May 292017
 

Medical transition for trans people has only been available in the United States since the 1970’s. Because it’s so new we only have limited data about long term risks and benefits. When I was first learning about trans health I was frustrated by the lack of data. Are trans women protected from heart attacks like cis women are? Do trans men have lower risk for osteoporosis like their cis men peers do? We simply don’t know.

Today’s study is an exploration of the long term morbidity and mortality of trans people who have had surgery. Morbidity and mortality are just fancy words. Morbidity refers to disease or suffering. For example, morbidity may refer to how many people had a heart attack but are alive. Or how many people live with depression, or low back pain. Mortality is how many people died.

Who did they study?

Simonsen et al took advantage of the Denmark health system. In Denmark, there is one national health system. So they were able to look up how many trans people there are in Denmark. They were then able to figure out who had had gender-related surgery. Using medical billing codes, they looked at the diseases and disorders those trans people were diagnosed with. And they used death certificates to determine cause of death. They looked at records from 1970 to April 2014.

In total Simonsen et al looked at the records of 104 trans people. 56 were trans women and 48 were trans men. Surgery was performed between 1978 and 2010. So the patients with the most recent surgery would have been 4 years post surgery.

Most trans women (65%) started hormones age 22-42 and had surgery 9-23 years before the study. Trans men started at similar ages, 21-38 and had surgery 4-1

Beech trees in Denmark, where this study of morbidity and mortality was done

Beech trees in Denmark, where this study of morbidity and mortality was done

6 years before the study.

Their findings

In total, 20 trans people (19%) were diagnosed with a disease/disorder before surgery. That increased to 24 after surgery (23.2%). However, the difference wasn’t statistically significant. That means the difference was likely because of chance.

Diseases seen in this study included cancer, cardiovascular disease, musculoskeletal disease, chronic lung disease, and alcoholic liver disease. Almost all of the diseases were related to behavior and not to hormone therapy or the surgery.

Cardiovascular disease was seen in 10.7% of trans women and 25% of trans men. Compare that to 3.5% of cis women and 4.4% of cis men. The high rate of cardiovascular disease is likely a result of smoking, since high rates of chronic lung disease were also soon. Chronic lung disease includes COPD, which is usually caused by smoking tobacco. Chronic lung disease was seen in 3.8% of trans people. In comparison, 1.3% of cis people had chronic lung disease. There was no difference between before and after surgery in either cardiovascular disease or lung disease.

In contrast, there was a difference seen with alcohol. Alcohol-related diseases were seen in 3.8 of trans people before surgery. After surgery that number dropped to zero.

Musculoskeletal disease was unique. It was found in 10.5% of trans people, compared to 13.9% of the general cis population. So musculoskeletal disease was the only one that trans people, as a population, had less of.

Cancer rates were also higher in trans people. 6.2% of trans men and 3.6% of trans women were diagnosed with cancer. The general population rates are 1.6% of cis men and 2.4% of cis women. The cancer rates seem to be because of increased risk of lung cancer from smoking, however Simonsen et al did not publish the details.

What about deaths?

10 trans people had died in Denmark between 1970 and 2014. That’s 9.4% of all the trans people in Denmark. The average age of death was 53.5 years. The average age of death for the general population in Denmark is 81.9 years for women and 78 years for men. The causes of death were mostly from smoking and alcohol abuse. However, two trans people committed suicide. One was 19 years after surgery, the other was 26 years after surgery.

What do these results mean?

First, that gender-related surgery for trans people does not increase the risk for medical disease. There was no change in disease before and after surgery.

Second, rates of cardiovascular disease, lung disease, cancer, and alcohol-related disease are higher in trans people than in cis people. Smoking tobacco and alcohol seem to be the cause, not hormones. And smoking and alcohol are likely because of stress from discrimination and gender dysphoria.

Third, the average life expectancy for trans people in Denmark is much lower than the general life expectancy. Again, this is because of smoking, alcohol, and suicide.

What are the caveats?

This was a tiny sample. While 104 trans people is a large sample for trans research, it’s a small sample to try to draw large conclusions from. Worse, some of the sub groups were miniscule. It’s near impossible to draw accurate conclusions from only 4 people with lung disease, or 2 suicides.

I was also surprised at the lack of HIV-related diagnoses in this study. HIV is prevalent in trans women in the US for complex reasons. Is the rate lower in Denmark? I don’t know.

And as always, this was one study in one country. Every culture and country is different, with different levels of discrimination and different cultural standards. So we can’t make assumptions about other cultures based on this one study.

