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The ≈11 million lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) adults in the United States remain a marginalized group with meaning health disparities compared with their heterosexual and cisgender (individuals with a gender identity that matches their sexual practice assigned at birth) counterparts (encounter Table one for glossary of terms).1 As described in the 2011 National University of Medicine report on LGBTQ health, LGBTQ adults confront psychosocial stressors (eg, discrimination and bias-motivated violence) that negatively affect their health and well-being.2 Recognizing the need for increased research on LGBTQ populations, the National Institutes of Health established the Sexual & Gender Minority Inquiry Office in 2015 and designated LGBTQ people as a wellness disparity population in 2016. Despite growing attending to LGBTQ health in the past decade, knowledge gaps remain about the health disparities that affect this population.
| Bisexual | People who experience sexual, romantic, concrete, or spiritual allure to people of their own gender and toward another gender (sometimes shortened to bi). |
| Cisgender | A term used to describe people whose gender identity is congruent with what is traditionally expected on the basis of their sexual activity assigned at birth. |
| Gay | A term used to describe boys/men who are attracted to boys/men only oft used and embraced by people with other gender identities to describe their aforementioned-gender attractions and relationships. Often referred to every bit homosexual, although this term is no longer used by the bulk of people with same-gender attractions. |
| Gender expression | The ways in which a person communicates femininity, masculinity, androgyny, or other aspects of gender, oftentimes through speech communication, mannerisms, gait, or style of clothes. All people have ways in which they express their gender. |
| Gender identity | A person's inner sense of being a girl/woman, a boy/homo, a combination of girl/woman and male child/human being, or something else, or having no gender at all. Everyone has a gender identity. |
| Gender minority | A broad diversity of people who feel an incongruence betwixt their gender identity and what is traditionally expected on the basis of their sex assigned at nativity, such as transgender and gender nonbinary people. |
| Gender nonbinary | A term used by some people who identify equally a combination of girl/woman and male child/man, as something else, or as having no gender. Often used interchangeably with gender nonconforming. |
| Lesbian | Used to describe girls/women who are attracted to girls/women; applies for cisgender and transgender girls/women. Often referred to as homosexual, although this term is no longer used by the majority of women with same-gender attractions. |
| Queer | Historically a derogatory term used against LGBTQ people, it has been embraced and reclaimed past LGBTQ communities. Queer is often used to correspond all individuals who identify outside of other categories of sexual and gender identity. Queer may also be used by individuals who experience as though other sexual or gender identity labels practice not fairly describe their experience. |
| Sex assigned at birth | Usually based on phenotypic presentation (ie, genitals) of an babe and categorized as female or male person; distinct from gender identity. |
| Sex | Biological sex characteristics (chromosomes, gonads, sex hormones, or genitals); male, female person, intersex. Synonymous with sexual practice assigned at birth. |
| Sexual minority | A broad diversity of people who take a sexual orientation that is annihilation other than heterosexual/straight and typically includes gay, bisexual, lesbian, queer, or something else. |
| Sexual orientation | A person's concrete, emotional, and romantic attachments in relation to gender. Conceptually separate from gender identity and gender expression. Everyone has a sexual orientation. |
| Straight | Boys/men or girls/women who are attracted to people of the other binary gender than themselves; can refer to cisgender and transgender individuals. Often referred to as heterosexual. |
| Transgender man | Someone who identifies every bit male person merely was assigned female sex at birth. |
| Transgender woman | Someone who identifies equally female only was assigned male sexual activity at birth. |
