Trauma May Increase CVD Risk for Lesbian, Bisexual Women

Patrice Wendling

November 08, 2018

CHICAGO — Trauma may rank alongside tobacco use, binge drinking, and overeating as a potential risk factor for cardiovascular disease (CVD) in lesbian and bisexual women, new research suggests.

Among more than 500 sexual-minority women, childhood trauma, including abuse and parental neglect, was as an independent risk factor for diabetes, increasing the odds by 58%.

Adult and lifetime trauma also emerged as independent predictors of obesity and hypertension, raising the odds by 16% to 30% in a study to be presented this week at the American Heart Association Scientific Sessions 2018.

"The big first step in this is assessing a patient's sexual identity," principal investigator Billy A. Caceres, PhD, RN, Columbia University School of Nursing, New York City, told | Medscape Cardiology.

"I think every provider probably has taken care of a lesbian or bisexual woman, whether they know it or not," he said. "And it's important if we're taking care of people in this population to know what cardiovascular risk factors might be elevated because we don't readily assess for things like experiences of trauma."

Lesbian and bisexual women are known to have higher rates than heterosexual women of CVD risk factors, such as tobacco use, obesity, and hyperglycemia. Interpersonal trauma is also thought to increase CVD risk, but few studies have examined its effect in sexual-minority women, said Caceres.

Estimates are that of the 11 million Americans who are lesbian, gay, bisexual, or transgender (LGBT), 5 million identify as sexual-minority women.

"Yet even in institutions where sexual identity was part of the electronic health record, only 13% to 17% of physicians were actually asking the question," he said.

Caceres and his team did a secondary analysis of data on 547 lesbian and bisexual women who participated in the third wave of the Chicago Health and Life Experiences of Women (CHLEW) study, which is the longest running study of sexual-minority women's health. Now in its fourth wave, wave 3 had an added focus on bisexual, younger, and Black and Latina women.

About a third of participants were 18 to 30 years of age, 36% were black, 22% were Latina, and 71.3% had healthcare insurance. Self-reported rates of obesity, hypertension, and diabetes were 38.8%, 17.7%, and 8.4%.

Cumulative childhood trauma was rated according to experiences of physical abuse, sexual abuse, and parental neglect, with a score of 0 indicating that the participant reported none of the three types of trauma and a score of 3 indicating that the participant reported all three types. In all, 19.7% of women had a score of 0, 40.2% a score of 1, 33.3% a score of 2, and 6.8% a score of 3.

Cumulative adulthood trauma was rated according to experiences of physical abuse, sexual abuse, and intimate partner violence, with 38.2%, 31.3%, 20.8%, and 9.7% of women, respectively, having scores of 0, 1, 2, and 3.

Cumulative lifetime trauma, or the sum of the two previous scales, was scored on a 6-point scale, with 12.0% of women having a score of 0, 45.6% a score of 1 or 2, 33.8% a score of 3 or 4, and 8.6% a score of 5 or 6.

Psychosocial factors were measured using the 10-item version of the Center for Epidemiological Studies Depression Scale (CES-D-10), the short Post-Traumatic Stress Disorder (PTSD) Symptom scale, and the Multidimensional Scale of Perceived Social Support.

All forms of trauma were associated with a probable diagnosis of PTSD and lower perceived social support, according to the study, which was named the best cardiovascular stroke nursing abstract of the session.

After adjustment for demographic factors, the odds ratios (OR) were increased among lesbian and bisexual women by:

  • 30% for anxiety with adult trauma (OR, 1.30; 95% CI, 1.05 - 1.60)

  • 41% for depression with childhood trauma (OR, 1.41; 95% CI, 1.11 - 1.81)

  • 22% for depression with lifetime trauma (OR, 1.22; 95% CI, 1.06 - 1.40).

When the investigators examined the behavioral risk factors of tobacco use, binge drinking, and overeating, only childhood trauma was associated with an adjusted increased risk, and only for overeating in the past 3 months (OR, 1.44; 95% CI, 1.07 - 1.92).

After further adjustment for psychosocial and behavioral factors, childhood trauma was significantly associated with diabetes, but not obesity or hypertension. Adult trauma and lifetime trauma significantly upped the women's odds of obesity and hypertension, but not diabetes.

Outcomes Related to Trauma
Outcome Childhood Trauma OR (95% CI)* Adulthood Trauma OR (95% CI)* Lifetime Trauma OR (95% CI)*
Obesity 1.16 (0.93–1.47) 1.22 (1.01–1.49) 1.16 (1.01–1.33)
Hypertension 1.22 (0.89–1.68) 1.30 (1.01–1.68) 1.22 (1.01–1.46)
Diabetes 1.58 (1.02–2.44) 0.94 (0.67–1.33) 1.12 (0.98–1.43)
*Adjusted for demographics, psychosocial factors, and behavior factors.

The divergent cardiometabolic findings might be explained in part by the use of self-reported diabetes and hypertension, which is a limitation of the study, Caceres said. Fear of discrimination by healthcare providers, poverty, and lack of health insurance can also lead to under-reporting of health conditions.

Other limitations include a lack of information on severity and duration of interpersonal trauma and the potential for residual confounders.

Although more research has focused on the role of HIV among men having sex with men and hormone replacement therapy among transgender populations as potential cardiovascular risk factors, there is far less understanding about what's driving the disparities seen in sexual-minority women, particularly those of color, he said.

"For me, I think it has to do with higher rates of social stresses and, in many ways, this may make them more invisible because some of the traditional risk factors we think about in LGBT populations aren't there," Caceres said. "The larger point is for providers at all levels to understand what some of the psychosocial risk factors might be in sexual-minority women and why it is important to assess sexual identity."

"I don't think every provider needs to be an expert in LGBT health or the needs of sexual-minority women, but they need to be open to understanding it and understanding some of the unique risk factors that they experience."

Caceres reports no relevant conflicts of interest. Coauthor Tonda Hughes reports support from the National Institute on Alcohol Abuse and Alcoholism, and coauthor Pat Stone reports support from Comparative and Cost Effectiveness Research for Nurse Scientists.

American Heart Association (AHA) Scientific Sessions 2018: Abstract 299. Presentation November 10, 2018.

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