Peer-reviewed / Observational study / People
Transgender people are twice as likely to die compared to cis men and cis women, according to an analysis of national data from the Netherlands spanning five decades. The findings, published in The Lancet Diabetes & Endocrinology journal, indicate that the heightened mortality risk among transgender people did not decrease between 1972 and 2018, highlighting a pressing need for action to address these long-standing and significant health disparities.
Previous studies have reported increased mortality rates among transgender people, however, it was not known whether this trend has changed over the past few decades.
Lead author Professor Martin den Heijer, of Amsterdam UMC, the Netherlands, said: “The findings of our large, nationwide study highlight a substantially increased mortality risk among transgender people that has persisted for decades. 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.
“Gender-affirming hormone treatment is thought to be safe, and most causes of death in the cohort were not related to this. 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.” [1]
Transgender people can undergo medical therapies that bring about physical changes that more closely match their gender identity. These typically include gender-affirming hormone therapy and surgery. Transgender men receiving gender-affirming hormone therapy are usually treated with testosterone to promote the development of masculine features, while transgender women typically receive antiandrogens and oestrogens, which induce feminine physical characteristics.
The study cohort consisted of 4,568 adult transgender people (2,927 transgender women and 1,641 transgender men) who had attended the gender identity clinic at Amsterdam UMC between 1972 and 2018, and were receiving gender-affirming hormone treatment. Data was gathered from medical files on participants’ age at the start of hormone treatment, the type of treatment, smoking habits, medical history, and the last date of follow-up. The average age at the start of hormone treatment was 30 years in transgender women and 23 years in transgender men. The average follow-up time in transgender women was 11 years and 5 years in transgender men.
The ratio of deaths among transgender men and transgender women compared to rates for the adult Dutch population were calculated using data held by Statistics Netherlands (CBS), which holds a record of all death of residents of the Netherlands. Where possible, mortality risk was divided into categories including cardiovascular disease, infection, cancer, and non-natural causes including suicides. Data on cause of death (if known) was available from 1996 onwards.
During follow-up, 317 (10.8%) transgender women and 44 (2.7%) transgender men died, resulting in an overall mortality of 628 deaths per 100,000 people per year.
Mortality risk was almost double among transgender women compared to men in the general Dutch population, and nearly three times greater compared to cis women (ratios of 1.8 and 2.8, respectively). Mortality risk did not decrease over the five decades included in the analysis.
Compared with cis men, transgender women had 1.4 times greater risk of death because of cardiovascular disease (1.4 mortality ratio). Mortality risk was almost double for lung cancer (2.0 ratio), more than five times greater for infection (5.4 ratio), and nearly three times as high for non-natural causes of death (2.7 ratio). The greatest mortality risk from infection was associated with HIV-related disease, at nearly 15 times higher than for cis men (14.7 ratio). For non-natural causes of death, the greatest risk was suicide, at three times greater than for cis men (3.1 ratio).
Compared with cis women, transgender women were more than two times as likely to die of cardiovascular disease (2.6 ratio). They were three times more likely to die from lung cancer (3.1 ratio), almost nine times more likely to die from infection (8.7 ratio), and six times more likely to die from non-natural causes (6.1 ratio). Heart attacks accounted for the greatest risk of death from cardiovascular disease, at three times higher than for cis women (3.0 ratio). Mortality risk from HIV-related disease was close to 50 times higher than for cis women (47.6 ratio), while the risk of suicide was almost 7 times greater (6.8 ratio).
Mortality risk in transgender men was similar to cis men (1.1 ratio) but almost double compared to cis women (1.6 ratio). Mortality risk for transgender men did not decrease over the five decades studied. Mortality risk in transgender men who started hormone treatment between 1990 and 2000 was two and half times as high as cis women (2.6 ratio). Compared to cis women, mortality risk for transgender men was more than double from 2000 to 2010 and 2010 to 2018 (2.1 and 2.4 ratios, respectively). Transgender men were at more than three times greater risk of death from non-natural causes (3.3 ratio) than cis women. No increased mortality risk was observed compared with cis men.
