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Killexams : Apple Troubleshooting test - BingNews Search results Killexams : Apple Troubleshooting test - BingNews Killexams : Best Computer Hardware Certifications

Becoming a computer technician is a great point of entry into the IT field. In addition, computer hardware certifications can help demonstrate your knowledge and competency in maintaining computers, mobile devices, printers and more. Below, you’ll find our pick of six computer hardware certifications to help you get your IT career off the ground.

Although we cover our favorite hardware certifications here, the idea that hardware can operate independently of software (or vice versa) isn’t true. If you dig into the curriculum for any specific hardware-related certs in any depth, you’ll quickly realize that software is in control of hardware.

Software comes into play for installation, configuration, maintenance, troubleshooting and just about any other activity you can undertake with hardware. The hardware label simply indicates that devices are involved, not that hardware is all that’s involved.

Job board search results (in alphabetical order, by certification)

Certification SimplyHired Indeed LinkedIn Jobs Total
A+ (CompTIA) 1,566 2,396 2,282 2,187 8,431
ACMT (Apple) 134 258 196 44 632
BICSI Technician (BICSI) 384 657 30 92 1,163
CCT (Cisco) 473 826 601 722 2,622
RCDD (BICSI) 276 378 377 104 1,135
Server+ (CompTIA) 2,318 3,064 1,250 1,069 7,701

Differing factors, such as specific job role, locality and experience level, may impact salary potential. In general, hardware professionals can expect to earn somewhere in the mid-$60,000s. SimplyHired reports average earnings at $71,946 for IT technicians, with highs reported at almost $116,000. The average national salary for computer hardware technicians ranges from about $31,000 to more than $53,000. However, some certifications command higher salaries. Certification Magazine’s “Annual Salary Survey” (Salary Survey 2018) average salaries for CompTIA Server+ at $98,060 and the A+ credential at $97,730.

CompTIA A+

The CompTIA A+ certification is the granddaddy and best known of all hardware credentials. For anyone serious about working with PCs, laptops, mobile devices, printers or operating systems, the A+ should at least be on their radar, if not in their game plan.

Since the first A+ credential was awarded in March 1993, the program continues to draw active interest and participation. With more than 1 million IT professionals now possessing the A+ credential, it is something of a checkbox item for PC technicians and support professionals. It also appears in a great many job postings or advertisements.

A+ is also ISO 17024 compliant and accredited by ANSI. Thus, this credential must be renewed every three years in keeping with concomitant requirements for continuing education or regular examinations to maintain certification currency. Some 20 continuing education units (CEUs) are required for renewal.

Earning an A+ from CompTIA involves passing two exams: 220-901 and 220-902. test 220-901 focuses on hardware, networking, mobile devices, connectivity and troubleshooting. test 220-902 draws on knowledge of installing and configuring common operating systems (Windows, Linux, OS X, Android and iOS). It also covers issues related to cloud computing, security and operational procedures. Candidates will find a variety of question formats, including standard multiple-choice, drag-and-drop and performance-based questions on these exams.

Candidates who earn the A+ often find themselves in job roles that include technical support specialist, field service technician, IT support technician, IT support administrator or IT support specialist. The A+ is recognized by the U.S. Department of Defense (in DoD Directive 8140/8570.01-M). Also, technology companies, such as Ricoh, Nissan, Blue Cross Blue Shield, Dell, HP and Intel, require staff to earn the A+ certification to fill certain positions.

The A+ certification encompasses broad coverage of PC hardware and software, networking and security in its overall technical scope.

A+ Facts and Figures

Certification name  CompTIA A+
Prerequisites & required courses 9-12 months of experience recommended
Number of exams  Two exams (maximum of 90 questions, 90 minutes): 220-901 and 220-902 (CompTIA Academy Partners use the same numbers)
Cost per exam  $211 per exam. Exams administered by Pearson VUE. test vouchers available at CompTIA
Self-study materials CompTIA offers several self-study materials, including test objectives, sample questions and study guides ($178 for the eBook $198 for the print edition), as well as classroom and e-learning training opportunities. Credential seekers may also want to check out the CertMaster online learning tool. Links to CompTIA training materials may be found on the certification webpage.

Recommended books:

CompTIA A+ 220-901 and 220-902 test Cram, 1st Edition, by David L. Prowse, published Jan. 30, 2016, Pearson IT Certifications, test Cram Series, ISBN-10: 0789756315, ISBN-13: 978-0789756312

CompTIA A+ Certification All-in-One test Guide, 9th Edition (Exams 220-901 and 220-902) by Michael Meyers, published Jan. 4, 2016, McGraw-Hill Education, ISBN-10: 1125958951X, ISBN-13: 978-1259589515

ACMT: Apple Certified Macintosh Technician

Given the popularity of Apple products and platforms, and widespread use of Macintosh computers in homes and businesses of all sizes, there’s demand galore for Mac-savvy technicians.

The AppleCare Mac Technician (ACMT) 2018 credential is Apple’s latest hardware-related ACMT certification. (The credential was formerly called the Apple Certified Macintosh Technician or Apple Certified Mac Technician.) Per Apple, the ACMT 2018 “qualifies a technician to repair all the Mac products that were covered by prior ACMT certifications, plus all other Mac products that were produced before April 2018.” Technicians with the ACMT certification who work at an Apple-authorized service facility are allowed to perform service and repairs.

The ACMT’s two required exams are the Apple Service Fundamentals and the ACMT 2018 Mac Service Certification. Service Fundamentals focuses on customer experience skills, ESD and safety, troubleshooting and deductive reasoning, and product knowledge. The Mac Service test covers troubleshooting and repair of Mac hardware (mainly Apple iMac and MacBook Pro systems). Note that the Apple Service Fundamentals test is also required for the Apple Certified iOS Technician (ACiT) 2018 certification.

The ACMT 2018 is a permanent credential and does not require annual recertification. However, as new products are added to the Apple portfolio, AppleCare will make associated courses available through Apple Technical Learning Administration System (ATLAS). You must complete these courses to service new products.

ACMT Facts and Figures

Certification name AppleCare Mac Technician (ACMT) 2017
Prerequisites & required courses AppleCare Technician Training recommended
Number of exams Two exams (must be taken in this order):

Apple Service Fundamentals test (SCV-17A) OR Apple Service

Fundamentals test (SVC-18A)


ACMT 2018 Mac Service Certification test (MAC-18A) Each exam: 70 questions, 2 hours, 80 percent passing score

Tests administered by Pearson VUE; Apple Tech ID number required

Cost per exam TBD
Self-study materials Self-paced training: Apple Technical Learning Administration System (ATLAS)

AppleCare Technician Training, $299

Instructor-led training courses: LearnQuest

BICSI Technician and Registered Communications Distribution Designer

BICSI is a professional association that supports the information and communications technology (ICT) industry, mainly in the areas of voice, data, audio and video, electronic safety and security, and project management. BICSI offers training, certification and education to its 23,000-plus members, many of who are designers, installers and technicians.

BICSI offers several certifications aimed at ICT professionals, who mainly deal with cabling and related technologies. Two credentials, the BICSI Technician and the BICSI Registered Communications Distribution Designer (RCDD) are pertinent (and popular) in this story.

The BICSI Technician recognizes individuals who lead an installation group or team, perform advanced testing and troubleshooting of cable installations, evaluate cabling requirements, recommend solutions based on standards and best practices, and roll out new and retrofit projects. Technicians must be well versed in both copper and fiber cabling.

Candidates need a good deal of knowledge about the hardware, networking devices and communications equipment to which they connect cables.

To earn the credential, candidates must pass a single two-part test consisting of a hands-on practical evaluation and a written exam. In addition, candidates must possess at least three years of verifiable ICT industry installation experience within the past five years. Credentials are valid for three years. Certification holders must earn 18 hours of continuing education credits (CECs) in each three-year credentialing cycle and pay the current renewal fees to maintain this credential.

Interested candidates should also check out other BICSI certifications, such as the Installer 1 (INST1), Installer 2 Copper (INSTC) and Installer 2 Optical Fiber (INSTF).

An advanced credential, the Registered Communications Distribution Designer (RCDD) is so well respected that the Department of Defense Unified Facilities requires RCDD for all telecom-related design projects. The RCDD is geared toward experienced ICT practitioners with at least five years of ICT design experience. Alternatively, candidates who do not have the requisite experience but who possess at least two years of design experience plus three years of knowledge “equivalents” (combination of approved education, certifications or education), may also sit for the exam. All experience must have been within the preceding 10 years.

RCDD candidates should be able to create and prepare system design specifications and plans, as well as recommended best practices for security design requirements, for business automation systems. RCDDs are also well versed in data center, cabling systems and design for wireless, network, and electronic security systems.

To earn the credential, candidates must meet the experience requirements, submit the application plus credentialing fees, along with a current resume. In addition, candidates must submit four letters of reference two of which much be from current or former clients. One reference may be personal while the remaining references must come from the candidate’s employer.

Other advanced BICSI certifications include the  Outside Plant (OSP) Designer, Data Center Design Consultant (DCDC) and Registered Telecommunication Project Manager (RTPM).

BICSI Technician Facts and Figures

Certification name BICSI Technician
Prerequisites & required courses Three or more years of verifiable ICT industry installation experience (must be within past five years to qualify)

Adhere to the BICSI Code of Ethics and Standards of Conduct

Physical requirements: Distinguish between colors, stand for extended periods, lift and carry up to 50 pounds, climb ladders, and possess manual dexterity necessary to perform fine motor tasks

Technician test prereqs: Both the Installer 2, Copper and Installer 2, Optical Fiber credentials OR the Installer 2 credential

Note: There are no additional credentials required for candidates attempting the Technician Skip-Level exam.

Recommended prerequisites:

50 hours review of BICSI Information Technology Systems Installation Methods Manual (ITSIMM)

TE350: BICSI Technician Training course ($2,545)

IN225: Installer 2 Copper Training course ($2,305)

IN250: Installer 2 Optical Fiber Training course ($2,505)

Number of exams One two-part exam, including written test (140 multiple-choice questions*) and hands-on, performance-based test (hands-on performance test delivered last day of TE350 course; written test administered the day after the completion of the TE350 course)

*If the candidate doesn’t have both the Copper and Optical Fiber Installer 2 credentials or an Installer 2 credential, the written Skip Level test will have 170 questions.

Cost per exam $295 (non-refundable application fee must be received by BICSI 15 days prior to exam; retake fee of $130 applies)
Self-study materials Information Technology System Installation Methods Manual, 7th edition electronic download, $220 member/$240 non-member; print and download combo, $260 member/$290 non-member; printed manual, $220 member/$240 non-member, Web-based training through BICSI CONNECT

BICSI Registered Communications Distribution Designer (RCDD) Facts and Figures

Certification name BICSI Registered Communications Distribution Designer (RCDD)
Prerequisites & required courses Five or more years of verifiable ICT industry design experience (must be within past 10 years to qualify)


Two or more years of verifiable ICT design experience (must be within the past ten years) plus three additional years of ICT equivalents from approved education, experience, or ICT licenses or certification (CCNA, for example)

Adhere to the BICSI Code of Ethics and Standards of Conduct

Recommended prerequisites:

Minimum of 125-150 hours review of BICSI’s Telecommunications Distribution Methods Manual (TDMM)

DD101: Foundations of Telecommunications Distribution Design ($1,030) (BICSI  CONNECT online course)

DD102: Designing Telecommunications Distribution Systems ($2,815)

125-150 hours of TDMM study

TDMM flash cards ($275)

RCDD Test Preparation Course ($925) (BICSI CONNECT online course)

Number of exams One test (100 questions, 2.5 hours)
Cost per exam $495 BICSI member/$725 non-member application fee, (non-refundable application fee must be received by BICSI 15 days prior to exam; retake fee of $225 BISCI member/$340 non-member)
Self-study materials Telecommunications Distribution Methods Manual, 13th edition (TDMM) electronic download ($310 member/$380 non-member; print and download combo, $350 member/$435 non-member; printed manual, $310 member/$380 non-member)

Web-based training through BICSI CONNECT

CTT Routing & Switching: Cisco Certified Technician Routing & Switching

Cisco certifications are valued throughout the tech industry. The Cisco Certified Technician, or CCT, certification is an entry-level credential that demonstrates a person’s ability to support and maintain Cisco networking devices at a customer site.

The Routing & Switching credential best fits our list of best computer hardware certifications, and it serves as an essential foundation for supporting Cisco devices and systems in general.

The CCT requires passing a single exam. Topics include identification of Cisco equipment and related hardware, such as switches and routers, general networking and service knowledge, working with the Cisco Technical Assistance Center (TAC), and describing Cisco IOS software operating modes. Candidates should also have a working knowledge of Cisco command-line interface (CLI) commands for connecting to and remotely servicing Cisco products.

CCT Routing & Switching Facts and Figures

Certification name Cisco Certified Technician (CCT) Routing & Switching
Prerequisites & required courses None

Recommended training: Supporting Cisco Routing and Switching Network Devices (RSTECH) ($299)

Number of exams One: 640-692 RSTECH (60-70 questions, 90 minutes)
Cost per exam  $125

Exam administered by Pearson VUE.

Self-study materials Cisco Study Material page provides links to the course, study groups, test tutorials, and other related content, including test syllabus, training videos and seminars.

CompTIA Server+

CompTIA also offers a server-related certification, which steps up from basic PC hardware, software, and networking Topics to the more demanding, powerful, and expensive capabilities in the same vein usually associated with server systems.

The CompTIA Server+ credential goes beyond basic Topics to include coverage of more advanced storage systems, IT environments, virtualization, and disaster recovery and business continuity topics. It also puts a strong emphasis on best practices and procedures for server problem diagnosis and troubleshooting. Although Server+ is vendor-neutral in coverage, organizations such as HP, Dell, Intel, Microsoft, Xerox, Lenovo and HP use Server+ credentialed technicians.

Those who work or want to work in server rooms or data centers, with and around servers on a regular basis, will find the Server+ credential worth studying for and earning. It can also be a steppingstone into vendor-specific server technician training programs at such companies as those mentioned above, or with their authorized resellers and support partners.

