Mortality risk in transgender people is twice as high as in cisgender people, data show The BMJ 02.09.21

The mortality risk in transgender people using hormone treatment is twice as high as in cisgender people and has not decreased in the past five decades, a Dutch retrospective analysis has suggested.1

However, the researchers concluded that the increased mortality risk in transgender people did not seem to be a specific effect of gender affirming hormone treatment.

Transgender people often seek medical treatment to bring about physical changes that more closely match their gender identify, and this can include hormone treatment and surgery. For transgender women, gender affirming hormone treatment consists of oestrogen in combination with a testosterone lowering medication. For transgender men gender affirming hormone treatment consists of testosterone.

The study, published in the Lancet Diabetes & Endocrinology,1 included 2927 transgender women and 1641 transgender men who visited the gender identity clinic of Amsterdam University Medical Centre in the Netherlands and received hormone treatment from 1972 to 2018. The average age at the start of hormone treatment was 30 in transgender women and 23 in transgender men. The average follow-up time was 11 years in transgender women and five years in transgender men.

During follow-up, 317 transgender women (10.8%) and 44 transgender men (2.7%) died, resulting in an overall mortality of 628 deaths per 100 000 people per year. The mortality risk was almost twice as high in transgender women as in men in the general Dutch population (standardised mortality ratio 1.8 (95% confidence interval 1.6 to 2.0)) and nearly three times as high as in cis women (2.8 (2.5 to 3.1)). The mortality risk in transgender men was higher than in women in the general population (1.8 (1.3 to 2.4)) but was similar to the risk in cis men (1.2 (0.9 to 1.6)).

Causes of death

When compared with cis men, transgender women had 1.4 times the risk of death from cardiovascular disease. Mortality risk was almost double from lung cancer, more than five times greater from infection, and nearly three times as high from non-natural causes of death. The greatest mortality risk from infection was associated with HIV related disease, which was nearly 15 times higher than in cis men. Among non-natural causes of death the greatest risk was suicide, which was three times as high as in cis men.

When compared with cis women, transgender women were more than twice as likely to die from cardiovascular disease. They were three times as likely to die from lung cancer, almost nine times as likely to die from infection, and six times as likely to die from non-natural causes. Myocardial infarction accounted for the greatest risk of death from cardiovascular disease, being three times as high as in cis women. Mortality risk from HIV related disease was nearly 50 times as high as in cis women, and the risk of suicide was almost seven times as high.

One of the study’s authors, Martin den Heijer, said, “The findings of our large, nationwide study highlight a substantially increased mortality risk among transgender people that has persisted for decades. Increasing social acceptance, and monitoring and treatment for cardiovascular disease, tobacco use, and HIV, will continue to be important factors that may contribute to decreasing mortality risk in transgender people.

“Gender affirming hormone treatment is thought to be safe, and most causes of death in the cohort were not related to this. However, as there is insufficient evidence at present to determine [the treatments’] long term safety, more research is needed to fully establish whether they in any way affect mortality risk for transgender people.”

The lead study author, Christel de Blok, added, “We found that most suicides and deaths related to HIV occurred in the first decades we studied, suggesting that greater social acceptance and access to support, and improved treatments for HIV, may have played an important role in reducing deaths related to these causes among transgender people in recent years.”

One limitation of the study is that it was retrospective, so information about lifestyle and other factors may be incomplete. There were also relatively few deaths among transgender men in the cohort, so analysis on cause of death was limited. The population was also more than 90% white, so the authors said that the data should be interpreted with caution in other regions.

De Block  C, Wiepjes  C, van Velzen  D, et al. Mortality trends over five decades in adult transgender people receiving hormone treatment: a report from the Amsterdam cohort of gender dysphoria. Lancet Diabetes Endocrinol2021. doi:10.1016/S2213-8587(21)00185-6.

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