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Nayak SS, Fraser T, Aldrich DP, Panagopoulos C, Kim D. County-level political group density, partisan polarization, and individual-level mortality among adults in the United States: A lagged multilevel study. SSM Popul Health 2024; 26:101662. [PMID: 38813457 PMCID: PMC11134911 DOI: 10.1016/j.ssmph.2024.101662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/28/2024] [Accepted: 03/18/2024] [Indexed: 05/31/2024] Open
Abstract
Objective To investigate the associations between county-level political group density, partisan polarization, and individual-level mortality from all causes and from coronary heart disease (CHD) in the United States. Methods Using data from five survey waves (1998-2006) of the General Social Survey-National Death Index dataset and the County Presidential Election Return 2000 dataset, we fit weighted Cox proportional hazards models to estimate the associations between (1) political group density and (2) partisan polarization measured at the county level in 2000 (n = 313 counties) categorized into quartiles with individual-level mortality (n = 14,983 participants) from all causes and CHD, controlling for individual- and county-level factors. Maximum follow-up was from one year after the survey up until 2014. We conducted these analyses using two separate measures based on county-level vote share differences and party affiliation ideological extremes. Results In the overall sample, we found no evidence of associations between county-level political group density and individual-level mortality from all causes. There was evidence of a 13% higher risk of dying from heart disease in the highest quartile of county-level polarization (hazards ratio, HR = 1.13; 95% CI = 0.74-1.71). We observed heterogeneity of effects based on individual-level political affiliation. Among those identifying as Democrats, residing in counties with high (vs. low) levels of polarization appeared to be protective against mortality, with an associated 18% lower risk of dying from all causes (HR = 0.82, 95% CI = 0.71-0.94). This association was strongest in areas with the highest concentrations of Democrats. Conclusions Among all study participants, political group density and polarization at the county level in 2000 were not linked to individual-level mortality. At the same time, we found that Democratic party affiliation may be protective against the adverse effects of high polarization, particularly in counties with high concentrations of Democrats. Future research should further explore these associations to potentially identify new structural interventions to address political determinants of population health.
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Affiliation(s)
- Sameera S. Nayak
- Department of Sociology, Anthropology, and Public Health, College of Arts, Humanities, and Social Sciences, University of Maryland, Baltimore County, Baltimore, MD, USA
- Center for Health, Equity, & Aging, University of Maryland, Baltimore County, Baltimore, MD, USA
| | - Timothy Fraser
- Systems Engineering Program, Cornell University, Ithaca, NY, USA
| | - Daniel P. Aldrich
- College of Social Sciences and Humanities, Northeastern University, Boston, MA, USA
- School of Public Policy and Urban Affairs, Northeastern University, Boston, MA, USA
| | - Costas Panagopoulos
- College of Social Sciences and Humanities, Northeastern University, Boston, MA, USA
| | - Daniel Kim
- School of Public Policy and Urban Affairs, Northeastern University, Boston, MA, USA
- School of Community Health & Behavioral Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA
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McKetta S, Hoatson T, Hughes LD, Everett BG, Haneuse S, Austin SB, Hughes TL, Charlton BM. Disparities in Mortality by Sexual Orientation in a Large, Prospective Cohort of Female Nurses. JAMA 2024; 331:1638-1645. [PMID: 38662342 PMCID: PMC11046401 DOI: 10.1001/jama.2024.4459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 03/06/2024] [Indexed: 04/26/2024]
Abstract
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.
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Affiliation(s)
- Sarah McKetta
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard University, Boston, Massachusetts
- Department of Epidemiology, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Tabor Hoatson
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard University, Boston, Massachusetts
| | - Landon D. Hughes
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard University, Boston, Massachusetts
- Department of Epidemiology, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | | | - Sebastien Haneuse
- Department of Biostatistics, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - S. Bryn Austin
- Department of Social and Behavioral Sciences, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
- Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Tonda L. Hughes
- Center for Sexual and Gender Minority Health Research, School of Nursing, Columbia University, New York, New York
| | - Brittany M. Charlton
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard University, Boston, Massachusetts
- Department of Epidemiology, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
- Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Channing Division of Network Medicine, Harvard Medical School and Brigham and Women’s Hospital, Harvard University, Boston, Massachusetts
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Hubbell JT. Elucidating Intimate Partner Violence Rate Disparities Between Same- and Opposite-Sex Couples: A Demographic Approach. JOURNAL OF INTERPERSONAL VIOLENCE 2024; 39:651-675. [PMID: 37705427 DOI: 10.1177/08862605231197781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Studies on intimate partner violence (IPV) rates typically find higher rates for same-sex couples than opposite-sex couples. Regardless of sexual orientation, the risk for IPV perpetration is concentrated among young adults. Given that the HIV/AIDS epidemic significantly lowered the life expectancy of sexual minority men and that recent social movements have encouraged more youths to "come out," population age differences may contribute to the observed differences in IPV rates between same- and opposite-sex couples. The present study applies direct age standardization and decomposition techniques to data from the National Incident-Based Reporting System and the American Community Survey to examine this possibility across 2,584 same-sex male, 4,029 same-sex female, and 284,614 opposite-sex physical IPV incidents. The results of the direct standardization procedures indicate physical IPV rates for same-sex male and same-sex female households would be 11.8% and 27.3% lower, respectively, if they had the same population age structure as opposite-sex households. The results of the decompositions indicate that differences in population age structure contribute 48% and 44% of the elevation in IPV rates in same-sex male and same-sex female households, respectively, compared to opposite-sex households. These findings demonstrate the promise of demographic methods to explain differences in offending rates between groups. These results suggest the need for prevention and intervention strategies aimed at youths. Future studies should be conducted with data on sexual orientation and gender identity to better elucidate the contribution of population age structure among various sexual and gender minority groups. Research comparing trends among sexual minority populations to the heterosexual population in particular should account for age where possible.
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Clark KA, Blosnich JR. Sexual Orientation and Disclosure of Suicidal Thoughts Before Suicide Mortality. Am J Prev Med 2023; 65:953-963. [PMID: 37429387 PMCID: PMC10772205 DOI: 10.1016/j.amepre.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 07/03/2023] [Accepted: 07/03/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Disclosure of suicidal thoughts and behaviors represents an opportunity to intervene before suicide mortality, representing a cornerstone for suicide prevention. Sexual minority (e.g., lesbian/gay, bisexual) people experience sharply elevated suicide risk, yet there is scant research on patterns of disclosure of suicidal thoughts and behaviors before suicide that might uncover missed opportunities for suicide prevention. Thus, authors leveraged postmortem suicide data to evaluate associations among sexual orientation, sex, and disclosure of suicidal thoughts and behaviors in the month preceding death. METHODS Data on suicides from the 2013-2019 National Violent Death Reporting System (N=155,516) were classified for sexual orientation and denoted disclosure of suicidal thoughts and behaviors and to whom suicidal thoughts and behaviors were disclosed in the month preceding death. Logistic regression models stratified by sex and adjusted for sociodemographic covariates assessed the associations between sexual orientation and suicidal thoughts and behaviors disclosure. Analyses were conducted from October 2022 to February 2023. RESULTS Among females, sexual minority decedents were 65% more likely to disclose suicidal thoughts and behaviors than heterosexual decedents (95% CI=37%, 99%, p<0.001). No difference in suicidal thoughts and behaviors disclosure was observed between sexual minority and heterosexual men. Of decedents who disclosed suicidal thoughts and behaviors, one in five sexual minority decedents disclosed to a friend/colleague, whereas fewer than 5% disclosed to a healthcare professional. Among sexual minority females, younger age, intimate partner problems, and physical health problems were positively associated with disclosing suicidal thoughts and behaviors. CONCLUSIONS These findings suggest that reducing suicide mortality in sexual minority populations will require considering contexts beyond the healthcare system, including engaging peer networks. Gatekeeper training for suicide prevention may be an especially promising approach for reducing suicide among sexual minority women.
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Affiliation(s)
- Kirsty A Clark
- Department of Medicine, Health, and Society, Vanderbilt University, Nashville, Tennessee.
| | - John R Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California
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Wong CN, Wilczek MP, Smith LH, Bosse JD, Richard EL, Cavanaugh R, Manjourides J, Orkaby AR, Olivieri-Mui B. Frailty Among Sexual and Gender Minority Older Adults: The All of Us Database. J Gerontol A Biol Sci Med Sci 2023; 78:2111-2118. [PMID: 37485864 PMCID: PMC10613018 DOI: 10.1093/gerona/glad149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Indexed: 07/25/2023] Open
Abstract
BACKGROUND Despite known disparities in health status among older sexual and gender minority adults (OSGM), the prevalence of frailty is unknown. The aim of this study was to develop and validate a deficit-accumulation frailty index (AoU-FI) for the All of Us database to describe and compare frailty between OSGM and non-OSGM participants. METHODS Developed using a standardized approach, the AoU-FI consists of 33 deficits from baseline survey responses of adults aged 50+. OSGM were self-reported as "not straight" or as having discordant gender and sex assigned at birth. Descriptive statistics characterized the AoU-FI. Regression was used to assess the association between frailty, age, and gender. Validation of the AoU-FI used Cox proportional hazard models to test the association between frailty categories (robust <0.15, 0.15 ≤ pre-frail ≤ 0.25, frail >0.25) and mortality. RESULTS There were 9 110 OSGM and 67 420 non-OSGM with sufficient data to calculate AoU-FI; 41% OSGM versus 50% non-OSGM were robust, whereas 34% versus 32% were pre-frail, and 26% versus 19% were frail. Mean AoU-FI was 0.19 (95% confidence interval [CI]: 0.187, 0.191) for OSGM and 0.168 (95% CI: 0.167, 0.169) for non-OSGM. Compared to robust, odds of mortality were higher among frail OSGM (odds ratio [OR] 6.40; 95% CI: 1.84, 22.23) and non-OSGM (OR 3.96; 95% CI: 2.96, 5.29). CONCLUSIONS The AoU-FI identified a higher burden of frailty, increased risk of mortality, and an attenuated impact of age on frailty among OSGM compared to non-OSGM. Future work is needed to understand how frailty affects the OSGM population.
