Health inequalities among sexual minority adults: evidence from ten U.S. states, 2010

Sexual Orientation and Lifetime Prevalence of Skin Cancer Across Racial and Ethnic Groups

Importance

Sexual minority (SM) persons have been found to have differential rates of skin cancer, but limited data exist on differences across racial and ethnic groups and by individual sexual identities.

Objective

To examine differences by sexual orientation in the lifetime prevalence of skin cancer among US adult females and males across racial and ethnic groups and by individual sexual identity.

Design, Setting, and Participants

This cross-sectional study used data from the Behavioral Risk Factor Surveillance System from January 1, 2014, to December 31, 2021, for US adults from the general population. Data were analyzed from December 1, 2023, to March 1, 2024.

Main Outcomes and Measures

Self-reported lifetime prevalence of skin cancer by sexual orientation. Age-adjusted prevalence and adjusted prevalence odds ratios (AORs) compared heterosexual and SM adults in analyses stratified by individual race.

Results

Of 1 512 400 participants studied, 805 161 (53.2%) were heterosexual females; 38 933 (2.6%), SM females; 638 651 (42.2%), heterosexual males; and 29 655 (2.0%), SM males. A total of 6.6% of participants were Hispanic; 3.4%, non-Hispanic Asian, Pacific Islander, or Hawaiian; 7.5%, non-Hispanic Black; 78.2%, non-Hispanic White; and 4.3%, other race and ethnicity. Mean (SE) age was 48.5 (0.03) years (incomplete data for age of respondents ≥80 years). The lifetime prevalence of skin cancer was overall higher among SM males compared with heterosexual males (7.4% vs 6.8%; AOR, 1.16; 95% CI, 1.02-1.33), including specifically among Hispanic males (4.0% vs 1.6%; AOR, 3.81; 95% CI, 1.96-7.41) and non-Hispanic Black males (1.0% vs 0.5%; AOR, 2.18; 95% CI, 1.13-4.19) in analyses stratified by race and ethnicity. Lifetime prevalence rates were lower among SM females compared with heterosexual females among non-Hispanic White females (7.8% vs 8.5%; AOR, 0.86; 95% CI, 0.76-0.97) and were higher among Hispanic (2.1% vs 1.8%; AOR, 2.46; 95% CI, 1.28-4.70) and non-Hispanic Black (1.8% vs 0.5%; AOR, 2.33; 95% CI, 1.01-5.54) females in analyses stratified by race and ethnicity.

Conclusions and Relevance

In this cross-sectional study of US adults, differences in the lifetime prevalence of skin cancer among SM adults compared with heterosexual adults differed across racial and ethnic groups and by individual sexual identity among both females and males. Both Hispanic and non-Hispanic Black and SM females and males had higher rates of skin cancer compared with their heterosexual counterparts. Further research addressing the individual factors contributing to these differences is needed to inform screening guidelines and public health interventions focused on these diverse, heterogeneous populations.

Early adversity and sexual diversity: the importance of self-reported and neurobiological sexual reward sensitivity

Work shows that sexually-diverse individuals face high rates of early life adversity and in turn increased engagement in behavioral outcomes traditionally associated with adversity, such as sexual risk taking. Recent theoretical work suggests that these associations may be attributable to heightened sexual reward sensitivity among adversity-exposed women. We aimed to test these claims using a combination of self-report and EEG measures to test the relationship between early adversity, sexual reward sensitivity (both self-reported and EEG measured) and sexual risk taking in a sexually diverse sample of cis-gender women (N = 208) (Mage = 27.17, SD = 6.36). Results showed that childhood SES predicted self-reported sexual reward sensitivity which in turn predicted numbers of male and female sexual partners. In contrast we found that perceived childhood unpredictability predicted neurobiological sexual reward sensitivity as measured by EEG which in turn predicted male sexual partner number. The results presented here provide support for the notion that heightened sexual reward sensitivity may be a pathway through which early life adversity augments future sexual behavior, and underscores the importance of including greater attention to the dynamics of pleasure and reward in sexual health promotion.

Characterization of content associated with lesbian, gay, bisexual, transgender, intersex, and queer individuals in Chilean medical schools: a cross-sectional survey

BACKGROUND

Lesbian, gay, bisexual, transgender, intersex, queer, and other sexual and gender identities (LGBTIQ+) individuals face health inequities. Additionally, medical students report a lack of confidence in providing specific health care to LGBTIQ + individuals, and medical schools do not offer the breadth and depth of coverage needed to fully prepare and make them comfortable in caring for these individuals. This study aims to characterize the teaching of curricular content related to LGBTIQ + health issues in medical schools in Chile.

METHODS

This was a cross-sectional descriptive mixed-methods study based on a 15-question survey sent to school directors of the 24 medical schools in Chile, conducted between October 2020 and July 2021. The questions included in the study were mostly based on two pre-existing questionnaires covering content, assessment methods, and identification of barriers to teaching this content.

RESULTS

The validated questionnaire was answered by 14 of 24 Chilean medical schools, with 11 schools (78.9%) declaring that they included some training in their curriculum. The predominant range of time allocated to LGBTIQ + training in medical programs was between 1 and 5 h. The most addressed topics were HIV (92.85%), sexual orientation (78.57%), and chronic disease risk in LGBTIQ + populations (78.57%). Most schools, accounting for 71.5%, considered the content they delivered to be "moderately insufficient" or "insufficient". Regarding the teaching methodologies, the most used were lectures (92.8%), clinical cases (42.9%), and clinical simulation (28.6%).

CONCLUSION

Most surveyed medical schools reported curricular spaces dedicated to teaching health issues of LGBTIQ + individuals, primarily during the pre-internship training period. However, the time allocated is insufficient, and there is little approach to topics beyond the patient's sexual history or sexual orientation. Given the crucial role of medical schools, they must adopt both local and national strategies to enrich training focused on the care of LGBTIQ + patients.

Higher Risk of Many Physical Health Conditions in Sexual Minority Men: Comprehensive Systematic Review and Meta-Analysis in Gay- and Bisexual-Identified Compared with Heterosexual-Identified Men

Purpose: The purpose of this study was to provide a systematic review and, where possible, meta-analysis on the prevalence of physical health conditions in sexual minority men (SMM, i.e., gay- and bisexual-identified men) compared with heterosexual-identified men. Methods: A systematic literature search in the databases MEDLINE, Embase, CENTRAL, CINAHL, and Web of Science was conducted on epidemiological studies on physical health conditions, classified in the Global Burden of Disease project and published between 2000 and 2021. Meta-analyses comparing odds ratios were calculated. Results: In total, 23,649 abstracts were screened, and 32 studies were included in the systematic review. Main findings were that (1) Largest differences in prevalence by sexual identity were found for chronic respiratory diseases, particularly asthma: overall, SMM were significantly almost 50% more likely to suffer from asthma than heterosexual men. (2) Evidence of higher prevalence was also found for chronic kidney diseases and headache disorders in gay men and for hepatitis B/C in both gay and bisexual men. (3) We found an overall trend that bisexual men were more affected by some of the physical health conditions compared with gay men (e.g., cardiovascular diseases, asthma). However, regarding cancer, headache disorders, and hepatitis, gay men were more affected. Conclusion: We found evidence of physical health disparities by sexual identity, suggesting more health issues in SMM. Since some of these findings rely on few comparisons or small samples of SMM only, this review is intended to be a vehement plea for routinely including sexual identity assessment in health research and clinical practice.

Health Care Utilization and Care-seeking Behavior Among Vulnerabilized Sexual Minority Women: A Social-ecological Approach

Sexual minority women (SMW) experience worse health than their heterosexual counterparts but have largely been omitted from health services research. To address this gap, we conducted 25 semi-structured, in-depth interviews with SMW. Transcripts were analyzed using thematic analysis, and findings were organized using a modified socioecological framework. Key themes at each socioecological level include (1) structural: stigma, sociocultural norms, health infrastructure; (2) organizational: stigma, patient-provider relationship, hours and location, linkage to care and co-location of services; (3) interpersonal: stigma and social support; (4) individual: internalized stigma, self-efficacy, socioeconomic status, health literacy, and intersecting identities. Stigma is the central theme affecting vulnerabilized SMW's experiences accessing care. Anti-stigma initiatives and factors that lead to personal resilience and can mitigate care access barriers were identified at each level. Interventions should focus on building inclusive policies/infrastructure and using SMW's unique social networks to empower and improve care access and health outcomes among vulnerabilized SMW.

LGBTQ Utilization of a Statewide Tobacco Quitline: Engagement and Quitting Behavior, 2010-2022

INTRODUCTION

Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) individuals use tobacco at disproportionately high rates but are as likely as straight tobacco users to want to quit and to use quitlines. Little is known about the demographics and geographic distribution of LGBTQ quitline participants, their engagement with services, or their long-term outcomes.

AIMS AND METHODS

Californians (N = 333 429) who enrolled in a statewide quitline 2010-2022 were asked about their sexual and gender minority (SGM) status and other baseline characteristics. All were offered telephone counseling. A subset (n = 19 431) was followed up at seven months. Data were analyzed in 2023 by SGM status (LGBTQ vs. straight) and county type (rural vs. urban).

