At least 20 million LGBTQ+ adults in the United States experience worse heart health compared to their cisgender heterosexual peers, according to a recent statement from the American Heart Association (AHA). Circumstances such as discrimination, barriers to receiving care, and higher levels of smoking, drinking, drug use, and stress can affect heart health.
The statement is a reminder that heart disease, the leading cause of death in the United States, can affect anyone, regardless of sexual orientation or gender identity. A study published in April 2019 in Circulation: Cardiovascular Quality and Outcomes analyzed health survey data from a four-year period to compare rates of cardiovascular disease and heart attacks in transgender men and women with those of cisgender men and women. The researchers found that, on average, transgender people have a higher risk of heart attack than their cisgender counterparts.
“I think there’s a growing recognition that this disparity exists,” says Abha Khandelwal, MD, a clinical associate professor of cardiovascular medicine at Stanford Medicine in California.
Early treatment and prevention of heart disease is critical
Philip Chan, MD, associate professor in the department of medicine at Brown University in Providence, Rhode Island, says fear of discrimination and stigma is a major factor in the LGBTQ+ community.
“Preventive health is crucial to cardiovascular health,” says Dr. Chan, who is also the chief medical officer at Open Door Health, Rhode Island’s first clinic dedicated to providing primary and sexual health care to LGBTQ+ patients. “Many people in the LGBTQ+ community have had negative experiences with the health care system.” This discourages people from seeking health care for any reason, including basic primary care, he says, explaining that as a result, “sometimes these people present with much more serious illnesses and complications because it wasn’t addressed earlier.”
Despite the growing acceptance of LGBTQ+ individuals in society, 1 in 8 LGBTQ+ adults report experiencing health insurance discrimination, and many LGBTQ+ people hesitate to see a doctor because of discrimination. LGBTQ+ people also use tobacco products at higher rates than heterosexual people; 1 in 6 lesbian, gay and bisexual adults smoke compared to 1 in 8 heterosexual people, according to the American Lung Association (ALA). Another ALA report (PDF) details that stigma and stressors such as homophobia and discrimination are factors that lead to more smoking, which is a major risk factor for heart disease.
More LGBTQ+ research is needed
Research to date has looked at how stressors affect cardiovascular health, but data focused on the LGBTQ+ community remains limited. In the past decade, studies have looked at how mental health plays a role in physical health and how stress can contribute to increased inflammation, which affects heart health. A summary published in American Journal of Hypertension found that depression, traumatic stress, anxiety and exposure to daily stressors all have negative impacts on heart health.
It is well established that LGBTQ+ people have higher rates of mental health disorders, such as anxiety and depression, as reported by the census.
Dr. Khandelwal says her LGBTQ+ patients often ask her if taking hormones could affect their heart health, but the research isn’t there yet. “We don’t have great population-based studies for me to run on,” she says.
Health providers and clinics must be culturally competent
Khandelwal says medical school training specific to caring for LGBTQ+ patients has been evolving, but it still doesn’t cut it. “As doctors, we are not well trained to care for this community. It’s becoming increasingly apparent that we need to improve our medical education system to be better equipped to care for these patients,” she says.
At Open Door Health, doctors put the patient first and listen to their perspective, Chan explains, but that’s not necessarily the norm. “Clinics in general should try to be patient-centered and patient-friendly,” he says. “We try not to be as prescriptive as guidelines and try to work with the patient to achieve mutual goals to improve things like cardiovascular health.”
The AHA statement recommends increased training so that physicians are better equipped to treat LGBTQ+ people in an appropriate and compassionate manner.
“Incorporating LGBTQ+ content into health professions school curricula and graduate training, and requiring LGBTQ+ health continuing education for all practicing physicians that includes content on cardiovascular health disparities, would go a long way toward addressing disparities,” it says. Donald Lloyd-Jones. MD, a former president of the AHA who is currently chairman of the department of preventive medicine at the Feinberg School of Medicine at Northwestern University in Chicago.
Chan says using the correct patient pronouns is a key way to create a positive patient-doctor dynamic. According to the book Cultural competence in the care of LGBTQ patients, healthcare facilities can do much more to be more welcoming to the LGBTQ+ community. Health care providers and workers should familiarize themselves with LGBTQ+ terminology; hire LGBTQ+ staff; include brochures, posters and magazines that are LGBTQ+ specific to health conditions; and audit forms to ensure patients can correctly record their gender, sexuality and relationship status.