Gay Men, Bisexual Women Face Unique Hypertension Risks

Hypertension is diagnosed nearly 20% more often among gay men and bisexual women in comparison to their heterosexual counterparts, a large observational study shows. But while gay men, when diagnosed, are more likely to be on the necessary antihypertensive medications, bisexual women with hypertension have a higher risk of their disease being untreated.

Billy A. Caceres, PhD, RN (Columbia University School of Nursing, New York, NY), senior author of the paper published in Circulation: Cardiovascular Interventions, told TCTMD that prior research has shown lesbian, gay, and bisexual (LBG) people are at higher risk of developing hypertension. This study explores that question but adds another layer: whether hypertension, when diagnosed, is properly managed.

The findings, by showing variations among sexual-minority adults, hint at the complexity of the unique risks they face.

“Our results highlight the need for healthcare providers to create affirming clinical settings for LGB people. Healthcare organizations and providers need to openly express their commitment to providing inclusive care to the LGB community,” Caceres said in an email.

Routinely asking about sexual identity during clinic visits and affirming that discrimination won’t be tolerated will go a long way, he suggested. “This will do a lot to make LGB people feel seen and supported by healthcare providers. Increasing trust in healthcare providers and the healthcare system more generally will go a long way to actively engage LGB people in their healthcare.”

LGB adults experience significant discrimination throughout their lives, and nearly 10% specifically report experiencing discrimination from healthcare providers in the past. Billy A. Caceres

Led by Yashika Sharma, RN (Columbia University School of Nursing), the researchers looked at 420,340 participants in the Behavioral Risk Factor Surveillance System (BRFSS; 2015-2019), a telephone-based survey. Mean age was 49.7 years, and two-thirds reported being non-Hispanic white. Around 35% said they had a diagnosis of hypertension, with 78% of those individuals currently taking antihypertensive medications.

Among the data set’s 226,850 women, 95.2% of women identified as heterosexual, 1.3% as lesbian, 2.9% as bisexual, and 0.6% as other. Compared with those who described themselves as heterosexual, sexual-minority women tended to be younger and to have lower annual income, less education, and less healthcare insurance coverage. They were less likely to report having a routine checkup in the past year or being diagnosed with hypertension, and they were more likely to be lifetime smokers.

Bisexual women in particular also were more likely than heterosexual women to have obesity (40.6% vs 32.2%) and among those diagnosed with hypertension, less likely to be on medication to treat the disease (57.0% vs 82.8%; P < 0.001 for both).

Among the 193,490 men, 95.6% identified as heterosexual, 2.3% as gay, 1.6% as bisexual, and 0.5% as other. Again, there were numerous sociodemographic differences in comparison to the heterosexual reference group. Sexual-minority men on the whole had lower annual incomes, while gay and bisexual men tended to be younger and were less likely to be obese. Gay men had higher levels of education, for instance, while bisexual and other sexual-minority men were less apt to have healthcare insurance. Bisexual men were less likely to be diagnosed with hypertension (31.7% vs 38.2%) and to be taking antihypertensives (60.6% vs 75.1%; P < 0.001) compared with heterosexual men.

The researchers adjusted for age, race/ethnicity, annual income, educational attainment, healthcare coverage, last routine checkup, lifetime smoking, and body mass index. Even with these adjustments, bisexual women and gay men showed disparities in diagnosis compared with heterosexual women and men, respectively. There were no such differences seen for lesbian women, bisexual men, and those reporting their identity as other.

Hypertension Diagnosis, Treatment by Sexual Identity

Although they adjusted for many potential confounders, there could still be others that remained, Caceres pointed out. “It is likely that additional social determinants (such as experiences of discrimination) that have been shown to influence hypertension diagnosis and treatment are particularly important to examine among LGB adults. LGB adults experience significant discrimination throughout their lives, and nearly 10% specifically report experiencing discrimination from healthcare providers in the past.” These factors, in turn, may influence healthcare utilization.

He cautioned that a limitation of the BRFSS is that all data—both blood pressure and sexual identity—are self-reported, whereas their group’s earlier research has shown greater differences when using objective blood pressure measurements. A strength of the BRFSS, however, is its sample size.

Why Are Bisexual Women at Risk?

Bisexual women stand out as a group worthy of further study to understand what factors are driving the differences, Caceres said. “In particular, research that explores why bisexual women with hypertension are less likely to engage in care is needed to inform efforts to eliminate this disparity.”

Possible explanations are that bisexual women tend to be at a socioeconomic disadvantage compared to heterosexual and lesbian women, and in general bisexual people tend to experience more discrimination, in comparison to not only heterosexual people but also gay/lesbian people, he noted. “It is likely that increased exposure to socioeconomic disadvantage and discrimination place bisexual women at greater risk of hypertension. In addition, socioeconomic disadvantage likely drives the higher prevalence of untreated hypertension we found among bisexual women with hypertension.”

Gay men, in contrast, didn’t see the same lack of treatment. “Because of the higher risk of HIV observed among gay men and healthcare providers' increased recognition of HIV as a health concern for gay men, they are often more likely than lesbian and bisexual individuals to receive preventive care. Thus, hypertension may be more likely to be identified and treated among gay men versus other groups,” he explained.

Caceres said their group is continuing to look at hypertension treatment and diagnosis in lesbian, gay, and bisexual adults, with a follow-up study in the works.

Humberto López Castillo, MD, PhD, and Omar Martínez, JD (both from University of Central Florida, Orlando), writing in an accompanying editorial, also point to the “multifactorial nature driving health disparities among sexual minority individuals.” Creating evidence-based CV health interventions that address this intricacy will require joint efforts by researchers, clinicians, and community stakeholders, they note. Moreover, “given that social and structural conditions, including racism and discrimination, and their manifestation and structural stigma continue to drive disparities and inequities in cardiovascular disease among sexual minority populations,” future studies must use validated measures to take these factors into account, the editorialists say.

The chronic stress often experienced by sexual minorities can lead to increased allostatic load and biological responses, such as the body’s release of catecholamines and glucocorticoids, they observe, suggesting that researchers “include stress biomarkers (eg, cortisol and C-reactive protein) when approaching hypertension disparities by sexual orientation.”