Investigating the Associations of Sexual Minority Stressors and Incident Hypertension in a Community Sample of Sexual Minority Adults

Abstract

Background

Sexual minority adults are at higher risk of hypertension than their heterosexual counterparts. Sexual minority stressors (i.e., unique stressors attributed to sexual minority identity) are associated with a variety of poor mental and physical health outcomes. Previous research has not tested associations between sexual minority stressors and incident hypertension among sexual minority adults.

Purpose

To examine the associations between sexual minority stressors and incident hypertension among sexual minority adults assigned female sex at birth.

Methods

Using data from a longitudinal study, we examined associations between three sexual minority stressors and self-reported hypertension. We ran multiple logistic regression models to estimate the associations between sexual minority stressors and hypertension. We conducted exploratory analyses to determine whether these associations differed by race/ethnicity and sexual identity (e.g., lesbian/gay vs. bisexual).

Results

The sample included 380 adults, mean age 38.4 (± 12.81) years. Approximately 54.5% were people of color and 93.9% were female-identified. Mean follow-up was 7.0 (± 0.6) years; during which 12.4% were diagnosed with hypertension. We found that a 1-standard deviation increase in internalized homophobia was associated with higher odds of developing hypertension (AOR 1.48, 95% Cl: 1.06–2.07). Stigma consciousness (AOR 0.85, 95% CI: 0.56–1.26) and experiences of discrimination (AOR 1.07, 95% CI: 0.72–1.52) were not associated with hypertension. The associations of sexual minority stressors with hypertension did not differ by race/ethnicity or sexual identity.

Conclusions

This is the first study to examine the associations between sexual minority stressors and incident hypertension in sexual minority adults. Implications for future studies are highlighted.

Sexual minority (such as gay/lesbian and bisexual) adults who reported higher internalized homophobia (defined as internalization of negative societal values about sexual minority people) were 48% more likely to be diagnosed with high blood pressure than those who reported lower internalized homophobia.

Introduction

Sexual minority (e.g., lesbian/gay, bisexual, queer) adults experience worse health outcomes than their heterosexual counterparts [1]. For example, they are more likely to report suicidal thoughts and behaviors, poor mental health, and disability [1]. To address these disparities, improving the health and well-being of sexual minority individuals was included as an objective of Healthy People 2030 [2]. Although disparities related to mental health, substance use, and HIV/AIDS are well documented among sexual minority adults, little attention has been given to disparities related to cardiovascular health in this population [3].

In light of growing evidence of sexual orientation-related cardiovascular health disparities, leading health organizations have underscored the importance of cardiovascular health research among sexual minority individuals [1, 3]. Cardiovascular disease is the leading cause of death worldwide [4, 5] with modifiable factors accounting for over 90% of the risk of cardiovascular disease in adults [6]. Hypertension (defined as blood pressure of ≥ 130/80) is the leading modifiable risk factor for cardiovascular disease, affecting an estimated 116 million adults in the United States (U.S.) [7]. A growing body of research indicates that sexual minority adults have a higher prevalence of risk factors for hypertension relative to heterosexual adults, such as a higher prevalence of current and lifetime nicotine exposure [3, 8]. In addition, sexual minority women are more likely than heterosexual women to have short sleep duration [9–11] and obesity [3]. Multiple studies have found that sexual minority women and bisexual men have higher systolic and diastolic blood pressure than heterosexual adults [12–14]. Despite this evidence, almost no research has examined potential contributors to hypertension risk in this population [3, 8].

The Minority Stress Model of Cardiovascular Health [3] draws upon existing frameworks to address cardiovascular health disparities in sexual minority adults [15–17]. This conceptual model posits that sexual minority adults are exposed to sexual minority stressors (defined as unique stressors attributed to one’s sexual minority identity) that contribute to negative cardiovascular outcomes [3]. These sexual minority stressors exist at multiple levels, including at the individual (e.g., internalized homophobia, stigma consciousness), interpersonal (e.g., experiences of discrimination), and structural (e.g., laws, social norms) levels [17]. Greater exposure to sexual minority stressors is posited to indirectly increase hypertension risk in sexual minority adults through mediated psychosocial (e.g., depression), behavioral (e.g., tobacco use, physical inactivity), and physiological (e.g., sympathetic arousal, hypothalamic-pituitary-adrenal axis dysfunction) pathways [3]. Although sexual minority stressors have been shown to contribute to poor mental health and substance use among sexual minority adults [8, 18–25], little is known about the impact of sexual minority stressors on hypertension risk.

