Sexual orientation-related disparities in employment, health insurance, healthcare access and health-related quality of life: a cohort study of US male and female adolescents and young adults

The relationship of race, ethnicity, gender identity, sex assigned at birth, sexual orientation, parental education, financial hardship and comorbid mental disorders with quality of life in college students with anxiety, depression or eating disorders

BACKGROUND

Previous studies showed that comorbidity and demographic factors added to burden on health-related quality of life (HRQoL). Only one study explored the relationship between HRQoL and comorbidity in college students with mental disorders, leaving generalizability of findings uncertain. Less is known about the association of demographics on HRQoL. This study investigated HRQoL based on demographics and comorbidity among college students with mental disorders.

METHODS

Participants were students (N = 5535) across 26 U.S. colleges and universities who met criteria for depression, generalized anxiety, panic, social anxiety, post-traumatic stress, or eating disorders based on self-report measures. ANOVA and linear regressions were conducted.

RESULTS

Overall, female, minoritized (gender, sexual orientation, race, or ethnicity), and lower socioeconomic status students reported lower HRQoL than male, heterosexual, White, non-Hispanic, and higher socioeconomic status peers. After accounting for comorbidity, differences in physical HRQoL based on sex assigned at birth and gender were no longer significant. For mental HRQoL, only gender and sexual orientation remained significant. A greater number of comorbidities was associated with lower HRQoL regardless of demographic group.

LIMITATIONS

The non-experimental design limits causal inference. The study focused on univariable associations without examining potential interactions between demographic factors. Future research should explore structural factors like discrimination.

CONCLUSION

Results suggested that increased comorbidities placed an additional burden on HRQoL and that certain demographic groups were more vulnerable to HRQoL impairment among students with mental disorders. Findings suggest the need for prevention of disorders and their comorbidity and implementing tailored interventions for specific student subgroups with increased vulnerability.

Sexual Orientation-Related Disparities in Neonatal Outcomes

OBJECTIVE

To evaluate whether disparities exist in adverse neonatal outcomes among the offspring of lesbian, gay, bisexual, and other sexually minoritized (LGB+) birthing people.

METHODS

We used longitudinal data from 1995 to 2017 from the Nurses' Health Study II, a cohort of nurses across the United States. We restricted analyses to those who reported live births (N=70,642) in the 2001 or 2009 lifetime pregnancy questionnaires. Participants were asked about sexual orientation identity (current and past) and same-sex attractions and partners. We examined preterm birth, low birth weight, and macrosomia among 1) completely heterosexual; 2) heterosexual with past same-sex attractions, partners, or identity; 3) mostly heterosexual; 4) bisexual; and 5) lesbian or gay participants. We used log-binomial models to estimate risk ratios for each outcome and weighted generalized estimating equations to account for multiple pregnancies per person over time and informative cluster sizes.

RESULTS

Compared with completely heterosexual participants, offspring born to parents in all LGB+ groups combined (groups 2-5) had higher estimated risks of preterm birth (risk ratio 1.22, 95% CI, 1.15-1.30) and low birth weight (1.27, 95% CI, 1.15-1.40) but not macrosomia (0.98, 95% CI, 0.94-1.02). In the subgroup analysis, risk ratios were statistically significant for heterosexual participants with past same-sex attractions, partners, or identity (preterm birth 1.25, 95% CI, 1.13-1.37; low birth weight 1.32, 95% CI, 1.18-1.47). Risk ratios were elevated but not statistically significant for lesbian or gay participants (preterm birth 1.37, 95% CI, 0.98-1.93; low birth weight 1.46, 95% CI, 0.96-2.21) and bisexual participants (preterm birth 1.29, 95% CI, 0.85-1.93; low birth weight 1.24, 95% CI, 0.74-2.08).

CONCLUSION

The offspring of LGB+ birthing people experience adverse neonatal outcomes, specifically preterm birth and low birth weight. These findings highlight the need to better understand health risks, social inequities, and health care experiences that drive these adverse outcomes.

COVID-19 Knowledge Among Sexual and Gender Minority Adults in New York City

Purpose: This study describes sources of COVID-19 vaccine information and COVID-19 knowledge among sexual and gender minority (SGM) adults in New York City (NYC). Methods: A sample of 986 SGM adults in NYC completed an online survey between June 25 and December 1, 2021. Participants indicated their top three sources of COVID-19 vaccine information from a list of 10 options. Participants were also categorized into low or high COVID-19 knowledge using a 14-item questionnaire. We described knowledge sources, then conducted bivariate and multivariable logistic regression to identify characteristics associated with greater knowledge. Results: The mean age of participants was 29 years (range 18-68 years). Only 12.5% identified their health care provider as a main COVID-19 vaccine information source. Social media (54.9%) and TV news channels (51.4%) were most reported as a main COVID-19 vaccine information source. COVID-19 vaccine knowledge was moderate, with four of eight questions showing correct responses in approximately 70% or more participants. In the multivariable logistic regression model, having at least some college education (adjusted odds ratio [aOR]: 2.34, 95% confidence interval [CI]: 1.55-3.52), attaining a master's degree (aOR: 3.28, 95% CI: 1.93-5.57), reporting a household income of $25,000-$49,999 per year (aOR: 1.68, 95% CI: 1.14-2.46), and having health insurance (aOR: 2.12, 95% CI: 1.51-2.96) were significantly associated with high COVID-19 knowledge. Conclusion: Our sample demonstrated high levels of COVID-19 knowledge, particularly among educated individuals and those with health insurance. Primary access to health information was through social media and TV news channels.

Structural Determinants of Health and Markers of Immune Activation and Systemic Inflammation in Sexual Minority Men With and Without HIV

Among sexual minority men (SMM), HIV and use of stimulants such as methamphetamine are linked with immune activation and systemic inflammation. Throughout the COVID-19 pandemic, SMM encountered financial challenges and structural obstacles that might have uniquely contributed to immune dysregulation and systemic inflammation, beyond the impacts of HIV and stimulant use. Between August 2020 and February 2022, 72 SMM with and without HIV residing in South Florida enrolled in a COVID-19 prospective cohort study. Multiple linear regression analyses examined unemployment, homelessness, and history of arrest as structural correlates of soluble markers of immune activation (i.e., sCD14 and sCD163) and inflammation (i.e., sTNF-α receptors I and II) at baseline after adjusting for HIV status, stimulant use, and recent SARS-CoV-2 infection. Enrolled participants were predominantly Latino (59%), gay-identified (85%), and with a mean age of 38 (SD, 12) years with approximately one-third (38%) of participants living with HIV. After adjusting for HIV status, SARS-CoV-2 infection, and recent stimulant use, unemployment independently predicted higher levels of sCD163 (β = 0.24, p = 0.04) and sTNF-α receptor I (β = 0.26, p = 0.02). Homelessness (β = 0.25, p = 0.02) and history of arrest (β = 0.24, p = 0.04) independently predicted higher levels of sCD14 after adjusting for HIV status, SARS-CoV-2 infection, and recent stimulant use. Independent associations exist between structural barriers and immune activation and systemic inflammation in SMM with and without HIV. Future longitudinal research should further elucidate complex bio-behavioral mechanisms linking structural factors with immune activation and inflammation.

Improving Access to Care Through Youth-Focused Virtual Sexual Health Navigation

PURPOSE

Gender and sexually diverse adolescents and young adults in Baltimore City, Maryland, are disproportionately impacted by HIV. The Virtual and Online Integrated Sexual Health Services for Youth program is a health navigation program which combines virtual sexual health service delivery and health navigation to link youth at risk for HIV acquisition to HIV testing/prevention and sexual healthcare services.

METHODS

Youth between 13 and 26 years old and residing in the Baltimore area were eligible to participate in the program. Demographic and engagement data from 238 youth (average age 21.4, SD = 2.5) who requested navigation were collected and recorded in a Health Insurance Portability and Accountability Act (HIPAA)-secure medical database and examined for associations between demographics, referral source, and the number of navigational services to which they were linked. Focused populations were defined as residents of high HIV prevalence zip codes who identify as sexual and gender diverse youth.

RESULTS

Receipt of navigational services was significantly associated with self-identifying as sexually diverse. A multivariate regression revealed a significant association between the count of navigational services a youth was linked to and recording one's sexual orientation, identifying as a cisgender male, and residing in a high HIV-prevalence zip code.

DISCUSSION

Virtual health navigation has the potential to engage priority populations, including sexual and gender diverse youth. By refining linkage and identification approaches to health navigation, future outreach attempts can be tailored to support vulnerable communities, with the potential to improve sexual healthcare access.

"It's probably an STI because you're gay": a qualitative study of diagnostic error experiences in sexual and gender minority individuals

BACKGROUND

There is a critical need to identify specific causes of and tailored solutions to diagnostic error in sexual and gender minority (SGM) populations.

