Cardiovascular Health of Youth During Gender-Affirming Testosterone Treatment: A Review

Many birth-assigned female/transgender male and nonbinary people (identified as masculine spectrum here) begin gender-affirming testosterone therapy by the age of 24 years. Few data inform assessment of cardiovascular health of masculine spectrum youth as a specific subgroup of the 1.5 million transgender people in the United States. The purpose of this review is to help youth-serving practitioners consider, understand, and evaluate cardiovascular health in adolescent and young adult masculine spectrum patients receiving gender-affirming testosterone treatment. This is a narrative review intended to synthesize a broad body of clinical and research literature. Common cardiovascular health changes associated with testosterone include increased red blood cell mass and likely insignificant changes in high-density lipoprotein and low-density lipoprotein levels. Changes in heart mass, heart electrophysiology, and endothelial reactivity are likely, based on extrapolation of data from adults. Testosterone may have indirect effects on cardiovascular health through influences on depression, anxiety, stress, and anorexia nervosa as well as on behaviors such as tobacco use. Testosterone contributes importantly to the cardiovascular health and well-being of masculine spectrum gender-diverse youth. We need to do a better job of supporting these young people with data on cardiovascular health over the life span.