Lynsie Ranker
3/19/13
Heart Disease: A Major Health Issue for Sexual Minority Women
Heart Disease: An Introduction
According to the Centers for Disease Control (CDC), heart disease is the leading cause of
death in the United States (US) among women.1 Individuals with high blood pressure, high
cholesterol, diabetes or who are overweight are at high risk of heart disease.2 These biological
risk factors can be influenced by genetic predisposition, but there are also lifestyle behaviors that
can put individuals at increased risk for heart disease.1
On a physiological level, heart disease can cause angina, myocardial infarction (heart
attack), heart failure, arrhythmias, and other negative health outcomes including permanent
disability.1 Heart disease can take an emotional toll as chronic illness, causing individuals to rely
on medications, be hospitalized for long periods, and experience disability.2 Individuals must
also face the resulting stress and great financial burden of disease.3 On a societal level, heart
disease is the most costly illness in the US.3 In 2006, national spending and lost productivity due
to heart disease was estimated at over $400 billion.3
Heart Disease Among Sexual Minority Women
While the majority of studies have shown no difference in heart disease prevalence and
risk among sexual minorities, heart disease is still considered one of the largest health threats to
sexual minority women (SMW).1,4 Yet, few studies have explored diagnosis by a medical
professional or biomarkers of heart disease, relying instead on self-reported disease risk. A few
self-report studies suggest both lesbians and bisexuals are more likely than heterosexuals to
report heart disease diagnosis, others self-reported heart disease among bisexuals alone may be
higher, and others have found no difference.4,5 Yet, studies consistently find higher rates of heart
disease risk factors among SMW, including smoking6–8, binge drinking9–11, and being
overweight or obese.12,13 A study by Conron, which aggregated data from the Massachusetts
Behavioral Risk Factor Surveillance survey (BRFSS) years 2001 to 2008, used logistic
regression to explore the association between self-identified sexual orientation and health
outcomes, including heart disease.14 Although sexual minorities were more likely to report heart
disease risk factors than heterosexuals, the groups did not differ in lifetime heart disease risk.14
When separated into subgroups, both bisexual women and lesbians were both more likely to
report having multiple heart disease risk factors compared to heterosexuals.14 A similar pattern is
seen in the California Quality of Life Survey where SMW were more likely to report risk
behaviors but had similar heart disease and related outcomes to heterosexual women.15
The evidence regarding the association between heart disease and sexual orientation may
be inconclusive due to numerous challenges faced in research. These include obtaining
representative samples, variations regarding the operational and societal definitions of sexual
orientation, obtaining sufficient sample sizes, willingness of participants to disclose their sexual
orientation, and the complexity of choosing appropriate comparison groups.16,17 Also, it may be
difficult to show a disparity, when the prevalence of heart disease in the heterosexual population
is also very high.18 Finally, SMW are more likely to report reduced medical care access, which
may lead to under-detection of heart disease, particularly subclinical stages, biasing any possible
differential between SMW and heterosexual groups toward the null.14
Even with these challenges, research on heart disease risk factors among SMW suggests
there may be a higher prevalence of cardiovascular risk factors.4,13 Contrary to the findings
regarding heart disease risk, the presence of multiple disease risk factors suggests SMW are a
high risk group. Furthermore, certain components of the risk profile appear unique to SMW,
suggesting this group may benefit from targeted interventions accounting for these differences. A
2
review of the literature suggests SMW women may be at higher risk for the major heart disease
risk factors of smoking, being overweight or obese, and heavy alcohol consumption.