PURPOSE

To identify challenges to diagnosis in SGM adults, understand the impacts of patient-reported diagnostic errors on patients' lives and elicit solutions.

METHODS

Qualitative study using in-depth semistructured interviews. Participants were recruited using convenience and snowball sampling. Recruitment efforts targeted 22 SGM-focused organisations, academic centres and clinics across the USA. Participants were encouraged to share study details with personal contacts. Interviews were analysed using codebook thematic analysis.

RESULTS

Interviewees (n=20) ranged from 20 to 60 years of age with diverse mental and physical health symptoms. All participants identified as sexual minorities, gender minorities or both. Thematic analysis revealed challenges to diagnosis. Provider-level challenges included pathologisation of SGM identity; dismissal of symptoms due to anti-SGM bias; communication failures due to providers being distracted by SGM identity and enforcement of cis-heteronormative assumptions. Patient-level challenges included internalised shame and stigma. Intersectional challenges included biases around factors like race and age. Patient-reported diagnostic error led to worsening relationships with providers, worsened mental and physical health and increased self-advocacy and community-activism. Solutions to reduce diagnostic disparities included SGM-specific medical education and provider training, using inclusive language, asking questions, avoiding assumptions, encouraging diagnostic coproduction, upholding high care standards and ethics, involving SGM individuals in healthcare improvement and increasing research on SGM health.

CONCLUSIONS

Anti-SGM bias, queerphobia, lack of provider training and heteronormative attitudes hinder diagnostic decision-making and communication. As a result, SGM patients report significant harms. Solutions to mitigate diagnostic disparities require an intersectional approach that considers patients' gender identity, sexual orientation, race, age, economic status and system-level changes.

The Psychometric Properties of the World Health Organization Quality of Life-BREF Questionnaire in College Students

Background and Purpose: Because there are conflicting perspectives on the factor structure of the World Health Organization Quality of Life-BREF (WHOQOL-BREF) Questionnaire among college students, we evaluated the psychometric properties of the instrument in a sample of U.S. college students. Methods: We conducted secondary analysis of data collected from 1,138 undergraduate students from a large metropolitan university in the southeastern United States. Results: Confirmatory factor analysis did not support the original 4-factor structure. Based on exploratory factor analysis, three factors were retained and rotated using Varimax rotation, which accounted for 96% of the item variance. Coefficient alphas for the factors were: social/psychological health, 0.84; physical health, 0.81; and environment, 0.77. Sexual minorities had significantly lower scores on all factors than those who identified as heterosexuals. Conclusions: In this sample of college students, the WHOQOL-BREF was three-dimensional, and a significant amount of the item variance was explained. Lower quality of life scores of nonWhites and sexual minority college students point to a critical need that should be addressed.

Disparities in Mortality by Sexual Orientation in a Large, Prospective Cohort of Female Nurses

Importance

Extensive evidence documents health disparities for lesbian, gay, and bisexual (LGB) women, including worse physical, mental, and behavioral health than heterosexual women. These factors have been linked to premature mortality, yet few studies have investigated premature mortality disparities among LGB women and whether they differ by lesbian or bisexual identity.

Objective

To examine differences in mortality by sexual orientation.

Design, Setting, and Participants

This prospective cohort study examined differences in time to mortality across sexual orientation, adjusting for birth cohort. Participants were female nurses born between 1945 and 1964, initially recruited in the US in 1989 for the Nurses' Health Study II, and followed up through April 2022.

Exposures

Sexual orientation (lesbian, bisexual, or heterosexual) assessed in 1995.

Main Outcome and Measure

Time to all-cause mortality from assessment of exposure analyzed using accelerated failure time models.

Results

Among 116 149 eligible participants, 90 833 (78%) had valid sexual orientation data. Of these 90 833 participants, 89 821 (98.9%) identified as heterosexual, 694 (0.8%) identified as lesbian, and 318 (0.4%) identified as bisexual. Of the 4227 deaths reported, the majority were among heterosexual participants (n = 4146; cumulative mortality of 4.6%), followed by lesbian participants (n = 49; cumulative mortality of 7.0%) and bisexual participants (n = 32; cumulative mortality of 10.1%). Compared with heterosexual participants, LGB participants had earlier mortality (adjusted acceleration factor, 0.74 [95% CI, 0.64-0.84]). These differences were greatest among bisexual participants (adjusted acceleration factor, 0.63 [95% CI, 0.51-0.78]) followed by lesbian participants (adjusted acceleration factor, 0.80 [95% CI, 0.68-0.95]).

Conclusions and Relevance

In an otherwise largely homogeneous sample of female nurses, participants identifying as lesbian or bisexual had markedly earlier mortality during the study period compared with heterosexual women. These differences in mortality timing highlight the urgency of addressing modifiable risks and upstream social forces that propagate and perpetuate disparities.

Barriers to Cervical Cancer Screening by Sexual Orientation Among Low-Income Women in North Carolina

We sought to examine cervical cancer screening barriers by sexual orientation among low-income women in North Carolina. The MyBodyMyTest-3 Trial recruited low-income women (< 250% of federal poverty level) aged 25-64 years who were 1+ year overdue for cervical cancer screening. We compared perceptions of cervical cancer screening among those who self-identified as lesbian, gay, bisexual, or queer (LGBQ; n = 70) to straight/heterosexual women (n = 683). For both LGBQ and straight respondents, the greatest barriers to screening were lack of health insurance (63% and 66%) and cost (49% and 50%). LGBQ respondents were more likely than straight respondents to report forgetting to screen (16% vs. 8%, p = .05), transportation barriers (10% vs. 2%, p = .001), and competing mental or physical health problems (39% vs. 27%, p = .10). Addressing access remains important for improving cervical cancer screening among those under-screened. For LGBQ women, additional attention may be needed for reminders, co-occurring health needs, and transportation barriers.

LGBTQ+ outpatients present to eating disorder treatment earlier and with more severe depressive symptoms than cisgender heterosexual peers

Community evidence indicates high eating disorder (ED) and comorbid symptom severity among LGBTQ+ compared to cisgender heterosexual (CH) individuals. Little is known about such disparities in ED treatment samples, especially in outpatient treatment. We aimed to descriptively characterize and investigate baseline group differences in symptom severity between LGBTQ+ and CH ED outpatients at treatment intake. Data from 60 (22.3%) LGBTQ+ and 209 (77.7%) CH ED outpatients were used to examine: (1) demographic and diagnostic differences; (2) differences in ED, depressive, and emotion dysregulation symptoms. Objectives were tested using Fisher-Freeman-Halton exact and independent samples t-tests, and analyses of covariance adjusted for age and diagnosis, respectively. Most LGBTQ+ outpatients were bisexual (55.2%), and 6.5% identified as transgender and non-binary. LGBTQ+ outpatients presented to treatment at younger ages (Mean Difference [MD] = -3.39, p = .016) and reported more severe depressive symptoms (MD = 5.73, p = .004) than CH patients, but endorsed similar ED symptom and emotion dysregulation severity. Groups did not differ in other demographic or diagnostic characteristics. LGBTQ+ individuals may develop more severe depression and similarly severe EDs at earlier ages but seek outpatient care sooner than CH peers. Managing depressive symptoms may be particularly important for LGBTQ+ ED patients.

Preferences for mHealth Intervention to Address Mental Health Challenges Among Men Who Have Sex With Men in Nepal: Qualitative Study

BACKGROUND

Men who have sex with men (MSM) are disproportionately burdened by poor mental health. Despite the increasing burden, evidence-based interventions for MSM are largely nonexistent in Nepal.

OBJECTIVE

This study explored mental health concerns, contributing factors, barriers to mental health care and support, and preferred interventions to improve access to and use of mental health support services among MSM in Nepal.

METHODS

We conducted focus groups with MSM in Kathmandu, Nepal, in January 2023. In total, 28 participants took part in 5 focus group sessions. Participants discussed several topics related to the mental health issues they experienced, factors contributing to these issues, and their suggestions for potential interventions to address existing barriers. The discussions were recorded, transcribed, and analyzed using Dedoose (version 9.0.54; SocioCultural Research Consultants, LLC) software for thematic analysis.

RESULTS

Participants reported substantial mental health problems, including anxiety, depression, suicidal ideation, and behaviors. Contributing factors included family rejection, isolation, bullying, stigma, discrimination, and fear of HIV and other sexually transmitted infections. Barriers to accessing services included cost, lack of lesbian, gay, bisexual, transgender, intersex, queer, and asexual (LGBTIQA+)-friendly providers, and the stigma associated with mental health and sexuality. Participants suggested a smartphone app with features such as a mental health screening tool, digital consultation, helpline number, directory of LGBTIQA+-friendly providers, mental health resources, and a discussion forum for peer support as potential solutions. Participants emphasized the importance of privacy and confidentiality to ensure mobile apps are safe and accessible.