Cardiovascular disease (CVD) remains the leading crusade of morbidity and bloodshed worldwide. Despite declining rates of CVD bloodshed in the United States, pregnant disparities (eg, sex, race, and income) persist.3 There is growing evidence that LGBTQ adults experience worse cardiovascular health (CVH) relative to their cisgender heterosexual peers.iv,five Nonetheless, CVH has received express attention relative to other wellness topics (eg, HIV/AIDS and substance use) in this population. Only 4.0% of all National Institutes of Health–funded studies on LGBTQ health between 1989 and 2011 focused on CVD or CVD chance factors (eg, diet, diabetes, and obesity).6 Therefore, in 2011, the National Academy of Medicine recommended increased research on CVD in LGBTQ adults.2
The inclusion of sexual orientation and gender identity (SOGI) measures in population-based surveys has provided nationally representative data on the CVH of LGBTQ adults in the Us. Analyses of population-based data have found a college prevalence of CVD risk factors among sexual minority (eg, gay, lesbian, bisexual, and other nonheterosexual) adults compared with their heterosexual counterparts (eg, tobacco use,vii–10 elevated body mass index [BMI],4 and diabetes8,11). Analyses of BRFSS (Behavioral Risk Factor Surveillance Arrangement) data, the only national wellness survey that assesses gender identity, have documented a college prevalence of self-reported tobacco use10 and CVD diagnoses12 in gender minority (ie, transgender and gender-diverse populations) adults relative to cisgender people. Although LGBTQ people are often grouped together, subgroups within this population have distinct health risks and exposures; multiple studies have identified variations in CVD risk past sex assigned at birth, gender identity, sexual orientation, and race.12–xv
To improve the CVH of LGBTQ adults, a greater understanding of existing prove is needed. The objective of this scientific statement was to examine enquiry on the CVH of LGBTQ adults to develop a conceptual model that elucidates potential mechanisms underlying CVH disparities in LGBTQ adults, to identify inquiry gaps, and to provide suggestions for improving CVH enquiry and care of LGBTQ people. The American Heart Association's My Life Cheque–Life's Uncomplicated 7 was used to organize findings for tobacco utilise, concrete activity, nutrition, BMI, blood pressure, glycemic status, and lipids.sixteen
Conceptual Model
Our review of the literature was guided by the conceptual model (Figure) that describes potential mechanisms by which LGBTQ adults feel poor CVH. This conceptual model was informed by existing frameworks used to study LGBTQ wellness (ie, the minority stress17,18 and social ecological models)19 and is intended to guide CVH research with LGBTQ adults. Exposure to stress is posited equally the main driver of LGBTQ health disparities.17,18 The predominant theory to explain LGBTQ health disparities is the minority stress model, which describes how, in addition to general life stressors, LGBTQ people are exposed to multilevel minority stressors (ie, intrapersonal, interpersonal, and structural) that contribute to wellness disparities.17,eighteen Originally developed to study mental health disparities in sexual minorities, the minority stress model was later adapted for gender minority health.xx There are no existing adaptations of the minority stress model tailored for the study of CVH disparities in LGBTQ adults. In addition, the social ecological model recognizes how an individual's health is influenced past factors in the social environs, including family unit, interpersonal, community, and societal factors.19
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Effigy. Conceptual model of cardiovascular health in lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) adults.
Minority Stressors
LGBTQ adults face unique individual/intrapersonal stressors because of their SOGI (eg, self-stigma, expectations of rejection, and concealment of SOGI).17,18 Furthermore, LGBTQ individuals experience a high number of interpersonal stressors (ie, discrimination, family rejection, and violence)2 that are associated with higher rates of substance use,21,22 poor mental health,22 and cardiometabolic risk across the life span.23,24 Despite limited evidence, structural stressors might also compromise the health of LGBTQ adults. In 2018, <50% of LGBTQ people lived in states that had employment or public accommodation (eg, hospitals and schools) nondiscrimination laws.25 There are also laws that explicitly codify discrimination such equally those preventing transgender people from using public restrooms that align with their gender identity.
