even as the allergic environment changes in conjunction with our climate, there are steps you can take to manage the impact of seasonal allergies and reduce sneezing and itchy eyes.

• Work with your doctor to treat your allergies with medications such as antihistamines, nasal steroids, eye drops, and asthma medications if needed. If you take other medications that may interact with over-the-counter allergy medications such as Benadryl or Sudafed, let your doctor know.
• Discuss with your doctor whether you would benefit from allergy testing, a referral to an allergist, or prevention methods like allergy injections or sublingual immunotherapy, which, by exposing your body in a controlled manner, slowly conditions your immune system not to respond to environmental allergens.
• Track the local pollen count and avoid extended outdoor activities during peak pollen season, on peak pollen days. However, most doctors would agree that it isn’t healthy to cut back on exercise, hobbies, or time in nature, so this is a less than satisfying solution at best. You could plan for an indoor exercise program on high-pollen days.
• Wash clothing and bathe or shower after being outdoors to remove pollen.
• Close windows during peak allergy season or on windy days.
• Wear a mask when outdoors during high pollen days, and keep car windows rolled up when driving.
• If your house has been flooded, be on the lookout for mold. There are services that you can hire that will inspect your home for mold, and remove the mold if it is thought to be harmful.
• Have as small a carbon footprint as possible and plant trees. Even though they are responsible for some of the pollen that many of us choke and gag on each spring, summer, and fall, trees contribute to their environment by taking in carbon dioxide and producing the oxygen we breathe, thereby improving air quality. We have to protect and plant trees, even as allergy sufferers, as climate change is arguably the biggest threat that we, as a species, now face.

About the Author

Peter Grinspoon, MD, Contributor

Dr. Peter Grinspoon is a primary care physician, educator, and cannabis specialist at Massachusetts General Hospital; an instructor at Harvard Medical School; and a certified health and wellness coach. He is the author of the forthcoming book Seeing … See Full Bio View all posts by Peter Grinspoon, MD

Three months into the year is a good time to recalculate if you’ve been slacking on your resolution to eat healthy. And if you’ll be leaving home base or school soon and foraging for yourself (plus or minus roommates), it’s a great time to learn about healthy, low-cost choices for your grocery list.

The basics: A weekly shop

A healthy diet is rich in vegetables, fruits, legumes (beans or lentils), whole grains, nuts, seeds, lean proteins, and low-fat dairy products. Trying to fill your cart with all of those goodies can feel overwhelming. But just think in terms of twos.

“Get two fruits and two vegetables of different colors, and two types of lean protein — such as fresh, frozen, or canned fish, chicken or lean ground turkey, or plant-based options,” suggests Nancy Oliveira, a registered dietitian and manager of the Nutrition and Wellness Service at Harvard-affiliated Brigham and Women’s Hospital.

Oliveira also recommends getting two foods in each of these categories on your weekly shopping trip:

• plant proteins, such as canned or dried beans, tofu, tempeh, veggie burgers, or unsalted nuts or seeds
• whole grains, such as whole-grain bread, whole-grain pasta, brown or black rice, quinoa, or farro
• dairy or nondairy milk items, such as nonfat Greek yogurt or cheese.

Go ahead and add one or two healthy treats or snacks, such hummus or dried apricots.

Do you need to choose organic foods?

Organic produce is grown without synthetic fertilizers and pesticides, which are linked to many health problems. While US scientists debate whether foods grown with organic fertilizers (such as animal waste) are safer for your health, other countries, including European Union nations, have banned or phased out synthetic pesticides still used in the United States.

That doesn’t mean that everything you buy must be organic. But try to stay away from conventionally grown produce with thin skins, such as strawberries, spinach, kale, peaches, and grapes. They tend to absorb more chemicals compared to produce with thick skins, such as avocados or pineapples.

The Environmental Working Group creates an annual list to help shoppers avoid high-pesticide produce, and another one that highlights the least contaminated produce.