RESULTS

Overall, 7.0% of participants were LGBTQ, including 7.4% and 5.4% of urban and rural participants, respectively. LGBTQ participants were younger than straight participants but had similar cigarette consumption. Fewer LGBTQ participants reported a physical health condition (42.1% vs. 48.4%) but more reported a behavioral health condition (71.1% vs. 54.5%; both p's < .001). Among both LGBTQ and straight participants, nearly 9 in 10 chose counseling and both groups completed nearly three sessions on average. The groups had equivalent 30-day abstinence rates (24.5% vs. 23.2%; p = .263). Similar patterns were seen in urban and rural subgroups.

CONCLUSIONS

LGBTQ tobacco users engaged with and appeared to benefit from a statewide quitline even though it was not LGBTQ community-based. A quitline with staff trained in LGBTQ cultural competence can help address the high prevalence of tobacco use in the LGBTQ community and reach members wherever they live.

IMPLICATIONS

This study describes how participants of a statewide tobacco quitline broke down by sexual orientation and gender. It compares participants both by SGM status and by type of county to provide a more complete picture of quitline participation both in urban areas where LGBTQ community-based cessation programs may exist and in rural areas where they generally do not. To our knowledge, it is the first study to compare LGBTQ and straight participants on their use of quitline services and quitting aids, satisfaction with services received, and rates of attempting quitting and achieving prolonged abstinence from smoking.

Sexual orientation and gender identity inequities in cervical cancer screening by race and ethnicity

BACKGROUND

In the United States, inequities in preventive health behaviors such as cervical cancer screening have been documented. Sexual orientation, gender identity, and race/ethnicity all individually contribute to such disparities. However, little work has investigated their joint impact on screening behavior.

METHODS

Using sampling weighted data from the 2016 and 2018 Behavioral Risk Factor Surveillance System, we assessed differences in two metrics via chi-square statistics: 1) lifetime uptake, and 2) up-to-date cervical cancer screening by sexual orientation and gender identity, within and across racial/ethnic classifications.

RESULTS

Within all races, individuals who identify as members of sexual and gender minority (SGM) communities reported higher rates of never being screened (except for Black transgender men) than straight or cisgender individuals (p < 0.0001). [*START* Across all races, the Asian/Pacific Islander transgender population (32.4%; weighted n (w.n.) = 1,313) had the lowest proportion of lifetime screening, followed by the Asian/Pacific Islander gay/lesbian (53.0%, w.n. = 21,771), Hispanic transgender (58.7%; w.n. = 24,780), Asian/Pacific Islander bisexual (61.8%, w.n. = 54,524), and Hispanic gay/lesbian (69.6%, w.n. = 125,781) populations. *END*] Straight or cisgender Non-Hispanic White (w.n. = 40,664,476) individuals had the highest proportion of lifetime screening (97.7% and 97.5%, respectively). However, among individuals who had been screened at least once in their lifetime, identifying as SGM was not associated with a decreased proportion of up-to-date screening within or between races.

CONCLUSIONS

Due to small sample sizes, especially among Asian/Pacific Islander and Hispanic populations, confidence intervals were wide. Heterogeneity in screening participation by SGM status within and across racial/ethnic groups were observed.

IMPACT

These screening disparities reveal the need to disaggregate data to account for intersecting identities and for studies with larger sample sizes to increase estimate reliability.

Inequities in colorectal and breast cancer screening: At the intersection of race/ethnicity, sexuality, and gender

Objective

To investigate the joint impact of sexual orientation, gender identity, and race/ethnicity on colorectal and breast cancer screening disparities in the United States.

Methods

Utilizing sampling weighted data from the 2016 and 2018 Behavioral Risk Factor Surveillance System, we assessed differences in two metrics via chi-square statistics: 1) lifetime uptake, and 2) up-to-date colorectal and breast cancer screening by sexual orientation and gender identity, within and across racial/ethnic classifications.

Results

Within specific races/ethnicities, lifetime CRC screening was higher among gay/lesbian (within NH-White, Hispanic, and Asian/Pacific Islander) and bisexual individuals (Hispanic) compared to straight individuals, and lowest overall among transgender women and transgender nonconforming populations (p < 0.05). Asian transgender women had the lowest lifetime CRC screening (13.0%; w.n. = 1,428). Lifetime breast cancer screening was lowest among the Hispanic bisexual population (86.6%; w.n. = 26,940) and Hispanic transgender nonconforming population (71.8%; w.n. = 739); within all races, SGM individuals (except NH-White, Hispanic, and Black bisexual populations, and NH-White transgender men) had greater breast cancer screening adherence compared to straight individuals.

Conclusions

Due to small, unweighted sample sizes, results should be interpreted with caution. Heterogeneity in screening participation by SGM status within and across racial/ethnic groups were observed, revealing the need to disaggregate data to account for intersecting identities and for studies with larger sample sizes to increase estimate reliability.

Nutrition and Health in the Lesbian, Gay, Bisexual, Transgender, Queer/Questioning Community: A Narrative Review

Sexual and gender minorities have a higher risk for health and nutrition-related disparities across the life course compared to the heterosexual or cisgender population. Experiences of stigmatization and discrimination are associated with diminished mental health quality and psychological distress, which are risk factors for developing various eating disorders. Other nutrition disparities include increased risk for food insecurity, body dissatisfaction, and weight complications, such as those experienced by the transgender population in association with gender-affirming hormone therapies. Despite the need for tailored nutrition recommendations that address the unique needs of the lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ+) community, there are currently no such guidelines in North America. The purpose of this review is to summarize major LGBTQ+ nutrition disparities and highlight the need for tailored recommendations. We examine the evidence on mental health and social disparities in this group, including vulnerabilities to disordered eating, food insecurity, and healthcare provider discrimination. Importantly, we identify a scarcity of literature on dietary concerns and nutrition care guidelines for LGBTQ+ groups, including studies that address intersectionality and differences among specific gender and sexual orientations. These gaps underline the urgency of prioritizing nutrition for LGBTQ+ health needs and for developing tailored public health nutrition recommendations for this underserved population. Our review suggests that future LGBTQ+ health and nutrition research agendas should include personalized and precision nutrition, social determinants of health, diet quality, body image, and healthcare provider cultural competency and responsiveness. Moreover, the current evidence on LGBTQ+ nutrition and health will be strengthened when research studies (including clinical trials) with robust methodologies amplify inclusion and representation of this community to elucidate health and nutrition disparities in sexual and gender minorities.

Double Disparity of Sexual Minority Status and Rurality in Cardiometabolic Hospitalization Risk: A Secondary Analysis Using Linked Population-Based Data

Studies have shown separately that sexual minority populations generally experience poorer chronic health outcomes compared with those who identify as heterosexual, as do rural populations compared with urban dwellers. This Canadian national observational study explored healthcare patterns at the little-understood intersections of lesbian, gay, or bisexual (LGB) identity with residence in rural and remote communities, beyond chronic disease status. The secondary analysis applied logistic regressions on multiple linked datasets from representative health surveys, administrative hospital records, and a geocoded index of community remoteness to examine differences in the risk of potentially avoidable cardiometabolic-related hospitalization among adults of working age. Among those with an underlying cardiometabolic condition and residing in more rural and remote communities, a significantly higher hospitalization risk was found for LGB-identified persons compared with their heterosexual peers (odds ratio: 4.2; 95% confidence interval: 1.5-11.7), adjusting for sociodemographic characteristics, behavioral risk factors, and primary healthcare access. In models stratified by sex, the association remained significant among gay and bisexual men (5.6; CI: 1.3-24.4) but not among lesbian and bisexual women (3.5; CI: 0.9-13.6). More research is needed leveraging linkable datasets to better understand the complex and multiplicative influences of sexual minority status and rurality on cardiometabolic health to inform equity-enhancing preventive healthcare interventions.

Disparities in physical activity between sexual minority and heterosexual women: A systematic review and meta-analysis

Research examining potential differences in physical activity (PA) between sexual minority women (SMW) and heterosexual women have yielded inconsistent results.

OBJECTIVE

Therefore, the purpose of this systematic review and meta-analysis is to examine potential differences in PA between SMW and heterosexual women and to identify potential moderators that may partially explain observed differences in PA.

METHODS

All studies were peer reviewed, published in English, and included a continuous measure of PA for SMW and heterosexual women. A standardized mean difference effect size (ES) was used to compare groups, with random effects models used to estimate a mean ES and 95% CI using a 3-level meta-analysis model to adjust for the correlation between effects nested within studies.

RESULTS

The cumulative results of 24 effects gathered from 7 studies indicated there was no difference in PA between SMW (n = 1619) and heterosexual women (n = 103,295) (ES = -0.038, 95%CI -0.179 to 0.102, p = 0.576). Despite no mean differences, moderate-high heterogeneity was observed, indicating that the results were not consistent across effects (I2 = 64.8%, Q23 = 36.7, p = 0.035). The difference in PA was associated with age (β = -0.018, 95%CI -0.034 to -0.003, p = 0.022) and BMI (β = -0.145, 95%CI -0.228 to -0.061, p = 0.002), with a quadratic relationship observed for both variables.

CONCLUSIONS

Although the results of the current analysis did not indicate significant differences in PA behaviors between SMW and heterosexual women, age and BMI modify the association and are curvilinear in nature; such that smaller differences in PA were observed between SMW and heterosexual women when samples were middle-aged and overweight.