CONCLUSIONS

The findings of this study have potential transferability to other low-resource settings facing similar challenges. Intervention developers can use these findings to design tailored mobile apps to facilitate mental health care delivery and support for MSM and other marginalized groups.

Factors Associated With Abstinence Among Young Adult Smokers Enrolled in a Real-world Social Media Smoking Cessation Program

OBJECTIVE

Social media platforms are promising to provide smoking cessation support. This study aimed to identify baseline factors associated with cigarette smoking abstinence among young adult smokers enrolled in a real-world social media-based smoking cessation program.

AIMS AND METHODS

We analyzed data from young adult smokers (aged 18-30 years) participating in a publicly available Facebook-based smoking cessation program serving the San Francisco Bay Area. The analytic sample consisted of 248 participants who completed both the baseline and follow-up surveys at 3 months. Multivariable logistic regression analysis determined baseline factors significantly associated with self-reported 7-day cigarette smoking abstinence at 3 months.

RESULTS

Participants were race/ethnically diverse, well-educated, and 47.6% reported LGB + sexual identity. Those who reported dual use of cigarettes and e-cigarettes in the past 30 days (vs. cigarette use only), current alcohol users (vs. non-users), and those aged 25-30 years (vs. 18-24 years) were significantly less likely to report 7-day abstinence at 3 months. Non-daily smokers (vs. daily smokers) and those with high desire to quit smoking (vs. low to moderate desire) were more likely to report abstinence. Results also showed reduction in the percentage of e-cigarette and other tobacco product use among participants.

CONCLUSIONS

Social media interventions may be more effective for young adult non-daily smokers and those with high desire to quit smoking. Smoking cessation programs may help reduce use of other tobacco products among treatment-seeking smokers. Smoking cessation interventions for young adults need to explicitly address dual use of cigarettes and e-cigarettes and use of alcohol.

IMPLICATIONS

Findings of this study highlight the need for future interventions to address dual use of cigarettes and e-cigarettes and use of alcohol to improve cigarette smoking abstinence outcomes. The reduction in the use of other tobacco products among program participants indicates that social media smoking cessation programs may exert a broader positive influence on overall tobacco consumption. The large number of LGB+ smokers participating in the program suggests social media is a promising cessation channel for this hard-to-reach group, warranting further study.

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.

Changes in Health Insurance During COVID-19 Among a U.S. National Cohort of Cisgender Gay and Bisexual Men and Transgender Individuals

The extant data suggest that LGBT communities were disproportionately impacted by the economic ramifications of the pandemic and were more likely to report being uninsured throughout the first two years of the pandemic. Additionally, these groups are at heightened vulnerability for several health conditions that require insurance to manage or prevent. Thus, there is a need to assess changes in pandemic-era insurance coverage among these populations. This study uses data collected as part of the Together 5,000 study, a U.S. national, internet-based cohort study of cisgender men, trans men, and trans women who have sex with men. We analyze insurance data across three different assessments between 2019 and 2021, exploring changes in insurance coverage and type. Among our sample, 6.4% lost their insurance in 2020 because of the pandemic. Insurance loss was associated with living in a state that had not expanded Medicaid, race/ethnicity, employment status, and income. Among those who lost their insurance in early 2020, most (59.2%) reported gaining insurance by 2021, with those living in non-expanded states less likely to gain insurance. Finally, those who were uninsured prior to the pandemic were less likely to report gaining insurance by 2021, when compared to those uninsured as a result of the pandemic. This suggests that there are uninsured cisgender gay and bisexual men and transgender individuals that continue to go unreached by policies to assuage uninsurance. Further policy intervention is needed to address uninsurance among LGBT individuals, which has important implications for addressing health disparities among these populations.

Associations between police harassment and distrust in and reduced access to healthcare among Black sexual minority men: A longitudinal analysis of HPTN 061

OBJECTIVE

Evaluate associations between racialized and homophobia-based police harassment (RHBPH) and healthcare distrust and utilization among Black Sexual Minority Men (BSMM).

METHODS

We utilized data from a longitudinal cohort study from HIV Prevention Trials Network (HPTN) 061 with baseline, six and 12 month follow-up assessments. Using multivariable analysis, we evaluated associations between RHBPH and healthcare distrust and utilization reported at the 6 and 12 month visits.

RESULTS

Of 1553 BSMM present at baseline, 1160 were available at six-month follow-up. In multivariable analysis, increasing frequency of RHBPH was associated with increasing levels of distrust in healthcare providers (aOR 1.31, 95% CI: 1.00, 1.74) and missing 50% or more of healthcare visits at six-month follow-up (aOR 1.93, 95% CI: 1.09, 3.43).

CONCLUSIONS

Recent experiences of RHBPH are associated with reduced trust in and access to healthcare among BSMM, with more frequent RHBPH associated with greater vulnerability.

Cost-related avoidance of oral health service utilization among lesbian, gay, and bisexual individuals in Canada

OBJECTIVES

This study estimates the frequency of cost-related oral health service avoidance (CROHSA) among lesbian, gay, and bisexual (LGB) individuals in Canada relative to heterosexual persons.

METHODS

Heterosexual and sexual minority individuals in Canada were compared using the national probability-based Canadian Community Health Survey 2017-2018. Logistic regression was used to quantify associations between LGB status and CROHSA. Mediators were tested following Andersen's behavioral model of health service utilization and included partnership status, oral health status, presence of dental pain, educational attainment, insurance status, smoking status, general health status, and personal income.

RESULTS

From our sample of 103,216 individuals, 34.8% of LGB individuals reported avoiding oral health care due to cost compared to 22.7% of heterosexual persons. Disparities were most pronounced among bisexual individuals (odds ratio [OR] 2.29 95% confidence interval [CI] 1.42, 3.49). Disparities persisted despite adjustment for confounding using age, gender/sex, and ethnicity (OR 2.23 95% CI 1.42, 3.49). Disparities were fully mediated by eight hypothesized mediators namely, educational attainment, smoking status, partnership status, income, insurance status, oral health status, and the presence of dental pain (OR 1.69 95% CI 0.94, 3.03). In contrast, lesbian/gay individuals did not have elevated odds of experiencing CROHSA compared to heterosexual individuals (OR 1.27 95% CI 0.84, 1.92).

CONCLUSION

CROHSA is elevated for bisexual individuals relative to heterosexual individuals. Targeted interventions should be explored to improve oral healthcare access among this population. Future research should assess the role of minority stress and social safety on oral health inequities among sexual minority groups.

Prevalence of Self-Reported Kidney Disease in Older Adults by Sexual Orientation: Behavioral Risk Factor Surveillance System Analysis (2014-2019)

SIGNIFICANCE STATEMENT

Studies discusses CKD disparities by age, race and ethnicity, and socioeconomics. However, despite well-documented disparities in CKD risk factors in LGBT+ adults, limited literature addresses CKD prevalence in this population. This analysis uses Behavioral Risk Factor Surveillance System (2014-2019) data to compare self-reported kidney disease prevalence in LGBT+ older adults (older than 50 years) with their heterosexual peers. Our findings indicate that LGBT+ older adults have higher rates of self-reported kidney disease and a higher incidence of CKD risks including smoking, activity limitations, adverse health outcomes, and limited access to health care, housing, and employment. These results support increasing access to screening for CKD risk factors, providing culturally responsive health care, and addressing societal drivers of vulnerability in older LGBT+ adults.

BACKGROUND

Existing research documents disparities in CKD by age, race and ethnicity, and access to health care. However, research on CKD in lesbian, gay, bisexual, and trans (LGBT+) older adults, despite their higher rates of diabetes, heart disease, smoking, and alcohol use, is limited.

METHODS

Pooled data from the Behavioral Risk Factor Surveillance System (2014-2019) for 22,114 LGBT+ adults and 748,963 heterosexuals aged 50 and older were used to estimate the prevalence of self-reported kidney disease. Logistic regressions were used to compare older adults by sexual orientation.

RESULTS

Older LGBT+ men (adjusted odds ratio=1.3; 95% confidence interval [CI], 1.09-1.54) were more likely than their heterosexual counterparts to report kidney disease, after controlling for sociodemographic factors, health behaviors, access to health care, and self-reported coronary heart disease, HIV, and diabetes; LGBT+ men and women also reported higher incidences of known risk factors for CKD. For example, both LGBT+ men (odds ratio [OR]=1.39; [95% CI], 1.26-1.54) and LGBT+ women (OR=1.39; [95% CI], 1.25-1.55) were more likely to be smokers and have a higher incidence of activity limitations, adverse health outcomes, and limited access to health care, housing, and employment.

CONCLUSION

These results support increasing access to screenings for CKD risk factors, providing preventative education and culturally responsive and affirming care, and addressing other societal drivers of vulnerability in older LGBT+ adults. The findings also support the value of interventions that address the interaction between CKD risk factors and the social marginalization that older LGBT+ adults experience.

