profile/4586Capturenn.PNG

Sandy

July 2023 Is Hottest Month Ever Recorded In Modern History

In July 2023, NASA's Goddard Institute for Space Studies (GISS) reported that it was the hottest month ever recorded in global temperature history. The analysis highlighted the urgency of President Biden's strong stance on climate change, given the backdrop of extreme events such as wildfires and floods. July 2023 was 0.43°F (0.24°C) hotter than any other July on record and 2.1°F (1.18°C) warmer than the average July between 1951 and 1980. The GISS analysis, which focuses on long-term temperature changes, revealed that this rise in temperature aligns with a trend of human-induced warming due to greenhouse gas emissions. The impact of climate change is being felt globally, with regions like South America, North Africa, North America, and the Antarctic Peninsula experiencing particularly high temperatures. NASA's data comes from a variety of sources, including air and sea surface temperature data, which is used to analyze and understand the implications of ongoing climate change

profile/4586Capturenn.PNG

Sandy

Bill Gates' Former Wife Has Shut The Door To Him Forever

profile/4586Capturenn.PNG

Sandy

The Only Foreigner At The Wuhan Virus Lab Says She Doesn't Believe The Center Leaked It

profile/4586Capturenn.PNG

Sandy

Is President Donald Trump Sick?

profile/4586Capturenn.PNG

Sandy

Getting The Benefits Of Sleep Even If It Is Short (Sleep Guide Included)

People with insomnia struggle to get a good night's rest and wonder how to sleep better They may be plagued by trouble falling asleep, unwelcome awakenings during the night, or fitful sleep - alone or in combination. They may feel drowsy during the day and yet be unable to nap. Insomnia can leave a person feeling anxious and irritable or forgetful and unable to concentrate. 

profile/4586Capturenn.PNG

Sandy

The Body, The Self

The care of people with intersex traits evolves as clinicians and researchers learn more—and listen more

An otherwise healthy baby is born with a phallus that seems small for a penis but big for a clitoris. The labia are partially fused so that they resemble a scrotum.

A young girl complains of abdominal tenderness. An exam for a suspected inguinal hernia instead finds a pair of undescended testes.

A teen raised as a male comes to the doctor bleeding from his penis. An ultrasound reveals that a previously undetected uterus has shed its lining through the urethra: he’s experiencing his first period.

Each year, a portion of the population is born with biological characteristics—sex chromosomes, gonads, genitalia, hormones, or a combination—that don’t fit textbook definitions of male or female. Most differences present at birth. A minority are accompanied by significant, even life-threatening, medical concerns. Others pose little or no danger. In many cases, the physical and psychological risks are uncertain.

Since the 1990s, when patient advocacy groups gained a national platform, debates have churned about which differences indicate pathology and which represent a spectrum of human sex characteristics that deserve acceptance. Such questions have fueled disagreement over whether to refer to atypical sex characteristics as “disorders of sex development,” or DSDs, as they’ve been classified by the medical profession since 2006; as “differences of” or “diverse” sex development to avoid pathologizing language; as intersex traits or variations in sex characteristics; or to abandon umbrella categories and use only the names of specific conditions.


It isn’t clear how common DSDs are, in part because they encompass some forty to sixty conditions with an even greater number of causes. Estimates of incidence range from more than 1 in 100 to less than 1 in 5,000 births, suggesting a prevalence between 66,000 and 3.3 million people in the United States. For comparison, Down syndrome occurs in 1 in 800 births.

The relative rarity of cases, combined with anemic material in medical school curricula and significant research gaps, leaves many physicians, surgeons, mental health specialists, and others struggling to understand how best to care for these underserved people. Throw in conflicting pressures from professional, patient advocacy, and human rights groups, and the waters grow ever muddier.

Clinical and bioethical questions abound. What’s the best way to work with families to assign the “right” sex when babies are born with diverse genital presentations? When and how should health care teams recommend intervening? How do providers act responsibly without a definite diagnosis or long-term outcome data? How to balance safety with patient autonomy? How to uncouple medical necessity from societal pressures that call for people to conform to a sex binary?

It can be hard even to talk about it.

“I think these conditions get stigmatized and compartmentalized because they’re sexual,” says psychiatrist Vernon Rosario, PhD ’93 MD ’95. “We feel like we’re supposed to hide DSDs from patients, especially children.”

DSD care is “complicated medically, surgically, politically, and in other ways, and especially recently, it’s an area that’s been under attack,” says David Diamond, an HMS professor of surgery, the HMS Alan B. Retik Chair and Professor of Pediatric Surgery at Boston Children’s Hospital, and a member of the hospital’s Ethics Advisory Committee. “There aren’t a lot of colleagues who have the courage to discuss this.”

“A lot of clinicians have closed ranks,” says Jameson Garland, a Harvard Law School alumnus and researcher at Uppsala University in Sweden, who specializes in children’s rights in biomedicine. “They’re under incredible scrutiny, incredible pressure to not talk, and many of them struggle to have dialogue outside of their specialty and the medical profession in general.”
Generalists can expect to encounter a handful of patients with DSDs throughout their careers.
But avoiding conversation does a disservice to both patients and practitioners, not least because generalists can expect to encounter a handful of patients with DSDs throughout their careers.

“If you practice long enough, you’ll definitely come across it,” says Vincent Smith, a neonatologist and an HMS assistant professor of pediatrics at Boston Children’s. “It helps to think about it and talk about it before it becomes an issue directly related to you, so you don’t have to cope with it on the fly.”

