Associations of sexual and gender minority status with health indicators, health risk factors, and social stressors in a national sample of young adults with military experience

Experiences and perceptions of military and emergency services personnel identifying as LGBTQIA+ and their families: a qualitative systematic review protocol

OBJECTIVE

The objective of this review is to explore the perceptions and experiences of military and emergency personnel who identify as lesbian, gay, bisexual, transgender, questioning, intersex, asexual, or other (LGBTQIA+), and the perceptions and experiences of their families.

INTRODUCTION

LGBTQIA+ military and emergency first response personnel report disproportionately poorer career and personal outcomes than their cisgender and heterosexual counterparts. Research examining the underlying lived experiences and perceptions of people serving who are LGBTQIA+, particularly those of their family members, is sparse. Hence, the aim of this review is to identify, aggregate, and synthesize relevant qualitative research findings.

INCLUSION CRITERIA

This review will consider studies of LGBTQIA+ military or emergency first response personnel and their families that include qualitative data capturing their experiences and perceptions of navigating industrial institutions and service communities. Military personnel include those employed in any role within any military organization; emergency first response personnel will include ambulance workers, paramedics, police, firefighters, and other public safety roles. Families will be limited to any configuration of immediate family members of active or retired LGBTQIA+ service personnel. No limits will be applied to the age of service personnel or their family members, nor to duration or chronology of service.

METHODS

Databases searched will include PsycINFO, PubMed Central, ProQuest Central, Scopus, MEDLINE, Embase, and PTSDpubs. Domain-specific journals will be manually searched, and gray literature and unpublished studies will be searched via ProQuest Central. Study screening and selection against inclusion criteria will be performed in Covidence. Data extraction and critical appraisal will be performed using the standardized JBI templates and checklists for qualitative research. All stages will be performed by 2 independent reviewers, with conflicts resolved by a third reviewer.

REVIEW REGISTRATION

PROSPERO CRD42022323913.

Costs of (In)visibility: Issues of Disclosure and Data for Health Equity Research with Sexual and Gender Minority Veterans

Sexual and gender minority (SGM) veterans experience numerous disparities in health conditions, behavioral risks, and social adversities compared with non-SGM veterans. Although survey data have illuminated these differences, SGM veterans remain largely invisible in administrative data such as electronic health records due to lack of sexual orientation and gender identity information. Administrative data hold promise for propelling SGM health equity research, but several issues must be addressed, including weighing the benefits and threats of visibility for SGM people in data sets that are tied to receipt of services.

Lesbian Gay Bisexual Transgender and Queer Health-Care Experiences in a Military Population

ABTRACTThis study aimed to understand the experiences of lesbian, gay, bisexual, transgender, and queer of former military service members. Data for this analysis was collected from the two open-ended survey questions as part of a larger online survey. The analysis was performed using the web-based data analysis application Dedoose. Eighty-eight qualitative responses were used. Analysis of the responses revealed five main themes: (1) identity, (2) negative experiences, (3) impact of experiences, (4) policy, and (5) positive experiences. These findings can influence future military research by focusing on the effects of the Don't Ask Don't Tell policy, negative and positive experiences, and the impact of those experiences.

A disproportionate burden: Prevalence of trauma and mental health difficulties among sexual minority versus heterosexual U.S. military veterans

This study examined sociodemographic, military, and trauma characteristics, and mental health concerns that differ by sexual orientation in a nationally representative sample of U.S. military veterans. Data were analyzed from 4069 veterans who participated in the National Health and Resilience Veterans Study (NHRVS). Compared with veterans who self-reported as heterosexual (n = 3,491, 94.7%), sexual minority veterans (n = 161, 5.3%) were more likely to be younger, women, Hispanic, unmarried/partnered, have lower household income, and to have enlisted in the military, and served for 4-9 years (relative to 3 or less or 10 or more). After adjusting for demographic variables, sexual minority veterans remained more likely to report childhood sexual abuse (odds ratio [OR] = 2.82), military sexual trauma (OR = 2.29), adverse childhood experiences (Cohen's d = 0.11), current and lifetime drug use disorder (ORs = 3.66 and 2.41, respectively), current alcohol use disorder (OR = 1.62), current and lifetime posttraumatic stress disorder (PTSD; ORs = 2.03 and 1.55, respectively), non-suicidal self-injury (NSSI; OR = 3.19), and future suicide intent (OR = 2.65). Among sexual minority veterans, more years of military service was associated with greater odds of lifetime PTSD, and lower annual household income with greater odds of lifetime drug use disorder and NSSI. Consistent with research in non-veterans, results suggest that sexual minority veterans experience greater trauma and mental health burden relative to their heterosexual peers. They further underscore the importance of interventions that prevent and mitigate adverse mental health outcomes in this population.