Note that the CompTIA Server+ test is still listed on that organization’s website as “good for life,” meaning it does not impose a renewal or continuing education requirement on its holders. The SK0-004 launched on July 31, 2015. Typically, exams are available for at least two years. If CompTIA’s revision history for Server+ is any guide to future updates and revisions, then it’s likely that we’ll see a new test making an appearance sometime before the end of 2019.

Server+ Facts and Figures

Certification name  CompTIA Server+
Prerequisites & required courses  No prerequisites

Recommended experience includes CompTIA A+ certification plus a minimum of 18-24 months IT-related experience

Number of exams  One: SK0-004 (100 questions, 90 minutes, 750 out of 900 passing score)
Cost per exam $302. test administered by Pearson VUE. test vouchers available at CompTIA.
Self-study materials CompTIA offers a number of self-study materials, including test objectives, its CertMaster online study tool, sample questions, books and more. Formal training courses are also offered. Links to CompTIA training courses may be found on the certification web page. Additional resources may also be found at the CompTIA Marketplace.


CompTIA Server+ Study Guide: test SK0-004, 1st edition, by Troy McMillan, published June 20, 2016, Sybex, ISBN-10: 1119137829, ISBN-13: 978-1119137825

Beyond the Top 5: More hardware certifications

There are many more hardware-oriented certifications available that you might want to consider. As you get into IT and start to develop a sense of your own interests and observe the hardware systems and solutions around, you’ll be able to dig deeper into this arena.

You can investigate all the major system vendors (including HP, Dell, IBM, and other PC and server makers) as well as networking and infrastructures companies (such as Juniper and Fortinet) to find hardware-related training and certification to occupy you throughout a long and successful career.

Although ExpertRating offers many credentials, we rejected them after viewing several complaints regarding the general quality of the courses. Obviously, such complaints are from disgruntled customers but were enough to make us proceed with caution.

This is also an area where constant change in tools and technology is the norm. That means a course of lifelong learning will be essential to help you stay current on what’s in your working world today and likely to show up on the job soon.

Tue, 11 Oct 2022 12:00:00 -0500 en text/html
Killexams : Apple Confirms More Problems For iPhone 14, iPhone 14 Pro Buyers

The launch of Apple’s iPhone 14 range has not gone to plan, with sales of non-Pro models underwhelming and an unusually high number of bugs. And now Apple has confirmed yet another problem impacting the range.

In a memo sent to authorized retailers, first seen by MacRumors and which I have subsequently seen and Tested via an Apple partner, Apple has acknowledged a widely reported bug with SIMs. Affected iPhone 14 models display a “SIM Not Supported” error message, then the phones freeze, rendering them unusable until they are hard reset. But there is some good news.

In the memo, Apple states it is investigating the problem, and while a fix still awaits, the company did confirm the issue is not hardware-related. This means it can be fixed by software, so a recall of impacted iPhone 14 models will not be required. Until a fix arrives, Apple recommends that iPhone 14 owners try waiting because, in some cases, the error message will disappear, and the phones become responsive again.

That said, Apple does warn against hard resetting your new phone, which has been the most popular course of action. Instead, you should take your iPhone 14, iPhone 14 Plus, iPhone 14 Pro or iPhone 14 Pro Max to an Apple Store or authorized retailer for assistance.

For now, confusion surrounds the problem because iPhone models sold in the US do not have a physical SIM card slot. Consequently, it is unclear whether the issue is limited to eSIM or simply a software bug that has nothing to do with the SIM/eSIM malfunctioning.

Either way, this is just the latest in a long line of problems to hit the iPhone 14 range, including iMessage and FaceTime authentication errors, CarPlay and data migration bugs, random reboots, glitches with the Dynamic Island, Lockscreen and high battery drain — the latter of which appears to be impacting a lot of older iPhones as well after updating to iOS 16.

So if you plan to upgrade to an iPhone 14 model, my advice is to wait until Apple has resolved more of these issues. The first market is iOS 16.1, which launches in late October and should come with a lot of fixes. Until then, Apple has its work cut out.


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Sun, 16 Oct 2022 23:31:00 -0500 Gordon Kelly en text/html
Killexams : Food labeling guidelines are not enough

Charles Milliken

We may be thankful our government takes on the never-ending and thankless task of trying to get the citizens of this formerly great nation (only extremists want it great again) to do what we are supposed to do.

Green New Deals and electric cars get the bulk of the attention, but nothing evades the gimlet eye of our contemporary nannies. I refer to a conference on “hunger, nutrition and health” coming up at the White House. As part of this affair, the continuing problem with food labeling once again comes to the fore.

Faithful readers might remember, about 18 months ago, I commented on the great advances in food labeling taking place since I was a kid in the dark unenlightened days of the ’50s. As any of you who go shopping are aware, there is no end of helpful stuff printed on the sides and backs of about anything you buy not found in the fresh foods aisles. This has all been mandated, with ever increasing stringency, over the decades. We label applesauce, apple pie filling, apple juice — when do we finally mandate a label on the apple?

Alas, as the president for the delightfully yclept “Center for Science in the Public Interest points out, “…it’s clear that it’s not having the desired impact to advance the public health.” When all this labeling info was mandated, it was asserted the consumer, being health and safety conscious, would adjust his diet to conform to the latest (latest is important because they keep changing) suggestions.

Unfortunately, that hasn’t happened. We just keep eating more and getting fatter and dying from COVID as a result, not to mention a host of other problems. Spearheaded by Democrats in Congress, legislation is proposed requiring warnings about certain ingredients, and to cause those warnings to migrate from the side of the can to the front. One suggestion is to make icons in the shape of a stop sign, and put red, yellow and green backgrounds to make  apparent the severity of the risk.

Inevitably, manufacturers don’t want to clutter up their labels with stop signs. Those darn manufacturers just don’t care about “public interest” do they? They even have the temerity to suggest that since, admittedly, hardly anyone pays any attention now, why will cluttering up the carefully designed label make any difference?

They are of course, even though for selfish reasons, correct. We consumers just continue to go on our merry way, drinking sugar, eating fat, sprinkling salt and heaven knows what else in defiance of what our betters are quite sure is proper for us. Why? I, for example, LIKE sugar and fat. It tastes good. So I’m 15 pounds overweight? So what! I might live another two or three years, into my 90s, with Alzheimer's in the home. I’ll pass, thank you. The destination is always the same, so I prefer, in moderation, to enjoy the journey.

As the folks at the “Center” surely know, front of label will be as ignored as side or back.

Fortunately, years ago when I took a stab at a futuristic novel, I had come up with the solution. By 2060 (when I set the novel) every transaction will be done electronically. Cash will be banned. Therefore, every time a shopper goes to the store, everything the shopper buys will be recorded. Also, every health metric for the shopper will  be in the massive data banks then, as now, routinely maintained. So, let us say you are a 40-year-old female, for which exists a profile of the proper diet. At the beginning of each month, said female will be given a list of what she may — or may not — buy. Anything not on the list, or in quantities greater than permitted, simply cannot be purchased. Rationing during World War II was a crude version of this.

Mandatory physical exams monitor results, with modifications made as necessary. See how simple this is? We supply tickets for failing to wear seat belts. Why not tickets for failing to eat right?

Charles Milliken is a professor emeritus after 22 years of teaching economics and related subjects at Siena Heights University. He can be reached at

This article originally appeared on The Daily Telegram: Charles Milliken: Food labeling guidelines are not enough

Sat, 15 Oct 2022 20:00:00 -0500 en-US text/html
Killexams : You can now get hearing aids without a prescription. Here’s how

People with mild to moderate hearing loss can now obtain medical-grade hearing aids without a prescription or a specialist's help, slashing the cost by hundreds or thousands of dollars.

A new Food and Drug Administration rule went into effect Monday, vastly expanding the market for over-the-counter hearing aids. Dozens of previously approved devices will now be available without a prescription or a professional consultation. (If you're under 18 or suffer severe hearing loss, you will still need to see an otolaryngologist or audiologist.)

The move is expected to bring hearing aids to more retail outlets where consumer electronics are sold, as well as drawing more mainstream manufacturers into the field. One of the first to jump in is Sony Electronics, which announced its first two hearing aid models last week.

By making it easier and less expensive to obtain hearing aids, experts say, many of the millions of Americans with untreated hearing loss may finally take action.

"Everybody loses hearing as you get older. That’s just a fact of life," said Dr. John Oghalai, an otolaryngologist with Keck Medicine of USC. It's worse for some people than others, he added, noting that certain forms of hearing loss are hereditary.

The National Institute on Deafness and Other Communication Disorders estimates that 1 in 8 Americans age 12 or older — about 30 million people — has lost some hearing in both ears. But people who've been told they need hearing aids typically wait five to seven years to get them, said Barbara Kelley, executive director of the Hearing Loss Assn. of America.

Here's one other thing to consider. Equipping yourself with a hearing aid isn't as simple as buying practicing glasses. It will require more tech savvy, more patience and — even in the new era of over-the-counter devices — more money.

The devices aren't cheap — prices start around $800 — and insurance plans may not cover them. Medicare, for example, doesn't pay for hearing aids or exams, although some Medicare Advantage plans might.

Nevertheless, the cost should be far lower with an over-the-counter sale than it would be to buy the same hearing aid through a specialist.

The Times talked to medical experts, consumer advocates and industry insiders for tips on what to expect.

How do I know if I need a hearing aid?

Sound waves traveling through your ear canal cause your eardrum to vibrate. Those vibrations send signals through the tiny bones in your inner ear to the fluid-filled cochlea, where they're transformed into electrical signals that stimulate your auditory nerves. A variety of factors — age, disease, injury, hygiene — can interfere with that signal chain, dimming or even obliterating sounds you once heard clearly.

Typical symptoms of mild to moderate hearing loss include having trouble hearing people on the phone, turning up the TV volume so much that other people complain, becoming tired from listening and hearing but not being able to understand conversations when there's background noise. Often, Kelley said, your companions will notice your hearing issues before you do.

Oghalai said that if you don't find yourself in many group settings — you don't eat out often or don't get called into many meetings — then you may not need hearing aids. Not everyone needs the same level of hearing functionality.

Further, some hearing problems aren't the kind you can resolve with over-the-counter gadgets. The FDA says that if you can't make out voices even when the room is quiet, or if you can't hear loud music, power tools or other high-volume noises, your hearing loss is too severe for nonprescription devices to address.

Plus, the FDA says, some issues — including blood or fluid leaking from the ears, a sudden change in hearing, problems in one ear but not the other, vertigo or hearing loss that worsens and then gets better — are a sign of medical problems that need professional attention.

So how can you tell if your ears aren't delivering the goods? An audiologist will typically put you in a soundproof booth, then determine how loud a sound has to be at a number of frequencies (that is, pitches) before you can detect it. That will produce a graph showing the frequencies in which you've suffered loss, as well as how significant the loss is.

As hearing aids move to over-the-counter sales, those tests will shift to the web and smartphone apps. You can see an example of a self-administered hearing test at, a Los Angeles-based site that sells hearing aids. The result is a graph showing how your left and right ear should detect sound at various frequencies and how well they actually do.

Be sure to take the test in a quiet room — the whoosh of air conditioning and the rumble of traffic could throw off your results.

Everyone's ears are unique, as are their hearing issues. But if you're an older person experiencing presbycusis (age-related hearing loss), it's probably increasing as the sound frequency rises, said Dr. Nina L. Shapiro, an otolaryngologist at UCLA's David Geffen School of Medicine.

Shapiro illustrated this point with a fun fact: "Older individuals tend to have a harder time hearing female voices, because they're higher pitched." (Insert your aging married couple joke here.)

I've tested my hearing. What else will I have to do?

The other main service you would get if you went to a hearing professional is a custom "fit." That refers to how well the hearing aid matches your hearing loss, not to how good it feels in your ear (which we'll get to in a minute).

Most hearing aids work by cranking the volume on the sounds reaching the eardrums. They have one or two miniature microphones and an amplifier that feed a tiny speaker wedged into your ear canal.

High-end hearing aids can be adjusted to provide more amplification in the specific frequency bands where you need it and less in the ones you don't. The lower-end models aren't as programmable; instead, they tend to offer a few optional settings to adapt the amplification to various environments, such as to help you understand speech in a noisy room.

The simpler devices "will be a fine solution for many people who don't even know they have hearing loss," Shapiro said.

Soundly Chief Executive Blake Cadwell predicts that most over-the-counter products will connect via Bluetooth to a smartphone app that will administer a hearing test, then customize the hearing aids to match hearing loss. Some apps will tune the hearing aids automatically in response to the test results; others will require the user to adjust settings in the app.

For example, if you buy the new Jabra Enhance Plus, the first thing you'll do after putting them in your ears is connect them to the app and take a hearing test. The app will use those results to fit the hearing aids to your needs, while allowing you to switch to different presets according to social situation.

Taking the hearing specialist out of the equation is expected to cut more than half the cost of obtaining hearing aids, and it's something consumers welcome, Cadwell said. According to a study by the consumer electronics company Bose, hearing aid customers "were happier with their outcomes when they were in control" of the settings, he said.

Unlike eyeglasses, however, hearing aids don't make an immediate difference in your senses.

"Your brain has to get used to being able to hear again," said Calum MacDougall, a marketing executive at Jabra. "It takes time and adaptation."

In other words, it takes patience and, possibly, fine-tuning and adjustment.

Hearing aids also need to physically fit well to be effective and comfortable. On that front, different styles present different challenges. Some models put most of the electronics behind the ear, then run a wire or tube to a receiver in the ear canal or fit it into the outer ear. Others sit visibly in the ear, like earbuds, and others are inserted completely into the ear canal.

Given these factors, Cadwell said, it's important to recognize how much support consumers will require after they buy over-the-counter devices. When Soundly vets products, he said, it asks manufacturers whether they will have an audiologist on staff and a team of people ready to take customers' calls.