If anything is clear, it’s that the hetereogeneity of DSDs reflects a diversity of patient identities and opinions and prevents one-size-fits-all health care decision-making.

Let’s talk about sex

Sperm meets egg and chromosomes mix and match. Most embryos inherit two sex chromosomes, either XX or XY, which typically lead to bodies classified as female and male. But the story isn’t always so simple. Genetic mutations or variations on the sex chromosomes or elsewhere can create discrepancies between the classic karyotypes and physical characteristics. DSDs also can arise if embryos inherit unusual numbers of sex chromosomes, such as X or XXY, or develop different karyotypes in different cells, known as genetic mosaicism. Nongenetic factors contribute as well.

Early fetuses have a structure called the urogenital ridge that gives rise to the gonads, kidneys, and adrenal glands. This interconnectedness explains several DSDs, including why babies with changes in the Wilms’ tumor suppressor gene WT1 have a high risk of kidney failure and tumors in childhood along with underdeveloped gonads and genitourinary variations.

Rarely, gonads fail to develop altogether, leaving nonfunctional streaks of fibrous tissue with high cancer risk. Or, in the second most common cause of diverse genital presentation, embryos develop one mature gonad, usually a testis, and one streak gonad. In ovotesticular DSD, infants have a mix of gonadal tissue.

In some DSDs, the Wolffian ducts, which usually become the vas deferens, epididymis and seminal vesicles in males and disappear in females, or the Müllerian ducts, which usually become the Fallopian tubes and uterus in females and disappear in males, don’t develop as expected. Boys with persistent Müllerian duct syndrome have problems producing or detecting the hormone that normally suppresses maturation of female-associated structures. In girls with Mayer-Rokitansky-Küster-Hauser syndrome, the Müllerian ducts don’t form at all.

Many DSDs alter development of the external genitalia, which usually form as clitoris and labia unless exposed to testosterone from the testes.

People with XY chromosomes whose bodies can’t detect androgens appear female at birth, and at puberty they develop breasts as testosterone gets converted to estrogen, but they don’t produce sperm, have a uterus, or develop secondary male sex characteristics.

Inherited enzyme deficiencies can disrupt cortisol production by the adrenal glands, known as classic or severe congenital adrenal hyperplasia (CAH). The glands churn out excess androgens as they try to compensate. In fetuses that are genetically female, this androgen bath virilizes the genitals, sometimes to the extent that they’re presumed male at birth. In about 75 percent of cases, the adrenal glands also can’t produce hormones that balance salt and water in the kidneys, which, if not treated, can cause fatal complications in the weeks following birth. All fifty states screen newborns for classic CAH. Like insulin for type 1 diabetes, people with CAH need hormone supplements for life. CAH is the most common DSD for people with XX chromosomes.

If a genetic male has trouble converting testosterone to dihydrotestosterone, the urethra, initially located between scrotum and anus, may not reach its destination at the tip of the penis. Research suggests that this condition, hypospadias, affects about 0.4 percent of babies assigned male and is on the rise, likely because of environmental chemical exposure. Such exposure may also be triggering a rise in the incidence of undescended testes. Less commonly, failure of testosterone conversion can lead to diverse genital presentations in XY babies, who then develop male secondary sex characteristics at puberty when androgens surge.

Many more variations can arise from developmental byways. While effects vary, it’s common for people with DSDs to experience infertility or low fertility and to need hormone replacement to induce puberty or carry out other biological processes.

The weight of research

For many infants who present with diverse genitalia, the precise etiology remains unknown. Without a definitive diagnosis, clinicians can’t rely on evidence or experience to guide care, says Rosario.

Researchers have unearthed dozens of genes and even more variants that contribute to DSDs. Still, the ever-expanding list explains a mere fraction of physical diversity. Sequencing techniques currently can detect a genetic cause for 20 percent to 45 percent of intersex babies.

Geneticists are trying to change that. At HMS and Boston Children’s, a team led by Joel Hirschhorn, MD ’95 PhD ’95, and Ingrid Holm is conducting whole-exome sequencing of infants with classic DSDs as well as infants with a broader range of variations to illuminate the genetics of sex development and assess how parents respond to test results.

“The person who has to live with this should have a voice when it’s appropriate. If there’s a medical indication to not wait, that trumps other things. But all else equal, it’s better for the person to contribute.”
International databases and multi-institutional research networks are making another dent in the unknown. The International DSD Registry hosts data from about 3,000 patients, ranging in age from infancy to 77 years, in thirty-four countries. The National Institutes of Health-funded DSD Translational Research Network, spanning twelve U.S. clinical sites, is examining genetic causes and participants’ physical and mental health.

By centralizing and standardizing data collection, such efforts have begun to identify new DSDs and biomarkers and track short- and long-term outcomes of DSDs and treatments, information that’s historically been in short supply, with the goal of improving diagnosis and care. The results also could clarify how often people with DSDs are assigned a sex at birth that they later do not identify with, a rate that studies estimate to be between 5 percent and 60 percent, depending on the condition.

Consensus statements from groups that include physicians, surgeons, bioethicists, lawyers, and patient advocates have attempted to synthesize the slim but growing body of research on DSDs and facilitate agreement on how to proceed. The first, known as the Chicago consensus, was published in 2006 and initiated many of the changes seen in intersex care, including the coining of “disorders of sex development” and a recommendation that patients be assessed by multidisciplinary teams in specialty centers. In 2016, a Global DSD Update revised the Chicago report. Still, gaps remain between recommendations and practice.