Expanding mechanistic cognition on how LGBTQ-specific minority stressors touch the CVH of LGBTQ adults is crucial to developing and tailoring multilevel CVH interventions for this population. At that place is extensive evidence that stress exposure related to discrimination and stigma can atomic number 82 to unhealthy coping behaviors and arouse psychological and physiological stress reactions that negatively affect the wellness of stigmatized people.26 Yet, testing of these mechanisms in LGBTQ adults has been express.27 Enquiry on the link between stress and CVH in other stigmatized populations (eg, racial and ethnic minorities) can help inform CVH research in LGBTQ adults. Recent systematic reviews have documented the link between discrimination and CVH health indexes (eg, tobacco use and elevated blood pressure and weight) in stigmatized populations.27,28
Full general Stressors
Consistent with the minority stress and social ecological models, nosotros hypothesize that circuitous interactions between LGBTQ-specific minority stressors and general life stressors across multiple levels contribute to CVH disparities in LGBTQ adults. At that place is mounting evidence that LGBTQ populations feel significant general stressors (eg, life arduousness and financial stress) beyond multiple levels that negatively influence their health beyond the life span. At the interpersonal level, LGBTQ adults are more likely than non-LGBTQ peers to report concrete and sexual corruption in childhood,29 also equally a higher prevalence of interpersonal violence in adulthood.23,30 At that place is limited evidence of structural-level determinants of health amid LGBTQ adults. Nonetheless, analyses of BRFSS information from 35 states bespeak that LGBTQ adults have college rates of poverty than cisgender heterosexual people (21.6% versus 15.vii%). Poverty rates are highest amid bisexual men (19.5%) and women (29.4%), transgender people (29.4%), and LGBTQ people living in rural areas.31 Inside the LGBTQ population, Latinx (37.3%), Black (30.8%), and American Indian/Native Alaskan (32.4%) adults are more likely to live in poverty compared with their White peers (15.iv%).31 In many circumstances, full general stressors are best understood inside the context of minority stress. For instance, economic disparities among LGBTQ adults might be driven past structural-level minority stressors; poverty rates are more pronounced amidst LGBTQ people living in southwestern states that, until the Supreme Court's decision in June 2020, provided them with no legal protection against employment discrimination.31 Therefore, multilevel minority and general stressors can collaborate across levels to impair the health of LGBTQ adults by limiting opportunities for proper employment, housing, and access to health care.26
From the existing testify, we posit that demographic, social, and clinical factors moderate the associations of multilevel LGBTQ-specific and general stressors with CVH outcomes in LGBTQ adults (Figure). LGBTQ-specific minority stressors can operate synergistically with full general stressors and stress related to other stigmatized identities across multiple levels to confer excess CVD risk through psychosocial, behavioral, and physiological pathways. For example, a Blackness bisexual woman may experience stress related to her racial and sexual minority identity, as well as being female person and low income, that might be distinct from the stress that other LGBTQ adults experience. Thus, the potential influence of intersecting stigmatized identities on the CVH of LGBTQ adults is recognized.
Additional Gamble Factors
Transgender women and sexual minority men behave a disproportionate burden of HIV compared with non-LGBTQ people.32 HIV is associated with increased take a chance for CVD equally a result of a loftier prevalence of CVD risk behaviors amidst people with HIV, dyslipidemia and other cardiometabolic changes associated with certain HIV treatments, and the physiological effects of HIV illness itself.33
Moreover, the employ of gender-affirming hormone therapy has been identified as a potential contributor to poor CVH in transgender people because of the potential cardiovascular furnishings of these treatments.five,34–36 Although studies accept identified an increased risk for venous thromboembolism amid transgender women taking estrogen,5,35 information on other CVD outcomes and their causes are express. Show of elevated CVD gamble in transgender men remains limited and is more often than not inconsistent.5,34,35
Land of the Science on CVH in LGBTQ Adults
We use Life'southward Simple 7 to organize findings past CVH metrics and to summarize evidence on CVD diagnoses in LGBTQ adults. This statement does non include information on several populations that are function of the LGBTQ community (eg, queer and questioning people) because of limited evidence to provide a reliable report of CVH disparities in these groups. Withal, we utilise the term LGBTQ throughout this statement because the conceptual model, limitations, and suggestions for futurity research and clinical practice also apply to queer and questioning individuals.
Tobacco Apply
LGBTQ adults are more than likely to report current and lifetime tobacco use than their cisgender heterosexual peers.4,7–10 Sexual minority women are more probable to use tobacco than heterosexual women and men and sexual minority men.7 Despite limited evidence on tobacco use among transgender people, a recent analysis of BRFSS data found a college prevalence of cigarette and smokeless tobacco use in transgender adults compared with their cisgender counterparts.10 Research on social determinants of tobacco utilize in LGBTQ populations is scarce but growing. Almost notably, analyses of population-based data indicate that past-year sexual orientation bigotry is a predictor of past-year cigarette smoking in sexual minority adults.21
Physical Activity
Findings on physical activity in LGBTQ populations are mixed. A systematic review of 35 studies found that sexual minority men reported higher levels of physical activity than heterosexual men.37 The authors posited that these findings appear to exist driven, in part, by social norms, including a desire to adapt to body ideals (ie, thinness and muscularity) among sexual minority men, which might influence physical activity.37 Data on sexual minority women are conflicting, with some studies reporting lower levels of physical activity than for heterosexual women,37 whereas other studies have found college levels.9,38 Analyses of the Nurses' Wellness Study Ii information bespeak that although sexual minority women study college levels of aerobic physical action, they also have college levels of sedentary behaviors relative to heterosexual women.38 Moreover, a systematic review found that transgender adults had lower physical activity levels than their cisgender counterparts.39 A recent report found that transgender individuals taking gender-affirming hormones had greater trunk satisfaction, which was associated with higher physical activity.40 This suggests that gender-affirming care might play a role in promoting physical activity among transgender people.