Looking Back, a View to the Future of the Health and Readiness of Gender and Sexual Diverse U.S. Service Members

The objective is to provide a brief overview of the history of gender and sexual diverse service members, health utilization rates, outcomes, and disparities, as well as perceived challenges accessing health care and gaps in the evidence base underpinning sex- and gender-appropriate care. The article also provides strategies going forward to address these issues and optimize health care delivery.

Continuing the legacy of a military women's health research interest group

The Military Women's Health Research Interest Group (MWHRIG) was established in 2010. The purpose of the MWHRIG is to support military clinicians and leaders in determining research priorities, and making evidence-based practice and policy decisions relevant to sex- and gender-appropriate healthcare. This article highlights the history of the MWHRIG, and current activities inclusive of research, mentorship, and collaboration. Future activities for the MWHRIG will focus on continued use of a theoretical framework for military women's health research, inclusivity of gender sexual diversity (GSD), and metrics for future success.

Disparities in Mental Health and Health Risk Behaviors for LGBT Veteran Subgroups in a National U.S. Survey

Purpose: This study examined differences in mental health and health risk behaviors across sexual orientation and gender identity among U.S. veterans. Methods: Veterans were recruited through targeted social media advertising, community organizations, and listservs to complete an online survey (N = 1062). Generalized linear regression was used to evaluate differences in outcomes between subgroups, which included cisgender heterosexual men and women, lesbian women, gay men, bisexual men and women, transgender men and women, and veterans with other gender identities. Results: Transgender men and women reported a significantly higher prevalence of lifetime suicide plans and attempts compared to all other subgroups within the respective genders. Beyond this finding, patterns of all outcomes varied by gender. Compared to other subgroups of men, transgender men reported higher prevalence of posttraumatic stress disorder, whereas cisgender gay men reported higher prevalence of lifetime cocaine use and positive human immunodeficiency virus (HIV) status. Within the women subgroups, all LGBT subgroups reported higher prevalence of lifetime smoking and past-year marijuana use compared to heterosexual women. Cisgender lesbian women also reported higher prevalence of past-month heavy episodic drinking, and cisgender bisexual women reported higher prevalence of lifetime cocaine and stimulant use compared to other groups. Conclusion: Transgender women and men reported significantly higher prevalence of lifetime suicide plans and attempts than other groups, highlighting this as an area in need of urgent public health attention. Other disparity patterns indicated the importance of examining subgroups within the LGBT veteran community.

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.

Health disparities among millennial veterans by sexual orientation

The objective of this study was to examine sexual orientation-based disparities in six self-reported health outcomes among millennial aged military veterans. We collected data using The Millennial Veteran Health Study, a cross-sectional internet-based survey with extensive quality control measures. The survey was fielded April through December 2020 and targeted millennial aged veterans across the United States. A total of 680 eligible respondents completed the survey. We assessed six binary health outcomes: alcohol use, marijuana use, frequent chronic pain, opioid misuse, high psychological distress, and fair or poor health status. Using logistic regression adjusted for a range of demographic, socioeconomic, and military-based covariates, we find that bisexual veterans consistently report worse health than straight veterans for all six health outcomes tested. Results for gay or lesbian, compared to straight veterans, were less consistent. Sensitivity models with continuous outcomes, and stratified by gender, found similar results. These results have implications for improving the health of bisexual individuals, including addressing discrimination, belonging, and social identity, particularly in institutional settings that have traditionally heteronormative and masculine cultures such as the military.

