Hidden in the Hills: Cardiovascular Risk in Transgender Populations in Rural Appalachia

Background: Transgender adults have a higher burden of several cardiovascular risk factors in national surveys.Electronic health record data from rural Central Appalachia, a region with high background cardiometabolic risk, are lacking.Objective: This study aims to compare the prevalence of cardiovascular risk factors between transgender and cisgender adults receiving care at the same rural Appalachian clinic and to describe patterns by gender identity and by gender-affirming hormone therapy (GAHT).Materials and methods: We conducted a retrospective cross-sectional study of electronic health record data from an academic outpatient clinic in southern West Virginia.We compared 74 transgender adults with documented gender identity and 69 randomly selected cisgender adults from the same clinic.Outcomes were current tobacco use, current alcohol use, obesity, hypertension, diabetes, prediabetes or diabetes, lowdensity lipoprotein cholesterol (LDL-C) ≥100 mg/dL, statin use, and aspirin use.Firth penalized logistic regression was used to estimate adjusted odds ratios (aORs) for age and sex assigned at birth.Sensitivity analyses varied the covariates, age range, and outcome definitions and used multiple imputation for missing data.Results: Mean age was 30.4 years among transgender adults and 29.9 years among cisgender adults.Current tobacco use was more common among transgender adults (33.8% vs 11.6%, aOR 3.64 (95% CI 1.55-9.28)),and this finding was consistent across all sensitivity analyses.Prediabetes or diabetes was also more common (17.6% vs 4.3%, aOR 3.94 (95% CI 1.20-16.43)),although the estimate was imprecise and did not remain significant after correction for multiple comparisons.Obesity (54.1% vs 53.6%), hypertension, and elevated LDL-C did not differ between the groups.Among transgender adults, obesity was more common in transgender men than in transgender women (68.1% vs 29.6%).In analyses restricted to transgender adults, GAHT was not associated with tobacco, alcohol, or statin use.Conclusions: In this rural Appalachian clinic, the prevalence of current tobacco use among transgender adults was nearly three times that among cisgender adults, and prediabetes or diabetes was more common, against a high shared prevalence of obesity.These hypothesis-generating findings support guideline-based tobacco cessation treatment and glycemic screening in gender-affirming and primary care.