Pub Date: Thursday, Jul 08, 2021
Author: Loren Bauerband, PhD
Affiliation: University of Missouri - Columbia
The proportion of the population that are transgender or gender diverse (TGD) is increasing. Society’s awareness of TGD individuals and their health needs has rapidly expanded in the last decade. Since the Institute of Medicine (IOM) report in 20111, research into the prevalence and etiology of health disparities in this population has improved. As noted by Streed and colleagues, the majority of this research studied HIV infection, mental health, and substance use. TGD individuals are at increased risk for poor cardiovascular (CV) outcomes, but this area of research is severely limited.2
Minority Stress Theory 3,4 (MST) explains the mental and physical health disparities experienced by TGD individuals is the result of increased internal and external stressors of holding a socially stigmatized identity. The AHA statement extends this model to incorporate the effects of intersecting minority identities, structural factors, and resilience promotion by presenting The Intersectional Transgender Multilevel Minority Stress Model (ITMMSM). This model provides a framework for understanding the complex factors that increase CV risk for this population, and should be considered by both researchers and health care professionals when working with TGD individuals.
Streed et al. provide a comprehensive summary of known risk across the AHA’s Life’s Simply 7® that further highlights the dearth of information available on TGD CV risk. Specifically, few studies have been conducted, and often contradictory results provides unclear evidence about which factors are most significant among TGD individuals. However, the presented research does not discuss the implications in context of the ITMMSM or the diversity of TGD identities and gender pathways. Although understanding the risk associated with cross-gender hormone use is important for both patient and physician decision making, this binary and simplified explanation of risk discounts the diverse individual experiences of TGD persons.
Historically, TGD individuals have been primarily viewed through a traditional binary, medical understanding of gender. This approach is still how TGD individuals are viewed in medical research, especially when risks are presented based on hormone use for transgender men and women. As the TGD population grows, the number of nonbinary individuals, and individuals who select pathways towards gender congruence different from the traditional medical transition are also increasing. Health care professionals are then tasked with providing guidance and support to TGD individuals, without the scientific information desired by both patient and provider. Future research into CV risk needs to incorporate the diversity of TGD identities, but in the meantime, clinicians can turn to the ITMMSM when assessing CV risk with individual patients.
TGD individuals experience structural violence (e.g., discrimination, poor healthcare), and these incidents compound increasing internal stigma and psychosocial stress. Elevated, TGD specific stress, increases the likelihood and necessity in coping in ways that increase risk for CV (e.g., smoking, alcohol use, poor sleep). For many TGD individuals, accessing health care and desired medical interventions improves mental health and increases confidence in one’s body.5 Additionally, changes due to medical intervention and increased confidence can reduce risk for structural violence, further decreasing stress. Thus, affirmative and competent healthcare, with clinicians who empathize and understand the stress TGD individuals may be coping with is essential for reducing CV risk. All TGD individuals need to be comfortable disclosing their identity and empowered to make decisions about their health, to encourage engagement in preventative care, not just transition-related care.
The AHA statement proposes a call to action to increase TGD CV risk research. The TGD population is diverse in experience and identity. As the population grows, societal awareness, legal understanding of gender, and health care approaches are rapidly changing. Traditional research methods may not be adequate or fast enough to meet the needs of this population. While more population-based surveys need to add TGD identifiers in the surveys and longitudinal research is needed, there are methods that can be employed now to improve our understanding of CV risk. Specifically, age-period-cohort analyses that seek to understand how TGD health has changed across birth cohorts, and after significant medical changes (e.g., Changes in World Professional Association for Transgender Health Standards of Care6) can be utilized with cross sectional survey data. Additionally, novel methods that incorporate the diversity of gender paths among both binary and nonbinary TGD individuals are needed to assess the health implications of transition beyond hormone use.
It has been a decade since the IOM report documented the lack of research on TGD health. Since that time, NIH has increased their funding of TGD research, and the field has made significant progress. Still, including TGD individuals in population surveys is a challenge, and little is known about specific pathways that lead to increased CV risk. The AHA statement highlights the continued need for TGD health research into psychosocial factors, health behaviors, and medical processes that impact CV health.
Streed CG Jr, Beach LB, Caceres BA, Dowshen NL, Moreau KL, Mukherjee M, Poteat T, Radix A, Reisner SL, Singh V; on behalf of the American Heart Association Council on Peripheral Vascular Disease; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Radiology and Intervention; Council on Hypertension; and Stroke Council. 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 July 8, 2021]. Circulation. doi: 10.1161/CIR.0000000000001003
- Institute of Medicine (U.S.), Committee on Lesbian G 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. National Academies Press; 2011.
- Streed CG Jr, Beach LB, Caceres BA, Dowshen NL, Moreau KL, Mukherjee M, Poteat T, Radix A, Reisner SL, Singh V; on behalf of the American Heart Association Council on Peripheral Vascular Disease; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Radiology and Intervention; Council on Hypertension; and Stroke Council. 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 July 8, 2021]. Circulation. doi: 10.1161/CIR.0000000000001003
- Hendricks ML, Testa RJ. A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the Minority Stress Model. Prof Psychol Res Pract. 2012;43(5):460-467. doi:10.1037/a0029597
- Frost DM, Lehavot K, Meyer IH. Minority stress and physical health among sexual minority individuals. J Behav Med. Published online July 18, 2013. doi:10.1007/s10865-013-9523-8
- Becker I, Auer M, Barkmann C, et al. A Cross-Sectional Multicenter Study of Multidimensional Body Image in Adolescents and Adults with Gender Dysphoria Before and After Transition-Related Medical Interventions. Arch Sex Behav. 2018;47(8):2335-2347. doi:10.1007/s10508-018-1278-4
- Coleman E, Bockting W, Botzer M, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. Int J Transgenderism. 2012;13(4):165-232. doi:10.1080/15532739.2011.700873
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