Gambling, Gaming, and Internet Behavior in a Sexual Minority Perspective. A Cross-Sectional Study in Seven European Countries

Background

Addictive behavior of gambling, gaming and internet activity is partly a new research domain and has not been well investigated with regard to sexual minority populations. Although health disparities between sexual minorities and the general population are well documented, there is a lack of inclusion of sexual minorities in both research and clinic. Among lesbian, gay and bisexual populations certain features could be present that play a role for the development of addictive behaviors, such as social isolation and increased risk of other psychiatric problems. The aim of this study was to investigate problem gambling, problem gaming and problematic internet behavior in a European context and if it is affected by sexual orientation status.

Methods

An online web-survey was distributed among web-panels in England, Poland, Switzerland, Italy, Spain, Denmark, and Sweden in 2017-2018.

Result

10 983 complete answers were collected. 7.1% of the participants had a sexual minority status (n = 774). Regression models found that there was no difference in gambling, gaming and internet behavior among heterosexual and sexual minority men. Sexual minority women were associated with problematic gambling and gaming behavior, when also controlling for age and nationality. When also controlling for psychological distress, women defining as having another sexual minority status than lesbian and bisexual remained significant for having a problematic gaming behavior (AOR = 2.3).

Conclusion

An awareness of female sexual minority perspectives is relevant in facilities treating behavioral addiction as well as in future research in behavioral addiction. More research is needed in problematic gambling and gaming behavior in different sexual minority populations with regard to psychiatric comorbidity and living conditions. An inclusion of sexual minority groups defining as other than gay and bisexual is needed in future research. No significant differences were found between heterosexual and sexual minority men in adjusted analysis in this study.

Understanding the clinical characteristics of lesbian, gay, and bisexual military service members and adult beneficiaries within an inpatient psychiatric sample

BACKGROUND

Limited knowledge exists regarding targets for suicide-focused care among high-risk United States (U.S.) civilian and military sexual minorities.

PURPOSE

This study aimed to understand the demographic and clinical characteristics of a suicidal sexual minority sample, psychiatrically hospitalized in military treatment facilities, to advance future targeted care for this vulnerable subgroup.

METHODS

Secondary analysis of baseline data from a multisite psychotherapy randomized controlled trial was performed comparing those who self-identified as lesbian, gay, or bisexual (LGB; n = 39) to heterosexual participants (n = 170).

RESULTS

LGB participants were more likely than heterosexual participants to be younger, female, never married, and enlisted rank. LGB participants reported significantly lower family support, higher perceived burdensomeness, lower acquired capability for suicide, and were twice as likely to report that they could not control their suicidal thoughts. LGB and heterosexual participants reported similar levels of other suicide risk indicators and similar lifetime suicidal ideation and attempt histories.

CONCLUSIONS

Compared to heterosexual participants, LGB participants reported increased risk indicators for suicide yet similar lifetime suicidal ideation and attempt histories. Suicide prevention programs should address the unique needs of this vulnerable subgroup. Interventions targeting family support, perceived burdensomeness, and controllability of suicidal thoughts may be promising.

Military service experiences and reasons for service separation among lesbian, gay, and bisexual individuals in a large military cohort

BACKGROUND

The well-being of lesbian, gay, and bisexual (LGB) individuals is a topic of increasing concern within the military where significant institutional barriers, targeted aggression, and differential organizational policies such as "Don't Ask Don't Tell" have historically contributed to experiences of exclusion and discrimination. However, limited research has examined specific military and post-separation experiences among LGB service members and veterans. The goal of this study was to examine differences in military and service separation experiences by sexual orientation among a large representative sample of United States service members and veterans.

METHODS

Survey data from the 2016 Millennium Cohort Study follow-up questionnaire were used to assess sexual orientation and multiple outcomes of interest: military experiences (morale, feelings about the military, missed workdays) and service separation experiences (reasons for separation, post-separation employment). The associations between sexual orientation (LGB versus heterosexual) and each of these outcomes were evaluated in a series of adjusted logistic regression models, stratified by sex when interactions were observed.

