Issue: March 2021
Source: Caceres BA, et al. Circulation. 2020;doi:10.1161/CIR.0000000000000914.
Disclosures: Caceres, Deutsch, Mukherjee and Streed report no relevant financial disclosures.
March 18, 2021
11 min read
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More data needed as LGBTQ+ populations face disparities in CV health

Issue: March 2021
Source: Caceres BA, et al. Circulation. 2020;doi:10.1161/CIR.0000000000000914.
Disclosures: Caceres, Deutsch, Mukherjee and Streed report no relevant financial disclosures.
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CVD mortality has steadily decreased in the U.S. for some populations, but mounting data indicate LGBTQ+ adults have worse CV health compared with their straight, cisgender counterparts.

These disparities are thought to be particularly driven by exposure to psychosocial stressors across the life span.

However, little attention has been given to CV health in the LGBTQ+ populations compared with other health issues such as HIV and substance abuse. In fact, only 4% of all NIH-funded research on LGBTQ+ health from 1989 to 2011 focused on CV health and associated risk factors, according to an American Heart Association scientific statement released in October 2020.

Monica Mukherjee, MD, MPH, FACC, FASE, FAHA, from Johns Hopkins University, discussed CV risks in the LGBTQ+ population.

Source: James H. Clark, MD, Johns Hopkins University. Printed with permission.

Reports from the National Academy of Medicine in 2011 and 2020 recommended an increase in research efforts to focus on CV health in LGBTQ+ adults, a call that was answered in part by the AHA document. Stakeholders from multiple sectors should integrate best practices into health promotion and CV care as well as to develop and test interventions to address the multilevel stressors affecting this population, experts said.

“While there is increasing awareness on the presence of health disparities in the LGBTQ+ population, methodologic limitations in research such as the absence of biosocial determinants of health as well as the lack of relevant content in educational curricula — in both medical school and continuing medical education — continues to have significant clinical and research implications,” Monica Mukherjee, MD, MPH, FACC, FASE, FAHA, associate professor of medicine and director of Johns Hopkins Echocardiographic Research at Johns Hopkins University and a member of the AHA scientific statement writing committee, told Cardiology Today.

“LGBTQ+ adults face unique individual and intrapersonal stressors that have several downstream clinical implications including increased cardiovascular morbidity and mortality,” Mukherjee said. “The AHA statement proposes a novel LGBTQ+ focused conceptual model that incorporates these unique factors. Life stressors such as discrimination, violence, marginalizing structural norms, self-stigma, stress related to concealment and disclosure of gender identity all contribute to psychosocial (increased rates of depression and anxiety), behavioral (increased smoking, poor diet quality, physical inactivity) and physiologic factors, including alterations in hormonal axis in transgendered individuals. Future research that guides education of the medical community is imperative and should include both social and clinical determinants of cardiovascular health in LGBTQ+ adults. There are a multitude of opportunities available to reduce cardiovascular health disparities in this at-risk population.”

Cardiology Today spoke with experts about disparities that exist between LGBTQ+ individuals and non-LGBTQ+ individuals, stressors that may cause these disparities and knowledge gaps that remain.

Lack of awareness

Billy A. Caceres

A lack of awareness of the health disparities among the LGBTQ+ population remains.

“Based upon previous research conducted among internal medicine residents and oncology residents about their knowledge of LGBTQ+ health in general, what has been found is that the medical community seems to have little or moderate knowledge about this population of patients,” Billy A. Caceres, PhD, RN, AGPCNP-BC, assistant professor at the School of Nursing and the Program for the Study of LGBT Health at Columbia University, told Cardiology Today. “Most of the research that has been done on awareness among physicians or other health care providers has focused on their comfort in caring for LGBTQ+ patients and not so much on their knowledge of health issues that this population experiences.”

Additionally, there is little content in health care education curricula on LGBTQ+ health, Caceres, who chaired the AHA scientific statement committee, added.

“This further leads to the assumption that most people in the medical community who are providing care for LGBTQ+ patients are not fully aware of the disparities that this community experiences,” Caceres said.

Carl G. Streed Jr., MD, MPH, FACP, assistant professor of medicine at Boston Medical Center and vice chair of the AHA scientific statement committee, added that, “The medical community has become better within the past decade or so in terms of getting the research out, getting more policy statements published and working toward getting more national organizations to provide statements on the topic.

“The American Medical Association has also worked to educate its members and advocate for evidence-based policies around improving physician knowledge of LGBTQ+ health. The Association of American Medical Colleges also has a slew of recommendations on how to improve training on this, but they are not required. As a result, people who want to know, know, but those who do not care to know are unaware of the issue,” Streed told Cardiology Today.

Madeline Deutsch

Mukherjee agreed.