Experiences of peer navigators implementing a bilingual multilevel intervention to address sexually transmitted infection and HIV disparities and social determinants of health

INTRODUCTION

Sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) disproportionately affect young gay, bisexual and other men who have sex with men (GBMSM) and transgender women of colour. We explored the experiences of community-based peer navigators ('Community Navigators') who participated in Impact Triad, a bilingual multilevel intervention developed by our community-based participatory research partnership to reduce STIs and HIV and address social determinants of health (e.g., employment, education, social support and discrimination) among young GBMSM and transgender women of colour.

METHODS

Individual in-depth interviews were conducted with 15 Community Navigators who participated in Impact Triad. Themes were identified through constant comparison.

RESULTS

Community Navigators' mean age was 31.4 years. Seven were self-identified as African American/Black, 5 as Latine, 2 as multiracial/multiethnic, 1 as Asian American, 10 as cisgender men, 4 as transgender women and 1 as gender nonbinary. Thirteen themes emerged in three domains: (1) key aspects of the Community Navigator role (e.g., desire to serve as a community resource, the importance of being part of the communities in which one was working, the value of having an official role, being connected to other Community Navigators to problem-solving and sustaining intervention aspects long-term); (2) experiences implementing Impact Triad (e.g., engaging community members, meeting prioritized needs, building trust, using social media, increasing awareness and knowledge and challenges related to COVID-19) and (3) lessons learned for future interventions (e.g., facilitating access to broader resources, building additional skills and increasing interactions among Community Navigators).

CONCLUSION

Interviews identified important learnings about serving as Community Navigators and implementing Impact Triad that can guide future efforts to address STI/HIV disparities and social determinants of health through community-based peer navigation.

PATIENT OR PUBLIC CONTRIBUTION

Throughout this intervention trial, our partnership worked collaboratively with a study-specific community advisory board (CAB) comprised primarily of young GBMSM and transgender women of colour. Members of this CAB participated in all aspects of the trial including trial design, intervention development, recruitment and retention strategies, data collection and analysis, interpretation of findings and dissemination.

Using the Community Readiness Model and Stakeholder Engagement to Assess a Health System's Readiness to Provide LGBTQ+ Healthcare: A Pilot Study

Background

Despite broad social and policy changes over the past several decades, many LGBTQ+ people face barriers to healthcare and report mistreatment and disrespect in healthcare settings. Few health systems level interventions have been shown to improve sexuality- and gender-related health disparities. Using the Community Readiness Model, we developed and implemented a rigorous assessment and priority-setting intervention at one mid-sized health system in the midwestern US. We evaluated the system's readiness to provide LGBTQ+ healthcare and developed immediate action steps that are responsive to local context. We engaged diverse stakeholder groups throughout the process.

Methods

Led by the Community Readiness Model, we identified key groups within the health system and conductedstructured interviews with 4-6 key informants from each group. Two trained scorers external to the study team individually scored each interview on a numerical scale ranging from 1 (no awareness of the problem) to 9 (community ownership of the problem) and discussed and reconciled scores. Group scores were averaged for each dimension of readiness and overall readiness, and then triangulated with stakeholders to ensure they reflected lived experiences. Finally, specific recommendations were generated to match the needs of the system and move them towards higher levels of readiness.

Results

We convened an advisory committee of LGBTQ+ patients of the health system and a panel of local experts on LGBTQ+ wellness. Both groups contributed significantly to research processes. 28 interviews across 6 staff subcommunities indicated readiness levels ranging from "3: Vague Awareness" of the issue, and the "4: Preplanning" stage. Discrepancies across staff groups and dimensions of readiness suggested areas of focus for the health system. The evaluation process led to immediately actionable recommendations for the health system.

Conclusions

This pilot study demonstrates the potential impact of the Community Readiness Model on improving health systems' readiness to provide LGBTQ+ healthcare. This model combines strengths from community-based research and implementation science approaches to form an intervention that can be widely disseminated and maintain the flexibility and agility to meet local needs. Future research will evaluate changes in readiness at the same health system and test the process in additional health systems.

Life Events and Loneliness Among Older Women of Diverse Sexual Identities: Application of the Stress Process Model

Loneliness among older adults has been a topic of interest in recent years. We analyse four waves of data from the Australian Longitudinal Study on Women's Health. We estimate growth models to examine differences in loneliness trajectories from age 50 for women who identify as exclusively heterosexual, plurisexual (bisexual, mainly heterosexual, mainly lesbian) and exclusively lesbian. We find no significant differences in levels of loneliness across sexual identity groups at age 50. We find that while loneliness trajectories of exclusively heterosexual women trend down, levels of loneliness increase with age among plurisexual women. Adverse health events and relationship problems increase loneliness to a greater extent among plurisexual women compared to exclusively heterosexual and exclusively lesbian women. Our results suggest older lesbian women may have accumulated social or personal resources or developed coping mechanisms over the courses of their lives, while plurisexual women remain a vulnerable group.

Age-related patterns of cocaine and methamphetamine use across the life course in the United States: Disparities by gender and sexual identity among adults

PURPOSE

Research showing substance use decreases over the life course has focused primarily on heterosexual adults. We examined how age-related patterns of cocaine and methamphetamine use vary by sexual identity and gender among a national sample.

METHODS

We included 191,954 adults aged 18-64 from the 2015-2019 National Survey on Drug Use and Health. We described the weighted prevalence of past-year cocaine and methamphetamine use and used logistic regressions to estimate relative odds of past-year cocaine and methamphetamine use by age, stratified by gender and sexual identity (heterosexual, gay/lesbian, bisexual).

RESULTS

Cocaine and methamphetamine use was highest among lesbian, gay, and bisexual (LGB) adults compared to their heterosexual counterparts. Gay/lesbian men and women and bisexual men were also more likely to use cocaine at later ages. Heterosexual adults ages 26-34 (adjusted odds ratio [aOR] = 0.73; confidence interval [CI] = 0.65-0.83) were less likely than those 21-25 to report past-year cocaine use, but there were no differences between those ages 26-34 and 21-25 among any LGB sub-group. Heterosexual (aOR = 1.62; CI = 1.28-2.04) and gay (aOR = 2.93; CI = 1.26-6.80), men ages 26-34 were more likely to report past-year methamphetamine use than their counterparts ages 21-25. There were no age-related differences in past-year methamphetamine use between bisexual men and gay/lesbian women.

CONCLUSIONS

Patterns of cocaine and methamphetamine use across the life course for LGB individuals differ from those of heterosexuals. This has implications for targeted prevention efforts to address stimulant use among minoritized populations.

Disability, workplace inclusion and organizational citizenship behavior: an exploratory study of the legal profession

Purpose –

Many workers with disabilities face cultures of exclusion in the workplace, which can affect their participation in decisions, workplace engagement, job attitudes and performance. The authors explore a key indicator of engagement-perceptions of organizational citizenship behavior (OCB)-as it relates to disability and other marginalized identities in the workplace.

Design/methodology/approach –

Using an online survey, legal professionals answered questions about their workplace experiences. Ordinary least squares (OLS) multivariate regression analysis with progressive adjustment was used to investigate the effect of demographic and organizational factors on perceptions of OCB.

Findings –

The authors find that employees with disabilities have lower perceptions of OCB, both before and after controlling for other personal and job variables. The disability gap is cut nearly in half, however, when controlling for workplace culture measures of co-worker support and the presence of an effective diversity, equity and inclusion (DEI) policy. Disability does not appear to interact with gender, race/ethnicity and LGBTQ + status in affecting perceptions of OCB.

Originality/value –

The results point to the workplace barriers faced by people with disabilities that affect their perceptions of engagement, and the potential for supportive cultures to change these perceptions.

Looking at Diabetes-Related Distress through a New Lens: The Socio-Ecological Health Model

Diabetes-related distress (DRD) is defined as an emotional state experienced by people with diabetes (PWD) who are worried about their disease management, the emotional burden from the condition, and/or potential difficulties accessing care or support. The psychosocial aspect of diabetes management is a factor that directly influences patients’ well-being as well as the chronic management of the condition yet is not a primary clinical problem being addressed within the healthcare setting. This review advocates for a re-evaluation and subsequent adjustment of the current DRD screening methodology by implementing the five primary components (Intrapersonal, Interpersonal, Organizational, Community, and Public Policy) of the Socio-Ecological Model of Health (SEMH), bridging the gaps from a public-health perspective. We searched two electronic databases for studies published in the United States from 1995 to 2020 reporting the effects of social determinants of health (SDOH) on DRD. Articles that contained at least one of the five elements of the SEMH and focused on adults aged 18 years or older were included. SDOH, which include circumstances where individuals grow, work, and age, are highly influenced by external factors, such as the distribution of wealth, power, and resources. Current DRD screening tools lack the capacity to account for all major components of SDOH in a comprehensive manner. By applying the SEMH as a theory-based framework, a novel DRD screening tool addressing sex, ethnicity, and socioeconomic background should be implemented to better improve diabetes management outcomes. By exploring the relationships between each level of the SEMH and DRD, healthcare professionals will be better equipped to recognize potential stress-inducing factors for individuals managing diabetes. Further efforts should be invested with the goal of developing a novel screening tool founded on the all-encompassing SEMH in order to perpetuate a more comprehensive diabetes treatment plan to address barriers within the SDOH framework.