RESULTS

Of the 99,599 participants, 3.4% identified as LGB. In adjusted models, LGB service members had significantly higher odds than heterosexual service members of feeling: unimpressed by the quality of unit leadership, unsupported by the military, and negative about the military overall. Bisexual women were more likely than heterosexual women to feel less unit camaraderie; both gay and bisexual men felt less camaraderie than heterosexual men. LGB veterans were more likely than heterosexual peers of the same sex to separate from service due to unplanned administrative reasons. Compared to heterosexual women, lesbian and bisexual women were more likely to separate from service due to dissatisfaction with promotions/pay and disability/medical reasons, while bisexual women specifically separated due to dissatisfaction with leadership and incompatibility with the military. Gay and bisexual men also reported separating due to incompatibility with the military, but only bisexual men were more likely to report separating due to disability/medical reasons compared to heterosexual men.

CONCLUSIONS

Less positive military- and separation-specific experiences disproportionately affected LGB service members in this study. Promoting inclusion and increasing support for LGB service members may improve satisfaction with military service and retention.

Mental Health, Sexual Orientation, and Perceived Social Network Support in Relation to Hazardous Alcohol Consumption Among Active Duty Military Men

Knowledge surrounding perceived network support and alcohol consumption among active duty U.S. military personnel is limited, particularly among sexual minorities.We sought to determine the correlates of hazardous alcohol consumption and whether perceived network support moderated the relationship between sexual orientation and Alcohol Use Identification Test (AUDIT-C) score.The sample comprised cisgender men currently serving in the U.S. military (N = 292). Participants were recruited through respondent-driven sampling and completed an online survey. Logistic regression analysis evaluated associations between positive AUDIT-C with sociodemographic characteristics (including sexual orientation), military service, mental health, and perceived social network support. Interaction analysis assessed the moderating effect of perceived network support on sexual orientation and AUDIT-C.Among study participants, 52.7% (154/292) had positive AUDIT-C, while 65.4% (191/292) self-identified as heterosexual/straight and 34.6% (101/292) identified as gay or bisexual. In adjusted analysis, positive AUDIT-C was associated with increased post-traumatic stress disorder symptomatology (adjusted odds ratio [adjOR] 1.03; 95% CI [1.00, 1.06]; p = .019) and high perceived network support (adjOR 1.85; 95% CI [1.04, 3.29]; p = .036), while mental health service utilization had reduced odds of positive AUDIT-C (adjOR 0.40; 95% CI [0.20, 0.78]; p = .007). In interaction analysis, high perceived network support was associated with increased odds of positive AUDIT-C among sexual minority men (adjOR 3.09; 95% CI [1.21, 7.93]; p = .019) but not heterosexual men (adjOR 1.38; 95% CI [0.68, 2.81]; p = .37).Hazardous alcohol use was prevalent among all men in our sample. Perceived social network support may influence hazardous alcohol consumption, particularly among sexual minority servicemen. These findings suggest the potential role of tailored social network-based interventions to decrease hazardous alcohol use among military personnel.

A Descriptive Study of Transgender Active Duty Service Members in the U.S. Military

Purpose: Department of Defense policy prohibits, with limited exceptions, transgender individuals from serving in their affirmed gender in the U.S. Military, citing potential impact on unit cohesion and military readiness. To date, however, little is known about the sociodemographic profile and health of transgender military personnel. Methods: U.S. Military personnel who self-identified as transgender completed anonymous online measures of demographics and military service. Participants also completed measures of health, mood, eating pathology, and risk behaviors. Results: One hundred ninety-five service members (mean age: 28.9±7.2 years, 48.7% transmale, 70.3% non-Hispanic White, 7.83±5.9 years in service) completed the survey. The majority of respondents first identified as transgender before military accession. Most had disclosed their gender identity to their command and providers, and had undertaken steps toward gender affirmation. The sample as a whole reported above average physical health, with mood symptoms within normal ranges and few reported risk behaviors. Analyses of covariance indicated that transmales reported significantly better mental health and psychosocial functioning compared with transfemales. Conclusion: In light of current policy that precludes, with limited exceptions, transgender individuals from serving in the U.S. Military in their affirmed gender, the current study provides an initial sociodemographic profile of this understudied population and indicates that transgender service members report above average physical health and few risk behaviors. Preliminary analyses indicated that transfemales in the military may be at higher risk for mental health concerns, compared with transmales. Additional research is needed to elucidate risk and protective factors among transgender service members.

