Sexual minority populations and disparities in cardiovascular healthcare

Introduction

Cardiovascular disease (CVD), such as heart attack, coronary heart disease, and stroke, remains the leading cause of death worldwide (1,2). The prevalence of CVD is expected to increase by 90% due to population aging and rising rates of obesity, hypertension, and diabetes (2). Regional disparities are anticipated to persist, with the highest cardiovascular mortality projected in Central Europe, Eastern Europe, and Central Asia (2,3). Therefore, it is critical to address the cardiovascular health (CVH) disparities that have been observed across several population groups (1).

Sexual minority (SM; e.g., lesbian, gay, bisexual, queer, and other non-heterosexual) people represent a growing population globally that has been documented to have a higher prevalence of several CVD risk factors compared to heterosexual people across the lifecourse (4–6). A recent online survey conducted in 43 countries estimated that 3–11% of adults identify as SM with higher estimates observed among those living in progressive environments and younger generations (7). For instance, in the United States (US), approximately 23% of Gen-Z (those born between 1997–2006) identifies as SM (8).

Table 1 summarizes research on CVH disparities among SM people. Multiple studies have demonstrated that SM youth and adults have a higher prevalence of tobacco (9–13) and alcohol use (12,14–16) compared to their heterosexual counterparts. These disparities are attributed in part to efforts by tobacco and alcohol companies to market their products at SM bars and community events (17,18). Moreover, SM youth and adults are at higher risk of sleep problems (e.g., short sleep duration, poor sleep quality) than heterosexual people (19–22).

Table 1.

Summary of research on cardiovascular health disparities among sexual minority people.

Risk factors	Relevant findings
Tobacco use	• Higher prevalence of tobacco use among sexual minority people compared to their heterosexual counterparts across the lifecourse • Tobacco use appears to be highest among bisexual adults
Alcohol use	• Higher prevalence of alcohol use among sexual minority people compared to their heterosexual counterparts across the lifecourse • Tobacco use appears to be highest among sexual minority women and bisexual adults
Sleep health	• Higher prevalence of sleep problems (e.g., short sleep duration, poor sleep quality) among sexual minority people compared to their heterosexual counterparts across the lifecourse • Sleep problems are highest among sexual minority women and people of color
Physical activity	• Findings for sexual minority women and bisexual men are mixed • Gay men, particularly younger men, are more likely to meet physical activity recommendations than heterosexual men • Older gay men are less likely to engage in physical activity than older heterosexual men • Sexual minority girls and boys have a higher prevalence of physical inactivity than their heterosexual peers
Diet quality	• Gay and bisexual men have better diet quality than gay men • Findings for sexual minority women are mixed
Obesity	• Sexual minority women are consistently shown to be more likely to meet criteria for obesity relative to heterosexual women • Bisexual men may be more likely than heterosexual men to meet criteria for obesity • Gay men are less likely than heterosexual me to meet criteria for obesity • Sexual minority people of color are at higher risk of obesity than both their White sexual minority and heterosexual counterparts
Hypertension	• Findings are mixed, but sexual minority people of color are at highest risk of hypertension than both their White sexual minority and heterosexual counterparts
Diabetes	• Findings are mixed • Younger sexual minority women are at higher risk of developing diabetes than younger heterosexual women • Sexual minority people of color are at highest risk of diabetes than both their White sexual minority and heterosexual counterparts
Hyperlipidemia	• No consistent disparities observed between sexual minority and heterosexual people

Fewer studies have examined disparities in physical activity (PA) and diet quality, but findings for SM women are largely mixed (23–26). In contrast, gay men report higher PA than heterosexual men (23,24). Studies conducted in the US and France have found that gay and bisexual men have better diet quality than heterosexual men (6,25–27). Among youth, SM boys and girls are less likely to PA recommendations than heterosexual youth (12,28,29).

There is overwhelming evidence that SM women are more likely than heterosexual women to meet criteria for obesity (4,6,30,31). Gay men appear less likely than heterosexual men to meet criteria for obesity, whereas findings for bisexual men are conflicting (4,6,30,32,33). SM girls and bisexual boys in the US have 32–53% higher odds of meeting criteria for obesity than their heterosexual peers (12).