Smoking
According to the CDC, smoking cigarettes can increase individual risk of heart disease by
two to four times.1 Smoking leads to atherosclerosis, or thickening of the artery walls, which
raises blood pressure and increases risk of vascular disease, angina, and myocardial infarction.1
Nicotine in cigarettes can also raise blood pressure, placing further strain on the heart.1
Evidence suggests SMW have a high smoking risk.4,6,19 While traditionally the smoking
literature has been limited to convenience sampling, there is growing evidence from populationbased studies using random sampling.19 Conron found lesbians had higher odds of current and
former smoking, and bisexual women were more likely to be current smokers than heterosexual
women.14 Another study used data from the California Health Interview Survey (CHIS), a large
population-based telephone survey. Based on response to a self-identification question, 343
women identified as lesbian and 511 identified as bisexual.20 After adjusting for demographics,
lesbians and bisexual women were significantly more likely to be current smokers than
heterosexual women.20 The analysis also investigated differences by demographics noting
variables such as being non-Hispanic White, being age 35-44, and having low-education
attainment and income as common predictors of smoking among SMW.20 In general, higher
prevalence of smoking among SMW is fairly consistent in the literature, with only a few studies
showing no significant difference between sexual minorities and heterosexuals.7,19
In addition to literature on adults, there has been growing focus on smoking among
sexual minority youth, as early initiation of smoking has been linked to smoking later in life.21 A
study by Corliss used data from the Growing Up Together Study (GUTS), a US community-
3
based longitudinal cohort of adolescents and emerging adults (12-24), to explore the relationship
between smoking and orientation among youth.8 Among past year smokers, youth SMW smoked
more cigarettes and more frequently than exclusively heterosexual females.8 SMW were also
found to have a higher relative risk of smoking as compared to sexual minority males (SMM),
suggesting gender as a modifier of the relationship between orientation and smoking.8 This is
consistent with prior studies on youth where SMW have been shown to have higher substance
use compared to SMM.8,22 This pattern may be unique to sexual minorities as studies of general
populations of youth suggest males are more likely to smoke than females.8 Yet, generalizability
of the Corliss and other youth studies may be limited as samples are often largely comprised of
middle class, non-Hispanic White youth.8 Therefore, results may not hold true for general SMW,
particularly those from low income families or of other racial or ethnic groups.
There are several gaps in the SMW smoking literature. First, small SMW sample sizes
limit statistical power of many studies.8 Researchers often collapse subgroups to gain statistical
power, masking any potential subgroup differences.20 Another gap is studies often focus only on
identity as the metric for sexual orientation, excluding those who may not identify as SMW, such
as individuals with same-sex attractions or behaviors. Such facets may be important to consider
as studies that have included behavioral or attraction metrics have shown differences in smoking
compared to heterosexuals.8,19 Such as a study by Gruskin which found women who engage in
same-sex behavior were more likely to be current smokers compared to heterosexual women.19
Research regarding the reason for the link between sexual minority status and smoking
mostly focuses on smoking as a coping mechanism.23 As a group, sexual minorities have
increased exposure to multiple stressors, including discrimination, stigma, rejection, identity
concealment, and internalized homophobia.24 The Minority Stress Model, proposed by Meyer,
4
suggests such environmental stressors increase stress and contribute to use of coping behaviors
such as smoking among sexual minority youth, young adults, and adults.24,25,26 Several studies
have shown a link between stressors such as rejection and greater risk of smoking.27,28 This
model suggest SMW use cigarettes to cope with negative feelings related to their orientation.
Gender identity may play a role in increasing smoking risk among SMW. Corliss
suggests females may cope with stress differently than males.8 In addition, gender expression
may be different among SMW who seek to express more masculine characteristics (such as
butch lesbians) through substance use behaviors such as smoking.29 Further research is needed
to explore the role of gender identity and expression in smoking.
Alcohol
Excessive alcohol use influences heart health. Heavy drinking and chronic use increases
blood pressure and buildup of triglycerides, leading to atherosclerosis. Thus, it is important to
explore how patterns of high alcohol use among SMW may increase heart disease risk.