Intersex research funding is on the rise, though it has a long way to go. In fiscal year 2017, the NIH funded just eight projects related to DSDs, according to a portfolio analysis by the institutes’ Sexual and Gender Minority Research Office. It’s a morsel, and hunger is growing.

“When I attend sexual and gender minority research meetings, there are increasing numbers of research scientists interested in exploring this area,” says Jennifer E. Potter, MD ’87, an HMS professor of medicine at Beth Israel Deaconess Medical Center. “So that’s a real positive.”

No more simply pink or blue

Medical and surgical practices are evolving as well, both in technique and philosophy. As times change and patients speak up, more practitioners question a tradition in intersex care that reinforces gender binaries and heterosexual norms.
For some people with DSDs, gender identity aligns with the sex they were assigned at birth; for some it does not. Some identify as male or female; some do not. Some are straight; some are not. For many, gender identity and sexuality are complicated.

“We’ve basically been thinking about sex development and gender identity all wrong for a very long time, and that has done a disservice to an entire population of people who do not fit our traditional expectations,” says Potter.

Another mid- to late-century trend now seen as a blunder was a tendency for practitioners and parents to hide DSD diagnoses.
In the 1950s and ’60s, influential but now discredited research argued that having “normal”-looking genitalia and a clear gender of rearing would lead to “stable male or female identity” and prevent same-sex attraction. The research intensified practices that had begun in the 1920s in which infants with variant or discordant sex characteristics were surgically altered to conform to certain male and female standards, and parents were encouraged to reinforce the assigned gender. Surgeons tended to prioritize fertility for those assigned female and sexual satisfaction for those assigned male. Vaginoplasty was recommended for female-assigned infants not only so those with a uterus could menstruate at puberty but also on the assumption that those with or without a uterus would later want to accommodate penile intercourse. Cosmetic outcomes frequently took precedence over future sexual function and sensation.

Another mid- to late-century trend now seen as a blunder was a tendency for practitioners and parents to hide DSD diagnoses. Patients sometimes didn’t discover they were intersex until well into adulthood. Many children weren’t told they’d undergone procedures or weren’t told why.

Documentation of psychological harm stemming from secrecy, legal requirements for informed consent, and other practical considerations—that patients will eventually grow up and see their medical records, that they will need to manage any related health issues—have led to greater transparency and shared decision-making between doctors and families. The American Psychological Association recommends explaining DSD diagnoses to children “throughout their lives in an age-appropriate manner.”




Along with openness has come an increasing emphasis on patient consent and autonomy. Many of the intersex people who have spoken publicly about their experiences express anger and anguish at not having been involved in major decisions about their bodies, especially when procedures resulted in infertility or in altered or “wrong” genitalia. Emotions have run even higher since research and patient testimonies revealed higher than expected rates of surgical complications such as pain, scarring, stenosis, poor sensation or sexual enjoyment, reduced sexual function, incontinence, and other dysfunctions.

Pause, consider

Shifting to a consent-based model translates to postponing medically unnecessary interventions until patients are old enough to weigh in. A key question in intersex care then becomes what to consider unnecessary.

Sometimes distinctions are clear, as with salt-losing CAH, WT1 mutations, and other serious issues that may accompany diverse genitalia, such as an incomplete urethra or rectum, defects in the heart or other organs, microcephaly, joined fingers, epilepsy, or thalassemia. More often than not, however, the line isn’t so sharp.

“Some kids are born with significant midline malformations that require surgery just to survive,” says psychiatrist Rosario, who served on a multidisciplinary care team in a children’s DSD clinic at UCLA and sees patients through the Los Angeles County Department of Mental Health. “I don’t think even intersex activists would say you shouldn’t do that. The challenge then is determining what is lifesaving versus what’s more cosmetic. That is a gray area.”

It used to seem clear that surgeons should remove gonads because they carried high risk of becoming cancerous. Then researchers found that malignancy isn’t such a given. As studies narrow down gonadal cancer likelihood and timing for individual DSDs, recommendations have shifted toward active surveillance or watchful waiting to extend fertility and allow natural induction of puberty. Most people with DSDs can now safely retain well-developed gonads until puberty or later if desired, allowing them to participate in decision-making about risks and benefits. For those who do remove gonads because of cancer risk or to avoid initiating puberty in a gender they don’t identify with, doctors may be able to offer fertility preservation options.

Clinicians also are revisiting estimates of the likelihood that being born with a shared exit for the urethra and vagina leads to repeated urinary tract infections. If the risk proves lower than previously thought, surgeons may be able to delay procedures on this region until patients can have their say.

It’s been standard practice to surgically correct hypospadias. Stakeholders are now asking if the purpose is to allow urine and semen to exit the penis in a “normal” location, must it be done during infancy, or can it wait?

But the eye of the storm swirls around surgery primarily intended to make internal and external structures more definitively male or female.

A say in the matter

Arguments in favor of performing non­­urgent, so-called gender-normalizing operations in infancy range from the surgical to the social, including that children won’t remember the procedures, wound healing is faster and bleeding less, children won’t grow up “confused” about their sex or gender, and patients and families won’t be bullied or stigmatized for being different.

“With some of these anatomic disorders, it’s much easier technically to do a surgical procedure when a child is little,” says Diamond. “Usually when it’s easier for the surgeon it’s an easier recovery for the patient.”

