Abstract Body (Do not enter title and authors here): Background
Over 550 Anti-LGBT (lesbian, gay, bisexual, transgender) bills were introduced at the state-level during the 2025 legislative sessions. Increased state-level anti-LGBT laws are associated with greater chronic stress among LGBT individuals compared to their LGBT peers living in states with codified protections for these populations. Additionally, chronic stress enhances one’s CVD risk. Here, we examined the association of state-level LGBT protections with incident CVD risk among LGBT veterans.

Methods
A validated natural language processing algorithm applied to the Veterans Healthcare Administration EHR identified LGBT veterans; we retained those with >2 outpatient encounters in fiscal years 2010-2019 who were free of CVD at baseline (first primary care appointment on or after 10/1/09). State-level tallies of LGBT anti-discrimination laws in 2010 (sum of 7 domains where higher values indicate greater protections) were obtained from the Movement Advancement Project and were merged with veterans’ EHR data based on state of residence. Incident CVD (MI, stroke, CHF, CVD Death) was assessed through 9/30/19. We used Cox regression to assess the association of LGBT anti-discrimination policies in veterans’ state of residence with incident CVD.

Results
Among 183,346 LGBT veterans, 27,261 CVD events occurred during a median of 8.6 years of follow-up. The sample was 75% male, 71% White, with an average age of 49 years. Over half (57%) of the sample resided in states with a negative policy index, indicating a potentially harmful policy environment. Adjusting for age, sex, and race, greater overall tallies of state-level LGBT anti-discrimination laws were associated with decreased CVD incidence (p<0.0001; Table); 5/7 components of the overall tally were also associated with decreased CVD risk. Upon additional adjustment for CVD risk factors and mental health socioeconomic factors, the overall tally, as well as 4 of its components, remained significantly associated with decreased CVD risk (Table).

Conclusion
In a nation-wide sample of US veterans, LGBT veterans residing in states with more LGBT non-discrimination laws experienced lower CVD incidence. These findings are in-line with prior work demonstrating the harmful impact of discriminatory legislation on LGBT mental health and well-being. Future work should incorporate policy changes over time and include matched heterosexual cisgender veterans to exclude the potential confounding effect of regionality.