MacDougall said Jabra — whose owner, the Danish company GN, also makes prescription hearing aids sold under the ReSound and Beltone brands — recognizes that over-the-counter devices will require a lot more customer support than the smartphone earbuds it sells. Among other things, the company plans to offer in-person help for Jabra Enhance Plus buyers at its Beltone stores, MacDougall said, adding, "We're going to hold your hand much farther through the process."

Who'll make them, and where will I find them?

Hearing aid manufacturers are allowed to offer at least some of their previously prescription-only devices as over-the-counter products, and Cadwell predicts that a number of them will do so.

"I don't know that we're going to have any large, unexpected players who are not active in this space today," he said.

The hearing aid market is dominated by five companies that sell products under dozens of names; aside from Jabra, none are familiar consumer brands. Consumers who are used to paying $100 to $200 for earbuds also won't recognize the prices: A set of Lexie B1 hearing aids, which the FDA approved for over-the-counter sale, lists for $899.

Before today, the products were sold mainly in places with hearing specialists, such as an audiologist's office or Costco hearing center. But electronics superstore Best Buy and pharmacy chain Walgreens have announced that they will carry over-the-counter hearing aids, and other big-box retailers and pharmacists are expected to follow suit.

One big question is whether Apple will jump in and disrupt the market the way it did with MP3 players and smartphones. It hasn't announced a hearing aid, but it has added technology to its AirPods Pro line to help people with mild to moderate hearing loss.

While Apple's products are designed first and foremost for phone calls and music, they are influencing the hearing aid market, MacDougall said. Apple not only popularized the earbud style, he said, but normalized the sight of people wearing earbuds all the time — even when interacting socially.

Is there a cheaper alternative?

In addition to prescription and over-the-counter hearing aids, there is a third type of hearing device, a personal sound amplification product. While it looks like a hearing aid, it sells for a much lower price — less than $50 in some cases.

Cadwell is not a fan.

"It amplifies sounds without taking into consideration your individual fingerprint of hearing loss," he said.

The devices might come with a few presets to emphasize different frequency bands, he said, but otherwise they just make everything louder.

"You definitely can hear more, because the world just got turned up," he said. But in busy environments, that can make the world more confusing.

Oghalai shared Cadwell's concerns.

"These things are actually kind of dangerous," he said, because they amplify everything and may not block sounds that are loud enough to cause damage.

What features should I look for?

Here are some things to consider when comparing the first crop of devices:

  • Physical comfort. Does the device fit comfortably in your ear? How big is it, and how much does it weigh? Is it easy to remove and clean? If you plan to wear it all day, these considerations matter a lot more than if you'll be using it intermittently.
  • Battery life. This will also be a priority if you'll be wearing it for long periods. The FDA requires that hearing aid packages indicate the type and number of batteries required, and whether the batteries are rechargeable. You'll also want to know how long the device is expected to work on a single charge; products typically support at least one full day of use, Cadwell said, with rechargeable batteries becoming the norm.
  • App features. Can the app program the hearing aids to automatically match your hearing loss? What sort of presets are available to adapt to different environments? Is the app available for your type of phone?
  • After-sale support. Does the manufacturer offer the sort of expert guidance a hearing specialist would provide? How, where and for how long is the support available?
  • Returns and exchanges. Kelley said you should check whether the manufacturer has a return policy and, if so, what it entails. You don't want to buy a device that doesn't meet your needs, then have no help from the manufacturer to figure out whether a different model or approach would do the trick.
  • Connectivity. Some, but not all, hearing aids can connect to your phone and other Bluetooth-capable devices for calls and streaming audio. Also, some have telecoils that can connect directly to the audio feeds at theaters and other public spaces, blocking out background noise.

It's important to remember that the market for these devices is in its infancy. Although millions of Americans might benefit from hearing aids, there's no telling how many will buy over the counter. If the field draws in more consumer electronics companies, Kelley said, all sorts of innovation could ensue.

"Fifteen years ago, who would have thought that we could hold our computer, phone and TV in our hand?" she said. "That's what this new market will allow for as well."

This story originally appeared in Los Angeles Times.

Mon, 17 Oct 2022 06:19:01 -0500 en-US text/html
Killexams : You and the Skeptical Patient: Who's the Doctor Here?

Gregory A. Hood, MD, remembers a patient of his who was perpetually dubious about COVID-19 — and then couldn't be saved.

"I spoke to him on many occasions about the dangers of COVID, but he just didn't believe me," said Hood, an internist in Lexington, Kentucky. "He just didn't supply me enough time to help him. He waited to let me know he was ill with COVID and took days to pick up the medicine. Unfortunately, he then passed away."

The Rise of the Skeptical Patient

It can be extremely frustrating for doctors when patients question or disbelieve their physician's medical advice and explanations. And many physicians resent the amount of time they spend trying to explain or make their case, especially during a busy day. But patients' skepticism about the validity of some treatments seems to be increasing.

"Patients are now more likely to have their own medical explanation for their complaint than they used to, and that can be bad for their health," Hood said.

Hood sees medical cynicism as part of Americans' growing distrust of experts, leveraged by easy access to the internet. "When people Google, they tend to look for support of their opinions, rather than arrive at a fully educated decision," Hood said.

Only about half of patients believe their physicians "provide fair and accurate treatment information all or most of the time," according to a 2019 survey by the Pew Research Center.

Patients' distrust has become more obvious during the COVID-19 pandemic, said John Schumann, MD, an internist with Oak Street Health, a practice with more than 500 physicians and other providers in 20 states, treating almost exclusively Medicare patients.

"The skeptics became more entrenched during the pandemic," said Schumann, who is based in Tulsa, Oklahoma. "They may think the COVID vaccines were approved too quickly, or believe the pandemic itself is a hoax."

"There's a lot of anti-science rhetoric now," Schumann added. "I'd say about half of my patients are comfortable with science-based decisions and the other half are not."

What Are Patients Mistrustful About?

Patients' suspicions of certain therapies began long before the pandemic. In dermatology, for example, some patients refuse to take topical steroids, said Steven R. Feldman, MD, a dermatologist in Winston-Salem, North Carolina.

"Their distrust is usually based on anecdotal stories they read about," he noted. "Patients in other specialties are dead set against vaccinations."

In addition to refusing treatments and inoculations, some patients ask for questionable regimens mentioned in the news. "Some patients have demanded hydroxychloroquine or Noromectin, drugs that are unproven in the treatment of COVID," Schumann said. "We refuse to prescribe them."

Hood said patients' reluctance to follow medical advice can often be based on cost. "I have a patient who was more willing to save $20 than to save his life," he said. "But when the progression of his test results fit my predictions, he became more willing to take treatments. I had to wait for the opportune moment to convince him."

Many naysayer patients keep their views to themselves, and physicians may be unaware that the patients are stonewalling. A 2006 study estimated that about 10%-16% of primary care patients actively resist medical authority.

Schumann cited patients who don't want to hear an upsetting diagnosis. "Some patients might refuse to take a biopsy to see if they have cancer because they don't want to know," he said. "In many cases, they simply won't get the biopsy and won't tell the doctor that they didn't."

Sometimes Skeptics' Arguments Have Merit

Some patients' concerns can be valid, such as when they refuse to go on statins, said Zain Hakeem, DO, a physician in Austin, Texas.

"In some cases, I feel that statins are not necessary," he said. "The science on statins for primary prevention is not strong, although they should be used for exceedingly high-risk patients."

Certain patients, especially those with chronic conditions, do a great deal of research, using legitimate sources on the Web, and their research is well supported.

However, these patients can be overconfident in their conclusions. Several studies have shown that with just a little experience, people can replace beginners' caution with a false sense of competence.

For example, "Patients may not weigh the risks correctly," Hakeem said. "They can be more concerned about the risk of having their colon perforated during a colonoscopy, while the risk of cancer if they don't have a colonoscopy is much higher."

Some highly successful people may be more likely to trust their own medical instincts. When Steve Jobs, the founder of Apple, was diagnosed with pancreatic cancer in 2003, he put off surgery for 9 months while he tried to cure his disease with a vegan diet, acupuncture, herbs, bowel cleansings, and other remedies he read about. He died in 2011. Some experts believe that delay hastened his death.

Of course, not all physicians' diagnoses or treatments are correct. One study indicated doctors' diagnostic error rate could be as high as 15%. And just as patients can be overconfident in their conclusions, so can doctors. Another study found that physicians' stated confidence in their diagnosis was only slightly affected by the inaccuracy of that diagnosis or the difficulty of the case.

Best Ways to Deal With Cynical Patients

Patients' skepticism can frustrate doctors, reduce the efficiency of care delivery, and interfere with recovery. What can doctors do to deal with these problems?

1. Build the patient's trust in you. "Getting patients to adhere to your advice involves making sure they feel they have a caring doctor whom they trust," Feldman said.

"I want to show patients that I am entirely focused on them," he added. "For example, I may rush to the door of the test room from my last appointment, but I open the door very slowly and deliberately, because I want the patient to see that I won't hurry with them."

2. Spend time with the patient. Familiarity builds trust. Schumann said doctors at Oak Street Health see their patients an average of six to eight times a year, an unusually high number. "The more patients see their physicians, the more likely they are to trust them," he said.

3. Keep up to date. "I make sure I'm up to date with the literature, and I try to present a truthful message," Hood said. "For instance, my research showed that inflammation played a strong role in developing complications from COVID, so I wrote a detailed treatment protocol aimed at the inflammation and the immune response, which has been very effective."

4. Confront patients tactfully. Patients who do research on the Web don't want to be scolded, Feldman said. In fact, he praises them, even if he doesn't agree with their findings. "I might say, 'What a relief to finally find patients who've taken the time to educate themselves before coming here,'" he said.

Feldman is careful not to dispute patients' conclusions. "Debating the issues is not an effective approach to get patients to trust you," he said. "The last thing you want to tell a patient is 'Listen to me! I'm an expert.' People just dig in."

However, it does help to supply patients feedback. "I'm a big fan of patients arguing with me," Hakeem said. "It means you can straighten out misunderstandings and Improve decision-making."

5. Explain your reasoning. "You need to communicate clearly and show them your thinking," Hood said. "For instance, I'll explain why a patient has a strong risk for heart attack."

6. Acknowledge uncertainties . "The doctor may present the science as far more certain than it is," Hakeem said. "If you don't acknowledge the uncertainties, you could break the patient's trust in you."

7. Don't use a lot of numbers. "Data is not a good tool to convince patients," Feldman said. "The human brain isn't designed to work that way."

If you want to use numbers to show clinical risk, Hakeem advises using natural frequencies, such as 10 out of 10,000, which is less confusing to the patient than the equivalent percentage of 0.1%.

It can be helpful to refer to familiar concepts. One way to understand a risk is to compare it with risks in daily life, such as the dangers of driving or falling in the shower, Hakeem added.

Feldman often refers to another person's experience when presenting his medical advice. He explained, "I might say to the patient, 'You remind me of another patient I had. They were sitting in the same chair you're sitting in. They did really well on this drug, and I think it's probably the best choice for you, too.'"

8. Adopt shared decision-making. This approach involves empowering the patient to become an equal partner in medical decisions. The patient is given information through portals and is encouraged to do research. Critics, however, say that most patients don't want this degree of empowerment and would rather depend on the doctor's advice.


It's often impossible to get through to a skeptical patient, which can be disheartening for doctors. "Physicians want to do what is best for the patient, so when the patient doesn't listen, they may take it personally," Hood said. "But you always have to remember, the patient is the one with disease, and it's up to the patient to open the door."

Still, some skeptical patients ultimately change their minds. Schumann said patients who initially declined the COVID vaccine eventually decided to get it. "It often took them more than a year," he said, "but it's never too late."

For more news, follow Medscape on Facebook, Twitter, Instagram, and YouTube

Fri, 14 Oct 2022 04:10:00 -0500 en text/html
Killexams : Get the tech that takes you places No result found, try new keyword!Grab some today. Apple's AirPods Pro 2 Discounted at Amazon, Save on Apple's Latest Earbuds Now Apple's AirPods Pro 2 Discounted at Amazon, Save on Apple's Latest Earbuds Now The AirPods Pro 2 ... Fri, 08 Apr 2022 20:36:00 -0500 en text/html Killexams : What Your Pedicurist Knows About You, Just From Looking At Your Feet

We all started out with lovely feet. Just play “This Little Piggie” with a baby and you’ll see what used to be yours, before city sidewalks, uncomfortable shoes and pounding exercise contributed to years of wear and tear.

While many of us want to feel good about what we’re showing off in sandals, it can be a leap of faith to remove our shoes and socks in the presence of a professional, whether it’s a pedicurist or a podiatrist. Are they checking out our feet and judging? And what, if anything, can they tell about us from looking at our feet?

“There are so many people who apologize for the condition of their feet when calling for an appointment,” said manicurist Erin Beckett-Gland. “They’re embarrassed and warn me that they look awful. But that’s why I’m here — to help them find the healthy feet they can feel confident in showing during sandal season.”

Even if your feet truly look bad, keep in mind that professionals have seen pretty much everything.

“Truth be told, there are a lot of gnarly things that can happen to your feet, and you should not feel embarrassed about them one bit,” said podiatrist Brad Schaeffer, a cast member of the TLC showMy Feet Are Killing Me.” “Everyone has wild foot issues, and most of them are easily treated with proper care.”

What Your Feet Can Say About You

“Feet often tell a story,” Beckett-Gland said. “I can tell when someone is wearing shoes too small for them by the way their toenails split or their toes are curled into hammer toes or claw toes. I can tell when they over pronate, roll their feet inward too much or need an arch support because they have the signs of a bunion and the big toe deviating.”

Podiatrist Robert Spalding, author of “The Science of Pedicures,” said that “hyper-thickened calluses are a dead giveaway of abnormal pressure points on the foot or toes.”

One of the first things he does is check out the shoes someone wore to the appointment. “I match the foot to the shoe, since shoes can aggravate or Improve almost 90% of most foot and toe problems,” Spalding said.

You might even be giving away some clues to your profession during an appointment. “We podiatrists have a big patient base among those whose jobs require a lot of standing, like warehouse employees, letter carriers and restaurant employees,” Spalding said. “I’ll notice the shape of their foot, since the more that pressure is applied to the foot, the more it will splay, which means it gets wide and long over time.”