Those in favor of waiting until patients can participate in decision-making emphasize bodily and reproductive autonomy and the risk of physical and psychological trauma. Surgical complications could overshadow the benefits, they argue. Construction or elimination of genitals could fail to align with the child’s ultimate gender identity. Children are denied the opportunity to say whether atypical genitalia bother them or are just fine.

“Sometimes we get it wrong, and the person who has to live with this should have a voice when it’s appropriate,” says neonatologist Smith. “If there’s a medical indication to not wait, that trumps other things. But all else equal, it’s better for the person to contribute.”

Without long-term outcome data, the risks of individual procedures can’t be quantified, nor can the advantages of waiting versus intervening early. It’s also unclear whether patients who’ve gone public reflect most intersex people’s experiences. Clinicians don’t know how much of the reported distress arises from outdated surgical techniques, nor do they know yet whether current procedures will prove any better.

Researchers are attempting to better gauge outcomes and satisfaction rates. A forthcoming European report will describe the opinions of more than one thousand intersex patients and their doctors regarding satisfaction with “anatomical and functional results of genital surgery,” according to a 2019 review article in the Journal of Pediatric Urology. Institutions are conducting other retrospective and prospective studies, such as a U.S. endeavor at multiple sites, including HMS.

Clinicians also are turning to transgender patients for insight. Teens and adults can provide immediate feedback on medical and surgical procedures and describe broad ranges of desired outcomes, which can then inform intersex care, says surgeon Diamond. The relationship seems fitting, since certain surgical interventions for transgender affirmation were informed by procedures developed for infants with DSDs.

But for many intersex advocates, the wait is too long for the results of such endeavors. Over the past decade, advocacy groups have led a global movement calling for a moratorium on genital and gonadal surgeries without patient consent. International health and human rights organizations, including the United Nations and the World Health Organization, have condemned the procedures, and several countries have restricted them. In February, the European Parliament urged member states to prohibit nonconsensual sex-normalizing surgeries “as soon as possible.” Some medical societies, consortia, and prominent figures such as a trio of former U.S. surgeons general have echoed the call. Several states, such as California, have considered bans.

This sea change has evoked an array of reactions, even among patients. People with CAH in particular say that an outright ban will do more harm than good by depriving families of the option to choose surgery. Appending an objection to a 2019 consensus paper by German academics that supported a ban, one CAH group said the majority of those with CAH who identify as female are satisfied with the results of their feminizing surgery and glad to have completed it in infancy.

The idea that the bodily autonomy of intersex children supersedes parents’ traditional roles as health care proxies remains a point of contention. National medical ethics councils in Finland, Germany, Sweden, and Switzerland say parents cannot authorize medically unnecessary surgery on genitals or gonads; the 2016 Global DSD Update says they can. Though the United States has not ruled on DSDs, its law and culture generally side with parents’ right to choose, say Garland and Diamond, and many clinicians continue to defer to them on intersex care.

“When we discuss the pros and cons of surgery with the family and they say, ‘We understand the different ways to go and this is what we think is best for our child,’ I accept that that is a responsible way to manage the child,” says Diamond.

Some clinicians fear losing the ability to use their medical expertise to guide families and make decisions based on individual cases. “It is not logical to impose mandatory restrictions on surgery in an area as complicated as this,” reads a 2017 joint statement from seven U.S. urology and endocrinology societies.

Rosario served as chair of the medical advisory board for the Intersex Society of North America from 2002 to 2006 before he joined the UCLA DSD clinic. Initially against infant genital-normalizing surgery, he found that “my opinion softened with actual clinical experience,” he says.

Arguments roil about where gender-normalizing surgery falls along the spectrum of acts performed on infant genitalia. All fifty U.S. states condemn female genital mutilation, some advocates point out, so why should intersex surgery be considered differently? Others make comparisons to male circumcision, yet that practice also has been questioned. Professional societies are increasingly supporting interventions for transgender patients, so why deny the choice to those with DSDs, people ask?

While individual clinicians may support restricting infant genital-normalizing surgery, Garland wonders whether the threat of malpractice litigation explains why the U.S. medical profession tends to emphasize following the standard of care rather than trying nonintervention. He adds that in countries where “the law requires scientific evidence and careful testing to establish the safety and efficacy of medical interventions, it’s been determined that these surgeries clearly don’t meet that standard.”

“As physicians and as a society, we’ve evolved, but we’re not to the point where we can routinely be comfortable with ambiguity. Some families can take that leap, but they are so uncommon.”
Pressure to change may come from peers, such as the Massachusetts Medical Society, which is debating a recommendation to delay surgeries on infants with DSDs “that are of a non-emergent status until the individual has the capacity to participate in the decision.” Doctors listen to other doctors, points out Smith, who serves on the LGBTQ committee that submitted the proposal.

Lawsuits also could influence U.S. medical practice. In a case that settled out of court in 2017, parents sued two South Carolina hospitals and a social services department for having performed feminizing surgery on a child they later adopted who grew up to identify as male.

Should DSD care shift, “we will need a new way of thinking about how to determine when a child is able to consent,” says Garland.

Those who worry about the lack of comparative data between early, delayed, and no intervention may take note as more nations and institutions restrict surgery on minors.

“We may have our control group developing in Europe,” says Diamond.

As more practitioners view forgoing surgery as an option, they turn to more flexible alternatives meant to support patients’ gender expression, such as hormone treatments. Surgeons also consider middle-ground procedures that preserve gender options as children grow.