Evidence from multiple studies suggests that minority stressors, primarily experiences of discrimination, are associated with higher risk of hypertension among racial/ethnic minority adults in the general population [26–30]. In a meta-analysis of 44 studies, investigators found that experiences of racial discrimination were associated with a higher likelihood of having hypertension [28]. Research on the links between other minority stressors and hypertension remains limited, but significant associations have been identified [29, 30]. For instance, in a sample of 1,533 men, Orom and colleagues [29] found that compared to white men, higher levels of stigma consciousness (i.e., the extent to which one expects to be stereotyped) were associated with higher odds of hypertension among racial/ethnic minority men.

It is important to note that none of the aforementioned studies examined the link between minority stressors and hypertension among sexual minority adults. Research on the links between minority stressors and hypertension risk in sexual minority adults is limited [3]. However, two recent cross-sectional studies found that sexual orientation-based discrimination was not associated with hypertension risk in sexual minority adults [31, 32]. In addition, only one cross-sectional study has investigated the associations between internalized homophobia (i.e., internalization of negative societal values towards sexual minority individuals) and hypertension in sexual minority adults [33]. In a community sample of 1,029 Black and white sexual minority women, Molina and colleagues [33] found no significant associations between internalized homophobia and hypertension. To our knowledge, researchers have yet to examine whether stigma consciousness influences hypertension in sexual minority individuals.

Sexual minority individuals who hold multiple stigmatized identities (e.g., Black bisexual women) experience increased exposure to intersectional forms of minority stress that may negatively impact their health [1, 34]. With few exceptions, there is limited research that has examined racial/ethnic and sexual identity (e.g., gay/lesbian vs. bisexual) differences in hypertension among sexual minority adults [3]. Prior work has shown that Black sexual minority women have a higher prevalence of hypertension than white sexual minority women [35, 36]. Moreover, bisexual individuals experience worse mental health and substance use outcomes compared to gay and lesbian individuals [37–40], factors that are associated with hypertension [4, 41, 42]. Multiple studies have also found that bisexual individuals have a higher risk of hypertension than their monosexual (e.g., gay/lesbian, heterosexual) counterparts [13, 14, 35, 43]. One explanation for these health disparities among bisexual people is the “double closet” phenomenon [44], which proposes that they are exposed to discrimination and marginalization from both heterosexual and sexual minority communities. This added stress can place them at greater risk of hypertension and other negative health outcomes.

The objective of the current study was to examine the longitudinal associations of key sexual minority stressors with incident hypertension among sexual minority adults assigned female sex at birth. Using data from the Chicago Health and Life Experiences of Women (CHLEW) study, we hypothesized that greater report of internalized homophobia, stigma consciousness, and sexual orientation-based discrimination would be associated with higher odds of incident hypertension in this sample. In exploratory analyses we tested whether the associations between sexual minority stressors and incident hypertension differed by race/ethnicity and sexual identity. Based on prior evidence [13, 35, 36], we hypothesized that the associations of sexual minority stressors with incident hypertension would be stronger among people of color and bisexual participants.

Methods

Sample

The CHLEW is a longitudinal study of risk and protective factors associated with sexual minority women’s health that was launched in 1999. Detailed information about study methods, including recruitment and retention, can be found in a recently published report [45]. In brief, using convenience sampling, CHLEW Wave 1 (2000–2001) recruited English-speaking women ages 18 years or older from the Chicago metropolitan area who identified as lesbian/gay (n = 447). At CHLEW Wave 2 (2003–2005), 384 participants (86% of the original sample) were re-interviewed. In Wave 3 (2010–2012), 353 participants (79% of the original sample) were retained. Additionally, a supplemental sample of 373 participants was added to increase the number of younger (18–25 years), bisexual, and racial/ethnic minority participants. CHLEW Wave 4 (2017–2019) retained 73% of the original sample and 68% of the combined sample (n = 513). All CHLEW participants were assigned female sex at birth. At Wave 4, 7 participants identified as transgender men and an additional 16 reported their gender identity was something other than female or male (e.g., gender non-binary, genderqueer, gender fluid). Wave 5 was recently completed but data are not yet ready for analyses. We used data from Waves 3 and 4 because they include the largest and most racially/ethnically diverse sample and were the first waves to assess self-reported hypertension. All study procedures were approved by the Institutional Review Board at the University of Illinois Chicago and Columbia University.

