Discrimination contributes to poorer heart health for LGBTQ adults

In terms of health, LGBTQ orientation is considered a "sexual minority," and transgender or gender non-conforming is considered a "gender minority."

The statement examines existing research about LGBTQ-specific links to cardiovascular health disparities, identifies gaps in the body of knowledge and provides suggestions for improving cardiovascular research and care of LGBTQ people.

"This is particularly important now, at a time when there is increased awareness of health inequities related to unequal treatment and discrimination in the U.S.," says Billy A. Caceres, Ph.D., R.N., FAHA, chair of the writing group for the statement and an assistant professor at the Columbia University School of Nursing in New York City. "LGBTQ individuals are delaying primary care and preventative visits because there is a great fear of being treated differently. Being treated differently often means receiving inadequate or inferior care because of sexual orientation or gender identity."

LGBTQ populations face unique stressors, such as family rejection and anxiety over concealment of their sexual orientation or gender identity. Multi-level minority stressors and general stressors often interact in complicated ways to impair LGBTQ health. In addition, LBGTQ adults in historically underrepresented racial or ethnic groups experience higher poverty levels, insecure housing and fewer health care options compared to their white LGBTQ peers.

The writing group noted trust toward health care professionals is still lacking among many members of the LGBTQ community, and health care professionals need more education on how to provide appropriate care for LGBTQ patients. Caceres says, "It is paramount to include content about LGBTQ health in clinical training and licensure requirements in order to address these cardiovascular health disparities."

Accrediting bodies and organizations responsible for health care professional curricula have not specifically required LGBTQ-related content, thus very little exists in health professional education training. A 2018 online survey of students at 10 medical schools found approximately 80% of students did not feel competent to provide care for transgender patients. Another study of more than 800 physician residents across 120 internal medicine residencies in the U.S. found no difference in knowledge between the baseline and post-graduate years when it came to LGBTQ-specific health topics. The statement notes that the Accreditation Review Commission on Education for the Physician Assistant began requiring LGBTQ curricular content in September 2020.

The writing committee suggests assessment and documentation of sexual orientation and gender identity information in electronic health records could provide an opportunity to address specific health concerns for LGBTQ patients, and to strengthen our ability to examine cardiovascular health of LGBTQ adults more broadly. They also note basic understanding of the terminology of LGBTQ identities is important. The statement includes a glossary to detail and clarify the various key words and terms used to describe members of the LGBTQ community such as bisexual, transgender, gay, gender nonbinary, etc.

"Health care systems need to play a significant role -- to enact policies to encourage and support researchers and health care professionals to ask these questions in a respectful manner and to implement structures that emphasize the clinical importance of understanding the many layers related to caring for people with a minority sexual orientation or gender identity," said Caceres.

The statement also notes that while there's limited information on the cardiovascular health of LGBTQ people, a few risk factors stand out from existing data. They identify areas that require specific cardiovascular health efforts focused on the LGBTQ population:

• LGBTQ adults are more likely to report tobacco use than their cisgender heterosexual peers.
• Transgender adults had lower physical activity levels than their cisgender counterparts, according to a systematic review. The statement suggests gender-affirming care might play a role in promoting physical activity among transgender people.
• Transgender women may be at increased risk for cardiovascular disease due to behavioral and clinical factors (such as the use of gender-affirming hormones like estrogen).
• Transgender women and non-binary persons are more likely to binge drink.
• Lesbian and bisexual women have a higher prevalence of obesity than heterosexual women.

Future research is needed across the entire spectrum of the LGBTQ community to better understand the complex and multiple levels of psychological and social stressors that can impact the cardiovascular health of LGBTQ people and to develop and implement appropriate interventions that support improved cardiovascular health and overall well-being.

In addition, data is also lacking about differences in risk for cardiovascular disease by race and ethnicity and by socioeconomic level for persons who are members of the LGBTQ community. This is because most previous studies have relied heavily on samples from white, educated LGBTQ adults.

"There is much work to be done to understand and improve the cardiovascular health of LGBTQ adults," Caceres said. "We need more robust research that allows us to draw stronger conclusions, as well as initiatives to increase clinicians' knowledge, thereby improving care and health outcomes for LGBTQ adults."

The Scientific Statement was developed by the writing group on behalf of the American Heart Association's Council on Cardiovascular and Stroke Nursing; the Council on Hypertension; the Council on Lifestyle and Cardiometabolic Health; the Council on Peripheral Vascular Disease; and the Stroke Council.

Co-authors are Carl G. Streed, Jr., M.D., M.P.H., FACP, Vice Chair; Heather L. Corliss, M.P.H., Ph.D.; Donald M. Lloyd-Jones, M.D., Sc.M., FAHA; Phoenix A. Matthews, Ph.D.; Monica Mukherjee, M.D., M.P.H.; Tonia Poteat, Ph.D., PA-C, M.P.H.; Nicole Rosendale, M.D.; and Leanna M. Ross, Ph.D. Author disclosures are in the manuscript.