Hypertension risk in sexual and gender minority individuals

KEYWORDS:

• Hypertension
• sexual and gender minorities
• social discrimination

1. Introduction

Over the past decade there has been growing evidence that sexual and gender minority (SGM) individuals are at higher risk of hypertension compared to their non-SGM counterparts [1]. The SGM population includes individuals with diverse sexual orientations (such as gay, lesbian, bisexual, pansexual, questioning, and those who are attracted to people of the same gender) and gender identities (such as transgender and gender non-binary). Although disparities in the prevalence and treatment of hypertension based on race, ethnicity, socioeconomic status, and sex have been extensively studied [2], little is known about the psychosocial, behavioral, and physiological mechanisms associated with hypertension risk among SGM individuals [1]. Sexual minority individuals report a significantly higher prevalence of risk factors for hypertension, including poor mental health, tobacco use, and short sleep duration than their heterosexual counterparts [1]. In addition, compared to heterosexual women, lesbian, and bisexual women are more likely to meet criteria for obesity [1,3,]. Previous research has found that gender minority adults have a higher prevalence of myocardial infarction and stroke than their cisgender (i.e. those whose gender identity is aligned with their sex assigned at birth) counterparts [1,4,5]. The use of exogenous hormones (such as estrogen and testosterone) among gender minority adults has been hypothesized to contribute to their greater risk of CVD, however, existing evidence of the influence of exogenous hormones on hypertension risk in gender minority adults is conflicting [1,6].

The health disparities experienced by SGM individuals are largely attributed to their greater exposure to minority stressors (defined as unique stressors attributed to an individual’s minority identity), which in turn can lead to negative health outcomes [7]. Therefore, one’s sexual orientation or gender identity are not risk factors for negative health outcomes, but rather it is the greater psychosocial stressors that SGM people experience that place them at greater risk for negative health outcomes. The Minority Stress Model is the predominant evidence-based framework used to examine health disparities among SGM individuals [7]. Although the original Minority Stress Model was developed to describe mental health disparities among SGM individuals, an extension of the model focused on cardiovascular health was recently published by the American Heart Association [1]. Minority stressors exist at multiple levels, including at the individual (such as internalized homophobia and expectations of rejection), interpersonal (such as experiences of discrimination), and structural (such as laws, policies, and social norms) levels [7].

There is growing data indicating that social determinants, such as experiences of discrimination and interpersonal violence, increase hypertension risk in marginalized adults [8,9]. Even though SGM adults are more likely to experience discrimination and interpersonal violence (such as physical and sexual abuse) compared to non-SGM adults [10], very few studies have examined social determinants of hypertension in this population [1]. Multiple studies indicate that interpersonal violence is associated with a higher prevalence of self-reported hypertension among sexual minority women [11,12]. In contrast, the associations of experiences of discrimination with hypertension in sexual minority adults are largely conflicting [1]. Furthermore, recent studies suggest that hypertension risk among sexual minority adults may be highest among bisexual individuals and people of color [13]. With the exception of one study [14], research on social determinants of hypertension in gender minority adults is limited.

2. Recommendations for clinical practice

Clinicians play a pivotal role in the treatment and management of their patients and can implement health promotion strategies to reduce hypertension risk among SGM adults. Overall, there are limited data on how to best prevent and manage hypertension in SGM adults. However, based on existing evidence [1], we recommend that clinicians closely monitor blood pressure in SGM adults. Clinicians should also use validated measures to routinely screen SGM individuals for modifiable risk factors, including psychosocial factors (e.g. depressive symptoms) and health risk behaviors (e.g. tobacco use, physical inactivity), that have been shown to increase hypertension risk.

There is a need to educate clinicians about the psychosocial, behavioral, and physiological factors that influence hypertension risk in SGM adults. Academic institutions must implement initiatives that strengthen how future and practicing clinicians are educated about SGM health. These efforts would help clinicians better address SGM health disparities. In addition, best practices for caring for SGM individuals should be integrated into continuing education programs for practicing clinicians. Although not specific to hypertension or cardiovascular care, there is evidence that fear of discrimination and harassment from clinicians may lead SGM individuals to avoid or delay health-care services [15]. Therefore, it is important for clinicians to implement strategies to create welcoming healthcare environments for SGM patients.

