Gender-Inclusive Research, Clinical Practice, and Education: Where to Start?

A person who has a scary symptom like chest pain is probably worried and stressed. For some people, their worry includes not only their health, but also whether they will be refused treatment, called by a name and pronouns that don’t reflect their identify, laughed or gawked at, assumed to have behavioral or sexual health issues, or offered treatments that have not been assessed in people like them. This is the reality that many transgender people face.

image via https://broadlygenderphotos.vice.com/, shared under a creative commons license

image via https://broadlygenderphotos.vice.com/, shared under a creative commons license

Fellow AHA Early Career Blogger, Allison Webel, PhD, recently wrote about cardiovascular disease in the transgender population. Please check out her post— it’s excellent. Some key background to remember is that transgender people live in all 50 states and over 1.4 million Americans identify as transgender1. This means that no matter where you work and what your specialty is, you are likely to encounter transgender and other gender non-conforming folks (including people who identify as genderqueer, non-binary, or other designations). It is up to you to decide to meet their needs— the systems currently in place will not ensure this. For the medical community to effectively reach transgender people, we must address their needs through research, clinical practice and education. Early career professionals need to be leaders in this effort — changing long-established ideas and practices is not easy.



Historically, the research community hasn’t done a great job of ensuring gender equity in science. As Dr. Paul Chan notes in a recent editorial, gender disparity research has picked up in recent years, but very little of it explicitly includes transgender people2. We are only beginning to generate evidence to direct our care of transgender people, and much of that evidence focuses on sexual or behavioral health. Thanks to a recent article by Dr. Talal Alzarhani and colleagues, however, we now know that the transgender population has a higher incidence of myocardial infarction than the cisgender population3. This finding is not surprising, but it is a clear sign that we must do better designing research to advance understanding the unique health needs of transgender people. But how?

  • Don’t make excuses. Women were excluded from medical research for a long time because of concerns about hormonal cycling and pregnancy. This choice has created persistent disparities4. Don’t perpetuate such inequality with the transgender population. Develop research and analysis strategies to deal with the diversity that exists rather than collapsing it or ignoring it for the sake of convenience or cost.
  • Use inclusive language to capture accurate data about gender. Dr. Chan suggests gender categories that include at a minimum cisgender male, cisgender female, transgender male, transgender female, and other2. Importantly, this strategy removes assumption that cisgender is normal and expected and allows people of all gender identities to respond authentically.


Clinical Practice: 

Much as women’s health isn’t limited to OB/GYN care, trans health is not limited to hormone therapy. Transgender people need the full spectrum of health care that cisgender people do, but many have been refused care or felt unwelcomed and mistreated in medical settings5. Primary care providers, behavioral health providers, and endocrinologists are likely to encounter transgender patients, but so are cardiologists, oncologists, surgeons, and others. Culturally and medically competent care is imperative in all of these contexts. Provider discomfort should not be a barrier. Here’s what you can do to improve:

  • Educate yourself about gender diversity. Remember that it is not your patient’s job to teach you the basics. Go to sessions at conferences, seek out knowledgeable colleagues, and read up.(Resources are listed at the end of this post to get you started).
  • Be welcoming: ask your patients what their pronouns are, and train staff to do this also. Don’t avoid addressing people because you are unsure or uncomfortable. Make sure your forms allow people to self-identify their gender with inclusive options. If you make a mistake, apologize and move on.
  • Practice with a trauma-informed approach (read an introduction to the topic here. Recognize that trust must be built. Transgender people are more likely to face significant psychosocial stressors and discrimination, including in health care. This will affect their experience.



Though health professions students report a high level of comfort with lesbian, gay, bisexual, and transgender health, they receive little formal training6. Educators in the health professions can explicitly include transgender people across curriculums to improve this perception. Here are some strategies:

  • Use gender diverse images in your education materials. Find some here.
  • Create cases and content including trans people when teaching about common health concerns.
  • Invite an expert. Find someone who cares for transgender people in your community to speak to your students.


So, early career professionals, the ball is in your court. What are you doing to enhance gender inclusivity in your work?



National LGBT Health Education Center (lgbthealtheducation.org)

UCSF center of excellence for transgender health (http://transhealth.ucsf.edu/)

GLMA (http://www.glma.org/index.cfm?fuseaction=Page.viewPage&pageId=1025&grandparentID=534&parentID=940&nodeID=1)



  1. Flores, A.R, Herman, J.L., Gates, G.J. & Brown, T.N.T. (2016). How Many Adults Identify as Transgender in the United States? Los Angeles, CA: The Williams Institute.
  2. Chan, P. (2019). Invisible gender in medical research. Circulation: Cardiovascular Quality & Outcomes, 2019(12).
  3. Alzahrani, T. et al. (2019). Cardiovascular disease risk factors and myocardial infarction in the transgender population. Circulation: Cardiovascular Quality & Outcomes, 2019(12).
  4. Shansky, R. (2019). Are hormones a “female problem” for animal research? Science, 364(6442),.
  5. Liszewski, W., Peebles, J., Yeung, H., & Arron, S. (2018). Persons of nonbinary gender— Awareness, visibility, and health disparities. The New England Journal of Medicine, 379(25).
  6. Greene, M., France, K., Kreider, E., Wolfe-Roubatis, E.,, Chen, K., & Yehla, B. (2018). Comparing medical, dental, and nursing students’ preparedness to address lesbian, gay, bisexual, transgender, and queer health. PLoS One, 13(9).