Identifying Healthcare Stereotype Threat in Older Gay Men Living with HIV

Healthcare stereotype threat (HCST) is defined as "being reduced to group stereotypes within an individual's healthcare encounter," leading to experiences of stigma and discrimination. This current study explores how older gay men living with HIV attribute their healthcare experiences to their social identities. Using HCST as a guiding framework, a content and structural coding analysis was conducted on transcripts from 11 interviews of older gay men living with HIV. The majority of HCST experiences were connected to the social identities of sexual orientation, HIV status, and age. Many of the healthcare experiences that participants discussed were related to interactions with healthcare providers and the attitudes of healthcare providers. This study illustrates how participants attributed social identities to healthcare experiences that showed qualities of HCST. These outcomes highlight how marginalized social identities impacted the lifetime healthcare experiences of this group of older gay men living with HIV.

Differences in HIV testing among sexual orientation subgroups in the United States: A national cross-sectional study

Understanding differences in HIV testing among US adults is a crucial step for HIV prevention. This study used cross-sectional data to assess whether HIV testing varies across sexual orientation subgroups and by important psychosocial factors. Data were from the National Epidemiological Survey on Alcohol and Related Conditions-III (NESARC-III; n = 36 309, response rate = 60.1%), a nationally representative survey of the US non-institutionalized adult population. Using logistic regression, we examined HIV testing among heterosexual concordant, heterosexual discordant, gay/lesbian, and bisexual adults. Psychosocial correlates included adverse childhood experiences (ACEs), discrimination, educational attainment, social support, and substance use disorders (SUDs). Bisexual (77.0%) and gay/lesbian (65.4%) women had a greater prevalence of HIV testing than concordant heterosexual women (51.6%), and bisexual women had a significantly higher testing prevalence than discordant heterosexual women (54.8%). Gay (84.0%) and bisexual (72.1%) men also had a significantly higher testing prevalence than discordant (48.2%) and concordant (49.4%) heterosexual men. In multivariable models, bisexual men and women (AOR = 1.8; 95% CI = 1.3-2.4) and gay men (AOR = 4.7; 95% CI = 3.2-7.1) had significantly greater odds of HIV testing than heterosexual concordant adults. A higher number of ACEs, greater social support, history of SUDs, and higher educational attainment were positively associated with HIV testing. HIV testing prevalence varied across sexual orientation subgroups; discordant heterosexual men had the lowest prevalence. Health care providers should consider a person's sexual orientation, ACEs, educational attainment, social support, and history of SUDs when evaluating HIV testing needs in the US.

Review of current 2SLGBTQIA+ inequities in the Canadian health care system

Gender identity and sexual orientation are determinants of health that can contribute to health inequities. In the 2SLGBTQIA+ community, belonging to a sexual and/or gender minority group leads to a higher risk of negative health outcomes such as depression, anxiety, and cancer, as well as maladaptive behaviors leading to poorer health outcomes such as substance abuse and risky sexual behavior. Empirical evidence suggests that inequities in terms of accessibility to health care, quality of care, inclusivity, and satisfaction of care, are pervasive and entrenched in the health care system. A better understanding of the current Canadian health care context for individuals of the 2SLGBTQIA+ community is imperative to inform public policy and develop sensitive public health interventions to make meaningful headway in reducing inequity. Our search strategy was Canadian-centric and aimed at highlighting the current state of 2SLGBTQIA+ health inequities in Canada. Discrimination, patient care and access to care, education and training of health care professionals, and crucial changes at the systemic and infrastructure levels have been identified as main themes in the literature. Furthermore, we describe health care-related disparities in the 2SLGBTQIA+ community, and present available resources and guidelines that can guide healthcare providers in narrowing the gap in inequities. Herein, the lack of training for both clinical and non-clinical staff has been identified as the most critical issue influencing health care systems. Researchers, educators, and practitioners should invest in health care professional training and future research should evaluate the effectiveness of interventions on staff attitudinal changes toward the 2SLGBTQIA+ community and the impact on patient outcomes.

Is socioeconomic status related to youth e-cigarette use? Examining family affluence and sexual identity

There is limited evidence about the relationship between socioeconomic status (SES) and youth electronic cigarette use, particularly among sexual minorities. This study investigates whether family affluence is significantly associated with e-cigarette use among youth, including sexual minority youth. Data came from the 2021 National Youth Tobacco Survey (N = 10,515). The prevalence of e-cigarette use for all participants and sexual minority youth (N = 1376) by SES was calculated and ranked according to the Family Affluence Scale. A propensity score weighting method was used to address the imbalance in characteristics among SES groups. The associations of SES with current e-cigarette use and current flavored e-cigarette use were estimated using univariate survey logistic regression for all participants and self-identified sexual minority students. The prevalence of e-cigarette use was similar among socioeconomic groups for all participants and sexual minorities. The propensity score weighting analysis showed no significant association between SES and current e-cigarette use for all participants and sexual minority students. Equally, there was no significant association between SES and current flavored e-cigarette use. Findings suggest that other protective and risk factors might explain youth e-cigarette use more than SES (family affluence scale).

The impact of an educational program based on the reproductive health of LGBT individuals developed for nursing students to improve the knowledge, skills and attitudes of students: A quasi-experimental study

AIM

This study aimed to investigate the impact of an educational program developed for nursing students to evaluate their knowledge of the lesbian, gay, bisexual and transgender (LGBT) community, their reproductive health and recording their reproductive history. The program aimed to assess the effective communication skills and attitudes of nursing students toward LGBT individuals after completion of the program.

BACKGROUND

Issues related to the reproductive health of LGBT individuals are not adequately addressed in the nursing curriculum. Innovative approaches using active learning methods will increase the knowledge and skills of the students regarding LGBT reproductive health and help them gain positive attitudes toward LGBT individuals.

DESIGN

A quasi-experimental (single group pretest-posttest) design.

METHODS

This study was conducted with 48 students in the 4th year in the Spring semester of the Academic year 2020-2021 at the Faculty of Nursing in a university. The eight-week education program included a discussion of modules developed for the reproductive health of LGBT individuals, film display and analysis, sample video display and analysis, role-play activities and standardized patient interviews. The research data were collected using a semi-structured questionnaire, Information Evaluation Test for LGBT Individuals, Attitude Scale Toward LGBTI Individuals, Reproductive Health History Taking Skills Checklist, Effective Communication Skills Evaluation Form and Student Satisfaction Evaluation Form. The data were analyzed using the mean, standard deviation, frequency, percentage distributions and Wilcoxon signed-rank test.

RESULTS

The study identified a significant increase in the median students' knowledge about LGBT individuals (p < 0.001), a substantial positive development in their attitudes toward LGBT individuals (p < 0.001) and a significant increase in the median scores of effective communication with LGBT individuals and recording the reproductive health history (p < 0.001) at the end of the education program.

CONCLUSION

The education program resulted in positive knowledge, attitude and skill changes in the nursing students supporting the reproductive health of LGBT individuals. Education programs based on LGBT reproductive health using active learning methods should be integrated into undergraduate nursing curricula to combat disparities toward LGBT individuals.

The Role of Contextual Factors in the Health Care Utilization of Aging LGBT Adults

BACKGROUND AND OBJECTIVES

Research suggests lesbian, gay, bisexual, and transgender (LGBT) populations have unique health care challenges. The purpose of this study was to understand contextual factors, including minority stress and social resources, associated with the health care utilization of LGBT middle-aged and older adults.

RESEARCH DESIGN AND METHODS

Using data from the Caring and Aging With Pride: National Health, Aging, and Sexuality/Gender Study (N = 2,560), multiple logistic regression investigated associations between minority stress (i.e., internalized stigma and LGBT identity disclosure) and health care utilization (i.e., health screenings, emergency room use, routine checkups, and regular provider). We also examined the moderating effect of social resources (i.e., social network size, social support, and LGBT community belonging) in these associations.

RESULTS

Internalized stigma was negatively associated with having a routine checkup in the previous year. LGBT identity disclosure was positively associated with having a health screening within the past 3 years. Social support moderated the association between LGBT identity disclosure and health screenings.

DISCUSSION AND IMPLICATIONS

Health and human service professionals and their clients should be educated about the ways that LGBT identity disclosure can affect health care utilization. Providers should consistently assess the social support of their aging LGBT clients and inform them about the potential risk of low social support in health care utilization.

A Meta-Ethnography on the Impact of Cancer for Lesbian and Queer Women and Their Partners

Lesbian and queer women face unique experiences navigating cancer care, including challenges in accessing services that incorporate their relational supports. Given the importance of social support for survivorship, this study examines the impact of cancer on lesbian/queer women in romantic relationships. We conducted the seven stages of Noblit and Hare's meta-ethnography. PubMed/MEDLINE, PsycINFO, SocINDEX, and Social Sciences Abstract databases were searched. Two hundred and ninety citations were initially identified, 179 abstracts were reviewed, and 20 articles were coded. Themes were (a) intersectionality of lesbian/queer identity in the cancer context; (b) institutional and systemic supports and barriers; (c) navigation of disclosure; (d) characteristics of affirmative cancer care; (e) survivors' critical reliance on their partner(s); and (f) shifts in connection after cancer. Findings indicate the importance of accounting for intrapersonal, interpersonal, institutional, and socio-cultural-political factors for understanding the impact of cancer for lesbian and queer women and their romantic partners. Affirmative cancer care for sexual minorities fully validates and integrates partners in care, removes heteronormative assumptions in services provided, and offers LGB+ patient and partner support services.