“LGBTQ+ specific research and the relevant medical curricula has been limited despite increasing awareness of these disparities,” Mukherjee said. “Incorporating biobehavioral approaches into cardiovascular research and education will help elucidate mechanisms by which minority stressors contribute to cardiovascular health disparities in LGBTQ+ adults and improve clinical care and cardiovascular outcomes for this community.”

Minority stress model

Research has shown that the LGBTQ+ population is a unique subset of patients with increased risk for CV morbidity and mortality associated with life stressors that are caused by psychosocial, behavioral and physiologic factors.

The minority stress model — a social research and public health model designed to help better understand the actual experiences of people of oppressed communities — indicates that LGBTQ+ people are exposed to unique stressors across multiple intersecting levels that increase their risk for negative health outcomes, including CVD.

Stressors can be considered on three different levels: individual, interpersonal and structural.

Individual level stressors can be defined as one’s awareness as an LGBTQ+ person about their ability to be rejected or discriminated against by other people because of their LGBTQ+ identity.

“Expectations of rejection from family members and the anticipation of being discriminated against by society are examples of individual level stressors,” Caceres said. “This is something that racial and ethnic minorities have been dealing with for a very long time and has been found to be associated with negative health outcomes among minority populations.”

Interpersonal level stressors encompass an individual’s actual experience of discrimination.

“Interpersonal stressors are probably the most well-known and have been found to occur among other discriminated-against populations such as racial minorities and those who are overweight,” Caceres said.

Structural level stressors include policies and social norms that could potentially place LGBTQ+ people at increased risk for negative health outcomes and/or negative experiences. These may include same-sex marriage laws and legal protection against discrimination in health care settings or in other public settings.

“This all ties into the chronic and complex PTSD — there are significantly high rates among LGBTQ+ individuals, ranging from things like just living in society and not being accepted to one’s physical safety being threatened and the lack of legal protections,” Madeline Deutsch, MD, MPH, medical director for transgender care at the University of California at San Francisco, told Cardiology Today. “People experience rejection from their family, are bullied and beaten up in school and may even leave school because they are bullied.

“Looking at legal and structural issues, there are many states where not only anti-bullying protection does not exist for school, but there are actually states where there are laws making it illegal to have an anti-bullying policy for LGBTQ+ individuals, such as Missouri and South Dakota,” Deutsch added. “Additionally, Alabama, Louisiana, Mississippi, Oklahoma, South Carolina and Texas restrict the inclusion of any LGBTQ+ content in school. We then have these individuals leaving school, and in turn, have low education status, which is another predictor of minority stress because lower education levels are associated with a range of poor health outcomes, including cardiovascular disease.”

As documented on lgbtmap.org, there are 23 states without legal protection against discrimination in health care settings or other public settings in the U.S., Caceres said.

“We know that individuals who live in areas where there are less supportive policies for LGBTQ+ people tend to experience worse mental health, including higher rates of depression and suicidal ideation,” Caceres added. “However, the effect of all of this on cardiovascular health has not been well studied. The important thing to think about is that on top of these three stressors, which are unique to LGBTQ+ people, all other stressors that the rest of society experiences from simply living in the world are experienced by this population as well.”

Deutsch said because of this, every transgender person should be considered to be at a high likelihood of having experienced PTSD and, depending on the kind of life course and type of gender identity development life story an individual has, should be considered to have had a significant adverse effect on their health.

“Some of these individuals had to grow up bottling this up for years and experienced trauma throughout their childhood,” Deutsch said. “That may have an even more significant impact down the line than isolated trauma incidents as an adult.”

On top of this, the LGBTQ+ population has low rates of health insurance, which further places them at risk for not receiving proper care. They are also more likely to live in poverty than non-LGBTQ+ people.

Other factors

Disparate rates of adverse CV-associated outcomes are well documented as secondary to the significant and unique psychosocial stressors that lead to increased CV risk among LGBTQ+ individuals.

“Compared with their cisgender heterosexual counterparts, LGBTQ+ individuals have higher rates of tobacco abuse and obesity and are more likely to lead a sedentary lifestyle. They also have increased rates of hypertension, dyslipidemia and diabetes,” Mukherjee said.

According to a study that examined sexual orientation differences in modifiable risk factors for CVD and CVD diagnoses in men published in LGBT Health, bisexual-identified men reported higher rates of mental distress (adjusted OR = 2.39; 95% CI, 1.46-3.9), higher rates of obesity (aOR = 1.69; 95% CI, 1.02-2.72), elevated BP (aOR = 2.3; 95% CI, 1.43-3.7) and HbA1c (aOR = 3.01; 95% CI, 1.38-6.59) compared with heterosexual men.

The data highlight the need for future directions for sexual minority health research in this area and the need for CVD and mental health screenings, particularly in bisexual-identified men, according to Caceres and colleagues.

Many of these disparities are modifiable risk factors that can and should be improved upon.

Carl G. Streed Jr.

