Bridging the Disparity Gap in Cardiovascular Health in Transgender and Gender Diverse Population: Insight into the Scientific Statement from the American Heart Association
In recent years, there has been increased attention to health-related disparities experienced by the transgender and gender diverse population (TGD). In fact, it has become a public health priority to improve the health, safety, and well-being of lesbian, gay, bisexual, and transgender people in the U.S. Therefore, one of the Healthy People 2030 goals is to target the collection of data on LGBT health issues to help inform effective health promotion strategies for LGBT people.1 The topics of adolescents, drugs and alcohol use, mental health issues, sexually transmitted infections, and our public health infrastructure are highlighted as key objectives for the Healthy People 2030 Goals.1
Nearly a decade ago, the 2011 report from The Institutes of Medicine (IOM) highlighted the need to look at the distinct health concerns and needs of the TGD community and its subgroups. It also reported on the importance of understanding differences based on race, ethnicity, socioeconomic status, geographic location, age, and other factors among lesbians, gay men, bisexual men and women, and transgender people.2 Based on the 2011 IOM report, lesbians and bisexual women encounter higher rates of breast cancer than heterosexual women. The data on whether lesbians had a higher risk for cardiovascular disease was conflicting at the time. Limited research suggested that transgender groups may experience negative health outcomes, because of long-term hormone use.2
Recent studies suggest that trans people appear to have an increased risk for myocardial infarction and death due to cardiovascular disease when compared to cisgender people. In studies that followed trans people on hormone therapy, the rates of myocardial infarction and stroke were consistently higher in trans women than trans men. Estrogen therapy for trans women has been reported to increase their risk for venous thromboembolism.3 This presents opportunities for screening TGD groups for cardiometabolic risk factors in much the same way as their cisgender counterparts.4 A recent scientific statement from the American Heart Association emphasizes on the importance of screening and risk reduction for cardiovascular disease in TGD people.
In this scientific statement, distal and proximal minority stressors are presented, which may contribute to higher overall stress levels that can increase the risk for poor mental and physical health outcomes in TGD individuals. The Gender and Minority Stress Resilience model is presented and highlights these factors, as well as the presence of resilience factors that may counteract the effects of transphobic violence and stigma, and promote TGD health equity.5 This Scientific Statement is definitely a step in the right direction to address cardiovascular related health disparities for TGD people. It addresses the value of Life’s Simple 7 (tobacco use, physical activity, diet, weight status, blood pressure, glycemic status, and lipids), targeting key risk factors towards the reduction of cardiovascular disease. Other factors such as HIV infection status, vascular dysfunction, alcohol use, lack of sleep, stigma, discrimination, violence, lack of affordable housing and access to health care are also discussed.5
Advancing the cardiovascular health of people who are TGD will require a multifaceted approach that integrates best practices into health promotion, cardiovascular care, and research for this understudied population. This presents opportunities for innovation in areas such as the electronic health record, especially to capture sociocultural factors relevant to heart health among TGD groups. Longitudinal research examining psychosocial, behavioral, and clinical determinants of optimal cardiovascular health in TGD people at the individual, interpersonal, and structural levels is also advocated. Healthcare professionals and clinician training on the proper assessment of sex and gender in healthcare settings, and identification of TGD health disparities will also be necessary to the identification of interventions and the reduction of disparities experience by TGD groups.5
In conclusion, the recent Scientific Statement from the American Heart Association on TGD people highlights the unique, health care needs of TGD individuals. It also highlights opportunities to improve their health status though screening and preventive lifestyle practices incorporating Life’s Simple 7. Clinician education and training on the psychosocial, cultural, behavioral, and biological factors in TGD people may help bridge the gaps in cardiovascular care for these groups.
- S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2030. LGBT: Goal: Improve the health, safety, and well-being of lesbian, gay, bisexual, and transgender people. https://health.gov/healthypeople/objectives-and-data/browse-objectives/lgbt. Published 2020. Accessed July 13, 2021.
- Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington (DC): National Academies Press (US); 2011. https://www.ncbi.nlm.nih.gov/books/NBK64806/ doi: 10.17226/13128. Accessed July 12, 2021.
- Irwig MS. Cardiovascular health in transgender people. Rev Endocr Metab Disord. 2018;19(3):243-251. doi:10.1007/s11154-018-9454-3
- Slack DJ, Safer JD. Cardiovascular health maintenance in aging individuals: the implications for transgender men and women and hormone therapy. Endocr Pract. 2021;27(1):63-70. doi:10.1016/j.eprac.2020.11.001
- Streed CG Jr, Beach LB, Caceres BA, et al. Assessing and Addressing Cardiovascular Health in People Who Are Transgender and Gender Diverse: A Scientific Statement from the American Heart Association [published online ahead of print, 2021 Jul 8]. Circulation. 2021; CIR0000000000001003. doi:10.1161/CIR.0000000000001003
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