Seeing and Serving Invisible Populations

Like many of you, I chose to be a nurse because I wanted to serve people during their most vulnerable times, knowing that this work would make a difference. Working with people at their most vulnerable has taught me a lot, including that my patients can be braver, kinder, more frightened, angrier, disappointed, lovelier, and in general more surprising than I expect when I walk in the door.

A growing and perhaps surprising population at disproportionally high risk for heart attacks are individuals who identify as transgender. Transgender individuals are those whose gender identity is different from the sex they were assigned at birth. People identifying as transgender can be any age or race, from any background, and reside in all 50 states. In 2016 there were approximately 1.4 million people in the United States who identified as transgender.  Given the increase in the transgender population, new initiatives are attempting to understand the unique health needs of this population in order to provide high-quality health care. Little is known about the cardiovascular health of this population, which prompted a recent study by Dr. Alzahrani from George Washington University who found that the transgender population had a higher reported history of heart attacks compared with the cisgender (those whose gender corresponds with their birth sex) population.

This first-of-its-kind study examined approximately 720,000 U.S. adults who completed the telephone-based Behavioral Risk Factor Surveillance System survey, conducted by the Centers for Disease Control and Prevention between the years of 2014-2017. Of these, 3,055 adults identified as transgender. In gender stratified analyses, Dr. Alzahrani and colleagues found that after adjusting for known cardiovascular risk factors transgender men had (i.e. they were told by a doctor, nurse or health care professional that they had a heart attack) compared to cisgender men and women. And transgender women had a 2-fold increase in the rate of heart attacks compared with cisgender women. Importantly, the investigators also found that transgender men and women were more likely to smoke and be sedentary, and that these and other traditional risk factors were associated with increased odds of experiencing a heart attack. This suggests that while there are about the long-term cardiovascular risk of gender affirming-hormones, mitigating these traditional risk factors are important first line targets for this and all populations.

In an accompanying editorial Dr. Paul Chan evoked Ralph Ellison’s Invisible Man, citing the narrator “I am invisible, understand, simply because people refuse to see me.” Dr. Chan states that today transgender individuals are invisible. But they don’t have to be. We have to actively reject any implicit or explicit expectations we have about this population and simply see them and treat them as they present. This sentiment is echoed by Dr. Billy Carceres, Nurse and Post-Doctoral Fellow at Columbia University Program for Study of LGBT health, “There’s this perception that we can spot transgender people; but if we don’t ask the question about gender identity we might be missing out on people who are at risk. Patients want to have conversations with health care providers about things that influence their health.”

Table 1 lists several steps that can help us start to have these conversations. Adopting such steps in our clinical practice and research are critical against the backdrop of the increased social stress, poor socioeconomic status, health disparities, violence, and a perpetuating fear of mistreatment by healthcare professionals experienced by transgender populations. These steps will help us to see this invisible population, gain their trust, and ultimately help engage them in activities to improve their cardiovascular health.

Table 1. Steps to Reducing Cardiovascular Risk in Transgender Populations

  1. Assess the gender of all your patients or research participants on multiple levels
  2. Ask which pronouns they would like you to use
  3. Understand the terminology used by the trans community
  4. Recognize that transgender people may avoid seeking out health care because of fear of discrimination and create a safe and welcoming environment
  5. Assess all potential cardiovascular risk factors for transgender patients and work with them to collaboratively develop a plan to reduce their risk factors
  6. Learn more about the unique health care needs of your transgender patients. Your health care institution may have good local resources and the Center of Excellence for Transgender Health at UCSF and the World Professional Association for Transgender Health have up-to-date resources.

While Dr. Alzahrani’s new article highlights a significant disparity in an often overlooked and vulnerable population, ultimately we need a lot more data before we can develop and tailor cardiovascular treatment guidelines for transgender populations. As Dr. Sangyoon Shin, Medical Director of Co-Management Service for Gender Affirmation Surgery of Mount Sinai stated, “Its important to realize that the transgender population has specialized needs because they are more marginalized and face high rates of discrimination; But the health care practices the guidelines geared towards them need to be just as evidence-based as with any other population.“ Anything less would be a disservice.

People who seek out a health care provider – a nurse, physician, physical therapist, or pharmacist – do so because they need our help. Our job is to serve them, all of them, as they are, with high quality evidence-based health care. How we treat invisible populations, no matter how different or perplexing they are to us, is the true mark of our professionalism.