Diet
The majority of studies have identified no differences in diet quality betwixt LGBTQ individuals and their heterosexual and cisgender peers,4 whereas some propose differences with variable directionality.41,42 Compared with their heterosexual peers, gay men and sexual minority women report worse nutrition quality (eg, lower fruit/vegetable consumption) and less favorable eating environments.41 In contrast, prospective data from the Nurses' Health Study 2 indicate that, between 26 and 67 years of age, sexual minority women have better diet quality and diets lower in glycemic index than heterosexual women.42 Thus far, in that location is limited enquiry on nutrition quality in transgender people.
Trunk Mass Alphabetize
Most research has shown that sexual minority women have a higher prevalence of subjectively and considerately measured obesity than heterosexual women.4 Racial and ethnic differences in BMI be among sexual minority women, with Black women more likely to be obese than White women.43 Gay men have a like or lower prevalence of obesity compared with heterosexual men.4 Recent analyses of objective data from the NHANES (National Health and Nutrition Test Survey) suggest that bisexual men have a 69% college odds of obesity than heterosexual men.13 Data examining elevated BMI in transgender people are express with mixed results. These studies have more often than not focused on changes in BMI among transgender men afterward the initiation of gender-affirming hormone therapy.5
Blood Force per unit area
A systematic review of 31 studies published betwixt 1985 and 2015 found no evidence that sexual minority adults take a higher prevalence of elevated blood force per unit area relative to their heterosexual counterparts.4 More recent show suggests that sexual minority men are more likely to have elevated blood pressure than heterosexual men.xiii,44 Analyses of data from Add Health (National Longitudinal Study of Boyish to Developed Health) have identified higher diastolic claret pressure in gay men relative to heterosexual men.45 Bisexual men in NHANES have 2 times higher odds of hypertension than heterosexual men13; in particular, Black bisexual men have college diastolic claret pressure level than White heterosexual men.14
Overall, studies examining blood pressure level in transgender adults are limited.v Some data suggest that transgender women have minimal increases in claret pressure level after the initiation of feminizing hormones. Similarly, testosterone utilize has been associated with slight increases in systolic blood force per unit area in transgender men.5,35 Although these changes in claret pressure were statistically significant, they had modest outcome sizes and are of questionable clinical significance.
Glycemic Status
Although a systematic review identified few differences in diabetes past sexual orientation,4 the included studies had methodological limitations (eg, cross-sectional designs and reliance on cocky-reported information). Analyses of longitudinal data from the Nurses' Wellness Written report Ii and Add Health found that sexual minority women had a greater incidence of diabetes than heterosexual women.11,46 These differences were accentuated in younger women (24–39 years of historic period) and largely explained by elevated BMI.46 Similarly, analyses of cross-sectional NHANES data constitute that sexual minority women had a 56% greater prevalence of prediabetes compared with heterosexual women.8 Although nigh studies indicate that in that location are few sexual orientation differences in diabetes amid men,four data from NHANES suggest that bisexual men have iii times higher odds of diabetes compared with heterosexual men.13 In addition, a contempo analysis of NHANES plant that Black sexual minority men have higher glycosylated hemoglobin than their White heterosexual peers.fourteen
Almost studies have found few differences in diabetes between transgender and cisgender adults.5 However, ii studies analyzing health record data plant that transgender men and women had a college prevalence of diabetes compared with cisgender people.47,48 Wierckx and colleagues47 found that transgender women were 2 and 6 times more probable to have diabetes than cisgender women and men, respectively.