Sample Selection

A total of 152 participants who did not report a diagnosis of hypertension at Wave 3 were lost to follow-up at Wave 4. These non-responders were more likely to have lower household income and lower educational attainment, to be current smokers, and to identify as Black/African American or Hispanic/Latinx, or bisexual (all p’s < .05). Non-responders were also less likely to report having health insurance coverage (p < .05).

The present analysis includes 380 individuals who participated in Waves 3 and 4 of the CHLEW study, and who did not report a diagnosis of hypertension at Wave 3. We excluded participants enrolled in Wave 4 who reported having hypertension at Wave 3 (n = 127) or who had missing data for hypertension at Waves 3 (n = 1) or 4 (n = 1). We also excluded four participants who identified as heterosexual or mostly heterosexual. In only the fully adjusted models, an additional 32 participants were dropped from analyses due to missing data for household income (n = 10), body mass index (n = 4), internalized homophobia (n = 2), or sexual orientation-based discrimination (n = 16).

Measures

Sexual minority stressors

We examined three sexual minority stressors. Internalized homophobia was assessed using a previously validated 10-item scale [46, 47]. Participants were asked to rate on a 5-point Likert scale (1 = “strongly disagree”; 5 = “strongly agree”) how strongly they agreed with 10 statements. Example items include: “I would like to get professional help in order to change my sexual orientation”, “I have no regrets about being lesbian/gay/bisexual”, and “I am proud that I am lesbian/gay/bisexual”. Several items were reverse-coded so that higher scores indicate greater internalized homophobia. Responses to all items were summed to calculate an internalized homophobia score. Cronbach’s alpha at Wave 3 was 0.82.

The Stigma Consciousness Questionnaire [48], a valid and reliable measure among sexual minority adults [49], was used to assess stigma consciousness. We used separate but parallel measures specific to participants’ sexual identity to assess this variable in lesbian/gay- and bisexual-identified individuals. Lesbian/gay and bisexual participants were asked the same 10 items with specific wording that matched their sexual identity [50]. Example items include: “I never worry that my behaviors will be viewed as stereotypical of lesbians/bisexuals”, “Most heterosexuals do not judge lesbians/bisexuals on the basis of their sexual orientation”, and “I almost never think about the fact that I am lesbian/bisexual when I interact with heterosexuals”. Bisexual participants were asked an additional item: “I feel others view my bisexual identity as ‘untrue’ or not a real identity”. The response options for both scales ranged from strongly disagree (1) to strongly agree (5). Given that the scales used for lesbian/gay and bisexual participants differed in the number of items, scores were standardized. Every participant received a stigma consciousness score that corresponded to their sexual identity. Cronbach’s alphas at Wave 3 for lesbian/gay (ɑ = 0.73) and bisexual (ɑ = 0.81) participants were adequate.

The Experiences of Discrimination questionnaire, a reliable and valid measure of perceived discrimination [51], was used to assess past-year sexual orientation-based discrimination. We first assessed whether participants experienced six types of discriminatory experiences in the past 12 months across various contexts. Discriminatory experiences included: (i) ability to obtain healthcare or health insurance coverage, (ii) treatment in healthcare, (iii) being called names, (iv) discrimination in public settings, (v) being harassed (e.g., picked on, threatened) and (vi) any other discriminatory experience (e.g., at work) [51]. Responses were dichotomized as never (0) and once or more (1). For every discriminatory experience endorsed, participants were asked a follow-up question that asked the main reason(s) they attributed to each (e.g., sexual orientation, race, all equally). They could select more than one main reason. We summed the discriminatory experiences attributed to sexual orientation (either alone or in combination with other reasons) to create a measure of sexual orientation-based discrimination (range = 0-6).

