Cardiovascular and metabolic risk factors are increased in transgender adolescents compared to adolescents who are not transgender. Elevated lipid levels and body mass index (BMI) also occur in adult transgender patients, new research shows.
“This is the first study of this size in the United States that we know will examine the chances of adolescents diagnosed with gender dysphoria with medical diagnoses related to general metabolic and cardiovascular health,” said the lead author Anna Valentine, MD said in a press release.
Although previous studies have shown that transgender adults have a higher BMI and an increased risk of cardiovascular events such as stroke or heart attack compared to non-transgender people, research on adolescent transgender patients has been lacking.
With a recent survey showing that nearly 2% of teens identify as transgender, interest in health outcomes is high in younger patients.
To investigate this, Valentine of Colorado Children’s Hospital, Aurora, Colorado, and colleagues evaluated data from the PEDSnet database for children of 4,177 adolescents diagnosed with gender dysphoria. Participants were enrolled at six locations from 2009 to 2019. The researchers compared these patients in a ratio of 1: 4 to 16,664 control subjects who had not been diagnosed with gender-specific dysphoria. They reported their results as a poster at the latest virtual ENDO 2021: The Endocrine Society Annual Meeting.
For the propensity score analysis, the participants were compared in the database according to year of birth, age at the last visit, location, race, ethnicity, insurance status and duration.
In both the transgender and control groups, about 66% were female at birth, 73% were white, and 9% were Spanish.
For both groups, the mean age at the last visit was 16.2 years. The average duration in the database was 7 years.
The study made no distinction between those who received sex-affirming hormones and those who didn’t
In the retrospective study, the diagnosis rates for dyslipidemia (odds ratio) were determined among those identified as transgender [OR]1.6; P <0.0001) and metabolic syndrome (OR 1.9; P = 0.0086) were significantly higher than in patients without gender-specific dysphoria.
Diagnosis rates for overweight / obesity (OR, 1.7; P <0.0001) and polycystic ovarian syndrome were higher among transgender males (born women) but not transgender women (born men) ( OR, 1.9, P =). 0006) compared to controls.
Sex-affirming hormone therapy such as testosterone or estradiol is one of the suspected culprits for the cardiovascular effects. Importantly, however, this study did not distinguish between patients who received estradiol or testosterone to confirm their sex and those who did not, Valentine said.
“We do not know it [whether gender-affirming hormone therapy is a cause]Since we haven’t looked at that, “she told Medscape Medical News.” We will look at this in our next analysis and will include this in our future publication.
“We will also look at the relationship between overweight / obesity and the other diagnoses that affect cardiovascular health (high blood pressure, liver dysfunction and abnormal cholesterol), as that could certainly play a role, too,” she said.
For many transgender patients, gender-affirming hormone therapy is lifelong. One question that needs to be assessed is whether the dose of such therapy plays a role in cardiovascular effects, and if so, whether adjustments could be made without compromising therapeutic effects, Valentine noted.
“This is an important question and future research is needed to evaluate whether doses [of gender-affirming hormones] are linked to cardiometabolic outcomes, “she said.
Possible confounders in the study are the fact that the rate of overweight and obesity is higher in adolescents with gender-specific dysphoria. This in itself can increase the risk of other disorders, Valentine noted.
In addition, rates of mental health comorbidities are higher among adolescents with gender dysphoria. One consequence of this could be less physical activity, she said.
Hormone therapy, healthcare disparities, or both could explain the risk
Joshua D. Safer, executive director of the Center for Transgender Medicine and Surgery of the Mount Sinai Health System in New York City, said of the study that similar cardiovascular effects are also known in transgender adults. They may or may not be hormonal. Other factors can increase the risk.
“In transgender adults, differences in lipids or cardiac risk factors compared to cisgender individuals may be due to either hormonal therapy or healthcare differences,” he told Medscape Medical News.
“The data is mixed. Most of the differences may be due to lack of access to care and abuse by society,” he said. “Even studies that focus on hormones see a worsening situation between trans women and trans men.”
Other recent research showing possible cardiovascular effects in adult transgender men includes a study of more than 1,000 transgender men (born women) who received testosterone. This study, which was also presented at the ENDO meeting and reported by Medscape Medical News, found an increased risk of high hematocrit levels, which could lead to a thrombotic event.
However, a study published in Pediatrics earlier this month, also reported by Medscape, that enrolled 611 transgender adolescents who had received gender-affirming hormone therapy for more than a year, found no increased risk of thrombosis, even with the presence of risk factors for thrombosis, including obesity , Tobacco use, and family history of thrombosis. However, the lead author of this study pointed out that the follow-up period in this study was relatively short and therefore an increased risk of thrombosis may not have been identified.
Safer found that transgender teenagers and adults are exposed to a variety of cultural factors that could play a role in increased cardiovascular risks.
“For adults, social abuse and especially for trans women, progestins are the most important explanations for a poor BMI and cardiac risk factors.
“For the youth, the main statements made by the candidates are social abuse and lack of access to athletics,” he said.
The authors and Safer have not disclosed any relevant financial relationships.
ENDO 2021: Annual Meeting of the Endocrine Society: Abstract P44-2. Presented on March 20, 2021.
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