Total Cholesterol and Lipids
Studies assessing total cholesterol and lipids in LGBTQ adults, particularly objective measures, are limited.iv It appears that there are no differences in full cholesterol or lipids between sexual minority and heterosexual adults.4 In transgender individuals, changes in lipid profiles have been linked to the use of gender-affirming hormones. A systematic review of 29 studies plant higher triglyceride levels in transgender women taking feminizing hormones but no modify in other lipids. In addition, this review found that masculinizing hormone therapy for transgender men was associated with lower high-density lipoproteins and college triglycerides and low-density lipoproteins.36 In dissimilarity, a more than recent review ended that in that location is no disarming testify of lipid abnormalities among transgender men.35 The significance of lipid changes on CVD outcomes (eg, myocardial infarction, stroke) in transgender people requires further investigation.
Additional Adventure Factors
This statement focuses on CVH metrics included in Life'south Simple seven. However, boosted risk factors such as heavy booze employ16 are elevated in LGBTQ adults. Sexual minority women are more probable to report heavy drinking than heterosexual women.4,8,9,44 Transgender women and gender nonbinary individuals are more likely to rampage potable relative to cisgender women.10 However, there is limited enquiry on the cardiovascular furnishings of heavy drinking in LGBTQ adults.
Inadequate sleep duration and poor sleep quality have been identified as risk factors for incident hypertension, diabetes, and CVD.49 A review of 31 studies identified that short sleep duration was higher among sexual minority women compared with heterosexual women. Findings for sexual minority men were mixed, and merely 4 studies were identified that examined sleep duration in transgender people.50 Other dimensions of sleep health (eg, sleep quality, sleep apnea, and insomnia) remain understudied in LGBTQ adults.50 The study of slumber health in LGBTQ adults is a nascent expanse that has important implications for understanding their CVH.
Cardiovascular Affliction
Although sexual minority adults showroom elevated risk for CVD compared with heterosexual adults, few differences in CVD diagnoses accept been identified.4 There is a notable discrepancy between observed CVD risk and CVD prevalence in sexual minorities. The higher prevalence of CVD amid transgender women compared with cisgender adults establish in the few studies that accept used health records34,51 suggests that this paradox in sexual minorities might be caused past a lack of advisable measurement of CVD stop points. Analyses of health tape data indicate that transgender women on gender-affirming hormones accept college incident myocardial infarction,51 venous thromboembolism,51 ischemic stroke,51 and cardiovascular mortality34 than their cisgender peers. In addition, analyses of information from the BRFSS have institute that transgender women have higher odds of self-reported CVD than cisgender people.12,52 Despite show of higher risk in transgender women, findings for CVH disparities among transgender men are inconsistent.five,35 Furthermore, several reviews have concluded that evidence of higher cardiovascular morbidity and mortality in transgender people is limited by methodological issues, including the use of retrospective cohorts with short follow-upwards, cross-sectional designs, inadequate information on gender-affirming hormones, and a lack of inclusion of transgender older adults.5,34,35
Limitations of Existing Research
Testing of Mechanisms
At that place is a lack of understanding nearly mechanisms that link LGBTQ-specific stressors with CVH in LGBTQ adults, which impedes the evolution of interventions to promote their CVH. Despite increased take a chance, there is a dearth of show-based interventions for CVD chance reduction in LGBTQ people. Longitudinal research is needed to elucidate potential psychosocial and behavioral targets for interventions to improve the CVH of LGBTQ adults. In item, qualitative inquiry to empathise how attitudes and beliefs inside LGBTQ subgroups influence their CVH is needed before interventions tin be designed. For example, a desire to accommodate to body ideals in their community may drive sexual minority men to appoint in more compulsive exercising compared with heterosexual men.25 On the contrary, among sexual minority women, a greater acceptance of diverse body types and rejection of heteronormative standards of female beauty may contribute to differences in physical activity and BMI.37,53 Increasing noesis near grouping-specific attitudes and behavior on health behaviors is needed to heighten the acceptability of interventions designed to improve the CVH of LGBTQ adults. These interventions should account for the influence of interpersonal and structural drivers of CVH in LGBTQ adults.