Professionals might also get a hint about some of your activities based on your feet. “When someone comes in with fungal issues, I might ask questions to see if they picked those up from walking around their gym barefoot, or from frequenting poor-quality nail salons,” Schaeffer said.

It’s easiest to spot runners and climbers because of the damage to their big toenails, said nail artist Vanessa Sanchez McCullough. “Constantly banging the big toe against the sneaker usually creates nail damage that will appear bruised, and many times causes the nail to lift from the nail bed.”

Other types of shoes leave their mark, too. “People who wear high heels a lot will very often have bunions and excessive calluses around the toes,” she said.

Jon Feingersh Photography Inc via Getty Images

Certain cues can tell your pedicurist a lot about your hobbies, especially if you're a runner.

They Can Even Flag Health Issues That May Require A Doctor

“A well-educated pedicurist can spot potential health issues, because both fingernails and toenails can be windows to a person’s health,” McCullough said.

Beckett-Gland said she refers customers to a health care professional if she notices a serious abnormality or other cause for concern.

Sometimes, concerns about a foot problem can lead to a serious diagnosis, Schaeffer said. “We look at the skin, pulses and nerves to determine any underlying conditions,” he said. “Diabetes is probably the most common diagnosis that we can assess during a foot exam. Other times, melanoma can be found in the feet.”

The Mistake Most People Make Before An Appointment

For your safety, you shouldn’t use shave your legs for the day or two before a pedicure. “A razor nick can be a perfect portal for infection,” Spalding said.

There’s also no need to prep your toenails before a pedicure.

“So many times, people get impatient and cut their toenails before their appointment,” McCullough said. “They come see me with really short nails that are difficult to make look pretty.”

Instead, follow Beckett-Gland’s advice to keep it clean and simple: “I wish people would just take a shower before they come in for an appointment. I want them to come with clean, dry feet, with no added lotion, creams or oils. I need to see the feet in their natural state so I can actually see what the issues are.”

How To Take Care Of Your Feet Between Appointments

There are steps you can take at home to keep your feet looking and feeling good. “Exfoliate the sole of the foot once a week with a foot file or a good scrub,” Beckett-Gland said. “Pumice stones are too porous, harbor too much bacteria and are not beneficial to the exfoliation process.”

But don’t stop there. “You must moisturize your feet after exfoliation,” McCullough said. “If you don’t, you’ll find your feet will be drier than before you started.”

Choose a rich lotion intended for feet, experts said. “The basic body lotion isn’t going to cut it when it comes to the soles of the feet,” Beckett-Gland said. “The sole of the foot has no hair follicles, so there are no sebaceous glands to help protect the skin from drying out. Soles also have an extra layer of skin that is nowhere else on the body. Choose products that have a molecular structure small enough to penetrate the sole of the foot skin.”

When in doubt, go to the professionals.

“The best way to maintain a great pedicure is to get pedicures often,” McCullough said. “Most of my clients get bi-weekly pedicures along with their manicures, and they have beautiful feet. Bi-weekly may be too much commitment for some people, so every four weeks is sometimes more realistic.”

Want to save some big bucks and supply yourself a salon-quality pedicure at home? Here’s everything you’ll need, recommended by the pros.

HuffPost may receive a share from purchases made via links on this page. Every item is independently selected by the HuffPost Shopping team. Prices and availability are subject to change.

An elevated foot stand to make pedicures easier

Contorting yourself into odd angles just reach your toes can be a deal-breaker when it comes to giving yourself a pedicure. This waterproof, sturdy and adjustable pedicure assistant holds your foot at a comfortable slant so you can paint your toes with ease and save yourself the back pain. The anti-skid feet are compatible with any floor surface, and it easily folds flat for storage.

An electric callus remover for baby-soft heels

Thick calluses and rough, cracked heels can be embarrassing to have and even more difficult to get rid of. This electric rotating callus remover may help you get the baby-soft feet of your dreams. The waterproof design makes this safe for use in the shower, and three attachments with different gradients work to easily exfoliate and soften thick skin.

An ergonomic nail polish brush topper for greater control when painting

If shaky and unsure hands prevent you from achieving a perfectly painted nail, this attachable polish handle by Olive & June might be able to help, even when using your non-dominant hand. Compatible with most nail polish bottles, this ergonomic wide-based handle allows you to have better control by providing you a more secure and comfortable grip.

A peel-off cuticle guard for perfectly painted nails

If you're prone to coloring outside the lines and hate dealing with the tedious post painting cleanup, this liquid polish barrier might be your new best friend. Just paint this low-odor and quick-drying latex around the nail bed and along the cuticle before painting your nails. Once the polish has dried, easily peel away the barrier to reveal cleanly painted nails without that pesky polish spillover.

A nail care kit that includes all of your mani and pedi essentials

Made of durable stainless steel and covered in a non-slip rubber coating, this 18-piece manicure set features cuticle cutters and four different sizes of nail clippers for more precise trimming, as well as a nail cleaner and scraping knife to remove stubborn bits of nail polish.

A luxury vibrating and heating foot spa

This large-capacity foot spa can be a great way to bring the nail salon experience to your home. The adjustable shower bar at the front of the tub can relax stiff and sore shin or calf muscles, and a six-option motorized massage base can help relieve foot pain and Improve circulation. Additionally, the tub's quick-heat feature can keep a temperature of 118 degrees Fahrenheit for up to hour, but you can freely adjust the temperature to your preference. Detachable rollers also make this tub easy to move, while a convenient automatic drain pipe makes cleanup simple.

A bag of popular soaking salts to soothe tired feet

With nearly 15,000 five-star ratings on Amazon, this best-selling epsom salt foot soak is made with a proprietary and soothing blend of oils like eucalyptus, tea tree, lavender, peppermint and rosemary to not just relieve achy, tired feet but to also combat toe fungus, odor-causing bacteria, stubborn calluses and more. One Amazon user said that this foot soak even got rid of her husband's toenail fungus that he has been battling for over 40 years.

A deluxe filing set to buff, shape and shine nails

This 14-piece set of professional nail files includes emery boards and filing blocks all of varying grit to help shape, file and buff nails. It also includes two tempered crystal glass nail files which can be good for shaping nails while also reducing the chances of nail splitting and breakage.

A bottle of “mani-saving”drops that instantly dry your polish

Nothing is worse than a smudged set of freshly painted nails. Fortunately, just a few drops of this quick-drying solution by Olive & June can dry nails in about 80 seconds, so you don't have to wait around for an hour while your manicure dries. A blend of jojoba seed oil also leaves nails with a salon-finish shine, and the easy squeeze tube makes for an easy one-handed application.

A crowd favorite cuticle oil for nourished and healthy nails

This nourishing nail and cuticle oil by Essie can be a great way to Improve nail health, especially in between potentially damaging gel or acrylic manicures. Formulated with a conditioning blend of apricot kernel, sweet almond and jojoba oils, this is a fast-absorbing treatment that leave nails feeling shiny and healthy.

A gel nail polish kit with a UV light

For a salon-quality gel manicure at home that lasts longer than traditional nail lacquer, this professional-style essentials kit has everything you need to get started, including an LED curing light to harden the gel and acetone to remove it. The bottles are clearly labeled to guide you along the process, and you can find a wide range of gel nail colors also on Amazon for $9.99 per bottle.

A rechargeable professional drill for a number of mani and pedi needs

For jagged nail edges, uneven nail surfaces, stubborn gel polish residue, cuticle and callus removal or overly thick nail beds, this cordless electric sanding drill for nails is a great effective option. It comes with 10 different sapphire and felt attachments and has three speed settings, as well as an integrated LED light.

A nourishing cream to hydrate hands and feet

Formulated with 15% shea butter for deep hydration, this custard-like cream from L'Occitane is great for cracked heels, toes and palms. It also contains soothing ingredients like arnica and lavender to help relieve the feeling of tired feet — an ideal post-manicure and pedicure treatment.

A cuticle dissolver for easy and effortless removal

For particularly stubborn cuticles, this fast-acting exfoliating serum makes cuticle removal effortless, without having to use clippers or uncomfortable cuticle pushers. The phthalate-free product breaks down excess skin in about 15 seconds while ingredients like chamomile and aloe nourish and soften cuticles.

A magnifier light to reduce straining

Easily spot missed cuticles or unpainted nail edges with this bendable magnifying LED light. The heavy base sits securely on any surface, or you can use the included clamp to attach to a table edge. The flexible gooseneck measures 13.5 inches in height, and the genuine glass can magnify up to 176%.

Fri, 23 Sep 2022 11:03:00 -0500 en text/html
Killexams : Unity Software: Focused On The Long Term
Gamer Room


Unity Software's (NYSE:U) stock continues to face headwinds as investors shun unprofitable growth stocks. This has been exacerbated by problems with their monetization business, although these now appear to be largely resolved. Unity continues to invest aggressively in the capabilities of its platform and will need to begin showing returns on these investments going forward. The company's ability to successfully integrate ironSource (IS) and Weta is also crucial. Problems here could drive the stock even lower.


Unity’s Create segment provides tools that allow the creation of engaging and interactive real-time 3D experiences. At the moment, this business is driven by the gaming sector, but in coming years use cases outside of gaming, like digital twins and media, will become increasingly important. The business outside of gaming currently represents 40% of the total Create business and is growing rapidly.

Unity has seen record adoption of their 2021 Long-Term Stable (LTS) version. The LTS version is supported with biweekly fixes for two years and doesn’t introduce feature or API changes, allowing users to lock in production with confidence. Additions and improvements include:

  • Visual scripting
  • Editor extensibility
  • Scene view overlays for artist driven tools and asset ingestion

The Tech Stream version provides earlier access to new features and in 2022 updates include:

  • Refined our user input framework
  • Improved developer and artist productivity, through features like better spline tooling and better material variant productivity
  • Connectivity with other creation tools

Unity have also expanded the capabilities of their Data-Oriented Tech Stack (DOTS). DOTS is a technology stack that is data oriented rather than object oriented and offers 10-100x performance improvements for rich environments that have a lot of content, interactive objects and real-time 3D objects. Unity intend to introduce easy-to-use versions of DOTS into their core technology over the next 2-3 years. DOTS enabled V Rising to scale up the world size and the number of players and was a key factor behind Stunlock choosing Unity.

Unity continues to have the most success in mobile games, but has a growing presence across Console, PC, AR/VR and Web. Unity powers more than 70% of the top mobile games, and nearly half of Steam games for PC were made with Unity in 2021. Those games are also breaking through to the Steam charts, where 13 of the top 20 games in May were made with Unity. Unity games made up 80% of the most popular games on Oculus Quest in July and 72% of the top selling games.

The latest success of the Oculus Quest 2 is a potential indicator that the AR / VR market is reaching an inflection point. The Quest 2 has sold over 14.8 million units since launching in Q4 2020. For perspective, this is more sales than the HTC Vive and Xbox Series X and S, although less than the Nintendo Switch and PlayStation 5.

Meta (META) also has the Oculus Quest 3 and Project Cambria in the pipeline, with the latter supposedly targeted more at metaverse applications than gaming. The Quest 2 is by far the most popular VR headset, making up 78% of all sales in 2021. In comparison, DPVR captured 5.1% of sales and ByteDance’s PicoVR accounted for 4.5% of sales.

Google Trends "Meta Quest 2" Search Index

Figure 1: Google Trends "Meta Quest 2" Search Index (source: Created by author using data from The Federal Reserve)

Apple (AAPL) is also rumored to be working on an AR/VR headset and AR smart glasses, which could further accelerate the adoption of 3D experiences. Apple reportedly has a research unit with hundreds of employees working on AR and VR, with a product expected in 2023. The headset will reportedly focus on gaming, video streaming and video conferencing and could be priced over 2,000 USD.

In addition to the focus of companies like Meta and Apple on AR / VR hardware, a number of high-profile companies are working on 3D content. Meta views the metaverse as a successor to the mobile internet, and wants to control its own platform so that it is not at the mercy of companies like Apple. Meta have over 10,000 people working on their metaverse ambitions and are committing tens of billions of dollars. Roblox (RBLX), NVIDIA (NVDA) and Microsoft (MSFT) have also been building out virtual worlds.

Another indicator of the growing importance of 3D applications are LiDAR sales, which continue to grow rapidly, driven in large part of transportation use cases. Apple also recently introduced LiDAR to their mobile phones.

Global LiDAR System Sensor Sales

Table 1: Global LiDAR System Sensor Sales (source: Created by author using data from Statista)

Unity’s Create business outside of games includes media and entertainment, e-commerce, industrial and manufacturing, architecture and engineering and construction amongst other industries. The use of digital twins is increasing rapidly and Unity are investing in capabilities to capitalize on this opportunity. One such example in Neural Radiance Field (NeRF), which uses a neural network to create a 3D scene from a series of 2D images, democratizing the creation of digital twins.

Google Trends "Digital Twin" and "Metaverse" Search Indices

Figure 2: Google Trends "Digital Twin" and "Metaverse" Search Indices (source: Created by author using data from Google Trends)

The growing importance of Unity’s non-gaming business necessitates a shift in their sales model though. Unity recently partnered with Capgemini to develop sector-specific solutions and services for Unity’s customers. Targeted sectors include consumer goods, retail, telecommunications, energy and utilities. Capgemini is a consulting company that leverages technology to enable digital transformation. 85% of the 200 largest public companies on the Forbes Global 2000 list are Capgemini clients. This type of partnership is generally an important part of the go-to-market strategy for enterprise sales.

In addition to expanding the use of game engines outsides of gaming, Unity’s other focus for the Create business is democratizing the creation of 3D content. Creating 3D content is currently difficult for a number of reasons:

  • Complex
  • Expensive
  • Large file sizes
  • Complicated rendering techniques

Unity acquired Weta specifically to make powerful artistic tools more widely available. This has the potential to foster the development of 3D applications and significantly expand Unity’s market opportunity. For the potential of this acquisition to be realized, Weta must be integrated into Unity’s platform. Management believes this process is progressing well, with previews available for customers this year and the first Weta tools released next year, ahead of the initial M&A integration schedule.


