Transforming cardiovascular treatment for the transgender population

April 03, 2021

An estimated 1.4 million people in the U.S. identify as transgender, constituting 0.6% of the population. However, these numbers are likely conservative due to the broad range of terms used to describe transgender identities, and most notably, lack of data collection in population-based studies. Many surveys have been undertaken looking at the delivery of health care for people who identify as transgender and gender diverse. The numbers are sobering:

  • 19% are uninsured.
  • 19% have been refused care due to their gender-nonconforming status.
  • 28% have postponed necessary medical care due to discrimination by medical providers.
  • 33% delayed or did not try to get preventive health care due to discrimination by medical providers.
  • 50% reported teaching their medical providers about transgender care.

The lack of knowledge has been identified as the largest barrier to health care for transgender individuals.

The percentage of individuals who identify as transgender among adults is highest in those ages 18 to 24, at 700 per 100,000 (0.7%), compared with 600 per 100,000 (0.6%) in those ages 25 to 64, and 500 per 100,000 (0.5%) in those age 65 and older. According to U.S. Transgender Survey results, by age 20:

  • 94% of respondents began to feel that their gender was different from their sex assigned at birth.
  • 73% of respondents began to think that they were transgender.
  • 52% began to tell others that they were transgender.

Transgender men are assigned female sex at birth, while transgender women are assigned male sex at birth. The proportion of transgender women to transgender men is reported as high as 2-to-1. However, these ratios should not be taken as a definitive indication of population sizes, given the limitations in methodology used to record them.

Transgender patients have higher rates of health concerns that negatively impact their cardiovascular health, including depression, substance abuse, tobacco use, obesity and lack of health care. In regard to cardiovascular disease mortality and morbidity in the transgender population, studies have indicated that the mortality rate from cardiovascular causes in transgender females is higher than in cisgender females (1.64 to 2.11 with a 95% CI, 1.32 to 3.21), although similar to that in cisgender males. The mortality rate has improved as oral estrogen dosing has decreased or been switched to transdermal formulations.

The mortality rate in transgender males is similar to that of cisgender females. In small European studies, transgender women seem to have a higher cardiovascular disease risk than do transgender males. Transgender males using testosterone do not seem to have an increased cardiovascular disease risk, which would not follow the typical tendencies of testosterone use in cisgender males.

There is a paucity of large, randomized trials to assess the cardiovascular disease risk in transgender women. Common limitations of the studies available include small cohorts, study design and study length. In one electronic medical record-based cohort study, transgender female participants had a higher incidence of venous thromboembolism, with two- and eight-year risk differences of 4.1 (95% CI, 1.6 to 6.7) and 16.7 (CI, 6.4 to 27.5) per 1,000 people relative to cisgender men and 3.4 (95% CI, 1.1 to 5.6) and 13.7 (95% CI, 4.1 to 22.7) relative to cisgender women.

The overall analyses for ischemic stroke and myocardial infarction demonstrated similar incidence across groups. More pronounced differences for venous thromboembolism and ischemic stroke were observed among transgender female participants who initiated hormone therapy during follow-up. Other smaller studies have had similar results.

Transgender and Intersex Specialty Care Clinic

Mayo Clinic developed a multidisciplinary Transgender and Intersex Specialty Care Clinic in Rochester, Minnesota, in 2015. The mission of the clinic is to provide specialty, multidisciplinary, person-affirming care for transgender, gender diverse and intersex individuals in a safe and respectful environment while optimizing physical, emotional and social health. The vision is to become a premier center for transgender health, serving transgender, gender-diverse and intersex individuals by:

  • Providing the Mayo Clinic Model of Care to patients
  • Sharing knowledge with providers, learners, patients and the community to promote better health for patients
  • Advancing the science of transgender medicine through scholarly activity

Women's Heart Clinic

The Mayo Clinic Women's Heart Clinic has partnered with the medical and surgical teams of the Transgender and Intersex Specialty Care Clinic to provide culturally sensitive cardiovascular risk assessments, as well as assessment of the cardiovascular risk of gender-affirming surgery. The Women's Heart Clinic uses the most up-to-date information available to best meet the needs of the patients. A multifaceted approach using questionnaires, risk assessment tools and laboratory data is employed in conjunction with the comprehensive review by the Transgender and Intersex Specialty Care Clinic social worker to best look at the seven determinants of health and how they apply to the cardiovascular health of each patient.

