Higher Risk of Chronic Disease in Trans vs Cisgender Individuals

Alicia Ault

October 13, 2021

A new study that looked at a large database of privately insured Americans has found that transgender individuals have a higher risk of chronic disease than their cisgender counterparts.

Transgender people had higher rates of cardiovascular, neurologic, and endocrine conditions, mental health and substance use disorders, chronic pulmonary disease, anemia, liver disease, renal failure, rheumatoid arthritis, cancer, AIDS/HIV, and peptic ulcer disease. The study was published in the September issue of Health Affairs and by lead author Landon Hughes, a doctoral candidate at the University of Michigan in Ann Arbor.

Although the researchers did not set out to explain what might be at the root of the elevated risk, Hughes told Medscape Medical News he believed "a lot of it ultimately comes down to stigma and discrimination."

Asked to comment, Michael S. Irwig, MD, director of transgender medicine at Beth Israel Deaconess Medical Center in Boston, Massachusetts, said that the increased risk of cardiovascular conditions may be related to "minority stress," but also "more sedentary lifestyles and increased rates of smoking, obesity, diabetes, cholesterol abnormalities, and hypertension."

Irwig told Medscape Medical News that the study's main strength was its large sample size, which "enabled it to more accurately compare the prevalence of certain conditions between trans and cis populations," and that it analyzed some cardiovascular conditions that have not been well studied in cis populations, such as arrhythmia, valvular disease, and congestive heart failure (CHF).

Transmasculine at Greatest Risk

The sample used matched cohorts of 36,069 transgender individuals and 1,263,420 cisgender individuals who had private insurance claims from 2001 to 2019. Two thirds of the overall sample were White, and 70% were aged 18-64.

Twenty-three percent were under age 18, and just 7% were over age 65 (the database included Medicare Advantage, but not Medicare).

Researchers used an algorithm to identify transgender people whereby those who received diagnoses such as gender dysphoria or "endocrine disorder not otherwise specified" were included in the transgender category. Individuals who had claims for "gender-affirming care" were also included.

The authors were also able to stratify the population into "transfeminine and nonbinary" (for example, those born male who may identify along the nonbinary-to-female spectrum and have received feminizing hormones or surgery) and "transmasculine and nonbinary" (for example, those born female who may identify along the nonbinary-to-male spectrum and who have received masculinizing hormones or surgery).

The total morbidity score (from zero to 26) was calculated as the sum total for each of the 26 disease categories.

Researchers found that "transmasculine and nonbinary" individuals had the highest total mean morbidity score of 3.5 versus 2.62 for "transfeminine and nonbinary" individuals, 1.89 for cisgender men, and 2.08 for cisgender women.

Trans men were at greatest risk for 19 of the 26 conditions, with the greatest relative disparity being for rheumatoid arthritis.

Transmasculine and nonbinary individuals were at greatest risk for diabetes, chronic pulmonary disease, and liver disease compared with all other cohorts. They were also at elevated risk for peripheral vascular disorders but at less risk for CHF than cisgender men.

Other studies have indicated that use of gender-affirming hormones may play a role in elevated cardiovascular risk, say the authors.

They also note that prior research has shown cisgender women have a greater predicted probability of chronic pulmonary disease relative to cisgender males, which may partly explain the elevated risk in transmasculine individuals.

Psychiatric Risk Skewed

Hughes and colleagues found a huge disparity in predicted probability of mental health conditions.

Transgender people had a four times higher probability of psychoses, 2.7 times higher probability of depression, 2.5 times higher probability of drug use disorder, and 1.6 times higher probability of alcohol use disorder than cisgender individuals.

The probability of HIV/AIDS was also higher in transgender people, especially for transfeminine and nonbinary people relative to all other cohorts.

"Prior research has linked these disparities in HIV/AIDS and mental health to minority stress and stigma, which restrict access to health-promoting resources and contribute to poor physical and mental health outcomes for this population relative to cisgender people," the authors write.

But Hughes also noted that some of the mental health diagnoses, such as depression, might be overstated in the transgender cohort. Insurers often require transgender individuals to receive a psychiatric diagnosis or mental health counseling to receive any gender-affirming treatments.

As a result, other mental health issues such as alcohol and substance use disorders were likely being diagnosed more often in transgender individuals, said Hughes.

"It's almost certain that trans people are at higher risk, we just likely are overstating the difference to some extent," said Hughes.

Alicia Ault is a Lutherville, Maryland-based freelance journalist whose work has appeared in publications including JAMA, Smithsonian.com, The New York Times, and The Washington Post. You can find her on Twitter: @aliciaault.

Hughes has reported receiving support from the Rackham Merit Fellowship and grants from the National Institute on Aging and the Eunice Kennedy Shriver National Institute of Child Health and Development.

Additional note: Before the September 2021 journal issue embargo date, the authors discovered an error in the Optum data used for the study that affected the distribution of their identified transgender and cisgender cohorts. The article has been corrected online, but the version that appears in the print volume (volume 40, issue 9) includes the uncorrected analysis

Health Aff (Millwood). 2021;40:1440-1448. Abstract

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