Research on disparities in hypertension and diabetes among SM people is conflicting (5,31,32,34–36). However, SM women and bisexual men have a higher risk of hypertension in studies that have objectively assessed blood pressure (32,34–36). Most studies suggest that there are no differences in hyperlipidemia or the use of lipid-lowering medications between SM and heterosexual adults (4,6,36–38). Evidence on disparities in CVD diagnoses is conflicting and has been primarily based on self-reported data (4,39–44).

Leading health organizations have called for increased efforts to address CVH disparities among SM populations; however, significant gaps remain. To our knowledge, no interventions specifically target CVD risk and/or management among SM people, which presents a barrier to progress in the field. Further, the mechanisms underlying these disparities remain unclear. Understanding mechanisms contributing to CVH disparities among SM people can help identify effective targets for clinical and public health interventions. Therefore, the purpose of this state-of-the-art review was to: 1) elucidate the potential mechanisms underlying CVH disparities among SM populations; 2) analyze research gaps; and 3) provide suggestions for improving cardiovascular care and identifying potential targets for clinical and public health interventions in this population.

Importantly, this review does not include gender minority (e.g., transgender, nonbinary) people. Gender minority people encounter distinct clinical factors (e.g., gender-affirming care) and greater social challenges that can impact their CVH differently than SM people (45). Thus, the CVH of gender minority people warrants tailored interventions and separate investigation from SM people.

Potential Mechanisms of CVH Disparities among SM People

Social determinants of health, such as socioeconomic status and experiences of discrimination, can influence stress exposure and access to care (46). The minority stress model, the prevailing explanation for health disparities among SM people (47,48), was adapted in 2020 to examine CVH disparities among SM people (4). The newly adapted minority stress model of CVH integrates the minority stress (47,48) and socioecological models (49) to explicate how chronic exposure to minority stressors is a fundamental driver of adverse cardiovascular outcomes among SM people (4). Minority stressors at the individual (e.g., expectations of rejection), interpersonal (e.g., experiences of discrimination), and structural (e.g., discriminatory policies) levels are theorized to influence CVD risk among SM people through psychosocial (e.g., depressive symptoms), behavioral (e.g., tobacco use), and physiological (e.g., chronic inflammation) pathways (4).

Structural stigma (i.e., “the societal-level conditions, cultural norms, and institutional policies that constrain opportunities, resources, and wellbeing [59])” is an important but understudied minority stressor in the literature. Acceptance of SM people and discriminatory policies, which may impact the CVH of SM people, vary widely globally. For instance, same-sex relationships are criminalized in approximately one-third of countries (51). There has also been a recent proliferation of discriminatory policies targeting SM people in Europe, the Middle East, Asia, and North America (52,53). These policies can heighten chronic stress, which can affect their CVH.

Guided by the AHA’s Life’s Essential 8 (54), we summarize research on mechanisms of disparities in tobacco use, sleep health, PA, diet quality, obesity, hypertension, diabetes, hyperlipidemia, and CVD diagnoses among SM people. Given that psychological health and alcohol use are associated with CVH (55,56) and because of their heightened prevalence among SM people (4,16,57,58), we also summarize evidence for these factors.

Psychological Health

Psychological health plays an important role in CVD development (56,59). Indeed, the addition of depression to Life’s Essential 8 enhances prediction of cardiovascular and all-cause mortality (56,59). Therefore, researchers have called for the addition of psychological health to CVD risk prediction algorithms (56).

Adverse psychological health outcomes are hypothesized as key drivers of CVH disparities among SM people (4). Meta-analyses indicate that SM youth and adults have a higher prevalence of adverse psychological health outcomes, such as depression and anxiety, that is primarily attributed to minority stressors and interpersonal violence (e.g., physical abuse, sexual abuse) (57,58).

Alcohol Use

Multiple studies from the US have found that minority stressors, interpersonal violence, and living in socially conservative environments are associated with higher alcohol use among SM people (60–62). Structural stigma has also been linked with higher alcohol use and adverse alcohol-related outcomes among SM populations, particularly SM people of color (63,64).