Buying cost-conscious fresh food and staples

Healthy food, especially organic produce, has a reputation for being expensive. But it doesn’t have to be. Just do a little comparison shopping, and follow Oliveira’s tips to save money on a grocery run:

• Shop in a smaller store with fewer choices.
• Never enter a store hungry, since you might buy more than you normally would.
• Carry a shopping list and stick to it.
• Go directly to the aisles you need. Avoid browsing elsewhere, which may lead to extra purchases.
• Be flexible, have several options within your food categories, and go with sale items.
• Always check the day-old produce cart that offers perfectly edible fresh produce at 50% to 75% off regular prices.
• Buy unseasoned canned or frozen whole foods such as vegetables, chicken, or fish (salmon, sardines, tuna), which are often cheaper than fresh versions.
• Wait for sales of healthy nonperishable staples like quinoa, brown rice, whole-grain pasta, and high-fiber cereals.
• Use coupons and coupon apps.

Easy healthy snacks to reach for

Move on from easy grab-n-go snacks, which are typically processed foods. They often contain unhealthy ingredients and promote overeating. Instead, Oliveira suggests keeping healthy snacks on hand, such as:

• unsalted mixed nuts
• string cheese
• grapes and berries (rinse before eating)
• clementines, bananas, or other fruits that don’t need washing
• a rice cake with nut butter or hummus
• fat-free Greek yogurt
• a peeled hard-boiled egg.

“To save money, buy certain foods in larger amounts when possible, such as an 8-ounce bar of cheese that you slice into small cubes and store in a sealed container in the fridge,” Oliveira says.

Crowdsource shopping tips and savings

Don’t be shy about asking for shopping tips from friends and family members who’ve already developed shortcuts, and grocery store staffers who can offer insider advice.

You can also turn to apps for help. Oliveira recommends two faves:

• Mealime is a meal-planning app with simple, healthy plant-based recipes that automatically create grocery lists for the ingredients.
• List Ease creates lists for grocery runs. You can search for items to add or scan barcodes to add to lists.

“And if you prefer not to use apps, just jot down notes after a quick pantry or fridge inventory, or text yourself every time you remember something you need,” Oliveira advises. “With a little practice, you’ll quickly work out the best system for you.”

About the Author

Heidi Godman, Executive Editor, Harvard Health Letter

Heidi Godman is the executive editor of the Harvard Health Letter. Before coming to the Health Letter, she was an award-winning television news anchor and medical reporter for 25 years. Heidi was named a journalism fellow … See Full Bio View all posts by Heidi Godman

About the Reviewer

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Howard LeWine, M.D., is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

In today’s fast-paced world, our waking hours are filled with decisions — often surrounding what to eat. After a long day, dinner could well be fast food or takeout. While you may worry about the toll food choices take on your waistline or blood pressure, as a liver specialist, I also want to put fatty liver disease on your radar.

One variant, officially called nonalcoholic fatty liver disease (NAFLD), now affects one in four adults globally. Sometimes it progresses to extensive scarring known as cirrhosis, liver failure, and higher risk for liver cancer. The good news? Fatty liver disease can be prevented or reversed.

What is fatty liver disease?

Fatty liver disease is a condition caused by irritation to the liver. Liver tissue accumulates abnormal amounts of fat in response to that injury. Viral hepatitis, certain medicines (like tamoxifen or steroids, for example), or ingesting too much alcohol can all cause fatty liver disease.

However, NAFLD has a different trigger for fat deposits in the liver: a group of metabolic risk factors. NAFLD is most common in people who have high blood pressure, high cholesterol, insulin resistance (prediabetes), or type 2 diabetes. It is also common among people who are overweight or obese, though it is possible to develop NAFLD even if your body mass index (BMI) is normal.

What helps prevent or reverse NAFLD?

