Pub Date: Thursday, Oct 08, 2020
Author: Erin D. Michos, MD, MHS
Affiliation: Division of Cardiology, Johns Hopkins School of Medicine
A 2017 Gallup poll reported that 4.5% of US adults identify themselves as Lesbian, Gay, Bisexual, Transgender, and Queer or Questioning (LGBTQ) which translates to approximately 11 million adults. Numerous studies have suggested that LGBTQ adults are more vulnerable to poorer cardiovascular health (CVH) relative to their non-LGBTQ peers due to social, psychological, behavioral, and biological factors. Similar to other stigmatized groups, real and perceived discrimination presents a barrier to optimization of CVH and healthcare delivery.
This newly released American Heart Association (AHA) Scientific Statement led by Caceres et al  provides guidance for healthcare professionals on the knowledge to date regarding the status of CVH among LGBTQ individuals. This document discusses potential contributors to poorer CVH indices among LGBTQ individuals, calls urgently for better training & dissemination of knowledge to clinicians on LGBTQ health issues, and highlights the need for further research in this area, for the ultimate goal of improving the CVH of this community.
The medical community must universally create a safe, non-threatening, and supportive environment that provides equitable care for LGBTQ persons. Alarmingly, a significant number of sexual minority and transgender individuals have been denied healthcare services – approximately 8% denied care based on sexuality and 27% for being transgender or gender non-conforming. Thus, unfortunately, many LGBTQ adults worry about how the medical community will treat them and may not feel comfortable seeking health care. A more welcoming inclusive environment is needed to facilitate LGBTQ patients to be more willing to disclose their health concerns and develop better partnerships in health with their clinicians to ultimately improve their care and health outcomes. It is imperative that LGBTQ individuals feel safe and comfortable discussing all aspects of their lives and health with their clinicians. Avoidance of care delays the delivery of appropriate preventive lifestyle and pharmacologic recommendations.
While this AHA statement groups LGBTQ individuals together for the purposes of this framework, the authors note that the potential excess CVD risk among LGBTQ individuals is not uniform across this whole population. There are variations in CVD risk variations by one’s sex assigned at birth, their gender identity, sexual orientation, and race/ethnicity. It is also important to recognize the potential influence of intersectionality with other stigmatized identities.
As reviewed by Caceres et al in this AHA statement, there are multi-level stressors that impact the CVD of LGBTQ adults. Stressors include general life stressors (i.e., life adversity, financial stress, work stress, family stress), structural/institutional (i.e., laws, social norms), interpersonal (i.e., discrimination, bias, and violence), and intrapersonal (i.e., concealment of identity, expectations of rejection, decreased self-acceptance). Psychological stressors negatively impact health and well-being. Psychosocial stressors can lead to activation of the hypothalamic-pituitary-adrenal axis, resulting in dysregulation of autonomic nervous system, and promotion of a pro-inflammatory and pro-coagulant state that can increase the risk of CVD. All of this in turn can influence traditional risk factors such as elevated blood pressure, insulin resistance, dyslipidemia, obesity which increases CVD risk.
Members of the LGBTQ community are also at higher risk of depression, loneliness and suicide later in life. Psycho-social stressors can influence adverse lifestyle choices regarding tobacco use, diet quality, and physical activity. LGBTQ individuals have greater prevalence of psychological distress, heavy smoking, and heavy drinking.
In general, LGBTQ adults are more likely to report current and lifetime tobacco use. Electronic cigarette use is also more common about LGTBQ persons. There also some differences in other CVH metrics regarding body mass index (BMI), diet, and physical activity but these health metrics vary across subgroups among LGBTQ. For example, sexual minority women are more likely to have elevated BMI than heterosexual women; on the other hand, sexual minority men are more likely to have more favorable levels of physical activity than heterosexual men. Additionally, there are added CV risks from co-existing conditions such as HIV which has higher prevalence in transgender women and sexual minority men compared to non-LGBTQ individuals.
For transgender individuals, there are also potential CV risks associated with gender-affirming hormone therapy. Observational data suggest an increased risk of stroke and venothromboembolism among transgender women taking oral estrogens and myocardial infarction among transgender men taking testosterone, compared to their cis-counterparts. However, there are methodologic issues with many of these studies linking transgender hormone therapy to increased CVD risk, and the lack of randomized clinical trials and paucity of data comparing the various routes and formulations of transgender hormone therapy limit the knowledge regarding the potential CV risks. Nevertheless, CVD risk factors should be screened and managed to best optimize CVH in these individuals, such as addressing smoking, elevated blood pressure, and dyslipidemia, which if present could potentiate hormone therapy-associated risks.
Many knowledge gaps exist regarding the true impact and scale of CVH among LGBTQ individuals, as most population studies collected no or limited information on relevant social and clinical determinants for LGBTQ adults’ health. We need further dedicated research on the needs of this community, but investigators first need to build trust with this marginalized population. This is why partnership with LGBTQ communities to design and implement research studies is needed to increase trust and collaboration.
Overall, clinicians and public health professionals need to improve competency in delivering culturally sensitive care for LGBTQ individuals. Lack of sufficient training regarding LGBTQ health in medical or other professional schools, and in post-graduate clinical training programs (i.e. residency, fellowships) limit the quality of care that LGBTQ individuals receive. Clinicians and public health practitioners need better implementation of strategies to mitigate CVD risk in sexual minorities. Awareness of the problem and the knowledge gaps is the first step to action. This AHA document provides a useful starting framework for cardiologists and other clinicians to be thinking about the multi-level factors needed to optimize CVH of these vulnerable patients. Together, in partnership with multi-disciplinary teams, we can improve the mental and physical health of LGBTQ patients. The time for action is now.
Caceres BA, Streed CG Jr, Corliss HL, Lloyd-Jones DM, Matthews PA, Mukherjee M, Poteat T, Rosendale N, Ross LM; on behalf of the American Heart Association Council on Cardiovascular and Stroke Nursing; Council on Hypertension; Council on Lifestyle and Cardiometabolic Health; Council on Peripheral Vascular Disease; and Stroke Council. Assessing and addressing cardiovascular health in LGBTQ adults: a scientific statement from the American Heart Association [published online ahead of print October 8, 2020]. Circulation. doi: 10.1161/CIR.0000000000000914
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