Assessing and Addressing Cardiovascular Health in People Who Are Transgender and Gender Diverse: A Scientific Statement From the American Heart Association

Abstract

There is growing evidence that people who are transgender and gender diverse (TGD) are impacted by disparities across a variety of cardiovascular risk factors compared with their peers who are cisgender. Prior literature has characterized disparities in cardiovascular morbidity and mortality as a result of a higher prevalence of health risk behaviors. Mounting research has revealed that cardiovascular risk factors at the individual level likely do not fully account for increased risk in cardiovascular health disparities among people who are TGD. Excess cardiovascular morbidity and mortality is hypothesized to be driven in part by psychosocial stressors across the lifespan at multiple levels, including structural violence (eg, discrimination, affordable housing, access to health care). This American Heart Association scientific statement reviews the existing literature on the cardiovascular health of people who are TGD. When applicable, the effects of gender-affirming hormone use on individual cardiovascular risk factors are also reviewed. Informed by a conceptual model building on minority stress theory, this statement identifies research gaps and provides suggestions for improving cardiovascular research and clinical care for people who are TGD, including the role of resilience-promoting factors. Advancing the cardiovascular health of people who are TGD requires a multifaceted approach that integrates best practices into research, health promotion, and cardiovascular care for this understudied population.

Keywords: AHA Scientific Statements; cardiovascular disease; intersectionality; minority stress theory; social determinants of health; stigma; transgender.

Figure 1.

Gender minority stress and resilience model. Minority stress and resilience factors in people who are transgender and gender diverse. Dashed line indicates inverse relationships. Copyright © 2015 by American Psychological Association. Reproduced with permission from Testa et al.14

Figure 2

The Intersectional Transgender Multilevel Minority Stress model reframes and expands the scope of minority stress theory to include an explicit intersectional lens and to clarify the role of multilevel socioecological factors on the health of TGD populations. In brief, marginalization on the basis of intersecting socialized identities is depicted as leading to a degree of stigmatization in relation to social power systems. Stigma-related stressors are depicted dynamically in relation to resilience promoting factors, which are theorized to combat the harmful effects of stigma and thereby offer potential points for future multilevel health equity promotion interventions. When stigmatization rather than resilience is the dominant effect in the model, the resulting net effect of intersectional stigmatization contributes to poor population health via 1) psychological distress, 2) CVD behavioral risk factors, and 3) physiological response to chronic stress. These pathways independently contribute to clinical CVD risk factors and outcomes. They also add to the higher chronic stress burden associated with the development of clinical CVD risk factors and ultimately CVD and CVD disparities among marginalized populations, including TGD persons.