Tobacco Use

Several determinants of tobacco use have been identified among SM people. A recent systematic review found that of the 28 studies that assessed experiences of discrimination, 86% (n=24) identified discrimination as a contributor to tobacco use among SM people (65). A notable gap was that only five (11.3%) studies were conducted outside the US (65). Experiences of discrimination are also associated with concurrent use of two or more tobacco products among SM adults (66). Further, a cross-sectional study of over 11,000 SM adolescents in the US found that family rejection was independently associated with increased tobacco use (67).

Interpersonal violence is an important predictor of tobacco use among SM people. Analyses of US data (N = 15,612) found that peer victimization and sexual abuse were significantly associated with increased tobacco use among SM adolescents (68). These findings are consistent with prior work among SM adults (69,70).

Social connectedness (i.e., one’s perception of belongingness) appears to influence tobacco use among SM people. In a sample of SM women in the US (N = 501), investigators found that in-person social support was associated with both increased and decreased tobacco use during the beginning of the COVID-19 pandemic (71). In addition, an analysis of over 670,000 adults in the US found that SM people living in rural areas had 38% higher odds of smoking than those living in urban areas (72). Evidence from qualitative studies suggests that SM people engage in smoking as a way to facilitate bonding and reinforce a sense of community people (73).

Studies from Canada, the Netherlands, and the US indicate that structural stigma is positively associated with tobacco use among SM people across the lifecourse (64).

Sleep Health

A scoping review of 76 US-based studies found that minority stressors were the most widely studied determinants of sleep health among SM people; however, only one study examined structural stigma (19). In a sample of 17,378 people in the US, investigators found that women in same-sex couples who lived in states with lower support for same-sex marriage reported feeling less rested relative to women in different-sex couples (74). Studies in the US and China have shown that minority stressors, including experiences of discrimination, anticipated discrimination (i.e., expectation of encountering discrimination), and internalized homophobia (i.e., one’s internalization of negative societal values towards SM people), are associated with shorter sleep duration and poor sleep quality among SM adults (75–77). Moreover, studies in France have found that lower perceived neighborhood safety, greater financial hardship, and greater neighborhood crime are associated with poor sleep quality among SM men (78–80).

Physical Activity

Few studies have examined determinants of PA among SM adults, but qualitative studies from the US and Australia provide plausible explanations for the higher PA observed among gay men (81–83). Gay men report their PA regimens are largely motivated by a desire to achieve and/or maintain a slim or muscular body and fears of not conforming to body expectations within the gay community (81). Although findings related to PA among SM women are largely mixed (23,24), motivations for engaging in PA may vary by age (84). For instance, younger SM women appear more likely to view body diversity as empowering, while older SM women place a greater emphasis on engaging in PA to promote their health (84).

There is more evidence on factors that drive lower engagement in PA among SM youth (12,28,29). A study of adolescents in the US (N = 1,926) found that lower PA and lower engagement in team sports among SM participants were partially explained by greater childhood gender nonconformity and lower athletic self-esteem (29). Higher parental expectation for PA was associated with lower PA among SM boys, but not SM girls (29). Another potential explanation is provided by social identity theory, which posits that heteronormativity in sports as well as both covert and overt discriminatory attitudes contribute to lower PA among SM youth (85).

Diet Quality

SM people have a higher prevalence of disordered eating across the lifecourse (86,87) that is partially attributed to minority stressors (26,88,89) and can influence their diet quality. Moreover, food insecurity (i.e., lack of regular access to sufficient food for healthy living) is an important contributor to poor diet quality (90,91), CVD risk, and cardiovascular mortality (92,93). SM women are more likely to experience food insecurity than heterosexual women (26,94). Investigators have yet to examine whether disordered eating and food insecurity play a role in the documented disparities in diet quality among SM women (25).

Obesity

As described above, SM women appear to have a higher prevalence of obesity than heterosexual women. This has been attributed, in part, to their rejection of heteronormative standards of women’s beauty and greater acceptance of diverse body types (95). Determinants of obesity among SM women include greater childhood and adult trauma (96–98), depressive symptoms, binge eating, and heavy drinking (99,100). Longer relationship length and lower relationship consensus also contribute to increased risk of obesity among SM women (99). Factors associated with a lower likelihood of obesity among SM women include exercising with a same-sex peer (29) and living in an environment that is supportive of SM people (101).