Impact of the COVID-19 Pandemic on Women's Health Care Access: A Cross-Sectional Study

Background: There has been limited study of how the COVID-19 pandemic has affected women's health care access. Our study aims to examine the prevalence and correlates of COVID-19-related disruptions to (1) primary care; (2) gynecologic care; and (3) preventive health care among women. Materials and Methods: We recruited 4,000 participants from a probability-based online panel. We conducted four multinomial logistic regression models, one for each of the study outcomes: (1) primary care access; (2) gynecologic care access; (3) patient-initiated disruptions to preventive visits; and (4) provider-initiated disruptions to preventive visits. Results: The sample included 1,285 women. One in four women (28.5%) reported that the pandemic affected their primary care access. Sexual minority women (SMW) (odds ratios [OR]: 1.67; 95% confidence intervals [CI]: 1.19-2.33) had higher odds of reporting pandemic-related effects on primary care access compared to women identifying as heterosexual. Cancer survivors (OR: 2.07; 95% CI: 1.25-3.42) had higher odds of reporting pandemic-related effects on primary care access compared to women without a cancer history. About 16% of women reported that the pandemic affected their gynecologic care access. Women with a cancer history (OR: 2.34; 95% CI: 1.35-4.08) had higher odds of reporting pandemic-related effects on gynecologic care compared to women without a cancer history. SMW were more likely to report patient- and provider-initiated delays in preventive health care. Other factors that affected health care access included income, insurance status, and having a usual source of care. Conclusions: The COVID-19 pandemic disrupted women's health care access and disproportionately affected access among SMW and women with a cancer history, suggesting that targeted interventions may be needed to ensure adequate health care access during the COVID-19 pandemic.

Assessing widening disparities in HbA1c and systolic blood pressure retesting during the COVID-19 pandemic in an LGBTQ+-focused federally qualified health center in Chicago: a retrospective cohort study using electronic health records

INTRODUCTION

To assess disparities in retesting for glycated hemoglobin (HbA1c) and systolic blood pressure (SBP) among people with diabetes mellitus (DM) and hypertension (HTN), respectively, we analyzed medical records from a lesbian, gay, bisexual, transgender, queer-specialized federally qualified health center with multiple sites in Chicago.

RESEARCH DESIGN AND METHODS

We identified people with DM seen in 2018 and 2019 then assessed if individuals had HbA1c retested the following year (2019 and 2020). We repeated this using SBP for people with HTN. Rates of retesting were compared across gender, sexual orientation, and race and ethnicity and across the 2 years for each categorization with adjustment for socioeconomic indicators.

RESULTS

Retesting rates declined from 2019 to 2020 for both HbA1c and SBP overall and across all groups. Cisgender women and transgender men with DM (vs cisgender men) and straight people (vs gay men) had significantly lower odds of HbA1c retesting for both years. There was evidence of widening of HbA1c retesting disparities in 2020 between gay men and other orientations. Cisgender women, straight people, and black people (vs white) with HTN had significantly lower odds of SBP retesting for both years. There was evidence of narrowing in the retesting gap between black and white people with HTN, but this was due to disproportionate increase in no retesting in white people rather than a decline in no retesting among black people with HTN.

CONCLUSIONS

Disparities in DM and HTN care according to gender, race, ethnicity, and sexual orientation persisted during the pandemic with significant widening according to sexual orientation.

Anonymous Online Survey on Disordered Eating, Drive for Muscularity, Sexual Orientation, and Satisfaction with Life in Young Swedish Males

Psychiatric conditions in general, including eating disorders, are stigmatizing conditions. The stigma of eating disorders is even more pronounced among males. We conducted an anonymous, online survey to explore the feasibility of recruiting participants for collecting sensitive information, and the relation among eating disorders, drive for muscularity, satisfaction with life, and sexual preference in males (N = 824) aged 15-30 years in Sweden. Internet survey method was a feasible way of recruiting males and obtaining sensitive information. Drive for muscularity was positively related to eating psychopathology. Interestingly, only the attitudinal aspect of the drive for muscularity was negatively related to satisfaction with life, whereas the behavioral component of the drive for muscularity was unrelated to quality of life. Drive for muscularity and disordered eating were not significantly different across participants with various sexual orientations. Our findings corroborate and extend previous research by using an anonymous Internet-based survey that may be less contaminated by social desirability or reporting bias due to the sensitivity of some of the questions.

Heterogeneity of quality of life in young people attending primary mental health services

AIMS

The utility of quality of life (QoL) as an outcome measure in youth-specific primary mental health care settings has yet to be determined. We aimed to determine: (i) whether heterogeneity on individual items of a QoL measure could be used to identify distinct groups of help-seeking young people; and (ii) the validity of these groups based on having clinically meaningful differences in demographic and clinical characteristics.

METHODS

Young people, at their first presentation to one of five primary mental health services, completed a range of questionnaires, including the Assessment of Quality of Life-6 dimensions adolescent version (AQoL-6D). Latent class analysis (LCA) and multivariate multinomial logistic regression were used to define classes based on AQoL-6D and determine demographic and clinical characteristics associated with class membership.

RESULTS

1107 young people (12-25 years) participated. Four groups were identified: (i) no-to-mild impairment in QoL; (ii) moderate impairment across dimensions but especially mental health and coping; (iii) moderate impairment across dimensions but especially on the pain dimension; and (iv) poor QoL across all dimensions along with a greater likelihood of complex and severe clinical presentations. Differences between groups were observed with respect to demographic and clinical features.

CONCLUSIONS

Adding multi-attribute utility instruments such as the AQoL-6D to routine data collection in mental health services might generate insights into the care needs of young people beyond reducing psychological distress and promoting symptom recovery. In young people with impairments across all QoL dimensions, the need for a holistic and personalised approach to treatment and recovery is heightened.

Race and Sexual Identity Differences in PrEP Continuum Outcomes Among Latino Men in a Large Chicago Area Healthcare Network

U.S. HIV incidence is threefold higher among Latino individuals than non-Latino Whites. Pre-exposure prophylaxis (PrEP) uptake remains low among Latino men. Most HIV studies view Latino communities as a monolithic group, ignoring racial and sexual diversity. This analysis examines PrEP-related outcomes including eligibility, first prescription, and second prescription across race and sexual identity in a sample of Latino cisgender men (n = 8271) who sought services from a healthcare network in Chicago in 2012-2019. Logistic regression was used to calculate adjusted odds ratios. Latino-only participants had lower odds of PrEP eligibility and first prescription compared to White-Latino participants. No other significant differences by race were detected. While bisexual participants had equivalent odds of PrEP eligibility, they had lower odds of first PrEP prescription compared to gay participants. Heterosexual participants also had lower odds of PrEP eligibility and initiation. Future research should address unique factors shaping PrEP-related outcomes among diverse Latino populations.

COVID-19 vaccine uptake and factors associated with being unvaccinated among lesbian, gay, bisexual, transgender, queer, and other sexual identities (LGBTQ+) New Yorkers

Routine data on vaccine uptake are not disaggregated by lesbian, gay, bisexual, transgender, queer, and other sexual identities (LGBTQ+) populations, despite higher risk of infection and severe disease. We found comparable vaccination uptake patterns among 1032 LGBTQ+ New Yorkers and the general population. We identified critical socioeconomic factors that were associated with vaccine hesitancy in this economically vulnerable population.

Prescription Drug Insurance and Cost-Related Medication Nonadherence Among Lesbian, Gay, and Bisexual Individuals in Canada

Purpose: This study estimates the frequency of uninsurance for prescription drugs and cost-related medication nonadherence (CRNA) among lesbian, gay, and bisexual (LGB) persons in Canada, compared with the heterosexual population. Methods: Logistic regression was used to quantify associations between sexual orientation, insurance status, and CRNA within the national probability-based Canadian Community Health Survey, 2015-2016. This sample included 98,413 individuals aged 15-80 years, including 2803 LGB individuals. Results: From our sample of Canadians, 22.2% of LGB respondents reported being uninsured for prescription drugs, compared with 20.0% of heterosexual persons (unadjusted odds ratio [UOR] 1.00, 95% confidence interval [CI] 0.75-1.33). LGB individuals had more than twice the odds of reporting CRNA compared with heterosexual individuals (UOR 2.48, 95% CI 1.99-3.10). This disparity was most pronounced among bisexual respondents, who had over three times the odds of reporting CRNA in comparison to heterosexual respondents (UOR 3.45, 95% CI 2.65-4.51). The odds ratio (OR) for CRNA comparing bisexual with heterosexual individuals remained statistically significant after adjustment for race/ethnicity, gender/sex, and age (OR 2.67, 95% CI 1.97-3.61) and was further attenuated with adjustment for partnership status, employment status, income, educational attainment, prescription drug insurance status, general health status, and immigration status (OR 2.09, 95% CI 1.51-2.89). Conclusion: LGB Canadians reported more CRNA but comparable prescription drug insurance frequencies to heterosexual persons. Factors pertaining to medication access (e.g., income, partnership status) and health needs appear to be the most important contributors to disparities.

