Obesity and Gender Incongruence  

As we highlight the Endocrine Society’s Special Interest Groups, we talk to Michelle Cordoba Kissee, MD, from the Transgender Research and Medicine SIG, who discusses the prevalence of obesity in this patient population.

Michelle Cordoba Kissee, MD

In 2019, the Endocrine Society launched its Special Interest Groups (SIGs) so members with a similar interest could come together and collaborate both within and outside the SIG.

These member-led communities give members a means to expand their professional networks, identify potential collaborators, and explore innovations in research and care. Presently there are four different SIGs: Adrenal and Pituitary, Early Career, Entrepreneurship, and Transgender Research and Medicine.

SIGs have formal Steering Groups comprised of three or more members who are responsible for ensuring the online community is active by encouraging post discussions, scheduling quarterly webinars or live chats, and planning in-person networking opportunities at ENDO and/or CEU. Through annual workplans, steering groups are tasked with engaging the SIG membership to create a workplan that ensures the SIG’s activities are relevant to the community.

In conjunction with the Transgender SIG, Michelle Cordoba Kissee, MD, an endocrinologist at DHR Health: Bariatric and Metabolic Institute in Edinburg, Texas, answers some questions regarding gender incongruence and obesity, why transgender people are at a higher risk for obesity, various treatment options, and more. 

Endocrine News: Why are transgender people at risk for obesity?

Michelle Cordoba Kissee: Transgender people have higher rates of poverty and lower rates of accessing healthcare. In addition, some people experience unemployment, exclusion from parental insurance, or change in marital status as a result of their gender affirming transition, all of which can negatively impact patients’ access to care.

As endocrinologists who evaluate and treat patients with both gender incongruence as well as obesity, it is important to understand challenges that transgender people with obesity may face and how these conditions may affect each other.

As endocrinologists who evaluate and treat patients with both gender incongruence as well as obesity, it is important to understand challenges that transgender people with obesity may face and how these conditions may affect each other.

Barriers also exist for transgender people who participate in sports.Studies have demonstrated that obesity and gender incongruence individually are diagnoses that put people at risk for bias from medical providers. Patients with both are especially vulnerable to experiencing trauma when seeking medical care, and they may also experience chronically high levels of stress — known as minority stress — as members of a stigmatized minority group. Endocrinologists who provide gender affirming hormone therapy may be the first medical providers patients see in years, which could be an opportunity to discuss other health issues such as obesity.

EN: How does gender affirming hormone therapy affect obesity? 

MCK: While weight gain after starting gender affirming hormone therapy has been reported, hormone therapy may also have a positive effect on obesity.Some of my patients who were previously on medications for diabetes had their diabetes go into remission after starting hormone therapy and losing weight. They are more comfortable in public places such as gyms and parks. They report feeling less isolated and more motivated and have been able to avoid unhealthy food choices because they feel better about themselves. Additionally, while weight and BMI may increase after starting hormone therapy, research needs to evaluate how lean body mass, percent body fat, and other metabolic parameters change.

EN: Can obesity affect gender expression?

MCK: Obesity can affect how a person might be perceived as masculine or feminine. For example, excess adipose tissue contributes to the aromatization of testosterone to estrogen, and the resulting gynecomastia may be a desired change for transgender females with obesity. Female patients have told me they are happy with their excessive weight gain because they want to appear “curvy.” Male patients who were designated as female at birth may also welcome the oligomenorrhea and hirsutism that can occur with weight gain. Having increased abdominal girth might also make chest tissue less noticeable as well. Clinicians should be mindful of potential underlying body dysphoria when they consider discussing obesity with their patients.

EN: What are some considerations for gender affirming hormone therapy in patients seeking metabolic (bariatric) surgery?

MCK: The best approach regarding hormone therapy around the time of metabolic surgery is an individualized discussion of the risks and benefits. Recently, more guidance has been published to discourage unnecessarily suspending hormone therapy with surgeries in general. However, obesity itself is associated with an increased venous thromboembolic risk, and after metabolic surgery, many patients routinely receive anticoagulation therapy to avoid thromboembolic events.

While weight gain after starting gender affirming hormone therapy has been reported, hormone therapy may also have a positive effect on obesity.Some of my patients who were previously on medications for diabetes had their diabetes go into remission after starting hormone therapy and losing weight.

Continuing testosterone replacement at the time of many surgeries is likely safe. However, suspending testosterone in someone with a uterus could result in unwanted vaginal bleeding which could be devastating for someone who is recovering from surgery. For transgender patients undergoing metabolic surgery at our center, I have recommended continuation of gender affirming testosterone therapy with careful monitoring to ensure our patients maintain their testosterone in a physiologic male range. 

The American Society for Metabolic and Bariatric Surgery, in conjunction with other organizations, has recommended that estrogen be discontinued three to four weeks prior to metabolic surgery, although this is based on expert opinion. More research is needed to address the perioperative hormone therapy recommendations in the specific setting of metabolic surgery. While one might argue that the risk of thromboembolism in someone with obesity is sufficiently concerning to discuss holding estrogen, the mental health of the patient needs to be strongly considered. Transgender people have alarmingly high rates of suicidality, and patients who undergo metabolic surgery should be assessed for mood disorders as the risk of suicide can also increase postoperatively. 

EN: What questions remain regarding obesity and gender incongruence?

MCK: Potential areas of study include whether different routes of hormone administration, such as oral versus injected, have varied efficacy in the setting of obesity. Another question would be how hormone regimens and levels may change after metabolic surgery, potentially due to altered absorption of oral medications. As endocrinologists who evaluate and treat patients with both gender incongruence as well as obesity, it is important to understand challenges that transgender people with obesity may face and how these conditions may affect each other.

For more information about the Transgender Research and Medicine SIG and other SIGs, please go to: https://www.endocrine.org/our-community/special-interest-groups

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