For SM men, lower educational attainment (102), unemployment (103), greater childhood sexual abuse (104), greater disordered eating and body dissatisfaction (105), and higher depressive, anxiety, and stress symptoms (103) are associated with higher risk of obesity. Among SM college students, men living in environments that are supportive of SM people appear to have lower odds of having elevated body mass index (101).

Few studies have examined the influence of minority stressors on obesity among SM people and evidence is mixed. A recent study of 731 gay men in Taiwan found that minority stress strengthened the influence of childhood sexual abuse on obesity (104). Similarly, a study of 367 SM youth in the US found that microaggressions (defined as “verbal and behavioral interactions that intentionally or unintentionally communicate disparaging and invalidating messages to minoritized people” (106)) were associated with 88% higher odds of meeting criteria for obesity (107); however, SM internalized stigma and SM victimization were not associated with obesity (107).

Hypertension

Research investigating mechanisms leading to hypertension disparities has largely focused on minority stressors and interpersonal violence (97,98,108,109). Analyses of data from the Chicago Health and Life Experiences of Women (CHLEW) Study found that both lifetime exposure to trauma and revictimization (i.e., experiencing trauma in both childhood and adulthood) were associated with higher odds of hypertension among SM women (97,98). In this same dataset, investigators found that internalized homophobia, but not sexual orientation-based experiences of discrimination, was associated with 48% higher odds of developing hypertension at 7-year follow-up (N = 380) (109). However, this contradicts findings from a previous cross-sectional study that found no association between internalized homophobia and hypertension among SM women (108).

Findings are mixed for SM men. Analyses of data from the National Longitudinal Study of Adolescent to Adult Health (Add Health; N = 6,678) in the US found that gay and mostly gay men had higher odds of hypertension compared to heterosexual men (110). This finding remained significant after adjusting for experiences of discrimination and physical abuse (110). Among men who have sex with men (MSM) living with HIV in the US (N = 60), those who reported experiences of racial discrimination had greater odds of hypertension compared with those who did not (111). However, sexual orientation-based discrimination was not associated with hypertension (111). New evidence suggests that conversation therapy (i.e., practices used to change same-sex attractions and behaviors and/or SM identities) may impact hypertension risk among SM men (112). Investigators in the US found that SM men (N = 703) who were ever exposed to conversion therapy had higher systolic and diastolic blood pressure and had 2.8 times higher odds of reporting a diagnosis of hypertension than those who did not receive conversion therapy (112).

Although family-related factors are important for the well-being of SM people (113), limited research has examined their role in the development of hypertension in this population (4). A notable exception is a cross-sectional analysis of CHLEW data that found that greater family social support, but not disclosure of sexual orientation to family, was associated with lower odds of developing hypertension among SM women (114).

Additional analyses of Add Health data (N = 3,396) found that a higher number of state-level sexual orientation-based nondiscrimination laws was protective, with an 18–20% lower risk of hypertension during pregnancy among African American/Black SM women as well as among White women regardless of their sexual orientation (115).

Diabetes & Hyperlipidemia

Fewer studies have examined determinants of diabetes and hyperlipidemia among SM people. Analyses of CHLEW data (N = 547) found that childhood trauma, but not adulthood trauma, was associated with 58% higher odds of self-reported diabetes among SM women (98). In another study of SM women (N = 1,029), investigators found that internalized sexism, but not internalized homophobia, was associated with 2 times higher odds of self-reported diabetes (108). Given that there are few sexual orientation differences in hyperlipidemia, it is not surprising that there is limited evidence on determinants of hyperlipidemia.

CVD Diagnoses

There is a paucity of studies examining determinants of CVD diagnoses among SM people. Some studies have identified associations between sexual orientation and CVD diagnoses that persist despite adjusting for social determinants, suggesting that there are unmeasured factors that drive CVH disparities among SM adults (41,42,44,116,117). Although not measured in existing studies, researchers postulate that the development of CVD among SM adults is influenced by exposure to minority stressors.

Mediating Factors

There is growing research regarding factors that mediate the associations of minority stressors and other social determinants with CVD risk among SM people. Most of this work has focused on psychological health. Consistent with the minority stress model of CVH, multiple studies have found that depressive symptoms, anxiety, and psychological distress partially mediate the associations of minority stressors with tobacco use (118–120), alcohol use (121–123), and sleep problems (22,77,124) among SM youth and adults. Further, adulthood trauma appears to mediate the associations of childhood trauma with tobacco use among bisexual women (125). In addition, analyses of population-based data from the US found that depression and anxiety mediated the association of SM status with CVD prevalence (126). Evidence for other CVD risk factors is lacking. Overall, this evidence suggests that behavioral interventions that simultaneously target minority stressors and psychological health may be beneficial for CVD prevention and management among SM people.

