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BEAUTY HEALTH YOGA

Gun violence: A long-lasting toll on children and teens

A classroom with several rows of empty desks and chairs in front of large-multipaned windows

In the aftermath of the killing of 19 children and two adults in an elementary school in Uvalde, Texas, there is a lot of discussion — and argument — about what we should do to prevent shootings like this from happening.

In the midst of all the back and forth between banning guns and arming teachers, there is an important question that cannot be lost: what does it do to a generation of children to grow up knowing that there is nowhere they are safe?

There is increasing research that growing up amidst violence, poverty, abuse, chronic stress, or even chronic unpredictability affects the brains and bodies of children in ways that can be permanent. These adverse childhood experiences put the body on high alert, engaging the flight-or-fight responses of the body in an ongoing way. This increases the risk of depression, anxiety, and substance abuse, but it does so much more: the stress on the body increases the risk of cancer, heart disease, chronic disease, chronic pain, and even shortens the lifespan. The stress on the brain can literally change how it is formed and wired.

Long-term effects on a generation

Think for a moment about what this could mean: an entire generation could be forever damaged in ways we cannot change. The ramifications, not just for their well-being but for future generations and our work force and health care system, are staggering: stress like this can be passed on, and affects parenting.

As we talk about arming teachers and increasing armed police at schools, it is important to remember that research shows that the more guns, the higher the risk of homicide. It’s also important to remember that many children die every year from unintentional shootings in the home. In fact, guns have overtaken motor vehicle accidents as the leading cause of death in children. The idea of “arming the good guys” is an understandable response to horrible events like Uvalde, Parkland, and Sandy Hook, but the data would suggest that it may not be the most successful one. Violence begets violence, and guns aren’t reliably used the way we want them to be.

It’s not just guns, of course. There are other stressors, like poverty, community violence, child abuse, racism and all the other forms of intolerance, and lack of access to health care and mental health care. The pandemic has likely forever altered this generation in ways we cannot change, too.

The communities our children are growing up in and the world they are growing up in are increasingly becoming scary places. If we care about our children, if we care about our future, we need to stop fighting among ourselves and come together to create solutions that support the health and well-being of children, families, and communities. We need to nurture our children, not terrify them.

About the Author

photo of Claire McCarthy, MD

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

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BEAUTY HEALTH YOGA

Period equity: What it is and why it matters

Photo of tampons, pads, and menstrual hygiene products on floor

It’s happened to so many people who menstruate: you’re going about your life until you realize that you just got your period. The ungainly scramble to find a restroom and the fervent prayer that you packed a menstrual product leaves you feeling anxious, vulnerable, and exposed. This is compounded by the fact that our society stigmatizes menstruation — or really, anything to do with a uterus — and a taboo hangs over these discussions.

This scenario is far worse if you are one of the nearly 22 million women living in poverty in the US who cannot afford menstrual hygiene products, a problem known as period poverty. One study in Obstetrics & Gynecology demonstrated that 64% of women reported ever having difficulty affording menstrual products, such as pads, tampons, or reusable products like menstrual cups. And 21% reported that they were unable to afford these products every month. People who are homeless or incarcerated are at particularly high risk of not having access to adequate menstrual hygiene products.

Why are period products a luxury?

Menstruating is a basic fact of human existence. Menstrual hygiene products are necessities, not luxuries, and should be treated as such. Unfortunately, food stamps and subsidies under the WIC (women, infants, and children) program that help with groceries do not cover menstrual products.

I have had patients tell me that they use toilet paper or paper towels instead of pads or tampons because they cannot afford menstrual products. People with heavy periods requiring frequent changes of these products particularly face financial challenges, as they must buy even more pads or tampons than the average menstruating person. If they try to extend the life of products by using them for multiple hours at a time, they can wind up with vulvar irritation and vaginal discomfort. They may also be at greater risk for toxic shock syndrome, a life-threatening infection.

Why is it important to talk about stigma around periods?

We need to address stigma around menstruation in order to understand and fix the challenges people face around access to menstrual hygiene products. Period poverty is real. Period equity should be real, too. Embarrassment or taboos may prevent people from advocating for themselves, but if that stigma is removed — or even eased by talking through these issues — we as a society can move forward to address the needs of half of our population. There is no equity when half the population bears the financial and physical distress as a consequence of the reproductive cycle needed to ensure human survival.

