Transgender and Diabetes Health Care
By Matthew Garza
From navigating the healthcare system to figuring out how to manage diabetes medications while on gender-affirming hormone therapy, being a transgender person with diabetes comes with additional challenges on top of diabetes self-management.
Editor's Note: Some of the terms around this topic may be new or unfamiliar. Jump to the end of the article for a few helpful definitions.
Diabetes doesn’t discriminate. People who are transgender are just as likely, if not more likely, to have diabetes as the general population. But because of health inequities, gender-affirming hormone therapy, and transphobia, managing diabetes as a member of this community comes with additional challenges.
Though significantly more research is needed, understanding the risk for diabetes in the transgender community, as well as the specific healthcare needs and recommendations for these individuals, is crucial to improving care. We spoke to Juli Royal, a young transgender woman from Athens, GA, who has had type 1 diabetes for 22 years (she was diagnosed the day before she turned seven), to learn more about the real-life experience of living at this intersection.
Screening and prevalence of diabetes in the transgender community
Unfortunately, due to a lack of research and the challenges in collecting data for people who are transgender, we don’t know much about the true prevalence of diabetes in the transgender community. We also don't know for sure if there is a difference in a person’s risk for diabetes if they are transgender.
The few studies we do have suggest that both transgender men and women may be at a slightly increased risk for type 2 diabetes than their cisgender counterparts. This may be caused by a number of risk factors in this community, including:
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Higher rates of tobacco and excessive alcohol use
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Weight gain or insulin resistance caused by gender-affirming hormone therapy
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Higher rates of other conditions that put people at risk for diabetes such as HIV (more common in transgender women) or polycystic ovarian syndrome (more common in transgender men).
Screening can help you identify if you have diabetes or prediabetes early and begin treatments to bring your glucose levels down. If you are not on gender-affirming hormone therapy, the American Diabetes Association (ADA) recommends getting screened for type 2 diabetes beginning at age 35 (except in special cases where someone may have obesity or excess weight). Screening should be repeated every three years.
The current recommendations for getting screened for type 2 diabetes if you are currently taking gender-affirming hormones (which may impact blood pressure, glucose levels, and weight) is to be screened when starting hormones and each year after. If you have a family history of diabetes, or if you gain more than 5 kg (around 10 lbs) after starting hormone therapy, you may need to be screened more often.
Risk factors and diabetes management
The added risk factors that transgender people face can also complicate diabetes management and the prevention of complications – even for those with previously diagnosed diabetes.
Royal’s parents took on a very active role in her diabetes management when she was a child. When going off to college at the University of North Georgia, the transition to having more responsibility for her self-management while figuring out her own gender identity made her feel like she couldn’t escape her health.
She found herself testing her glucose levels much less, dealing with depression and mental health challenges, and engaging in substance use. Though she now has a much healthier relationship with her diabetes, at the time, Royal says these factors definitely impacted her diabetes management.
Today, Royal focuses on taking her diabetes management one day at a time. She uses a Medtronic MiniMed 670G pump for her insulin needs and a blood glucose meter to check her glucose levels throughout the day. She tries to put everything into perspective, especially around food and insulin needs.
“I’m not interested in guilt,” she said. Food is the priority, and she does her best not to let judgment around her food choices influence her.
Navigating the healthcare system
Part of what makes understanding the prevalence of diabetes in this community, and screening properly for diabetes, is that navigating the healthcare system for transgender people can be complex, uncomfortable, and extremely difficult – even when diabetes isn’t thrown into the mix. Eventually, some people are lucky enough to find their groove, but that’s not the case for everyone.
“I have definitely figured out how to navigate [the healthcare system] with time,” said Royal. “As I have developed my own confidence and identity, I have been able to be less reactive to being misgendered or things like that.”
Finding a healthcare team that is affirming and supportive of transgender people is already challenging, so finding a team that is also knowledgeable about the specific healthcare needs of transgender people with diabetes can be almost impossible.
Some tips for finding a team that can provide you the care you need as someone who is transgender:
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Go to a healthcare center that specifically cares for LGBTQ+ people. Check out the CDC’s curated list of LGBTQ+ health centers.
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Ask other members of the transgender or diabetes communities – especially the online community (connecting with others is how many people find care teams in their area).
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Ask a current healthcare professional who you trust for recommendations (Royal’s primary care physician, who is LGBTQ+ inclusive and helped her as she navigated her transition, has given her specific recommendations for endocrinologists and other specialists).
“I want [healthcare professionals] to know that [transgender people] are okay,” said Royal. “We don't need to be coddled. We are human beings who have the capacity to not get upset with things. If I get misgendered I am not going to fly into a rage and start hitting things…and I don’t expect any form of special treatment.”
However, Royal acknowledged that while this mindset has allowed her the peace to be able to regularly attend the necessary appointments, this is not the case for everyone – and transgender people shouldn’t be subjected to transphobia and prejudice just so they can get healthcare.
Compassionate care should be a priority for everyone in the healthcare space. If you are a healthcare professional, ask the people you are treating what pronouns and terminology they use, and then make sure these are respected office-wide. Think about how your office space is set up. Are there private or gender-neutral bathrooms available? Do you have the ability to use the correct pronouns or terminology in the electronic medical record software you use?