Hypertension

Self-reported hypertension at Waves 3 and 4 was assessed by asking participants: “Have you ever been diagnosed with hypertension (high blood pressure)?” Responses were dichotomous: 1 (“Yes”) or 0 (“No”). Participants who did not report having a diagnosis of hypertension at Wave 3, but who reported having hypertension at Wave 4 were categorized as having incident hypertension (“1”). Those who responded “No” to the hypertension items at both Waves 3 and 4 were categorized as not having hypertension (“0”).

Demographic and clinical factors

We assessed several factors that have been shown to be associated with hypertension risk and which were included as covariates in our analyses [4, 43, 52, 53]. These included age (continuous), sexual identity (lesbian/gay; mostly lesbian/gay; bisexual; other sexual identity [e.g., pansexual, queer]), race/ethnicity (Black/African American; Hispanic/Latinx; white; another race), educational attainment (high school or less; some college; bachelor’s degree or higher), household income (< $20,000; $20,000–40,000; $40,000–75,000; ≥ 75,000), current smoking (yes, no) and health insurance coverage (yes, no) at Wave 3. Body mass index (kg/m²) was calculated based on participants’ self-reported height and weight at Wave 3 [54]. To assess gender identity, at Wave 4 participants were asked: “What is your current gender identity?” Responses included female, male, and “different identity.” Those who reported a different identity were asked to specify their gender identity using a follow-up question.

Statistical Analyses

Analyses were performed in R Version 4.1.2. We used Student’s t-test and Chi-Square to assess differences in the diagnosis of hypertension across continuous and categorical variables. We also conducted bivariate analyses to examine the associations of covariates, sexual minority stressors, and incident hypertension. Following a Bonferroni correction, the significance level for bivariate analyses was set at p < .01 to account for multiple comparisons. Next, we ran unadjusted and mutually adjusted multiple logistic regression models to estimate odds ratios (ORs) and adjusted ORs (AORs) with 95% confidence intervals (CIs) for the associations of sexual minority stressors (i.e., internalization homophobia, stigma consciousness, and sexual orientation-based discrimination) with incident hypertension. Covariates were selected a priori. Fully adjusted models examining these associations adjusted for age, gender identity, race/ethnicity, household income, educational attainment, health insurance coverage, current smoking, and body mass index. Multicollinearity was assessed using the variance inflation factor (VIF) with a VIF greater than 2.5 considered indicative of multicollinearity [55].

To test the hypothesis that the associations between sexual minority stressors and incident hypertension differed by race/ethnicity and sexual identity, we ran separate fully adjusted logistic regression models with an interaction term between each sexual minority stressor and race/ethnicity. We then ran separate fully adjusted models with an interaction term between each sexual minority stressors and sexual identity.

Results

Table 1 summarizes sample characteristics by hypertension diagnosis. The sample included 380 participants, of whom 196 (52.1%) identified as lesbian/gay, 73 as mostly lesbian/gay (19.2%), 79 (20.7%) as bisexual, and 30 (7.9%) as another sexual identity. A total of 173 participants (45.5%) were white, 106 (27.9%) Black/African American, 84 (22.1%) Hispanic/Latinx, and 17 (4.5%) were another race. Approximately 6% of participants reported their gender identity was something other than female or male. In the follow-up of approximately 7.0 (± 0.6) years between Waves 3 and 4, 47 participants (12.4%) were diagnosed with hypertension. Compared to participants without hypertension, those with hypertension were older (44.3 vs. 36.8 years, p < .001) and had a higher body mass index (30.5 kg/m² vs. 27.3 kg/m², p < .01). Participants with hypertension also reported higher internalized homophobia (16.3 vs. 14.2, p = .01). We found no differences in hypertension diagnosis based on stigma consciousness (p = .40) or sexual orientation-based discrimination (p = .35).

Table 1.