Sexual orientation disparities in food insecurity and food assistance use in U.S. adult women: National Health and Nutrition Examination Survey, 2005-2014

Background

Nearly 40 million American adults report past year food insecurity. This is concerning, as food insecurity is associated with chronic disease morbidity and premature mortality. Women disproportionately experience food insecurity, and sexual minority women (i.e., lesbian, bisexual, and heterosexual women reporting same-sex behavior; SMW) may be at greater risk for experiencing food insecurity disparities. The purpose of this study was to investigate patterns and prevalence of food insecurity and food assistance use in sexual minority and exclusively heterosexual women using population-level health surveillance data.

Methods

Using pooled 2004–2014 National Health and Nutrition Examination Survey data (N = 7379), we estimated weighted point prevalence of past 12-month food insecurity, severe food insecurity, Supplemental Nutrition Assistance Program (SNAP) use, and emergency food assistance use. We then used Poisson regression with robust variance to estimate prevalence ratios comparing SMW to exclusively heterosexual women on all outcomes. Women were classified by sexual identity and lifetime same-sex behavior as lesbian (n = 88), bisexual (n = 251), heterosexual and reporting same-sex behavior (heterosexual WSW; n = 366), or exclusively heterosexual women (referent; n = 6674).

Results

Between 20.6–27.3% of lesbian, bisexual, and heterosexual WSW reported past 12-month food insecurity (versus 13.1% of exclusively heterosexual women). All SMW reported greater prevalence of past 12-month food insecurity and severe food insecurity than exclusively heterosexual women: prevalence ratios (PR) ranged from 1.34 (95% confidence interval [CI], 1.05–1.70) to 1.84 (95% CI, 1.13–3.01). No differences were found in SNAP participation by sexual orientation, but more lesbians and heterosexual WSW reported using emergency food assistance in the past 12-months (PR = 1.89; 95% CI, 1.29–2.79 and PR = 1.43; 95% CI, 1.03–2.00 respectively).

Conclusions

All SMW reported higher prevalence of food insecurity than exclusively heterosexual women. Lesbians and heterosexual WSW were also more likely to rely on emergency food assistance. This is problematic as SNAP use may reduce food insecurity over time, but emergency food resources (e.g., food pantries) do not. More evidence is needed to understand the multilevel factors driving food insecurity in this population to develop policy and community-based efforts to increase SNAP participation and decrease food insecurity.

The evolution of mental health outcomes across a combat deployment cycle: A longitudinal study of the Guam Army National Guard

In the United States, National Guard soldiers have been called upon at unprecedented rates since 2001 to supplement active duty military forces. Frequent military deployments generate many occupational and environmental stressors for these citizen-soldiers, from serving in a dangerous zone to being away from family and home for long periods of time. Whereas there is a substantial amount of research focused on deployment-related health outcomes in relation to active duty (i.e., full-time) military populations, reserve forces are less understood. This study focuses on a United States Army National Guard combat unit deployed to Afghanistan. This prospective longitudinal study was conducted over the course an operational deployment cycle (i.e., before, during, and after) to document the evolution of salient mental health outcomes (i.e., post-traumatic stress, depression, general anxiety, and aggression). The findings show that both combat (e.g., killing others) and non-combat (e.g., boredom) stressors negatively affect mental health outcomes, and the severity of these outcomes increases over the course of a deployment cycle. Of special note, the study reveals key gender differences in the evolution of post-traumatic stress (PTS), depression, and anxiety across a deployment cycle: females report increased PTS, depression, and anxiety 6 months post-deployment, whereas the levels reported by males stabilize at their mid-deployment levels. The findings offer insights for medical providers and policymakers in developing more targeted health promotion campaigns and interventions, especially at the post-deployment phase.