Despite the limitation, this is an excellent exploratory study. We should continue to look for more data coming out of Denmark to see what more we can learn.

Want to read the study for yourself? The abstract is publicly available!

Aug 012016
 

Welcome back to Open Minded Health Promotion! This week we’re looking at health promotion for transgender men and individuals assigned female at birth. Depending on your history some of these tips will apply more or less to you.

TransgenderPlease remember that these are specific aspects of health in addition to the standard recommendations for everyone (e.g., colonoscopy at age 50). Based on your health and your history, your doctor may have different recommendations for you. Listen to them.

All transgender men should consider…
  • Talk with their doctor about their physical and mental health
  • Practice safer sex where possible. Sexually transmitted infections can be prevented with condoms, dental dams, and other barriers. If you share sexual toys consider using condoms/barriers or cleaning them between uses.
  • Consider using birth control methods if applicable. Testosterone is not an effective method of birth control. In fact, testosterone is bad for fetuses and masculinizes them too. Non-hormonal options for birth control include condoms, copper IUDs, diaphragms and spermicidal jellies.
  • If you’re under the age of 26, get the HPV vaccine. This will reduce the chance for cervical, vaginal, anal, and oral cancers.
  • Avoid tobacco, limit alcohol, and limit/avoid other drugs. If you choose to use substances and are unwilling to stop, consider strategies to limit your risk. For example, consider participating in a clean needle program. Vaporize instead of smoke. And use as little of the drug as you can.
  • Maintain a healthy weight. While being heavy sometimes helps to hide unwanted curves, it’s also associated with heart disease and a lower quality of life.
  • Exercise regularly. Anything that gets your heart rate up and gets you moving is good for your body and mind! Weight bearing exercise, like walking and running, is best for bone health. Another tip to control your weight is using the best diet pills in the market.
  • Be careful when weight lifting if you’re newly taking testosterone. Muscles grow faster than tendon, thus tendons are at risk for damage when you’re lifting until they catch up.
  • Consider storing eggs before starting testosterone if you want genetic children. Testosterone may affect your fertility. Consult a fertility expert if you need advising.
  • Seek help if you’re struggling with self injury, anorexia, or bulimia. Trans men are at higher risk than cis men for these aspects of mental health.
  • If you have unexplained vaginal bleeding, are on testosterone, and have not had a hysterectomy notify your doctor immediately. Some “breakthrough” bleeding is expected in the first few months of testosterone treatment. Once your dose is stable and your body has adapted to the testosterone you should not be bleeding. Bleeding may be benign but it may also be a sign that something more serious is going on. Contact your doctor.
  • In addition, talk with your doctor if you have pain in the pelvic area that doesn’t go away. This may also need some investigation. And s/he may be able to help relieve the pain.
  • Be as gentle as you can with binding. Make sure you allow your chest to air out because the binding may weaken that skin and put you at risk for infection. Be especially careful if you have a history of lung disease or asthma because tight binding can make it harder to breathe. You may need your inhaler more frequently if you have asthma and you’re binding. If this is the case, talk with your doctor.
  • If you’ve had genital surgery and you’re all healed from surgery: there are no specific published recommendations for caring for yourself at this point. So keep in touch with your doctor as you need to. Call your surgeon if something specific to the surgery is concerning. Continue to practice safe sex. And enjoy!
Your doctor may wish to do other tests, including…
  • Cervical cancer screening (if you have a cervix). The recommendation is every 3-5 years minimum, starting at age 21. Even with testosterone, this exam should not be painful. Talk with your doctor about your needs and concerns. Your doctor may offer a self-administered test as an alternative. Not every doctor offers a self-administered test.
  • Mammography even if you’ve had chest reconstruction. We simply don’t know what the risk of breast cancer is after top surgery because breast tissue does remain after top surgery. Once you turn 50, consider talking with your doctor about the need for mammography. In addition, if you’re feeling dysphoric discussing breast cancer then it may be helpful to remember that cis men get breast cancer too.
  • If you have not had any bottom surgery you may be asked to take a pregnancy test. This may not be intended as a transphobic question. Some medications are extremely harmful to fetuses. Hence doctors often check whether someone who can become pregnant is pregnant before prescribing. Cisgender lesbians get this question too, even if they’ve never had contact with cisgender men.

And most importantly: Take care of your mental health. We lose far too many people every year to suicide. Perhaps worse, far more struggle with depression and anxiety. Do what you need to do to take care of you. If your normal strategies aren’t working then reach out. There is help.

Want more information? You can read more from UCSF’s Primary Care Protocols and the Gay and Lesbian Medical Association.