Differences in sample characteristics by hypertension status (N = 380)

	Participants without hypertension	Participants with hypertension	p-value
	(n = 333)	(n = 47)
Demographic and clinical factors
Age (in years; range 18–79)	36.8 (12.72)	44.3 (11.92)	< .001*
Sexual identitya			.81
Lesbian/gay	171 (51.4%)	27 (57.4%)
Mostly lesbian/gay	66 (19.8%)	7 (14.9%)
Bisexual	69 (20.7%)	10 (21.3%)
Other sexual identity	27 (8.1%)	3 (6.4%)
Gender identityb			.99
Cisgender female	313 (94.0%)	44 (93.6%)
Transgender male	6 (1.8%)	1 (2.1%)
Other gender identity	14 (4.2%)	2 (4.3%)
Race/ethnicity			.20
White	154 (46.2%)	19 (40.4%)
Black/African American	87 (26.2%)	19 (40.4%)
Hispanic/Latinx	76 (22.8%)	8 (17.1%)
Another race	16 (4.8%)	1 (2.1%)
Educational attainment			.17
High school or less	37 (11.1%)	9 (19.1%)
Some college	92 (27.6%)	15 (31.9%)
Bachelor’s degree or higher	204 (61.3%)	23 (48.9%)
Household income			.63
< $20,000	88 (27.2%)	13 (27.7%)
$20,000–40,000	57 (17.6%)	8 (17.0%)
$40,000–75,000	79 (24.5%)	8 (17.0%)
≥ 75,000	99 (30.7%)	18 (38.3%)
Current smoking	71 (21.4%)	10 (21.3%)	.99
Health insurance coverage	248 (74.7%)	33 (70.2%)	.51
Body mass index	27.3 (7.13)	30.5 (7.68)	.01*
Sexual minority stressors
Internalized homophobia (range 10–38)	14.2 (4.98)	16.3 (6.52)	.01*
Stigma consciousness (standardized; range −2.55 to 2.82)	0.117 (0.98)	−0.01 (0.88)	.40
Sexual orientation-based discrimination	0.67 (1.13)	0.50 (1.09)	.35

Sample sizes vary due to missing data for household income, body mass index, internalized homophobia, and sexual orientation-based discrimination. Student’s t test and Chi-square testing were used for continuous and categorical study variables, respectively, to determine differences between participants with and without hypertension at Wave 4.

^aOther sexual identity includes participants who identified as something other than lesbian/gay, mostly lesbian/gay, or bisexual (e.g., pansexual, queer).

^bOther gender identity includes participants who identified as something other than female or transgender male (e.g., gender non-binary, genderqueer, gender fluid).

^* p < .01.

In additional bivariate analyses we found that greater stigma consciousness was positively associated with internalized homophobia (p < .001) and sexual orientation-based discrimination (p < .001). Internalized homophobia was not associated with sexual orientation-based discrimination (p = .54). Age (p < .001) and educational attainment (p < .001) were negatively associated with sexual orientation-based discrimination. Age was also negatively associated with stigma consciousness (p < .01). In addition, bisexual (p < .001) and mostly lesbian/gay participants (p < .01) reported higher internalized homophobia than lesbian/gay participants. Individuals who reported their gender identity was something other than female or male reported greater sexual orientation-based discrimination than cisgender (i.e., non-transgender) female participants (p < .01). Current smokers also reported greater sexual orientation-based discrimination (p < .001).

Table 2 presents the results of multiple logistic regression models examining the associations of sexual minority stressors with incident hypertension. There was no evidence of considerable multicollinearity (VIF = 1.23). In unadjusted logistic regression models, we found that a 1-standard deviation increase in internalized homophobia was significantly associated with higher odds of incident hypertension (OR 1.41, 95% Cl: 1.07–1.84, p = .02). Stigma consciousness (OR 0.88, 95% CI: 0.64–1.19, p = .43) and sexual orientation-based discrimination (OR 0.86, 95% CI: 0.60–1.15, p = .46) were not associated with incident hypertension. In mutually adjusted logistic regression models with covariate adjustment, we found that a 1-standard deviation increase in internalized homophobia scores was associated with higher odds of incident hypertension (AOR 1.48, 95% Cl: 1.06–2.07, p = .02). Stigma consciousness (AOR 0.85, 95% CI: 0.56–1.26, p = .32) and sexual orientation-based discrimination (AOR 1.07, 95% CI: 0.72–1.52, p = .51) were not associated with incident hypertension.

Table 2.

