In the face of genetically engineered therapies for many cancers and the incredibly rapid development of effective vaccines for COVID-19, it’s easy to lose sight of the breadth and depth of unsolved puzzles in medical science. Many of these remaining mysteries may be at least partially resolved as we overcome the mind/body dichotomy. A fascinating example of this issue has emerged with recent evidence of the excessive prevalence of Type 1 diabetes (T1D) in transgender children and adults.
The earliest report of this association came in 2017 from a retrospective study in Belgium that revealed a 2.3-fold higher prevalence of T1D among 1,081 transgender adults, compared to the general population. In 2019, another retrospective study out of the University of Wisconsin looked at 749,284 patients between 10 and 21 years old over a 10-year period. The prevalence of T1D proved to be 9.5 times greater in the gender dysphoric children than in the remainder of the population. Most recently, a group out of Boston Children’s Hospital reported a prevalence for T1D in their 1,014 transgender youth that is 5.11 times the general population. An additional interesting finding of the latter two studies was that children with gender dysphoria were diagnosed with T1D at a much younger age than the national average. The age of diagnosis in Boston and Wisconsin were 8.5 and 9.9 respectively, compared to the national average of 14.5.
Notably, the dual diagnosis patients across these studies varied. In Belgium, eight of the 10 were transgender women. In Boston, nine of 11 were transgender males, and in Wisconsin, there were three transgender males, three transgender females, one identifying as gender-fluid, and one as gender-neutral. Taking the three studies in aggregate, the correlation of T1D with gender dysphoria appears to exist equally for all transgender people.
The authors of these studies propose two potential explanations for this surprising correlation. One is the possibility that people going to endocrinology clinics for T1D may be more likely to identify as gender dysphoric as many transgender and diabetes clinics are co-located. These transgender “friendly” locations may drive increased rates of transgender identification, resulting in the appearance of a correlation with T1D. To the extent there is truth in this hypothesis, it speaks to the importance of providers offering safe, non-judgmental clinical settings where labels are destigmatized, and patients are able to share this critically important information about themselves.
The second explanation for this finding is that the stress of gender dysphoria acts as a trigger for those with a genetic predisposition to T1D. One argument in favor of the stress as trigger theory, is that patients with T1D who underwent hormonal therapy (either suppression or augmentation) experienced an improvement in their HbA1c following the initiation of treatment.
Though much more work needs to be done to clearly identify the causal relationship between gender dysphoria and Type 1 diabetes, these studies challenge us to overcome our longstanding paradigm that views mind and body separately. Even the idea that the two interact with each other rather than exist as differing manifestations of one whole self should be called into question. To fully understand this and other medical mysteries before us, we may very well need to develop an entirely new vocabulary.
Martin Lustick is a physician and senior vice-president and principal, NextGen Healthcare.
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