First author Christel de Blok, of Amsterdam UMC, the Netherlands, said: “We found that most suicides and deaths related to HIV occurred in the first decades we studied, suggesting that greater social acceptance and access to support, and improved treatments for HIV, may have played an important role in reducing deaths related to these causes among transgender people in recent years. It was surprising that mortality risk was higher in transgender people who started gender-affirming hormone treatment in the past two decades, but this may be due to changes in clinical practice. In the past, health care providers were reluctant to provide hormone treatment to people with a history of comorbidities such as cardiovascular disease. However, because of the many benefits of enabling people to access hormone therapy, nowadays this rarely results in treatment being denied.” [1]
The authors acknowledge some limitations. The occurrence and causes of death were well documented, however, it cannot be ruled out that other factors not recorded in medical files may contribute to increased mortality risk. As there were relatively few deaths among transgender men in the cohort, analysis on cause of death was limited. Although the cohort included people with a wide age rage, the population was relatively young. Analysis of data on transgender youth was also not possible as the young people in the cohort were very diverse, starting hormone therapy at different ages and stages of puberty. As this study focused only on transgender people who received treatment in the Netherlands, more than 90% of which were white, the authors say the data should be interpreted with caution in other regions.
Writing in a linked Comment, Dr Vin Tangpricha of Emory University, USA, who was not involved in the study, addresses the subject of gender-affirming hormone therapy, saying: “Increased publication of data on the safety of gender-affirming hormone therapy in the transgender population, which is lifesaving for many people, is encouraging. Continued refinement of delivery of care for transgender people will help to improve the lives of a clinically vulnerable growing population.”
On observed disparities between transgender women and transgender men, Dr Tangpricha says: “Transgender men do not appear to have as significantly increased comorbidity following receipt of gender-affirming hormone therapy when compared with transgender women. These results could reflect the use of an established regimen of testosterone administration extrapolated from hypogonadal men. The differences could also reflect disparities in the access of health care, differences in the effect of sex hormones on cardiometabolic risk profile, differences in body composition, or societal factors. Future studies should examine which factors—hormone regimen, hormone concentrations, access to health care, or other biological factors—explain the increased risk of morbidity and mortality observed in transgender women as opposed to transgender men.”
NOTES TO EDITORS
No funding was received for this study. It was conducted by researchers from Amsterdam UMC, Netherlands.
If you are reporting on this study, please consider including a link to information and support for your readers.
In the USA, the National Suicide Prevention Lifeline can be contacted on 1-800-273-8255 or visit https://suicidepreventionlifeline.org/.
In the UK, Samaritans can be contacted on 116 123, or email: jo@samaritans.org or visit www.samaritans.org
For those outside the USA and UK, Befrienders Worldwide also provide support: http://www.befrienders.org/
Guidance on appropriate language use when discussing transgender health: https://epath.eu/wp-content/uploads/2019/03/language-and-trans-health.pdf
The labels have been added to this press release as part of a project run by the Academy of Medical Sciences seeking to improve the communication of evidence. For more information, please see: http://www.sciencemediacentre.org/wp-content/uploads/2018/01/AMS-press-release-labelling-system-GUIDANCE.pdf if you have any questions or feedback, please contact The Lancet press office pressoffice@lancet.com
[1] Quote direct from author and cannot be found in the text of the Article.
The labels have been added to this press release as part of a project run by the Academy of Medical Sciences seeking to improve the communication of evidence. For more information, please see: http://www.sciencemediacentre.org/wp-content/uploads/2018/01/AMS-press-release-labelling-system-GUIDANCE.pdf if you have any questions or feedback, please contact The Lancet press office pressoffice@lancet.com
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Observational study
People
Mortality trends over five decades in adult transgender people receiving hormone treatment: a report from the Amsterdam cohort of gender dysphoria
1-Sep-2021
We declare no competing interests.
IMAGE: DR SUPAKSH GUPTA view more
CREDIT: DR SUPAKSH GUPTA
Warmer weather is linked to a worsening of chronic obstructive pulmonary disease (COPD) symptoms, according to research to be presented on Sunday at the ‘virtual’ European Respiratory Society International Congress [1].
Analysis of data from 1,177 current and former smokers with COPD in the USA showed that approximately two days after an increase in ambient temperatures, there was an increase in COPD exacerbations.
Dr Supaksh Gupta, a pulmonary and critical care fellow at the University of Washington, USA, told the Congress: “We found that each one-degree Celsius increase in ambient temperature was associated with a 2% increase in the likelihood of COPD exacerbations in the following two days among this group of patients.