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Affiliation(s)
- Chelsea N Wong
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Louisa H Smith
- Roux Institute, Northeastern University, Portland, Maine, USA
- Department of Health Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts, USA
| | - Jordon D Bosse
- School of Nursing, Northeastern University, Boston, Massachusetts, USA
| | - Erin L Richard
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, San Diego, California, USA
| | | | - Justin Manjourides
- Roux Institute, Northeastern University, Portland, Maine, USA
- Department of Health Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts, USA
| | - Ariela R Orkaby
- New England Geriatric Research, Education, and Clinical Center, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
- Division of Aging, Department of Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brianne Olivieri-Mui
- Roux Institute, Northeastern University, Portland, Maine, USA
- Department of Health Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts, USA
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Chum A, Kim C, Nielsen A, Dusing GJ, O'Campo P, Matheson FI, Barker L, Vigod S, Ling V, Fung K, Kennedy S. Disparities in Suicide-Related Behaviors Across Sexual Orientations by Gender: A Retrospective Cohort Study Using Linked Health Administrative Data. Am J Psychiatry 2023; 180:660-667. [PMID: 37282552 DOI: 10.1176/appi.ajp.20220763] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE The authors used a population-representative sample and health administrative data to quantify suicide-related behavior leading to acute care or deaths across self-identified heterosexual, gay/lesbian, and bisexual individuals. METHODS Data from a population-based survey (N=123,995) were linked to health administrative data (2002-2019), and differences in time to suicide-related behavior events across sexual orientations were examined using Cox proportional hazards regression. RESULTS The crude incidence rates of suicide-related behavior events per 100,000 person-years were 224.7 for heterosexuals, 664.7 for gay/lesbian individuals, and 5,911.9 for bisexual individuals. In fully adjusted (gender-combined) models, bisexual individuals were 2.98 times (95% CI=2.08-4.27) more likely to have an event, and gay men and lesbians 2.10 times (95% CI=1.18-3.71) more likely, compared with heterosexual individuals. CONCLUSIONS In a large population-based sample of Ontario residents, using clinically relevant outcomes, the study found gay/lesbian and bisexual individuals to be at elevated risk of suicide-related behavior events. Increased education among psychiatric professionals is needed to improve awareness of and sensitivity to the elevated risk of suicide-related behavior among sexual minority individuals, and further research on interventions is needed to reduce such behaviors.
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Affiliation(s)
- Antony Chum
- School of Kinesiology and Health Science, York University, Toronto (Chum, Kim, Dusing); Dalla Lana School of Public Health, University of Toronto, Toronto (Chum, Matheson); MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Chum, Nielsen, O'Campo, Matheson); Department of Psychiatry, Women's College Hospital, Toronto (Barker, Vigod); Department of Psychiatry, University of Toronto, Toronto (Vigod); Institute for Clinical Evaluative Sciences, Toronto (Ling, Fung); Centre for Depression and Suicide Studies, St. Michael's Hospital, Toronto (Kennedy)
| | - Chungah Kim
- School of Kinesiology and Health Science, York University, Toronto (Chum, Kim, Dusing); Dalla Lana School of Public Health, University of Toronto, Toronto (Chum, Matheson); MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Chum, Nielsen, O'Campo, Matheson); Department of Psychiatry, Women's College Hospital, Toronto (Barker, Vigod); Department of Psychiatry, University of Toronto, Toronto (Vigod); Institute for Clinical Evaluative Sciences, Toronto (Ling, Fung); Centre for Depression and Suicide Studies, St. Michael's Hospital, Toronto (Kennedy)
| | - Andrew Nielsen
- School of Kinesiology and Health Science, York University, Toronto (Chum, Kim, Dusing); Dalla Lana School of Public Health, University of Toronto, Toronto (Chum, Matheson); MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Chum, Nielsen, O'Campo, Matheson); Department of Psychiatry, Women's College Hospital, Toronto (Barker, Vigod); Department of Psychiatry, University of Toronto, Toronto (Vigod); Institute for Clinical Evaluative Sciences, Toronto (Ling, Fung); Centre for Depression and Suicide Studies, St. Michael's Hospital, Toronto (Kennedy)
| | - Gabriel John Dusing
- School of Kinesiology and Health Science, York University, Toronto (Chum, Kim, Dusing); Dalla Lana School of Public Health, University of Toronto, Toronto (Chum, Matheson); MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Chum, Nielsen, O'Campo, Matheson); Department of Psychiatry, Women's College Hospital, Toronto (Barker, Vigod); Department of Psychiatry, University of Toronto, Toronto (Vigod); Institute for Clinical Evaluative Sciences, Toronto (Ling, Fung); Centre for Depression and Suicide Studies, St. Michael's Hospital, Toronto (Kennedy)
| | - Patricia O'Campo
- School of Kinesiology and Health Science, York University, Toronto (Chum, Kim, Dusing); Dalla Lana School of Public Health, University of Toronto, Toronto (Chum, Matheson); MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Chum, Nielsen, O'Campo, Matheson); Department of Psychiatry, Women's College Hospital, Toronto (Barker, Vigod); Department of Psychiatry, University of Toronto, Toronto (Vigod); Institute for Clinical Evaluative Sciences, Toronto (Ling, Fung); Centre for Depression and Suicide Studies, St. Michael's Hospital, Toronto (Kennedy)
| | - Flora I Matheson
- School of Kinesiology and Health Science, York University, Toronto (Chum, Kim, Dusing); Dalla Lana School of Public Health, University of Toronto, Toronto (Chum, Matheson); MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Chum, Nielsen, O'Campo, Matheson); Department of Psychiatry, Women's College Hospital, Toronto (Barker, Vigod); Department of Psychiatry, University of Toronto, Toronto (Vigod); Institute for Clinical Evaluative Sciences, Toronto (Ling, Fung); Centre for Depression and Suicide Studies, St. Michael's Hospital, Toronto (Kennedy)
| | - Lucy Barker
- School of Kinesiology and Health Science, York University, Toronto (Chum, Kim, Dusing); Dalla Lana School of Public Health, University of Toronto, Toronto (Chum, Matheson); MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Chum, Nielsen, O'Campo, Matheson); Department of Psychiatry, Women's College Hospital, Toronto (Barker, Vigod); Department of Psychiatry, University of Toronto, Toronto (Vigod); Institute for Clinical Evaluative Sciences, Toronto (Ling, Fung); Centre for Depression and Suicide Studies, St. Michael's Hospital, Toronto (Kennedy)
| | - Simone Vigod
- School of Kinesiology and Health Science, York University, Toronto (Chum, Kim, Dusing); Dalla Lana School of Public Health, University of Toronto, Toronto (Chum, Matheson); MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Chum, Nielsen, O'Campo, Matheson); Department of Psychiatry, Women's College Hospital, Toronto (Barker, Vigod); Department of Psychiatry, University of Toronto, Toronto (Vigod); Institute for Clinical Evaluative Sciences, Toronto (Ling, Fung); Centre for Depression and Suicide Studies, St. Michael's Hospital, Toronto (Kennedy)
| | - Vicki Ling
- School of Kinesiology and Health Science, York University, Toronto (Chum, Kim, Dusing); Dalla Lana School of Public Health, University of Toronto, Toronto (Chum, Matheson); MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Chum, Nielsen, O'Campo, Matheson); Department of Psychiatry, Women's College Hospital, Toronto (Barker, Vigod); Department of Psychiatry, University of Toronto, Toronto (Vigod); Institute for Clinical Evaluative Sciences, Toronto (Ling, Fung); Centre for Depression and Suicide Studies, St. Michael's Hospital, Toronto (Kennedy)
| | - Kinwah Fung
- School of Kinesiology and Health Science, York University, Toronto (Chum, Kim, Dusing); Dalla Lana School of Public Health, University of Toronto, Toronto (Chum, Matheson); MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Chum, Nielsen, O'Campo, Matheson); Department of Psychiatry, Women's College Hospital, Toronto (Barker, Vigod); Department of Psychiatry, University of Toronto, Toronto (Vigod); Institute for Clinical Evaluative Sciences, Toronto (Ling, Fung); Centre for Depression and Suicide Studies, St. Michael's Hospital, Toronto (Kennedy)
| | - Sidney Kennedy
- School of Kinesiology and Health Science, York University, Toronto (Chum, Kim, Dusing); Dalla Lana School of Public Health, University of Toronto, Toronto (Chum, Matheson); MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Chum, Nielsen, O'Campo, Matheson); Department of Psychiatry, Women's College Hospital, Toronto (Barker, Vigod); Department of Psychiatry, University of Toronto, Toronto (Vigod); Institute for Clinical Evaluative Sciences, Toronto (Ling, Fung); Centre for Depression and Suicide Studies, St. Michael's Hospital, Toronto (Kennedy)
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Shebl FM, Qian Y, Foote JHA, Wattananimitgul N, Reddy KP, Neilan AM, Ciaranello AL, Losina E, Freedberg KA, Hyle EP. The association between all-cause mortality and HIV acquisition risk groups in the United States, 2001-2014. PLoS One 2023; 18:e0290113. [PMID: 37590260 PMCID: PMC10434931 DOI: 10.1371/journal.pone.0290113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 08/01/2023] [Indexed: 08/19/2023] Open
Abstract
OBJECTIVE To investigate associations between all-cause mortality and human immunodeficiency virus (HIV) acquisition risk groups among people without HIV in the United States. METHODS We used data from 23,657 (NHANES) participants (2001-2014) and the Linked Mortality File to classify individuals without known HIV into HIV acquisition risk groups: people who ever injected drugs (ever-PWID); men who have sex with men (MSM); heterosexually active people at increased risk for HIV (HIH), using low income as a proxy for increased risk. We used Cox proportional hazards models to estimate adjusted and unadjusted all-cause mortality hazard ratios (HR) with 95% confidence intervals (CI). RESULTS Compared with sex-specific heterosexually active people at average risk for HIV (HAH), the adjusted HR (95% CI) were: male ever-PWID 1.67 (1.14, 2.46), female ever-PWID 3.50 (2.04, 6.01), MSM 1.51 (1.00, 2.27), male HIH 1.68 (1.04, 2.06), female HIH 2.35 (1.87, 2.95), and male ever-PWID 1.67 (1.14, 2.46). CONCLUSIONS Most people at increased risk for HIV in the US experience higher all-cause mortality than people at average risk. Strategies addressing social determinants that increase HIV risk should be incorporated into HIV prevention and other health promotion programs.
