Hormone Replacement Therapy & Racial Health Disparities

Many pre-existing conditions that are closely monitored for folx on HRT are also present at higher rates among Black, Indigenous, and other Persons of Color (BIPOC) communities.

As we’ve seen with COVID, our healthcare systems do not care for BIPOC bodies as well as they care for white bodies. Unfortunately, this systemic inequality existed well before our current pandemic. Part of the work here at FOLX is to ensure we are seeing people as their full selves, including the persistent racism some people face day-in-and-day out.

Let’s start here: health disparities are often not caused by race, but by racism.

In the US, people who are identified as Black, Hispanic/Latinx/Latine, and/or American Indian/Alaskan Native have higher rates of diabetes and high blood pressure than those who identify as white. A 2011 study found that while there don’t appear to be racial disparities in rates of high cholesterol, white people with high cholesterol are more likely to have it well-controlled by medication. Some people wrongly assume that this is due to genetic differences based on race. However, recent research reveals that these health disparities are not due to race, but racism. 

Racism can be defined as “prejudice, discrimination, or antagonism directed against a person or people on the basis of their membership in a particular racial or ethnic group.” This discrimination shows up in places like our criminal justice, education, and health care systems.

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There are three main ways that racism leads to inequities in health.

In a 2019 literature review, a group of researchers discuss three ways that racism leads to inequities in health:

  1. Cultural racism: the way that the superiority of white people relative to other people of other races is buried within our cultural images, norms and ideas. It is the foundation that supports all other types of racism. When BIPOC internalize these ideas, it can trigger mental and behavioral responses that are harmful to a person’s overall well-being. Even being exposed to cultural racism can create chronic stress that harms BIPOC health.

  2. Structural/institutional racism: the way that cultural racism plays out in institutions like schools, prison, housing, healthcare, etc. Structural racism makes it harder for BIPOC to access grocery stores, health care services, neighborhoods that are safe enough to jog in, and other activities that are commonly recommended for a person’s health.

  3. Individual level discrimination: how an individual experiences racism coming from institutions and the people around them. Discrimination experienced at the individual level can lead to biological changes that increase one’s risk of physical and mental illness. When people experience discrimination from individuals in health care settings, they may become less likely to seek out health care in the future. And individually held biases can lower the quality of care that BIPOC receive.

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Hormones on their own are not inherently harmful or risky, however, there are other factors that increase risks of HRT, and these factors are directly related to racism and transphobia.

Two of the most commonly prescribed medications for HRT, estrogen and testosterone, can cause changes in many different parts of the body, including the blood and blood vessels. While both instances of these are fairly uncommon, there is a risk of estrogen or testosterone increasing the risk for certain health conditions. For those who don’t have preexisting health conditions or family history, these risks are low.

  • High levels of estrogen can increase risks for blood clots in the veins, called DVTs (deep vein thrombosis) in the legs and PE (pulmonary embolism) in the lungs. High levels of estrogen may also increase the risk for heart attacks and strokes.

  • Testosterone causes the bone marrow to produce more red blood cells. We use tests like hemoglobin (the protein in red blood cells responsible for carrying oxygen from the lungs to the rest of the body) and hematocrit (the volume of red blood cells in the blood) to monitor the levels. Having too many red blood cells causes the blood to become ‘thicker,’ which can increase the risk of blood clots, leading to heart attacks and strokes.

As a consequence of racism and transphobia, BIPOC on HRT are more likely to have pre-existing conditions that increase the risk for heart attacks and strokes. Estrogen and testosterone can enhance those risks:

  • High blood pressure: Over time, elevated blood pressure causes damage to the inner lining of the arteries and causes the heart to work harder. Both testosterone and estradiol can further increase blood pressure.

  • High cholesterol: This can cause plaque to build up inside the arteries, especially in combination with high blood pressure and diabetes. Eventually the plaque buildup can cause your arteries to harden in places like the heart or legs, or they might break off and get caught up in a small blood vessel, leading to strokes. Estradiol and testosterone may affect cholesterol levels

  • Diabetes: Uncontrolled diabetes means that there are high amounts of  glucose or sugar in the blood. These high glucose levels can stiffen blood vessels. There is mixed and unclear information on whether estradiol or testosterone affect sugar levels.

The good news is that many people with these conditions are still able to safely take HRT.

Sharing all of this information is not meant to deter anyone from pursuing HRT. Here at FOLX, we want to make sure that everyone understands the risks associated with taking all of the medications we prescribe. That’s why our intake forms include questions about conditions like diabetes, high blood pressure, and high cholesterol along with information on how those conditions may be impacted by HRT. 

We do not automatically exclude anyone with those conditions, for many reasons including the disproportionately high negative impact it would have on BIPOC members of our community. And since we deeply value informed consent, every FOLX member has the opportunity to meet with one of our clinicians to discuss their personal risk in more detail along with lifestyle changes that may help decrease those risks.

Ultimately: it’s about understanding the body, acknowledging why a condition might be the case, and making a plan with a provider to safely take and monitor hormone levels, and FOLX closely monitors members’ testosterone labs and estrogen labs.

For those who want to know more about how to decrease their personal risk, our FOLX member advocates are happy to help source answers before starting, and our FOLX clinicians are available whenever a member needs. Don't hesitate to reach out at support@folxhealth.com.