Electrocardiography, stress testing and echocardiography are used to further assist with the overall assessment in those individuals at cardiovascular high risk as well as those with symptoms suggestive of cardiovascular disease. Dietitians and exercise specialists are available to assist with specific questions. However, it is important to recognize that normative data for the transgender population is lacking. This limited information underscores the need to collect as much data as possible to allow for comprehensive discussion and evaluation.

Gender-affirming surgeries can be part of the health care experience for transgender patients. Reviews of outcomes have indicated that, in the past, cardiovascular events were seen more commonly in patients undergoing gender-affirming genital surgery than in the cisgender general population undergoing surgical procedures of similar risk.

Major perioperative concerns facing transgender patients include venous thromboembolism such as deep vein thrombosis and pulmonary embolism; the rate is reported as high as 6%. Based on the most recent evidence from a high-volume center, holding gender-affirming hormone therapy for two to four weeks pre- and postoperatively mitigates 50% to 70% of the rate of venous thromboembolism. Additionally, utilizing comprehensive cardiovascular risk assessment tools and cardiac care preoperatively mitigates much of the rest of the increased rate of events.

The appropriateness of hormone replacement therapy in the general population is one of the indications for consultation to the Women's Heart Clinic. Given the adverse findings of the Women's Health Initiative, there is greater need for discussion about implementation of hormone therapy for menopausal women.

One of the key findings from the Women's Health Initiative is that cisgender women over age 60 have a greater risk of cardiovascular events when initiated on hormone replacement therapy, thus the notion that "aged" vasculature has an adverse response to exogenous estrogen therapy. As cisgender males have greater incidence of atherosclerosis than do cisgender females of the same age, the risk of feminizing hormones in older transgender women must be recognized and appropriately addressed.

The Women's Heart Clinic has expertise in the discussion about the benefits and risks of hormone replacement therapy for cisgender women. Thus, it is logical to be the place where transgender women can be evaluated for their own appropriateness of initiation of gender-affirming hormone therapy, as well as preoperative risk and longitudinal risk assessment across all age groups.

The priorities for research on barriers to transgender health care must include determination of the gaps in knowledge among the provider workforce across the range of training, potential interventions for those gaps, determination of indirect barriers such as environment and stigma, and potential solutions to overcome those barriers. Several papers recommend looking at the length of time a patient has been on hormone therapy to determine whether to use natal sex or affirmed gender to determine cardiovascular risk, medication therapy and imaging parameters. However, specific guidelines do not exist.

"We are currently collecting data to help determine guidelines for imaging," says Rekha Mankad, M.D., Cardiovascular Medicine, at Mayo Clinic in Rochester, Minnesota. "Our cardiac rehabilitation specialists have completed a survey of the transgender patients that they have seen so they can best provide culturally sensitive care. The patients were forthcoming with the positive and negative experiences they have encountered. Based on this information, changes have been made to the physical cardiac rehabilitation area as well as to the instruction provided. The changes have been well received by the transgender patients as well as their cisgender counterparts.

"The National Academy of Medicine has identified transgender adults as an understudied population in critical need of health research. In the U.S., there has been little attempt to determine the specific workforce needs to provide care or to determine the current status of that care. The interest is now being recognized, but it is outstripping the available science. Research needs to be done carefully so that suboptimal methods do not beget suboptimal science."

For over 20 years, the Women's Heart Clinic has been a national and international leader in the provision of evidenced-based, gender-specific care to women with heart disease. The clinic was formed because of an identified disparity in the quality of cardiac care available for women. "We have a strong history of sex-based clinical research, knowledge of hormone therapy and cardiovascular risk, and dedication to providing care to an underserved population," says Kari A. Dessner, APRN, C.N.P., with Cardiovascular Medicine in Rochester, Minnesota. The providers of the Women's Heart Clinic are uniquely qualified to advance the cardiovascular care of transgender patients and are committed to using their knowledge and resources to do so.

For more information

2015 U.S. Transgender Survey. National Center for Transgender Equality.

Transgender and Intersex Specialty Care Clinic. Mayo Clinic.

Women's Health Initiative.

Women's Heart Clinic. Mayo Clinic.

National Academy of Medicine. National Academy of Sciences.