Results of multiple logistic regression models examining the associations of sexual minority stressors with incident hypertension

	Model 1a	Model 2a
	OR	AOR
	(95% Cl)	(95% Cl)
Internalized homophobia	1.41 (1.07–1.84)*	1.48 (1.06–2.07)*
Stigma consciousness	0.88 (0.64–1.19)	0.85 (0.56–1.26)
Sexual orientation-based discrimination	0.86 (0.60–1.15)	1.07 (0.72–1.52)
Age (in years)	–	1.05 (1.02–1.09)*
Sexual identity	–
Lesbian/gay		Ref
Mostly lesbian/gay		1.14 (0.46–2.83)
Bisexual		1.10 (0.42–2.89)
Other sexual identity		1.56 (0.09–27.71)
Gender identity	–
Cisgender female		Ref
Transgender male		4.22 (0.32–55.70)
Other gender identity		0.77 (0.06–10.24)
Race/ethnicity	–
White		Ref
Black/African American		1.26 (0.51–3.05)
Hispanic/Latinx		0.77 (0.27–2.02)
Another race		0.84 (0.04–5.08)
Educational attainment	–
High school or less		Ref
Some college		0.92 (0.31–2.80)
Bachelor’s degree or higher		0.49 (0.16–1.54)
Household income	–
< $20,000		Ref
$20,000–40,000		1.30 (0.44–3.69)
$40,000–75,000		0.88 (0.27–2.73)
≥75,000		2.01 (0.70–6.00)
Current smoking	–
No		Ref
Yes		1.05 (0.43–2.39)
Health insurance coverage	–
Yes		Ref
No		1.98 (0.83–4.75)
Body mass index	–	1.05 (1.00–1.10)*

Model 1 = Odds ratios are from separate unadjusted logistic regression models; Model 2 = Odds ratios are from logistical regression model mutually adjusted for sexual minority stressors and demographic and clinical factors. Sample sizes vary across models due to missing data for household income, body mass index, internalized homophobia, and sexual orientation-based discrimination. Sample sizes for Model 1 were 378 for both internalized homophobia and stigma consciousness. The sample size for Model 1 was 362 for sexual orientation-based discrimination. The sample size for Model 2 was 348.

^aIncident hypertension was measured at Wave 4. All other variables were measured at Wave 3. Internalized homophobia and stigma consciousness were standardized for logistic regression models.

^* p < .05.

Our exploratory analyses revealed no significant interactions between sexual minority stressors with race/ethnicity or sexual identity; suggesting that the association of sexual minority stressors with incident hypertension did not differ by race/ethnicity or sexual identity.

Discussion

Results of this study make an important contribution to hypertension and sexual minority health research. This is the first study to document that internalized stigma is associated with incident hypertension in any population of adults. The CHLEW study provided a unique opportunity to examine the longitudinal associations of sexual minority stressors with hypertension in a racially/ethnically diverse sample. Although other studies have examined sexual orientation differences in the prevalence of hypertension [56–59], researchers have not examined correlates of incident hypertension in sexual minority adults [3].

Findings of prior research on the links between internalized stigma (e.g., internalized racism, internalized sexism) and hypertension in the general population have been mixed [30, 60, 61]. It is important to note that all prior studies examining these associations were cross-sectional. Using data from the National Survey of American Life, Chae and colleagues [30] found that Black/African American men (N = 1,261) who reported more negative racial group attitudes had 21% higher odds of reporting a diagnosis of cardiovascular disease (i.e., hypertension, heart attack, stroke, atherosclerosis). In contrast, in another cross-sectional study of 91 Black/African American men, Chae and colleagues [61] found that internalized racial bias was not associated with hypertension prevalence. Similarly, Tull et al [60]. found that among Black/African American women (N = 129) internalized racism was not associated with blood pressure.

Our findings contradict those of the only other study that has investigated the associations of internalized stigma with hypertension among sexual minority adults [33]. In a sample of 1,029 Black and white sexual minority women, Molina and colleagues [33] found no significant association between internalized homophobia and hypertension. Notably, the Molina study was cross-sectional, whereas a major strength of the present study was the use of longitudinal data. Molina and colleagues [33] had a larger overall sample size, but their sample was significantly younger than participants in the CHLEW study and did not include Hispanic/Latinx participants. In addition, the number of Black/African American participants (n = 75) was lower than in the present study (n = 105).

