Improving the cardiovascular health care of transgender and non-binary persons

Abstract

Research consistently shows that gender-affirming practices improve markers of cardiovascular health. Consequently, the focus of the management of the cardiovascular health of transgender and non-binary populations should not be on their hormone therapies and surgical histories, but should instead be rooted in the routine screening of cardiovascular risk factors.

Despite declining rates of morbidity and death related to cardiovascular disease (CVD) in Western countries owing to advances in clinical care, substantial disparities in the prevalence of CVD persist across specific populations. In particular, limited research has focused on the cardiovascular health of transgender and non-binary persons¹ (referred to collectively as trans persons in this article). As trans populations account for approximately 0.6% of the adult population and nearly 2% of the high-school-aged population in the USA, their long-term health — including their cardiovascular health — requires specific attention from researchers and clinicians.

To best address the management of the cardiovascular health of trans populations, clinicians must understand the various traditional and novel factors that affect short-term and long-term health. The American Heart Association focuses on eight key health behaviours and factors that affect cardiovascular health: having a healthy diet, engaging in physical activity, avoiding or ceasing tobacco use, ensuring quality sleep, and managing body weight and plasma cholesterol, blood sugar and blood pressure levels². However, despite inequities across nearly all these traditional factors¹, trans individuals often have their cardiovascular health reduced to their gender-affirming care — specifically, exogenous hormone therapy. Although research consistently shows an increased risk of venous thromboembolism among trans persons who are receiving oestrogen therapy (with varying risk based on the type and dose of oestrogen therapy)³, the effects of exogenous hormones on cardiovascular morbidity and mortality are less clear¹. For example, changes in blood lipid profiles attributable to gender-affirming hormone therapy are measurably small and of unknown clinical significance¹, and research that has explored the association between gender-affirming hormone therapy and the development of diabetes mellitus provides contradictory results on the effects of these therapies on factors associated with diabetes (such as insulin resistance and changes in body mass composition)¹. Although studying the effects of gender-affirming hormones on cardiovascular health is important, gender-affirming hormone therapy should not be at the forefront of how cardiologists and other clinicians treat and manage the heath of trans individuals, given that not all trans people view and/or desire gender-affirming hormones as part of their gender goals⁴.

Instead, more effort needs to be made to address the lack of studies that delineate the mechanisms by which social determinants of health (SDOH) affect known physiological pathways and contribute to chronic inflammation and cardiovascular outcomes in trans people — an important research gap that is the result of limited knowledge and study of the lived experiences of trans people with regards to SDOH. For example, a review published in 2022 described the link between chronic psychosocial and environmental stressors and multiple cardiovascular risk factors and disease outcomes, including chronic psychosocial stressors such as discrimination, depression, social isolation, work-related stress and subjective social status, as well as environmental stressors such as neighbourhood socioeconomic status, food insecurity and structural racism⁵. However, none of the studies included in this review sampled trans populations. Several studies have documented the presence of similar psychosocial and environmental stressors in trans populations, in addition to ‘minority’ stressors (those experienced by members of stigmatized minority groups) across SDOH that they experience owing to their trans identity, including those related to accessing health care, education and housing, as well as economic and workplace stressors, and stressors related to navigating the criminal justice system⁶ (Fig. 1). These minority stressors are multilevel and include external factors, such as gender-based structural stigma and discrimination (for example, transphobia), rejection, violence and gender non-affirmation, that are partially mediated by internalized stressors, such as concealment, self-stigma and internalized transphobia — all of which have been found to be associated with psychological distress, depression and suicidality^6–8. Moreover, owing to the presence of multiple intersecting marginalized identities, trans communities of colour, in particular, experience additional types of stressors such as structural racism⁶, which have been linked to CVD development and progression in other systematically minoritized racial groups⁵. Given that similar and unique stressors across SDOH are experienced by trans populations, examining the links between how such stressors can activate pathophysiological pathways to trigger chronic inflammation and influence cardiovascular outcomes is warranted and crucial for understanding how to address and improve cardiovascular health in trans populations.

Fig. 1 |. Social determinants of health relevant to the cardiovascular health of the trans population.

Multilevel stressors exist in every domain of social determinants of health for transgender and non-binary persons (here referred to collectively as trans persons), which, together with gender-affirmative interventions, can influence biological pathways to trigger chronic inflammation and contribute to the development and progression of cardiovascular disease.

Although medical gender affirmation is crucial to the well-being of trans populations, several of its domains have yet to be fully mapped out and integrated into cardiovascular research and clinical practice⁶. Gender affirmation in the health-care context applies to the provision of high-quality social, psychological, legal, medical and surgical services that affirm, align and meet trans people’s gender goals, identity and health needs⁶. Medical interventions such as hormone and surgical-care services have been shown to improve quality of life and mental health, including reduced psychological distress, depression and suicidality^6,9. Additional sources of gender affirmation also exist across SDOH, although limited research has been conducted on their influence on cardiovascular health outcomes in trans populations directly. For example, social support, community connectedness and familial acceptance (often referred to as community or social resilience) have been shown to be protective against chronic psychosocial and environmental stressors, as well as to reduce suicide risk and psychological distress⁶. Similarly, access to legal name and gender-marker changes has also been shown to be protective against structural transphobia and is associated with reduced adverse mental-health outcomes⁶. Moreover, the effect of rejecting internal stressors at the individual level through self-identity affirmation (for example, self-acceptance of and a positive attitude towards transgender identity) has been shown to improve physiological resilience via a more adaptive cardiovascular profile, particularly when reacting to stress¹⁰. Some research suggests that what might have the largest effect on the cardiovascular health of trans populations is affirmation across multiple modalities, including medical and surgical interventions, as well as social and political changes.

Although not all trans people desire medical and surgical interventions as part of their gender affirmation goals, those who do require cardiology care must have a cardiologist who engages with primary care clinicians and gender-affirming care providers as a team to closely and safely monitor the physiological effects of hormone and surgical interventions. Appropriate gender-affirming care of trans patients has been shown to improve quality of life and mental health, including reduced psychological distress, depression and suicidality^6,9. As such, the focus of cardiovascular health management of trans individuals should not be on their hormone and surgical histories alone, but should instead be rooted in the routine screening of cardiovascular risk factors regardless of their medical gender-affirmation history. In addition, clinical cardiovascular care should incorporate gender-affirming practices that can help to alleviate some multilevel stressors in health-care settings, such as positive and affirming interactions with health-care providers and staff and ensuring that medical records accurately reflect the correct gender and name of the patient and that the anti-discrimination policies of the clinic are explicitly inclusive of all genders and race. Ultimately, improving the cardiovascular health and general well-being of trans populations requires investments in research, while simultaneously using what information we have available.