“This study is one of the few to explore the impact of ambient temperature on the risk of COPD exacerbations in a group of people with established COPD for whom we have detailed medical information. Overall, it contributes to the emerging body of knowledge regarding ambient temperature and risk of COPD-related health problems. A major strength of the study is the number of people included, who live in various major US towns and cities.
“Other studies have shown a connection between extreme heat exposure and increased risk of health problems and death in people with COPD. There are concerns that these problems will accelerate with the ongoing and worsening climate crisis. Therefore, it is important to quantify the health risks associated with changes in ambient temperature, while also determining who is most at risk to inform policy-makers and healthcare providers.”
Dr Gupta and colleagues looked at current and former smokers who had enrolled in the SubPopulations and InteRmediate Outcome Measures in COPD Study (SPIROMICS) between 2010 and 2015, and who had had at least one COPD exacerbation since joining the study. They assessed the risk of COPD exacerbations based on local, ambient temperatures recorded on the day of the exacerbation and in the preceding seven days.
The average age of the participants was 64 and the average time to the first exacerbation was 603 days (just over a year and a half). The risk of exacerbations increased with increasing temperatures during the preceding six days, with the highest risk two days after temperatures rose. The researchers were able to adjust their results to take account of humidity levels, which have been implicated in the risk of exacerbations.
“Our findings raise concerns about the risk of increased exacerbations with climate change. While not conclusive, the study suggests that those living with COPD may want to avoid exposure to adverse and extreme environmental conditions by limiting outdoor activities during periods of elevated temperatures relative to normal. Moreover, while not within the scope of this paper but based on previously existing literature, those who reside in areas with increased temperature, or increased temperature variability, may benefit from access to indoor air cooling,” said Dr Gupta.
The mechanisms involved in the link between heat and COPD exacerbations are not entirely understood, but may include hyperventilation, which increases the possibility of a process called dynamic hyperinflation. During dynamic hyperinflation, a person does not exhale completely before starting to inhale again. This can lead to less efficient and effective breaths. At its extreme, dynamic hyperinflation could lead to increased pressure in the chest cavity and a subsequent decrease in blood flow back to the heart. Elderly patients are also less able to adjust their body temperatures and maintain adequate hydration. Additionally, some asthma studies have suggested that breathing hot, humid air can result in constriction of the airways.
Dr Gupta concluded: “I wanted to contribute to research involving a disease process that affects the lives of many of my patients. My goal is to help inform our understanding of the ongoing climate crisis on healthcare outcomes and utilisation. I hope our research will help guide public policy recommendations and promote health precaution guidelines for people with COPD during periods of increased ambient temperature.”
Zorana J. Andersen, who was not involved in the study, is Chair of the European Respiratory Society Environment and Health Committee Chair and Professor in Environmental Epidemiology at the Department of Public Health, University of Copenhagen, Denmark. She said: “The climate emergency is proving to have far-reaching effects in areas of everyday life where it might not necessarily be expected to have an impact. This study offers a fascinating insight into the way it could be affecting the lives of people living with COPD and is yet more proof of the urgent need to tackle climate change and the world’s rising temperatures.”
(ends)
[1] Abstract no: OA103, “Effects of ambient temperature on COPD symptoms and exacerbations in the SubPopulations and InteRmediate Outcome Measures in COPD Study (SPIROMICS) cohort”, presented by Supaksh Gupta. Environment and respiratory health session, 09:30-11:00 CEST on Sunday 5 September 2021, https://k4.ersnet.org/prod/v2/Front/Program/Session?e=262&session=13719
Observational study
People
The SubPopulations and InteRmediate Outcome Measures In COPD Study (SPIROMICS) cohort, the dataset for which this study was conducted, is funded by the US National Heart, Lung, and Blood Institute (NHLBI) and the COPD Foundation. SPIROMICS was supported by contracts and grants from the US National Institutes for Health (NIH), supplemented by contributions made through the Foundation for the NIH and the COPD Foundation.
Mountaintop mining causes 40% loss of aquatic biodiversity
Environmental scan of DNA turns up 10,000 species living in streams
Peer-Reviewed PublicationIMAGE: MOUNTAINTOP MINING THREATENS STREAMS IN THE APPALACHIAN REGION, A GLOBAL HOTSPOT OF BIODIVERSITY. view more
CREDIT: CREDIT: DAVID HERASIMTSCHUK, FRESHWATERS ILLUSTRATED
DURHAM, N.C. – Trickling down over rocks, surrounded by wildflowers and ferns, Appalachian mountain streams are chock-full of life. They hold some of the world’s greatest diversity of freshwater animals, including many species that can’t be found anywhere else in the world.
