Preventing cardiovascular disease among sexual and gender minority persons

With growing awareness of the unique health risks and disparate outcomes among sexual and gender minority ([SGM] e.g., lesbian, gay, bisexual, transgender, queer [LGBTQ]) populations, the U.S. National Academies of Sciences, Engineering, and Medicine recently released a report highlighting these health disparities. Among the conditions discussed, the NASEM stressed the importance of assessing and addressing cardiovascular disease (CVD) risk behaviors leading to adverse outcomes across the lifespan and specifically called attention to the need for preventive health interventions.¹

Summary of Cardiovascular Health Concerns in SGM Populations

The American Heart Association (AHA) recently published, “Assessing and Addressing Cardiovascular Health Among Sexual and Gender Minority Adults,” a comprehensive overview of the existing evidence regarding SGM adults and their increased CVD risk compared to heterosexual and cisgender peers.² Although SGM populations are often grouped together, subgroups within these populations have distinct health risks and exposures. For example, analyses of Behavioral Risk Factor Surveillance System (BRFSS) data have documented a higher prevalence of self-reported tobacco use³ and CVD diagnoses⁴ in gender minority (i.e., transgender and gender diverse populations) adults relative to cisgender persons. Central to understanding CVD risk rests on understanding the varied disparities across the AHA Life’s Simple Seven (i.e., tobacco use, exercise, nutrition, weight management, lipid profile, blood pressure, and glycemic control) (Table 1).

Table 1:

Summary of Existing Evidence on Cardiovascular Risks Targets for Intervention

Populations	Tobacco Use	Inadequate Exercise	Poor Nutrition	Diabetes	Dyslipidemia	Hypertension	Excess weight
Cisgender Lesbian Women	↑	↑	↔	↑	↔	↔	↑
Cisgender Bisexual Women	↑	↑	↑	↑	↔	↔	↑
Cisgender Gay Men	↑	↓	↑	↑	↔	↑	↓
Cisgender Bisexual Men	↑	↑	↔	↑	↔	↑	↑
Transgender Women	↑	↔	↔	↔	↓	↔	↔
Transgender Men	↑	↔	↔	↔	↑	↑	↔

↑: Higher likelihood

↓: Lower likelihood

↔: Mixed results across studies and subgroups

Addressing Cardiovascular Health

Primary and secondary prevention

Primary prevention remains the foundation of cardiovascular health. Given the historical and economic forces that have led to the tobacco and alcohol industries targeting SGM communities,⁵ tobacco and alcohol consumption remain significant CVD risks for SGM persons. A recent systematic review notes that sexual minority adults report higher odds of tobacco use than heterosexual peers.³ In separate population-based studies, gender minority adults in the U.S. report a higher prevalence of smokeless tobacco use than cisgender peers.⁶ Notably, research has found that discrimination is a predictor of tobacco use.⁷ With regards to alcohol, sexual minority women are more likely to report higher alcohol consumption than heterosexual peers.³ Addressing tobacco and alcohol consumption will require utilizing community interventions that acknowledge the various forces that motivate and reinforce their use. As such, clinicians must be prepared to connect SGM patients to appropriate interventions.

Beyond primary prevention, the goals of cardiovascular care include secondary prevention. However, methodologic limitations in studies of gender minority persons further contributes to gaps in the secondary prevention of CVD risk in SGM populations. For example, most cardiovascular research on transgender people has focused on examining gender-affirming hormone therapy (e.g., estrogen, testosterone) and their relationship to CVD. Gender-affirming hormone therapy, used by many transgender persons to acquire secondary sex characteristics consistent with their gender identity, has been shown to increase certain CVD risk factors.⁸ While several studies have found transgender women receiving feminizing hormones may be at increased risk for myocardial infarction and ischemic stroke,⁹ research on the associations of testosterone therapy and CVD risk in transgender men is generally mixed.² Overall, 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 samples.²

Data collection

A major challenge in advancing cardiovascular research and clinical care has been the lack of available data on sexual orientation and gender identity (SOGI) across clinical databases. As cardiovascular health disparities research and the interventions derived from it rely on quality data, standardized collection of SOGI data in clinical and population-based settings must be implemented. Additionally, existing research has not included comprehensive assessments of minority stressors or other social determinants linked to cardiovascular health disparities in SGM people.² Consequently, identity-specific interventions are limited.

Education

Improving the cardiovascular health of SGM persons also requires clinicians to be trained to address the various health disparities unique to these populations.¹⁰ Even though curricular recommendations regarding SGM populations exist, substantial resources, in the form of structured educational content, are needed. This content must include improvements in health professions training (e.g., undergraduate and graduate medical education) as well as inclusion in continuing education, licensure, and maintenance of certification for practicing clinicians.

Conclusions

SGM individuals represent a unique subset of patients that have increased CVD risk related to behavioral, psychosocial, and physiologic factors. Even though there is a growing body of research documenting cardiovascular health disparities among SGM populations, efforts to specifically addresses these concerns can be improved, including clinician participation in data collection, awareness of unique factors contributing to disparate health outcomes, revised educational content, and population-based improvements in methodologic approaches. Clinicians must continue to follow guidance on primary prevention while also recognizing the factors contributing to increased CVD risk in SGM populations. Ultimately future research that leverages EHRs is needed to expand research initiatives and develop evidence-based interventions to promote the cardiovascular health of SGM populations. Incorporating a comprehensive approach that encompasses biobehavioral factors has the capacity to improve clinical care and cardiovascular outcomes for patients and populations.