Unity’s Operate business has struggled this year due to the combination of technical issues with their platform and general weakness in the digital advertising market.

Unity had a data quality issue and problems with the accuracy of their audience pinpointer product earlier in the year that impacted the monetization business. Unity have now removed the bad data and improved their monitoring capabilities to try and prevent the same issue from occurring again. Audience Pinpointer accuracy is also improving and Unity plan on introducing features in the second half of the year that will Improve customers' return on ad spend. Revenue has not increased as quickly as expected though due to a combination of macroeconomic headwinds and the difficulty of projecting the trajectory of the monetization business.

Unity Gaming Service

Unity Gaming Service (UGS) allows customers to build their games in a single platform by providing tools for multiplayer services, game operations, user acquisition and monetization. UGS is a suite of tools and services that enable developers to create, host and manage their games in the cloud in a single dashboard experience. UGS is designed to be modular so that creators can select the best tools for their use case, whether the game was built with Unity Unreal or any other game engine.

UGS was released in beta in October 2021 and became generally available in June 2022, with more than 50,000 game developers signed up and 2,300 new customers added since the launch.

Unity Gaming Service

Figure 3: Unity Gaming Service (source: Created by author using data from Unity)

Unity's merger with ironSource is supportive of their monetization strategy as it enables the combination of creation and growth into a single platform to increase creator success.

Gaming Market

The gaming industry is currently undergoing a post-pandemic correction, with US consumer spending on video game hardware, content and accessories in 2022 expected to decline by 8.7% relative to 2021. So far the impact of this decline on Unity's Create business appears to be muted, but there could still be a flow through impact in coming quarters. The Operate business is likely being hit by a combination of reduced consumer screen time and a reduction in advertiser budgets.

Longer term, global entertainment and media revenue is expected to continue outpacing global growth, rising approximately 10% annually through 2026.

Projected Global Entertainment and Media Revenue

Figure 4: Projected Global Entertainment and Media Revenue (source: Created by author using data from PWC)

The entertainment and media industry is expected to become more digital, more mobile, more dependent on advertising and more evenly distributed globally. These are all generally positive trends for Unity, which has a dominant position in mobile gaming and continues to advance its advertising business. Advertising currently represents 32.2% of total entertainment and media industry revenues and is expected to increase at a 6.6% CAGR through 2026.

Share of Global Entertainment and Media Spending

Table 2: Share of Global Entertainment and Media Spending (source: Created by author using data from PWC)

Video games revenue is expected to increase at an 8.4% CAGR through 2026, growing into a 321 USD billion industry.

Global Video Games Revenue

Figure 5: Global Video Games Revenue (source: Created by author using data from PWC)

VR revenue is projected to increase at a 24.1% CAGR between 2021 and 2026, growing to reach 7.6 billion USD annually. The global active installed base is expected to increase to 65.9 million by 2026.


AppLovin (APP) made Unity an acquisition offer in August for approximately 59 USD per share. The deal made a lot of sense for AppLovin, from both a strategic and financial perspective, as the company is vulnerable to the combined Unity / ironSource entity, and has a weak balance sheet. Unity's strong position in mobile gaming is obviously attractive to an ad mediation platform. Ad mediation is used by app developers to connect multiple ad networks to their app and serves as an ad network optimizer for developers looking to increase their ad revenue. With Unity combining their ad network with ironSource's ad mediation, the competitive position of AppLovin is significantly undermined.

It is not clear what value AppLovin would provide to Unity though, and it is doubtful the deal was given serious consideration. With the large potential of Unity's Create business, AppLovin having control of the company would be something akin to the tail wagging the dog.

Financial Analysis

Despite making progress with issues in the operate business, Unity lowered full year revenue guidance in the most latest quarter to 1.3-1.35 billion USD. This was attributed to a combination of the weak macroeconomic environment and difficulties projecting the revenue trajectory of their monetization business.

Operate revenue was down 13% YoY in the second quarter, likely in part due to monetization issues, the weak macro environment and the difficult comparable period in 2021. The number of large customers (more than 100,000 USD trailing 12 months revenue) grew 22% YoY in the second quarter and Unity’s net dollar expansion rate was 121%, compared to 142% a year earlier. Both of these figures were lower due to the Operate business.

Over 75% of Unity’s revenue is generated outside of the US, which is likely to be a headwind in coming quarters due to the significant appreciation of the US dollar.

Unity Segment Revenue

Figure 6: Unity Segment Revenue (source: Created by author using data from Unity)

Unity’s cost of revenue consists primarily of hosting expenses, personnel costs for employees associated with product support and professional services, allocated overhead, third-party license fees, and credit card fees, as well as amortization of related capitalized software and depreciation of related property and equipment. Gross margins appear to be trending down over time, although it is not really clear why this is the case. Once monetization issues are resolved, gross margins will bounce back somewhat, but investors should look for a stabilization or improvement in margins as ironSource is integrated and Weta tools are commercialized.

Unity Gross Profit Margins

Figure 7: Unity Gross Profit Margins (source: Created by author using data from Unity)

Unity’s operating expenses are extremely high due to the R&D investments they are making in the capabilities of their platform. These are primarily personnel costs and investors will likely want to see the burden of operating expenses fall before the stock moves higher. This should come through a combination of operating leverage and a 100 million USD cost saving program that was announced in the previous quarter.

Unity Operating Expenses

Figure 8: Unity Operating Expenses (source: Created by author using data from company reports)

Unity Operating Expenses

Figure 9: Unity Operating Expenses (source: Created by author using data from Unity)

Unity’s pace of hiring slowed significantly during second quarter of 2022, which was possibly related to macro weakness. Since then, hiring has picked up modestly but it is not clear if this is due to growth reaccelerating or Unity continuing to invest in the long-term capabilities of their platform.

Unity Hiring Trend

Figure 10: Unity Hiring Trend (source:

The number of job openings mentioning Unity continues to trend upwards modestly, with no real significant change in trend that would indicate a change in business fundamentals.

Job Openings Mentioning Unity in the Job Requirements

Figure 11: Job Openings Mentioning Unity in the Job Requirements (source:


Unity’s stock is down by over 80% since its peak in November 2021, driven in part by a general pullback in growth stocks and in part by company specific problems. The stock now appears reasonably priced relative to peers and should provide significant upside potential once macroeconomic conditions stabilize and growth reaccelerates. Based on a discounted cash flow analysis I estimate that Unity’s stock is worth approximately 100 USD per share, although the company will likely to make significant progress towards profitability before these types of prices are seen again.

Unity Relative Valuation

Figure 12: Unity Relative Valuation (source: Created by author using data from Seeking Alpha)


Unity’s heavy investments in R&D, coupled with a weak macro environment, mean the stock may continue to struggle in the short term. If the integration of ironSource can be successfully executed, a rebound in advertising and the commercialization of Weta tools should set Unity up well for the long term. The stock’s current valuation is more than reasonable given the company’s long-term prospects, although this is unlikely to matter in the short term due to Unity’s ongoing losses.

Thu, 13 Oct 2022 21:42:00 -0500 en text/html
Killexams : How to Tell If Over-the-Counter Hearing Aids Are Right for You

For the first time, you can now buy OTC hearing aids as easily as you can buy practicing glasses. Here's how to figure out if they might work for you.

© Provided by Consumer Reports

By Catherine Roberts

Over-the-counter (OTC) hearing aids are finally here.

As of Oct. 17, you will be able to officially purchase over-the-counter hearing aids in stores and online, without needing to see a doctor, an audiologist, or a licensed hearing aid specialist. For the millions of people with hearing loss who don’t yet use the devices, the new product category is intended to increase access and lower costs.

Over-the-counter hearing aids are only meant for people with self-perceived mild-to-moderate hearing loss, so they’re not right for everybody. Still, if you seem to be having trouble hearing, you may wonder if these devices could be right for you. 

Some tools are already available that can help you figure that out. And keep in mind: The vast majority of people with hearing loss have a mild or moderate amount, according to a 2016 study in the American Journal of Public Health. Researchers estimated that about 36.1 million U.S. residents age 12 or older have either mild or moderate hearing loss, while only about 2.2 million have severe or profound hearing loss. (Note that over-the-counter hearing aids are only intended for adults; children still need to see an audiologist or other hearing specialist for a hearing evaluation.)

Here, we explain some of the existing tools and strategies you can use to figure out if an over-the-counter hearing aid might be right for you.

© Provided by Consumer Reports

An Eargo OTC hearing aid

Photo: Eargo

Start With Simple Questions

The Food and Drug Administration requires that over-the-counter hearing aids be labeled with some of the common signs of mild-to-moderate hearing loss. These include having trouble hearing speech in noisy places or in groups, having a hard time hearing when talking on the phone, or finding that you have to turn up the TV volume to hear it and other people tell you it’s too loud. Another sign: Listening makes you tired. If any of these apply to you, you might want to try an over-the-counter hearing aid. 

The agency also provides information about the signs that might suggest that your hearing loss may be too severe for an over-the-counter hearing aid to be of much use. These include not being able to hear speech even if the room is quiet, and not being able to hear loud sounds well (such as engines, power tools, or loud music). If that’s the case for you, then visiting a doctor or an audiologist is a better bet.

You should also think carefully about your hearing needs. Some people—even with milder hearing loss—may want to visit an audiologist simply because they have unusually complex or specific hearing needs, says Sumit Dhar, PhD, a professor in the department of communication sciences and disorders at Northwestern University. This might include someone like an air traffic controller, a litigator who frequently works in a large and echoey courtroom, or a teacher in a large classroom filled with children in all directions.

Rule Out Other Problems

Most hearing loss is irreversible. Still, sometimes changes in hearing can be caused by medical issues such as infections, earwax buildup, or certain types of injuries. In those cases, you’ll need to see a doctor to resolve the problem rather than jumping right to a hearing aid.

The FDA also requires hearing aids to be labeled with a list of “red flags” that indicate you need to see a doctor to get your ears checked out. These include symptoms such as blood, pus, or fluid coming out of your ears recently, ear pain or discomfort, feelings of dizziness or vertigo, and sudden changes in your hearing. 

You can also use an online tool called the Consumer Ear Disease Risk Assessment (CEDRA), developed at Northwestern University, to help rule out any ear problems that warrant a trip to the doctor. 

© Provided by Consumer Reports

A Bose OTC hearing aid

Photo: Lexi

Consider Testing Options

If you think you’re a likely candidate for an over-the-counter hearing aid, you can still decide to get an in-person hearing exam. There’s no need to go it alone.

“For consumers, the gold standard would be go get your hearing tested from a licensed provider, get a copy of that test, and then come home and do your own research on what the best options for you are,” says Kim Cavitt, AuD, a hearing healthcare consultant.

Increasingly, providers are unbundling hearing assessments or consultations from the cost of hearing aids themselves, so you should be able to find a provider who’ll test you even if you don’t want to buy hearing aids from their office. Call ahead to find out how much a test would cost, whether it would be covered by your insurance, and whether you need a referral. Medicare, for example, only covers a hearing test if your doctor refers you for one.

Still, if you’d rather go the DIY route, a number of valid remote or self-test hearing screening options are available that can help you gauge your level of hearing loss without even leaving your house. 

Tone-based testing apps. Typically, in-person hearing examinations include what’s called pure-tone audiometry. This is done with audio tones played in decreasing volumes to determine your specific level of hearing loss. An app-based version can’t totally replicate the in-office experience. Still, certain well-designed apps can produce a measurement called a “pure-tone average” (PTA), or, as some public health experts call it, your “hearing humber.” 

The hearing number reflects how loud speech must be for you to be able to hear it, and provides a simple shorthand for your level of hearing loss. A hearing number of about 25 to 40 means you have mild hearing loss, while 41 to 60 means moderate hearing loss. 

One benefit of the hearing number is that it provides a simple measurement of hearing loss that’s also more concrete than the imprecise labels of “mild” and “moderate,” says Nicholas Reed, AuD, an assistant professor of epidemiology and audiology with the Johns Hopkins Cochlear Center. “For OTCs to succeed, we actually need common language around hearing loss,” Reed says. “We can’t use this vague language.”

The limitation of remote or app-based pure-tone audiometry is that it requires specifically calibrated equipment to work—to ensure the tones are played at the proper volume. This tends to be more achievable within the Apple ecosystem, since the specs for both the devices and the Apple-made headphones are controlled by the same company.

Two iPhone apps will reliably produce a hearing number: Mimi or SonicCloud, according to a group of scientists advocating for more widespread use of the hearing number. Find instructions on how to get the hearing number from these apps here.

If you do get an in-person hearing test, you can also ask the provider who gives you the test for this number.

Digits-in-noise or speech-in-noise tests. In this type of test, your task is to identify spoken numbers or other words while background noise plays. These tests have their own advantages, including that they don’t require any special equipment, which makes them more accessible. And they provide a more real-world test of hearing, says Dewet Swanepoel, DPhil, a professor of audiology at the University of Pretoria in South Africa. “That’s actually what people have difficulty with when they have hearing loss—speech in background noise,” he says. “So this test really gets to the heart of what people have difficulty with.”

The downside: Speech-in-noise tests don’t provide as precise a measure of hearing loss as pure-tone audiometry. Still, they can be a useful screening tool to help you figure out whether you might have at least some degree of hearing loss. 

The World Health Organization’s hearing test app, hearWHO, employs such a testing method, as does an online hearing screening offered by Best Buy. Many other websites also offer to screen your hearing with a digits or speech-in-noise test. Keep in mind, Cavitt advises, that online tests may also be accompanied by marketing pitches from various companies offering hearing aids or hearing care services. 

An evidence-based self-assessment. Another approach for figuring out if an over-the-counter hearing aid is right for you involves assessing how much hearing difficulty you experience in daily life. After all, the FDA’s rules about OTC hearing aids say the devices are meant to address self-perceived hearing loss. 

