Cardiovascular Care for Transgender and Gender-Diverse Patients
For transgender and gender-diverse (TGD) individuals, various barriers to health care and a range of unique risk factors may increase risk for cardiovascular disease (CVD), highlighting the need for affirming and culturally competent cardiovascular care in this population.1,2
In a 2024 meta-analysis of 10 studies, the authors concluded that the risk for CVD is 40% higher among TGD individuals compared with cisgender individuals of the same birth sex.3 While some studies have suggested that gender-affirming hormone treatment may be a contributing factor in the increased CVD risk among TGD patients, findings on this topic are largely inconclusive to date.4,5
Cardiovascular Health Disparities in TGD Patients
“Although CVD risk appears to be higher for TGD people than for the general population in some cross-sectional studies, it is not clear that the increased risk relates to hormone therapy or other gender-affirming treatment,” said Joshua D Safer, MD, executive director of the Mount Sinai Center for Transgender Medicine and Surgery and professor of medicine in the division of endocrinology, diabetes, and bone disease at the Icahn School of Medicine at Mount Sinai in New York, New York.6
“There is emerging research to suggest that exogenous hormone therapy may not be the most significant driver of disparities in cardiovascular health” in TGD individuals, explained C Streed Jr, MD, MPH, associate professor of medicine in the section of general internal medicine at the Boston University Aram V Chobanian & Edward Avedisian School of Medicine and research director of the GenderCare Center at Boston Medical Center.5,7
“Consequently, we must consider additional pathways that account for disparities in outcomes for TGD people,” said Dr Streed, who co-authored a scientific statement from the American Heart Association (AHA) on managing cardiovascular health in LGBTQ+ adults.8
According to Dr Safer, “It may be that the biggest driver of greater disease burden in this population relates to social determinants of health, including access to health care.”5,9 In a study by Dr Safer and colleagues, they found that the main barrier to health care reported by TGD individuals was a lack of providers knowledgeable about TGD medicine.10
Marginalized populations, including TGD individuals, face numerous disparities in cardiovascular risk due to unique stressors, Dr Streed noted.
“With significant anti-trans animus in society, TGD people experience higher levels of anxiety and depression, both of which have been linked to worse cardiovascular health,” he continued.11,12 “Additionally, with higher levels of discrimination, TGD people are known to have a higher prevalence of tobacco use, and elevated levels of acute and chronic stress may contribute to higher prevalence rates of hypertension and diabetes” in these patients.8
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It is time we moved beyond recommending training on TGD issues in undergraduate, graduate, and continuing medical education and make it a requirement of licensure.
C Streed Jr, MD, MPH
Strategies for CVD Prevention and Treatment in TGD Patients
“Simply creating safe spaces for TGD people to make their medical homes may be a huge opportunity for change,” Dr Safer stated. “Clinicians should be prepared to use names and pronouns supplied by the patients and should make no assumptions about anatomy or sexual behavior.”
“Cardiologists should ensure that patient-reported sexual orientation and gender identity data are a standard part of intake,” Dr Streed recommended. “We cannot identify population-level concerns without appropriate data.”
Clinicians should also consider how sex-based protocols for care may need to be adjusted for TGD patients, Dr Safer said. Currently, it is not known if hormone therapy influences CVD risk and whether the duration of treatment has any impact on risk. “Until such data are generated, the most conservative approach would be to apply the risk calculator of the sex that would result in earlier monitoring and treatment.”
For general cardiovascular care, “The AHA’s Life’s Essential 8 remain the mainstays of preventing CVD in TGD populations—this means explicitly screening for hypertension, diabetes, dyslipidemias and so on, but also being prepared to offer tailored interventions,” Dr Streed advised.5
“Beyond ensuring safety of medical interventions in the presence of exogenous hormone therapy, clinicians must consider behavioral interventions that incorporate key components of our patients’ lived experience,” he added. “Clinicians should work with their teams to identify community resources that support patients in engaging in positive behavior change for their well-being,” such as smoking cessation and exercise programs that are TGD-friendly or tailored to LGBTQ+ populations.
Facilitating such support requires clinician awareness of some of the historical factors that contribute to disparities among TGD patients, according to Dr Streed. “For example, as bars were often the only gathering places that were safe for TGD people, tobacco and alcohol industries have deliberately targeted them for consumption,” he said.13 “Therefore, we must foster healthier community connections that challenge the hold these industries have on marginalized communities.”
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Broader Measures to Support TGD Health
While participation in athletic activity is a significant way to improve CV health in a population, the “current hostility regarding participation of TGD people in sports—especially the participation of transfeminine people in the girls and women’s categories—results in less sports participation by TGD people,” Dr Safer explained.
“We need more thoughtful consideration regarding when it is important to focus on the concern that a transgender woman who underwent a typical male puberty might have an athletic advantage vs when the point of the sporting activity is more social, and the focus should be to recruit as many people as possible to play,” said Dr Safer.
In terms of medical care, “TGD [patients] have an appropriate level of mistrust of clinicians and the broader health care system,” Dr Streed stated. “Clinicians need to actively engage in system-level change that ensures our health care systems and entire staffs create a welcoming clinical encounter for our patients.”
In addition, he cited the need to ensure competence among current and future clinicians regarding the unique needs of TGD people. “It is time we moved beyond recommending training on TGD issues in undergraduate, graduate, and continuing medical education and make it a requirement of licensure.”
This article originally appeared on The Cardiology Advisor
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