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Affiliation(s)
- Fatma M. Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, Unite States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Yiqi Qian
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, Unite States of America
| | - Julia H. A. Foote
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, Unite States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Nattanicha Wattananimitgul
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, Unite States of America
| | - Krishna P. Reddy
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, Unite States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Anne M. Neilan
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, Unite States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of General Academic Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Andrea L. Ciaranello
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, Unite States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research (CFAR), Cambridge, Massachusetts, United States of America
| | - Elena Losina
- Harvard University Center for AIDS Research (CFAR), Cambridge, Massachusetts, United States of America
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Kenneth A. Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, Unite States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research (CFAR), Cambridge, Massachusetts, United States of America
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Emily P. Hyle
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, Unite States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research (CFAR), Cambridge, Massachusetts, United States of America
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8
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Kelly LM, Shepherd BF, Brochu PM, Zajac K. Co-occurring suicidal ideation and alcohol-related problems: An intersectional analysis of Native American and White adults with minoritized sexual identities. Addict Behav 2023; 142:107674. [PMID: 36905898 PMCID: PMC10262151 DOI: 10.1016/j.addbeh.2023.107674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 02/11/2023] [Accepted: 02/23/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND Disparities in suicidal ideation (SI) and alcohol use disorder (AUD) are evident in both Native American and minoritized sexual identity groups, relative to non-Hispanic White and heterosexual groups. However, Native Americans report lower drinking and binge drinking rates than White adults. Persons with intersecting identities, specifically Native Americans with minoritized sexual identities, may be at greater risk for SI and drinking, binge drinking, and AUD than White and Native American heterosexual adults. METHODS Five years (2015-2019) of National Survey of Drug Use and Health data were combined (N = 130,157). Multinomial logistic regressions tested racial (Native American vs White) and sexual identity (lesbian/gay/bisexual vs heterosexual) differences in odds of SI, drinking, and co-occurring SI + drinking, versus neither SI/drinking. Subsequent analyses examined SI + binge drinking, and SI + AUD. RESULTS Compared to White heterosexual adults, Native American heterosexual adults reported lower co-occurring SI + drinking odds, whereas Native American sexual minoritized adults reported higher odds. Native American sexual minoritized groups showed greater co-occurring SI + binge drinking odds and greater co-occurring SI + AUD odds compared to White heterosexual adults. Native American sexual minoritized adults showed greater SI only compared to White sexual minoritized adults. Sexual minoritized Native Americans showed higher odds of co-occurring SI + drinking, binge drinking, and AUD than White heterosexual adults. CONCLUSIONS Native American sexual minoritized groups showed higher likelihood of co-occurring SI + drinking, binge drinking, and AUD relative to both White and Native American heterosexual adults. Disparities warrant outreach for suicide and AUD prevention for Native American sexual minoritized adults.
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Affiliation(s)
- Lourah M Kelly
- University of Connecticut, School of Medicine, United States
| | - Benjamin F Shepherd
- Nova Southeastern University, Department of Clinical and School Psychology, United States
| | - Paula M Brochu
- Nova Southeastern University, Department of Clinical and School Psychology, United States
| | - Kristyn Zajac
- University of Connecticut, School of Medicine, United States.
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9
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Nielsen A, Azra KK, Kim C, Dusing GJ, Chum A. Is the association between sexual minority status and suicide-related behaviours modified by rurality? A discrete-time survival analysis using longitudinal health administrative data. Soc Sci Med 2023; 325:115896. [PMID: 37084702 DOI: 10.1016/j.socscimed.2023.115896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 03/08/2023] [Accepted: 04/06/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND While self-reported data shows that lesbian, gay, and bisexual (LBG) individuals have a greater suicide-related behaviours (SRB) risk, little is known about how rurality may amplify SRB risk associated with sexual minority status. Sexual minority individuals in rural areas may experience unique stressors due to stigma and a lack of LGB-specific social and mental health services. Using a population-representative sample linked to clinical SRB outcomes, we examined whether rurality modifies the association between sexual minority status and SRB risk. METHODS A nationally representative survey linked to administrative health data was used to construct a cohort of individuals (unweighted n = 169,091; weighted n = 8,778,115) in Ontario, Canada, and captured all SRB-related emergency department visits, hospitalizations, and deaths between 2007 and 2017. Sex-stratified discrete-time survival analyses were used to examine interactions between rurality and sexual minority status on SRB risk while controlling for potential confounders. RESULTS Sexual minority men had 2.18 times higher SRB odds compared to their heterosexual counterparts (95%CI 1.21-3.91), while sexual minority women had 2.07 times higher odds (95%CI 1.48-2.89) after adjusting for the confounders. The Rurality Index of Ontario and the Index of Remoteness were associated with the odds of SRB in a dose-response manner. No significant interactions were observed between rural and sexual minority status. CONCLUSIONS Our study provides evidence that rural and sexual minority status both independently contribute to an elevated likelihood of SRB; however, rurality did not appear to modify SRB risk by sexual orientation. Implementation and evaluation of interventions to reduce SRB in both rural and sexual minority populations are required.
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Affiliation(s)
- Andrew Nielsen
- Canadian Institute for Health Information, 4110 Yonge St Suite 300, North York, ON M2P 2B7, Canada
| | - Karanpreet Kaur Azra
- Ontario Shores Centre for Mental Health Sciences, 700 Gordon St, Whitby, Ontario, L1N 5S9, Canada
| | - Chungah Kim
- School of Kinesiology and Health Science, York University, 4700 Keele St, Toronto, Ontario, M3J 1P3, Canada
| | - Gabriel John Dusing
- School of Kinesiology and Health Science, York University, 4700 Keele St, Toronto, Ontario, M3J 1P3, Canada
| | - Antony Chum
- School of Kinesiology and Health Science, York University, 4700 Keele St, Toronto, Ontario, M3J 1P3, Canada; Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, Ontario, M5T 3M7, Canada; Unity Health Toronto, MAP Centre for Urban Health Solutions, 209 Victoria Street, 3rd floor, Toronto, Ontario, M5B 1T8, Canada.
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10
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Azra KK, Nielsen A, Kim C, Dusing GJ, Chum A. Investigating suicide related behaviours across sexual orientation and neighbourhood deprivation levels: A cohort study using linked health administrative data. PLoS One 2023; 18:e0282910. [PMID: 36989270 PMCID: PMC10058080 DOI: 10.1371/journal.pone.0282910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 02/24/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND There have been no studies examining how neighbourhood deprivation modifies the effects of sexual minority status on suicide-related behaviours (SRB). Sexual minority individuals in deprived areas may face unique challenges and stressors that exacerbate their risk of SRB. This study aims to investigate the association between sexual minority status and clinical SRB, and examine whether the effect of neighbourhood deprivation differs across sexual orientation. METHODS A population-representative survey sample (169,090 respondents weighted to represent 8,778,120 individuals; overall participation rate 75%) was linked to administrative health data in Ontario, Canada to measure SRB-related events (emergency department visits, hospitalizations, and deaths) from 2007 to 2017. Neighbourhood-level deprivation was measured using the Ontario Marginalisation index measure of material deprivation at the dissemination area level. Discrete-time survival analysis models, stratified by sex, tested the effects of neighbourhood deprivation and sexual minority status, while controlling for individual-level covariates. RESULTS Sexual minority men had 2.79 times higher odds of SRB compared to their heterosexual counterparts (95% CI 1.66 to 4.71), while sexual minority women had 2.14 times higher odds (95% CI 1.54 to 2.98). Additionally, neighbourhood deprivation was associated with higher odds of SRB: men in the most deprived neighbourhoods (Q5) had 2.01 times higher odds (95% CI 1.38 to 2.92) of SRB compared to those in the least deprived (Q1), while women had 1.75 times higher odds (95% CI 1.28 to 2.40). No significant interactions were observed between sexual minority status and neighbourhood deprivation levels. CONCLUSION In both men and women, sexual minority status and neighbourhood deprivation are independent risk factors for SRB. Despite the lack of effect modification, sexual minorities living in the most deprived neighbourhoods have the highest chances of SRB. Future investigations should evaluate interventions and policies to improve sexual minority mental health and address neighbourhood deprivation.