Lack of Existing Information
The methodological weaknesses of the existing literature limit our understanding of the causes of CVH disparities in LGBTQ adults. Most studies on CVH in LGBTQ adults clarify self-reported data from population-based surveys, which exercise non capture the sociocultural and clinical factors relevant to understand their CVH. There has more often than not been a focus on identifying differences in CVD risk factors between LGBTQ and non-LGBTQ adults with piffling examination of the causes of CVH disparities. Furthermore, the lack of objective measures limits the reliability of existing data. This is peculiarly important given that several studies have constitute that sexual minorities have higher odds of objectively measured hypertension and hyperglycemia relative to heterosexuals.viii,11,thirteen,14,45
To appointment, there are no published data on the CVH of sexual minority adults in the U.s. that use health tape information. The inclusion of SOGI measures in electronic wellness records (EHRs) provides an opportunity to leverage these data to examine CVH in LGBTQ individuals, including healthcare employ amid those with CVD. Given the evidence that LGBTQ adults experience bigotry in healthcare settings,54 EHRs tin be used to examine potential variations in care delivery amongst LGBTQ adults living with CVD. In improver, the availability of information on social determinants (eg, interpersonal violence, poverty, and nutrient insecurity) in EHRs could allow researchers and clinicians to obtain a more comprehensive understanding of social factors associated with CVH in LGBTQ adults. Information technology is important to recognize that EHR information are biased toward LGBTQ adults who engage in wellness intendance and those who feel comfortable disclosing their SOGI to clinicians.
Information from population-based studies are based primarily on White cisgender samples of LGBTQ adults with relatively high educational attainment, limiting the ability to examine intersectional differences in CVH (eg, by SOGI, race, and socioeconomic condition). In that location is growing evidence that Blackness and Latinx LGBTQ adults, particularly sexual minority women, accept higher BMI, blood pressure, and glycosylated hemoglobin than their heterosexual peers.14,15,43 A demand exists to examine CVH in stigmatized groups within the LGBTQ population who may face up additional structural barriers to achieving optimal CVH (eg, people of color). Additional CVH enquiry on subgroups within the LGBTQ customs who were not included in this statement (eg, queer and questioning individuals) is critically needed.
Social and Clinical Determinants of LGBTQ CVH
Consistent with the minority stress and social ecological models, at that place is a need for research that examines multilevel social determinants of CVH in LGBTQ adults. There is evidence that sexual orientation bigotry contributes to college odds of tobacco use in sexual minorities.21,55 The stiff evidence linking discrimination with poor CVH in racial and ethnic minorities warrants further test of discrimination equally a social determinant of CVH in LGBTQ adults.27,28 Among sexual minority women, interpersonal violence is associated with higher odds of obesity, hypertension, and diabetes.24 Furthermore, despite evidence of economic disparities in LGBTQ populations, only one study has assessed the influence of economical strain on the CVH of sexual minority adults (24–32 years of historic period).56 Conducting an analysis of Add Health data, investigators constitute that the associations of economic strain with metabolic syndrome did non differ between sexual minority and heterosexual adults. Because the prevalence of metabolic syndrome increases with historic period, the zippo findings in that study might be explained by the young age of participants.56 In addition, although findings from qualitative studies advise that social support is associated with college physical activity and diet quality in sexual minority adults,53,57 there is express research examining whether resilience factors (eg, social back up and stress-related coping) can buffer the cardiovascular effects of life adversity in LGBTQ adults.
Researchers should examine the influence of multilevel social determinants of CVH in LGBTQ adults rather than examining solely i level. For case, researchers could examine the associations of discriminatory policies (eg, antidiscrimination laws) with interpersonal discrimination (eg, experiences of discrimination) and intrapersonal stressors (eg, darkening of SOGI) to estimate their combined influence on CVH metrics in LGBTQ adults. This farther supports the need for information sources that include SOGI and social determinants data and for research that combines multiple sources (eg, linking EHR data with state-level antidiscrimination policies) to examine CVH disparities in LGBTQ adults.
Enquiry on the CVH of transgender adults is limited by the methodological weaknesses in the extant literature and should be interpreted with circumspection.5,34,35 In that location is evidence that, despite their hypothesized cardiovascular effects, gender-affirming hormones might reduce psychosocial and behavioral run a risk factors in transgender people.40 Therefore, the potential cardiovascular effects of gender-affirming hormones should be evaluated against the benefits on their mental health and wellness behaviors. In improver, limited data examine CVH between transgender individuals taking gender-affirming hormones and those who are non. Overall, given the methodological limitations of studies on the CVH of transgender people,v,34,35 rigorous research is needed to ascertain the potential cardiovascular effects of gender-affirming hormones.