Evaluation of Survey Nonresponse in Measuring Cardiometabolic Health Risk Factors and Outcomes among Sexual Minority Populations: A National Data Linkage Analysis

Understanding cardiometabolic health among lesbian, gay, and bisexual (LGB) people is challenged by methodological constraints, as most studies are either based on nonprobability samples or assume that missing values in population-based samples occur at random. Linking multiple years of nationally representative surveys, hospital records, and geocoded data, we analyzed selection biases and health disparities by self-identified sexual orientation in Canada. The results from 202,560 survey respondents of working age identified 2.6% as LGB, 96.4% as heterosexual, and <1.0% with nonresponse to the sexual identity question. Those who did not disclose their sexual identity were older, less highly educated, less often working for pay, and less often residing in rural and remote communities; they also had a diagnosed cardiometabolic condition or experienced a cardiometabolic-related hospitalization more often. Among those reporting their sexual identity, LGB individuals were younger, more likely to smoke tobacco or drink alcohol regularly, more likely to have heart disease, and less likely to have a regular medical provider than heterosexual persons. This investigation highlighted the potential of leveraging linked population datasets to advance measurements of sexual minority health disparities. Our findings indicated that population health survey questions on sexual identity are not generally problematic, but cautioned that those who prefer not to state their sexual identity should neither be routinely omitted from analysis nor assumed to have been randomly distributed.

Interactions of Sexual Orientation and Gender Identity with Race/Ethnicity in Prevalence of Lifetime and Current Asthma Diagnosis

Purpose: The current study explored how sexual orientation and gender identity interact with race/ethnicity to predict self-reported lifetime and current diagnosis of asthma. Methods: Using the 2020 Behavioral Risk Factor Surveillance System survey, we conducted logistic regression analyses, weighted for complex samples, stratified by sexual orientation and gender identity, and controlling for race/ethnicity, age, smoking, population density, and body mass index. Results: Analyses showed that there were significantly higher adjusted odds of lifetime asthma among gay men and bisexual men in comparison to heterosexual men, gay/lesbian women and bisexual women in comparison to heterosexual women, and transgender men in comparison to cisgender individuals. In addition, analyses showed that there were significantly higher odds of current asthma among women with other minority sexual orientations in comparison to heterosexual women. Finally, there was a significant interaction between race/ethnicity and sexual orientation among men. Conclusions: Sexual minority men of color might be particularly vulnerable to chronic asthma. Future research should examine asthma prevalence in sexual and gender minority (SGM) individuals of specific marginalized racial/ethnic groups. Future responses to SGM asthma inequities should include low-cost screening and treatment targeting SGM individuals, and policies improving air quality in urban areas.

Factors that impact assigned female sexual minority individuals health care experiences: A qualitative descriptive study

This qualitative descriptive study identified factors that impact assigned female at birth (AFAB) cisgender and non-binary sexual minority individuals' decision to engage, or not engage, in health-seeking behaviors and receive preventative health care services. AFAB sexual minority individuals were asked to describe their health care experiences to determine modifiable factors that could improve their intention to seek care and improve their health care experiences. Purposive sampling was used to recruit AFAB sexual minority individuals between 18-30 years of age in the Chicago metropolitan area. Three main themes emerged from data acquired through individual interviews: (1) "ask the right questions"; main themes (2 lack of trust in health professionals; (3 the need for better sexual health education. An important finding was participants wanted to be asked about their sexual orientation, sexual behavior, and gender identity. Participants wanted to be able to share their sexual orientation and gender identity with health care professionals so they could receive appropriate care, accurate information, and feel comfortable sharing aspects about their life. Additionally, the results suggested that general and health sciences curricula should include content about diverse sexual and gender minority populations. Findings have important implications for health education and clinical practice.

Temporal and Geographic Patterns of Documentation of Sexual Orientation and Gender Identity Keywords in Clinical Notes

OBJECTIVE

Disclosure of sexual orientation and gender identity correlates with better outcomes, yet data may not be available in structured fields in electronic health record data. To gain greater insight into the care of sexual and gender-diverse patients in the Veterans Health Administration (VHA), we examined the documentation patterns of sexual orientation and gender identity through extraction and analyses of data contained in unstructured electronic health record clinical notes.

METHODS

Salient terms were identified through authoritative vocabularies, the research team's expertise, and frequencies, and the use of consistency in VHA clinical notes. Term frequencies were extracted from VHA clinical notes recorded from 2000 to 2018. Temporal analyses assessed usage changes in normalized frequencies as compared with nonclinical use, relative growth rates, and geographic variations.

RESULTS

Over time most terms increased in use, similar to Google ngram data, especially after the repeal of the "Don't Ask Don't Tell" military policy in 2010. For most terms, the usage adoption consistency also increased by the study's end. Aggregated use of all terms increased throughout the United States.

CONCLUSION

Term usage trends may provide a view of evolving care in a temporal continuum of changing policy. These findings may be useful for policies and interventions geared toward sexual and gender-diverse individuals. Despite the lack of structured data, the documentation of sexual orientation and gender identity terms is increasing in clinical notes.

Is the uptake, engagement, and effectiveness of exclusively mobile interventions for the promotion of weight-related behaviors equal for all? A systematic review

Mobile health interventions are promising behavior change tools. However, there is a concern that they may benefit some populations less than others and thus widen inequalities in health. This systematic review investigated differences in uptake of, engagement with, and effectiveness of mobile interventions for weight-related behaviors (i.e., diet, physical activity, and sedentary behavior) based on a range of inequality indicators including age, gender, race/ethnicity, and socioeconomic status. The protocol was registered on PROSPERO (CRD42020192473). Six databases (CINAHL, EMBASE, ProQuest, PsycINFO, Pubmed, and Web of Science) were searched from inception to July 2021. Publications were eligible for inclusion if they reported the results of an exclusively mobile intervention and examined outcomes by at least one inequality indicator. Sixteen publications reporting on 13 studies were included with most reporting on multiple behaviors and inequality indicators. Uptake was investigated in one study with no differences reported by the inequality indicators studied. Studies investigating engagement (n = 7) reported differences by age (n = 1), gender (n = 3), ethnicity (n = 2), and education (n = 2), while those investigating effectiveness (n = 9) reported differences by age (n = 3), gender (n = 5), education (n = 2), occupation (n = 1), and geographical location (n = 1). Given the limited number of studies and their inconsistent findings, evidence of the presence of a digital divide in mobile interventions targeting weight-related behaviors is inconclusive. Therefore, we recommend that inequality indicators are specifically addressed, analyzed, and reported when evaluating mobile interventions.

Sexual Orientation and Gender Identity-Related State-Level Policies and Perceived Health Among Lesbian, Gay, Bisexual, and Transgender (LGBT) Older Adults in the United States

ObjectivesWe examined the associations between state-level policies and the health of lesbian, gay, bisexual, and transgender (LGBT) older adults. Methods: Using data from the 2018-2020 Behavioral Risk Factor Surveillance System surveys, we assessed physical and mental health by the tally of points for enacted LGBT-related policies (Low= <0-49.9% of possible points, High= 50-100% of possible points) in 10,032 sexual minority (i.e., lesbian, gay, and bisexual) and 1,072 transgender (non-sexual minority) adults aged 50 and older from 41 states. Results: Sexual minority adults in low tally states had greater odds of reporting fair or poor general health and 14 or more days of poor physical health in the past 30 days. Transgender participants in low tally states also had greater odds of reporting fair or poor general health. Discussion: Lesbian, gay, bisexual, and transgender adults have significantly greater risk of poor health if they live in a state with fewer LGBT anti-discriminatory policies enacted.

Disclosure and comfort during genetic counseling sessions with LGBTQ+ patients: An updated assessment

Disclosure is the act of sharing a stigmatized identity, and members of the LGBTQ+ community make decisions related to disclosure multiple times throughout their life. Disclosure in medical settings can impact perceptions of care and outcomes for LGBTQ+ patients; however, little is understood about the process of decision-making regarding disclosure in the genetic counseling setting. As such, this study aimed to explore LGBTQ+ experiences in genetic counseling sessions and their disclosure behaviors. Fifty-five LGBTQ+ individuals who attended a genetic counseling session and 91 genetic counselors completed online surveys. The patient survey assessed for disclosure behaviors, experiences of discrimination, and comfort in genetic counseling sessions. The counselor survey evaluated comfort with the LGBTQ+ population in a counseling setting, whether counselors facilitate disclosure in sessions, and whether counseling is tailored for the LGBTQ+ population. Eighty-two percent of genetic counselors "rarely" or "never" ask about sexual orientation, and 69% "rarely" or "never" ask about gender identity. The majority of patients indicated they were not asked about their sexual orientation (87%) or gender identity (80%). Some patients reported experiencing discrimination or homo/transphobia in their genetic counseling sessions, with 6.12% of LGBQ+ patients experiencing discrimination and 24.1% of trans+ patients reporting discrimination. Over half of genetic counselors reported receiving training in LGBTQ+ healthcare and the majority reported comfort with providing care to LGBTQ+ patients. However, discrepancies between patient-reported experiences and genetic counselors' descriptions of their care for the LGBTQ+ population warrant further research and suggest additional training or changes in practice may be necessary.