Implementing simple changes can help assure transgender people feel safe and respected in the healthcare setting.
Diabetes management for transgender people
For the most part, recommendations for managing your diabetes – whether type 1 or type 2 – as someone who is transgender are exactly the same as those who are not.
However, there are a few exceptions for anyone on gender-affirming hormone therapy. Healthcare providers and the people they treat should discuss the potential effects that hormone therapy can have on glucose levels and insulin sensitivity.
Not everyone will experience these effects. Royal mentioned that though she’s been on estrogen now for several years now, she has not noticed any tangible relationships between her hormone therapy and diabetes medications or glucose levels. Some of the effects you may experience, and treatment recommendations, include:
For those taking feminizing hormones (ex: estrogen)
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Potential effect: Potential for increased insulin resistance.
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Recommendations for treatment: Increased risk for hyperglycemia. Discuss increasing insulin dosing with your healthcare provider, if needed.
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Potential effect: Potential for decreased LDL and triglycerides, increased HDL cholesterol, and increased risk for venous thromboembolism (VTE).
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Recommendations for treatment: Maintain lipid screening schedule per ADA guidelines (at diagnosis and at least every five years after if under 40). Consider using a transdermal estrogen patch, especially if under 40 to lower risk for VTE.
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For those taking masculinizing hormones (ex: testosterone)
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Potential effect: Potential for increased insulin sensitivity.
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Recommendations for treatment: Increased risk for hypoglycemia. Discuss decreasing insulin dosing with your healthcare provider, if needed.
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Potential effect: Potential for increased LDL cholesterol and triglycerides, decreased HDL cholesterol.
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Recommendations for treatment: Follow ADA screening recommendations for dyslipidemia and heart complications given the additive risk of both treatments and conditions.
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For those taking puberty blockers (ex: GnRH therapy)
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Potential effect: Potential for hyperglycemia.
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Recommendations for treatment: Closely monitoring glucose levels and A1C when starting hormone therapy and at least annually thereafter.
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Recommendations adapted from “Considerations for Transgender People With Diabetes” by Moverley, et. al.
If you are taking hormones or planning on starting hormone therapy, work closely with your primary care provider and endocrinologist to make sure that you are able to manage your diabetes well and be monitored for potential complications, while still receiving the gender-affirming care you desire.
It is recommended that you have reasonably well-controlled diabetes prior to starting hormone therapy. However, even in those who did not, there are anecdotal accounts of people’s A1C levels improving after starting gender-affirming treatments. This may be due to improvements in mental health and self-care.
Finally, as a reminder for healthcare providers, gender-affirming hormone therapy is a life-saving treatment. If issues arise that make diabetes management difficult as a result of hormone therapy or other gender-affirming treatments, discuss all possibilities – including changing diabetes medications or devices or collaborating with other people on their healthcare team – to find a solution. Only stop gender-affirming care in extreme circumstances.
Other considerations
Remember that there are many aspects surrounding the experience of being transgender and having diabetes that goes beyond how hormone therapy might affect glucose levels or whether someone’s diabetes is reasonably well-controlled before starting hormone therapy.
For example, Royal remarked how figuring out how to attach and position her insulin pump while wearing a dress was something she always struggled with.
"There are a lot of things that I was never taught, that a lot of girls are taught when they're young. And the intersection of that with diabetes is interesting,” she said.
For transgender people, there can be issues with mental health, body image, and simply navigating the world that are already challenging – adding in diabetes, the wearable devices and medication needs, and constant management, only complicate them further.
However, finding the right balance is crucial, and it's important to remember that you are not the only person who is experiencing these challenges.
“Society makes you feel like your body is broken in so many ways,” said Royal. “It makes you feel like whatever you do will never be enough. And that is such a lie.”
The bottom line is that transgender people with diabetes deserve the same level of compassionate care and respect that all people deserve. “For me personally, I am simply a human, who also has diabetes, who also happens to be trans,” she said.
Editor’s note: Defining terms
Some of the terms around this topic may be new or unfamiliar. Here are a few helpful definitions:
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Transgender: The term transgender (or “trans”) refers to people whose gender identity and/or expression is different from cultural expectations based on the sex they were assigned at birth. This term is an umbrella term that captures many different experiences – there is no “right way” to be transgender.
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Cisgender: This term could be considered the opposite of transgender and describes someone whose gender identity aligns with the sex assigned to them at birth.
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Non-binary: This term describes a person who does not identify exclusively as a man or a woman. Non-binary people may identify with being both a man and a woman, somewhere in between, or completely outside these categories. Non-binary people may also identify as transgender, though not all do. Other similar terms which are often used to mean the same thing include agender, bigender, genderqueer, or gender-fluid.
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Transitioning/gender-affirming care: These include a number of processes that some, but not all, transgender people may undergo to live more fully as their true gender. This can include social (ex: wearing clothes that match their gender or changing their pronouns) or legal transitioning (ex: changing name and sex on government documents). It can also include medical transitioning or gender-affirming care which may include gender-affirming hormone therapy or surgery.