A growing body of research, including results from several national, population-based
studies, has found that SMW have higher risks of hazardous drinking, alcohol dependence and
alcohol abuse.9–11,30,31 One example is a study by Drabble and colleagues, which used data from
the 2000 National Alcohol survey to examine alcohol consumption and related consequences by
sexual orientation.30 This study benefited from randomized sampling through random digit
dialing and also incorporated a behavioral component into the sexual orientation metric by
asking if participants were homosexual identified, bisexual identified, heterosexual identified
with same sex partners or exclusively heterosexual.30 The results showed lesbian and bisexual
women were significantly more likely to report higher alcohol use and greater odds of alcoholrelated social consequences, dependence, and a history of seeking help for an alcohol related
5
problem.30 These findings are in line with other studies which found SMW were more likely
than heterosexual women to binge drink, report dependence issues, and experience negative
consequences related to alcohol use.9,19
Even though there has been increasing research regarding SMW and alcohol use,
limitations remain.11 Due to low samples sizes, many studies collapse SMW subgroups to gain
statistical power. 11 This is problematic as several studies suggest differences by subgroup. First,
several studies suggest age-related differences in alcohol use. A study by Gruskin found SMW
20 to 34 had higher weekly consumption compared to SMW and heterosexual women.6 Another
study found greatest disparity in alcohol usage patterns between homosexually and
heterosexually experienced women aged 26-35.32 Second, evidence suggests heavy drinking
rates may be highest among bisexuals. Conron found bisexual women were more likely than
heterosexuals to binge drink, while lesbians showed no significant difference.14 Similar results
from Burgard showed bisexually active women had significantly higher alcohol use than
heterosexually active women, while those who were recently exclusively homosexually active
showed no difference.32 This relationship may be masked in studies collapsing across SMW.
Studies surrounding alcohol often use sexual orientation metrics based on identity.11
Thus, results are limited to those who identify as SMW, and may be different among those who
desire or participate in same-sex behavior but do not identify as an SMW.16 On the other hand,
research incorporating a behavioral or attraction component, such as Burgard, may exclude
individuals who may not be sexually active or experience attraction over a given time interval.11
Few studies have investigated why SMW are at higher risk for alcohol-related issues, but
some feel behaviors may relate to social context.10 In a study by Trocki and colleagues using
data from the 2000 National Alcohol Survey, researchers examined the prevalence of leisure
6
time at bars and parties, two heavy drinking contexts.31 The results suggest SMW spend more
time in bars compared to heterosexual women.31 They also found heterosexual women with
same-sex partners and bisexual women drank more at bars than lesbians.31 Overall, SMW may
spend more time in heavy drinking contexts than to heterosexual women.31 Qualitative studies
support these findings with women often seeing bars and parties as important centers for
developing social networks and feeling a sense of belonging within the SMW community.10
Another possible mechanism is increased alcohol use as a coping mechanism for stress
induced by minority status, as supported by the Minority Stress Model.10,24 Several studies
suggest stressors, such as internalized homophobia, increase binge drinking among SMW.10,33
Particularly for youth and young adults who are exploring multiple identities in addition to
sexuality, the combination of sexual, gender, and developmental stressors may strain individual
coping abilities, increasing the likelihood SMW will turn to alcohol as a coping strategy.26
Overweight and Obesity
Being overweight or obese are major risk factors for heart disease.1 Excess body fat is
linked to higher cholesterol, triglycerides, and blood pressure all of which can negatively impact
heart and vessel health, contributing to increased heart disease risk.1 Furthermore, being
overweight or obese can lead to diabetes and other conditions linked to heart disease.1
Several large population-based studies have been conducted regarding body mass index
(BMI) of SMW. The results of these studies suggest lesbians have higher rates of overweight and
obesity than heterosexual women, with bisexual women showing lower risk.12,34–36 Though the
studies benefited from large, national samples some may not be representative of the general
SMW population, and the majority focus on lesbians. For example, one study used data from the
Nurses’ Health Study II (NHSII), a study population being composed of predominately white
7
nurses and including only lesbian SMW.36 A recent study by Boehmer and colleagues included
bisexuals as well as women who did not identify as heterosexual, lesbian or bisexual.12 The
researchers found lesbians had roughly twice the odds of being overweight or obese, while those
identifying as bisexual or “something else” did not show increased odds of being overweight or
