Transsexualism is a rare condition and in scientific literature there are few reports on the long-term safety of different treatment protocols and on the physical and psychological outcomes of medical treatments. The safety of long-term high doses oestrogen or testosterone in subjects of the opposite sex has been debated and data on long term effects are scant at best. The Asscherman paper therefore represents a very important and reassuring reference for professionals working in this field suggesting that mortality is increased among transsexuals although due to causes unrelated to cross sex replacement therapy.
These results will benefit the care and treatment of these subjects. In April , the European Journal of Endocrinology published an important paper in scientific literature dealing with transsexual subjects. The study showed that this increased mortality is mainly due to non-hormonal causes; suicide, AIDS and illicit drug related deaths were higher when compared to the general population.
Transsexualism is a rare condition affecting approximately one in 12 males and one in 30 females 3 and collecting data from more than patients treated within the same medical center is remarkable. Compared to other papers dealing with this topic, this article appears particularly relevant considering both the sample size and the length of follow-up. Good data on mortality rates in transsexual subjects undergoing cross-sex hormone treatment with or without SRS are scanty.
Asscheman and colleagues 4 , 5 are not new to this research having reported the effects of hormonal treatment in and and, since then, findings from this group have confirmed that increased mortality in these subjects is not due to hormonal causes. The length of follow-up is also remarkable since it was suggested in a previous report that mortality rate differences start to appear after 10 years. The good news is that once EE is stopped, the risk seems to return to being indifferent from control subjects.
This paper reinforce this recommendation showing that current risk of cardiovascular events are threefold increased in those subjects that did not want to stop EE compared to past or never users. It remains to be established whether it is cost-effective to screen MtF before or during hormonal treatment for thrombophilia because genetic predisposition may further increase the risk.
Another interesting aspect emerging from the Asscheman paper is the difference in the mortality rate between FtM and MtF transsexuals. FtM subjects do not present a higher mortality rate nor does cause-specific mortality appear to be significantly different to that of the general population. Even considering that FtM are numerically inferior compared to MtF and that FtM subjects aged over 65 years are small number, still this is a significant difference between the two groups. Testosterone treatment is safe in these women and does not lead to increased cardiovascular mortality.
In some transsexual groups, the suicide rate appears to be higher in subjects who did not undergo surgery, but other studies do not confirm these findings. The Dutch health system allows easier, faster and cost-free access to reassignment surgery for almost all transsexuals, whereas in most other European countries, access to surgery is limited.
Numbers in this study do not allow for comparison on the mortality rate between those subjects who undergo sex reassignment surgery and those who do not, and this remains an important issue requiring further exploration. Therefore, whether stopping hormone treatment at an older age may lead to any health benefits also remains unclear. In conclusion, we would like to stress the importance of this paper in scientific literature on this topic.
The missing answers to some questions on the safety of cross-sex hormone administration in transsexuals will only be solved through large multicenter follow-up studies including many gender centers treating subjects with shared protocols based on the best available evidence-based medicine. A longterm follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. Endocrine treatment of transsexual persons: J Clin Endocrinol Metab.
Long-term treatment of transsexuals with cross-sex hormones: Mortality and morbidity in transsexual patients with cross-gender hormone treatment.
Mortality and morbidity in transsexual subjects treated with cross-sex hormones. Incidence of thrombophilia and venous thrombosis in transsexuals under cross-sex hormone therapy. Venous thrombosis and changes of hemostatic variables during cross-sex hormone treatment in transsexual people. Effect of sex steroid use on cardiovascular risk in transsexual individuals: Risk of venous thromboembolism from use of oral contraceptives containing different progestogens and oestrogen doses: Danish cohort study, —9.
Hormone replacement therapy and risk of venous thromboembolism in postmenopausal women: Risk factors for venous thrombotic disease. Risk of venous thrombosis with oral versus transdermal estrogen therapy among postmenopausal women. Care of transsexual persons. N Engl J Med. Safety of physiological testosterone therapy in women: Review of studies of androgen treatment of female-to-male transsexuals: Testosterone decreases adiponectin levels in female to male transsexuals.
Cardiovascular and cancer safety of testosterone in women. Curr Opin Endocrinol Diabetes Obes. Female and male transgender quality of life: Minimum 2-year follow up of sex reassignment surgery in Brazilian male-to-female transsexuals.