Suggestions for Inquiry and Clinical Practise
Our suggestions for cardiovascular research and clinical practice with LGBTQ adults are presented in Table ii.
| Cardiovascular Enquiry | Clinical Practise |
|---|---|
| Develop standardized sexual orientation and gender identity measures and integrate them into current and hereafter NIH-funded cardiovascular prospective cohort studies to allow information harmonization | Ensure the collection of SOGI data in EHRs by providing clinicians with training on LGBTQ health disparities and the proper assessment of sexual orientation and gender identity in healthcare settings |
| Integrate biobehavioral measures into cardiovascular research with LGBTQ populations | Contain LGBTQ content into the curricula of health professions schools and postgraduate preparation |
| Leverage EHR data to increment agreement of LGBTQ cardiovascular health | Require continuing education on LGBTQ wellness for all practicing clinicians that includes content on cardiovascular health disparities |
| Partner with LGBTQ communities for measurement development, study design and comport, and research broadcasting to ensure that research reflects the needs of LGBTQ adults, specially stigmatized groups | |
| Develop and examination multilevel interventions for cardiovascular take a chance reduction in LGBTQ adults | |
| Examine social and clinical determinants of cardiovascular health in LGBTQ adults | |
| Characterize the role of resilience in buffering the cardiovascular effects of stress in LGBTQ people |
Enquiry Implications
The lack of SOGI information in existing studies limits the applicability and generalizability of research on CVH in LGBTQ adults. Despite calls to include SOGI data in ongoing CVH studies, a search in July 2020 of the National Heart, Lung, and Claret Constitute's Biological Specimen and Data Repository Information Analogous Center revealed that 0 of 229 studies collected SOGI data.58 Although population-based data have provided a greater agreement of the CVH of LGBTQ people,eight–12,44,45,59 they provide limited information on relevant social and clinical determinants for LGBTQ adults' health. But 2 cardiovascular cohorts, the SOL (Hispanic Community Wellness Study/Written report of Latinos) and CARDIA (Coronary Artery Risk Evolution in Young Adults), take plans to collect SOGI data. Electric current and futurity National Institutes of Health–funded cardiovascular cohort studies should include standardized SOGI measures that will let data harmonization to achieve larger samples of understudied groups inside the LGBTQ population.
Incorporating biobehavioral approaches into CVH research will help elucidate mechanisms by which minority stressors contribute to CVH disparities in LGBTQ adults. The proposed conceptual model is intended not only to inform hereafter observational research but as well to facilitate the evolution and testing of interventions that target modification of multilevel stressors.
Several steps should be taken to increase LGBTQ people's trust of the research community. This is particularly important for stigmatized groups within the LGBTQ community (eg, people of color and individuals with disabilities). Inquiry teams conducting LGBTQ inquiry should reflect the diversity that exists within the population. Researchers should also partner with LGBTQ communities during all stages of the scientific process to increase trust in their research.
Clinical Implications
The ability to collect SOGI information in EHRs has been required since 2018 as part of the meaningful use of EHRs; withal, this policy does not require clinicians to collect this information.60 About 56% of sexual minority and 70% of gender minority adults report having experienced some form of discrimination from clinicians (including the employ of harsh/abusive linguistic communication).54 Perhaps well-nigh alarming is that ≈8% and 25% of sexual minority and transgender individuals, respectively, have been denied health care by clinicians.54 Information technology is important for practicing clinicians and health professions students to receive didactics on LGBTQ health and the proper cess of SOGI in healthcare settings.
Although several organizations provide curricular recommendations near caring for LGBTQ adults, substantial resource are needed to reduce LGBTQ wellness disparities. Whereas The Articulation Commission and the US Department of Health and Human Services have comprehensive plans to improve LGBTQ wellness, the healthcare workforce remains unprepared to enact them. Accrediting bodies and organizations responsible for recommending curricular content such as the Accreditation Council on Graduate Medical Education, Accreditation Review Committee on Education for the Dr. Assistant, American Nurses Credentialing Center, Clan of American Medical Colleges, Liaison Committee on Medical Education, and Physician Assistant Education Clan provide little to no requirements for LGBTQ health content in the curricula. Notably, although the Association of American Medical Colleges provided recommendations, but non requirements, for LGBTQ wellness content in 2013, the Accreditation Review Committee on Education for the Dr. Banana will begin requiring LGBTQ curricular content in 2020.
