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Why Are Transgender and Gender-Diverse People at Greater Risk for Diabetes and Cardiovascular Disease?

Gender-affirming hormone therapy may play a role, but it’s only part of the story.

Medically reviewed in August 2021

Regardless of your age or gender, a number of factors can increase your risk of diabetes and heart disease. Eating an unhealthful diet, leading a sedentary lifestyle, smoking and drinking too much alcohol can all contribute.

Though it’s not fully understood why, transgender and gender-diverse people are at heightened risk for both conditions, particularly heart disease. Here's what is known—and what still needs to be studied—about these conditions, plus insights from experts on how to manage these risks and lead your healthiest life.

Hormone therapy may increase weight—and with it, diabetes risk
You may know that being on gender-affirming hormone therapy (also known as GAHT and sometimes referred to as hormone replacement therapy, or HRT) can have an impact on your body composition. Feminizing hormone therapy tends to lead to an increase in body fat percentage. Masculinizing hormone therapy, meanwhile, is associated with weight gain and an increase in lean muscle mass. Your body composition can, in turn, affect your risk of developing type 2 diabetes.

"We know that, for most people, gender-affirming hormone therapy can result in weight gain,” says Vin Tangpricha, MD, PhD, board-certified endocrinologist at Emory University School of Medicine and former president of the World Professional Association for Transgender Health (WPATH). “That's found particularly in transgender women. With weight gain there's a higher risk of diabetes."

A small 2019 study in the journal Diabetes Care reported increased insulin sensitivity in transgender men after one year of hormone therapy—but a decrease in insulin sensitivity in transgender women after one year of hormone therapy. (Roughly speaking, as insulin sensitivity falls and insulin resistance develops, the risk of type 2 diabetes rises.) The effect seemed mostly due to body composition changes stemming from the use of GAHT.

"Right now, we don't have a direct link to diabetes, but I think it's an area that definitely needs to be studied more," says Dr. Tangpricha.

The WPATH Standards of Care, which offers guidance for healthcare providers (HCPs) for gender-diverse people, states that feminizing hormone therapy (estrogen) may increase the risk of diabetes, while masculinizing therapy (testosterone) does not appear to increase the risk of diabetes unless you already have other risk factors. Because a variety of factors affect your risk of developing diabetes—from genetics to diet and exercise—it's hard to say exactly how big a role hormone therapy plays.

Until there is more definitive data, experts recommend that anyone who might be at elevated risk, including folks on GAHT, get screened regularly for type 2 diabetes. The American Diabetes Association recommends screening for everyone age 45 and older, as well as anyone who is considered overweight with any other risk factors, such as a family history of diabetes, a diagnosis of high blood pressure or high cholesterol, or an inactive lifestyle. (Someone is typically considered overweight when they have a body mass index, or BMI, of 25 or higher. The designation of overweight for Asians and Asian Americans is 23 or above.)

If you do have a current diagnosis of type 2 diabetes and are taking feminizing hormone therapy, make sure to follow up as recommended with your HCP. Having type 2 diabetes increases your risk of cardiovascular disease, in part due to its association with obesity and the way in which obesity plays a role in cardiovascular health. Your HCP will likely want to keep an eye on certain markers of heart disease—such as LDL (aka "bad" cholesterol) and triglycerides—that may become elevated as a result of your therapy.

How can hormone therapy affect heart disease risk?
Some research suggests that GAHT can affect cholesterol and triglyceride levels in a way that could increase one’s risk for heart disease. More data is needed to make definitive conclusions, but some experts take extra precautions with patients who are on gender-affirming therapy.

"I recommend annual cholesterol screening to all of my patients if they start on hormones," says Christina Milano, MD, a family physician and co-founder and medical director of the Transgender Health Program at Oregon Health & Science University. "And if they're continuing on hormones, I like to look at those with them annually just to see where there may be trends emerging."

Can hormone therapy contribute to blood clots?
Feminizing hormone therapy (estrogen in particular), has been associated with an increased risk of blood clotting, also known as VTE, or venous thromboembolism. If you have an otherwise increased risk of blood clots, your HCP may prescribe you the transdermal (or patch) form of estrogen rather than the oral form, as this may help reduce the risk of clotting.

It’s important to remember that the physical, mental and emotional benefits of receiving gender-affirming treatments should be considered along with any potential cardiovascular risks presented by GAHT. If you do take GAHT, the key is to maintain your hormone therapy in a consistent way and in consultation with an experienced HCP who has your overall wellness—mental and physical—in mind.

Why transgender people may be at greater risk for heart disease
There is a growing body of research suggesting that transgender and gender-diverse people have a disproportionate risk of heart disease. A large study published in 2019 in the journal Circulation: Cardiovascular Quality and Outcomes found that, even after controlling for factors like smoking and other health conditions, transgender men had twice the rate of heart attack of cisgender men and four times the rate of cisgender women. Transgender women, meanwhile, had twice the rate of heart attack of cisgender women.

