Mortality Rate Much Higher for Transgender People

Dr. Martin den Heijer

A new analysis shows transgender individuals have a significantly higher mortality rate when compared to cis men and women.

Using data compiled from the Netherlands spanning 5 decades, a team led by Dr. Martin den Heijer, of Amsterdam UMC, found the mortality risk among this population did not decrease between 1972-2018, based on a number of factors.

“The findings of our large, nationwide study highlight a substantially increased mortality risk among transgender people that has persisted for decades,” den Heijer said in a statement. “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.”

The Study

The study included 4568 adult transgender people—2927 transgender women and 1641 transgender men. Each participant attended the gender identity clinic at Amsterdam UMC to receive gender-affirming hormone treatment. The investigators analyzed data from medical files on participants’ age at the beginning of hormone treatment, the type of treatment, smoking habits, medical history, and the last day of follow-up.

The mean age of the patient population at the beginning of hormone treatment was 30 years for transgender women and 23 years for transgender men. The average follow-up time was 11 years for transgender women and 5 years for transgender men.

The investigators compared the ratio of deaths among transgender individuals to the rates for the adult Dutch population using data provided by the Statistics Netherlands (CBS), which holds a record of all death of residents of the Netherlands.

They also divided the mortality risk into different subgroups, including cardiovascular disease, infection, cancer, and non-natural causes including suicides.

Transgender individuals often seek a variety of medical therapies that bring the physical changes that can closely match their gender identities, including gender-affirming hormone therapy and surgery.

For transgender men, gender-affirming hormone therapy generally involves testosterone treatment to promote the development of masculine features. For transgender women, treatment can include antiandrogens and oestrogens, which can induce feminine physical characteristics.

Mortality Rates

A total of 317 (10.8%) transgender women and 44 (2.7%) transgender men died during the duration of the study, which equated to an overall mortality rate of 628 deaths per 100,000 people per year.

In comparison to men in the general Dutch population, the mortality risk was nearly double among transgender women and was nearly triple in comparison to cis women (ratios of 1.8 and 2.8, respectively).

An analysis of the subgroups show transgender women were 2.6 times as likely to die of cardiovascular disease, 3.1 times as likely to die from lung cancer, 8.7 times as likely to die from infection, and 6.1 times as likely to die from non-natural causes as cis women.

The greatest risk for those suffering from cardiovascular disease was heart attacks, which were 3 times higher in transgender women than cis women.

Most likely the starkest difference was the mortality risk from HIV, which was 47.6 times higher for transgender women in comparison to cis women.

Finally, the suicide rate was 6.8 times higher for transgender women.

While the differences were not as high for transgender men, they were still higher than cis women in comparison. Overall, the mortality rates between the 2 groups was similar, with transgender men 1.1 times as likely to die as cis men.

One difference, however, is transgender men who started hormone treatment between 1990-2000 was 2.6 times higher than cis women.

The mortality risk for transgender men was 2.1 times higher compared to cis women between 2000-2010 and 2.4 times higher between 2010-2018.

In addition, transgender men were 3.3 times more likely to die from non-natural causes than cis women.

The investigators also said more research is needed on this topic and there were some limitations due to the use of medical records that could have missing data or other discrepancies.

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