Continued efforts to engage SGM adults at high risk of hypertension in their care are needed. Public health campaigns to reduce hypertension risk among SGM individuals are limited but greatly needed. In 2021, the Human Rights Campaign in the United States launched the ‘My Heart, My Pride’ campaign, which highlighted the importance for SGM individuals to take steps to improve their heart health [16].

Clinicians are uniquely positioned to advocate for policies that positively impact the quality of care provided to marginalized populations. In particular, clinicians should advocate for widespread inclusion and documentation of sexual orientation and gender identity within electronic health records (EHRs) at their institutions. Although EHRs increasingly have the capability of capturing patients’ sexual orientation and gender identityclinicians are not required to routinely assess these during health encounters and they often lack adequate training to assess them in a culturally competent manner. To achieve a better understanding of hypertension in SGM individuals, sexual orientation and gender identity measures should be widely integrated into EHRs. These efforts will provide clinicians and researchers with access to data (such as patients’ social and family histories and laboratory results) that will help us better characterize hypertension risk in SGM people. Recommendations for clinical practice are summarized in Figure 1.

Figure 1. Clinical practice and research recommendations to address hypertension risk in sexual and gender minority indivduals.

3. Recommendations for research

Although significant progress has been made, there is a paucity of hypertension research among SGM individuals. Based on limitations of the existing literature [1], we provide several recommendations for future studies. The majority of research in this area has focused on examining differences in hypertension prevalence between SGM and non-SGM adults. Future research should use lifecourse approaches to identify critical periods of development most amenable to psychosocial and behavioral interventions to reduce hypertension risk in SGM individuals. Moreover, the very limited research on determinants of hypertension among SGM adults has focused on interpersonal factors to the exclusion of individual- (such as expectations of rejection) and structural-level factors (such as laws that do not protect individuals from discrimination on the basis of sexual orientation or gender identity). Researchers need to integrate a socioecological lens into future research to robustly examine multi-level determinants of hypertension risk among SGM individuals. These multi-level examinations will help identify strategies for future interventions to reduce hypertension risk in SGM individuals. Researchers should also conduct biobehavioral studies to investigate physiological mechanisms that drive hypertension risk in SGM adults. For instance, given inconsistent findings and considerable methodological concerns [1,6], more studies are needed that examine the influence of exogenous hormones on blood pressure in gender minority individuals.

Several measurement issues have also been identified in prior studies [1]. Most published studies on hypertension in SGM adults have been cross-sectional, which limits the ability to establish causality. Further, most of these studies have used self-report of hypertension rather than objective assessments of blood pressure, which can result in misclassification of hypertension [17]. Future studies must include objective assessment of blood pressure to accurately characterize hypertension risk in SGM individuals.

Even with this growing evidence, few behavioral interventions tailored specifically to reduce hypertension risk among SGM adults have been developed [1]. Clinical and public health interventions that address psychosocial and behavioral risk factors for hypertension among SGM individuals are needed. Clinicians and researchers must collaborate to develop, test, and disseminate tailored multi-level interventions that target behavior change among SGM adults in a culturally competent manner. Recommendations for research are summarized in Figure 1.

4. Conclusions

SGM adults experience significant psychosocial stressors that may increase their risk of hypertension. Despite growing evidence of higher risk of hypertension among SGM adults, there is a need for robust research to inform clinical efforts. There are several steps that clinicians and researchers a take to support efforts to reduce hypertension risk in SGM adults. With the increased attention on hypertension risk in SGM individuals, this is an ideal time to implement impactful interventions to address this emerging health disparity.

Declaration of interest

B Caceres has received funding from the National Heart, Lung, and Blood Institute. Y Sharma has received funding from the American Heart Association. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was funded by the American Heart Association (No. 899585) and the National Heart, Lung, and Blood Institute (no. K01HL146965).