“We see more tobacco use in this population, which is one of the most modifiable risk factors for cardiovascular health and subsequent mortality, and we see heavy alcohol use associated with poor cardiovascular outcomes,” Streed said. “We are also now seeing new information based upon large population-based surveys suggesting that hypertension is an issue and that it may be linked to higher rates of heart attack and stroke among certain populations, especially among transgender individuals.”

Moreover, the gender-affirming hormonal therapies that transgender individuals receive may add an additional risk for adverse CV outcomes.

In another study published in Circulation, investigators found that transgender women who receive hormone therapy had an increased incidence of venous thromboembolism and stroke compared with men and women not receiving hormone therapy.

Transgender women had a higher adjusted incidence of VTE (standardized incidence ratio [SIR] for women = 5.52; 95% CI, 4.36-6.9; SIR for men = 4.55; 95% CI, 3.59-5.69) and stroke (SIR for women = 2.42; 95% CI, 1.65-3.42; SIR for men = 1.8; 95% CI, 1.23-2.56). The risk for MI was higher in both transgender women (SIR = 2.64; 95% CI, 1.81-3.72) and transgender men (SIR = 3.69; 95% CI, 1.94-6.42) compared with reference women.

In a perspective accompanying the article on the study, Mukherjee wrote: “Interestingly, the authors did not factor in the presence of traditional risk factors such as smoking, hypertension, hyperlipidemia, type 2 diabetes or family history when performing this analysis. ... The present study continues to demonstrate that hormonal therapy in transwomen is similar and may have unique additional risk above and beyond traditional ASCVD risk, although further prospective studies are needed. Aggressive management of baseline ASCVD risk should be performed with stringent control of blood pressure, lipid levels, glycemic control and weight, in addition to cessation of smoking.”

Deutch noted that a similar study published in the Annals of Internal Medicine found elevated VTE risk in transgender women but not transgender men compared with cisgender individuals.

Yet another challenge facing transgender individuals is that they are sometimes denied access to hormone therapy without fully taking into consideration the risk/benefit ratio of harm vs. benefit.

“In some cases, we are overly concerned about cardiovascular risk related to hormone therapy in transgender people when we do not even know enough about cardiovascular risk in transgender people,” Deutsch said.

A call for more data

Although there are enough data to drive home the point that there are disparities in CV health among the LGBTQ+ population, more data are needed to improve overall health outcomes.

This was the impetus behind the recently issued AHA statement: to develop better research methods and standardized data collection as it relates to sexual orientation and gender identity and the associated health disparities and outcomes.

“We also need to better train our clinicians and everyone in the health care profession to be aware of LGBTQ+ health and how minority stress plays a significant role in a number of factors that affect the health and well-being of LGBTQ+ people,” Streed said.

Research in this area and the related relevant medical curricula remain limited. Therefore, incorporating biobehavioral approaches into CV research and education will help elucidate mechanisms by which minority stressors contribute to CV health disparities in LGBTQ+ adults and ultimately improve clinical care and CV outcomes for these communities, Mukherjee said.

Caceres agreed and added that LGBTQ+ content needs to be infused throughout the medical curricula for health care professionals to be better educated on the health disparities affecting these patients.

“We also need to think about the health care professionals who have been practicing medicine for 15 years or more and ensure that these individuals have an understanding of LGBTQ+ disparities,” Caceres said. “One of the biggest challenges in moving LGBTQ+ health forward is that a lot of physicians do not know that their patients are a part of this population. But the great thing is that we can ask important questions with technologies like electronic health records. Providers need to understand why these questions are important to ask and know how they can better support these patients.”

Many academic institutions are now acknowledging the paucity of formalized education in LGBTQ+ medicine and are focused on specifically instilling methods to improve access and care for these individuals, Mukherjee said.

“Much of this curriculum has, thus far, fallen under the larger topic of LGBTQ+ health inequity,” Mukherjee added. “However, there is a growing body of evidence to suggest that medical education focused on the specific topic of LGBTQ+ health disparity is important and crucial. A curriculum that specifically encompasses the unique and disparate health issues that affect these individuals has the capacity to improve LGBTQ-specific care.”

LGBTQ+ individuals develop health conditions and need medical care just like everyone else, Deutsch said.

“As clinicians, we must treat the person sitting in front of us and be aware of the issues that come wrapped around each individual,” Deutsch added. “This includes whether or not we call them by the right name or pronoun when they come to the clinic. We should try not to ascribe everything that they are dealing with health-wise to the fact that they may be taking or have taken hormone therapy. We should also avoid making assumptions about family structure and lifestyle because we want the patient to come back to see us. Treat the person in front of you, be mindful of past trauma and the disparities that may be swirling around that person in their life as well as in their sexuality. Have some empathy and cultural humility and let people tell you their stories instead of making assumptions.”