Diet can play a huge role. Because NAFLD is so closely tied to metabolic health, eating more healthfully can help prevent or possibly even reverse it. A good example of a healthful eating pattern is the Mediterranean diet.

Overweight or obesity is a common cause of NAFLD. A weight loss program that includes activity and healthy eating can help control blood pressure, cholesterol, and blood sugar. Among the many healthful diet plans that help are the DASH diet and the Mediterranean diet. Talk to your doctor or a nutritionist if you need help choosing a plan.

To vigorously study any diet as a treatment for fatty liver disease, researchers must control many factors. Currently, no strong evidence supports one particular diet over another. However, the research below highlights choices to promote a healthy liver.

Avoid fast food

A recent study in Clinical Gastroenterology and Hepatology linked regular fast-food consumption (20% or more of total daily calories) with fatty liver disease — especially in people who had type 2 diabetes or obesity. Fast foods tend to be high in saturated fats, added sugar, and other ingredients that affect metabolic health.

Steer clear of soft drinks and added sugars

Soft drinks with high-fructose corn syrup, or other sugar-sweetened beverages, lead directly to large increases in liver fat deposits, independent of the total calories consumed. Read labels closely for added sugars, including corn syrup, dextrose, honey, and agave.

Instead of sugary drinks, sip plain water. Black coffee or with a splash of cream is also a good pick; research suggests coffee has the potential to decrease liver scarring.

Avoid alcohol

Alcohol directly damages the liver, lacks nutritional value, and may affect a healthy microbiome. If you have NAFLD, it’s best to avoid any extra cause for liver injury. We simply do not know what amount of alcohol is safe for those with fatty liver disease — even social drinking may be too much.

Eat mostly whole foods

Vegetables, berries, eggs, poultry, grass-fed meats, nuts, and whole grains all qualify, but cutting out red meat may be wise. An 18-month trial enrolled 294 people with abdominal obesity and lipid imbalances such as high triglycerides. Regular activity was encouraged, and participants were randomly assigned to one of three diets: standard healthy dietary guidelines, a traditional Mediterranean diet, or a green-Mediterranean diet. (The green-Med diet nixed red and processed meats and added green tea and a dinner replacement shake rich in antioxidants called polyphenols.)

All three groups lost some weight, although the Mediterranean diet groups lost more weight and kept it off for a longer period. Both Mediterranean diet groups also showed reduced liver fat at the end of 18 months, but liver fat decreased twice as much in the green-Med group as in the traditional Mediterranean diet group.

Healthy fats are part of a healthy diet

We all need fat. Dietary fats help your body absorb vitamins and are vital in the protection of nerves and cells. Fats also help you feel satisfied and full, so you’re less likely to overeat. Low-fat foods often substitute sugars and starches, which affect blood sugar regulation in our bodies. But all fat is not created equal.

It’s clear that Mediterranean-style diets can help decrease liver fat, thus helping to prevent or possibly reverse NAFLD. These diets are high in healthful fats, such as monounsaturated fats found in olive oil and avocados and omega-3 fats found in walnuts and oily fish like salmon and sardines.

With so many choices, it’s hard to know where to start in the healthy eating journey. Let’s strive to eat whole foods in their natural state. Our livers will thank us for it.

About the Author

Kathleen Viveiros, MD, Contributor

Dr. Kathleen Viveiros is a clinical hepatologist at Brigham and Women’s Hospital who sees patients in Boston and in Foxborough and Westwood, MA. She is an instructor in medicine at Harvard Medical School. Her professional interests … See Full Bio View all posts by Kathleen Viveiros, MD

The transgender population is steadily increasing. Last year, investigators reported that 1.3% of people between the ages of 18 and 24 in the United States identify as transgender, compared to 0.55% of the country’s older adults. This trend has implications for public health, and one issue in particular concerns the risk of prostate cancer in transgender women.

