Heart Disease Risk in Transgender Adults Remains Dangerously Understudied, Researchers Warn

Cardiovascular disease kills more people than anything else on Earth, and in the United States it accounts for more than a quarter of all deaths. Yet according to a new perspective published in the Journal of General Internal Medicine, one population facing measurably higher heart disease risk has been almost entirely left out of the research agenda: transgender, nonbinary, and gender diverse adults. A team led by Roy Sistovaris of Boston University School of Public Health and senior author Carl G. Streed Jr. of Boston Medical Center argues that, at a moment when gender-affirming care is under intense political scrutiny, the science needed to protect trans hearts simply does not exist — and that filling this gap could improve cardiovascular health for everyone.

The scale of the blind spot is striking. As of 2026, roughly 1.1 percent of US adults identify as transgender, nonbinary, or gender diverse — more than four million people. A growing body of evidence indicates that these adults face a greater risk of developing cardiovascular disease than their cisgender peers, and, crucially, that this elevated risk persists regardless of whether they take gender-affirming hormone therapy. That last point matters because nearly all existing research has fixated on hormones alone, treating the question of trans cardiovascular health as a pharmacology problem rather than a whole-person, whole-population one.

The technical picture that does emerge from the literature is genuinely confusing — and the authors are candid about it. On one hand, studies suggest that transgender men taking testosterone face elevated heart attack risk relative to cisgender men and women, and prospective cohort work has documented cardiac morphological changes after masculinizing hormone therapy. On the other hand, a recent analysis of Veterans Health Administration data found that gender-affirming hormone therapy among transgender veterans assigned female at birth was significantly associated with a reduced hazard of major adverse cardiac events — myocardial infarction and ischemic stroke — even after accounting for traditional risk factors such as diabetes, hypertension, and dyslipidemia. In other words, the same class of intervention appears protective in one dataset and risky in another.

The authors attribute these contradictions less to biology than to methodology. Recent meta-analyses and systematic reviews confirm that the evidence base is dominated by observational studies with no standardization of hormone exposure definitions, follow-up windows, or cardiovascular outcome measures. Many studies fail to adjust for pre-existing cardiovascular disease or baseline risk factors, producing confounded results and inconsistent findings for both clinical markers and hard outcomes. Long-term data on hormone therapy are extremely sparse. The result is a literature too heterogeneous to support firm clinical guidance — for patients or for the physicians caring for them.

Hormones are also only one piece of the physiological puzzle. The perspective highlights the Minority Stress Model, which posits that chronic exposure to stigma, discrimination, violence, and hostile policy environments produces sustained physiological stress with measurable cardiovascular consequences. Trans people report higher rates of cigarette smoking, alcohol misuse, and illicit drug use than cisgender counterparts — all established contributors to cardiovascular disease — and emerging work suggests stress in these populations carries distinct physiologic sequelae, including hypertension and possible autonomic imbalance. Yet rigorous quantification of how much these psychosocial factors contribute to cardiovascular risk, relative to pharmacologic ones, remains largely absent.

Surgical care introduces further unknowns. All surgery carries some cardiac risk, and certain gender-affirming procedures — particularly urogenital surgeries such as phalloplasty — carry higher rates of postoperative complications and emergency re-presentation than others like vaginoplasty. Despite this, the authors note that no studies have examined the prevalence of cardiac events following gender-affirming surgery at all. For a field that routinely stratifies surgical risk by population, the omission is hard to explain except by historical neglect.

The paper also points to a data gap within the gap: intersectionality. Cardiovascular disease burden varies enormously by race and ethnicity, driven by the social and economic consequences of racism, but research on trans populations has rarely collected race and ethnicity data alongside gender identity. Without representative data across intersecting marginalized identities, researchers cannot identify the true prevalence or etiology of cardiovascular disease in the diverse communities that make up the trans population — and interventions designed without that knowledge risk serving only a narrow slice of it.

What would better research look like? The authors lay out an agenda that goes well beyond hormone monitoring. They call for integrating cardiovascular screening and prevention — routine blood pressure checks, lipid panels, risk estimation — into routine primary care for all trans patients, not just those on hormone therapy, since cardiovascular care has historically been siloed from gender-affirming care and vice versa. They call for mixed-methods studies of how trans communities actually engage with prevention strategies like exercise, nutrition, sleep, and stress reduction, noting that gyms and fitness spaces often lack inclusive policies, effectively excluding trans people from preventive health resources. And they call for community-based participatory research: trans-specific exercise programs, nutritional counseling that accounts for the intersection of body image and gender affirmation, and stress-reduction interventions designed around minority stress, all co-designed with the communities they are meant to serve.

The ethical dimension is treated as inseparable from the scientific one. The authors urge clinical institutions to train staff in engaging trans communities, citing programs such as the National LGBTQIA+ Health Education Center and Indian Country ECHO, and recommend collaborating with trans researchers and forming community advisory boards for long-term projects. Future cardiovascular clinical trials, they argue, must intentionally include trans participants so these communities are not excluded — or erased — from the benefits of evidence-based medicine. At a time when research and expertise themselves are under political pressure, they write, maintaining rigorous inquiry into trans health is both a scientific and a civic necessity.

The stakes extend far beyond the trans community. The authors argue that studying cardiovascular disease in trans populations stands to sharpen clinical understanding of sex hormone mechanisms, reveal how clinical signs differ and converge across genders, and demonstrate how socially constructed roles shape biology. When research prioritizes the most vulnerable populations, they conclude, it tends to produce knowledge that improves outcomes across society. With more than four million trans adults in the United States alone and cardiovascular disease remaining the nation’s leading killer, the question the paper poses is less why this research should happen now, and more why it has taken this long.

Subject of Research: Cardiovascular disease risk and research gaps in transgender and gender diverse populations

Article Title: Transgender Health and Cardiovascular Disease Risk: Future Directions for Research

Article References: Sistovaris, R., Lim, T., Restar, A. J., Navarra, M., Reisner, S., & Streed, C. G., Jr. (2026). Transgender Health and Cardiovascular Disease Risk: Future Directions for Research. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10757-0

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10757-0

Keywords: cardiovascular disease, transgender health, gender-affirming hormone therapy, health disparities, minority stress, preventive care, clinical research, health equity, primary care, public health, Transgender, Health