Stigma consciousness and sexual orientation-based discrimination were not associated with incident hypertension in this study. Overall, there is limited evidence of the influence of stigma consciousness on hypertension risk among adults and no previous study has examined these associations in sexual minority adults. Although we found that stigma consciousness was not associated with hypertension, in a cross-sectional study, Orom and colleagues [29] found that greater stigma consciousness was associated with a higher likelihood of being diagnosed with hypertension among Black/African American men, but not white men. Given their findings [29], it is possible that the associations of stigma consciousness and hypertension differ by demographic characteristics (e.g., race/ethnicity, gender). However, our exploratory analyses did not find evidence that these associations differed by race/ethnicity in the present sample.

In contrast with previous evidence on the associations of experiences of discrimination with hypertension in the general population [26–28], we found no significant associations between sexual orientation-based discrimination and incident hypertension. There are several possible explanations for this. Previous work has focused on lifetime exposure to discrimination [30, 62–66] whereas our study assessed the link between hypertension and sexual orientation-based discrimination in the past 12 months. It is possible that using a shorter timeframe underestimated the sample’s cumulative exposure to sexual orientation-based discrimination. Also, whereas most research on the link between experiences of discrimination and hypertension has examined experiences of discrimination attributed to race/ethnicity, our study focused on sexual orientation-based discrimination. Future studies should investigate if experiences of discrimination attributed to different identities (e.g., sexual orientation, race, gender) have different associations with hypertension risk in marginalized adults.

Recommendations for Future Research

Our findings have important implications for future research on hypertension in sexual minority adults and other marginalized groups. We found that internalized homophobia, an individual-level minority stressor, was associated with incident hypertension independent of other sexual minority stressors. Although prior work has not investigated these associations among sexual minority adults, recent studies have found that individual-level minority stressors, such as internalized stigma and anticipated discrimination, are important predictors of adverse health outcomes (e.g., poor sleep quality, pre-clinical cardiovascular disease) among racial/ethnic minority adults [30, 67, 68]. Specific to cardiovascular health, in a cross-sectional study of 55 Black/African American women, Lewis and colleagues [68] found that expectations of racism were associated with higher levels of carotid intima media thickness (a strong predictor of cardiovascular disease) independent of experiences of racism. One possible explanation for our findings and those of Lewis and colleagues [68] is that individual-level minority stressors may be more pervasive than interpersonal-level stressors, such as experiences of discrimination, which may not occur as frequently for marginalized persons.

Some investigators posit that internalized forms of stigma moderate the relationship between experiences of discrimination and hypertension. In prior work, Chae and colleagues [61] tested whether internalized stigma (in the form of implicit racial bias) moderated the associations of racial discrimination with hypertension. In a cross-sectional study of 91 Black/African American men they found that among participants with greater implicit racial bias, reporting more frequent experiences of racial discrimination was associated with a 51% higher probability of hypertension [61]. In contrast, in the present study we did not find that sexual minority stressors interacted with race/ethnicity or sexual identity to influence hypertension risk. Despite evidence that sexual minority people of color and bisexual individuals experience higher risk of hypertension [13, 35, 36], our hypotheses that the associations of sexual minority stressors with incident hypertension would be stronger among these groups were not supported. This is likely due to the small number of people of color (n = 28) and bisexual (n = 10) individuals in our study who developed hypertension between Waves 3 and 4. Findings from the present study and prior work indicate there is a need for future research that investigates the complex links between minority stressors across multiple levels and how they influence hypertension risk in sexual minority adults and other marginalized groups.

There is a need for future studies with larger samples of sexual minority adults that use intersectional approaches to investigate the associations between exposure to minority stressors due to multiple intersecting identities and hypertension [69, 70]. Given the lack of longitudinal data on correlates of hypertension among sexual minority adults, future work should investigate the impact of other psychosocial stressors (e.g., childhood trauma, intimate partner violence) that have been found to be associated with hypertension risk among adults in the general population [71–73]. The mounting evidence of health disparities among sexual minority individuals warrants the inclusion of measures of sexual orientation and minority stressors in population-based health studies [3, 74]. The availability of those data across population-based health studies would help researchers and other stakeholders (e.g., funding agencies, policymakers) better understand factors associated with hypertension risk in sexual minority individuals.