Although clinicians and public health professionals demand competence in providing treat LGBTQ patients, in that location are limited efforts to include relevant content in wellness professions curricula.61 With no LGBTQ-related accreditation or licensure requirements, health professions curricula (including for nurses,62 physicians,63 dr. administration,64 and public health practitioners65) have minimal content on LGBTQ health. A 2018 online survey of students at 10 medical schools found that ≈80% of students felt not competent at treating transgender patients.66 Furthermore, a recent study of >800 residents across 120 internal medicine residencies in the United States establish no difference in baseline knowledge across postgraduate years (eg, postgraduate twelvemonth 1 versus two) related to LGBTQ health topics.63 Although that report was limited to internal medicine residencies, these trends probable apply to clinicians beyond specialties. The knowledge of LGBTQ health and the training of clinicians specialized in cardiology are currently unknown. The lack of LGBTQ wellness content in wellness professions curricula may limit the quality of care that LGBTQ adults receive and further exacerbate existing disparities in CVH and other health outcomes.
Conclusions
LGBTQ adults experience significant psychosocial stressors that compromise their CVH health across the life span. There is consistent testify that LGBTQ adults are more likely to use tobacco than their cisgender heterosexual peers. Sexual minority women are more probable to have elevated BMI than heterosexual women. Differences in CVH metrics between sexual minority and heterosexual adults are more pronounced in studies that have used objective measures. Among transgender women, the use of gender-affirming hormones might be associated with cardiometabolic changes, but the strength of existing data is limited past methodological issues. Given the lack of bear witness on CVH in queer and questioning individuals, this is a disquisitional area for future piece of work. To accost cognition gaps in the literature, longitudinal research that examines mechanisms that link social and clinical determinants with CVH in LGBTQ adults is needed. In addition, hereafter research should apply qualitative and mixed methods to identify and develop culturally appropriate interventions for CVD risk reduction in LGBTQ adults. LGBTQ health content should be incorporated into wellness professions curricula, and LGBTQ-related accreditation and licensure requirements are needed. At that place are opportunities for enquiry, clinical, and public health efforts to improve empathize and reduce CVH disparities in the underserved population of LGBTQ adults.
Disclosures
| Writing Group Member | Employment | Enquiry Grant | Other Research Support | Speakers' Bureau/Honoraria | Expert Witness | Buying Interest | Consultant/Advisory Board | Other |
|---|---|---|---|---|---|---|---|---|
| Billy A. Caceres | Columbia University School of Nursing | None | None | None | None | None | None | None |
| Carl 1000. Streed Jr. | Boston University School of Medicine, Center for Transgender Medicine and Surgery | American Heart Association (career development award)† | None | None | None | None | None | None |
| Heather L. Corliss | San Diego State University | None | None | None | None | None | None | None |
| Donald K. Lloyd-Jones | Northwestern University, Feinberg School of Medicine | None | None | None | None | None | None | None |
| Phoenix A. Matthews | University of Illinois, Chicago | None | None | None | None | None | None | None |
| Monica Mukherjee | Johns Hopkins University School of Medicine | None | None | None | None | None | None | None |
| Tonia Poteat | University of North Carolina, Chapel Colina | None | None | None | None | None | None | None |
| Nicole Rosendale | University of California, San Francisco | None | None | American Academy of Neurology Annual Meeting (speaking honorarium)* | None | None | None | None |
| Leanna Thousand. Ross | Knuckles University Schoolhouse of Medicine, Duke Molecular Physiology Institute | None | None | None | None | None | None | None |
| Reviewer | Employment | Enquiry Grant | Other Research Support | Speakers' Bureau/Honoraria | Expert Witness | Ownership Interest | Consultant/Informational Lath | Other |
|---|---|---|---|---|---|---|---|---|
| Elizabeth Brondolo | St. John'southward University | None | None | None | None | None | None | None |
| Madeline Deutsch | UCSF | None | None | None | None | None | None | None |
| Scott E. Moore | Case Western Reserve University | None | None | None | None | None | None | None |
| S. Raquel Ramos | New York University | None | None | None | None | None | None | None |
Footnotes
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Source: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000914
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