15/10/2023
Cardiac Risk of Transgender The cardiovascular community must face
human rights regarding gender identity
that demands specific knowledge and skills
for cardiac disease prevention, diagnosis, and
multidisciplinary interaction.
We are not discussing genetic and
phenotypic sexual determination at birth, but
the personal perception of a non-originally
assigned gender, called transgender, in which
someone seeks for medical interventions
to alter the body to change from the born
gender through the self-perceived one, on
two conditions:
Transgender men, transmen, female-tomen, or FTM. The born women switch or want
to change to men.
Transgender women, transwomen, male-tofemale, or MTF. The born men switch or want
to change to women.1
To anticipate how often a person will
need professional attention, let us look at the
Mexican national statistics, considering that
these concepts are relatively new and may
exclude older people who feel uncomfortable
declaring their gender identity. The National
Institute of Statistics and Geography (INEGI from
Instituto Nacional de Estadística y Geografía)
estimates 0.9% transgender from the Mexican
population that may seek medical services
in all public institutes and private practice.2
This information brought a recently published
Mexican cardiology opinion.3
The current evidence points towards a
myocardial infarction risk increase of over
two-fold in FTM compared to cisgender men
and four-fold compared to cisgender women.
Contrarily, MTF has over two-fold risk against
cisgender women, suggesting FTM receives
a significant risk impact.4 This problem was
mentioned in the Mexican Consensus on
Chronic Ischemic Heart Disease. Non-invasive
diagnosis, classification, and stratification.
Mexican College of Interventional Cardiology
and Endovascular Therapy (COMECITE).5
Hormonal basics in cisgenders indicate
a progressive increase in cardiovascular risk
in men. In contrast, there is a rapid rise in
women after menopause, especially in early
menopause, either natural or surgical.6 The
gender-affirming hormone therapy may be
responsible for the risk mentioned above but
also associates to double the risk for ischemic
stroke on MTF against cisgender men, especially
in prolonged hormonal therapy for more than
six years. On prolonged oral hormone therapy,
the same group has 20 to 40 times the risk for
thromboembolic complications.7,8
Different publications render conflicting
results regarding cardiovascular risk factors.
Nonetheless, transgender people may have
more incidence of smoking, increased body
weight, alcohol and other substance abuse,
sedentarism, inadequate nutrition (more fastfood preference), dyslipidemia, and especially
HIV infection. The relationship between these
risk factors and cardiac events is unclear, except
for HIV infection, which unequivocally gives
evident high risk.9
Minority stress deserves particular attention,
yet being transgender is not easy but quite
difficult and stressful due to the self-perception
of rejection caused by transphobia, which leads
to physical and psychological violence and
isolation from society. The latter may be the more significant problem that this population
face, provoking a higher tendency towards
discrimination, depression, addictions, suicidal
ideas and acts, poverty, margination from
professional, family, and recreative activities,
underemployment, self-medication and
possible involvement in illegal activities.10-12
Finally, the more interesting issue concerns
transgender people’s medical service, which
is unequal, delayed, less efficient, and not
inclusive due to fear of mistreatment from
the subjects and rejection from clinical staff,
including physicians and other patients. This
phenomenon creates a vicious circle that
perpetuates and aggravates mental and physical
morbidities.13
Concerning the so-called conscientious
objection of medical and health personnel,
recognized and protected by the Political
Constitution of the United Mexican States, The
Supreme Court warned (unconstitutionality
action 54/2018) of the superlative risk that the
absolute and unlimited exercise of this right
could entail, especially against the sexual and
reproductive rights of women and people
of sexual and gender diversity, from the
problematic situation in which they find
themselves and their historical discrimination.
It states that the objection must be compatible
and not sacrifice the rights of the beneficiaries
of health services. Consequently, the Supreme
Court invalidated the article of the General
Health Law that authorized the conscientious
objection of medical and nursing personnel. That
means that, as of today, Mexican law does not
protect conscientious objection and that denying
health service for reasons of conscience could
lead to administrative, civil, or even criminal
liability. Besides, refusing health services to
sexually/gender diverse people puts their lives
at risk by not addressing their high health risks.14
Based on these concepts, our professional
community should have a substantial change
in transgender care, as follows:
Transgender is real, not fiction.
Transgender people need and seek medical
attention for mental and physical morbidities.
They do not need our opinion regarding
sexual genetic considerations.
Medical care must be inclusive
and egalitarian.
Cardiologists should interact in the
prevention of cardiovascular deterioration.
Mexican law does not currently protect
conscientious objection.
This historical moment is a time for
adaptation and interdisciplinary construction
to improve transgender people’s smooth
and easy life.