To highlight the need for further research specific to the gender-diverse population, the American Heart Association (AHA) published a special scientific statement in the journal Circulation in July 2021. While it’s unclear where the increased risk of cardiovascular disease comes from, the authors suggested that it may be "driven in part by psychosocial stressors across the lifespan at multiple levels, including structural violence (eg, discrimination, affordable housing, access to health care)."

It's known that chronic stress can directly impact heart health by raising blood pressure, cholesterol and triglyceride levels and contributing to the buildup of plaque in the arteries. Meanwhile, the chronic stress that results from enduring discrimination on a daily basis can impact a variety of additional risk factors for cardiovascular disease, including substance use.

"The macro picture is that the transgender population is at higher risk for potentially using things like tobacco, alcohol and substances in order to cope with the trauma of perpetual discrimination," explains Dr. Milano. "The question is, how do we help people cope with the stress of living as a trans person in a healthy way?”

Heart-healthy habits to foster today
The good news is that there are steps you can take to help lower stress levels while reducing the risks of diabetes and heart disease. Here’s how to start:

Move more. Exercise improves blood glucose levels, reduces high blood pressure and high cholesterol, and can help relieve stress. Aim to get at least 30 minutes of moderate-intensity physical activity each day. If working out in gyms or other group settings feels unsafe or uncomfortable, consider solo outdoor activities like running, walking, cycling or hiking.

Eat well. There is no one way to eat healthfully, but the basics come down to this: Fill your plate with fruits, vegetables and whole grains. Cut down on sugar, salt and saturated fat and swap in healthy fats from foods like olive oil and nuts. As much as possible, skip red and processed meats in favor of lean proteins like chicken, fish or plant-based sources like beans and legumes.

Quit smoking. Smoking may feel like a way to deal with stress in the near term, but it harms your health in significant ways over the long haul. Quitting can be a challenge and may take several attempts, but it’s important to try. Sharecare’s Craving to Quit program can help.

Reduce alcohol. If you enjoy having a drink every now and then, be sure to stick to the recommended limit of 1 to 2 per day. Every drink above that level increases your risk of heart disease and diabetes, along with other conditions, including cancer. If you don’t drink now, don’t start. If you’re trying to decrease your intake but are having a hard time, check in with an HCP.

Prioritize sleep. When you're stressed, it can be hard to get quality sleep. When you don’t get quality sleep, you may feel your stress levels compounding. To break the cycle, try to establish a schedule with regular bedtimes and wake-up times, along with an hour each night to wind down. Avoid alcohol or caffeine within a few hours of bedtime, as both can interfere with sleep. If steps like these don’t help, talk to an HCP about signing up for a sleep evaluation, which may help reveal whether an underlying condition, such as sleep apnea, is contributing to your troubles.

Address stress. Gender-diverse people often face a range of social stressors. If you’re experiencing levels of stress that interfere with your day-to-day life, talk to an HCP or trusted counselor about how you’re feeling. They might recommend therapy, medication or stress-relief approaches to try at home, such as yoga, tai chi or meditation.

Connect. Living with discrimination and stigma is an isolating experience. Connecting with other gender-diverse people, whether online or offline, and making use of the support systems created by organizations, advocates and activists are all helpful ways to stay afloat emotionally.

Your heart health depends on a variety of factors, many of which can be affected by stressors that disproportionately impact gender-diverse people. To better understand your risk of heart disease and diabetes, talk to a knowledgeable HCP about your risk factors and any recommended screening tests you might need. 

Medically reviewed in July 2021.

Sources:

Shadid S, Abosi-Appeadu K, De Maertelaere A-S, et al. Effects of Gender-Affirming Hormone Therapy on Insulin Sensitivity and Incretin Responses in Transgender People. Diabetes Care. 2020;43(2):411-417.
UCSF Transgender Care, Department of Family and Community Medicine, University of  California San Francisco. Overview of feminizing hormone therapy. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016.
UCSF Transgender Care, Department of Family and Community Medicine, University of California San Francisco. Overview of masculinizing hormone therapy. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016.
National Institutes of Health. Understanding Insulin Sensitivity and Diabetes. April 9, 2012.
The World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 7th Version.
Abid A, Ahmad S, Waheed A. Screening for Type II Diabetes Mellitus in the United States: The Present and the Future. Clin Med Insights Endocrinol Diabetes. 2016;9:19-22.
Streed CG, Beach LB, Caceres BA, et al. Assessing and addressing cardiovascular health in people who are transgender and gender diverse: A scientific statement from the American Heart Association. Circulation. Published online July 8, 2021:CIR0000000000001003.
American Heart Association. Stress and Heart Health. Last reviewed Jun 21, 2021.
University of Rochester Medical Center. Stress Can Increase Your Risk for Heart Disease. Accessed July 15, 2021.
Alzahrani T, Nguyen T, Ryan A, et al. Cardiovascular disease risk factors and myocardial infarction in the transgender population. Circ Cardiovasc Qual Outcomes. 2019;12(4):e005597.
UCSF Transgender Care, Department of Family and Community Medicine, University of California San Francisco. Cardiovascular disease. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016.

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