Thrombosis Risk in Transgender Adolescents Receiving Gender-Affirming Hormone Therapy

Abstract

BACKGROUND AND OBJECTIVES: Many transgender youth experience gender dysphoria, a risk factor for suicide. Gender-affirming hormone therapy (GAHT) ameliorates this risk but may increase the risk for thrombosis, as seen from studies in adults. The aim with this study was to examine thrombosis and thrombosis risk factors among an exclusively adolescent and young adult transgender population. METHODS: This retrospective chart review was conducted at a pediatric hospital-associated transgender health clinic. The primary outcome was incidence of arterial or venous thrombosis during GAHT. Secondary measures included the prevalence of thrombosis risk factors. RESULTS: Among 611 participants, 28.8% were transgender women and 68.1% were transgender men. Median age was 17 years at GAHT initiation. Median follow-up time was 554 and 577 days for estrogen and testosterone users, respectively. Individuals starting GAHT had estradiol and testosterone levels titrated to physiologic normal. Multiple thrombotic risk factors were noted among the cohort, including obesity, tobacco use, and personal and family history of thrombosis. Seventeen youth with risk factors for thrombosis were referred for hematologic evaluation. Five individuals were treated with anticoagulation during GAHT: 2 with a previous thrombosis and 3 for thromboprophylaxis. No participant developed thrombosis while on GAHT. CONCLUSIONS: In this study, we examined thrombosis and thrombosis risk factors in an exclusively adolescent and young adult population of transgender people receiving GAHT. These data suggest that GAHT in youth, titrated within physiologic range, does not carry a significant risk of thrombosis in the short-term, even with the presence of preexisting thrombosis risk factors.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

“…There is strong evidence demonstrating the benefits in quality of life and well-being of gender-affirming treatments, including endocrine and surgical procedures, properly indicated and performed as outlined by the Standards of Care (Version 8), in TGD people in need of these treatments (e.g., Ainsworth & Spiegel, 2010 ; Aires et al., 2020 ; Aldridge et al., 2020 ; Almazan & Keuroghlian, 2021 ; Al-Tamimi et al., 2019 ; Balakrishnan et al., 2020 ; Baker et al., 2021 ; Buncamper et al., 2016 ; Cardoso da Silva et al., 2016 ; Eftekhar Ardebili, 2020 ; Javier et al., 2022 ; Lindqvist et al., 2017 ; Mullins et al., 2021 ; Nobili et al., 2018 ; Owen-Smith et al., 2018 ; Özkan et al., 2018 ; T’Sjoen et al., 2019 ; van de Grift, Elaut et al., 2018 ; White Hughto & Reisner, Poteat et al., 2016 ; Wierckx, van Caenegem et al., 2014 ; Yang, Zhao et al., 2016 ). Gender-affirming interventions may also include hair removal/transplant procedures, voice therapy/surgery, counseling, and other medical procedures required to effectively affirm an individual’s gender identity and reduce gender incongruence and dysphoria.…”

Risk of Venous Thromboembolism in Transgender People Undergoing Hormone Feminizing Therapy: A Prevalence Meta-Analysis and Meta-Regression Study

“…811 papers were excluded as irrelevant, based on title and abstract reading. Hence, as shown in Figure 1, 99 studies were identified, of which 18 met the inclusion criteria (17,(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49). The studies by Asscheman and colleagues published in 1989 (50) and 2011 (51) were excluded since the population under investigation was already included in the paper by van Kesteren et al, 1997 (47).…”

Affirming Hormone Treatment for a Transgender Adolescent After a Venous Thromboembolic Event

“…The data regarding testosterone and VTE risk in the TGD population is mainly derived from adult subjects and lacks robust evidence from the adolescent population. A recent retrospective cohort study showed no cases of VTE among TGD adolescents on testosterone therapy in one clinical setting 20. Overall, conclusions from the literature regarding testosterone therapy have been conflicting, and case reports for the adolescent TGD population may suggest an association of testosterone and VTE 21–23.…”

“…A recent retrospective cohort study showed no cases of VTE among TGD adolescents on testosterone therapy in one clinical setting. 20 Overall, conclusions from the literature regarding testosterone therapy have been conflicting, and case reports for the adolescent TGD population may suggest an association of testosterone and VTE. [21][22][23] Among adolescents, one case report describes a 17-year-old transgender male receiving masculinizing therapy for male gender affirmation who presented with bilateral pulmonary emboli.…”