In a 2018 case review in the Journal of Pediatric Urology, Diamond and colleagues described three infants with genetic mosaicism and complex urogenital and gonadal features whose parents all opted, among other procedures, to create vaginas but preserve the phalluses while they waited for their children to develop a gender. Two families were tentatively raising their children female; the other, gender neutral.

“I wouldn’t have thought that way at all ten years ago,” says Diamond, who estimates he sees one hundred DSD patients a year in the Behavioral Health, Endocrinology, Urology (BE-U) program at Boston Children’s. “My frame of mind would have been that the surgical options were more of a binary choice.”

To those who believe that refraining from intervention does the least harm, Diamond says, “You do your best, and you do it with a lot of humility because you know that no matter what you do, as much data as you have, you may be wrong.”

Mind and body

Clinicians continue to learn how to avoid inadvertently making things worse for people with DSDs. Research studies and patient advocacy reports have documented the long-term psychological harm stemming from health care experiences such as repeated genital examinations and photography, depersonalization, and demeaning language.

That’s part of why psychologists and social workers have become essential members of DSD care teams over the past 20 years, although experts agree that psychosocial care still isn’t available to enough families.

“Surgeons and other specialists focus on their areas, particularly on the genitals, and they don’t pay as much attention to the rest of the person,” says Rosario. “My job is to ask, how are you doing in school, and how are you doing with friends?”

Although there is variation across conditions, initial research suggests that people with DSDs are more prone than the general population to mental health problems, including depression, anxiety, suicidal ideation, post-traumatic stress disorder, and trouble with intimacy. Such disparities may arise from treatment, culture, or the biology of the DSDs themselves.

“Maybe we should be trying to help parents, and by extension the people surrounding the parents—the extended family, the school system, all of these places—become more knowledgeable that there’s a spectrum of sex presentation.”
Other studies assess the frequency, severity, and nature of parental distress when children receive DSD diagnoses. Researchers at HMS and elsewhere have found that unexpected anatomical variations, the possibility of stigma, and lack of clarity about the child’s cancer risk, fertility, and future gender identity can cause significant anguish. Yet they also have found that caregivers of intersex children are no more depressed and, in fact, are less anxious than the general population.

Still more questions center on what should be done if the bulk of distress over DSDs arises from societal rather than medical issues.

Breaking away

In an era of gender-reveal parties and bathroom access controversies, having a “perfectly happy” baby with DSD “can be like a crisis for families,” says Smith. “If there are no accompanying medical issues, then it becomes an entirely social-driven crisis.”

Clinicians and parents often cite the desire to protect children from social harm when they opt for gender-normalizing procedures. Why, critics ask, in a culture built around binary sex, is the standard solution to alter bodies that are nonbinary rather than broaden societal conceptions of sex and gender?

“It’s really fraught when a concerned parent or physician thinks that a child who is intersex, and maybe doesn’t present in a typical manner, is therefore going to have a harder time in the world,” says Potter. “That might be true, it might not be true, but in any event, trying to ‘fix’ it so that they look like people with binary bodies may make a big mess of things.”

“Maybe we should be trying to help parents, and by extension the people surrounding the parents—the extended family, the school system, all of these places—become more knowledgeable that there’s a spectrum of sex presentation,” she adds. “Instead of conforming a child to something, transform the world in which they live. Then life may not be so hard.”

“That’s where law can also play a significant role, stopping discrimination and encouraging increased support for parents and children,” says Garland.

While Garland, Potter, and others envision a more DSD-friendly future, they acknowledge that the systemic changes required will take time and effort. Meanwhile, others point out, clinicians, patients, and families must live in today’s cultural contexts.

Discomfort with atypical sex characteristics “is very much a societal problem, but we are caring for human beings who are brought up in our society to think in certain ways,” says Diamond. “As physicians and as a society, we’ve evolved a great deal, but we’re not at the point, I think, where we can routinely be comfortable with ambiguity. Some families can take that leap, but they are so uncommon.”

As our culture progresses, that balance may shift. The sharing of people’s preferred pronouns, encompassing a spectrum of identities beyond “he/his” and “she/hers,” is becoming more common. People with transgender, gender nonconforming, nonbinary, and intersex identities are increasingly out and proud.

“I’ve been very surprised and pleased to see how much has changed in the LGBT arena in the past twenty years,” says Garland. “It’s dramatic worldwide. Acceptance has increased of people with different sexualities and genders.”

If trends continue, then in another generation or two, the agitation around DSDs may calm. Doctors may deliver healthy intersex babies and simply say: “Congratulations.”

profile/4586Capturenn.PNG

Sandy

Gender Bias Complaints Against Apple Card Signal A Dark Side To

The possibility that Apple Card applicants were subject to gender bias opens a new frontier for the financial services sector in which regulators are largely absent, argues

In late August, the Apple Card debuted with a minimalist look and completely “no fee” model, creating a frenzy of anticipation. Millions signed up to be alerted for the release. Designed to boost traffic to its slow-to-be-adopted Apple Pay system and increase consumer dependency on iPhones, the Apple Card marked another significant innovation in access to financial services.

Fast forward two months, and Apple Card may now find its place in history for a less positive reason—the dark side of the technological revolution rearing its ugly head. Last week, Danish programmer David Heinemeier Hansson tweeted that after both he and his wife Jamie applied for the Apple Card with much of the same or shared financial information, he was astonished to receive a credit limit 20 times higher, despite his wife’s higher credit score.