A double disparity: Rural sexual minorities and tobacco use among U.S. adults

BACKGROUND

Marginalized groups continue to face an uneven distribution of the risks and consequences of smoking cigarettes, with rural/urban geography and sexual orientation status examined independently. However, little is known about the intersection of rural/urban geography and sexual orientation regarding tobacco use disparities. This study examined rural-urban sexual minority differences in tobacco use in the United States.

METHODS

Data came from the 2018-2020 Behavioral Risk Factor Survey System (N = 675,221). We estimated cigarette smoking prevalence for each year of survey data by rural/urban status and sexual orientation. Multivariable logistic regressions were used to assess associations of rural/urban location and sexual orientation status with cigarette use. Additional Multivariable logistic regressions were conducted, including stratified analyses by sex on multiple sexual orientation categories.

FINDINGS

Cigarette smoking was higher among participants who lived in rural areas and identified as lesbian or gay and bisexual. Furthermore, the disparities in smoking rates were significantly different, with 38 % higher odds of smoking among rural sexual minorities than urban sexual minorities (aOR = 1.38, 95 % CI = 1.19, 1.60). Stronger odds of cigarette smoking were found among rural gays or lesbians (aOR = 1.83, 95 % CI = 1.47, 2.28) and rural bisexuals (aOR = 2.40, 95 % CI = 2.03, 2.84) compared to urban straight counterparts.

CONCLUSION

Findings highlight rural populations, particularly sexual minorities, might have an elevated risk of cigarette use. Prevention and cessation efforts that help these especially disadvantaged groups will be beneficial in addressing tobacco use disparities.

Comprehensive systematic review and meta-analysis on physical health conditions in lesbian- and bisexual-identified women compared with heterosexual-identified women

BACKGROUND

Sexual minority individuals experience discrimination, leading to mental health disparities. Physical health disparities have not been examined to the same extent in systematic reviews so far.

OBJECTIVES

To provide a systematic review and, where possible, meta-analyses on the prevalence of physical health conditions in sexual minority women (i.e. lesbian- and bisexual-identified women) compared to heterosexual-identified women.

DESIGN

The study design is a systematic review with meta-analyses.

DATA SOURCES AND METHODS

A systematic literature search in MEDLINE, EMBASE, CENTRAL, CINAHL, and Web of Science databases was conducted on epidemiologic studies on physical health conditions, classified in the Global Burden of Disease project, published between 2000 and 2021. Meta-analyses pooling odds ratios were calculated.

RESULTS

In total, 23,649 abstracts were screened and 44 studies were included in the systematic review. Meta-analyses were run for arthritis, asthma, back pain, cancer, chronic kidney diseases, diabetes, headache disorders, heart attacks, hepatitis, hypertension, and stroke. Most significant differences in prevalence by sexual identity were found for chronic respiratory conditions, especially asthma. Overall, sexual minority women were significantly 1.5-2 times more likely to have asthma than heterosexual women. Furthermore, evidence of higher prevalence in sexual minority compared to heterosexual women was found for back pain, headaches/migraines, hepatitis B/C, periodontitis, urinary tract infections, and acne. In contrast, bisexual women had lower cancer rates. Overall, sexual minority women had lower odds of heart attacks, diabetes, and hypertension than heterosexual women (in terms of diabetes and hypertension possibly due to non-consideration of pregnancy-related conditions).

CONCLUSION

We found evidence for physical health disparities by sexual identity. Since some of these findings rely on few comparisons only, this review emphasizes the need for routinely including sexual identity assessment in health research and clinical practice. Providing a more detailed picture of the prevalence of physical health conditions in sexual minority women may ultimately contribute to reducing health disparities.

Mental health condition indicators and e-cigarette use among sexual minority youth

BACKGROUND

Sexual minorities face mental health disparities compared to heterosexual people. There is limited research on the possible connections between mental health and e-cigarette use among sexual minority youth. This study examines anxiety, depression, and e-cigarette use for sexual minority youth only and between sexual minorities versus straight youth.

METHODS

Study data were drawn from the 2021 National Youth Tobacco Survey (n = 16,065). Prevalence of self-reported anxiety and depression by sexual minority status was calculated, and the univariate analysis was assessed using Rao-Scott Chi-Square tests. Multivariable logistic regression models were used to evaluate the association of current e-cigarette use with self-reported anxiety and depression among sexual minority youth. The study also examined current e-cigarette use between sexual minorities versus straight students for those with or without anxiety and depression, and stratified analyses were performed by sex.

RESULTS

Analysis showed a substantially higher prevalence of all self-reported mental health problems among sexual minorities than straight students. Sexual minority males with anxiety (aOR 1.91, 95 % CI, 1.22-3.00), depression (aOR 2.08, 95 % CI, 1.27-3.40), moderate depression and anxiety (aOR 1.85, 95 % CI, 1.16-2.97), and severe depression and anxiety (aOR 2.03, 95 % CI, 1.16-3.56) were more likely to be current e-cigarette users than their straight peers with similar mental health conditions.

LIMITATIONS

Self-reported measures and the analysis design precludes making causal inferences.

CONCLUSIONS

Sexual minority males with mental health conditions may be particularly vulnerable to e-cigarette use and may require special efforts toward prevention and cessation.

Adverse Childhood Experiences and Adult Tobacco Use Among Sexual and Gender Minority Populations: Examining the Role of Mental, Social, and Community Health

Purpose: We sought to evaluate the relationship between adverse childhood experiences (ACEs) and tobacco use, to assess the intersection of sexual orientation or gender identity (SOGI), and to explore risk and protective aspects of mental, social, and community health. Methods: This was a secondary analysis of the sexual and gender minorities (SGM) subsample (n = 1102) from a 2019 Community Health Needs Assessment. Nested binary logistic regression models were created to evaluate associations between ACEs and type of tobacco use: (1) cigarette use versus no cigarette or electronic nicotine delivery systems (ENDS) use, (2) ENDS use versus no cigarette or ENDS use, and (3) dual use versus use of either cigarettes or ENDS. Results: The sample population that reported four or more ACEs and ENDS use had statistically significant adjusted odds ratios (aORs) when adjusting the models for sociodemographic variables (aOR = 2.55; 95% confidence intervals [CIs]: 1.54-4.22), SOGI (aOR = 2.44; 95% CI: 1.46-4.10), current mental health (aOR = 2.23; 95% CI: 1.32-3.75), and social and community health (aOR = 2.19; 95% CI: 1.30-3.71). The sample population that reported poor mental health had statistically significant aORs when adjusting the models for sociodemographic variables, SOGI, and mental health (aOR = 2.26; 95% CI: 1.32-3.89) and social and community health (aOR = 2.06; 95% CI: 1.17-3.54). There was no statistically significant finding related to the other tobacco use variables (tobacco use and dual use). Conclusion: We found that high-risk ACEs were positively associated with cigarette use and ENDS use. SGM populations have differing experiences when considering community and social support.

A Socioecological Mixture Model of Asthma Prevalence Among Sexual Minority Adults in the United States

Purpose: Sexual minority (SM) identity as well as sociodemographic and socioeconomic factors are associated with asthma prevalence. A syndemics framework analyzes disease conditions in a population and the social, economic, and environmental contexts in which they are found. We used a syndemic model of individual-level socioecological factors to identify profiles of asthma prevalence among SM adults. Methods: Latent class analysis (LCA) was conducted on a subpopulation of SM adults aged 18-59 years from the 2001 to 2016 National Health and Nutrition Examination Survey. Indicators in the LCA model included current asthma, gender, sexual identity, poverty-income ratio, education, and serum cotinine level. Multinomial logistic regression analyzed the effects of covariates (race/ethnicity, nativity, age, marital status, body mass index, lifetime smoking, and mental health care seeking) on identified profiles. Results: Four classes were identified among our sample of n = 1097 SM adults. Classes 1 and 2 had 19% and 18% conditional probabilities of current asthma, respectively, and were primarily female and bisexual. Classes 3 and 4 had 5% and 2% conditional probabilities of asthma, respectively, and were primarily male and gay. Classes 1 and 3 also had conditional probabilities of high income and educational attainment. Black individuals had higher odds than White individuals of being in Class 1 (odds ratio [OR] = 4.46, 95% confidence interval [CI] = 1.43-13.93), Class 2 (OR = 21.66, 95% CI = 7.50-62.60), and Class 4 (OR = 7.41, 95% CI = 2.05-26.71), relative to Class 3. Conclusion: Findings extend past literature that suggests within-group asthma disparities among SM adults. Informational campaigns on asthma management should target this community to avoid severe disease exacerbations.

Sleep disturbance and suicide risk among sexual and gender minority people

Sleep disturbance has emerged as an independent, mechanistic, and modifiable risk factor for suicide. Sexual and gender minority (SGM) people disproportionately experience sleep disturbance and are at higher risk of death by suicide relative to cisgender and/or heterosexual individuals. The present narrative review evaluates nascent research related to sleep disturbance and suicide-related thoughts and behaviors (STBs) among SGM populations, and discusses how experiences of minority stress may explain heightened risk among SGM people. Although there is a growing understanding of the link between sleep disturbance and STBs, most research has not been conducted in SGM populations or has not examined suicide as an outcome. Research is needed to examine whether and how aspects of sleep disturbances relate to STBs among SGM people in order to better tailor sleep treatments for SGM populations.