Because removing the prostate can lead to urinary incontinence and other complications, doctors leave the gland in place when initiating hormonal treatments to induce female sex characteristics in transitioning people. This process, which is called feminizing or gender-affirming hormonal therapy (GAHT), relies on medications and surgery to block testosterone, a male sex hormone. Prostate cancer is fueled by testosterone, and therefore GAHT lowers overall risks for the disease. But transgender women can still develop prostate cancer in ways that remain poorly understood, according to the authors of a new paper.

“More individuals are openly identifying as transgender, particularly as advances are made in reducing the discrimination and marginalization that this group has faced,” says Dr. Farnoosh Nik-Ahd, a urologist at the University of California, San Francisco, and the paper’s first author. “Thus, it’s important to understand their health outcomes and how best to care for this population.”

Dr. Nik-Ahd and her colleagues wanted better insights into prostate cancer incidence and screening rates among transgender women, so they performed a comprehensive review of the literature that generated some notable findings. One is that that the prevalence of GAHT in the transgender population is still unknown. Some studies put the figure at roughly one in every 12,000 to 13,000 people who identify as transgender. But this is likely an underestimate, the authors claim, and it’s not broken out by sex.

Questions over GAHT

Similarly, little is known about the impact of GAHT on the likelihood of developing prostate cancer, the team reported. Prostate cancer rates do appear to be lower among transgender women than they are among cisgender men (men whose gender identify matches their sex at birth). For instance, one study found just a single case of prostate cancer among 2,306 transgender women receiving routine health care at a clinic in Amsterdam, Holland, between 1975 and 2006. Another study, also from Holland, detected six cases of prostate cancer among 2,281 transgender women over 17 years, which again is less than the comparable rate among cisgender men.

But the interpretation of these rates is limited by the fact that transgender women often experience barriers to care. Nearly a third of them live in poverty, and many avoid the health system for fear of mistreatment. Some scientists suspect that estrogen given during GAHT may somehow contribute to prostate cancer development when given over long durations. However, more confirmatory evidence is needed. Worryingly, one study found that survival among transgender women with prostate cancer is worse than it is in cisgender men with the disease, yet that research lacked data on GAHT use.

Interpreting PSA values for specific populations

Dr. Nik-Ahd’s team was especially concerned about the lack of guideline recommendations for prostate-specific antigen (PSA) screening in the transgender population. None of the available guidelines worldwide mention transgender women, and the PSA cutoff of 4 nanograms per milliliter (ng/mL) of blood — which raises suspicions for prostate cancer — is specific to cisgender men. PSA levels ordinarily plummet in people taking GAHT, so the limit for what’s considered normal in transgender women should be capped at 1.0 ng/mL, the researchers propose. In the absence of more specific guidance, they also recommend that people meeting age criteria for PSA screening get tested before starting on GAHT, in order to obtain a baseline value.

Many doctors are already familiar with other common drugs that alter PSA values — in this case with screening implications for cisgender men, points out Dr. Heidi Rayala, a urologist affiliated with Beth Israel Deaconess Medical Center in Boston, and a member of the Harvard Medical School Annual Report on Prostate Diseases editorial board. For instance, PSA values drop by half in men taking finasteride or dutasteride for hair loss (or to shrink an enlarged prostate). “Doctors take extra care when interpreting PSA in cisgender men who take these drugs,” she says. “The same care needs to be taken in interpreting PSA values in transgender women. And there needs to be broader education on this topic for both primary care doctors as well as the transgender community.

Dr. Nik-Ahd agrees. “Future research should aim to understand baseline PSA values for those on gender-affirming hormones, and to understand how to navigate some of the psychosocial barriers around PSA screening so as to not stigmatize transgender patients,” she says.