Cue the viral tweet storm that followed, rife with accusations of bias in Goldman Sachs’s underwriting model. (Goldman developed and issued the card.) Adding fuel to the fire, Apple co-founder Steve Wozniak shared that the same thing had happened to him and his wife. Officials from the New York Department of Financial Services quickly chimed in, assuring the Twitter sphere that they would investigate.

Technology is undeniably transforming the financial services industry. Fintechs, Big Tech, and banks are using increasing volumes of data, artificial intelligence, and machine learning to build new algorithms to determine creditworthiness. The lending process, which was historically plagued by frictions, is becoming potentially more accurate, efficient, and cost effective.

For small-business lending, technology is changing the game, providing access to capital for more small businesses that need it to grow and succeed. But when lending relies on algorithms to make loan and underwriting decisions, as the Apple Card situation illustrates, the potential for discrimination grows.

“WHEN LENDING RELIES ON ALGORITHMS TO MAKE LOAN AND UNDERWRITING DECISIONS, AS THE APPLE CARD SITUATION ILLUSTRATES, THE POTENTIAL FOR DISCRIMINATION GROWS."
Should the customers be able to see what pieces of data may have led to a loan rejection or a lower credit limit? Should regulators have access to the algorithms and test them for the impact they have on underserved or protected classes?

The Apple Card situation has raised these questions in a visible way and the public engagement has been strong and immediate. Clearly, this is a new frontier for the financial services sector—and the industry’s regulators are also operating without a roadmap. We need to stop arguing about more versus less financial regulation and begin the hard work of creating smart regulation. This would include at least three parts, all of which are all hard to accomplish:

Disclosure rules on who gets to see what is in the credit algorithms.
Increased expertise at the regulatory agencies.
Data collection to know who is getting loans and where the gaps are occurring.

The Apple Card fiasco is not going to be an isolated incident—it’s the canary in the coal mine for the financial services industry and regulators playing catch up to the implications of the fintech revolution. For all the promise that comes with the Apple Card or other new innovations for deploying capital, if creditworthy customers are being shut out, that’s a problem. Even worse, if we don't understand why, we can’t fix it.

profile/4586Capturenn.PNG

Sandy

A Perfect Guides For First-Time Parents

You've gone through pregnancy, labor, and delivery, and now you're ready to go home and begin life with your baby. Once home, though, you might feel like you have no idea what you're doing!

These tips can help even the most nervous first-time parents feel confident about caring for a newborn in no time.

Getting Help After the Birth

Consider getting help during this time, which can be very hectic and overwhelming. While in the hospital, talk to the experts around you. Many hospitals have feeding specialists or lactation consultants who can help you get started nursing or bottle-feeding. Nurses also are a great resource to show you how to hold, burp, change, and care for your baby.

For in-home help, you might want to hire a baby nurse, postpartum doula, or a responsible neighborhood teen to help you for a short time after the birth. Your doctor or the hospital can help you find information about in-home help, and might make a referral to home health agencies.

Relatives and friends often want to help too. Even if you disagree on certain things, don't dismiss their experience. But if you don't feel up to having guests or you have other concerns, don't feel guilty about placing restrictions on visitors.

Handling a Newborn

If you haven't spent a lot of time around newborns, their fragility may be intimidating. Here are a few basics to remember:

Wash your hands (or use a hand sanitizer) before handling your baby. Newborns don't have a strong immune system yet, so they're at risk for infection. Make sure that everyone who handles your baby has clean hands.

Support your baby's head and neck. Cradle the head when carrying your baby and support the head when carrying the baby upright or when you lay your baby down.

Never shake your newborn, whether in play or in frustration. 

Shaking can cause bleeding in the brain and even death. If you need to wake your infant, don't do it by shaking — instead, tickle your baby's feet or blow gently on a cheek.

Make sure your baby is securely fastened into the carrier, stroller, or car seat. Limit any activity that could be too rough or bouncy.

Remember that your newborn is not ready for rough play, such as being jiggled on the knee or thrown in the air.

Bonding and Soothing

Bonding, probably one of the most pleasurable parts of infant care, happens during the sensitive time in the first hours and days after birth when parents make a deep connection with their infant. Physical closeness can promote an emotional connection.

For infants, the attachment contributes to their emotional growth, which also affects their development in other areas, such as physical growth. Another way to think of bonding is "falling in love" with your baby. Children thrive from having a parent or other adult in their life who loves them unconditionally.

Begin bonding by cradling your baby and gently stroking him or her in different patterns. Both you and your partner can also take the opportunity to be "skin-to-skin," holding your newborn against your own skin while feeding or cradling.

Babies, especially premature babies and those with medical problems, may respond to infant massage. Certain types of massage may enhance bonding and help with infant growth and development. Many books and videos cover infant massage — ask your doctor for recommendations. Be careful, however — babies are not as strong as adults, so massage your baby gently.

Babies usually love vocal sounds, such as talking, babbling, singing, and cooing. Your baby will probably also love listening to music. Baby rattles and musical mobiles are other good ways to stimulate your infant's hearing. If your little one is being fussy, try singing, reciting poetry and nursery rhymes, or reading aloud as you sway or rock your baby gently in a chair.

Some babies can be unusually sensitive to touch, light, or sound, and might startle and cry easily, sleep less than expected, or turn their faces away when someone speaks or sings to them. If that's the case with your baby, keep noise and light levels low to moderate.