Access to health services among sexual minority people in the United States

Sexual minority people in the United States are less likely to have access to health services when compared to their heterosexual counterparts. Less is known about the within-group sociodemographic memberships among sexual minority people regarding access to health services. Using data from a nationally representative sample, a series of univariate and bivariate analyses were used to determine associations between sociodemographic group membership and access to health services. Results suggest there are significant differences in access to health services within the sexual minority population. Differences in access to health services when considering sex-at-birth, sexual identity, age, race/ethnicity, urbanicity, education level and income status were found. These findings offer insight into the role sociodemographic group membership has on the equity of access to health services. Specifically, results indicated that disproportionate access to health services among sexual minority people were more pronounced among those with group membership who experience social marginalisation. This was particularly true for sexual minority people who were bisexual, younger, Black and Latinx, lower-income earners and sexual minority people with less education attainment. Results from this study may be used to inform policies and practices aimed at improving access to health services including, but not limited to, the expansion of the Affordable Care Act and continued development of Federally Qualified Health Centers, while acknowledging the role of within-group differences among sexual minority people.

Excessive Drinking Among Men Who Have Sex With Men Recruited From Web-Based Resources: Cross-sectional Questionnaire Study

Background

US and Northern European studies have found a higher prevalence of alcohol-related problems among men who have sex with men (MSM) than among the general population of men (GPM). However, most of them relied on traditional sampling methods, not profiting from MSM dating apps and websites for recruitment. Besides, analogous comparisons in Southern Europe are lacking.

Objective

This study aimed to compare several indicators of excessive drinking between MSM and GPM in Spain.

Methods

Overall, 5862 MSM were recruited through dating apps or websites for the Méthysos Project, and 10,349 GPM were recruited using probability sampling via the Household Survey on Alcohol and Drugs in Spain from 2018 to 2020. The outcomes were the prevalence of hazardous or harmful drinking (Alcohol Use Disorders Identification Test [AUDIT] ≥8), hazardous drinking (AUDIT-Consumption ≥4), harmful drinking (AUDIT-Problem ≥4), regular hazardous drinking (>14 standard drinks per week), and monthly binge drinking. The prevalence of excessive drinking indicators was calculated for MSM and GPM and compared using the adjusted prevalence ratio (aPR). Two different aPRs and their 95% CIs were estimated using Poisson regression models with robust variance. The first was adjusted for sociodemographic characteristics, and the second was adjusted for the aforementioned covariates plus other drug use.

Results

The prevalence of hazardous or harmful drinking was 15.6% (913/5862) among MSM versus 7.7% (902/10,349) among GPM. After adjusting for sociodemographic covariates, the risk was higher in MSM than in GPM for harmful or hazardous drinking (aPR 1.8, 95% CI 1.6-2.0), harmful drinking (aPR 2.3, 95% CI 2.0-2.7), and binge drinking (aPR 1.7, 95% CI 1.5-1.9); the same in both populations for hazardous drinking (aPR 0.9, 95% CI 0.9-1.0); and higher in GPM than in MSM for regular hazardous drinking (aPR 0.7, 95% CI 0.6-0.9). The relative excess risk of harmful drinking and binge drinking among MSM tended to increase with increasing education level and size of the place of residence, and the opposite was true for the deficit risk in regular hazardous drinking. Additional adjustment for other drug use greatly buffered the relative excess risk in harmful drinking and binge drinking in MSM, while it deepened its deficit risk in regular hazardous drinking.

Conclusions

The use of web-based resources allowed recruiting a large sample of MSM. The risk of hazardous or harmful drinking was 80% greater in MSM than in GPM, which was mainly because of the higher risk of harmful drinking and binge drinking among MSM. Nearly 1 in 6 MSM would benefit from early brief alcohol intervention procedures. The subgroup with harmful or binge drinking combined with other drug use is an important contributor to excess MSM risk in hazardous or harmful drinking and must be a priority target for harm reduction interventions.

Examining Health Disparities and Severity of Depression among Sexual Minorites in a National Population Sample

Background: Health disparities and mental health issues have not been fully explored among sexual minorities. This study aims to examine health disparities and severity of depression among sexual minorities using a nationally representative sample of the US population. Methods: The National Health and Nutrition Examination Survey (NHANES) data from 2011 to 2016 were analyzed. The Patient Health Questionnaire (PHQ-9) was used to examine the severity of depression among sexual minorities compared to heterosexuals. Data were analyzed for descriptive statistics and associations using the Chi-squared test. A multivariate logistic regression analysis was used to quantify the magnitude of association between severity of depression and demographic characteristics. A p-value of <0.05 was considered statistically significant. Results: Among 7826 participants included, 426 (5.4%) were identified as a sexual minority. Moderately severe to severe depression was observed among 9.3% of sexual minorities with women having higher rates (64.2%) than men. Similarly, sexual minorities were two times more likely to have moderately severe to severe depression, two and half times more likely to see a mental health professional, and one and half times more likely to have genital herpes and be a user of illicit drugs than heterosexuals. In addition, they were less likely to be married and more likely to have been born in the United States, be a U.S. citizen, and earn less than USD 25,000 (p < 0.05). Conclusions: Sexual minorities are affected by a range of social, structural, and behavioral issues impacting their health. The screening of individuals with depression who are sexual minorities (especially females), illicit drug users, poor, or aged over 39 years may benefit from early intervention efforts.

Health Disparities Among Lesbian, Gay, and Bisexual Service Members and Veterans

INTRODUCTION

This study investigated whether health disparities exist among lesbian, gay, and bisexual individuals serving in the U.S. military by examining the associations of sexual orientation with mental, physical, and behavioral health among a population-based sample of service members and veterans.

METHODS

Sexual orientation and health outcomes were self-reported on the 2016 Millennium Cohort Study follow-up questionnaire (N=96,930). Health outcomes were assessed across 3 domains: mental health (post-traumatic stress disorder, depression, anxiety, binge eating, problematic anger), physical health (multiple somatic symptoms, physical functioning, BMI), and behavioral health (smoking, problem and risky drinking, insomnia). Adjusted logistic regression models conducted between 2019 and 2022 estimated the associations between sexual orientation and each health outcome.

RESULTS

Lesbian, gay, and bisexual individuals (3.6% of the sample) were more likely to screen positive for post-traumatic stress disorder, depression, anxiety, binge eating, problematic anger, multiple somatic symptoms, and insomnia than heterosexual individuals. Gay/lesbian and bisexual women reported more adverse health outcomes (overweight and obesity, smoking, problem/risky drinking) than heterosexual women. Gay and bisexual men reported some adverse health outcomes (e.g., smoking and problem drinking) but better physical health (e.g., less overweight/obesity) than heterosexual men.

CONCLUSIONS

Lesbian, gay, and bisexual service members reported poorer mental, physical, and behavioral health than heterosexual peers, most notably among gay/lesbian women and bisexual individuals. Findings suggest that lesbian, gay, and bisexual service members experience health disparities, despite many having equal eligibility for health care, highlighting the need for improved equity initiatives that promote cultural responsiveness, acceptance, and approaches to support the healthcare needs of lesbian, gay, and bisexual military members.

Exploring Relationships Between State-Level LGBTQ Inclusivity and BRFSS Indicators of Mental Health and Risk Behaviors: A Secondary Analysis

OBJECTIVES

Minority Stress Theory suggests that repeated exposure to enacted stigma adversely affects mental health. States have wide authority to enact policies affecting the level of inclusivity experienced by lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) residents. The purpose of this study was to explore relationships between states' level of LGBTQ inclusivity and indicators of mental health/risk behaviors among an LGBTQ sample.

METHODS

The 2018 Human Rights Campaign State Equality Index (SEI) and the 2018 Behavioral Risk Factor Surveillance Survey (BRFSS) were used to examine relationships between states' levels of LGBTQ inclusivity (predictor variable) and indicators of mental health/risk behaviors (outcome variables). Relationships were explored using descriptive statistics and survey-weighted logistic regression.

RESULTS

Lower state inclusivity increased odds of fair/poor general health (adjusted odds ratio [AOR]: 1.22, 95% confidence interval [CI]: 1.01-1.48), increased odds of poor mental health days (AOR: 1.34, 95% CI: 1.11-1.62), increased odds of smoking (AOR: 1.62, 95% CI: 1.27-2.07), and increased odds of heavy drinking (AOR: 1.54, 95% CI: 1.26-1.86) and binge drinking (AOR: 1.23, 95% CI: 1.01-1.49). State inclusivity did not influence odds of a depressive disorder diagnosis or driving under the influence of alcohol.

CONCLUSIONS

LGBTQ persons in restrictive states had increased odds of experiencing several indicators of mental health and risk behaviors. More research is needed to determine whether state policies affect other domains of LGBTQ persons' health. Health care providers should be mindful of LGBTQ persons' mental health/risk behaviors and the state policy environment, and should seek to implement mitigating health care strategies such as the use of validated assessment.

