Assessment of Cardiovascular Risk in Transgender Patients Presenting for Gender-Affirming Care



      The transgender population is rapidly growing in the United States and abroad. Transgender men and women are marginalized as a result of their transgender status, with resultant health repercussions. This and other factors such as increased substance use, mental health disorders, violence, and chronic stress may place transgender individuals at higher risk for cardiovascular disease. Additionally, many transgender patients pursue gender-affirming hormone therapy, which has been linked to increased rates of some cardiovascular events such as metabolic syndrome, venous thromboembolism, and stroke. Despite the likelihood of elevated cardiovascular risk in this population, there is a paucity of published data about the cardiovascular risk of this population.


      We present baseline cardiovascular data from a transgender population at a large tertiary care center prior to the initiation of hormone therapy.


      The described transgender population had much higher rates of mental health disorders and substance use than the general population. Furthermore, there were high rates of undiagnosed and untreated comorbidities, such as hypertension and dyslipidemia, that increase risk for cardiovascular disease. Baseline risk assessment using the ASCVD (Atherosclerotic Cardiovascular Disease) and QRISK3 calculators showed higher-than-expected cardiovascular risk, particularly given the young age of our patient population.


      Transgender individuals are at high baseline cardiovascular risk. These data help fill some important knowledge gaps in this patient subgroup, and provide us with much-needed data to help guide our management and counseling of individuals seeking this type of care.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • White Hughto JM
        • Reisner SL
        • Pachankis JE
        Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions.
        Soc Sci Med. 2015; 147: 222-231
        • Winter S
        • Diamond M
        • Green J
        • Karasic
        • et al.
        Transgender people: health at the margins of society.
        Lancet. 2016; 388: 390-400
        • Lagraauw HM
        • Kuiper J
        • Bot I.
        Acute and chronic psychological stress as risk factors for cardiovascular disease: insights gained from epidemiological, clinical, and experimental studies.
        Brain Behav Immun. 2015; 50: 18-30
        • Grant JM
        • Mottet LA
        • Tanis J
        • et al.
        National Transgender Discrimination Survey Report on Health and Health Care.
        National Center for Transgender Equality and the National Gay and Lesbian Task Force, Washington, DC2010
        • Parent MC
        • Arriaga AS
        • Gobble T
        • Wille L
        Stress and substance use among sexual and gender minority individuals across the lifespan.
        Neurobiol Stress. 2019; 10100146
        • Gorin-Lazard A
        • Baumstarck K
        • Boyer L
        • et al.
        Is hormonal therapy associated with a better quality of life in transsexuals? A cross-sectional study.
        J Sex Med. 2012; 9: 531-541
        • Jones BA
        • Haycraft E
        • Bouman WP
        • Arcelus J
        The levels and predictors of physical activity engagement within the treatment-seeking transgender population: a matched control study.
        J Phys Act Health. 2018; 15: 99-107
        • Elamin MB
        • Garcia MZ
        • Murad MH
        • Erwin PJ
        • Montori VM
        Effect of sex steroid use on cardiovascular risk in transsexual individuals: a systematic review and meta-analyses.
        Clin Endocrinol (Oxf). 2010; 72: 1-10
        • Streed CG
        • Harfouch O
        • Marvel F
        • Blumenthal RS
        • Martin SS
        • Mukherjee M.
        Cardiovascular disease among transgender adults receiving hormone therapy.
        Ann Intern Med. 2017; 167: 256-267
        • Shatzel JJ
        • Connelly KJ
        • DeLoughery G.
        Thrombotic issues in transgender medicine: a review.
        Am J Hematol. 2017; 92: 204-208
        • Caceres BA
        • Streed CG
        • Corliss HL
        • et al.
        Assessing and addressing cardiovascular health in LGBTQ adults: a scientific statement from the American Heart Association.
        Circulation. 2020; 142: e321-e332
        • Caceres BA
        • Brody A
        • Luscombe RE
        • et al.
        A systematic review of cardiovascular disease in sexual minorities.
        Am J Public Health. 2017; 107: e13-e221
        • Goff Jr, DC
        • Lloyd-Jones DM
        • Bennett G
        • et al.
        2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
        Circulation. 2014;; 129: S49-S73
        • Hippisley-Cox J
        • Coupland C
        • Brindle P
        Development and validation of QRISK3 risk prediction algorithms to estimate future risk of cardiovascular disease: prospective cohort study.
        BMJ. 2017; 357: j2099
        • Creamer MR
        • Wang TW
        • Babb S
        • et al.
        Tobacco product use and cessation indicators among adults – United States, 2018.
        MMWR Morb Mortal Wkly Rep. 2019; 68: 1013-1019
      1. National Institute of Mental Health. 2017 National Survey on Drug Use and Health. Available at: Accessed November 5, 2020.

      2. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry.2005;62(6):617-627.

        • Centers for Disease Control and Prevention
        Diabetes Report Card 2017.
        Centers for Disease Control and Prevention, US Dept of Health and Human Services, Atlanta, GA2018 (Available at) (Accessed April 26, 2021)
        • Centers for Disease Control and Prevention (CDC)
        Hypertension Cascade: Hypertension Prevalence, Treatment and Control Estimates Among US Adults Aged 18 Years and Older Applying the Criteria From the American College of Cardiology and American Heart Association's 2017 Hypertension Guideline—NHANES 2013-2016.
        US Department of Health and Human Services, Atlanta, GA2019
      3. Carroll MD, Fryar CD. Total and High-Density Lipoprotein Cholesterol in Adults: United States, 2015-2018. NCHS Data Brief, no 363. Hyattsville, MD: National Center for Health Statistics. 2020. Available at: Accessed April 26, 2021.

        • Khawaja IS
        • Westermeyer JJ
        • Gajwani P
        • Feinstein RE.
        Depression and coronary artery disease: the association, mechanisms, and therapeutic implications.
        J Psychiatry. 2009; 6: 38-51
        • Mensah GA
        • Collins PY.
        Understanding mental health for the prevention and control of cardiovascular disease.
        Glob Heart. 2015; 10: 221-224
        • Goodwin RD
        • Davidson KW
        • Keyes K.
        Mental disorders and cardiovascular disease among adults in the United States.
        J Psychiatr Res. 2009; 43: 239-246
        • U.S. Preventative Services Task Force
        Screening for depression in adults: recommendation statement.
        Am Fam Physician. 2016; 94 (340A-340D)
        • Katon WJ
        • Lin EHB
        • Vo Korff M
        • et al.
        Collaborative care for patients with depression and chronic illnesses.
        N Engl J Med. 2012; 363: 2611-2620
      4. Lambda Legal. When health care isn't caring: Lambda Legal's survey on discrimination against LGBT people and people living with HIV. 2010. Available at: Accessed February 9, 2021.

        • Zelin NS
        • Hastings C
        • Beaulieu-Jones BR
        • et al.
        Sexual and gender minority health in medical curricula in New England: a pilot study of medical student comfort, competence and perception of curricula.
        Med Educ Online. 2018; 231461513
        • Streed Jr, CG
        • Hedian HF
        • Bertram A
        • Sisson SD.
        Assessment of internal medicine resident preparedness to care for lesbian, gay, bisexual, transgender, and queer/questioning patients.
        J Gen Intern Med. 2019; 34: 893-898