Sexuality and Race/Ethnicity Intersect to Affect CV Health: NHANES Data

For women—but not men—who are part of the LGBTQ+ community, the overall CV health impact posed by being a sexual minority differs depending on their racial/ethnic background, an observational analysis shows.

Moreover, the relationships between sexuality and risk factors like smoking, body mass index (BMI), and blood pressure are distinct across Black, Hispanic, and white sexual-minority populations.

Lead author Nicole Rosendale, MD (University of California San Francisco), told TCTMD that this study is a follow-up to their group’s prior analysis, also using the National Health and Nutrition Examination Survey (NHANES) database, that adjusted for race/ethnicity when looking at the influence of sexual identity.

For the new study, published in JAMA Network Open, their calculations instead explored the idea of intersectionality, in this case the overlap between sexual identity and race/ethnicity, when it comes to CV health. “Someone isn’t just a single identity or experience that they bring in navigating the world. We have multiple identities that all intersect in our access to power and privilege, as well as discrimination [and other] experiences,” Rosendale said.

In medicine, “we’re starting to get to that nuance” by recognizing social determinants of health and other related concepts, she said, “but I think it’s still in its infancy and so this is a step in that direction.”

Indeed, a growing body of research is suggesting that LGBTQ+ individuals face unique stressors that may lead to worse CV health compared with cisgender, heterosexual adults. Bisexual women and gay men, for instance, are about 20% more likely to be diagnosed with hypertension than heterosexual individuals, with bisexual women at higher risk of untreated hypertension. Yet oftentimes sexuality and gender diversity aren’t addressed during healthcare encounters.

A key takeaway from their current paper is “the importance of understanding that even within a category like lesbian women or bisexual women, there are differences,” said Rosendale. “Different communities have different needs, so we really do have to individualize and focus on [the question of]: who is the person in front of us and what is their particular need?”

Sexuality Plus Race/Ethnicity

The researchers analyzed data on 12,180 adults (mean age 39.6 years) for the years 2007 to 2016. Half of the survey respondents were male. Most (42.1%) self-reported being white, with 27.0% identifying as Hispanic, 20.2% as Black, and 10.7% as “other” race/ethnicity. Self-reported sexual identity—categorized as heterosexual or sexual minority (ie, lesbian, gay, bisexual, or “something else”)—was available for 45.9% of participants.

The researchers scored each person’s CV health according to the American Heart Association’s Life’s Essential 8 metrics—diet quality, sleep quality, physical activity, exposure to cigarette smoking, body mass index, and levels of fasting blood glucose, total cholesterol, blood pressure—based on the NHANES questionnaire, dietary information, and a physical exam. They adjusted for age, survey year, and socioeconomic status.

Compared with heterosexual females, those who were a sexual minority had worse overall CV health. The link between sexuality and poor CV health was strongest among Hispanic female participants (β −5.9) but it was also seen in Black (β −3.2) and white (β −3.3) females. There was no interaction for the “other” racial/ethnic category. Digging deeper, Black (β −5.7) sexual-minority females had significantly lower overall CV health compared with white heterosexual females, whereas there was only a trend seen for Hispanic sexual-minority females.

Males who self-identified as a sexual minority, however, did not see worse CV health compared with heterosexual males, which remained true across all racial/ethnic categories.

Nicotine use may have driven part of the differences, given that Black sexual-minority females fared worse in this area than their Black heterosexual counterparts (β −16.5). Compared with white heterosexual females, white sexual-minority females had worse scores for nicotine (β −14.2) plus worse metrics for BMI (β −8.2); Hispanic sexual-minority females, compared with their heterosexual counterparts, had worse BMI (β −17.3) and worse blood pressure (β -5.1).

Although there was no difference in CV health scores across racial/ethnic groups for sexual-minority versus heterosexual males, there were some differences within individual racial ethnic/groups. Black sexual-minority males had worse exposure to nicotine (β −13.0) but better BMI (β 13.1) and blood pressure (β 6.8) compared with Black heterosexual males. Hispanic sexual-minority males, meanwhile, had worse nicotine exposure (β −20.1) but better BMI (β 11.0) compared with Hispanic heterosexual males. Diets tended to be healthier among Hispanic and white sexual-minority males compared with their heterosexual counterparts (β 8.8 and 7.9, respectively).

Who is the person in front of us and what is their particular need? Nicole Rosendale

Rosendale said she hopes future research can help get at the “why” driving the differences in women, though one partial explanation is the history of discrimination they’ve experienced both as people in the world and as patients receiving healthcare.

In the investigators’ earlier study of NHANES data, led Billy A. Caceres, PhD, RN (Columbia University School of Nursing, New York, NY), they showed that gay men in fact generally had better CV health than heterosexual men: this presents an opportunity to better understand which health practices and forms of community support might be working well in sexual-minority males, she observed. “How can we leverage that to improve cardiovascular health in total for all men?”

It's not so much that clinicians caring for LGBTQ+ patients need to be asking questions targeted at their sexual and racial/ethnic identity, said Rosendale. Rather, healthcare professionals should “be systematic in their approach [to risk factors] and actively listen to their patients . . . about their experiences in life.”

For instance, it is incorrect to assume that just “because someone is a lesbian who’s in a stable relationship and has a job and this and that, that they don’t necessarily need certain health screenings,” she noted.

A “strength-based approach” to counseling patients that highlights how well they’re taking care of their health also is powerful, Rosendale added. “Even the fact that they’re sitting in front of [you] is a huge step. . . . They’ve been through a lot, [so] acknowledge that and recognize the strength that it takes to get through and access the care that they need.”