Smoking-Attributable Doctor Visits and Emergency Room Utilization and Costs by California's Lesbian, Gay, and Bisexual Community

The lesbian, gay, and bisexual (LGB) community is known to smoke at greater rates than the general population, but there has been no study estimating the impact of cigarette smoking on healthcare utilization and costs in the LGB population. Using data from the 2005-2014 California Health Interview Surveys, we determine smoking-attributable healthcare utilization and costs among California's LGB-identified community. Our findings indicate that lesbian/bisexual women who smoke incur excess doctor visits and emergency room visits compared to their never smoking counterparts. No statistically significant differences were found for gay/bisexual men. Annual smoking-attributable costs were $58.3 million for the California LGB community (2019 dollars).

Sexual orientation, social support, and mental health resilience in a U.S. national sample of adults

Sexual minority mental health disparities can be attributed, in large part, to chronic exposure to stress. There is growing interest in understanding the factors associated with psychological resilience, or the ability to positively cope with life's stressors. Using nationally representative data (2012-2013; N = 14,470), this study compared differences in resilience status (operationalized empirically using SF-12 mental health score among respondents reporting 2+ past-year stressful life events; respondents were categorized as "flourishing," "average," or "languishing") by sexual orientation and assessed whether social support mediated sexual minority disparities in resilience. Comparisons were made across four sexual orientation groups: heterosexuals and three sexual minority subgroups (lesbians/gay men, bisexual, heterosexual-identified sexual minorities [HSM]). Generally, heterosexual respondents were more likely to be flourishing, less likely to be languishing, and reported more social support, compared to sexual minority respondents. In multivariable analysis, bisexual women, HSM women, and gay men had lower odds of resilience than heterosexual women and men, respectively. In mediation models, lower social support was associated with reduced resilience for all sexual minority subgroups except lesbian/gay women. This study demonstrated that sexual orientation is an important determinant of resilience, and further, that social support contributes to sexual minority peoples' abilities to flourish when faced with stress.

Minority Stress, Structural Stigma, and Physical Health Among Sexual and Gender Minority Individuals: Examining the Relative Strength of the Relationships

BACKGROUND

Sexual and gender minority (SGM; i.e., non-heterosexual and transgender or gender-expansive, respectively) people experience physical health disparities attributed to greater exposure to minority stress (experiences of discrimination or victimization, anticipation of discrimination or victimization, concealment of SGM status, and internalization of stigma) and structural stigma.

PURPOSE

To examine which components of minority stress and structural stigma have the strongest relationships with physical health among SGM people.

METHODS

Participants (5,299 SGM people, 1,902 gender minority individuals) were from The Population Research in Identity and Disparities for Equality (PRIDE) Study. Dominance analyses estimated effect sizes showing how important each component of minority stress and structural stigma was to physical health outcomes.

RESULTS

Among cisgender sexual minority women, transmasculine individuals, American Indian or Alaskan Native SGM individuals, Asian SGM individuals, and White SGM individuals a safe current environment for SGM people had the strongest relationship with physical health. For gender-expansive individuals and Black, African American, or African SGM individuals, the safety of the environment for SGM people in which they were raised had the strongest relationship with physical health. Among transfeminine individuals, victimization experiences had the strongest relationship with physical health. Among Hispanic, Latino, or Spanish individuals, accepting current environments had the strongest relationship with physical health. Among cisgender sexual minority men prejudice/discrimination experiences had the strongest relationship with physical health.

CONCLUSION

Safe community environments had the strongest relationships with physical health among most groups of SGM people. Increasing safety and buffering the effects of unsafe communities are important for SGM health.

Prevalence of Chronic Pelvic Pain by Sexual Orientation in a Large Cohort of Young Women in the United States

BACKGROUND

Sexual minority (lesbian, bisexual, mostly heterosexual) young women face many sexual and reproductive health disparities, but there is scant information on their experiences of chronic pelvic pain, including an absence of information on prevalence, treatment, and outcomes.

AIM

The purpose of this study was to describe the characteristics of chronic pelvic pain experiences of young women by sexual orientation identity and gender of sexual partners.

METHODS

The analytical sample consisted of a nationwide sample of 6,150 U.S. young women (mean age = 23 years) from the Growing Up Today Study who completed cross-sectional questionnaires from 1996 to 2007.

OUTCOMES

Age-adjusted regression analyses were used to examine groups categorized by sexual orientation identity (completely heterosexual [ref.], mostly heterosexual, bisexual, lesbian) and gender of sexual partner (only men [ref.], no partners, both men, and women). We examined differences in lifetime and past-year chronic pelvic pain symptoms, diagnosis, treatment, and quality of life outcomes. Sensitivity analyses also examined the role of pelvic/gynecologic exam history and hormonal contraceptive use as potential effect modifiers.

RESULTS

Around half of all women reported ever experiencing chronic pelvic pain, among whom nearly 90% had past-year chronic pelvic pain. Compared to completely heterosexual women, there was greater risk of lifetime chronic pelvic pain among mostly heterosexual (risk ratio [RR] = 1.30, 95% confidence interval [CI]: 1.22-1.38), bisexual (RR = 1.30, 95% CI: 1.10-1.52), and lesbian (RR = 1.23, 95% CI: 1.00-1.52) young women. Additionally, compared to young women with only past male sexual partners, young women who had both men and women as past sexual partners were more likely to report chronic pelvic pain interfered with their social activities (b = 0.63, 95% CI: 0.25-1.02), work/school (b = 0.55, 95% CI: 0.17-0.93), and sex (b = 0.53, 95% CI: 0.05-1.00).

CLINICAL IMPLICATIONS

Healthcare providers, medical education, and field-wide standards of care should be attentive to the way sexual orientation-based healthcare disparities can manifest into differential prognosis and quality of life outcomes for women with chronic pelvic pain (particularly bisexual women).

STRENGTHS & LIMITATIONS

Our study is the first to examine a variety of chronic pelvic pain outcomes in a nationwide U.S. sample across different outcomes (ie, past-year and lifetime). Though limited by sample homogeneity in terms of age, race, ethnicity, and gender, findings from this article provide foundational insights about chronic pelvic pain experiences of sexual minority young women.

CONCLUSION

Our key finding is that sexual minority women were commonly affected by chronic pelvic pain, and bisexual women face pain-related quality of life disparities. Tabaac AR, Chwa C, Sutter ME, et al. Prevalence of Chronic Pelvic Pain by Sexual Orientation in a Large Cohort of Young Women in the United States. J Sex Med 2022;19:1012-1023.

Disparities in alcohol use and heavy episodic drinking among bisexual people: A systematic review, meta-analysis, and meta-regression

BACKGROUND

Alcohol consumption is more prevalent among sexual minorities than among heterosexuals; however, differences between minority sexual orientation groups are understudied. This systematic review and meta-analysis aimed to summarize existing evidence on the prevalence of alcohol use among bisexual people compared to their lesbian/gay and heterosexual counterparts.

METHODS

A systematic review of literature from 1995 to May 2020 was performed using Medline, PsycInfo, and Embase (OVID), Scopus, CINHAL and LGBT Life (EBSCO), combining keywords for bisexuality and alcohol use. Peer-reviewed publications that reported quantitative data on alcohol use among bisexual people were included. A random-effects model was used to pool the prevalence of two outcomes: any alcohol use and heavy episodic drinking (HED). Subgroup analysis and random-effects meta-regression were used to explore heterogeneity.

RESULTS

Of 105 studies eligible for data extraction, the overall prevalence of alcohol use was higher among bisexuals compared to lesbian/gay and heterosexual people. For example, the prevalence of past-month HED was 30.0% (28.2, 31.8) among bisexual people versus 25.5% (23.8, 27.2) among lesbian/gay and 21.3% (19.6, 23.0) among heterosexual individuals. Pooled odds ratio estimates showed that bisexual people were more likely to report alcohol use and HED compared to their counterparts. Gender was a significant effect modifier in meta-regression analysis, with greater disparities among women than among men.

CONCLUSIONS

These results highlight the need for additional research to understand factors underlying bisexual people's greater risk, and particularly bisexual women, as well as alcohol use interventions that are targeted towards the specific needs of bisexual people.

Do Spirituality, Rurality, and LGBTQ Support Increase Outness and Quality of Health in Gay and Bisexual Men?

Although the existing research suggests that spirituality may positively affect health outcomes for gay and bisexual men, it is unclear to what extent it improves the quality of health over and above sociodemographic factors. Furthermore, there remains conflicting evidence regarding the role of residential location on levels of outness for gay and bisexual men. To that end, the present study used hierarchical linear regression analyses to examine the role of spirituality, rurality, and LGBTQ connectedness in outness and quality of health. The sample comprised 2,202 self-identified gay and bisexual men aged 18 and older who responded to the Social Justice Sexuality Project survey; participants represented all 50 states and Puerto Rico. The results indicate that whereas spirituality was positively associated with a greater quality of life, there was no significant difference in outness between rural versus nonrural participants. Moreover, bisexual men endorsed significantly lower levels of outness compared to their gay counterparts. Implications for future research regarding the role of spirituality and rurality in sexual minority health are discussed.

