Thread by @cjstreed

.@American_Heart @CircAHA @AHAScience Assessing & Addressing Cardiovascular Health in People Who Are #Transgender & Gender Diverse #transhearthealth.
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ahajournals.org/doi/10.1161/CI…

Author team Incl trans & non-binary researchers & clinicians. @laurenbbeach @billycaceres_ @Ndowshen @KerriMoreau @MMukherjeeMD @ToniaPoteat @AsaRadix @SariReisner @DrVineetaSingh5. Thank you to AHA staff (incl @P_Stlaurent)
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Top 10 things to know about the new @American_Heart Statement on Assessing and Addressing Health in #Transgender and Gender Diverse Persons Authored by Published in @CircAHA

https://twitter.com/AHAScience/status/1413169807046844419?s=20

This statement 1) presents a conceptual model to present pathways & mechanisms underlying cardiovascular health disparities in TGD persons, 2) identify research gaps, 3) provide suggestions for systematically improving research & care of TGD people.
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#Transgender & gender diverse (TGD) populations comprise a large & growing population in the US. Yet, understanding of TGD cardiovascular population health continues to lag.
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In 2018, 19.8% of @NIH #LGBTQ research incl #transgender populations, while 1.6% included gender diverse persons (e.g., non-binary, gender non-conforming). Most of these studies focused on HIV infection, mental health, & substance use. dpcpsi.nih.gov/sites/default/…
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Building on prior statement from @american_heart @circAHA, a growing body of research demonstrates that #transgender populations may be at disproportionate risk for poor CV outcomes. ahajournals.org/doi/10.1161/CI…
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Example: analyses of @BRFSS self-reported data revealed that #transgender men had a >2-fold & 4-fold increase in prevalence of myocardial infarction compared with cisgender men and cisgender women, respectively. ahajournals.org/doi/10.1161/CI…
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Additional data sources (e.g., STRONG, TransPop) are, as of posting, still being composed & analyzed & published to allow for interpretation of prevalence and incidence of CV outcomes. @williamspolicy transpop.org
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To improve the health of #transgender persons, more studies investigating not only CV risk factors but also mechanisms responsible for CV disparities are urgently needed.
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The Gender Minority Stress and Resilience Model (Figure 1) depicts how distal and proximal minority stressors experienced by TGD people contribute to TGD health disparities.
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Distal stressors incl gender non-affirmation & stigma, discrimination, rejection, & victimization based on gender identity. Proximal stressors incl internalized stigma or transphobia, negative expectations, hypervigilance, & concealment of gender identity.
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Distal & proximal minority stressors are hypothesized to contribute to higher overall stress levels, which reshape CV health behaviors as well as increase the likelihood of broad-ranging poor mental & physical health outcomes, including CVD.
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A growing body of empirical research has demonstrated the harmful impact of minority stress on CVD among several minority groups including racial and ethnic minority adults and sexual minority adolescents (e.g., Jackson Heart Study) ahajournals.org/doi/full/10.11…
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However, research has been limited on the relationships between minority stressors and CVD for TGD populations.
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This @circAHA statement uses @American_Heart’s Life’s Simple 7 to describe traditional CV risk factors that shape CV health and explores evidence on emerging CV risk factors thought to impact
heart.org/en/healthy-liv…
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Tobacco use remains one of the most clinically significant modifiable risk factors of CVD for #transgender persons and should be considered in the context of minority stress and gender affirmation.
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While physical activity remains an essential modifiable factor of CV health, ensuring a safe and welcoming environment is a critical component of being able to engage in such protective health behavior.
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There remains a clear methodologic gap exploring dietary intake, validity and reliability of nutrition assessment methods, and nutritional interventions for TGD persons across the lifespan
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Accessing gender-affirming medical and surgical care has been associated with improved quality of life among #transgender populations. BMI cut-offs can be a barrier to access this care
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Lipid profile changes in #transgender persons due to hormone therapy are measurably small & of unknown, if any, clinical significance. Future studies should focus on analyzing the effects of hormone therapy on lipid profiles among older #transgender persons.
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Research exploring effects of gender affirming hormone therapy on the acquisition of diabetes mellitus provides contradictory results and points to the need for more research utilizing longitudinal data.
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While there is research to suggest testosterone negatively affects blood pressure, data from @BRFSS has noted lower rates of hypertension among #transgender men compared to cisgender men. ahajournals.org/doi/10.1161/CI…
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In addition, investigators found that #transgender women who had received a progestin prescription had lower odds of having hypertension. liebertpub.com/doi/10.1089/tr…
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To date, there has been limited investigation of social determinants of hypertension or CVD in #transgender persons. The high burden of stigma and other SDoH among #transgender populations indicates such research is needed.
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Many #transgender people are also people of color and #LGBQ. Research centering how #transphobia, #racism, #homophobia #biphobia and other intersecting forms of stigma combine to affect transgender #CV health is lacking
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More research is needed to understand the impact of multiple marginalization on #transgender CV health. Our conceptual model connects intersectionality and multilevel stigma (including structural factors) to minority stress and CVD burden.
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Rates of CVD are higher for people w #HIV than for uninfected peers. Disaggregated data on #transgender persons w HIV are limited. However, existing research suggests that TGD persons w HIV may be at higher risk for CVD than cisgender people w HIV.
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Studies of vascular dysfunction among #transgender individuals are limited to adults receiving hormone therapy, and these studies are in turn limited in number, size, and scope.
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Studies have detected elevated rates of drinking in TGD populations and demonstrate that victimization and minority stress are associated with higher levels of alcohol use among TGD populations.
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The current lack of standardized gender identity data across various sources limit our examination of the prevalence, incidence, and disparities in CV health among TGD populations.
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EHR data underestimate #transgender CVD burden; does not include TGD persons not engaged in healthcare & TGD persons who feel uncomfortable disclosing their gender identity to clinicians are invisible in EHR data.
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Many EHR systems lack the ability to capture sociocultural factors relevant to understanding CV health.
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Current and future @NIH -funded CV cohort studies should include standardized measures of gender identity and expression that will permit data harmonization to achieve larger samples of understudied groups within TGD populations.
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Studies of the CV health of nonbinary and gender diverse people are lacking. Measures of gender identity should include options to identify both binary and nonbinary transgender people.
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Several steps should be taken to increase TGD persons’ trust of the research community (Table 2). An important mantra in doing any research focused on minoritized and marginalized populations should be “nothing about us without us.”
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#Transgender people and communities should always been included in the design, conduct, and reporting of research studies in transgender health.
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Critical to improving TGD health and access to appropriate health care is creating welcoming and compassionate spaces and clinical care teams.
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Content targeted specifically to #transgender health should be incorporated in health professions curricula and TGD-related accreditation and licensure requirements are needed for health professionals.
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