The health and well-being of LGBTQ serving and ex-serving personnel: a narrative review

The relaxation of discriminatory policies against lesbian, gay, bisexual, transgender, and queer (LGBTQ) service personnel has led to increased diversity among military populations. Given this increase, it is important to assess sexual and gender minority groups' health and well-being in the context of military service. This narrative review assessed these outcomes in LGBTQ military personnel. The electronic databases OVID Medline, PsycInfo, and Embase were searched for papers published between January 2000 and July 2018. Thirty papers were included. In line with life course model, studies aligned with four themes: (1) mental health and well-being; (2) stigma and healthcare utilization; (3) sexual trauma; and (4) physical health. These themes highlighted that LGBTQ military personnel and veterans have poorer mental health and well-being; report more stigma and barriers to mental healthcare, which reduces uptake of accessed healthcare services; experience more sexual trauma; and have poorer physical health than heterosexual military personnel and veterans. However, there are substantial gaps in the current evidence for this population. Future research should aim to address limitations of the literature, and to ensure that data on LGBTQ personnel and veterans is collected as standard.

Problematic Gaming and Internet Use but Not Gambling May Be Overrepresented in Sexual Minorities - A Pilot Population Web Survey Study

Background: Substance-related addictive disorders are known to be overrepresented in non-heterosexual individuals, but it is largely unknown whether this is also the case for behavioral addictions such as problem gaming and gambling. This study aimed, in a pilot web survey design, to assess whether problematic gambling, gaming and internet use may be more common in individuals with a non-heterosexual orientation. Methods: An online survey was distributed through media and social media, and answered by 605 individuals (51% women and 11% non-heterosexual). Problem gambling, problem gaming and problematic internet use were measured through structured screening instruments (the CLiP, the GAS and the PRIUSS, respectively). Results: Problem gaming and problematic internet use were significantly more prevalent in non-heterosexual subjects. Instead, problem gambling did not differ between heterosexual and non-heterosexual respondents. Psychological distress and social media use for more than 3 h daily were significantly more common in non-heterosexual respondents. In the overall sample, gaming and gambling were associated statistically. Conclusion: Based on the present pilot online survey, problematic gaming and internet use, but not problem gambling, may be more common in non-heterosexual populations. This area merits more and larger studies, and potentially preventive efforts aimed for non-heterosexual individuals in the population. Possible explanations and study limitations are discussed in the paper.

An Overview of Sexual Trauma in the U.S. Military

This article discusses the scope and impact of military sexual trauma (MST) in the U.S. Armed Forces. The authors explore aspects of the military setting that may make recovery from this form of sexual violence particularly difficult. Risk factors for MST as well as associated mental, physical, sexual, and relational health consequences are reviewed. The authors also introduce clinical issues unique to male and lesbian, gay, bisexual, and transgender (LGBT) survivors. Finally, first-line psychotherapies and pharmacotherapies for subsequent mental health difficulties are reviewed, as are strategies for reducing barriers to health care for this population.

A Systematic Review of Cardiovascular Disease in Sexual Minorities

BACKGROUND

Mental health and HIV disparities are well documented among sexual minorities, but there is a dearth of research on other chronic conditions. Cardiovascular disease remains the leading cause of death worldwide. Although sexual minorities have high rates of several modifiable risk factors for cardiovascular disease (including stress, tobacco use, and alcohol consumption), there is a paucity of research in this area.

OBJECTIVES

In this systematic review, we synthesized and critiqued the existing evidence on cardiovascular disease among sexual minority adults.

SEARCH METHODS

We conducted a thorough literature search of 6 electronic databases for studies published between January 1985 and December 2015 that compared cardiovascular disease risk or prevalence between sexual minority and heterosexual adults.

