Transgender people are twice as likely to die compared to cis men and cis women, according to an analysis of national data from the Netherlands spanning five decades.
The findings, published in The Lancet Diabetes & Endocrinology journal, indicate that the heightened mortality risk among transgender people did not decrease between 1972 and 2018, highlighting a pressing need for action to address these long-standing and significant health disparities.
Previous studies have reported increased mortality rates among transgender people, however, it was not known whether this trend has changed over the past few decades.
Transgender people can undergo medical therapies that bring about physical changes that more closely match their gender identity. These typically include gender-affirming hormone therapy and surgery. Transgender men receiving gender-affirming hormone therapy are usually treated with testosterone to promote the development of masculine features, while transgender women typically receive antiandrogens and oestrogens, which induce feminine physical characteristics.
The study cohort consisted of 4,568 adult transgender people (2,927 transgender women and 1,641 transgender men) who had attended the gender identity clinic at Amsterdam UMC between 1972 and 2018, and were receiving gender-affirming hormone treatment. Data was gathered from medical files on participants’ age at the start of hormone treatment, the type of treatment, smoking habits, medical history, and the last date of follow-up. The average age at the start of hormone treatment was 30 years in transgender women and 23 years in transgender men. The average follow-up time in transgender women was 11 years and 5 years in transgender men.
The ratio of deaths among transgender men and transgender women compared to rates for the adult population were calculated using data held by Statistics Netherlands (CBS), which holds a record of all death of residents of the Netherlands. Where possible, mortality risk was divided into categories including cardiovascular disease, infection, cancer, and non-natural causes including suicides. Data on cause of death (if known) was available from 1996 onwards.
During follow-up, 317 (10.8%) transgender women and 44 (2.7%) transgender men died, resulting in an overall mortality of 628 deaths per 100,000 people per year.
Mortality risk was almost double among transgender women compared to men in the general population, and nearly three times greater compared to cis women (ratios of 1.8 and 2.8, respectively). Mortality risk did not decrease over the five decades included in the analysis.
Compared with cis men, transgender women had 1.4 times greater risk of death because of cardiovascular disease (1.4 mortality ratio). Mortality risk was almost double for lung cancer (2.0 ratio), more than five times greater for infection (5.4 ratio), and nearly three times as high for non-natural causes of death (2.7 ratio). The greatest mortality risk from infection was associated with HIV-related disease, at nearly 15 times higher than for cis men (14.7 ratio). For non-natural causes of death, the greatest risk was suicide, at three times greater than for cis men (3.1 ratio).
Compared with cis women, transgender women were more than two times as likely to die of cardiovascular disease (2.6 ratio). They were three times more likely to die from lung cancer (3.1 ratio), almost nine times more likely to die from infection (8.7 ratio), and six times more likely to die from non-natural causes (6.1 ratio). Heart attacks accounted for the greatest risk of death from cardiovascular disease, at three times higher than for cis women (3.0 ratio). Mortality risk from HIV-related disease was close to 50 times higher than for cis women (47.6 ratio), while the risk of suicide was almost 7 times greater (6.8 ratio).
Mortality risk in transgender men was similar to cis men (1.1 ratio) but almost double compared to cis women (1.6 ratio). Mortality risk for transgender men did not decrease over the five decades studied. Mortality risk in transgender men who started hormone treatment between 1990 and 2000 was two and half times as high as cis women (2.6 ratio). Compared to cis women, mortality risk for transgender men was more than double from 2000 to 2010 and 2010 to 2018 (2.1 and 2.4 ratios, respectively). Transgender men were at more than three times greater risk of death from non-natural causes (3.3 ratio) than cis women. No increased mortality risk was observed compared with cis men.
First author Christel de Blok, of Amsterdam UMC, the Netherlands, said: “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. It was surprising that mortality risk was higher in transgender people who started gender-affirming hormone treatment in the past two decades, but this may be due to changes in clinical practice. In the past, health care providers were reluctant to provide hormone treatment to people with a history of comorbidities such as cardiovascular disease. However, because of the many benefits of enabling people to access hormone therapy, nowadays this rarely results in treatment being denied.”