Trends in Health Care Access/Experiences: Differential Gains across Sexuality and Sex Intersections before and after Marriage Equality

BACKGROUND

Sexual minority adults experience several health care access inequities compared to their heterosexual peers; such inequities may be affected by LGBTQ+ legislation, such as the 2015 national marriage equality ruling.

METHODS

Using population-based data (n = 28,463) from the Association of American Medical Colleges biannual Consumer Survey of Health Care Access, we calculated trend ratios (TR) for indicators of health care access (e.g., insurance coverage, delaying or forgoing care due to cost) and satisfaction (e.g., general satisfaction, being mistreated due to sexual orientation) from 2013 to 2018 across sexuality and sex. We also tested for changes in trends related to the 2015 marriage equality ruling using interrupted time series trend interactions (TRInt).

RESULTS

The largest increases in access were observed in gay men (TR = 2.42, 95% CI 1.28, 4.57). Bisexual men had decreases in access over this period (TR = 0.47, 95% CI 0.22, 0.99). Only gay men had a significant increase in the health care access trend after U.S. national marriage equality (TRInt = 5.59, 95% CI 2.00, 9.18), while other sexual minority groups did not.

CONCLUSIONS

We found that trends in health care access and satisfaction varied significantly across sexualities and sex. Our findings highlight important disparities in how federal marriage equality has benefited sexual minority groups.

Rapid, application-based survey to characterise the impacts of COVID-19 on LGBTQ+ communities around the world: an observational study

INTRODUCTION

Emerging evidence indicates that the COVID-19 pandemic, and the responses it has generated, have had disproportionate impacts on lesbian, gay, bisexual, transgender and queer (LGBTQ+) communities. This study seeks to build on existing information and provide regional insight.

METHODS

In response, a cross-sectional survey was administered to a global sample of LGBTQ+ individuals (n=13 358) between 16 April and 20 May 2020 via the social networking application Hornet. The survey contained questions that characterise the impact of COVID-19 and associated mitigation strategies on economics, employment, mental health and access to healthcare.

RESULTS

5191 (43.9%) individuals indicated they were somewhat, slightly or unable to meet basic needs with their current income, while 2827 (24.1%) and 4710 (40.1%) felt physically or emotionally unsafe in their living environment, respectively. 2202 individuals (24.7%) stated they are at risk for losing health insurance coverage. 2685 (22.7%) persons reported having skipped or cut meals as there was not enough money.

CONCLUSION

Many LGBTQ+persons who responded reported adverse consequences to mental health, economics, interruptions to care and lack of support from their government. This data is part of ongoing analyses but accentuates the unique needs of LGBTQ+ communities that will require targeted, ameliorative approaches.

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.

Predictors of Re-Initiation of Daily Oral Preexposure Prophylaxis Regimen After Discontinuation

Daily oral preexposure prophylaxis (PrEP) for reducing HIV transmission is recommended for those at elevated risk, including sexual gender and minorities assigned male at birth (SGM-AMAB). Few studies have examined re-initiation among PrEP discontinuers, which is critical to ensuring optimization of PrEP’s protection. The current study examined predictors of re-initiation in a longitudinal sample of SGM-AMAB PrEP discontinuers (n = 253) from 10 waves of an ongoing cohort study (analytic n = 1,129). Multilevel structural equation models were used to examine the effects of psycho-social variables on re-initiation. In adjusted models, health insurance, and partner HIV positive status were significantly positively associated with PrEP re-initation. Being bisexual was significantly negatively associated with re-initiation relative to gay participants. Single status and open relationship agreements were associated with higher odds of re-initiation relative to monogamous relationships. Findings suggest that demographic, partnership characteristics and structural factors influence decisions to re-initiate PrEP after discontinuation.

American Cancer Society's report on the status of cancer disparities in the United States, 2021

In this report, the authors provide comprehensive and up-to-date US data on disparities in cancer occurrence, major risk factors, and access to and utilization of preventive measures and screening by sociodemographic characteristics. They also review programs and resources that have reduced cancer disparities and provide policy recommendations to further mitigate these inequalities. The overall cancer death rate is 19% higher among Black males than among White males. Black females also have a 12% higher overall cancer death rate than their White counterparts despite having an 8% lower incidence rate. There are also substantial variations in death rates for specific cancer types and in stage at diagnosis, survival, exposure to risk factors, and receipt of preventive measures and screening by race/ethnicity, socioeconomic status, and geographic location. For example, kidney cancer death rates by sex among American Indian/Alaska Native people are ≥64% higher than the corresponding rates in each of the other racial/ethnic groups, and the 5-year relative survival for all cancers combined is 14% lower among residents of poorer counties than among residents of more affluent counties. Broad and equitable implementation of evidence-based interventions, such as increasing health insurance coverage through Medicaid expansion or other initiatives, could substantially reduce cancer disparities. However, progress will require not only equitable local, state, and federal policies but also broad interdisciplinary engagement to elevate and address fundamental social inequities and longstanding systemic racism.

Understanding the Psychological Impacts of Teenage Pregnancy through a Socio-ecological Framework and Life Course Approach

The relationship between mental health and teenage pregnancy is complex. Mental health can be both an antecedent and contributing factor to teenage pregnancy and a concurrent factor wherein pregnancy itself can contribute to depression. Expectant and parenting teens (EPT) are faced with the simultaneous challenges of pregnancy and parenting while navigating the developmental tasks of adolescence which increases their risk for mental health problems. In addition, adolescents growing up in stressful community or home situations where their parents experienced depression, further places them and their children at greater risk of repeated patterns over time. However, adverse mental health outcomes are not inevitable. The socio-ecological model combined with a life course perspective provides a framework for understanding the complexity of risk and protective factors at multiple levels that influence knowledge, attitudes, behaviors, and other health outcomes later in life and across generations. This approach has important implications for reducing adolescents' risk of an unintended/mistimed pregnancy and improving mental health and other outcomes for EPT. This paper describes the prevalence of mental health problems in EPT and using a socio-ecological framework and life course perspective explains variations in mental health outcome among EPT. Implications for interventions and innovative approaches are also discussed.

Partners' Consensus About Joint Effort and COVID-19 Prevention Among Sexual Minority Men

The current study examined the relevance of relationship functioning to partners' agreement or consensus about joint effort surrounding COVID-19 prevention. Interdependence theory has been widely used to understand how relationship partners influence health behavior, including how sexual minority male (SMM) couples regulate HIV risk. Couples with better relationship functioning tend to be more successful at negotiating joint (shared) goals and subsequently accomplishing them. The study recruited 134 cis-male, SARS-CoV-2 negative adults in relationships with cis-male partners from phone-based social networking applications. Participants completed an online survey assessing relationship functioning (Perceived Relationship Components Questionnaire), COVID-19 prevention behaviors, and risk perceptions. Partners' consensus around joint COVID-19 prevention effort was assessed using an adapted version of the Preferences for Sexual Health Outcomes scale. Path analyses indicated that consensus for joint prevention effort predicted social distancing (B = 0.23; p = .001) and the number of other COVID-19 prevention behaviors engaged in (B = 0.17; p = .003) above and beyond perceived risk and relationship functioning. Relationship satisfaction predicted higher levels of consensus for joint COVID-19 prevention effort (B = 0.40; p = .029). Findings suggest that the theoretical foundations of successful HIV prevention interventions that utilize joint goal formation may generalize to the prediction of COVID-19 prevention behavior and may be leveraged to mitigate the risk of SARS-CoV-2 infection among SMM in relationships. Interventions that overlook the potential for dyadic regulation of health behavior may miss opportunities to capitalize on shared coping resources and fail to address relational barriers to prevention.

Employment Loss as a Result of COVID-19: a Nationwide Survey at the Onset of COVID-19 in US LGBTQ+ Populations

INTRODUCTION

The unemployment rate in the US reached record highs during the COVID-19 pandemic, but little is known about the job loss experiences of lesbian, gay, bisexual, transgender, and queer (LGBTQ+) individuals, who are already economically disadvantaged due to structural and social inequities.

METHODS

Cross-sectional data on unemployment due to COVID-19 were collected between May and July 2020 among 1090 individuals across the US through an online survey.