How can we address period poverty?

There are simple solutions to period poverty. The first is to eliminate the tax on menstrual products. Think about it: just as food, a necessity for all of us, is not taxed, menstrual products should not be taxed. Products that are reusable, such as menstrual cups or underwear, should be subsidized, and their use encouraged, to eliminate excess waste from individually wrapped pads and tampons. If these products are publicized, promoted, and affordable, more women may opt for them. Pads and tampons should be available free of charge in schools and federal buildings (note: automatic download).

Finally, you can take action: write to or call your legislators! There is a fantastic bill, Menstrual Equity For All Act of 2019, sponsored by Representative Grace Meng, that was introduced on March 26, 2019, but never received a vote. There is no good reason why this bill, which would allow homeless people, incarcerated people, students, and federal employees free access to menstrual hygiene products, was never even brought forward for a vote. We live in one of the world’s wealthiest countries, and lack of menstrual hygiene products should never impact someone’s ability to work or go to school. It’s time to stop treating people with a uterus as second-class citizens.

About the Author

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Huma Farid, MD, Contributor

Dr. Huma Farid is an obstetrician/gynecologist at Beth Israel Deaconess Medical Center, and an instructor in obstetrics and gynecology at Harvard Medical School. She directs the resident colposcopy clinic and is the associate program director for the obstetrics and … See Full Bio View all posts by Huma Farid, MD

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BEAUTY HEALTH YOGA

An emerging treatment option for men on active surveillance

tightly cropped photo of a sheet of paper showing prostate cancer test results with a blood sample tube, stethoscope, and a pen all resting on top of it

Active surveillance for prostate cancer has its tradeoffs. Available to men with low- and intermediate-risk prostate cancer, the process entails monitoring a man’s tumor with periodic biopsies and prostate-specific antigen (PSA) tests, and treating only when — or if — the disease shows signs of progression.

Active surveillance allows men to avoid (at least for a while) the side effects of invasive therapies such as surgery or radiation, but men often feel anxious wondering about the state of their cancer as they spend more time untreated. Is there a middle path between not treating the cancer at all and aggressive therapies that might have lasting side effects? Emerging evidence suggests the answer might be yes.

During a newly-published phase 2 clinical trial, researchers evaluated whether a drug called enzalutamide might delay cancer progression among men on active surveillance. Enzalutamide interferes with testosterone, a hormone that drives prostate tumors to grow and spread. Unlike other therapies that block synthesis of the hormone, enzalutamide prevents testosterone from interacting with its cellular receptor.

A total of 227 men were enrolled in the study. The investigators randomized half of them to a year of daily enzalutamide treatment plus active surveillance, and the other half to active surveillance only. After approximately two years of follow-up, the investigators compared findings from the two groups.

The results showed benefits from enzalutamide treatment. Specifically, tumor biopsies revealed evidence of cancer progression in 32 of the treated men, compared to 42 men who did not get the drug. The odds of finding no cancer in at least some biopsy samples were 3.5 times higher in the enzalutamide-treated men. And it took six months longer for PSA levels to rise (suggesting the cancer is growing) in the treated men, compared to men who stayed on active surveillance only.

Enzalutamide was generally well tolerated. The most common side effects were fatigue and breast enlargement, both of which are reversible when men go off treatment.

In an accompanying editorial, Susan Halabi, a statistician who specializes in prostate cancer at Duke University, described the data as encouraging. But Halabi also sounded a cautionary note. Importantly, differences between the two groups were evident only during the first year of follow-up. By the end of the second year, signs of progression in the treated and untreated groups “tended to be very similar,” she wrote, suggesting that enzalutamide is beneficial only for as long as men stay on the drug. Longer studies lasting a decade or more, Halabi added, may be necessary to determine if early enzalutamide therapy changes the course of the disease, such that the need for more invasive treatments among some men can be delayed or prevented.

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, editor of the Harvard Health Publishing Annual Report on Prostate Diseases, and editor in chief of HarvardProstateKnowledge.org, said the study points to a new way of approaching active surveillance, either with enzalutamide or perhaps other drugs. “An option that further decreases the likelihood that men on active surveillance will need radiation or surgery is important to consider,” he says. “This was a pilot study, and now we need longer-term research.”