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Affiliation(s)
- Karanpreet Kaur Azra
- Department of Applied Health Sciences, Brock University, St. Catharines, Ontario, Canada
| | - Andrew Nielsen
- Department of Applied Health Sciences, Brock University, St. Catharines, Ontario, Canada
- Canadian Institute for Health Information, Toronto, Ontario, Canada
| | - Chungah Kim
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
| | - Gabriel John Dusing
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
| | - Antony Chum
- Department of Applied Health Sciences, Brock University, St. Catharines, Ontario, Canada
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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11
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Clark KA, Salway T, McConocha EM, Pachankis JE. How do sexual and gender minority people acquire the capability for suicide? Voices from survivors of near-fatal suicide attempts. SSM. QUALITATIVE RESEARCH IN HEALTH 2022; 2:100044. [PMID: 35845718 PMCID: PMC9282160 DOI: 10.1016/j.ssmqr.2022.100044] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Despite well-documented disparities by sexual and gender minority (SGM) status in suicide attempt and mortality rates, few studies have investigated the lived experiences that contribute to SGM people's disproportionate risk of suicide. Having a history of at least one near-fatal (or medically serious) suicide attempt serves as a proxy for suicide mortality, but no known study has involved SGM people who have made such an attempt. Ideation-to-action theories of suicide posit that individuals acquire the capability for suicide through repeated exposure to painful and provocative events - namely, traumatic, threatening, and risky experiences - that can diminish the pain and fear of death. Yet whether identity-specific features of acquired capability for suicide contribute to SGM people's disproportionate risk of suicide remains unknown. Drawing upon interviews with 22 SGM people who experienced a recent near-fatal suicide attempt, the current study sought to identify specific determinants of how SGM individuals acquire the capability to kill themselves, a potentially powerful, and modifiable, pathway to suicide. Results identified three SGM-specific contributors to the acquired capability for suicide: (1) identity invalidation during developmentally sensitive periods of childhood and adolescence that left participants feeling erased, invisible, and, in some cases, non-existent; (2) normalization of suicide within SGM social networks that increased acceptability and reduced the fear of suicide; and (3) structural stigma and SGM community trauma as habituating sources of pain that engendered feelings of exhaustion and positioned suicide as a reprieve from pervasive anti-SGM norms. This study demonstrates that dominant suicidology theories might need to be refined to account for the stigma-related determinants of SGM suicide. Further, this study reinforces the importance of qualitative methods for understanding the lived experience of suicide and calls for SGM-specific suicide prevention efforts to respond to stigma to support those SGM people who contemplate suicide.
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Affiliation(s)
- Kirsty A. Clark
- Department of Medicine, Health, and Society, Vanderbilt University, United States
- Corresponding. Department of Medicine, Health, and Society, Vanderbilt University, Nashville, TN, 37235, United States. (K.A. Clark)
| | - Travis Salway
- Faculty of Health Sciences, Simon Fraser University, Canada
| | | | - John E. Pachankis
- Department of Social and Behavioral Sciences, Yale School of Public Health, United States
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12
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Salway T, Rich AJ, Ferlatte O, Gesink D, Ross LE, Bränström R, Sadr A, Khan S, Grennan T, Shokoohi M, Brennan DJ, Gilbert M. Preventable mortality among sexual minority Canadians. SSM Popul Health 2022; 20:101276. [PMID: 36337988 PMCID: PMC9634359 DOI: 10.1016/j.ssmph.2022.101276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/02/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022] Open
Abstract
Background Epidemiologic studies point to multiple health inequities among sexual minority people, but few studies have examined mortality. Some causes of death are more preventable than others, and access to prevention is theorized to follow patterns of access to social and material resources. The objective of this study is to compare estimates of preventable mortality between sexual minority (SM)-i.e., bisexual, lesbian, gay-and heterosexual adults in Canada. Methods A population-based retrospective cohort with 442,260 (unweighted N) Canadian adults, ages 18-59 years, was drawn from the Canadian Community Health Survey/Canadian Mortality Database linked database (2003-2017). The Rutstein preventability rating index was used to classify cause-specific mortality (low/high). Longitudinal analyses were conducted using Cox proportional hazards models. Results SM respondents had higher hazard of all-cause mortality (unadjusted hazard ratio [uHR] 1.28, 95% CI 1.06, 1.55). The uHR increased when the outcome was limited to highly-preventable causes of mortality (uHR 1.43, 95% CI 1.14, 1.80). The uHR further increased in sensitivity analyses using higher thresholds of the Rutstein index. SM respondents had higher hazard of cause-specific mortality for heart disease (uHR 1.53, 95% CI 1.03, 2.29), accidents (uHR 1.97, 95% CI 1.01, 3.86), HIV (uHR 75.69, 95% CI 18.77, 305.20), and suicide (uHR 2.22, 95% CI 0.93, 5.30) but not for cancer (uHR 0.86, 95% CI 0.60, 1.25). The adjusted HR (aHR) for highly-preventable mortality was not attenuated by adjustment for confounders (aHR 1.57, 95% CI 1.20, 2.05) but was reduced by adjustment for hypothesized mediators relating to access to social and material resources (marital status, children, income, education; aHR 1.11, 95% CI 0.78, 1.58). Conclusions Preventable mortality was elevated for SM Canadians compared to heterosexuals. Early and broad access to sexual minority-affirming primary and preventive healthcare should be expanded.
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Affiliation(s)
- Travis Salway
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
- British Columbia Centre for Disease Control, Vancouver, Canada
- Centre for Gender and Sexual Health Equity, Vancouver, Canada
- Corresponding author. Blusson Room 11300, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada.
| | - Ashleigh J. Rich
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Olivier Ferlatte
- École de santé publique, Université de Montréal, Montréal, Canada
- Centre de Recherche en Santé Publique, Université de Montréal et CIUSSS du Centre-Sud-de-l’Île-de-Montréal, Montreal, Canada
| | - Dionne Gesink
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Lori E. Ross
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Richard Bränström
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Aida Sadr
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Syma Khan
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Troy Grennan
- British Columbia Centre for Disease Control, Vancouver, Canada
- Division of Infectious Diseases, University of British Columbia, Vancouver, Canada
| | - Mostafa Shokoohi
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - David J. Brennan
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada
| | - Mark Gilbert
- British Columbia Centre for Disease Control, Vancouver, Canada
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada
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13
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Clark KA, Mays VM, Arah OA, Kheifets LI, Cochran SD. Sexual Orientation Differences in Lethal Methods Used in Suicide: Findings From the National Violent Death Reporting System. Arch Suicide Res 2022; 26:548-564. [PMID: 32897837 PMCID: PMC7937759 DOI: 10.1080/13811118.2020.1811181] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We examined sexual orientation and sex differences in seven methods of suicide among adult suicides reported in the United States National Violent Death Reporting System (2012-2015; N = 59,075). Overall, most sexual minorities (i.e., lesbians, gay men, bisexuals) identified in the dataset used hanging (38%) followed by firearm (30%) and drug or poison ingestion (20%). Sexual minorities were more likely than heterosexuals to be younger, female, and Black/African American. Multivariate sex-stratified analyses in the overall sample showed that strong sexual orientation differences in lethal methods existed among men but not among women. However, when we compared sex differences in lethal methods among sexual minorities only, we found that lesbian/bisexual women, as compared to gay/bisexual men, were more likely to use a firearm or drug or poison ingestion than hanging. Findings suggest that the higher rate of suicide mortality among sexual minorities is likely driven by hanging, a method of suicide that is not particularly amenable to lethal method restricted-access prevention approaches. Future research directions, clinical training recommendations, and intervention opportunities are discussed.
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14
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Blosnich JR, Butcher BA, Mortali MG, Lane AD, Haas AP. Training Death Investigators to Identify Decedents' Sexual Orientation and Gender Identity: A Feasibility Study. Am J Forensic Med Pathol 2022; 43:40-45. [PMID: 34475319 PMCID: PMC8813878 DOI: 10.1097/paf.0000000000000705] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT There is growing impetus within mortality surveillance to identify decedents' sexual orientation and gender identity (SOGI), but key personnel to this effort (eg, death investigators) are not currently trained to collect SOGI information. To address this gap, we developed a training for death investigators on this topic and tested its feasibility with 114 investigators in 3 states. Participants completed pretraining and posttraining questionnaires that measured 4 perceived outcomes: training relevance, success of delivery, adequacy for future use, and likelihood of future use. Overall, strongly positive responses affirmed the training's relevance, success of delivery, and adequacy for future use. Responses about attempting to identify the decedent's SOGI in future cases were not quite as positive, with close to 80% of the participants saying that they were at least "somewhat likely" to collect this information. Despite design limitations, the study results support the feasibility of training death investigators to gather SOGI information. Although not systematically assessed in the study, investigators' positive endorsement of training outcomes seemed higher in training sites where leadership strongly supported SOGI identification, suggesting that the role of leadership may be key to encouraging SOGI identification among death investigators.