obese.12 Another study, focused specifically on self-identified lesbian and bisexual college
women completing the Spring 2006 National College Health Assessment, found both lesbians
and bisexual women are more likely to be overweight or obese than their heterosexual peers.37
Although there appears to be inconclusive evidence regarding weight issues among
bisexuals, additional studies support findings that lesbians are at-risk for being overweight or
obese.38 Aaron and colleagues found 31.6% of women nationally were overweight (BMI of 27.3
kg/m2 or higher). When compared to a sample of SMW from Pittsburgh who self-identified as
homosexual, lesbian or gay researchers found prevalence to be significantly higher (47.8%).39
Although there is a limitation in comparing local and national samples, findings are in line with
the literature. Another study by Smith used data from the Epidemiologic Study of Health Risk to
compare lesbian participants to a sample of heterosexual participants.40 The findings deviate
from prior studies mentioned in that the results suggest heterosexual women had a directionally
higher rate of being overweight while lesbians had a significantly higher rate of obesity.40
There are additional limitations in the literature that are worth noting. First, the majority
of studies have focus on BMI as a measure of healthy weight, when research suggests waist-tohip ratio (WHR) would give more of an indication of heart disease risk among SMW.13 Increased
abdominal/visceral adiposity creates a metabolic profile that is higher risk for heart disease.13 A
study by Roberts which compared lesbians to their heterosexual female sibling, found lesbians
had a significantly larger WHR.13 Second, the majority of studies rely on identity as the metric
8
for sexual orientation. Few investigate the relationship between same-sex attraction or behavior
and weight. It has been suggested that differences seen between bisexual and lesbian women in
terms of weight may relate to whether their regular partners are male or female, so it may be
important to consider behavior and attractions in addition to identity.12 A study by Boehmer and
Bowen examined data from 2001 to 2005 of the California Women’s Health Study, a probability
survey of California women which asked respondents if the gender of their sexual partner(s) in
the past twelve months were women, men, both or neither.41 This metric targets behavior, but the
drawback of this approach was that for women with no sexual partners in the past year, behavior
could not be determined (n=4,472).41 Still, the results show SMW reporting same-sex partners
are more likely to be overweight and obese compared to those reporting opposite-sex partners.41
Further research is also needed to understand the drivers of being overweight among
SMW. Studies have found few differences in dietary behavior, although several studies suggest
SMW consume fewer servings of fruits and vegetables than heterosexual women.13,35 Regarding
physical fitness, some research suggests SMW are more physically fit, even though they weigh
more, while others have found the opposite.38 Some research suggests attitudes towards weight
and differences in body image perceptions may explain the weight differential between lesbian
and heterosexual women.12 Several studies have shown SMW are more satisfied with their
appearance and may feel weight loss is unnecessary.34,42 Additionally, SMW may be more driven
to exercise to live a healthy lifestyle rather than desire for thinness.34 Minority stress should also
be considered as higher stress may influence activity and eating patterns.24
Looking Forward: Need for Further Research
The above findings suggest SMW have higher heart disease rates and related morbidity
than heterosexuals due to the higher prevalence of cardiovascular risk factors. Furthermore,
9
SMW may have a unique behavioral risk profile. However, evidence of higher risk of heart
disease among SMW remains elusive. Further research is needed to determine if this abundance
of risk factors contributes to increased heart disease risk, or if the risk profile of SMW is simply
unique and important to consider when developing heart health promotion programming.
Until recently, public health research has focused on “traditional” LGBT health issues
such as sexually transmitted infections, with far less research into disparities regarding chronic
disease risk.4 Although there is a growing body of research regarding risk and protective factors
related to chronic diseases such as heart disease, major population-based data is still limited as
few surveys consistently collect information regarding sexual orientation.4 In particular, large
national data sets such as the BRFSS that track the health status and health behaviors of the
population, should include sexual orientation measures that take into account sexual attraction,
identity and behavior. In order to do this, more research is needed on sexual orientation metrics
themselves in order to find metrics that will yield consistent, reliable and valid measures of
sexual orientation accounting for both identity, behavior and attraction components.16 By
beginning to better track the health status, risk factor prevalence and needs of SMW, public
health practitioners and agencies will be in a better position to respond to disparities and tailor
interventions accordingly.
