Heart Health in LGBTQ+ Patients

Did you know that the LGBTQ+ population may be at a higher risk for heart disease?

“Studies have shown that physical and mental stress causes inflammation, which can lead to heart disease. For LGBTQ+ patients, stressors can include discrimination and being stigmatized, which can lead to anxiety and depression as well as other mental health disorders,” says Mass General Brigham cardiologist Colleen Harrington, MD. Dr. Harrington cares for patients at Massachusetts General Hospital.

The LGBTQ+ community is a diverse group of patients, each of whom has individual needs when it comes to their medical care. At Mass General, Dr. Harrington is launching a new LGBTQ+ heart disease clinic that provides culturally sensitive care.

Higher risk of heart disease for LGBTQ+ patients

Each person’s experience as a member of the LGBTQ+ community is different, and they may face unique stressors and challenges. This stress can affect lifestyle factors that can impact heart health.

“When I’m seeing all patients, including LGBTQ+ patients, we always start off with Life’s Essential Eight. These are really important for improving your cardiovascular health,” explains Dr. Harrington.

The American Heart Association (AHA) defines Life’s Essential Eight as the lifestyle behaviors and health measures that can help improve heart and brain health. Here’s what you can do to lower your risk of heart disease:

• Eat a healthy diet.

• Be more physically active.

• Quit smoking and using other forms of tobacco.

• Get enough quality sleep.

• Manage your weight.

• Control your cholesterol.

• Control your blood sugar.

• Manage your blood pressure or hypertension.

“Patients who face discrimination or stigmatization are more likely to engage in unhealthy habits such as smoking, harmful use of alcohol, and illegal substances,” says Dr. Harrington. According to the Centers for Disease Control (CDC), LGBTQ+ patients have higher rates of tobacco usage. The AHA notes that transgender women and non-binary persons are more likely to binge drink than other people. While patients may use these substances to cope with stress, doing so can put even more strain on the heart.

Stress and fear of discrimination can also affect diet and physical activity levels. Dr. Harrington notes that LGBTQ+ patients tend to have higher rates of overweight, obesity, and even eating disorders, as published in the Journal of Adolescent Health. According to the CDC, lesbian, bisexual, and transgender women are more likely to have overweight or obesity compared to non-LGBTQ women or cisgender men (men who identify with their gender given at birth).

“Many patients express that they’re afraid to go outside and exercise. They’re scared to go to gyms. They’ve experienced discrimination in those places, or they don’t feel confident in their appearance, especially if they don’t feel their body aligns with their gender,” Dr. Harrington explains.

These issues are complex and not easily solved. Both external stressors from society (discrimination or prejudice from peers, family members, or the public), and internal stress (not feeling comfortable in their sexual orientation or gender identity, or always having to be prepared to deal with discrimination) have an impact.

In addition to counseling patients on their cardiac risk factors and treating existing heart conditions, health care providers can highlight additional resources for patients, including counselling or therapy, support groups, and community organizations.

“Affirming LGBTQ+ patients’ identities and connecting them with community support is so important. It’s not an easy solution. We can treat their cholesterol and their blood pressure but we must also address the patient’s mental and emotional health, to really make a difference,” Dr. Harrington confirms. Dr. Harrington notes the LGBTQ+ clinic is ready make referrals to behavioral health providers to help support patients’ mental health.

Balancing the risks and benefits of hormone therapy for gender-affirming care

The Human Rights Campaign defines gender-affirming care as a range of therapies that help people live as their true selves if their gender identity doesn’t match their sex assigned at birth. This can include gender-affirming hormone therapy, which allows transgender and non-binary people to develop the physical characteristics of their preferred gender. According to research published in Atherosclerosis Journal, this type of hormone therapy may increase the risk of heart disease.

It’s not clear whether the increased risks are due to the hormones themselves or the increased stress of being a transgender or gender non-conforming patient. Until recently, researchers often excluded LGBTQ+ patients from medical studies. Dr. Harrington notes that in 2018, less than 20% of National Institutes of Health-funded studies included transgender patients. None of those studies, of note, were on heart health.

“We are seeing an improvement in the diversity of the populations we study, but we are still light-years away from where we should be,” Dr. Harrington says.

This lack of data means it’s hard to calculate the traditional and specific risk factors that most impact LGBTQ+ patients, as well as the effectiveness of treatments.

“Gender-affirming hormone therapy, for all transgender patients, seems to be associated with an adverse cardiovascular risk,” says Dr. Harrington. She cites a recent large study that showed both transgender men and women had a higher risk of stroke and heart attacks.

For most patients, the mental health and quality of life benefits of affirming their gender identity through hormone therapy is more important than a potentially higher risk of heart disease.

“Patients are determined to match their inner self with their external appearance. For their mental and physical health, not taking the hormones isn’t an option. We then need to home in on those modifiable cardiovascular risk factors to improve their heart health,” Dr. Harrington says.

The importance of culturally sensitive medical care for LGBTQ+ patients