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Affiliation(s)
- John R. Blosnich
- University of Southern California, Suzanne Dworak-Peck School of Social Work, Los Angeles, CA
| | | | | | | | - Ann P. Haas
- Department of Health Sciences, City University of New York, Lehman College, New York, NY
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15
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Ramchand R, Schuler MS, Schoenbaum M, Colpe L, Ayer L. Suicidality Among Sexual Minority Adults: Gender, Age, and Race/Ethnicity Differences. Am J Prev Med 2022; 62:193-202. [PMID: 35000689 DOI: 10.1016/j.amepre.2021.07.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 07/14/2021] [Accepted: 07/20/2021] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Lesbian, gay, and bisexual individuals have elevated suicide risk, but there is little information available about how this risk may vary by gender, age, and race/ethnicity. METHODS This study examined past-year suicide thoughts, plans, and attempts among adult respondents to the 2015-2019 National Surveys on Drug Use and Health (pooled N=191,954). Logistic regression was used to examine the differences between lesbian, gay, and bisexual and heterosexual adults for each outcome, once by gender and age category and once by gender and race/ethnicity category, while controlling for core sociodemographic characteristics. Race/ethnicity and age differences were also estimated within sexual identity groups. RESULTS Suicide thoughts, plans, and attempts were more common among lesbian, gay, and bisexual adults in almost every age and race/ethnicity category relative to that among corresponding heterosexual adults. In some age and race/ethnicity categories, bisexual women were more likely to report suicidal thoughts than lesbian/gay women. Each outcome decreased significantly across age groups among women of all sexual identity groups and heterosexual men; yet, this age effect was less pronounced among gay and bisexual men. Black women had significantly lower rates of suicidal thoughts and plans than White women in all sexual identity groups. CONCLUSIONS In light of consistently elevated rates of suicide thoughts and behaviors, lesbian, gay, and bisexual adults may expressly benefit from enhanced prevention, identification, and treatment of suicide risk. Additional research is needed to assess the associations between sexual identity and suicide mortality as well as to understand the heterogeneity in suicide risk among lesbian, gay, and bisexual youth, particularly by race/ethnicity.
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Affiliation(s)
- Rajeev Ramchand
- National Institute of Mental Health, Bethesda, Maryland; RAND Corporation, Arlington, Virginia.
| | | | | | - Lisa Colpe
- National Institute of Mental Health, Bethesda, Maryland
| | - Lynsay Ayer
- National Institute of Mental Health, Bethesda, Maryland; RAND Corporation, Arlington, Virginia
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16
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Laughney CI, Eliason EL. Mortality Disparities Among Sexual Minority Adults in the United States. LGBT Health 2021; 9:27-33. [PMID: 34698549 DOI: 10.1089/lgbt.2020.0482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: This study aimed to investigate mortality disparities for sexual minority adults in the United States. Methods: We used data from 26,384 adult respondents using the 1999-2014 National Health and Nutrition Examination Survey, linked with National Death Index mortality files. Respondents reporting one or more same-sex sexual partners in their lifetime or who identified as gay, lesbian, or bisexual were considered sexual minority adults (617 sexual minority males and 963 sexual minority females). We examined gender-stratified mortality frequencies by sexual minority status and used gender-stratified Cox proportional hazard models to investigate mortality risk for sexual minority adults compared with non-sexual-minority adults. Results: We observed significantly elevated mortality risk among sexual minority females compared with non-sexual-minority females, robust across model specifications. Estimates ranged from an adjusted hazard ratio of 2.0 (95% confidence interval [CI]: 1.3-3.2) to 2.1 (95% CI: 1.4-3.3) among sexual minority females compared with non-sexual-minority females, with estimates at approximately double the risk of mortality. We found no evidence of differential mortality risk for sexual minority males compared with non-sexual-minority males. Conclusion: These results suggest mortality disparities for sexual minority females compared with non-sexual-minority females. Future research should consider mortality disparities among subgroups of sexual minority adults and include targeted data collection to increase understanding of the mechanisms behind mortality disparities.
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Affiliation(s)
| | - Erica L Eliason
- Columbia School of Social Work, Columbia University, New York, New York, USA
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17
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Lynch KE, Gatsby E, Viernes B, Schliep KC, Whitcomb BW, Alba PR, DuVall SL, Blosnich JR. Evaluation of Suicide Mortality Among Sexual Minority US Veterans From 2000 to 2017. JAMA Netw Open 2020; 3:e2031357. [PMID: 33369662 PMCID: PMC7770555 DOI: 10.1001/jamanetworkopen.2020.31357] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
IMPORTANCE Identification of subgroups at greatest risk for suicide mortality is essential for prevention efforts and targeting interventions. Sexual minority individuals may have an increased risk for suicide compared with heterosexual individuals, but a lack of sufficiently powered studies with rigorous methods for determining sexual orientation has limited the knowledge on this potential health disparity. OBJECTIVE To investigate suicide mortality among sexual minority veterans using Veterans Health Administration (VHA) electronic health record data. DESIGN, SETTING, AND PARTICIPANTS This retrospective population-based cohort study used data on 8.1 million US veterans enrolled in the VHA after fiscal year 1999 that were obtained from VHA electronic health records from October 1, 1999 to September 30, 2017. Data analysis was carried out from March 1, 2020 to October 31, 2020. EXPOSURE Veterans with documentation of a minority sexual orientation. Documentation of sexual minority status was obtained through natural language processing of clinical notes and extraction of structured administrative data for sexual orientation in VHA electronic health records. MAIN OUTCOMES AND MEASURES Suicide mortality rate using data on the underlying cause of death obtained from the National Death Index. Crude and age-adjusted mortality rates were calculated for all-cause death and death from suicide among sexual minority veterans compared with the general US population and the general population of veterans. RESULTS Among the 96 893 veterans with at least 1 sexual minority documentation in the electronic health record, the mean (SD) age was 46 (16) years, 68% were male, and 70% were White. Of the 12 591 total deaths, 3.5% were from suicide. Veterans had a significantly higher rate of mortality from suicide (standardized mortality ratio, 4.50; 95% CI, 4.13-4.99) compared with the general US population. Suicide was the fifth leading cause of death in 2017 among sexual minority veterans (3.8% of deaths) and the tenth leading cause of death in the general US population (1.7% of deaths). The crude suicide rate among sexual minority veterans (82.5 per 100 000 person-years) was higher than the rate in the general veteran population (37.7 per 100 000 person-years). CONCLUSIONS AND RELEVANCE The results of this population-based cohort study suggest that sexual minority veterans have a greater risk for suicide than the general US population and the general veteran population. Further research is needed to determine whether and how suicide prevention efforts reach sexual minority veterans.
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Affiliation(s)
- Kristine E. Lynch
- Veterans Affairs (VA) Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, The University of Utah, Salt Lake City
| | - Elise Gatsby
- Veterans Affairs (VA) Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah
| | - Benjamin Viernes
- Veterans Affairs (VA) Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, The University of Utah, Salt Lake City
| | - Karen C. Schliep
- Veterans Affairs (VA) Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Family and Preventive Medicine, The University of Utah, Salt Lake City
| | - Brian W. Whitcomb
- Department of Public Health and Health Sciences, University of Massachusetts, Amherst
| | - Patrick R. Alba
- Veterans Affairs (VA) Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, The University of Utah, Salt Lake City
| | - Scott L. DuVall
- Veterans Affairs (VA) Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Department of Internal Medicine, The University of Utah, Salt Lake City
| | - John R. Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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18
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Lindström M, Rosvall M. Sexual orientation and all-cause mortality: A population-based prospective cohort study in southern Sweden. PUBLIC HEALTH IN PRACTICE 2020; 1:100032. [PMID: 36101682 PMCID: PMC9461313 DOI: 10.1016/j.puhip.2020.100032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/05/2020] [Accepted: 07/07/2020] [Indexed: 11/26/2022] Open
Abstract
Objectives To investigate associations between sexual orientation and all-cause mortality. Study design Prospective cohort study. Methods The 2008 public health survey in Scania was conducted with a postal questionnaire later linked to 9.3-year prospective death register data, including 25,071 respondents, aged 18–80. Analyses were conducted with sex-stratified survival analyses. Results In the models including age, birth country and socioeconomic status, bisexual men had a hazard rate ratio (HRR) 1.91 (1.10–3.30) compared to heterosexual men, and bisexual women had a HRR 3.18 (1.64–6.18). No significant differences were observed for homosexuals. Other women had a HRR 2.32 (1.47–3.67). Conclusions Bisexuals men and women had higher mortality than heterosexuals. Studies on sexual identity and mortality are scarce and mostly from the USA. Most US studies concern homosexual men, far fewer minority women and bisexuals. Bisexual men and women had higher prospective mortality than heterosexuals. Mortality among homosexual men and women did not significantly differ from heterosexuals. Other women had significantly higher mortality than heterosexual women.
