Scientists say we urgently need more research on why transgender people face an increased risk of cardiovascular disease compared to cisgender people.

This story originally appeared on Them.

Trans people know that our unique health concerns are understudied. Just look at how many of us resort to Reddit forums as a source of anecdotal medical knowledge. Now, researchers are sounding the alarm on just how dangerous this lack of research can be for our heart health.

A new perspective piece published in a recent issue of the Journal of General Internal Medicine concludes that the cardiovascular health risks for trans people, especially regarding their possible interactions with hormone replacement therapy (HRT), are dangerously understudied. In the piece, researchers observe that amid heightened global scrutiny on gender-affirming healthcare, “insufficient effort has been made to address health disparities and fill health-related knowledge gaps impacting trans populations, particularly for [cardiovascular disease].”

The researchers assert that these stakes are especially high given that cardiovascular disease (CVD) remains the leading cause of death in the United States, accounting for more than a quarter (26.4%) of all deaths in the country. Consisting of scientists from the Boston University, University of Toronto, and Yale University, among other medical research institutions, the authors note that despite trans, gender-nonconforming and nonbinary people only making up 1.1% of the U.S. adult population, evidence suggests they experience disproportionate rates of CVD.

Broad healthcare guidelines currently state that some people who begin testosterone-based HRT may develop a higher risk of certain cardiovascular symptoms, such as high blood pressure — but the researchers also shared that data suggests all trans people, regardless of whether or not they take hormones, are at an elevated risk of CVD compared to cisgender people. They also maintain that despite “recent political changes” — namely the restriction of gender-affirming care by a litany of anti-trans laws and executive actions — healthcare practitioners and researchers must continue to identify gaps in evidence on CVD risk among trans people, synthesize these findings into actionable solutions, and conduct research that helps address these risks.

So, does HRT actually increase the risk of cardiovascular disease among trans people?

The question that remains for many trans patients is does their risk of cardiovascular disease increase when taking HRT? These researchers state that although the limited existing research suggests that gender-affirming hormone therapy (GAHT) can increase cardiovascular risk — with some data suggesting increased risk of blood clots for those who take estrogen and increased risk of high blood pressure for those who take testosterone — these findings draw from a very limited scope. They point out that “most research” on GAHT’s impact on CVD merely looks at its effect on cardiovascular risk factors like lipids, blood pressure, and anthropometrics, as opposed to a holistic view of the treatment’s overall influence. In addition, they note that many trans people do not take hormones.

“The focus on GAHT also creates a biased understanding of CVD risk and prevalence among trans people overall, as those who do not elect to utilize GAHT are not an insignificant proportion of the population,” the researchers write.

This means that the answer to whether or not taking gender-affirming care can impact your cardiovascular health could be far more complicated than previous conclusions have suggested. As an example, the researchers state out that while some research suggests transgender men who take testosterone-based HRT are at a higher risk for heart attacks compared to cisgender men and women, new data on transmasculine military veterans who take the same treatment suggests they were actually at a significantly reduced risk for any major adverse cardiac arrest.

The conflicting data underscores the need for a body of dedicated research on trans people and their risk for CVD.

Can transphobia cause an increased risk of cardiovascular disease?

In addition to existing findings linking HRT to increased risk of CVD lacking nuance, the researchers state that there might be another root to the disproportionate risk among all trans people, regardless of hormones: psychological stress.

“Trans people are frequently the target of stigma, violence, harassment, and discriminatory and oppressive policies, especially under the current administration,” the researchers write. And with increased transphobia comes with what researchers call increased “minority stress,” or the specific psychological distress faced by marginalized people.

It is well-documented that minority stress is linked to a litany of behaviors and risks associated with cardiovascular disease, including substance use, cigarette smoking, and illicit drug use, all of which trans people engage with at disproportionate rates and “all of which contribute to the development of CVD,” the researchers write.

So does transphobia translate to increased CVD? Because there is a lack of research on the topic, it is difficult to establish. But the authors say it’s clear that research on trans people and their risk for CVD needs to include, but not be limited to, an analysis of hormone therapy.

“Cardiovascular health research must expand beyond GAHT to encompass the full spectrum of trans people’s healthcare needs,” the researchers conclude. “While not all trans individuals pursue hormone therapy or gender-affirming care surgeries, evidence suggests elevated CVD risk persists across trans populations regardless of GAHT utilization.”

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