Understanding the Link Between Adolescent Same-Gender Contact and Unintended Pregnancy: The Role of Early Adversity and Sexual Risk Behavior

Past research suggests an apparent paradox: Women who engage in same-gender sexual behavior show higher rates of unintended pregnancy than women with exclusive other-gender sexual behavior. Such women also have disproportionate rates of early adversity (both harshness, such as abuse or neglect, and unpredictability, such as father absence). We used the Add Health data (N = 5,617 cisgender women) to examine the relative contributions of early adversity, adolescent same-gender sexual behavior, and general sexual risk behavior to women's risks for adult unintended pregnancy. Women who engaged in adolescent same-gender sexual behavior were more likely to report childhood adversity, and both childhood adversity and adolescent same-gender behavior made independent contributions to subsequent rates of unintended pregnancy. The association between adolescent same-gender sexual behavior and adult unintended pregnancy was partially attributable to the fact that women with adolescent same-gender sexual behavior engaged in greater sexual risk behavior more broadly. These findings suggest that same-gender sexual behavior in adolescence may relate to a broader set of sexual risk behaviors that augment future risk for unintended pregnancy, independent of sexual identity. We draw on life history theory to explain this pattern of results and suggest directions for future research.

Paradoxical Obesity and Overweight Disparities Among Sexual Minority Men: A Meta-Analysis

This study aims to analyze the prevalence and likelihood of overweight, obesity, and elevated body mass index (BMI) among sexual minority men (i.e., men who have sex with men [MSM], men who have sex with men and women [MSMW], and all sexual minority men), using men who have sex with women (MSW) as the reference group. Studies reporting mean BMIs or prevalence or likelihood of obesity, overweight, or elevated BMI categorized by sexual orientation were included. Data were pooled and analyzed to report mean differences (MDs) of BMIs, prevalence rates, odds ratios (ORs), and their respective 95% confidence intervals (CIs). Forty-three studies were included, with a median of 26,507 participants (median 3.37% sexual minority men). The respective mean overweight, obesity, and elevated BMI prevalence rates among MSM (36%, 23%, and 39%) and MSMW (33%, 27%, and 47%) were lower than those of MSW (44%, 26%, and 55%). This finding was consistent with a significantly lower BMI (MD −1.50 [−1.93, −1.08] kg/m²) and a decreased likelihood of overweight (OR 0.75 [0.64, 0.88]) and obesity (OR 0.84 [0.78, 0.90]). Sexual minority men present with a lower prevalence and likelihood of obesity and overweight than their heterosexual counterparts. The obesity paradox—a sustained catabolic state presenting with lower BMI—is a feasible explanation for this phenomenon, although further research exploring paradoxical cardiovascular findings is granted.

Refusal Rates to Sexual Orientation and Gender Identity Items in the Behavioral Risk Factor Surveillance System, 2014-2019

Objectives. To explore trends in sexual orientation and gender identity (SOGI) item refusal in the Behavioral Risk Factor Surveillance System (BRFSS). Methods. We used annual data from 7 US states that implemented the SOGI module of the BRFSS from 2014 to 2019 to examine prevalence of sexual orientation (n = 373 332) and gender identity (n = 373 336) item refusal. Analyses included the weighted Wald χ2 test of association between refusal and year and logistic regressions predicting refusal by year. We weighted analyses to account for complex sampling design. Results. We found low SOGI item refusal rates, significant declines in these refusal rates over time, and differences in refusal rates by age, sex, race, education, and language. We also found that Hispanic group membership did not explain SOGI item refusal when accounting for interview language; interview language was strongly associated with both sexual orientation and gender identity item refusal. Conclusions. Our results indicate acceptance of SOGI measurement and empirically support continuation of SOGI in health surveillance surveys. Findings indicate a need to further investigate the association between survey translation and item refusal.

Cancer Risk Behaviors, Cancer Beliefs, and Health Information Seeking Among Under-Represented Populations in San Francisco: Differences by Sexual Orientation and Gender Identity

Purpose

Sexual and gender minority (SGM) individuals in the United States are at increased risk of cancer compared to the non-SGM population. Understanding how SGM persons perceive cancer risk and their practices and preferences for accessing health information is key for improving the preventive and health care services they receive.

Methods

In this cross-sectional study, we analyzed data from the San Francisco Health Information National Trends Survey. SGM individuals were identified by self-report. Differences in cancer risk factors, cancer beliefs, and health information seeking were evaluated by SGM status using multivariable logistic regression models.

Results

Out of 1027 participants, 130 (13%) reported being SGM individuals. Current smoking (odds ratio [OR]=1.93, 95% confidence interval [CI]=1.24-3.01) and alcohol use (OR=1.69, 95% CI=1.10-2.59) were more common among SGM persons than among non-SGM persons. No differences by SGM status were observed in health information seeking behaviors, preferences, and cancer beliefs, but SGM participants reported significantly higher odds of feeling frustrated (OR=1.78, 95% CI=1.20-2.64) and having concerns about the quality of the information (OR=1.54, 95% CI=1.03-2.31) during their most recent health information search.

Conclusions

Intervention efforts aimed at SGM individuals with current use of tobacco and/or alcohol should be expanded. SGM communities also need improved access to consistent, reliable, and accurate sources of health information. Their increased frustration when seeking health information and concerns about the quality of the information they find have important implications for SGM health and care, and the drivers of these differences merit further evaluation.

Multiply marginalized: Linking minority stress due to sexual orientation, gender, and weight to dysregulated eating among sexual minority women of higher body weight

OBJECTIVE

This study assessed whether baseline levels of distal and proximal minority stressors related to sexual orientation, gender, and weight were associated with prospective risk for dysregulated eating in daily life among sexual minority women with overweight/obesity.

METHODS

Fifty-five sexual minority women ages 18-60 (M = 25 ± 9) with BMI > 25kg/m2 (M = 32 ± 5) completed baseline assessments of distal and proximal minority stressors due to sexual orientation, gender, and weight. Participants then completed an Ecological Momentary Assessment (EMA) protocol. For five days, participants responded to five random prompts assessing engagement in dysregulated eating (i.e., overeating, binge eating). The cumulative number of EMA-measured overeating and binge eating episodes was summed per participant.

RESULTS

Several minority stressors related to sexual orientation, gender, and weight were associated with prospective risk for dysregulated eating behaviors during EMA. Women with higher (vs. lower) baseline levels of internalized homophobia reported more cumulative episodes of binge eating during the EMA period. Women reporting greater (vs. less) baseline sexual orientation concealment reported more episodes of overeating during the EMA period. Women with greater (vs. less) baseline weight bias experiences and internalization reported more overeating and binge eating episodes during the EMA period.

CONCLUSIONS

Findings from this pilot study identify internalized homophobia, sexual orientation concealment, and experienced and internalized weight bias as potential risk factors for dysregulated eating behaviors among sexual minority women of higher body weight.

Sexual and gender minority identity in undergraduate medical education: Impact on experience and career trajectory

INTRODUCTION

The wellbeing of sexual and gender minority (SGM) medical students and the impact of their experiences on career trajectory remain poorly understood. The present study aimed to characterize the incidence of mistreatment in SGM trainees as well as general perspectives on the acceptance of SGM individuals across medical and surgical specialties.

METHODS

This was a cross sectional survey study of all actively enrolled medical students within the six University of California campuses conducted in March 2021. An online, survey tool captured incidence of bullying, discrimination, and suicidal ideation as well as perceived acceptance of SGM identities across specialties measured by slider scale. Differences between SGM and non-SGM respondents were assessed with two-tailed and chi-square tests. Qualitative responses were evaluated utilizing a multi-stage, cutting-and-sorting technique.

RESULTS

Of approximately 3,205 students eligible for participation, 383 submitted completed surveys, representing a response rate of 12.0%. Of these respondents, 26.9% (n = 103) identified as a sexual or gender minority. Overall, SGM trainees reported higher slider scale scores when asked about being bullied by other students (20.0 vs. 13.9, P = 0.012) and contemplating suicide (14.8 vs. 8.8, P = 0.005). Compared to all other specialties, general surgery and surgical subspecialties had the lowest mean slider scale score (52.8) in perceived acceptance of SGM identities (All P < 0.001). In qualitative responses, students frequently cited lack of diversity as contributing to this perception. Additionally, 67.0% of SGM students had concerns that disclosure of identity would affect their future career with 18.5% planning to not disclose during the residency application process.

CONCLUSIONS

Overall, SGM respondents reported higher incidences of bullying and suicidal ideation as well as increased self-censorship stemming from concerns regarding career advancement, most prominently in surgery. To address such barriers, institutions must actively promote diversity in sexual preference and gender identity regardless of specialty.

Overcoming technical and cultural challenges to delivering equitable care for LGBTQ+ individuals in a rural, underserved area

The lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ+) community is vulnerable to health-care disparities. Many health-care organizations are working to collect sexual orientation and gender identity in their electronic health records (EHRs), with the goal of providing more inclusive care to their LGBTQ+ patients. There are significant human and technical barriers to making these efforts successful. Based on our 5-year experience at Geisinger (an integrated health system located in a rural, generally conservative area), this case report provides insights to overcome challenges in 4 critical areas: (1) enabling the EHR to collect and use information to support the health-care needs of LGBTQ+ patients, (2) building a culture of awareness and caring, empowering members of the health-care team to break down barriers of misunderstanding and mistrust, (3) developing services to support the needs of LGBTQ+ patients, and (4) partnering with local communities to become a trusted health-care provider.