RESULTS

Respondents who had been employed prior to COVID-19 formed the analytic sample (n = 990). Of these, 298 (27.3%) reported job loss or being furloughed due to COVID-19. When controlling for all other factors, we found statistically significant higher rates of unemployment among younger participants, HIV-positive individuals, men, Black and White non-Hispanic participants, those with less educational attainment, and those in multi-person homes.

CONCLUSIONS

The employment of LGBTQ+ people has been undermined by COVID-19, but as with all populations, those with multiple minority identities, such as Black or HIV+ and LGBTQ+, have been most severely affected.

POLICY IMPLICATIONS

LGBTQ+ populations in the US have experienced high levels of unemployment due to COVID-19. This study highlights the need for national data collection on sexual orientation and gender identity for unemployment as well as the need for substantive policies, such as expanding unemployment to assist in the economic recovery for populations most affected by COVID-19 and the Equality Act to offer further workplace protections.

Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+) Communities and the Coronavirus Disease 2019 Pandemic: A Call to Break the Cycle of Structural Barriers

The coronavirus disease 2019 (COVID-19) pandemic has disproportionately impacted lesbian, gay, bisexual, transgender, and queer (LGBTQ+) communities. Many disparities mirror those of the human immunodeficiency virus (HIV)/AIDS epidemic. These health inequities have repeated throughout history due to the structural oppression of LGBTQ+ people. We aim to demonstrate that the familiar patterns of LGBTQ+ health disparities reflect a perpetuating, deeply rooted cycle of injustice imposed on LGBTQ+ people. Here, we contextualize COVID-19 inequities through the history of the HIV/AIDS crisis, describe manifestations of LGBTQ+ structural oppression exacerbated by the pandemic, and provide recommendations for medical professionals and institutions seeking to reduce health inequities.

Sexual orientation-based disparities in food security among adults in the United States: results from the 2003-2016 NHANES

BACKGROUND

Access to sufficient, safe, culturally appropriate, and nutritious food is essential for maintaining both physical and mental health. Despite a growing body of evidence suggesting that sexual minority (SM) people experience significant disparities in socioeconomic and material resource security, there remains a paucity of empirical studies examining the prevalence of food insecurity among SM people relative to their heterosexual peers.

OBJECTIVES

To determine the prevalence of adult and household food insecurity across sexual orientation groups in the United States after adjusting for multiple covariates.

METHODS

We combined 7 cycles of US NHANES, 2003-2016 (N = 21,300) to examine sexual orientation-based disparities in adult food security among lesbian/gay (n = 373), bisexual (n = 606), same-sex experienced (SSE, n = 693), other sexual minorities (OSMs, n = 88), and heterosexual (n = 19,540) people. Food (in)security was measured using the US Food Security Survey Module and categorized as secure, marginally insecure, moderately insecure, and severely insecure.

RESULTS

Severe adult food insecurity was higher among bisexuals (17.16%; 95% CI: 14.36, 20.38), SSE (13.71%; 95% CI: 11.34, 16.48), OSMs (12.50%; 95% CI: 7.04, 21.24), and lesbians/gays (13.14%; 95% CI: 10.07, 16.97) compared with heterosexuals (8.23%; 95% CI: 7.85, 8.62). Multivariable multinomial logistic regression analysis adjusting for gender, race/ethnicity, age, citizenship, education, household size, income, cycle year, emergency food use, and Supplemental Nutrition Assistance Program participation showed that bisexuals, OSMs, SSE, and lesbians/gays were more likely to experience moderate to severe food insecurity compared with heterosexuals.

CONCLUSIONS

SM people are significantly more likely to experience increased likelihood of food insecurity relative to their heterosexual peers.

Associations between sexual orientation, financial security and relationships with family and peers during the COVID-19 pandemic in Nigeria

Background: This study aimed to determine whether factors associated with financial insecurity during the COVID-19 pandemic were associated with worsening relationships with family, peers and friends of sexual minorities living in Nigeria. Methods: Data were collected using an online survey conducted from 29th June to 31st December 2020. The outcome variable was the quality of relationship with family, friends and peers during the COVID-19 pandemic. The explanatory variables were the sexual orientation (lesbian, gay, bisexual, heterosexual), COVID-19 status, and financial security (job loss or reduced/lost wages because of the COVID-19 pandemic). Multilevel logistic regression analysis models with robust estimation were built and used to assess the association between the outcome and explanatory variables. The models were adjusted for sociodemographic profile (age, sex at birth, education status). Results: Being a sexual minority was associated with higher odds of worsened relationship with family (AOR: 1.49) and friends and peers (AOR: 2.38) during the pandemic. Having COVID-19 symptoms but not getting tested was significantly associated with higher odds of reporting worsening of the relationship with family (AOR: 1.69) and history of job loss (AOR: 1.68), while having formal education (p<0.05) was significantly associated with lower odds of reporting worsening of the relationship with family. The factors significantly associated with higher odds of reporting worsened relationship with friends and peers were testing positive for COVID-19 (AOR: 1.60), reduced wages (AOR: 1.24), and being older (AOR: 1.01). Attaining a college/university education was significantly associated with lower odds of worsened relationship with friends and peers (AOR: 0.31). Conclusions: The COVID-19 pandemic may increase the risk of negative disruptions in the relationships with family, friends and peers, especially for sexual minorities. National COVID-19 response programs should include plans to support those who face social disruption in managing the crisis.

Prevalence and Sociodemographic Correlates of Identifying as Mainly Heterosexual: Stability and Change across Three Cohorts of Australian Women

In recent decades, the ways in which sexual minorities identify have changed dramatically. In response, social and health surveys have begun offering a greater range of response options within sexual orientation questions-for example, intermediate categories for "mainly heterosexual" and "mainly lesbian/gay" alongside the more common response options of "heterosexual," "bisexual," and "lesbian/gay." Recent studies indicate that women who identify as "mainly heterosexual" report poorer health, greater health-risk behaviors, and higher rates of victimization than women identifying as "exclusively heterosexual." However, we know very little about the demographic profile of women who choose the "mainly heterosexual" identity label compared to the adjacent "exclusively heterosexual" or "bisexual" labels or about changes over time in the prevalence and correlates of "mainly heterosexual" identification. This study addressed these knowledge gaps by modeling unique, high-quality survey data from three national cohorts of Australian women (Australian Longitudinal Study on Women's Health, 2000-2017, n = 76,930 observations). Consistent with the facilitative environments model, we document stark cross-cohort increases in the percentage of Australian women identifying as "mainly heterosexual"-from ∼1% of those born in 1946-1951 to ∼26% of those born in 1989-1995, coinciding with comparable declines in the percentage of women identifying as "exclusively heterosexual." We also found evidence of cohort differences in the associations between key sociodemographic factors-such as age, education, and socioeconomic status-and the likelihood of women identifying as "mainly heterosexual." Finally, our results indicate that same-sex sexual attractions were more strongly associated with "mainly heterosexual" identification than was same-sex sexual behavior.

Contraceptive Care Disparities Among Sexual Orientation Identity and Racial/Ethnic Subgroups of U.S. Women: A National Probability Sample Study

Background: Sexual minority women may use contraception for various reasons but face notable barriers to contraceptive care, including stigma and discrimination. However, studies examining sexual orientation disparities in contraceptive care have largely relied on nonprobability samples of predominately White women and may thus not be generalizable to U.S. women overall or Black and Latina women in particular. Materials and Methods: Using data from the 2006 to 2017 National Survey of Family Growth, a large national probability sample of U.S. women 15-44 years of age (N = 25,473), we used multivariable logistic regression to estimate adjusted odds ratios for receiving a contraceptive method or prescription and contraceptive counseling from a health care provider in the past year among sexual orientation identity and racial/ethnic subgroups of heterosexual, bisexual, and lesbian White, Black, and Latina women relative to White heterosexual women. Results: Among women overall, 33.9% had received contraception and 18.3% had obtained contraceptive counseling. Black (odds ratio [OR] = 0.73, 95% confidence interval [CI]: 0.65-0.82) and Latina (OR = 0.73, 95% CI: 0.64-0.82) heterosexual women, White (OR = 0.80, 95% CI: 0.65-0.99) and Black (OR = 0.43, 95% CI: 0.32-0.58) bisexual women, and White (OR = 0.23, 95% CI: 0.13-0.43), Black (OR = 0.19, 95% CI: 0.09-0.40), and Latina (OR = 0.08, 95% CI: 0.03-0.22) lesbian women had significantly lower adjusted odds of receiving contraception compared with White heterosexual women. White (OR = 0.36, 95% CI: 0.15-0.85), Black (OR = 0.42, 95% CI: 0.18-0.98), and Latina (OR = 0.22, 95% CI: 0.09-0.53) lesbian women also had significantly lower adjusted odds of obtaining contraceptive counseling relative to White heterosexual women. Conclusions: Policies, programs, and practices that facilitate access to person-centered contraceptive care among marginalized sexual orientation identity and racial/ethnic subgroups of U.S. women are needed to promote reproductive health equity.

