Let’s Improve Cardiovascular Health in Transgender People

Transgender and gender non-conforming people have higher risk of cardiovascular disease than the general population. This is due to a variety of factors including discrimination, minority stress, medical mistreatment, poverty, higher rates of comorbidities like HIV and tobacco dependence, and lack of access to routine, high-quality healthcare.

And, to some degree, it seems, gender-affirming hormone therapy (specifically with testosterone). Two recent publications (here and here) agree that lipid profiles are adversely affected in transgender men taking testosterone, and by extension, calculated cardiovascular risk is also affected. As more evidence accumulates, risk relationships are coming into clearer focus. And risk, it seems, is real.

Gender-affirming care saves lives

But don’t let this deter you: gender-affirming healthcare saves lives. Suicide is a major risk for transgender people. This is on top of the risks associated with lack of access to routine care. Providing safe access to gender-affirming care, including hormone therapy if desired, is a powerful tool that reduces suicide and improves quality of life. And the medical community knows how to mitigate the risk of cardiovascular disease.

Embrace diversity

The transgender and gender-nonconforming population is diverse (and for that reason, I’ll use the term “gender diverse” from here). Some people might use pronouns you’re not familiar with. Some might identify as non-binary or another category you’re not familiar with. Some might be children. Some might be old. They can and do have every comorbidity you can think of, just like everyone else. Of course, this includes the number one killer of US adults: cardiovascular disease. And it’s not always entirely clear what the risk is, given the paucity of evidence about this population (there’s no gender identity data in the Framingham Heart Study, is there?).

Risk reduction in practice

Whether testosterone is prescribed or not, clinicians who care for gender diverse patients need to integrate risk reduction into gender-affirming care in meaningful and robust ways. The conversation cannot stop at “let’s measure lipid levels at baseline and check in every once in a while”. It cannot stop at “we offered tobacco cessation counseling”. It cannot stop at “we discussed the risks and benefits”. We can do more.

Start with access to high-quality care

This is a health equity issue. Medical providers, are you doing your part?

• The most important intervention to improve the health of gender diverse people is to facilitate access to safe, high-quality health care. This includes ensuring that every clinical environment is gender-inclusive and trauma-informed.
• Ensure your patients’ basic needs being met. It’s hard to talk about nutrition and stress reduction if you’re not sure where you’re going to sleep. Ask. And make necessary referrals. This is a powerful step.
• Consider the full spectrum of risk-reduction options — including but not limited to pharmacological approaches? Don’t under-manage risk. And let individual patients’ values and preferences inform treatment decisions. This is the standard of care — are you applying it?

Focus on prevention and wellness

• Focus on prevention. Provide support for lifestyle approaches to risk reduction that meet your gender-diverse patients where they are. Give strong recommendations. Facilitate access to nutrition support, exercise programs, smoking cessation, counseling, or whatever else your patient might need.
• Use the tools available to you — brief motivational interviewing can enable positive change, even in a busy visit.
• Find or develop lists of queer-friendly gyms, coaches, and running or hiking groups in your areas. Exercise is a powerful wellness tool physiologically, psychologically, and socially, but not all spaces and professionals are inclusive.

Use the data for good

We’ll continue to see more evidence about the health of gender-diverse people over the coming years. More research is underway, and research protocols are slowly becoming more nuanced and inclusive. As the evidence matures, we’ll likely see more risk factors emerge. We are responsible for taking this evidence into context and using it to reduce risk — not to create barriers to care.