SELECTION CRITERIA

We included peer-reviewed English-language studies that compared cardiovascular disease risk or diagnoses between sexual minority and heterosexual individuals older than 18 years. We excluded reviews, case studies, and gray literature. A total of 31 studies met inclusion criteria.

DATA COLLECTION AND ANALYSIS

At least 2 authors independently abstracted data from each study. We performed quality assessment of retrieved studies using the Crowe Critical Appraisal Tool.

MAIN RESULTS

Sexual minority women exhibited greater cardiovascular disease risk related to tobacco use, alcohol consumption, illicit drug use, poor mental health, and body mass index, whereas sexual minority men experienced excess risk related to tobacco use, illicit drug use, and poor mental health. We identified several limitations in the extant literature. The majority of included studies were cross-sectional analyses that used self-reported measures of cardiovascular disease. Even though we observed elevated cardiovascular disease risk, we found few differences in cardiovascular disease diagnoses (including hypertension, diabetes, and high cholesterol). Overall, 23 of the 26 studies that examined cardiovascular disease diagnoses used subjective measures. Only 7 studies used a combination of biomarkers and self-report measures to establish cardiovascular disease risk and diagnoses.

AUTHORS' CONCLUSIONS

Social conditions appear to exert a negative effect on cardiovascular disease risk among sexual minorities. Although we found few differences in cardiovascular disease diagnoses, we identified an elevated risk for cardiovascular disease in both sexual minority men and women. There is a need for research that incorporates subjective and objective measures of cardiovascular disease risk. Public Health Implications: Cardiovascular disease is a major health concern for clinicians, public health practitioners, and policymakers. This systematic review supports the need for culturally appropriate interventions that address cardiovascular disease risk in sexual minority adults.

Recommendations for cardiovascular disease research with lesbian, gay and bisexual adults

AIMS AND OBJECTIVES

The purpose of this paper is to provide recommendations to strengthen cardiovascular disease research with lesbian, gay and bisexual adults, and highlight implications for practice.

BACKGROUND

Lesbian, gay and bisexual individuals face significant discrimination that negatively impacts their health. Health disparities research in lesbian, gay and bisexual adults have focused on mental health, sexually transmitted infections and substance use. Although cardiovascular disease is the leading cause of death and many lesbian, gay and bisexual adults report increased risk factors for cardiovascular disease, there has been limited research in this area.

DESIGN

This paper is a critical review.

METHODS

A literature search was conducted that compared cardiovascular disease risk and/or prevalence between lesbian, gay and bisexual and heterosexual adults.

RESULTS

Measures to assess cardiovascular disease risk factors and diagnoses varied widely across the 31 included studies. There was a lack of standardisation in definitions used for alcohol consumption, illicit drug use, mental health and self-rated physical health. Most studies that reported body mass index relied on participant self-report. Few studies included measures of physical activity and diet and those that did lacked standardisation. Only seven studies used laboratory data to establish diagnosis of cardiovascular disease.

CONCLUSIONS

This study is the first comprehensive review on this topic. In cardiovascular disease research with lesbian, gay and bisexual adults, there is a need for: (1) inclusion of stress as a risk factor for cardiovascular disease, (2) standardised measures, (3) objective measures for determining the presence of cardiovascular disease, (4) data from electronic health records to strengthen the study of cardiovascular disease in this population.

RELEVANCE TO CLINICAL PRACTICE

Strengthening cardiovascular disease research in lesbian, gay and bisexual adults is an important step in addressing health disparities in this population. Nurses and other healthcare professionals should assess sexual orientation in routine health assessments.