Recommendations for Clinical Practice

Our findings provide evidence that can be used to inform clinical practice with sexual minority adults. It is important that clinicians and health professions students be educated about factors associated with hypertension in sexual minority adults. Our results suggest that there is a need to develop tailored interventions to address internalized homophobia as a risk factor for hypertension in sexual minority adults. A recent systematic review of interventions to reduce minority stress among sexual and gender minority populations found that only 27% of them targeted internalized homophobia [75]. However, the majority of these interventions focused on reducing internalized homophobia among sexual minority men within the context of HIV and/or mental health [75]. Furthermore, very few interventions have focused on reducing hypertension risk among sexual minority adults [76, 77]. Our findings support the need to develop and test culturally tailored interventions that target internalized homophobia to reduce hypertension risk.

Limitations

Despite its strengths, this study has several limitations. First, hypertension diagnosis was self-reported. This may have led to underreporting of hypertension given that sexual minority adults have lower rates of health care utilization than heterosexual people [78–80], which is largely attributed to fear of discrimination from healthcare providers [81–83]. Despite evidence of moderate to high correlation between self-reported and objective measures of hypertension [84, 85], the use of objective measures is preferred to reduce misclassification [86, 87]. This is an important issue that must be considered in future work as approximately 20–30% of adults with hypertension in the U.S. remain undiagnosed [88, 89]. Second, the CHLEW sample was recruited using convenience sampling methods in the greater Chicago metropolitan area. Although many of the participants have moved to other parts of the U.S., the generalizability of our findings is limited. Third, it is important to acknowledge that the Stigma Consciousness Scale may not reflect all possible stereotypes that bisexual individuals encounter, and therefore, may underestimate stigma consciousness in this group. Further, important risk factors for hypertension, such as diet and physical activity [90], were not assessed, which may contribute to residual confounding. Lastly, we identified differential loss to follow-up between Waves 3 and 4. Non-responders were more likely to report lower household incomes [91, 92], lower educational attainment [91, 93, 94], racial/ethnic minority identity [35, 95, 96] and bisexual identity [13, 35, 43], each of which has been associated with increased hypertension risk in adults. It is possible that we underestimated the incidence of hypertension in the CHLEW study.

Conclusion

The study is among the first to examine the longitudinal associations of sexual minority stressors with hypertension in a racially/ethnically diverse sample of sexual minority adults assigned female sex at birth. Our results indicate that internalized homophobia was significantly associated with higher odds of incident hypertension. Other sexual minority stressors examined in this study were not associated with hypertension. Findings underscore the importance of educating clinicians and health profession students about risk factors for hypertension in sexual minority adults. Future studies should conduct comprehensive examinations of sexual minority stressors and other factors that may contribute to a higher risk of hypertension among sexual minority individuals.

Funding

Dr. Caceres was supported by National Heart, Lung, and Blood Institute (K01HL146965). Dr. Hughes was supported by National Institute on Alcohol Abuse and Alcoholism (R01AA013328-15). Yashika Sharma was supported by a predoctoral fellowship from the American Heart Association (Grant number 899585).

Compliance with Ethical Standards

Conflict of Interest: The authors declare that they have no conflict of interest.

Ethical Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

CRediT Author Statement: B.A.C.: conceptualization, methodology, writing—original draft preparation, writing—reviewing and editing, funding acquisition. Y.S.: ­conceptualization, writing—original draft preparation, writing—­reviewing and editing. A.L.: methodology, software, data curation, formal analysis. M.M.W.: conceptualization, methodology, supervision, formal analysis. T.L.H.: conceptualization, writing—reviewing and editing, supervision, project administration, funding acquisition.

Transparency Statements: (1) Study registration: The study was not formally registered. (2) Analytic plan pre-registration: The analysis plan was not formally pre-registered. (3) Data availability: De-identified data from this study are not available in a public archive. De-identified data from this study will be made available (as allowable according to institutional IRB standards) by emailing the corresponding author. (4) Analytic code availability: Analytic code used to conduct the analyses presented in this study are not available in a public archive. They may be available by emailing the corresponding author. (5) Materials availability: Materials used to conduct the study are not publicly available.