“The FDA is sending this signal that you can self-determine if you have mild to moderate hearing difficulty,” says Dhar. “Inherent in that claim is that your perception of mild-to-moderate hearing difficulty will be well-correlated” to a professional measurement of hearing loss.

The Hearing Handicap Inventory for the Elderly (HHIE) and its variant, the Hearing Handicap Inventory for Adults (HIAA) are tools that can help you with that self-assessment.

They involve either 10 or 25 questions that are designed to evaluate how much a hearing problem affects your life. The simple questionnaires, developed and validated by audiologists in the 1980s and 1990s, have been used for decades to assess the extent to which hearing loss affects people emotionally and socially. Questions include, “Does a hearing problem cause you to feel embarrassed when meeting new people?” and “Does a hearing problem cause you to have arguments with family members?” This approach can be a good way to figure out if you might get use out of an over-the-counter hearing aid.

“The factor that most likely determines whether somebody will seek hearing aids and use them and benefit from them, is their perceived hearing disability, not what the audiogram says,” says Larry Humes, PhD, a distinguished professor emeritus of speech, language, and hearing sciences at Indiana University. (An audiogram is a graph that shows the results of a hearing test.)

There aren’t a lot of user-friendly online versions of these tests just yet, but you can download a printable copy of the shorter version of the HHIA and the HHIE. If you score in the mild-to-moderate range, that means an over-the-counter hearing aid could be a good fit.

Consumer Reports is an independent, nonprofit organization that works side by side with consumers to create a fairer, safer, and healthier world. CR does not endorse products or services, and does not accept advertising. Copyright © 2022, Consumer Reports, Inc.

Sat, 15 Oct 2022 18:00:14 -0500 en-US text/html
Killexams : As children line up at gender clinics, families confront many unknowns


On the two-hour drive back from the hospital, Danielle Boyer kept replaying the doctor’s questions in her mind. Was her then-12-year-old child, Ryace, hearing voices? Was she using illegal drugs? Had she ever been hospitalized for psychiatric treatment? Had she ever harmed herself?

Danielle was still shaken when she and Ryace arrived home in this small town nestled in a bend of the Ohio River. Dinner would have to wait. She had to talk to her husband. “They were asking us these sad, terrible questions,” she told Steve Boyer as the two sat in their garage that August 2020 evening. “Do you know kids have tried to kill themselves?”

“I had no idea,” he said.

Ryace (pronounced RYE-us) was assigned male at birth, but by the time she was 4, it was clear to her parents that she identified as a girl. She referred to herself as a girl. She wanted to dress as a girl. But her parents feared for her safety if they let her live openly as a girl in their tightly knit rural community. So they struck an uneasy compromise. At home, Ryace could be a girl, wearing makeup and dresses. At school, around town and in family photos, Ryace would remain a boy.

Ryace chafed at the restrictions. When she started middle school, she grew increasingly anxious about what puberty would bring: facial hair, an Adam’s apple, a deeper voice. That’s when Danielle sought help at Akron Children’s Hospital and its new gender clinic, where staff told her they could treat Ryace with puberty-blocking drugs and sex hormones to help her transition.

“This is what I’ve always wanted,” Ryace told her mother as they left the hospital. Afterward, the pair went on a celebratory shopping trip for girl’s clothes. Danielle was relieved. After years of struggling in isolation to do what they thought was best for Ryace, the Boyers were now getting expert help from people who understood their situation.

But the initial consultation brought troubling new questions. The doctor at the Akron clinic told Danielle and Ryace that puberty blockers could weaken Ryace’s bones. The effects on her brain development and fertility weren’t well-understood. The risk of inaction was even more alarming: Without treatment, the doctor said, Ryace would remain at increased risk of suicide.

Mention of suicide raised the stakes. “She’s been asking for how many years now to be a girl?” Danielle said to her husband as they sat talking in their garage that evening. “We just keep telling her no, and we’re crushing her. If they can help us, let’s do this.”

The United States has seen an explosion in latest years in the number of children who identify as a gender different from what they were designated at birth. Thousands of families like the Boyers are weighing profound choices in an emerging field of medicine as they pursue what is called gender-affirming care for their children.

Gender-affirming care covers a spectrum of interventions. It can entail adopting a child’s preferred name and pronouns and letting them dress in alignment with their gender identity – called social transitioning. It can incorporate therapy or other forms of psychological treatment. And, from around the start of adolescence, it can include medical interventions such as puberty blockers, hormones and, in some cases, surgery. In all of it, the aim is to support and affirm the child’s gender identity.

But families that go the medical route venture onto uncertain ground, where science has yet to catch up with practice. While the number of gender clinics treating children in the United States has grown from zero to more than 100 in the past 15 years – and waiting lists are long – strong evidence of the efficacy and possible long-term consequences of that treatment remains scant.

Puberty blockers and sex hormones do not have U.S. Food and Drug Administration (FDA) approval for children’s gender care. No clinical trials have established their safety for such off-label use. The drugs’ long-term effects on fertility and sexual function remain unclear. And in 2016, the FDA ordered makers of puberty blockers to add a warning about psychiatric problems to the drugs’ label after the agency received several reports of suicidal thoughts in children who were taking them.

More broadly, no large-scale studies have tracked people who received gender-related medical care as children to determine how many remained satisfied with their treatment as they aged and how many eventually regretted transitioning. The same lack of clarity holds true for the contentious issue of detransitioning, when a patient stops or reverses the transition process.

The National Institutes of Health, the U.S. government agency responsible for medical and public health research, told Reuters that “the evidence is limited on whether these treatments pose short- or long-term health risks for transgender and other gender-diverse adolescents.” The NIH has funded a comprehensive study to examine mental health and other outcomes for about 400 transgender youths treated at four U.S. children’s hospitals. However, long-term results are years away and may not address concerns such as fertility or cognitive development.

U.S. children ages 6 to 17 diagnosed with gender dysphoria from 2017 through 2021

U.S. children starting on puberty blockers or hormones over the five-year period

Reliable national data on how many children receive care for gender dysphoria – defined as a feeling of distress from identifying as a gender different from the one assigned at birth – have long been unavailable. To get some idea of the increasing prevalence of these cases, Reuters asked health technology company Komodo Health Inc to analyze its database of U.S. insurance claims and other medical records on about 330 million Americans. The analysis, the first of its kind, found that at least 121,882 children ages 6 to 17 were diagnosed with gender dysphoria in the five years to the end of 2021. More than 42,000 of those children were diagnosed just last year, up 70% from 2020.

Though smaller, the number of children receiving medical treatments like those the Akron clinic outlined for the Boyers is also growing fast. The number of children who started on puberty-blockers or hormones totaled 17,683 over the five-year period, rising from 2,394 in 2017 to 5,063 in 2021, according to the analysis. These numbers are probably a significant undercount since they don’t include children whose records did not specify a gender dysphoria diagnosis or whose treatment wasn’t covered by insurance.

FACING REALITY: Ryace identified as a girl from early childhood, and after her mother took her for her first appointment at the Akron Children’s Hospital’s gender clinic, she was eager to start medical treatment to transition.  REUTERS/Megan Jelinger

Social acceptance

The surging numbers reflect in part the success of years of advocacy for transgender rights, which doctors say has made more children and their families comfortable about seeking help. Transgender children still live with discrimination, bullying and threats of violence. But as transgender identity has become more visible in popular culture, children with gender dysphoria have gained ready access on TV and social media to positive representations of young people who have received professional gender-affirming care.

Gender care for minors gained further legitimacy as medical groups endorsed the practice and began issuing treatment guidelines. Chief among them is the World Professional Association for Transgender Health, a 4,000-member organization that includes medical, legal, academic and other professionals from around the world. Over the past decade, its guidelines have been echoed by the likes of the American Academy of Pediatrics and the Endocrine Society, which represents specialists in hormones.

In its latest Standards of Care, released in September, WPATH notes the paucity of research supporting the long-term effectiveness of medical treatment for adolescents with gender dysphoria. As a result, the guidelines say, “a systematic review regarding outcomes of treatment in adolescents is not possible.” The Endocrine Society, in its own guidelines, acknowledges the “low” or “very low” certainty of evidence supporting its recommendations.

The federal government eased the path to treatment in 2016, when the administration of President Barack Obama prohibited health insurers and medical providers from limiting care because of a person’s gender identity. That prompted an expansion of public and private insurance coverage for gender-affirming care, including for children, which can cost tens of thousands of dollars a year for puberty blockers alone.

Today, more than half of states pay for gender-transition treatment through Medicaid, the government health insurance program for millions of low-income families. Nine states exclude youth gender care from Medicaid coverage. Florida, in its Medicaid prohibition, says treatments for gender dysphoria “do not meet the definition of medical necessity.”

That disparity among states is symptomatic of how gender-affirming care has become a flashpoint in the nation’s highly polarized politics.

Many conservatives decry it as a form of child abuse. “You don’t disfigure 10, 12, 13-year-old kids based on gender dysphoria,” Florida Governor Ron DeSantis, a Republican, said at an August news conference, just days before his state banned Medicaid coverage of gender care for children. Alabama, Arkansas and Texas have enacted laws or policies to broadly limit children’s access to care, all of them since blocked by courts. In more than a dozen other states, including Ohio, where the Boyers live, legislators have introduced bills that would ban care or penalize providers for treating children.

“Gender-affirming care for transgender youth is essential and can be life-saving.”

At the same time, at least a dozen states, including New York, California and Massachusetts, have aligned with transgender advocates and many medical providers by ensuring that children are guaranteed access to care. And in July, the Biden administration proposed an expansion of the Obama-era protections.

“Gender-affirming care for transgender youth is essential and can be life-saving,” Dr Rachel Levine, an assistant secretary at the U.S. Department of Health and Human Services, said in an interview with Reuters.

Levine, a pediatrician and a transgender woman, drew outcry from conservative opponents of children’s gender care and some medical professionals earlier this year when she told National Public Radio: “There is no argument among medical professionals – pediatricians, pediatric endocrinologists, adolescent medicine physicians, adolescent psychiatrists, psychologists, et cetera – about the value and the importance of gender-affirming care.”

Levine was right, insofar as healthcare providers generally agree that anyone with gender dysphoria has a right to supportive care, whether that entails social transition, or counseling and therapy, or medical interventions. But her statement glossed over deep fissures that have opened within the gender-care community over the way treatment has evolved in the United States as new patients pour into clinics.

A growing number of gender-care professionals say that in the rush to meet surging demand, too many of their peers are pushing too many families to pursue treatment for their children before they undergo the comprehensive assessments recommended in professional guidelines.

Such assessments are crucial, these medical professionals say, because as the number of pediatric patients has surged, so has the number of those whose main source of distress may not be persistent gender dysphoria. Some could be gender fluid, with a gender identity that changes over time. Some may have mental health problems that complicate their cases. For these children, some practitioners say, medical treatment may pose unnecessary risks when counseling or other nonmedical interventions would be the better choice.

“I’m afraid what we’re getting are false positives and we’ve subjected them to irreversible physical changes,” said Dr Erica Anderson, a clinical psychologist who previously worked at the University of California San Francisco’s gender clinic. “These errors in judgment are fodder for the naysayers – the people who want to eradicate this care.” Anderson, a transgender woman who still treats children with gender dysphoria in her private practice, resigned as president of WPATH’s U.S. chapter last year after her public comments about “sloppy” care prompted the organization to issue a temporary moratorium on board members speaking to the press.

In Europe, concern that too many children might be unnecessarily put at risk has prompted countries like Finland and Sweden that were early to embrace gender care for children to now limit access to care. The United Kingdom is shutting down its main clinic for children’s gender care and overhauling the system after an independent review found that some staff felt “pressure to adopt an unquestioning affirmative approach.”

Ranged against those advising caution in the United States are members of the gender-care community who say that denying treatment to any child with gender dysphoria is unethical and dangerous. “You shouldn’t have to jump through hoops to prove your own trans-ness,” said Dallas Ducar, a psychiatric nurse practitioner and trans health provider in Massachusetts.

Ducar and officials at other clinics said the waiting lists at many facilities show that children already face significant barriers to treatment due to a shortage of providers and a persistent stigma in healthcare attached to transgender patients. “If you put unnecessary roadblocks in the way, we know the kid will still be trans and they will continue to experience deep psychological stress that increases the risk of suicide attempts or suicide itself,” Ducar said.

Dr Marci Bowers, a surgeon specializing in transgender procedures who became WPATH’s president in September, said in an interview that the organization is trying to find a middle ground between “those who basically would have hormones and surgeries available at a vending machine, let’s say, versus others who think that you need to go through all sorts of hoops and hurdles.”

In its new Standards of Care, WPATH retained its longstanding recommendation of comprehensive assessments to determine that adolescents are suitable for medical treatment. “There are no studies of the long-term outcomes of gender-related medical treatments for youth who have not undergone a comprehensive assessment,” the guidelines note. Without such evidence, the document adds, “the decision to start gender-affirming medical interventions may not be in the long-term best interest of the young person at that time.”

Levine, the U.S. assistant secretary for health, said that clinics are proceeding carefully and that no American children are receiving drugs or hormones for gender dysphoria who shouldn’t. “It’s not like anyone who arrives automatically gets medical treatment,” she said.

EYES OPENED: Ryace says young transgender people she saw on television and online helped her realize she could transition. REUTERS/Megan Jelinger

A good candidate

Belpre, Ohio, is in Washington County, a rural community of farmhouses, trailer homes and churches set among lush green hills. The area has been home to generations of Boyers. Danielle, 37, works in education. Steve Boyer, a 36-year-old plumber and pipefitter, has served on the board of a local fair, where Ryace and her older brother, Aiden, have shown ducks and lambs they tended. Weekends are spent camping or attending horse shows where Ryace, an accomplished equestrian, competes in barrel races and roping events. “Everybody knows the Boyers,” Steve said.

Steve and Danielle had no direct experience with transgender people when Ryace was born. By around age 4, she referred to herself as a girl, played with girls at friends’ houses and became fascinated with women’s clothing and jewelry. On Christmas morning 2011, shortly before her 4th birthday, Ryace was thrilled when she got much of what she had wanted from Santa: Barbie dolls, a dollhouse, and toys in pink and purple.