The Impact of Discrimination on the Mental Health of Trans*Female Youth and the Protective Effect of Parental Support

Significant health disparities exist for transgender female (trans*female) youth. We assessed differences in mental health outcomes based on exposure to discrimination among transgender female youth in the San Francisco Bay Area aged 16-24 years. Youth were recruited using a combination of respondent driven sampling with online and social media methods. Logistic regression models were used to estimate odds ratios for the mental health outcomes, comparing levels of discrimination and levels of resiliency promoting protective factors among sexually active youth in the sample (N = 216). High transgender-based discrimination was significantly associated with greater odds of PTSD (AOR, 2.6; 95 % CI 1.4-5.0), depression (AOR, 2.6; 95 % CI 1.2-5.9), and stress related to suicidal thoughts (AOR 7.7, 95 % CI 2.3-35.2). High racial discrimination was significantly associated with greater odds of psychological stress (AOR 3.6; 95 % CI 1.2-10.8), PTSD (AOR 2.1; 95 % CI 1.1-4.2) and stress related to suicidal thoughts (AOR 4.3, 95 % CI 1.5-13.3). Parental closeness was related to significantly lower odds of all four mental health outcomes measured, and intrinsic resiliency positively reduced risk for psychological stress, PTSD, and stress related to suicidal thoughts. Transgender and racial discrimination may have deleterious effects on the mental health of trans*female youth. Interventions that address individual and intersectional discrimination and build resources for resiliency and parental closeness may have success in preventing mental health disorders in this underserved population.

Intimate partner violence among women veterans by sexual orientation

National estimates suggest intimate partner violence (IPV) rates are equal or higher among lesbian, bisexual, or questioning (LBQ)-identified women than heterosexual-identified women. Women veterans are a population at high risk for IPV, yet the occurrence of lifetime and past-year IPV experiences by sexual orientation have not been examined in this population. Lifetime and past-year IPV experiences and current IPV-related posttraumatic stress disorder (PTSD) symptoms were assessed with validated screening measures as part of a 2014 web-based national survey of women veterans. Among 403 respondents, 9.7% (n = 39) identified as LBQ, and 90.3% (n = 364) identified as heterosexual. When controlling for age, LBQ-identified women veterans were significantly more likely to report lifetime sexual and physical IPV and lifetime intimate partner stalking. In the past year, LBQ-identified veterans were twice as likely to endorse emotional mistreatment and physical IPV, and three times more likely to endorse sexual IPV, than were heterosexual-identified women veterans. However, sexual orientation was unrelated to IPV-related PTSD symptoms, when controlling for age, race, and number IPV forms experienced. IPV is prevalent among LBQ-identified women veterans, suggesting the need to understand the potentially unique contextual factors and health-care needs of this group.

Self-reported suicide ideation and attempts, and medical care for intentional self-harm in lesbians, gays and bisexuals in Sweden

BACKGROUND

Minority sexual orientation is a robust risk indicator for self-reported suicidal ideation and attempts. However, little is known about patterns of medical care for intentional self-harm in this vulnerable population. We investigate sexual orientation-related differences in self-reported lifetime suicide symptoms and medical care for intentional self-harm between 1969 and 2010, including age at initial treatment and recurrence.

METHODS

We used data from the Stockholm Public Health Cohort, a population-based sample of 874 lesbians/gays, 841 bisexuals and 67 980 heterosexuals, whose self-administered surveys have been linked to nationwide registers. Estimates of risk for medical care were calculated as incidence rate ratios (IRR) with 95% CIs.

RESULTS

Both suicidal ideation and attempts were more commonly reported by lesbian/gay and bisexual (LGB) individuals. Adjusting for risk-time and confounding, lesbians (IRR 3.8, 95% CI 2.7 to 5.4) and bisexual women (IRR 5.4, 95% CI 4.4 to 6.6) experienced elevated risk for medical care for intentional self-harm, as compared to heterosexual women. Gay men evidenced higher risk (IRR 2.1, 95% CI 1.3 to 3.4) as compared to heterosexual men. Recurrent medical care was more frequent in LGB individuals, especially in bisexual women and gay men. Lesbian and bisexual women were also younger than heterosexual women when they first received medical care for intentional self-harm.

CONCLUSIONS

Positive histories of suicidal ideation, attempts and medical care for intentional self-harm, including higher levels of recurrence, are more prevalent among LGB individuals in contrast to heterosexuals. Lesbian/bisexual women evidence an earlier age of onset of treatment. Tailored prevention efforts are urgently needed.