Cardiovascular health concerns in sexual and gender minority populations

Abstract

Growing evidence indicates that sexual and gender minority populations might be at greater risk of cardiovascular disease than the general population. Additional population and clinical health research is needed to inform the development of tailored, evidence-based interventions to promote the cardiovascular health of sexual and gender minority populations.

Sexual and gender minority (SGM) populations include diverse groups of individuals, with various sexual orientations and gender identities (TABLE 1). Over the past two decades, the health needs of SGM individuals have received growing attention worldwide. In 2020, the US National Academies of Sciences, Engineering, and Medicine released a report highlighting the varied health disparities that persist among SGM populations¹. These include, among others, a higher prevalence of depressive disorders, substance use and suicidality¹. The National Academies further highlighted the continued need to address SGM health across the lifespan and across physical and mental health domains.

Table 1 |.

Glossary of terms for sexual and gender minority health

Cisgender	People whose gender identity is aligned with traditional expectations based on their sex assigned at birth, such as a female-identified person who was assigned female sex at birth.
Gender identity	A person’s sense of being a boy/man, a girl/woman, a combination of boy/man and girl/woman, having no gender at all, or something else.
Gender minority	A broad group of people who experience an incongruence between their gender identity and what is traditionally expected based on their sex assigned at birth. Can include gender identities such as transgender and gender non-binary persons.
Gender non-binary	Used by some people who identify as either a combination of girl/woman and boy/man, as having no gender, or as something else.
Heterosexual/straight	A person who is attracted to people of the other binary gender to themselves. Cisgender and transgender individuals can be heterosexual/straight.
Sex	Biological sex characteristics (chromosomes, gonads, sex hormones and/or genitals). Can include male, female, intersex. Often used interchangeably with ‘sex assigned at birth’.
Sex assigned at birth	Based on phenotypic presentation of an infant and categorized as male or female; different from gender identity.
Sexual minority	A broad group of people who have a sexual orientation that is anything other than heterosexual/straight. Can include sexual orientations such as gay, bisexual, lesbian or something else.
Sexual orientation	A person’s physical, emotional and romantic attachments in relation to gender. Separate from gender identity. Everyone has a sexual orientation.

SGM cardiovascular health concerns

Rapidly growing evidence indicates that SGM adults have an increased risk of cardiovascular disease (CVD) compared with their cisgender, heterosexual counterparts^1,2. A systematic review of 31 studies found that sexual minority men and women reported higher rates of tobacco use than heterosexual adults³. Lesbian and bisexual women were also more likely to report higher alcohol consumption and to meet criteria for obesity than heterosexual women³. Greater exposure to discrimination and violence (such as sexual abuse) has been shown to increase self-reported CVD risk in sexual minorities².

Analyses of population-based data indicate that gender minority adults in the USA report a higher prevalence of smokeless tobacco use than cisgender women⁴. Also, gender non-binary adults are more likely than cisgender women to report heavy drinking⁴. Overall, research on social determinants of cardiovascular health in transgender adults is limited. Most cardiovascular research on transgender people has focused on examining gender-affirming hormone therapy (for example, using oestrogen or testosterone). Gender-affirming hormone therapy, a medical intervention used by many transgender adults to acquire secondary sex characteristics that are more aligned with their gender identity, has been posited to increase CVD risk in this population. Data on the associations between gender-affirming hormone therapy and CVD risk in transgender men is mixed^2,5. By contrast, several studies have found that transgender women taking feminizing hormones might be at increased risk of myocardial infarction and ischaemic stroke⁵. Research on CVD risk in transgender adults has methodological challenges that should be acknowledged, such as short-term follow-up and reliance on small clinical groups^2,5.

In 2020, we led the AHA’s first scientific statement on the cardiovascular health of SGM adults, which provided an overview of existing research investigating cardiovascular health disparities in SGM adults and an examination of the limitations of this body of evidence². Existing research on SGM cardiovascular health has been limited by a number of methodological weaknesses, including limited collection of data on sexual orientation and gender identity (SOGI) in population-based and clinical datasets. In general, existing research has not included comprehensive assessments of minority stressors or other social determinants hypothesized to drive SGM cardiovascular health disparities². The majority of studies have also used cross-sectional, self-reported data from the USA, with limited evidence from other countries.

Clinical recommendations

A major challenge in advancing cardiovascular research in SGM populations has been the lack of available data on SOGI across clinical databases. Given that clinicians depend on the data available to them, to even to begin identifying SGM populations and the health disparities they face, clinicians must be part of data-collection procedures. In the USA, the ability to collect SOGI data in electronic health records (EHRs) has been required since 2018 as part of the meaningful use of EHRs. However, this policy does not require clinicians actually to collect SOGI data; they must have the tools but they are not compelled to use them⁶. Collecting patient-reported data, including information on SOGI as well as social determinants of health, must be integrated into standard clinical practice not only for SGM populations but for all patients, where relevant. Through EHR data, researchers will then be able to modify and update clinical tools (such as cardiovascular risk calculators) to account more accurately for the unique cardiovascular risks and outcomes among SGM populations⁷.

Improving the cardiovascular health of SGM individuals requires clinicians to be trained to understand and address the various health disparities unique to these populations^8,9. Although several organizations provide curricular recommendations about caring for SGM populations, substantial resources are needed to reduce SGM health disparities. Local, national and international accrediting bodies and organizations responsible for setting curricular content must require the inclusion of SGM-related issues. This content applies not only to health-care professionals’ training (such as undergraduate and graduate medical education) but also to continuing education, licensure and maintenance of certification for practising clinicians.

Clinicians must uphold SGM-supportive and SGM-inclusive policies within their health-care systems. A survey in the USA found that 16% of SGM adults report being personally discriminated against because of their SGM status¹⁰. Additionally, 22% of transgender individuals avoided doctors or health care because of a concern that they would be discriminated against; 31% of transgender persons say they have no regular doctor or form of health care because of a fear of discrimination¹⁰. Clinicians must consider ways to support and increase the visibility of SGM patients in their health-care settings and society at large. This step is necessary to reduce the fear of discrimination and improve patient–clinician communication as well as patient and community well-being.

Despite growing evidence of cardiovascular health disparities in SGM adults and a lack of awareness about SGM health issues among clinicians, no study has so far investigated knowledge of SGM cardiovascular health concerns among cardiologists or other clinicians that provide cardiovascular care. Moreover, no clinical guidelines are available outlining best practices for addressing and reducing cardiovascular risk in SGM individuals. These knowledge gaps limit the development of culturally tailored, evidenced-based interventions to promote the cardiovascular health of SGM populations.

Conclusions

Although growing research demonstrates the cardiovascular health disparities among SGM populations, efforts to addresses these concerns are limited. In addition to expanding population health research on SGM cardiovascular health, future clinical research is needed to inform the development of evidence-based interventions to promote the cardiovascular health of SGM populations. Ultimately, to begin to address disparities in SGM cardiovascular health, clinical and public health professionals must build trust with SGM populations.