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19
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Blosnich JR, Clark KA, Mays VM, Cochran SD. Sexual and Gender Minority Status and Firearms in the Household: Findings From the 2017 Behavioral Risk Factor Surveillance System Surveys, California and Texas. Public Health Rep 2020; 135:778-784. [PMID: 33026962 DOI: 10.1177/0033354920954789] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Although lesbian, gay, bisexual, and transgender (LGBT) people have a higher prevalence of reporting a lifetime suicide attempt than non-LGBT people, suicide prevention research on access to lethal means (eg, firearms) among LGBT people is limited. Our study examined (1) the presence of firearms in the home and (2) among respondents with firearms in the home, the storage of firearms as stored unloaded, stored as loaded and locked, or stored as loaded and unlocked. METHODS We used data from the 2017 Behavioral Risk Factor Surveillance System surveys from California and Texas (N = 11 694), which were the only states to include items about both sexual orientation and gender identity and the status of firearms in the home. We used logistic regression analysis to assess the association of sexual orientation and gender identity with having firearms in the home while accounting for sociodemographic characteristics and survey state. All analyses were weighted to account for the complex sampling design. RESULTS Approximately 4.2% of the sample identified as lesbian, gay, and bisexual (LGB). About 18.2% of LGB people reported firearms in the home compared with 29.9% of their heterosexual peers. After adjusting for sex, age, race/ethnicity, educational attainment, and military veteran status, LGB respondents had significantly lower odds of reporting firearms in the home than their heterosexual peers (adjusted odds ratio = 0.47; 95% CI, 0.27-0.84). Among respondents with firearms in the home, firearm storage did not differ by sexual orientation. CONCLUSIONS Further research is needed to examine whether lower odds of firearms in the home are protective against suicide deaths among LGB populations.
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Affiliation(s)
- John R Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, USA.,98139 Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Kirsty A Clark
- 8783 Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Vickie M Mays
- Department of Psychology, University of California, Los Angeles, CA, USA.,Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, CA, USA.,Center for Bridging Research Innovation, Training and Education for Minority Health Disparities Solutions, University of California, Los Angeles, CA, USA
| | - Susan D Cochran
- 8783 Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA.,Center for Bridging Research Innovation, Training and Education for Minority Health Disparities Solutions, University of California, Los Angeles, CA, USA.,Department of Statistics, University of California, Los Angeles, CA, USA
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20
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Wells TT, Tucker RP, Kraines MA. Extending a Rejection Sensitivity Model to Suicidal Thoughts and Behaviors in Sexual Minority Groups and to Transgender Mental Health. ARCHIVES OF SEXUAL BEHAVIOR 2020; 49:2291-2294. [PMID: 31797224 DOI: 10.1007/s10508-019-01596-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/19/2019] [Accepted: 11/25/2019] [Indexed: 05/08/2023]
Affiliation(s)
- Tony T Wells
- Department of Psychology, Oklahoma State University, 116 North Murray, Stillwater, OK, 74078, USA.
| | - Raymond P Tucker
- Department of Psychology, Louisiana State University, Baton Rouge, LA, USA
| | - Morganne A Kraines
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Psychosocial Research Group, Butler Hospital, Providence, RI, USA
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21
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Feigelman W, Plöderl M, Rosen Z, Cerel J. Research Note on Whether Sexual Minority Individuals Are Over-Represented Among Suicide's Casualties. CRISIS 2019; 41:229-232. [PMID: 31657644 DOI: 10.1027/0227-5910/a000626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background: Past studies have repeatedly shown higher suicidal thoughts and attempts among sexual minority members, yet have remained opaque on whether these groups are more prone to taking their own lives. Aims: This short report focuses on suicide deaths among sexual minority members. Method: We utilized two large-scale surveys: one, among adults, the updated Cumulative General Social Surveys, and the other, among adolescents, The National Longitudinal Study of Adolescent Health (Add Health), where respondents' data were cross-linked to National Death Index death records. Results: Results confirmed pre-existent findings showing elevated suicide rates among sexual minority females but not among sexual minority males. Limitations: The shortfall of female adolescent suicides in the Add Health sample prevented us from examining the question of female sexual minority suicides within this population. Conclusion: Although ample evidence demonstrates higher suicidal thoughts and attempts among sexual minority males, three studies presently do not confirm their greater propensity to die by suicide, compared with heterosexual males; yet, for sexual minority females the evidence is steadily mounting showing their greater suicide risks.
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Affiliation(s)
- William Feigelman
- Sociology Department, Nassau Community College, Garden City, New York, NY, USA
| | - Martin Plöderl
- Department of Crisis Intervention and Suicide Prevention, Paracelsus Medical University, Salzburg, Austria
| | - Zohn Rosen
- School of Public Health, Columbia University, New York, NY, USA
| | - Julie Cerel
- College of Social Work, University of Kentucky, Lexington, KY, USA
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22
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Abstract
Although sexual minority women (SMW) and transgender women have become increasingly visible in recent years and have made progress in achieving civil rights, they continue to face significant levels of discrimination, stigma, and physical violence. As a result, each group faces a wide variety of health disparities, including mental illness and substance use disorders. Overall, both SMW and transgender women experience higher rates of mood and anxiety disorders, suicidality, and substance use disorders than their heterosexual and cisgender counterparts. This article is a general introduction to these issues and concludes with recommendations for working with sexual minority and transgender women.
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Affiliation(s)
- Julie K Schulman
- Department of Psychiatry, Allen Hospital, 5141 Broadway, 3 River East, New York, NY 10034, USA.
| | - Laura Erickson-Schroth
- Department of Psychiatry, Mount Sinai Beth Israel, 10 Nathan D. Perlman Place, New York, NY 10003, USA
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23
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Abstract
Many nurses practicing today lack basic education about LGBTQ (lesbian, gay, bisexual, transgender, queer) patient care. How can they better prepare to care for this population? This article provides insight on LGBTQ people, their health risks and disparities, and how nurses can work with LGBTQ patients to improve outcomes.
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Affiliation(s)
- Liz Margolies
- Liz Margolies is the founder and executive director of the National LGBT Cancer Network in New York City. Carlton G. Brown is a nurse consultant at Zenith Healthcare Solutions, LLC, in Portland, Ore., and a member of the Nursing2019 editorial board
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24
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Nystedt T, Rosvall M, Lindström M. Sexual orientation, suicide ideation and suicide attempt: A population-based study. Psychiatry Res 2019; 275:359-365. [PMID: 30959384 DOI: 10.1016/j.psychres.2019.04.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/03/2019] [Accepted: 04/03/2019] [Indexed: 01/12/2023]
Abstract
The aim is to investigate associations between sexual orientation and experience of suicide thoughts and suicide attempts. The 2012 public health survey in Scania, southern Sweden, is a cross-sectional population-based study including 28,029 participants aged 18-80 with 51.7% participation. The associations between sexual orientation and experience of suicide thoughts and attempts were investigated in multiple logistic regressions. A 8.2% proportion of men and 11.3% of women reported suicide thoughts more than a year ago, and 4.0% of men 4.1% of women had experienced such thoughts during the past year. A 2.6% proportion of men and 4.6% of women reported suicide attempt more than a year ago, and 0.6% of men and 0.7% of women during the past year. In the age- and multiple adjusted models, bisexual and homosexual men and bisexual women had significantly higher odds ratios of suicide thoughts than heterosexual men and women. Bisexual and homosexual men and bisexual women had significantly higher odds ratios of suicide attempt than heterosexual men and women. After multiple adjustments these patterns largely remained. The results indicate that bisexual men and women and homosexual men have an increased risk of experience of suicide thoughts and suicide attempt.
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Affiliation(s)
- Tanya Nystedt
- Social Medicine and Health Policy, Department of Clinical Sciences in Malmö, Lund University, S-205 02 Malmö, Sweden
| | - Maria Rosvall
- Social Medicine and Health Policy, Department of Clinical Sciences in Malmö, Lund University, S-205 02 Malmö, Sweden; Department of Community Medicine and Public Health, Institute of Medicine, University of Gothenburg, Sweden; Primary Health Care, Västra Götaland, Sweden
| | - Martin Lindström
- Social Medicine and Health Policy, Department of Clinical Sciences in Malmö, Lund University, S-205 02 Malmö, Sweden; Center for Primary Health Care Research, Skåne, Malmö, Sweden.
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25
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Men Who Have Sex With Men-Identification Criteria and Characteristics From the National Health and Nutrition Examination Survey, 1999 to 2014. Sex Transm Dis 2019; 45:337-342. [PMID: 29465678 DOI: 10.1097/olq.0000000000000762] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES This study aimed to provide identification criteria for men who have sex with men (MSM), estimate the prevalence of MSM behavior, and compare sociodemographics and sexually transmitted disease risk behaviors between non-MSM and MSM groups using data from a nationally representative, population-based survey. METHODS Using data from men aged 18 to 59 years who took part in the National Health and Nutrition Examination Survey (NHANES), 1999 to 2014, detailed criteria were developed to estimate MSM behavior-at least one lifetime same-sex partner (MSM-ever), at least one same-sex partner in the past 12 months (MSM-current), and at least one lifetime and zero same-sex partners in the past 12 months (MSM-past). RESULTS The estimated prevalence of MSM-ever was 5.5%-of these, 52.4% were MSM-current and 47.1% were MSM-past. Furthermore, MSM-ever are a nonhomogenous subpopulation, for example, 70.4% of MSM-current identified as homosexual and 71.2% of MSM-past identified as heterosexual (P < 0.001). CONCLUSIONS The prevalence of MSM behavior identified here is similar to other published estimates. This is also the first article, to our knowledge, to use National Health and Nutrition Examination Survey data to compare MSM by 2 recall periods (recent vs. lifetime) of last same-sex sexual behavior.
