Research from the UK has found that transgender people have mortality rates that are 34 – 75% higher than their cisgender peers.
The study, published 30 January 2023 in JAMA Network Open, revealed that transgender (TGD) people had a significantly higher risk of death from external causes such as suicide, homicide, and accidental poisoning, as well as death from endocrine disorders, and other ill-defined and unspecified causes.
The researchers said the findings highlight the need to understand the factors leading to minority stress and develop scientifically informed interventions to reduce mortality for TGD individuals, especially those without a record of gender-affirming care.
Lead author, Dr Sarah Jackson, from the US’ National Cancer Institute, explained that previous research had found mortality from external causes was between 2 to 19 times higher in TGD persons than their cisgender peers.
“Nearly 41% of TGD respondents in the US National Transgender Discrimination Survey reported attempting suicide, a proportion much greater than the 5% of US adults and the 10% to 20% of lesbian, gay, and bisexual adults who reported ever attempting suicide,” Dr Jackson said.
Similarly, the prevalence of alcohol abuse and tobacco use has been reported to be higher among TGD individuals as is the incidence of specific diseases such as HIV which, with a global prevalence among transgender women of 19%, occurs at nearly 50 times the frequency as found in the cisgender population.
“Previous analyses have focused on TGD people who use gender-affirming hormone therapy, thereby excluding those who do not use hormones but may have poorer health outcomes associated with marginalized group status,” Dr Jackson said.
“[And] many prior analyses were either based on small sample size or did not adjust for important risk factors for mortality (e.g., smoking, body mass index, or alcohol use). We sought to examine overall and cause-specific mortality in a cohort of TGD individuals compared with a matched cohort of cisgender people.”
Transfeminine (assigned male at birth) and transmasculine (assigned female at birth) individuals born between 1988 and 2019 were identified using diagnosis codes for gender incongruence and matched to cisgender men and women according to birth year, practice, and practice registration date and linked to the Office of National Statistics death registration.
Data analysis was performed from February to June 2022.
“This cohort study found that TGD individuals have an increased risk of overall mortality, ranging from 34% to 75%, compared with cisgender people,” the authors said.
“We found an increased mortality due to external causes, with nearly 2-fold increased risk of death among transfeminine adults and almost a 3-fold risk of death among transmasculine adults compared with cisgender women.
“When we compared all TGD people combined with cisgender people, we saw 3 to 5 times greater increased mortality from suicide or homicide and 2 to 5 times increased mortality from accidental poisonings.”
The team also discovered that TGD persons with unknown sex assigned at birth had mortality rates 1.71 to 2.11 times higher than those for cisgender men and women, respectively.
“This group, which consists of nonbinary persons who may not seek gender-affirming care, those who access hormone therapy outside the medical system, or those with limited access to medical care because of fears of discrimination and other barriers to health care, may experience higher levels of minority stress than TGD persons with a record of gender-affirming care,” they explained.
The minority stress model suggests that chronic stress due to repeated exposure to violence, discrimination, and economic and social marginalization can result in greater vulnerability to poor health outcomes and mortality among TGD individuals.
For example, the murder of TGD people has been increasing globally, particularly for transgender women, who accounted for 96% of homicides among this group and in the UK, transphobic hate crimes reported to the police have quadrupled over the past six years.
“Further research is needed to examine how minority stress may be contributing to deaths among TGD individuals to reduce mortality,” Dr Jackson said.
Cancer mortality for specific sites has also been reported to be higher among TGD, and they may also be at increased risk of mortality because of the long-term use of gender-affirming hormone therapy, with research indicating that transgender men have a 2-fold and 4-fold increased rate of myocardial infarction compared with cisgender men and cisgender women, respectively.
But when the team compared the most common cancer specific deaths among TGD people (gastrointestinal and lung cancers), they found no increase, with transfeminine adults actually having half the mortality risk of cisgender men.
The researchers postulated that these lower rates of cancer-specific mortality among the transfeminine population compared with cisgender men may be due to the lack of deaths from prostate cancer.
“There were 51 prostate cancer deaths in cisgender men, and none among transfeminine adults, who have a substantially lower risk of prostate cancer owing to the use of antiandrogen and estrogen hormone therapy,” the authors pointed out.
“Similarly, there were 116 breast cancer deaths among cisgender women but none among transmasculine adults, for whom risk is lower because of gender affirming chest surgery.
“However, our cohort is young, and more longitudinal data are needed to understand how long-term hormone use may affect cancer risk at older ages.”
The team found that HIV-related deaths had also decreased among TGD people over time owing to improved HIV treatment, however, mortality from endocrine disorders was more common among TGD individuals compared with cisgender women.
“Which to our knowledge, has not been reported before,” the authors said.
“[Overall], we confirmed that transfeminine and transmasculine individuals had higher mortality rates than cisgender individuals.
“Furthermore, we found that those without a record of gender-affirming care and nonbinary individuals may be at highest risk of mortality, underscoring the need for customized care for this population.”