But Danielle feared Ryace wouldn’t be accepted as a transgender girl in their conservative community, and she wanted to protect her child from the stares, hateful comments and broken relationships that would inevitably come. “The agreement was, house only,” Danielle said.

Ryace constantly pushed back. From early on, when friends and neighbors complimented her as a cute little boy, she would correct them: She was a girl. Danielle then felt compelled to correct Ryace.

Danielle sought compromises. In elementary school, they often settled on outfits for Ryace of neutral black leggings and brightly colored T-shirts. She picked up dresses and hair pins at yard sales and let Ryace wear them at home. On trips into town, Danielle had Ryace take off the dresses she wore over her boy’s clothes and leave them in the car.

As middle school – and puberty – loomed, Ryace started sneaking bras and mascara to school. She repeatedly texted her mom, “Will you start calling me a girl?”

Television and the internet had opened Ryace’s eyes to new possibilities. She watched “I Am Jazz,” the reality TV show about Jazz Jennings, a transgender girl who socially transitioned at an early age and went on to take puberty blockers and hormones and have surgery. She watched young people on YouTube discuss gender dysphoria and their transitions and saw the before-and-after images they shared. On Instagram, she followed Nikita Dragun, a makeup artist and model who came out as transgender as a teenager and now has 9 million followers.

“This is actually a thing,” Ryace recalled thinking at the time. “I can actually do this.”

A PAINFUL VICTORY: When Ryace was crowned Horse Princess at a local fair, some members of the crowd grumbled. REUTERS/Megan Jelinger
ACCOLADES: Ryace has adorned a wall in her bedroom with awards from sports and horse competitions. REUTERS/Megan Jelinger

Ryace is the type of child that doctors in the Netherlands focused on in their pioneering work in the early 2000s on medical treatment for adolescents with gender dysphoria. Researchers at the Amsterdam University Medical Center methodically screened their subjects to ensure they met certain criteria before receiving treatment. Like Ryace, these adolescents exhibited persistent gender dysphoria from a very early age, lived in supportive environments, and had no serious psychiatric issues that could interfere with a diagnosis or treatment.

The assessments generally lasted about six months before treatment could start. The children filled out a series of questionnaires, and clinicians talked to them frequently to confirm that their gender dysphoria was persistent and to ensure that they understood the long-term implications of treatment. For patients who had psychiatric problems, the researchers extended the assessment phase to more than 18 months before considering medical treatment.

In 2011, the Dutch published detailed results of their work. In one study involving 70 adolescents, the group showed fewer behavioral and emotional problems and fewer symptoms of depression after nearly two years on puberty blockers. Feelings of anxiety and anger were relatively unchanged. All of the patients went on to take hormones.

European countries and the United States adopted the Dutch model for the newly emerging field of gender-affirming care for minors. WPATH and other professional groups issued guidelines recommending comprehensive psychological evaluations before referring any child for medical treatment.

More recently, though, many of the patients flooding into clinics wouldn’t meet Dutch researchers’ criteria. Some have significant psychiatric problems, including depression, anxiety and eating disorders. Some have expressed feelings of gender dysphoria relatively late, around the onset of puberty or after, according to published studies, gender specialists and clinic directors. Such cases require more extensive evaluation to rule out other possible causes of the patient’s distress.

And for reasons not understood, a disproportionate number are patients assigned female at birth. In the NIH study of children’s treatment outcomes now under way, minors designated female at birth made up 61% of enrollees. The gender clinic at Children’s Wisconsin hospital in Milwaukee said 65% of its patients were assigned female at birth. Some researchers and clinics say transgender females are less likely to seek treatment because they face greater social stigma for doing so. Critics of children’s gender care blame peer pressure, reinforced by social media, for boosting the number of transgender males seeking care.

Dr Annelou de Vries, a specialist in child and adolescent psychiatry, is one of the Dutch researchers whose early work established the importance of rigorous patient assessments before starting medical treatment. She said that while she worries about the growing number of children awaiting treatment, the graver sin is to move too fast when puberty blockers and hormones may not be appropriate.

“The existential ethical dilemma in transgender care is between on one hand the (child’s) right for self-determination,” de Vries said. “On the other hand, the do-not-harm principle of medical intervention. Aren’t we intervening medically in a developing body where we don’t know the results of those interventions?” In the United States, in particular, she said, “the transgender right or child’s right seems to be put forward more strongly.” De Vries helped write the section on adolescents in WPATH’s updated Standards of Care. She said she was gratified that language stressing the importance of rigorous patient assessments remained.

In interviews with Reuters, doctors and other staff at 18 gender clinics across the country described their processes for evaluating patients. None described anything like the months-long assessments de Vries and her colleagues adopted in their research.

At most of the clinics, a team of professionals – typically a social worker, a psychologist and a doctor specializing in adolescent medicine or endocrinology – initially meets with the parents and child for two hours or more to get to know the family, their medical history and their goals for treatment. They also discuss the benefits and risks of treatment options. Seven of the clinics said that if they don’t see any red flags and the child and parents are in agreement, they are comfortable prescribing puberty blockers or hormones based on the first visit, depending on the age of the child.

“For those kids, there’s not a value of stretching it out for six months to do assessments,” said Dr Eric Meininger, senior physician for the gender health program at Riley Hospital for Children in Indianapolis. “They’ve done their research, and they truly understand the risk.”

“We do not have enough therapists and psychologists who have had adequate training in this area to keep up with the pace of more gender-diverse patients who have come out recently.”

Many clinicians bristle at suggestions they may be moving too fast, treating children before adequately vetting them. Months-long assessments and counseling in lieu of medical treatment puts children at risk, pathologizes them and denies them their fundamental identity, they say. For minors with psychiatric problems, they say, medical treatment often alleviates the distress of gender dysphoria and allows professionals to then address those other conditions.

“Being trans is an identity, not a diagnosis, and transgender people just want the care that affirms who they are,” said Ducar, the trans health provider in Massachusetts.

Ducar and others were disappointed that in its updated Standards of Care, WPATH noted that “social influence” may impact some adolescents’ gender identity. They said the idea of a “social contagion” infecting children perpetuates an offensive misconception that being transgender is a fad spread among impressionable adolescents by friends and social media and fails to recognize the stigma, bullying and discrimination transgender people experience.

Dr Eli Coleman, director of the University of Minnesota Medical School’s Institute for Sexual and Gender Health who oversaw the update of WPATH’s Standards of Care, said: “A knowledgeable and competent clinician can discern between a person’s gender identity that is marked and sustained and an identity that might be socially influenced.”

The issue of assessments is complicated by a chronic shortage of mental-health professionals for children that has only worsened amid soaring rates of depression, anxiety, mood disorders and self harm nationwide.

“We do not have enough therapists and psychologists who have had adequate training in this area to keep up with the pace of more gender-diverse patients who have come out recently,” said Dr Michael Irwig, an associate professor at Harvard Medical School and director of transgender medicine at Beth Israel Deaconess Medical Center. “We are going to miss some people who haven’t been vetted appropriately or who haven’t gotten the mental health care that they need.” That, he said, may increase the number of people who later detransition.

Reuters interviewed parents of 39 minors who had sought gender-affirming care. Parents of 28 of those children said they felt pressured or rushed to proceed with treatment.

Kate, a 53-year-old mother in New Jersey, said she and her husband were shocked in November 2020 when their 13-year-old told them he was transgender. The child, assigned female at birth, had always played with other girls and had never expressly identified as a boy. They just thought their child was a “tomboy.” Now, they learned, he had chosen a male name and wanted to start puberty blockers and get breast-removal surgery.

After an initial one-on-one consultation of little more than an hour with the teen, a psychiatrist said he was a good candidate for puberty blockers, Kate said. An endocrinologist recommended the same after talking with the family for 15 minutes. Kate and her husband also attended a parents’ support group organized by a local gender therapist. Through it all, Kate said, “the message was, let your kid drive the bus. Wherever they lead you, that’s what you should do.”

Kate, who asked that only her first name be used to protect her child’s identity, had read up on puberty blockers. Concerned about their off-label use and possible side effects, she wouldn’t agree to treatment. She supports her son’s social transition, using his preferred pronouns and buying the tape he uses to bind his breasts. But she thinks he is too young to make decisions about life-altering medical treatments.

“Children, when they are 13 or 14, are sometimes totally different people from when they are 18 or 19,” she said. As a result of her decision, her relationship with her son has been “fractured,” Kate said. If he chooses to pursue medical transition after he turns 18, she said, she and her husband won’t be happy, but they won’t stand in the way, either.

VIDEO: Ryace Boyer and her family’s journey through gender-affirming medical treatment.

Suicide Watch

The fragile truce between Ryace and her parents – girl at home, boy everywhere else – collapsed after Ryace started middle school.

In December 2019, Danielle let Ryace, 11 at the time, wear makeup and black bell-bottom pants to a basketball game at a nearby school. Danielle’s mother, Ruth Alden, was at the game, and afterward, she scolded Danielle. It was embarrassing to the family, Alden said, and other kids are “gonna beat the crap out of her.” Her granddaughter could be driven to suicide, she warned.

Danielle was incensed – and despondent. She felt trapped. She had long panic that she was pushing Ryace toward suicide by insisting that her identity remain a secret. That night, Danielle yelled at her own mother: “What do I do, Mom? Regardless of my decision, I could have a dead child.”

Early in the new year, Danielle, desperate for guidance, joined a Facebook group for Ohio parents of transgender children. That eventually led her to the children’s hospital a two-hour drive away in Akron, for the Aug. 6, 2020, meeting with Dr Crystal Cole and her team.

Dr Cole, an Akron native and specialist in adolescent medicine, founded the hospital’s Center for Gender Affirming Medicine in 2019. The clinic saw 25 patients that year. It now is treating more than 350 young people.

In their two-hour meeting, Cole started with general questions about Ryace, her family and their medical history. Then she sharpened the focus on Ryace’s mental health and readiness for treatment. Danielle exhaled with relief after Ryace responded that she wasn’t hearing voices, wasn’t using illegal drugs and had never tried to harm herself.

The doctor then laid out the treatment options. Ryace could socially transition. She could also opt to receive counseling and therapy to support her through transition. And she could receive treatment to medically transition. At age 12, Ryace was a candidate for puberty suppression to spare her the masculinizing features she feared, with known and unknown risks.

“Ryace is a very vibrant, well-adjusted young lady that just happened to be assigned male sex at birth.”

Cole then moved on to the danger of inaction. “The risk of people in the transgender population attempting suicide is over 40%,” she told Ryace and Danielle. “One of the things shown to lower that is affirming care and an affirming environment.”

The statistic Cole referred to came from the 2015 U.S. Transgender Survey, an anonymous online survey of nearly 28,000 transgender adults conducted by the National Center for Transgender Equality, a nonprofit advocacy group. Compared to the 40% of respondents who reported attempting suicide at some point their lives, the rate for the general U.S. population at the time was 4.6%, the authors of the 2015 survey said.

It’s one of several surveys that healthcare professionals cite when advising families with children seeking gender-affirming care. Another was by the Trevor Project, a nonprofit group that focuses on suicide prevention for LGBTQ youth. In that 2021 anonymous survey, 52% of transgender and nonbinary respondents ages 13 to 24 said they had seriously contemplated killing themselves. More than 13,000 survey respondents, or 38% of the overall sample, identified as transgender or nonbinary.

Dr Jonah DeChants, a Trevor Project research scientist, said the group’s survey data “tell a really important story about the mental health impact of being an LGBTQ person and living in a world that tells you that you’re wrong, that you’re an abomination and that you are not safe to be around other children.”

Such online surveys have become common in science, but researchers say they may not be fully representative of the larger population being studied. The authors of the 2015 U.S. Transgender Survey said: “It is not appropriate to generalize the findings in this study to all transgender people.”

Experts in gender care say more specific research is needed to determine whether medically transitioning as a minor reduces suicidal thoughts and suicides compared with those who socially transition or wait before starting treatment.

Some gender-care professionals complain that suicide risk is too often used to pressure and even frighten parents into consenting to treatment. “I think it’s irresponsible for clinicians to do that,” said Anderson, the former president of WPATH’s U.S. chapter. “As a clinical psychologist, I don’t do a suicide assessment by membership in a class. The level of risk varies tremendously across individuals.”

De Vries, the Dutch researcher, told Reuters there is no evidence that “providing care immediately leads to a decline in self harm or would prevent suicide.”

DeChants of the Trevor Project said he wouldn’t want the organization’s data to be used to pressure people on treatment decisions. “We would never say that gender-affirming healthcare is the only way to address suicide risk, but it is an important option for youth, their doctors, and their families to be able to consider,” he said.

After their two-hour evaluation of Ryace, Dr Cole and her team were confident that Ryace had gender dysphoria and was a strong candidate for medical treatment. “Ryace is a very vibrant, well-adjusted young lady that just happened to be assigned male sex at birth,” Cole said. Bringing up suicide on the first visit is scary for a lot of parents, she said, but “it’s a reality we have to ask about.”

A few weeks after visiting Akron, Danielle announced Ryace’s social transition in a Facebook message to family and friends. “I just wanted to let you know that Ryace started JH (junior high) as a female,” she wrote in a Sept. 19, 2020, post. “She can finally be who she feels she is. A girl. I wish this wasn’t our life sometimes but it is and it’s real and I have to let it be and be there to pick up the pieces when the world turns ugly. And it will, so we need all the love and support we can get.”

Many relatives and friends were supportive, including Alden, Danielle’s mother. Others stopped talking to the Boyers. Some parents complained to Ryace’s school about her using the girls’ bathroom. Previously, she had used a single-person bathroom. The principal backed Ryace.

Ryace was eager to begin treatment. “What are we waiting for?” she asked her mother. In November 2020, Danielle took Ryace to an appointment with the Akron clinic’s pediatric endocrinologist to learn more about puberty blockers. The endocrinologist scheduled Ryace for her first injection in March 2021.

