Discrimination, stress linked to poorer heart health in transgender, gender-diverse adults

The stress of experiencing discrimination — including transphobia, violence and public policies specifically targeting transgender and gender-diverse (TGD) people — is linked to higher rates of heart disease among the TGD population, according to a new scientific statement from the American Heart Association (AHA).

An expert analysis of current research with an aim to inform future guidelines, the statement was published today (July 8) in Circulation, the AHA’s flagship journal. 

While related to traditional cardiovascular risk factors, higher rates of cardiovascular prevalence and deaths among TGD people also are significantly driven by psychosocial stressors across the lifespan at multiple levels, including structural violence, discrimination, lack of affordable housing and limited access to health care, the statement said.

Breakdown of findings

• Transgender men are twice as likely to have a heart attack as cisgender men and four times as likely as cisgender women. 
• TGD people are more likely to experience blood clots when undergoing estrogen hormone therapy. 
• TGD populations face unique psychological stressors, including gender non-affirmation (e.g., being called by the incorrect pronoun), discrimination, rejection or concealment of gender identity and violence based on gender identity. These factors contribute to higher overall levels of stress, which, in turn, negatively affect heart health. 
• The statement cites studies showing that TGD persons experience disproportionate burdens of additional cardiovascular risk factors, including living with HIV, vascular dysfunction, trouble sleeping and alcohol abuse.
• TGD people who also are part of historically excluded racial or ethnic groups experience multiple layers of stress, such as lower income levels or limited access to health care. Research on how these complex and intertwined factors affect heart health within TGD populations is limited.

"Systematic transphobic discrimination results in a higher burden of workplace discrimination, job loss and unemployment among TGD populations,” said Lauren B. Beach, vice-chair of the statement-writing group and research assistant professor in the department of medical social sciences at Northwestern University's Feinberg School of Medicine. “Combined with experiences of discrimination in health care settings, lack of access to a stable income further limits health care access among TGD people. These structural factors result in simultaneously higher levels of chronic stress and lower levels of resources to prevent or manage a broad variety of health conditions including cardiovascular disease."

The writing group acknowledges limited data and encourages further research to understand the numerous and complex issues faced by TGD individuals and as a community. The statement emphasizes available information does illustrate that TGD people often experience challenges due to unique stressors, including internalizing gender identity, sexual victimization and concerns about hormone therapies and gender-affirming surgeries.

The statement reviews research on disparities among TGD people as it relates to the American Heart Association's Life's Simple 7 to measure ideal heart health and how hormone therapy may affect heart health for TGD people. Current research on blood pressure, lipid profiles or blood sugar levels for TGD persons is too sparse and inconclusive, although the writing group does suggest several areas of Life's Simple 7 that are directly linked to heart attacks and strokes. The evaluation of existing research found:

• TGD people are more likely (24%) to report tobacco use than the remainder of the U.S. population (18%).
• Transgender men are less likely to exercise, especially in older age.
• TGD persons undergoing gender-affirming hormone therapy are more physically active, which may be because they report being more satisfied with their bodies.
• TGD youth report eating more fast food and using unsafe ways of trying to manage their weight (e.g., diet pills, fasting or laxative abuse).
• TGD people report overall higher body mass index (BMI), yet they may experience additional stress about their weight because many surgeons have strict BMI cut-offs above which they will not perform gender-affirming surgeries.

This statement, specific to TGD persons, builds upon the Association's 2020 scientific statement, Assessing and Addressing Cardiovascular Health in Lesbian, Gay, Bisexual, Transgender and Queer (or Questioning) Adults, which noted that more than half (56%) of LGBTQ adults and 70% of those who are transgender or gender non-conforming reported experiencing some form of discrimination from a health care professional.

What can be done to improve heart health among TGD people?

Most gender identification options in a clinical or research setting include only "male" and "female," so while population-based studies can help researchers better understand some cardiovascular health risk factors, data on TGD people is scarce. The statement suggests studies should standardize measures of gender identity and expression to collect larger samples of underrepresented groups among TGD populations.

The writing group suggests increased training across health professions could enhance clinical practices and foster more compassionate care for TGD persons. While many institutions acknowledge the need for TGD educational content, efforts to include these topics into clinical curricula have not progressed. The statement suggests a collaborative effort with organizational-level mandates across governing bodies is needed to create a curriculum that encompasses gender affirming hormone therapy, surgical procedures, anatomy-based preventive health, social determinants of health and the proper assessment of sex and gender in health care settings.