Bone Health in Transgender People (Nursing)

00:01 Let's take a look at bone health and the specific population of transgender people.

00:07 Because of the impact of sex steroids on the bones, this becomes something you need to be aware of and understand the implication.

00:16 Because we have concerns about bone health in all people, but their unique concerns in trans people.

00:22 Now, of course, we need more research, which we need more research in most areas of healthcare.

00:28 But we definitely need more research in transgender people's bone health for more clarity.

00:34 So we've had some conflicting results in the recent study.

00:37 So when you're looking at the literature, and you're looking at the research, it's not quite clear exactly what the impact is.

00:45 But we're going to give you some general guidelines and things to expect.

00:49 Now look at that last point we have for you, I'm going to pause for a minute and let you read that to yourself.

01:02 Okay, oftentimes, when you're studying and you're reading, you read something and you see the words, but really to understand it, you need to think it through.

01:11 So sometimes you need to jot a word down or underline things, let's walk through this statement because I want you to have a clear idea of what we're communicating here.

01:20 So sometimes, we're talking about in trans women, A trans woman assigned male at birth identifies as a woman, sometimes they have a lower initial bone mass density, compared to cisgender men.

01:39 Okay, so what we're saying here is sometimes trans women who these were identified as male, and at birth, now they identify as a woman, before they make the transition, they tend to or can have a lower initial bone mass compared to cisgender men who were identified as male at birth and continue to identify as male.

02:06 Why are we taking the time to go through this? Well, it matters because initially, they may not be starting off with a really strong bone density.

02:17 Here's just one example of a study.

02:19 As in all studies, there are limitations to this one, it is not perfect for sure, but you're welcome to look this one up if you want to read it in detail.

02:28 See, there's concerns about bone health as hormones are important regulators of metabolism.

02:34 And trans people have to rely on gender affirming medications to maintain their hormone levels.

02:40 So if I am a trans woman, I'm going to have to block testosterone and take estrogen for the rest of my life.

02:50 Because if I stopped that, I'm no longer gonna have those characteristics or they will significantly diminish.

02:56 Remember, it always matters how high a dose you've been taking, and how long a dose you've been taking of any hormone or medication.

03:04 So this is why we're concerned, that this we want to look at.

03:07 Okay, we have a pretty good feel of how men respond as they age with osteoporosis, we have a pretty good feel how women respond as they age with osteoporosis.

03:18 But what are the differences for trans men and trans women who are taking significant amounts of sex steroids? What impact does that have on their bones? Because we know sex steroids play a big role in bone health.

03:34 So let's look at this study a little closer.

03:37 This looks the record of 3,059 trans people who received long term gender affirming hormonal therapy.

03:46 Okay, so we had how many men look at that? How many trans women? Okay, so we had more trans women than we had in trans men.

03:57 Now, when you're studying research, does that mean you could say, "Oh, there are clearly more trans women in the world and there are trans men?" Nope, that isn't what supports this.

04:06 That's not what we're talking about.

04:07 They're just telling us what the population was for this particular study in 2019.

04:14 Now, as we've already discussed, there are some limitations in this study.

04:19 All research studies have limitations, and they should identify those in the manuscript itself.

04:25 But for this one, it's the first one to look at fracture risk in a large population of adult trans people.

04:32 So that's why we're talking about it today.

04:35 Is it perfect? Nope.

04:37 Is it the first one to look at this larger population and specifically look at fracture risk in patients who have been on long-term hormonal therapy? Yes, that's why we're looking at this study.

04:50 Now, we looked at the fracture incidence and it was calculated in trans women and cis women have similar ages.

04:57 So that's what we're going to compare trans women and cis women have similar ages and it also looked at trans men and cisgender men of similar ages.

05:07 Now you'll see that we have their cis woman, cis men, that stands for cisgender, that means they are identified as one sex at birth.

05:16 And they continue to identify as that same sex.

05:20 So there's a few study limitations here.

05:23 But remember, this is something kind of groundbreaking for what we're looking at.

05:27 So let's look at the result in a way that's easier, right? So we're going to show you some tables and some graphics that will make it easier for you to break it down.

05:34 But I highly encourage you to Google this reference, pull the article and read it yourself so that you can be informed and get a little practice on reading a research article.

05:45 Now, when they looked at older trans women, meaning they're greater than 50 years of age, they had an increased fracture risk.

05:53 Okay, let's pause.

05:56 So if this is an older trans woman, I want you to right next to our graphic right there.

06:03 For a trans woman, what sex were they assigned at birth? And now what are they identifying as? Okay, so a trans woman was assigned male at birth, and now identifies as female.

06:17 And we know that everyone in this study was on long-term hormonal therapy.

06:22 So they found that this particular population, older trans women, greater than 50 of years had an increased fracture risk.

06:30 Now, the types of fractures differed in trans women with relatively more hip, spine, forearm and humerus fractures.

06:38 Interesting, isn't it? I don't have an explanation for that.

06:42 It's just what this particular study found.

06:45 Now, when you take older trans women greater than 50 years, these results when they have an increased fracture risk as because it's compared to age-matched reference cis men.

06:57 Okay, why are you comparing trans women to cis men? Remember, we're looking for a risk.

07:07 If you choose to make a transition beyond long-term hormonal therapy, do you have an increased risk of fractures? Right.

07:16 So if I was born male, and I identify as female, we're going to compare this population to those that are born male and remained identifying as male.

07:27 So when we compare older trans women to age-matched cis men, the trans women have an increased risk of fracture.

07:36 So that is what this result means.

07:38 Now, let's just think about how that plays out.

07:41 If I am a trans woman, that means I have chosen to take anti-androgens, that's a sex story that helps gives me strong bones.

07:55 So if I'm choosing to block that sex steroid and I'm taking estrogen, it does increase my risk for having fractures compared to someone who did not transition.

08:07 So keep that in mind when you're working with transgender people or clients that if they are a transgender woman, they have a higher risk of fractures or even osteoporosis, what we're assuming.

08:20 So when you're counselling them, make sure you're looking for those cues.

08:25 Ask the types of questions that you know how to ask that identify risk for osteoporosis.

08:31 Now, let's look at a young trans woman so there'll be less than 50 years.

08:35 We've just looked at an older trans woman greater than 50 years.

08:39 Now we're going to look at a younger trans woman less than 50 years.

08:44 So who are we going to compare him to? Same age of a cis woman.

08:49 So do you have an increased fracture risk if you're a young trans woman compared to a cis gender woman? And the answer is yes.

08:59 They found that a young trans woman has a higher risk for fractures than the same age cisgender woman.

09:08 What about trans men? They found that when you compare a trans man to an aged cis man, it's a lower fracture risk.

09:19 Isn't that interesting? So if I am a trans man, I was identified as female at birth, I am identifying as male now that's why I'm considered a transgender man.

09:32 I actually have a lower fracture risk than in age-matched cis gendered man.

09:39 Interesting.

09:40 Do we know exactly why? We don't.

09:43 We're just reporting the results of this study.

09:46 So keep that in mind that yes, there is an impact of sex hormone therapy, the sex steroids, the hormone therapy, that go along with gender affirming care on the risk of fractures.

10:00 So we've got it laid out there, I would recommend you pause the video.

10:04 Go back and write some notes that you have clear in your mind, who is assigned male at birth and now decides they are identifying as female? What is the correct and respectful terminology for them? So make sure you ask yourself multiple questions so that you'll have that you're comfortable with it before you're taking care of clients who are transgender people.