But this biological diversity is severely threatened by mountaintop coal mining, whose downstream pollution impacts many of these species, according to a study in the September 2021 issue of the journal Ecological Applications.
Researchers found that the effects of mountaintop coal mining are even more widespread than previously reported: Streams from heavily mined watersheds harbor 40% fewer species than streams with cleaner water.
That lost biodiversity includes fish, macro-invertebrates (such as insects, clams and crustaceans), algae, fungi, bacteria, unicellular organisms called protists, and more. In other words: it isn’t just the particularly sensitive species that are being affected.
“The impacts are really distributed across the whole tree of life,” said Marie Simonin, a researcher at France’s National Research Institute for Agriculture, Food and Environment (INRAE) and lead author of the study.
Simonin and her team looked at 93 streams along a gradient ranging from heavily mined watersheds to relatively pristine streams across the Appalachian range in West Virginia. They found a clear relationship between the density of mining activities and loss of biodiversity: the more mining there is, the fewer species one finds.
“It was really surprising to see how consistent this decline in biodiversity is across all these really different groups of organisms, starting at really low levels of disturbance,” said Emily Bernhardt, Professor and Chair of biology at Duke University and senior author of the paper.
The results highlight another concerning pattern: significant diversity loss was detected in streams whose water was still far below the maximum disturbance standards set by the Environmental Protection Agency (EPA).
“A very small increase in mining activities in the watershed is already too much,” Simonin said.
This means that the detrimental effects of pollutants in aquatic species start at much lower concentrations that previously assumed.
“By the time you get to the EPA’s reference point, you've already lost most of the species you're going to lose,” Bernhardt said.
Although biodiversity loss due to mining had been shown in several groups of species separately, this study stands out by looking at the whole tree of life at once, in the same streams, at the same time. To do this, the team used an innovative method called environmental DNA (eDNA), which measures fragments of genetic materials that organisms leave behind in their environment.
This DNA could originate from excrement, lost bits of skin or scales, or from unicellular organisms. To collect it, researchers gathered water samples from each stream and filtered them through extremely fine filters. DNA stays stuck on the filters, and can then be extracted, sequenced, and sorted.
Groups of organisms, such as algae for example, share common genes, or segments of genes. By comparing the DNA obtained from the filters with DNA known to belong to a certain species or groups of species, scientists can determine what is hanging out in each stream, not unlike CSI agents running samples through their databases (but with far less drama).
This method holds huge promise for biodiversity assessments and water quality impacts.
“eDNA is an inexpensive approach that can provide substantial insights into drivers of biodiversity,” Bernhardt said. “It can open the possibility for monitoring water quality impacts over a much larger number of rivers across the globe.”
The results obtained with eDNA are well in line with those obtained with more traditional methods, with a fraction of the work. As an example, the team detected 28 species of fish in all 93 sampled mined streams by using eDNA. That is comparable with previous studies that had painstakingly collected, counted and identified the fish diversity of the same region. eDNA provided a much quicker and less invasive method of diversity assessment, with similar results.
“You take a very small amount of water and you're able to see the impact on all those organisms. You don't need to kill any animals, you don't need a huge team of people skilled in identifying all of these species, everybody could do the field work,” Simonin said. “This can really change the scale at which we can monitor biodiversity.”
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This research was funded by NSF Grant No. EAR-1417405.
CITATION: “Consistent Declines in Aquatic Biodiversity Across Diverse Domains of Life in Rivers Impacted by Surface Coal Mining,” M. Simonin, J. D. Rocca, J. R. Gerson, E. Moore, A. C. Brooks, L. Czaplicki, M. R. V. Ross, N. Fierer, J. M. Craine, E. S. Bernhardt. Ecological Applications, June 17, 2021 (first published). DOI: 10.1002/eap.2389
Ecological Applications
Observational study
Animals
Consistent Declines in Aquatic Biodiversity Across Diverse Domains of Life in Rivers Impacted by Surface Coal Mining
17-Jun-2021
This research was funded by NSF Grant No. EAR-1417405.