Additional mediators have also been identified. A study of 2,649 SM young adults in the US found that the positive association between structural stigma and tobacco use was mediated by economic resources (i.e., financial strain and food insecurity) (127). Moreover, a study of SM adults in China (N = 401) found that primal threat (i.e., sense of threat to basic human needs) partially mediated the associations of experiences of discrimination and anticipated discrimination with sleep disturbances (76). In a study of 670 SM adults in the US, investigators found that both discriminatory experiences and internalized homophobia were indirectly associated with higher cumulative CVD risk through sense of mastery (i.e., perception of having control over one’s life) (128).

Research Gaps

Existing research on CVH disparities among SM people has significant methodological weaknesses. Most studies have focused on documenting differences in individual CVD risk factors rather than investigating the psychosocial, behavioral, and physiological mechanisms that may contribute to heightened CVD risk among SM people. Although psychological health has been identified as an important driver of CVD risk among SM people, other mechanisms remain understudied. This lack of attention to mechanisms has hindered the development of interventions to improve the CVH of SM people. The majority of studies that have focused on identifying mechanisms have been cross-sectional. Therefore, future studies with longitudinal designs are critical to illuminate these mechanisms.

Most studies use self-reported data to assess CVD diagnoses (4,39–44). This overreliance on self-reported data is a considerable limitation as SM adults, particularly women, are more likely to delay and avoid healthcare than heterosexual adults due to financial concerns and fear of discrimination in healthcare settings (129–132). Self-reported data are also susceptible to social desirability and recall bias and may underrepresent the true prevalence of CVD diagnoses. Therefore, the lack of objective cardiovascular assessments in the literature limits the reliability and generalizability of findings.

The limited inclusion of measures of sexual orientation in existing data sources, such as population-based studies and electronic health records, is another notable limitation. Much of the literature is based on overlapping datasets from the US and other high-income countries, which limits generalizability of findings to SM people living in low- and middle-income countries and our understanding of variations in CVD risk among SM populations across countries.

There is a need to examine multilevel determinants of CVH among SM people. Most evidence to date has primarily focused on interpersonal factors, such as experiences of discrimination and interpersonal violence, with limited attention to structural and neighborhood-level factors. There is also a gap related to the influence of protective factors (e.g., social support, community connectedness) on CVD risk among SM people.

Although there has been considerable work on the CVH of gay, lesbian, and bisexual people, significant gaps remain in our understanding of CVD risk among other SM groups (e.g., pansexual, asexual) (4). The prevalence of CVD risk factors and the determinants of CVH in these other SM groups remain unknown (4). Similarly, there has been limited research on CVH disparities among middle-aged and older SM adults with an existing CVD diagnosis. This is an important area for future work.

Suggestions

Despite the identified methodological limitations, there is consistent evidence that minority stressors are associated with a higher prevalence of tobacco use, alcohol use, sleep problems, physical inactivity, obesity, and hypertension among SM people across the lifecourse. Further, psychological health appears to mediate the associations of minority stressors with tobacco use, alcohol use, and sleep problems among SM people. These are important considerations that must be accounted for in future efforts to improve cardiovascular care and develop clinical and public health interventions to prevent and manage CVD among SM people.

Improving Cardiovascular Care

Figure 1 presents suggestions and implementation strategies for improving cardiovascular care of SM populations. Our suggestions provide strategies that clinicians, healthcare systems, academic institutions, community-based organizations, and policymakers can collaborate on to promote affirming cardiovascular care that meets the unique needs of SM patients. We recognize that implementation of these suggestions may vary across countries based on sociocultural context, availability of resources, healthcare infrastructure, and healthcare education.

Figure 1.

Suggestions for improving cardiovascular care of sexual minority populations.

