Mortality Risk In Transgender Men & Women Twice As High As In Cisgenders, Data Spanning 5 Decades Suggests

A study on the mortality risk of transgender people compared with cisgenders, using data from 1972 to 2018, suggests importance of addressing health disparities and increasing social acceptance

New Delhi: Transgender men and women are twice as likely to die compared to their cisgender counterparts, according to an analysis of data spanning five decades — from 1972 and 2018. The analysis indicates that the mortality risk of transgender people did not decrease with time. Rather, there was a two-fold increase in this risk.

Further, mortality risk was found to be higher in transgender women compared to transgender men, the study published in The Lancet Diabetes and Endocrinology journal notes.

The study analysed data from 4,568 transgender people in the Netherlands recorded between 1972 and 2018 retrospectively. 

The Mortality Numbers 

The data of 2,927 transgender women and 1,641 transgender men was collected from their medical files obtained from the gender identity clinic at Amsterdam UMC, which they attended between 1972 and 2018. They were also receiving gender-affirming hormone treatment. Data of the participant's age at the beginning of the treatment, the kind of treatment, smoking habits, medical history, and the last date of follow-up was gathered. The average ages of transgender men and transgender women at the start of the treatment were found to be 30 and 23, respectively.

The data held by Statistics Netherlands (CBS) was used to calculate the ratio of deaths among transgender men and transgender women compared to the adult Dutch population's death rates. Cardiovascular disease, infection, cancer, and non-natural causes of death were the different categories considered for this study.

As many as 317 or 10.8% of transgender women and 44 or 2.7% of transgender men died during follow-up. This caused the overall mortality rate to become 628 deaths per 100,000 people per year.

There was no decrease in mortality risk from 1972 to 2018. The mortality risk of transgender women was twice that of cis men in the Dutch population and about three times greater compared to cis women.

The mortality ratio of transgender women compared with cis men, because of cardiovascular disease, was 1.4, which means that the mortality risk of transgender women was 1.4 times that of cis men. The mortality ratios for lung cancer, infection, and non-natural causes of death were 2.0, 5.4, and 2.7 respectively, for transgender women. The greatest mortality risk for transgender women, from infection, was related to HIV-related disease and was nearly 15 times greater than that for cis men. This means that the mortality ratio is 14.7. 

Mortality risk of transgender women, compared with cis women, for lung cancer, cardiovascular disease, infection, and non-natural causes of death was 3.1, 2.6, 8.7, and 6.1 times the mortality risk for the same causes in cis men, respectively. The greatest risk of death in transgender women was due to heart attacks. The mortality risk associated with HIV-related diseases and suicide was 47.6 times and 6.8 times higher than those for cis women.

Mortality risk in transgender men was similar to cis men, but almost twice that of cis women. The mortality risk of transgender men associated with non-natural causes of death was 3.3 times that of cis women.

Causes Of Increased Mortality Risk In transgenders

Cardiovascular disease, HIV-related disease, suicide, and lung cancer resulted in greater risks of death among transgender women compared to cis men and cis women. 

The mortality risk of transgender men, due to non-natural causes of death like suicide, was greater compared to that of cis women. When compared with cis men, no differences in mortality risk were observed. 

The importance of increasing social acceptance and improving healthcare for transgender people is highlighted from the fact that gender-affirming hormone treatment and most causes of death in transgender people were not associated with each other.

First author Christen de Blok, of Amsterdam UMC, Netherlands, said the study found most suicides and deaths related to HIV to occur in the first decades studied. In recent years, deaths occurring because of these reasons had lessened in transgender people due to improved treatments for HIV, and greater social acceptance, she added. She also said that earlier, healthcare providers were reluctant to give hormone treatment to people with a history of diseases like cardiovascular diseases, but nowadays, treatment is not denied because there are many benefits of enabling people to access hormone therapy. 

The medical therapies which transgender people undergo, in order to bring about physical changes that match their gender identity more closely, include gender-affirming hormone therapy and surgery. The development of masculine features in transgender men is promoted with the help of testosterone treatment, while in women, feminine physical characteristics are induced through antiandrogens and oestrogens, as a part of gender-affirming therapy.

Dr. Vin Tangpricha of Emory University, USA, who was not involved in the study, wrote in a linked comment that people should be informed more about the safety of gender-affirming hormone therapy in the transgender population, by publishing more data of it being safe. He added that increased comorbidities after receiving such therapy were more significant in transgender women, compared with transgender men. 

What Do The Findings Indicate

On analysis of the national spanning five decades, it was found that the likelihood of death in transgender people was twice as that in cis men and cis women. The findings indicate that there was no decrease in heightened mortality risk among transgender people, between 1972 and 2018, and hence, it is urgent to address the significant health disparities. 

It was not known in previous studies whether the trend of heightened mortality rates among transgender people had changed over the past few decades.

Professor Martin den Heijer, the lead author of the study, said the findings suggest the persistence of increased mortality risk among transgender people, for decades. She explained that the mortality rate in transgender people can be decreased with measures such as increasing social acceptance, and monitoring and treatment for cardiovascular disease, tobacco use, and HIV. She also added that it was important to conduct more research on gender-affirming hormone treatment in order to be sure whether they are related to the mortality risk for transgender people.

Though there was proper documentation of the occurrence and causes of death, other factors which may lead to increased mortality risk were not recorded in the medical files. Analysis on the cause of death of transgender men was, however, limited because there were relatively few deaths among them, compared to transgender women. Also, the population included in the cohort was relatively young. It was not possible to analyse data on transgender youth because they started taking hormone therapy at different ages and stages of puberty. The authors also say that cautious interpretation of the data of transgender people receiving hormone treatment in regions other than the Netherlands must be carried out because 90% of the transgender people receiving such therapy in the Netherlands are white.

According to Dr Tangpricha, future studies should examine factors such as hormone regimen, hormone concentrations, access to healthcare, or other biological factors in order to understand which of them are responsible for increased risk of morbidity and mortality observed in transgender women as opposed to transgender men.