There are more than 11 million LGBTQ+ adults in the United States, yet they remain a marginalized group in health care settings. By looking at existing research on LGBTQ+-specific cardiovascular health disparities, the writing group for the statement highlights gaps in knowledge and offers suggestions for improving cardiovascular research and care for LGBTQ+ people. “Our recommendations underscore the need for healthcare professionals, researchers, and policy makers to understand the multi-level factors that influence cardiovascular health,” says Carl G. Streed, MD, vice chair of the writing group, an assistant professor of medicine at Boston University School of Medicine, and a physician at Boston Medical Center. “To better do this, we need improved research methods, better data collection, and clinical practice that acknowledges the diversity of sexual orientations and gender identities,” he says.
Specific Risk Factors
While there’s a lack of information on the cardiovascular health of LGBTQ+ people, there are a few specific risk factor areas identified that need attention:
LGBTQ+ adults are more likely to use tobacco than their cisgender heterosexual counterparts. Transgender adults may be less physically active than their cisgender peers. The statement suggests gender-affirming care might play a role in promoting physical activity among transgender people. Transgender women may be at increased risk for heart disease due to behavioral and clinical factors, like the use of gender-affirming hormones like estrogen. Transgender women and non-binary persons are more likely to binge drink. Lesbian and bisexual women have a higher prevalence of obesity than heterosexual women do.
Discrimination and Stigma
In addition to traditional risk factors, such as smoking and diet, which are focused on the individual, the statement lays out the various ways discrimination and stigma affect health through what is called the “minority stress theory," Streed says. “This perspective of health highlights how policies can affect community and individual health,” he notes. “Stress from society could influence individual-level behaviors as well as directly impact cardiovascular health. For instance, chronic stress affects inflammatory pathways associated with early cardiovascular disease.” According to the statement, more than half (56%) of LGBTQ+ adults and 70% of those who are transgender or gender non-conforming report experiencing some form of discrimination, including harsh or abusive language, from a healthcare professional. What’s even more concerning is that around 8% of sexual minority and 29% of transgender individuals have been denied health care by clinicians, according to the Center for American Progress.
Change Is Needed
To date, there has been very little LGBTQ+-related content in health care professional education training. A 2018 study surveyed students from 10 medical schools and found that approximately 80% of respondents didn’t feel capable of providing care for transgender patients. However, things may be changing. The Accreditation Review Commission on Education for the Physician Assistant began requiring LGBTQ+ curricular content in September 2020, the statement notes. “Most certainly the lack of formal education about the needs of LGBTQ+ patients across all of medicine, including cardiovascular areas, contributes to the disparity in the care of LGBTQ+ patients,” says Kathryn Berlacher, MD, MS, FACC, assistant professor of medicine and program director of the cardiology fellowship program at the University of Pittsburgh Department of Medicine. “We must advocate for the development of curriculum that adequately addresses disparity as it relates to LGBTQ+ patients. My hope is that we can begin to weave this education into every area of medical school so that it becomes part of our natural assessment of all patients rather than an extra step we do for some patients,” Berlacher says. “Curricula should include identification of disparity, specific effects of those disparities, and ways to mitigate disparities," Berlacher says. “Another topic that is vital for medical students (really all providers!) to understand is how other things such as race and ethnicity intersect with identifying as an LGBTQ+ individual. Often, this intersection leads to even greater health care disparities, which must be recognized before we can begin to combat them.” While Berlacher’s program doesn’t have a separate rotation or curriculum on the specifics of cardiac care of LGBTQ+ patients, they do ask their fellows to actively identify disparities of care in all patients, looking to identify and address the effects of age, sex, gender, race, ethnicity, sexuality, socioeconomic status, and education on health care. “Our educational conferences include discussions about the identification and measurement of health disparities,” Berlacher adds. “Many of our fellows focus their research on health disparities within cardiac care, in hopes of broadening our understanding of them and finding ways to better care for our patients.” Streed hopes the AHA statement will lead to more change for the better across the healthcare community at large. “What we hope most people will take away from this statement is the opportunities to address the gaps in research, improve clinical training, and inform policies that affect the health of LGBTQ+ persons and communities,” he says.