Known unknowns

Endo International plc and AbbVie Inc dominate the U.S. market for puberty blockers. The only FDA-approved use for these drugs in children is for central precocious puberty, a condition in which children begin to sexually mature before age 8 or 9 because of pituitary gland dysfunction.

One side effect in children who take these drugs can be a decline in bone density, which is often treated with vitamin D or calcium supplements. Studies have shown that bone density can return to normal once therapy ends, but also that for some transgender girls, it may not.

In September, the FDA published a study that found “no evidence for an increased risk of fracture” for precocious puberty patients who take leuprolide, the generic name for AbbVie’s Lupron and similar drugs. However, the FDA study didn’t review cases of children who took the drug for gender dysphoria.

In a 2018 study published in the medical journal Clinical Pediatrics, researchers at Yale University noted a sharp increase in the off-label use of puberty blockers and said these drugs “have not been thoroughly investigated in populations with normally timed puberty.”

In Texas earlier this year, bone scans indicated that a child, 15 years old at the time, had osteoporosis after 15 months on puberty blockers. The teen’s mother, who asked not to be identified because she works at the hospital where her child was treated, said she thought she had done everything right when her teen came out as a transgender girl. But after the bone scan results, reviewed by Reuters, she said she regretted putting her child on puberty blockers. She stopped the Lupron injections and wouldn’t agree to hormone therapy.

The child, who has socially transitioned, was at first furious with her and threatened to drop out of high school, she said. Their relationship is better now, she said, though “we don’t talk about gender.”

Another concern about puberty blockers emerged in 2016, when the FDA ordered drugmakers to add a warning about psychiatric problems to the drugs’ label as a treatment for children with precocious puberty. On its label for Lupron, AbbVie says: “Psychiatric events have been reported in patients” taking puberty blockers. Events include emotional symptoms “such as crying, irritability, impatience, anger and aggression.”

The FDA pursued the label change after receiving 10 reports through its adverse event reporting system of children who had suicidal thoughts, including one suicide attempt, according to a Dec. 5, 2016, agency report reviewed by Reuters. One of the cases involved a 14-year-old patient taking Lupron for gender dysphoria, the records show. In the report, the FDA said suicidal ideation and depression are “serious events,” and there is “enough evidence to warrant informing prescribers, even in the face of uncertainty about causality.”

The agency also asked drugmakers to closely monitor for these adverse events and file more detailed reports to the agency. “The FDA continues surveillance for psychiatric events associated with drugs indicated for the treatment of pediatric patients with central precocious puberty,” the agency said.

Adverse event reports from medical professionals, consumers and drugmakers help the FDA detect potential safety problems with a drug that may warrant investigation. However, the agency doesn’t receive reports for every adverse event, and there is no certainty that a reported event was caused by a drug. Reports may contain errors, partial data or duplicate information.

Reuters found 72 adverse event reports submitted to the FDA from 2013 through 2021 of children on puberty blockers who showed suicidal, self-injurious, or depressive behavior. The children were taking the drug for central precocious puberty or gender dysphoria or were simply identified as under 18.

A Dec. 17, 2020, adverse event report to the FDA describes a 15-year-old patient taking Lupron for gender therapy. The patient had a history of “major depressive disorder” and a family history of depression. The patient experienced “mental health deterioration” while on Lupron and attempted suicide twice. AbbVie wrote in the report to the FDA that “there is no reasonable possibility” that the adverse events were related to Lupron. The company did not elaborate.

Dr Brad Miller, division director of pediatric endocrinology at the University of Minnesota Medical School and M Health Masonic Children’s Hospital, expressed surprise at the number of adverse event reports Reuters found. He said he was particularly concerned because doctors prescribe puberty blockers for transgender children, who are already at higher risk of mental health problems.

Miller and several other doctors told Reuters they had repeatedly asked AbbVie, Endo and other makers of puberty blockers to seek FDA approval for the drugs in treating gender dysphoria in children and to conduct clinical trials to establish the drugs’ safety for such use. They said the companies always declined. “They would say it would cost a lot of money to get approval,” Miller said. “And they were not interested in going there because (transgender treatment) was a political hot potato.”

AbbVie declined to comment for this article. An Endo spokeswoman said the company has no plans to seek regulatory approval for the use of its drug for any new indications. The company did not respond to requests for further comment for this article.

As prescriptions of puberty blockers increase for off-label gender care, the drugmakers are making cheaper alternatives harder to get.

Endo’s puberty blocker is an implant in the upper arm that releases medication for as long as two years. About a year ago, the company told the FDA that it had discontinued an implant called Vantas that cost about $4,600. That left doctors and patients to use a similar Endo implant called Supprelin LA. It costs about $45,000, according to drug pricing data analyzed by Reuters. Some families with high-deductible insurance plans might have to pay several thousand dollars out of pocket.

AbbVie sells adult and pediatric formulations of Lupron, given by injection every few months. Doctors said that there is no meaningful difference between the two, but that they prefer to use the cheaper adult version, at about $4,700 for a three-month dose. They said insurers sometimes insist on the pediatric version, priced at more than $10,000, when the claim specifies that the patient is a child.

Some scientists and doctors also say they wonder about possible neurological effects of puberty blockers. The question: Hormones released during puberty play a major role in brain development, so when puberty is suppressed, can that result in reduced cognitive function, such as problem solving and decision making?

Dr John Strang, research director of the gender development program at Children’s National Hospital in Washington, D.C., and other researchers wrote in a 2020 paper that “pubertal suppression may prevent key aspects of development during a sensitive period of brain organization.”

Strang said at the time that “we need high-quality research to understand the impacts of this treatment – impacts which may be positive in some ways and potentially negative in others.” He declined to comment on whether he was pursuing such research or funding for it.

At their first meeting at the Akron clinic, Dr Cole was blunt with the Boyers about the unknowns related to puberty blockers and brain development. “We don’t know the long-term effects on cognitive function. It could make it better, worse. We have no idea,” Cole told them. But she said she wouldn’t recommend treatment “if I didn’t see the positive effect on patients.”

Back at the clinic seven months later, Ryace, 13 at the time, smiled in front of a whiteboard where the date, 3-4-21, was written in green marker. It was the day of her first Lupron injection. A photograph of Ryace from that day shows a small glittery bandage on her thigh peeking through her ripped jeans.

The family’s insurance is covering nearly all the cost.

As the months passed, Ryace complained of pain in her knees. She started taking vitamin D as a precaution, and her pain dissipated.

Questions about fertility

Early this year, the Akron clinic told the Boyers that it was time for Ryace to take the next step in her treatment: hormone therapy, to help her develop the feminine characteristics aligned with her gender identity.

Ryace was now 14. In its new guidelines, WPATH makes no age recommendation for hormones.

For decades, hormone therapy has been the central component of treatment to help adults transition – estrogen for transgender women and testosterone for transgender men.

But for children, the choice to take hormones is more complicated. As with much of transgender medicine, research on the impact of hormones on fertility consists of small observational studies or surveys of adults that have significant limitations, experts say.

Many doctors acknowledge that long-term hormone therapy may reduce fertility, and they say children who receive puberty blockers followed by hormones run the highest risk. But with no definitive science to rely on, doctors often leave the question open when talking to children and their parents.

One Tuesday earlier this year, 16-year-old Ethan S. and his mother were in an test room in suburban Portland to talk about testosterone therapy with Dr Kara Connelly, director of Oregon Health & Science University’s Doernbecher Gender Clinic. After reviewing the family’s medical history, Connelly, an associate professor of pediatric endocrinology, asked Ethan what he wanted from testosterone. “My deepening of the voice definitely, and the, like, distribution of my fat and stuff. And hopefully facial hair,” he said.


Ethan could expect those and other masculinizing changes, Connelly said. A deeper voice and hair growth would be permanent.

Connelly then turned to fertility: Nearly all patients who stop taking testosterone start to have menstrual cycles again, she told them, and they can go on to carry a pregnancy or have their eggs used by someone else. “We can’t predict with 100% certainty that testosterone would not have any effect on your fertility potential,” Connelly said. “All we know is generally what happens in a population, and that it does seem from that evidence that it is not as harmful to fertility potential as we once thought.”

Connelly based her comments on a 2014 study published in the journal Obstetrics & Gynecology that analyzed survey responses from 41 transgender men who had a baby. Twenty-five of them reported using testosterone before becoming pregnant. However, the researchers acknowledged that the survey excluded transgender men “who attempt to get pregnant and cannot and those who do not carry to term.”

Ethan was unconcerned about possible side effects from taking testosterone. “When is the soonest that I can get it?” he asked.

In Oregon, teens can take hormones without parental consent starting at age 15. A social worker handed him a form, and Ethan eagerly signed it.

Ethan’s mother, Melissa, was supportive. She said Ethan had already socially transitioned when he started talking about medically transitioning two years ago. Then Melissa’s father, suffering from alcoholism and depression, committed suicide in February 2021. Ethan had been close with his grandfather, and with that family history, Melissa said she panic even more about her son. “There’s the fear of what happens if I let him transition and then the fear of what happens if I don’t,” Melissa said after the appointment.

Few children choose to have their eggs or sperm preserved before gender treatment as insurance in case they decide they want to try to have children later in life. In particular, harvesting eggs can be expensive and invasive. And for both genders, it can increase the discomfort they experience with their bodies.

Dr Angela Kade Goepferd, a pediatrician and medical director of the gender health program at Children’s Minnesota hospital, sometimes asks parents to write a letter to their future adult child about the decision to start medications that may affect their fertility. An adolescent’s views on starting a family may change over time, so the aim is for the child to remember conversations and choices made when they were younger, Goepferd said, adding: “I don’t think these are easy decisions for families.”

In Akron, Dr Cole tried a similar approach with Ryace. She suggests that her patients try imagining themselves as a 35-year-old and think about what that person might want. “Kids by design don’t tend to think about long-term consequences. That is not how their brains work,” Cole said.

At home, Danielle asked Ryace if she was comfortable with the possibility of being unable to have her own biological children. Ryace said she would adopt. Also, a friend had already offered to have a baby for her after they became adults. “It could be sad, but I’m OK with it,” Ryace told her mother.

By April this year, Ryace was taking estrogen pills along with regular shots of Lupron. The endocrinologist started her on low-dose estrogen, gradually increasing the amount while weaning Ryace from the puberty blocker. Ryace also regularly sees a counselor. The Akron clinic, like many that Reuters spoke to, requires that most teens taking hormones receive counseling to help them through what can be a physically and emotionally challenging time.

CALMING INFLUENCE: Ethan makes use of one of the squeeze toys the Doernbecher Gender Clinic provides to patients to help ease their anxiety during consultations. REUTERS/Lindsey Wasson

‘They’re trying their best’

Ryace lives much of her life as any teenager. But as her transition has progressed, she has continued to confront disapproval from other relatives and the community.

At the county fair last year, members of the crowd grumbled when Ryace was crowned Horse Princess. In town, she spots people rolling their eyes and hears their snide comments. During a field trip in May, she broke down in sobs when she saw students teasing a 16-year-old boy from another school who had flirted with her and had asked to message her online.

Some patients who receive treatments like Ryace’s eventually decide to undergo “bottom surgery.” For transgender girls, the procedure, called vaginoplasty with penile inversion, involves the creation of a vagina and vulva from the patient’s penis and scrotum. Sometimes, the testicles are removed, too. The surgery is irreversible, expensive, and can result in serious complications that require follow-up procedures.

The authors of WPATH’s new standards considered advising that genital surgery generally not be performed until at least age 17, but ultimately they made no age-related recommendations. The Endocrine Society puts it at 18. In its latest policy statement, the Biden administration said gender-affirming surgeries were “typically used in adulthood or case-by-case in adolescence.”

Genital surgeries performed on minors are rare, but surgeons say interest is growing. The Komodo analysis of insurance claims found 56 genital surgeries, including vaginoplasty and other procedures, among patients ages 13 to 17 with a prior gender dysphoria diagnosis from 2019 to 2021. That doesn’t include surgeries not covered by insurance. In a 2017 research article that surveyed 20 WPATH-affiliated U.S. surgeons, the doctors said there had been “a definite increase in the number of minors” requesting information about vaginoplasty or being referred for surgery by their mental health providers.

Complications from genital surgeries are common. A California study found that a quarter of 869 vaginoplasty patients, with a mean age of 39, had a surgical complication so severe that they had to be hospitalized again. Among those patients, 44% needed additional surgery to address the complication, which included bleeding and bowel injuries.

For adolescents transitioning to female, puberty blockers and hormones can complicate eventual genital surgery. That’s because the medications can stunt development of the male genitalia from which a vagina and vulva are constructed. In 2020, de Vries and other Dutch researchers urged clinicians to inform transgender youth and their parents about this risk when starting puberty blockers.

Bowers, the new WPATH president and a transgender woman, said she has panic that some patients who begin puberty blockers at a young age won’t ever be able to have an orgasm because they never experienced one prior to pausing puberty, regardless of whether they have surgery. She said ongoing research has allayed many of her concerns, and “it seems not only probable but likely there is retention of orgasmic function.” She said she has encouraged doctors to talk about this risk with adolescents before they start medication.

The Akron clinic hasn’t discussed genital surgery with the Boyers yet. Akron Children’s Hospital doesn’t provide gender-affirming surgeries.

Overall, Ryace appears unfazed by the long-term implications of treatment. “I just go along with it pretty much,” she said.

In hindsight, she forgives her mother for making her conceal her identity for so long. “Sometimes she really wasn’t protecting me. She was just hurting me. And I know she didn’t mean it,” Ryace said. “I know a lot of parents probably do that, and they think they’re trying their best.”

Do you have an experience with gender-affirming care to share as a patient, family member or medical provider? Share it with Reuters.

Youth in Transition

By Chad Terhune, Robin Respaut and Michelle Conlin

Photography: Megan Jelinger and Lindsey Wasson

Photo editing: Corrine Perkins

Video editing: Christine Kiernan, Francesca Lynagh and Lucy Ha

Art direction: John Emerson

Edited by Michele Gershberg and John Blanton

Wed, 05 Oct 2022 23:00:00 -0500 en text/html
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