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26
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Mereish EH, Peters JR, Yen S. Minority Stress and Relational Mechanisms of Suicide among Sexual Minorities: Subgroup Differences in the Associations Between Heterosexist Victimization, Shame, Rejection Sensitivity, and Suicide Risk. Suicide Life Threat Behav 2019; 49:547-560. [PMID: 29604113 PMCID: PMC6167193 DOI: 10.1111/sltb.12458] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 01/10/2018] [Indexed: 12/01/2022]
Abstract
Despite sexual orientation disparities in suicide, there is limited research examining factors associated with suicide risk among sexual minorities while considering subgroup differences within this group. This study identified differences between sexual minorities at risk for suicide and those not at risk. The study also examined heterosexist victimization, as one form of minority stress, and two relational mechanisms (i.e., shame and rejection sensitivity) as risk factors for suicidality. We examined a moderated-mediation model, in which we tested gender and sexual orientation differences in the mediating effects of the relational mechanisms on the association between heterosexist victimization and suicide risk. Participants were recruited online and completed an online survey. The sample included 719 sexual minority adults. Of the sample, 27.7% were at risk for suicide. Suicide risk varied by age, gender, sexual orientation, income, education, and relationship status. Heterosexist victimization, shame, and rejection sensitivity were significant risk factors for suicide. Shame and rejection sensitivity were mediators of the association between heterosexist victimization and suicide risk for subgroups of sexual minorities, mostly lesbian and gay individuals and to some extent bisexual individuals. The findings underscore minority stress, shame, and rejection sensitivity as key intervention points.
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Affiliation(s)
- Ethan H Mereish
- Department of Health Studies, American University, Washington, DC, USA
| | - Jessica R Peters
- Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Shirley Yen
- Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, Rhode Island
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27
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Shipherd JC, Darling JE, Klap RS, Rose D, Yano EM. Experiences in the Veterans Health Administration and Impact on Healthcare Utilization: Comparisons Between LGBT and Non-LGBT Women Veterans. LGBT Health 2019; 5:303-311. [PMID: 29979640 DOI: 10.1089/lgbt.2017.0179] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE This study aimed to compare experiences related to healthcare of LGBT women and non-LGBT women in a sample of routine users of Veterans Health Administration (VHA) primary care services and examine the impact of those experiences on delaying or missing appointments for VHA care. METHODS Women veterans (N = 1391) who had at least three primary care visits in the previous year at 12 VHA facilities were surveyed by phone in January-March 2015 in a baseline wave of a cluster-randomized quality improvement trial. The majority identified as non-LGBT (1201; 85.6%) with 190 (14.4%) women identified as LGBT, based on items measuring sexual orientation and gender identity. RESULTS In models controlling for demographics, health status, and positive trauma screens, LGBT identity was predictive of women veterans experiencing harassment from male veterans at VHA in the past 12 months, as well as feeling unwelcome or unsafe at their VHA. Compared with non-LGBT women veterans, LGBT women veterans attributed missing needed care more often in the previous 12 months to concerns about interacting with other veterans. Participant descriptions of harassment indicated that male veterans' comments and actions were distressing and influenced LGBT women's healthcare accessing behavior. CONCLUSIONS Compared with non-LGBT women, LGBT women were more likely to report harassment and feeling unwelcome at VHA. Some LGBT women reported delaying or missing needed care, primarily due to concerns about interacting with other veterans. Additional work is necessary to help LGBT women veterans feel safe and welcome at VHA facilities and, thereby, reduce barriers to LGBT women veterans accessing needed care.
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Affiliation(s)
- Jillian C Shipherd
- 1 Lesbian, Gay, Bisexual, and Transgender (LGBT) Health Program, Office of Patient Care Services, Veterans Health Administration , Washington, District of Columbia.,2 Women's Health Sciences Division, National Center for PTSD , VA Boston Healthcare System, Boston, Massachusetts.,3 Department of Psychiatry, Boston University School of Medicine , Boston, Massachusetts
| | - Jill E Darling
- 4 VA Health Services Research and Development Center for the Study of Healthcare Innovation , Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California.,5 Dornsife Center for Economic and Social Research, University of Southern California , Los Angeles, California
| | - Ruth S Klap
- 4 VA Health Services Research and Development Center for the Study of Healthcare Innovation , Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Danielle Rose
- 4 VA Health Services Research and Development Center for the Study of Healthcare Innovation , Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Elizabeth M Yano
- 4 VA Health Services Research and Development Center for the Study of Healthcare Innovation , Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California.,6 Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles , Los Angeles, California
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28
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Nolan R, Kirkland C, Davis R. LGBT* After Loss: A Mixed-Method Analysis on the Effect of Partner Bereavement on Interpersonal Relationships and Subsequent Partnerships. OMEGA-JOURNAL OF DEATH AND DYING 2019; 82:646-667. [PMID: 30803318 DOI: 10.1177/0030222819831524] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Grief and bereavement are universal human experiences that do not discriminate based on sex, gender, or sexual orientation. Existing literature provides valuable insight into the bereavement experiences of persons who identify as heterosexuals, but much less can be found on persons who identify as lesbian, gay, bisexual, or transgender/queer* (LGBT*). Given that the historical experiences of loss and personal characteristics such as interpersonal, familial, and social patterns of coping with grief are likely to influence the bereavement process, this study focused on the impact of partner bereavement on the interpersonal relationships and subsequent partnerships of the LGBT* bereaved. To this end, the purpose of this study was to use a mixed-methods approach to better understand how LGBT* persons described their experiences with partner bereavement and to identify what effect these experiences had on interpersonal relationships and subsequent partnerships.
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Affiliation(s)
- Rachael Nolan
- College of Public Health, Kent State University, OH, USA
| | | | - Ronald Davis
- College of Public Health, Kent State University, OH, USA
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29
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Haas AP, Lane AD, Blosnich JR, Butcher BA, Mortali MG. Collecting Sexual Orientation and Gender Identity Information at Death. Am J Public Health 2018; 109:255-259. [PMID: 30571294 DOI: 10.2105/ajph.2018.304829] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Currently, no US jurisdiction or agency routinely or systematically collects information about individuals' sexual orientation and gender identity (SOGI) at the time of death. As a result, little is known about causes of death in people having a minority sexual orientation or gender identity. These knowledge gaps have long impeded identification of mortality disparities in sexual and gender minority populations and hampered the development of targeted public health interventions and prevention strategies. We offer observations about the possibilities and challenges of collecting and reporting accurate postmortem SOGI information on the basis of our past four years of working with death investigators, coroners, and medical examiners. This work was located primarily in New York, New York, and has extended from January 2015 to the present. Drawing on our experiences, we make recommendations for future efforts to include SOGI among the standard demographic variables used to characterize individuals at death.
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Affiliation(s)
- Ann P Haas
- Ann P. Haas is with the Department of Health Sciences, Lehman College, City University of New York, Bronx, NY. Andrew D. Lane was with the Johnson Family Foundation, New York. John R. Blosnich is with the West Virginia University (WVU) Injury Control Research Center and the WVU Department of Behavioral Medicine and Psychiatry, Morgantown. Barbara A. Butcher is with Barbara F. Butcher Associates, New York. Maggie G. Mortali is with the American Foundation for Suicide Prevention, New York, NY
| | - Andrew D Lane
- Ann P. Haas is with the Department of Health Sciences, Lehman College, City University of New York, Bronx, NY. Andrew D. Lane was with the Johnson Family Foundation, New York. John R. Blosnich is with the West Virginia University (WVU) Injury Control Research Center and the WVU Department of Behavioral Medicine and Psychiatry, Morgantown. Barbara A. Butcher is with Barbara F. Butcher Associates, New York. Maggie G. Mortali is with the American Foundation for Suicide Prevention, New York, NY
| | - John R Blosnich
- Ann P. Haas is with the Department of Health Sciences, Lehman College, City University of New York, Bronx, NY. Andrew D. Lane was with the Johnson Family Foundation, New York. John R. Blosnich is with the West Virginia University (WVU) Injury Control Research Center and the WVU Department of Behavioral Medicine and Psychiatry, Morgantown. Barbara A. Butcher is with Barbara F. Butcher Associates, New York. Maggie G. Mortali is with the American Foundation for Suicide Prevention, New York, NY
| | - Barbara A Butcher
- Ann P. Haas is with the Department of Health Sciences, Lehman College, City University of New York, Bronx, NY. Andrew D. Lane was with the Johnson Family Foundation, New York. John R. Blosnich is with the West Virginia University (WVU) Injury Control Research Center and the WVU Department of Behavioral Medicine and Psychiatry, Morgantown. Barbara A. Butcher is with Barbara F. Butcher Associates, New York. Maggie G. Mortali is with the American Foundation for Suicide Prevention, New York, NY
| | - Maggie G Mortali
- Ann P. Haas is with the Department of Health Sciences, Lehman College, City University of New York, Bronx, NY. Andrew D. Lane was with the Johnson Family Foundation, New York. John R. Blosnich is with the West Virginia University (WVU) Injury Control Research Center and the WVU Department of Behavioral Medicine and Psychiatry, Morgantown. Barbara A. Butcher is with Barbara F. Butcher Associates, New York. Maggie G. Mortali is with the American Foundation for Suicide Prevention, New York, NY
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30
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31
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Abstract
Although sexual minority women (SMW) and transgender women have become increasingly visible in recent years and have made progress in achieving civil rights, they continue to face significant levels of discrimination, stigma, and physical violence. As a result, each group faces a wide variety of health disparities, including mental illness and substance use disorders. Overall, both SMW and transgender women experience higher rates of mood and anxiety disorders, suicidality, and substance use disorders than their heterosexual and cisgender counterparts. This article is a general introduction to these issues and concludes with recommendations for working with sexual minority and transgender women.