Eating Competence and Dietary Intake of Sexual and Gender Minority College Students

Sexual and gender minority college students are underrepresented in nutrition research and may face unique challenges related to eating which impact their overall diet quality. We assessed the differences in eating competence and dietary intake between sexual and gender minority (SGM) and cisgender heterosexual (CH) college students. Participants (n = 2645) reported sexual orientation, gender identity and completed the Eating Competence Satter Inventory (ecSI 2.0™ through an online questionnaire. Three-day food records examined dietary intake. Intake was compared to recommendations for nutrients of public health concern. Chi-square and ANCOVA examined differences between eating competence and dietary intake. There were no differences in total ecSI 2.0™ scores. Subscale scores for Eating Attitudes and Contextual Skills were significantly higher in CH vs. SGM students (13.4 ± 0.1 vs. 12.4 ± 0.4 p = 0.01 and 10.7 ± 0.1 vs. 9.9 ± 0.3, p = 0.01, respectively). Most students (40.8%) met one nutrient recommendation. The proportion of students meeting nutrient recommendations were similar for SGM and CH. SGM populations may struggle with attitudes and eating behaviors. Dietary intake of SGM and CH students were similarly inadequate when compared to recommendations.

Does Sexual Orientation Complicate the Relationship Between Marital Status and Gender With Self-rated Health and Cardiovascular Disease?

A substantial body of work has demonstrated the importance of marital status for health, yet the vast majority of this work has studied heterosexual marriages and relationships. To understand the role of marital status in shaping health among heterosexual, lesbian, gay, and bisexual men and women, we examine data from a probability-based sample of adults living in 40 U.S. states for selected years between 2011-2015. We test two physical health outcomes-poor-to-fair self-rated health and cardiovascular disease-and present predicted probabilities and pairwise comparisons from logistic regression models before and after adjustment for demographic characteristics, socioeconomic status, health behaviors, and depression. Overall, findings reveal some important similarities and differences in the relationships between marital status and health by sexual orientation and gender. First, the health benefits of marriage extend to sexual minority adults, relative to adults who are either formerly or never married. Among heterosexual adults, adjusted models also highlight the healthy status of never-married adults. Second, the health benefits associated with intimate relationships appear less dependent on legal marriage among sexual minorities than among heterosexual adults. Third, we document a persistent health disadvantage for bisexual adults compared with heterosexual adults, particularly among women who are formerly married, indicating some elevated health vulnerability among selected sexual minority women. Fourth, associations between sexual orientation and health are more similar across marital status groups for men than women. Altogether, these findings add much needed nuance to our understanding of the association between marital status and health in an era of increasing diversity in adult relationships.

Sexual Identity Differences in Access to and Satisfaction With Health Care: Findings From Nationally Representative Data

Identification of barriers to adequate health care for sexual minority populations remains elusive given that they are complex and variable across sexual orientation subgroups (e.g., gay, lesbian, bisexual). To address these complexities, we used data from a US nationally representative sample of health-care consumers to assess sexual identity differences in health-care access and satisfaction. We conducted a secondary data analysis of 12 waves (2012-2018) of the biannual Consumer Survey of Health Care Access (n = 30,548) to assess sexual identity differences in 6 health-care access and 3 health-care satisfaction indicators. Despite parity in health insurance coverage, sexual minorities-with some variation across sexual minority subgroups and sex-reported more chronic health conditions alongside restricted health-care access and unmet health-care needs. Gay/lesbian women had the lowest prevalence of health-care utilization and higher prevalence rates of delaying needed health care and medical tests relative to heterosexual women. Gay/lesbian women and bisexual men were less likely than their heterosexual counterparts to be able to pay for needed health-care services. Sexual minorities also reported less satisfactory experiences with medical providers. Examining barriers to health care among sexual minorities is critical to eliminating health disparities that disproportionately burden this population.

Cervical cancer screening among sexual minority women: findings from a national survey

PURPOSE

Sexual minority women (SMW; lesbian, bisexual, and other women who have sex with women) are at risk for cervical cancer but less likely than non-SMW to receive regular cervical cancer screening (Pap- and/or HPV-testing). We examined factors contributing to receipt of guideline-based cervical cancer screening among SMW.

METHODS

During October 2019, we conducted an online survey of self-identified SMW aged 21-45 years living in the United States (n = 435). We estimated risk differences (RD) in women's likelihood of being within current cervical cancer screening guidelines by sociodemographic and health-related characteristics.

RESULTS

Overall, 75% of respondents were within current screening guidelines. Adjusting for other factors, SMW were more likely to be within guidelines if they were insured (aRD 0.26, 95% CI 0.13, 0.39), had a partner (aRD 0.18, 95% CI 0.09, 0.28), and were older (aRD 0.12, 95% CI 0.04, 0.20). Overall, the most common reasons for not being screened recently were lack of insurance/cost (42%) and perceiving it was unnecessary (28%).

CONCLUSION

Many SMW are not being screened for cervical cancer according to guidelines. Findings can inform efforts to improve screening among this population.

The Annual Examination for Lesbian, Gay, and Bisexual Patients

The annual examination is a comprehensive evaluation of patients in which all aspects of health and well-being are considered, including proper screening, appropriate preventive care, and recommendations and resources for healthy living. Clinicians commonly avoid certain topics with lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients because they may be unprepared to address their health needs. Therefore, clinicians should learn how to conduct an LGBTQ-friendly annual examination in order to provide high-quality care. This article focuses on both the general and unique health needs of lesbian, gay, bisexual, and queer patients; care for transgender and gender-diverse patients is considered elsewhere.

Sexual Minority Disparities in Health and Well-Being as a Consequence of the COVID-19 Pandemic Differ by Sexual Identity

Purpose: The coronavirus disease 2019 (COVID-19) pandemic has accentuated long-standing population health disparities in the United States. We examined how the pandemic and its social consequences may differentially impact sexual minority adults, relative to heterosexual adults. Methods: Data are from a U.S. national sample of adults (n = 2996; 18.06%) collected from online panels from April to May 2020. We used eight indicators of well-being-mental health, physical health, quality of life, stress, loneliness, psychological distress, alcohol use, and fatigue-to assess the degree to which sexual identity subgroups (i.e., heterosexual, gay/lesbian, bisexual, and "other" sexual minority) varied in retrospective pre- and postpandemic onset indicators of well-being and whether groups varied in their rate of change from pre- and postpandemic onset. Results: The results showed consistent patterns of decline in well-being across sexual identity subgroups, although changes in mental health, physical health, quality of life, stress, and psychological distress were more robust among sexual minority adults in general, relative to heterosexual adults. Adjusted multivariate models testing differences in change in retrospective pre- and postpandemic onset found that well-being among bisexual men and women was most negatively impacted by the pandemic. Conclusion: The COVID-19 pandemic may have distinct health consequences for sexual minority adults in the United States. Our findings support and further legitimize calls for more comprehensive surveillance and cultural responsiveness in emergency preparedness as it relates to sexual minority people and the COVID-19 pandemic.

Intersections between Young Women's Racial/Ethnic Identities and Sexual Orientation on Rates of Sexual Violence and Substance Use

Background

Little is known about whether there are differences in rates of sexual violence and its association with substance use based on women's identities, specifically the intersection of their race/ethnicity and sexual orientation.

Method

Women (N = 546; 18 to 29 years of age) recruited from a reproductive healthcare clinic reported their race, ethnicity, sexual orientation, sexual violence history and substance use. Five logistic regressions examined (a) rates of sexual violence, and (b) the strength of the associations between sexual violence and four substance use outcomes (heavy alcohol use, marijuana use, cigarette use, number of cigarettes used) based on sexual orientation. Subsequent logistic regressions examined race/ethnicity as a moderator of the associations between sexual orientation and (a) rates of sexual violence and (b) substance use.

Results

Most women surveyed were heterosexual (64%), and 35% of all women reported unwanted sex. Sexual minority women (SMW) reported higher rates of sexual violence and substance use than heterosexual women. Sexual violence was more strongly associated with heavy alcohol use, but not with marijuana or cigarette use, for SMW than heterosexual women. Rates of sexual violence varied based on the intersection of sexual orientation and race/ethnicity. Although SMW were more likely to report sexual violence than heterosexual women, this association was weaker for Black/Latinx women than for non-Hispanic White women (aOR = 0.39, 95%CI [0.18, 0.82]). Race/ethnicity did not moderate the strength of associations between sexual violence and substance use.

Conclusions

SMW exhibit increased risk for sexual violence and substance use, and victimization was associated with heavy alcohol use. Few racial/ethnic differences emerged as a function of sexual orientation, so SMW are a group with unique needs around sexual violence experiences and substance use, regardless of race/ethnicity. Healthcare providers should be aware of the link between substance use and prior victimization when treating SMW.