1. Healthcare systems and academic institutions must expand clinical training and education on SM health to increase clinicians’ ability to prevent and manage CVD among SM populations. One of the greatest challenges to reducing CVH disparities is the lack of SM health training within the healthcare and public health workforce globally (133). Recent work suggests that SM adults who report having an SM-affirming clinician are more likely to attend routine checkups and follow recommendations for preventive care and screening (134). While cultural humility and inclusive care are recognized as essential components of high-quality care (135), most health professions curricula have limited content on SM health (136,137). In addition to including SM didactic content in health professions curricula, educators can incorporate the use of simulated patient encounters with SM patients and clinical rotations in local SM-serving clinics or community-based organizations. Clinicians should also advocate for widespread SM health training as part of ongoing continuing education and licensure.

2. Cardiovascular clinicians should adopt a trauma-informed, culturally-responsive approach to providing care for SM patients. Trauma-informed care recognizes the impact of trauma and focuses on creating a safe, supportive, and empowering environment (138,139). Although counseling on lifestyle modification is part of standard cardiovascular care, it is often delivered without consideration to the experiences of SM patients who may have experienced significant exposure to minority stressors and/or interpersonal violence. Clinicians could assess past exposure to minority stressors and violence to better understand factors that influence SM people’s CVH as well as their utilization of healthcare services. When possible, clinicians should refer SM patients to SM-affirming resources in the community, such as SM-affirming mental health professionals and community-based organizations.

3. Cardiovascular clinicians should advocate for the routine collection of sexual orientation during healthcare visits. Globally, the collection of data on sexual orientation during healthcare encounters is limited and varies widely (140). Without standardized collection, it is difficult for cardiovascular clinicians to effectively tailor their care to the needs of SM patients. Practicing clinicians, health professions students, and healthcare staff should be trained in sensitive collection and use of data on sexual orientation to promote inclusive cardiovascular care for SM patients. They should be prepared to explain to patients why this information is being collected and how it could inform their care. Strategies to improve sexual orientation data collection must be tailored to local infrastructure and sociocultural context. For instance, where applicable, healthcare systems can incorporate structured fields for sexual orientation into electronic health records (EHRs). In settings where EHRs are not available, intake forms should be revised to collect this information.

4. Clinicians should promote nondiscrimination policies at the healthcare system, local, and national levels that explicitly include sexual orientation. These policies are essential for addressing marginalization in healthcare settings, reducing barriers to care, and creating healthcare environments where SM patients feel safe and supported. Importantly, nondiscrimination policies must be accompanied by efforts to ensure that inclusive practices are embedded throughout the healthcare system and institutional accountability mechanisms, such as anonymous reporting systems for bias-related incidents, structured processes for staff feedback, and quality improvement initiatives.

5. Clinicians and healthcare systems should partner with policymakers and SM-led organizations to remove structural barriers to high-quality cardiovascular care for SM people. For example, these partnerships can focus on developing community-based screening and referral, advocating for legal protections for SM people, addressing food insecurity among SM communities, and expanding access to SM-inclusive healthcare.

Development and Implementation of Clinical and Public Health Interventions

Interventions for CVD prevention and management among SM people remain limited. Tobacco and alcohol use are the CVD risk behaviors that have been most targeted in individual-level behavioral interventions for SM people. A scoping review of 15 tobacco cessation and prevention programs found that most interventions tailored for SM people focused on individual-level factors, such as readiness to quit, with limited attention to multilevel determinants (141). While culturally tailored tobacco cessation programs are associated with higher participant satisfaction and engagement among SM people, their effectiveness in achieving sustained cessation is mixed (141). There is a need for tailored tobacco cessation strategies for SM populations that target multilevel determinants to reduce tobacco-related inequities.

Alcohol-related interventions for SM populations have similar limitations. A scoping review identified 15 intervention studies targeting alcohol use, most of which focused on SM men (142). The majority of interventions for alcohol use have employed individual-level approaches, such as cognitive behavioral therapy (CBT) and motivational interviewing (142). Only two interventions were identified that targeted structural features of gay bars to reduce alcohol use among SM men (142). In addition, few interventions have explored differences in intervention effectiveness across SM subgroups (e.g., gay/lesbian vs. bisexual), highlighting an important gap in the literature (142).