Research regarding transgender health is lacking on many levels, so it comes as no
surprise that very little research exists on this subgroup with regards to heart health.24 There has
been some research to suggest transgender patients receiving hormone therapy may have
increased cardiovascular risk due to chronic hormone use.43 Yet, little has been done regarding
common risk factors for heart disease within this population.24 Part of this is due to lack of data
on this subgroup as few measures incorporate gender identity, excluding transgenders from being
10
properly identified within surveys.4,16 Inclusion of gender identity metrics in SMW research is
critical to assuring representation of this currently under-recognized and underserved subgroup.
Although heart disease risk factors have been more thoroughly researched than heart
disease itself, there is still some inconsistency in the SMW literature regarding etiology of risk
factors. Particularly, there is a lack of literature in how these behaviors may relate to SMW
specifically rather than sexual minorities in general. Future research should explore the role of
gender as well as intersectionality between sexual orientation, gender and other identities such as
racial or ethnic minority group status.4 Doing so will strengthen interventions for SMW.
Looking Forward: Need for Policy and Targeted Interventions
Although the association between heart disease and sexual orientation is still
inconclusive, and further research is warranted, the current body of evidence to support
disparities in prevalence of particular cardiovascular risk factors among SMW warrants targeted
interventions to meet the needs of this unique group. Creating programming to reduce prevalence
of these risk behaviors will improve the overall health of SMW, including their heart health.
Interventions promoting societal change and policy protection should be explored as a
mechanism to improve heart health. According to the Minority Stress Model, prevalence of the
discussed risk factors may be the result of unhealthy coping mechanisms among SMW. Focus on
advocacy to improve civil rights of SMW may reduce external stressors and resulting negative
coping behaviors. In addition, ensuring equal access to healthcare through policy focused on
providing insurance coverage and creating healthcare work forces that are competent in LGBT
health may encourage SMW to seek care and receive counseling on cardiovascular risk factors.
Societal influences should also be considered. Research suggests SMW may be tobacco
and alcohol industry targets.44 Marketing greatly influences consumer choice, and exposure to
11
tobacco and alcohol ads have been linked to increased uptake.45 A study by Dilley using
Washington State BRFSS data from 2003-2006 found, after adjusting for demographics and
smoking status, lesbian and bisexual women were more receptive to tobacco industry advertising
and had higher levels of exposure than heterosexual women.44 SMM were also heavily targeted,
but results show males are less receptive, suggesting SMW may be a highly targeted and
receptive group.44 Thus, direct to SMW alcohol and tobacco advertising should be controlled and
programming should be developed to increase resistance to industry messaging.
Specific, targeted interventions are also needed as few currently target the needs of
SMW.34 Interventions targeted to promote social support may reduce smoking and alcohol use.8
A study by Rosario found higher levels of positive support from family and friends reduced the
association between smoking and distress.27 Also, interventions that target social norms of SMW
regarding bars as ideal social spaces, may help to encourage them to spend less time in heavy
drinking contexts. Research by Fogel suggests programs that create judgment-free environments,
where SMW needs are taken into account, and that promote a sense of community may be
particularly important for weight-related programming.46 Weight interventions should also take
into account that SMW are more driven by the desire to stay healthy and improve overall health
rather than looking good or being thin.13,46
Final Thoughts
There is still a great deal of research needed to fully understand the unique risk profile of
SMW as it relates to heart health, and whether there is a disparity in heart disease and related
morbidity among SMW. Focus on chronic disease risk will further elucidate the relationship
between the increased prevalence of risk factors among SMW and heart health, as well as how
best this disparity should be addressed through policy and targeted programming.
12
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15