About the Author

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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

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BEAUTY HEALTH YOGA

Back pain: Will treatment for the mind, body—or both—help?

Imaging scan of a man's bones, trunk, and head viewed from the side on a dark background; orangey-red color on lower spine suggests low back pain

If you’ve ever struggled with low back pain, you know that it can be surprisingly debilitating, even if the discomfort is short-term. You may find it difficult to grocery shop, do housework, play sports, or even tie your shoelaces. When back pain is chronic, lasting 12 weeks or longer, it can impair quality of life and physical function, and contribute to or worsen stress, anxiety, and depression.

While people dealing with chronic back pain are often directed to physical therapy, research shows that psychological approaches that teach strategies to manage your experience of pain can help. So, would combining these approaches do more to ease the pain? A recent systematic review of multiple studies suggests that it might.

How big is this problem, and what did this study find?

Worldwide, low back pain is a leading cause of disability and affects more than 560 million people. In the US, four in 10 people surveyed in 2019 had experienced low back pain within the past three months, according to the Centers for Disease Control and Prevention.

Published in TheBMJ, the review drew on 97 studies of adults experiencing chronic, nonspecific low back pain, with or without leg pain. Using statistical modeling, the researchers compared the effectiveness of therapies aimed at improving

  • physical function, such as standing, climbing stairs, and managing personal care
  • fear avoidance, because fear of pain can lead people to avoid movement, which contributes to the cycle of muscle weakening and further pain
  • pain intensity, measured by pain scores from validated rating scales.

The review revealed that physical therapy plus psychological approaches, such as pain education and cognitive behavioral therapy, more effectively improved chronic low back pain than physical therapy alone. More specifically:

  • For improving physical function and fear avoidance, pain education programs in conjunction with physical therapy offered the most sustained effects.
  • For improving pain intensity, behavioral therapy combined with physical therapy offered the longest-lasting benefits.

The study shows the advantages of an interdisciplinary approach to chronic low back pain. Integrating behavioral therapy and physical therapy helped people achieve better function, reduce the cycle of avoidant behavior, and reduce the intensity of their pain. In their daily lives, this may lead to more productive workdays and better sleep, as well as enabling people to participate in more social activities, which boosts overall well-being.

What else should you know about this study?

The authors define chronic, nonspecific low back pain as pain between the bottom of the rib cage and buttocks crease, without an identified structural cause like spinal stenosis, cancer, or fracture.

However, “nonspecific” is a controversial term. Many experts on back pain believe that further evaluation might determine specific, multiple factors that contribute to pain.

A physiatrist, also known as a physical medicine and rehabilitation physician, can diagnose a range of pain conditions and help people navigate therapies to manage back pain.

In addition, the authors noted that the reporting of socioeconomic and demographic information was poor and inconsistent across the included studies. This means that the findings of the study may not apply to everyone.

How do psychological therapies help with pain?

Psychological therapies can help people reframe negative thoughts and change pain perception, attitudes, and behaviors. Examples of approaches that aim to reduce pain-related distress are cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), mindfulness-based stress reduction (MBSR), biofeedback, and pain reprocessing therapy (PRT). A recent study evaluating PRT showed that psychological treatment focused on changing beliefs about the causes and consequences of chronic low back pain may provide substantial, long-lasting pain relief.

Neuroscience has demonstrated that the brain and body are always connected, and pain is a combination of medical, cognitive, emotional, and environmental issues. Strategies to manage pain effectively must address your body and brain by integrating physical and psychological therapies, such as with functional restoration programs and working with a pain psychologist. Gaining a better understanding of pain, and treating all factors contributing to your chronic pain, can be empowering and healing.

Follow me on Twitter @DanielleSarnoMD

About the Author

photo of Danielle L. Sarno, MD

Danielle L. Sarno, MD, Contributor

Dr. Danielle Sarno is the director of interventional pain management in the department of neurosurgery at Brigham and Women’s Hospital, and an instructor of physical medicine and rehabilitation at Harvard Medical School. She is the founding … See Full Bio View all posts by Danielle L. Sarno, MD