Swaddling, which works well for some babies during their first few weeks, is another soothing technique first-time parents should learn. Proper swaddling keeps a baby's arms close to the body while allowing for some movement of the legs. Not only does swaddling keep a baby warm, but it seems to give most newborns a sense of security and comfort. Swaddling also may help limit the startle reflex, which can wake a baby.

Here's how to swaddle a baby:

Spread out the receiving blanket, with one corner folded over slightly.
Lay the baby face-up on the blanket with his or her head above the folded corner.

Wrap the left corner over the body and tuck it beneath the back of the baby, going under the right arm.

Bring the bottom corner up over the baby's feet and pull it toward the head, folding the fabric down if it gets close to the face. Be sure not to wrap too tightly around the hips. Hips and knees should be slightly bent and turned out. Wrapping your baby too tightly may increase the chance of hip dysplasia.

Wrap the right corner around the baby, and tuck it under the baby's back on the left side, leaving only the neck and head exposed. To make sure your baby is not wrapped too tight, make sure you can slip a hand between the blanket and your baby's chest, which will allow comfortable breathing. Make sure, however, that the blanket is not so loose that it could become undone.

Babies should not be swaddled after they're 2 months old. At this age, some babies can roll over while swaddled, which increases their risk of sudden infant death syndrome (SIDS).

All About Diapering

You'll probably decide before you bring your baby home whether you'll use cloth or disposable diapers. Whichever you use, your little one will dirty diapers about 10 times a day, or about 70 times a week.

Before diapering your baby, make sure you have all supplies within reach so you won't have to leave your infant unattended on the changing table. You'll need:

1. A clean diaper

2. Fasteners (if cloth prefold diapers are used)

3. Diaper ointment

4. Diaper wipes (or a container of warm water and a clean washcloth or cotton balls)

After each bowel movement or if the diaper is wet, lay your baby on his or her back and remove the dirty diaper. Use the water, cotton balls, and washcloth or the wipes to gently wipe your baby's genital area clean. When removing a boy's diaper, do so carefully because exposure to the air may make him urinate. When wiping a girl, wipe her bottom from front to back to avoid a urinary tract infection (UTI). To prevent or heal a rash, apply ointment. Always remember to wash your hands thoroughly after changing a diaper.

Diaper rash is a common concern. Typically the rash is red and bumpy and will go away in a few days with warm baths, some diaper cream, and a little time out of the diaper. Most rashes happen because the baby's skin is sensitive and becomes irritated by the wet or poopy diaper.

To prevent or heal diaper rash, try these tips:

Change your baby's diaper often, and as soon as possible after bowel movements.
Gently clean the area with mild soap and water (wipes sometimes can be irritating), then apply a very thick layer of diaper rash or "barrier" cream. Creams with zinc oxide are preferred because they form a barrier against moisture.

If you use cloth diapers, wash them in dye- and fragrance-free detergents.

Let the baby go undiapered for part of the day. This gives the skin a chance to air out.

If the diaper rash continues for more than 3 days or seems to be getting worse, call your doctor — it may be caused by a fungal infection that requires a prescription.

Bathing Basics

You should give your baby a sponge bath until:

1. The umbilical cord falls off and the navel heals completely (1–4 weeks)

2. The circumcision heals (1–2 weeks)

A bath two or three times a week in the first year is fine. More frequent bathing may be drying to the skin.

Have these items ready before bathing your baby:

1. A soft, clean washcloth
2. Mild, unscented baby soap and shampoo
3. A soft brush to stimulate the baby's scalp
4. Towels or blankets
5. A clean diaper
6. Clean clothes

Sponge baths. 
For a sponge bath, select a safe, flat surface (such as a changing table, floor, or counter) in a warm room. Fill a sink, if nearby, or bowl with warm (not hot!) water. Undress your baby and wrap him or her in a towel. Wipe your infant's eyes with a washcloth (or a clean cotton ball) dampened with water only, starting with one eye and wiping from the inner corner to the outer corner. Use a clean corner of the washcloth or another cotton ball to wash the other eye. Clean your baby's nose and ears with the damp washcloth. Then wet the cloth again and, using a little soap, wash his or her face gently and pat it dry.

Next, using baby shampoo, create a lather and gently wash your baby's head and rinse. Using a wet cloth and soap, gently wash the rest of the baby, paying special attention to creases under the arms, behind the ears, around the neck, and in the genital area. Once you have washed those areas, make sure they are dry and then diaper and dress your baby.

Tub baths. When your baby is ready for tub baths, the first baths should be gentle and brief. If he or she becomes upset, go back to sponge baths for a week or two, then try the bath again.

In addition to the supplies listed above, add:

an infant tub with 2 to 3 inches of warm — not hot! — water (to test the water temperature, feel the water with the inside of your elbow or wrist).
An infant tub is a plastic tub that can fit in the bathtub; it's a better size for babies and makes bathing easier to manage.
Undress your baby and then place him or her in the water immediately, in a warm room, to prevent chills. Make sure the water in the tub is no more than 2 to 3 inches deep, and that the water is no longer running in the tub. Use one of your hands to support the head and the other hand to guide the baby in feet-first. Speaking gently, slowly lower your baby up to the chest into the tub.

Use a washcloth to wash his or her face and hair. Gently massage your baby's scalp with the pads of your fingers or a soft baby hairbrush, including the area over the fontanelles (soft spots) on the top of the head. When you rinse the soap or shampoo from your baby's head, cup your hand across the forehead so the suds run toward the sides and soap doesn't get into the eyes. Gently wash the rest of your baby's body with water and a small amount of soap.