Interventions targeting PA, diet, and weight management among SM populations are limited. A recent scoping review found that only four interventions (all US-based) focused on PA among SM people (23). Although two of these interventions demonstrated modest improvements in PA, these interventions had notable limitations, including minimal cultural tailoring, failure to address minority stressors, and a lack of long-term follow-up (23). The Healthy Weight in Lesbian and Bisexual Women Study in the US is one of the only culturally tailored multicomponent interventions to address weight among SM women (aged 40 and older) (143). Approximately 95% of participants achieved at least one targeted health behavior change, and 58% achieved three or more, with improvements noted for PA, dietary quality, and waist-to-height ratio (143). Findings from this intervention highlight the potential benefits of multicomponent, community-based strategies that are tailored to the specific needs of SM populations (143).

To our knowledge, there are no evidence-based interventions that target other CVD risk factors (e.g., sleep health, hypertension) or that focus on improving CVD management among SM people.

Figure 2 presents suggestions and implementation strategies for clinical and public health interventions for CVD prevention and management among SM people. Our suggestions provide strategies that clinicians, healthcare systems, and community-based organizations can adopt to address CVH disparities among SM populations using a multidimensional equity-focused approach.

Figure 2.

Suggestions for clinical and public health interventions for cardiovascular disease risk reduction among sexual minority people.

1. Conduct longitudinal research to investigate the psychosocial, behavioral, and physiological mechanisms by which minority stressors and other social and structural determinants influence CVD risk and CVD management among SM people. This research can help identify the most important targets for future interventions. Strategies to enhance protective factors, such as peer support and connectedness to the SM community, should also be examined as they may influence the effectiveness of clinical and public health interventions. Moreover, although much of the existing research has focused on CVD risk, investigators must address critical knowledge gaps related to the experiences of SM people with CVD.

2. Design multicomponent interventions for the prevention and management of CVD among SM people. Prior work supports the effectiveness of interventions that target multiple risk factors, such as PA and diet quality (143). Future interventions should adapt similar modalities that incorporate multicomponent strategies.

3. Develop interventions that simultaneously target lifestyle modification, multilevel determinants (such as minority stressors, healthcare access, and food insecurity), and psychological health. Although CBT-based interventions have been successfully used to address minority stressors in the context of HIV, psychological health, and substance use among SM people (142,144), these approaches have not yet been extended to CVD risk reduction. We found that psychological health mediates the associations between minority stressors and CVH among SM people. Thus, interventions must also address psychological health to improve the CVH of SM people. For example, a multicomponent intervention could combine smoking cessation with brief CBT to manage minority stress and reduce depressive symptoms among SM people.

4. Healthcare systems should develop cross-sector partnerships with SM-led organizations to deliver community-based interventions to SM people. There is a need for public health interventions to complement clinical initiatives to support CVD prevention and management among SM people. Individual-level approaches, such as routine screening and motivational interviewing for tobacco use, can be combined with community-based strategies to reduce structural barriers to healthcare delivery. For instance, healthcare systems could partner with a local SM-led community-based organization to deliver health and social services (e.g., heart-healthy meals, peer support) to SM adults recently discharged following a CVD event.

5. Researchers and clinicians should partner with SM communities in the development and implementation of clinical and public health interventions. Community engagement is essential at each step of intervention development to ensure that interventions are culturally tailored, acceptable, and responsive to the distinct needs of subgroups within the SM community. For example, investigators developing a weight management intervention for SM women should collaborate with community members to explore values and norms around body image, potential barriers to intervention delivery, and preferred delivery methods (e.g., in-person vs. virtual; group vs. individual).

Conclusion

This state-of-the-art review builds on existing evidence regarding CVH disparities among SM people and provides suggestions for future work to eliminate these disparities. We identified multilevel determinants associated with the CVH of SM populations across the lifecourse. However, research on contributors to diabetes, hyperlipidemia, and CVD diagnoses among SM people remains limited. Based on existing evidence, we conclude that studies investigating CVH disparities among SM people have considerable methodological limitations. These limitations must be addressed in future work to improve our understanding of underlying mechanisms driving CVH disparities among SM people. We also provide suggestions for improving cardiovascular care and considerations for designing and implementing clinical and public health interventions for CVD prevention and management among SM people. This review can help cardiovascular clinicians and researchers devise strategies to reduce CVH disparities among SM populations.