About the Author

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

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

About the Reviewer

Marc B. Garnick, MD, Editor in Chief, Harvard Medical School Annual Report on Prostate Diseases; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Marc B. Garnick is an internationally renowned expert in medical oncology and urologic cancer. A clinical professor of medicine at Harvard Medical School, he also maintains an active clinical practice at Beth Israel Deaconess Medical … See Full Bio View all posts by Marc B. Garnick, MD

A simple word we all hear often — exercise — makes many people cringe. Unhappy childhood memories of school sports or gym classes, flat-out physical discomfort, guilty reluctance, or trouble finding time or pleasurable activities may help explain this. Additionally, for some people with obesity, fear of falling or injury is a high barrier to activity, recent research suggests.

That finding has important implications for health and well-being. So, how can we make movement safe and joyful for people of all weights?

Why be active?

As you may know, being physically active helps combat anxiety and depression. It prevents bone from thinning and tones muscle, helps you sleep better, lowers your blood pressure and blood sugar, and improves your cholesterol levels. It would take numerous medications to do all that routine physical activity can do for you.

Weight loss programs often incorporate exercise. Research shows that exercise helps with weight maintenance and may help with weight loss. Beyond burning calories, regular exercise also builds muscle mass. This matters because muscles are metabolically active, releasing proteins that play a role in decreasing appetite and food intake.

What does this study tell us?

The study found that many people with obesity fear injury and falling, which interferes with willingness to exercise. It followed 292 participants enrolled in an eight-week medical weight loss program in Sydney, Australia. All met criteria for obesity or severe obesity. The average age was 49; one-third of participants were male and two-thirds were female.

At the beginning of the study, participants filled out a 12-question injury perception survey. The majority reported fear of injury or falling, and believed their weight made injury more likely to occur. One-third said that their fear stopped them from exercising. The researchers also recorded weight, height, and waist circumference, and administered strength tests during the first, fourth, and last sessions.

When the study ended, the researchers found that the participants most concerned about getting injured hadn’t lost as much weight as those who did not express this fear. Those who hadn't lost as much weight also tended to have the highest scores of depression, anxiety, and sleepiness.

Fear of injury fuels a dangerous cycle

As noted, exercise is healthy at every weight: it protects your heart, lowers your blood sugar, boosts your mood, and tamps down anxiety. It also builds balance. Weight-bearing exercise such as walking prevents bone thinning.

If worries about injury or falls cause people to avoid exercise, they miss out on the balance-building, muscle-and-bone-strengthening, and mood-enhancing benefits of regular activity. They may be more likely to fall — and possibly more likely to experience fractures if they do.

Find a blend of activities that will work for you

Everyone, at every weight, needs to find ways to exercise safely, confidently, and joyfully.

• Start low and go slow. If you’re not currently active, start by simply sitting less and standing more. Try walking for two minutes every half hour. If you’re afraid of falling, try walking in place or alongside a friend or loved one who can provide security and comfort.
• Ask for guidance. Consider joining a YMCA where you can engage in supervised activities, or ask your doctor for a prescription to physical therapy to help you improve your balance and build your confidence.
• Try different activities to see what works for you. Walking is a simple, healthful activity, but it’s not the only form of activity you can try. You might enjoy swimming or water aerobics. Try pedaling a seated bike or an arm bike (upper body ergometer) that allows you to stay seated while you propel pedals with your arms instead of your feet. Adaptive activities and sports designed for people with physical limitations and disabilities are an option, too. Depending on your fitness level and interests, you might also consider dancing, biking, or anything else that gets you moving more often.

Lastly, keep in mind that many people suffer from anxiety, and a fear of falling is not insurmountable. If you’re really struggling, talk to your doctor or a mental health professional.

About the Author

Elizabeth Pegg Frates, MD, FACLM, DipABLM, Contributor

Dr. Beth Frates is a trained physiatrist and a health and wellness coach, with expertise in lifestyle medicine. She is an award-winning teacher at Harvard Medical School, where she is an assistant clinical professor. Dr. Frates … See Full Bio View all posts by Elizabeth Pegg Frates, MD, FACLM, DipABLM