Throughout the bath, regularly pour water gently over your baby's body so he or she doesn't get cold. After the bath, wrap your baby in a towel immediately, making sure to cover his or her head. Baby towels with hoods are great for keeping a freshly washed baby warm.

While bathing your infant, never leave the baby alone. If you need to leave the bathroom, wrap the baby in a towel and take him or her with you.

Circumcision and Umbilical Cord Care

Immediately after circumcision, the tip of the penis is usually covered with gauze coated with petroleum jelly to keep the wound from sticking to the diaper. Gently wipe the tip clean with warm water after a diaper change, then apply petroleum jelly to the tip so it doesn't stick to the diaper. Redness or irritation of the penis should heal within a few days, but if the redness or swelling increases or if pus-filled blisters form, infection may be present and you should call your baby's doctor immediately.

Umbilical cord care in newborns is also important. Some doctors suggest swabbing the area with rubbing alcohol until the cord stump dries up and falls off, usually in 10 days to 3 weeks, but others recommend leaving the area alone. Talk to your child's doctor to see what he or she prefers.

An infant's navel area shouldn't be submerged in water until the cord stump falls off and the area is healed. Until it falls off, the cord stump will change color from yellow to brown or black — this is normal. Call your doctor if the navel area looks red or if a foul odor or discharge develops.

Feeding and Burping Your Baby

Whether feeding your newborn by breast or a bottle, you may be stumped as to how often to do so. Generally, it's recommended that babies be fed on demand — whenever they seem hungry. Your baby may cue you by crying, putting fingers in his or her mouth, or making sucking noises.

A newborn baby needs to be fed every 2 to 3 hours. If you're breastfeeding, give your baby the chance to nurse about 10–15 minutes at each breast. If you're formula-feeding, your baby will most likely take about 2–3 ounces (60–90 milliliters) at each feeding.

Some newborns may need to be awakened every few hours to make sure they get enough to eat. Call your baby's doctor if you need to wake your newborn often or if your baby doesn't seem interested in eating or sucking.

If you're formula-feeding, you can easily monitor if your baby is getting enough to eat, but if you're breastfeeding, it can be a little trickier. If your baby seems satisfied, produces about six wet diapers and several stools a day, sleeps well, and is gaining weight regularly, then he or she is probably eating enough.

Another good way to tell if your baby is getting milk is to notice if your breasts feel full before feeding your baby and less full after feeding. Talk to your doctor if you have concerns about your child's growth or feeding schedule.

Babies often swallow air during feedings, which can make them fussy. To help prevent this, burp your baby often. Try burping your baby every 2–3 ounces (60–90 milliliters) if you bottle-feed, and each time you switch breasts if you breastfeed.

If your baby tends to be gassy, has gastroesophageal reflux, or seems fussy during feeding, try burping your little one after every ounce during bottle-feeding or every 5 minutes during breastfeeding.

Try these burping tips:

Hold your baby upright with his or her head on your shoulder. Support your baby's head and back while gently patting the back with your other hand.
Sit your baby on your lap. Support your baby's chest and head with one hand by cradling your baby's chin in the palm of your hand and resting the heel of your hand on your baby's chest (be careful to grip your baby's chin — not throat). Use the other hand to gently pat your baby's back.

Lay your baby face-down on your lap. Support your baby's head, making sure it's higher than his or her chest, and gently pat or rub his or her back.

If your baby doesn't burp after a few minutes, change the baby's position and try burping for another few minutes before feeding again. Always burp your baby when feeding time is over, then keep him or her in an upright position for at least 10–15 minutes to avoid spitting up.

Sleeping Basics

As a new parent, you may be surprised to learn that your newborn, who seems to need you every minute of the day, actually sleeps about 16 hours or more!

Newborns typically sleep for periods of 2–4 hours. Don't expect yours to sleep through the night — the digestive system of babies is so small that they need nourishment every few hours and should be awakened if they haven't been fed for 4 hours (or more often if your doctor is concerned about weight gain).

When can you expect your baby to sleep through the night? Many babies sleep through the night (between 6–8 hours) at 3 months of age, but if yours doesn't, it's not a cause for concern. Like adults, babies must develop their own sleep patterns and cycles, so if your newborn is gaining weight and appears healthy, don't despair if he or she hasn't slept through the night at 3 months.

It's important to always place babies on their backs to sleep to reduce the risk of SIDS (sudden infant death syndrome). Other safe sleeping practices include: not using blankets, quilts, sheepskins, stuffed animals, and pillows in the crib or bassinet (these can suffocate a baby); and sharing a bedroom (but not a bed) with the parents for the first 6 months to 1 year. Also be sure to alternate the position of your baby's head from night to night (first right, then left, and so on) to prevent the development of a flat spot on one side of the head.

Many newborns have their days and nights "mixed up." They tend to be more awake and alert at night, and more sleepy during the day. One way to help them is to keep stimulation at night to a minimum. Keep the lights low, such as by using a nightlight. Reserve talking and playing with your baby for the daytime. When your baby wakes up during the day, try to keep him or her awake a little longer by talking and playing.

Even though you may feel anxious about handling a newborn, in a few short weeks you'll develop a routine and be parenting like a pro! If you have questions or concerns, ask your doctor to recommend resources that can help you and your baby grow together.