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Affiliation(s)
- Julie K Schulman
- Department of Psychiatry, Allen Hospital, 5141 Broadway, 3 River East, New York, NY 10034, USA.
| | - Laura Erickson-Schroth
- Department of Psychiatry, Mount Sinai Beth Israel, 10 Nathan D. Perlman Place, New York, NY 10003, USA
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32
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Mattingly AE, Kiluk JV, Lee MC. Clinical Considerations of Risk, Incidence, and Outcomes of Breast Cancer in Sexual Minorities. Cancer Control 2017; 23:373-382. [PMID: 27842326 DOI: 10.1177/107327481602300408] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Breast cancer is a leading cause of cancer-related mortality in women. Limited research exists on the impact of sexual orientation on overall risk of and mortality from breast cancer. We sought to summarize the medical literature on breast cancer in sexual minority women and identify possible disparities in this population. METHODS A comprehensive literature search was conducted for English-language studies in peer-reviewed medical journals that referenced breast cancer and sexual minority, lesbian, bisexual, or transgender individuals. Articles published between January 2000 and November 2015 were included. They were reviewed for relevance to breast cancer risk stratification, breast cancer mortality, breast reconstruction, and transgender issues. RESULTS Behavioral risks, reproductive risks, and risks associated with decreased access to health care may all affect outcomes for sexual minorities with breast cancer. Limited studies have mixed results regarding mortality associated with breast cancer in sexual minorities due to an inconsistent reporting of sexual orientation. CONCLUSIONS Overall, the research examining breast cancer in sexual minority women remains limited. This finding is likely due to limitations in the reporting of sexual orientation within large databases, thus making broader-scale research difficult.
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Affiliation(s)
- Anne E Mattingly
- Comprehensive Breast Program, Moffitt Cancer Center, Tampa, FL, USA.
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33
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Thomeer MB, Reczek C. Happiness and Sexual Minority Status. ARCHIVES OF SEXUAL BEHAVIOR 2016; 45:1745-58. [PMID: 27102605 PMCID: PMC5679422 DOI: 10.1007/s10508-016-0737-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 01/26/2016] [Accepted: 03/07/2016] [Indexed: 05/13/2023]
Abstract
We used logistic regression on nationally representative data (General Social Survey, N = 10,668 and N = 6680) to examine how sexual minority status related to happiness. We considered two central dimensions of sexual minority status-sexual behavior and sexual identity. We distinguished between same-sex, both-sex, and different-sex-oriented participants. Because individuals transition between sexual behavior categories over the life course (e.g., from both-sex partners to only same-sex partners) and changes in sexual minority status have theoretical associations with well-being, we also tested the associations of transitions with happiness. Results showed that identifying as bisexual, gay, or lesbian, having both male and female partners since age 18, or transitioning to only different-sex partners was negatively related to happiness. Those with only same-sex partners since age 18 or in the past 5 years had similar levels of happiness as those with only different-sex partners since age 18. Additional tests showed that the majority of these happiness differences became non-significant when economic and social resources were included, indicating that the lower happiness was a product of structural and societal forces. Our findings clearly and robustly underscored the importance of taking a multi-faceted approach to understanding sexuality and well-being, demonstrating that not all sexual minority groups experience disadvantaged happiness. Our study calls for more attention to positive aspects of well-being such as happiness in examinations of sexual minorities and suggests that positive psychology and other happiness subfields should consider the role of sexual minority status in shaping happiness.
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Affiliation(s)
- Mieke Beth Thomeer
- Department of Sociology, University of Alabama at Birmingham, HHB 460, 1720 2nd Ave South, Birmingham, AL, 35294, USA.
| | - Corinne Reczek
- Department of Sociology, The Ohio State University, Columbus, OH, USA
- Department of Women's, Gender, and Sexuality Studies, The Ohio State University, Columbus, OH, USA
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Conejero I, Lopez-Castroman J, Giner L, Baca-Garcia E. Sociodemographic Antecedent Validators of Suicidal Behavior: A Review of Recent Literature. Curr Psychiatry Rep 2016; 18:94. [PMID: 27595860 DOI: 10.1007/s11920-016-0732-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Suicidal behavior and its prevention constitute a major public health issue. Etiology of suicidal behavior is multifactorial. Whereas current research is mostly focused on clinical and biological risk factors, the sociodemographic risk factors for suicidal behavior, first highlighted by Durkheim, have received less attention. Besides the well-known impact of age and gender, sociodemographic variables such as marital and parental status, education, occupation, income, employment status, religion, migration or minority status, and sexual orientation are repeatedly reported to play an important role in suicidal behavior. This narrative review aimed to summarize recent research on sociodemographic risk factors for suicidal behavior and to elicit possible implications for suicide prevention.
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Affiliation(s)
- Ismael Conejero
- Department of Emergency Psychiatry, CHRU Montpellier, Montpellier, France
| | - Jorge Lopez-Castroman
- Department of Psychiatry, CHU Nimes, Nimes, France. .,Inserm U1061, Hôpital La Colombiere, Pavillon 42, 39 Av Charles Flauhault, BP: 34493, 34093, Montpellier, France. .,University of Montpellier 1, Montpellier, 34000, France.
| | - Lucas Giner
- Department of Psychiatry, University of Sevilla, Sevilla, Spain
| | - Enrique Baca-Garcia
- IIS-Fundacion Jimenez Diaz, Department of Psychiatry, CIBERSAM, Madrid, Spain.,Department of Psychiatry at the New York State Psychiatric Institute and Columbia University, New York, NY, USA
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35
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Ferlatte O, Hottes TS, Trussler T, Marchand R. Disclosure of Sexual Orientation by Gay and Bisexual Men in Government-Administered Probability Surveys. LGBT Health 2016; 4:68-71. [PMID: 27657734 DOI: 10.1089/lgbt.2016.0037] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Researchers are increasingly using national population surveys (NPS) to understand the health of gay and bisexual men (GBM). However, valid inference from these surveys depends on accurate identification of GBM. METHODS We asked 8126 GBM in an anonymous, online, community-recruited survey about their willingness to reveal their sexual orientation in NPS. RESULTS Overall, 30% indicated that they would not reveal their sexual orientation; however, there were differences in frequencies according to sexual orientation, relationship status, age, HIV status, living environment, education, income, and ethnicity. CONCLUSION NPS might not be fully representative of GBM due to misclassification errors stemming from unwillingness to disclose.
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Affiliation(s)
- Olivier Ferlatte
- 1 Men's Health Research Program, University of British Columbia , Vancouver, Canada .,2 Community-Based Research Centre for Gay Men's Health , Vancouver, Canada
| | - Travis Salway Hottes
- 2 Community-Based Research Centre for Gay Men's Health , Vancouver, Canada .,3 Dalla Lana School of Public Health, University of Toronto , Toronto, Canada
| | - Terry Trussler
- 2 Community-Based Research Centre for Gay Men's Health , Vancouver, Canada
| | - Rick Marchand
- 2 Community-Based Research Centre for Gay Men's Health , Vancouver, Canada
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36
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Abstract
Many studies, reviews, and meta-analyses have reported elevated mental health problems for sexual minority (SM) individuals. This systematic review provides an update by including numerous recent studies, and explores whether SM individuals are at increased risk across selected mental health problems as per dimensions of sexual orientation (SO), genders, life-stages, geographic regions, and in higher quality studies. A systematic search in PubMed produced 199 studies appropriate for review. A clear majority of studies reported elevated risks for depression, anxiety, suicide attempts or suicides, and substance-related problems for SM men and women, as adolescents or adults from many geographic regions, and with varied SO dimensions (behaviour, attraction, identity), especially in more recent and higher quality studies. One notable exception is alcohol-related problems, where many studies reported zero or reversed effects, especially for SM men. All SM subgroups were at increased risk, but bisexual individuals were at highest risk in the majority of studies. Other subgroup and gender differences are more complex and are discussed. The review supports the long-standing mental health risk proposition for SM individuals, overall and as subgroups.
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Affiliation(s)
- Martin Plöderl
- a Department of Suicide Prevention , University Clinic of Psychiatry and Psychotherapy, University Institute of Clinical Psychology, Christian Doppler Clinic, Paracelsus Medical University , Salzburg , Austria
| | - Pierre Tremblay
- b Faculty of Social Work, University of Calgary , Calgary, Alberta , Canada
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Hottes TS, Bogaert L, Rhodes AE, Brennan DJ, Gesink D. Lifetime Prevalence of Suicide Attempts Among Sexual Minority Adults by Study Sampling Strategies: A Systematic Review and Meta-Analysis. Am J Public Health 2016; 106:e1-12. [PMID: 27049424 DOI: 10.2105/ajph.2016.303088] [Citation(s) in RCA: 227] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Previous reviews have demonstrated a higher risk of suicide attempts for lesbian, gay, and bisexual (LGB) persons (sexual minorities), compared with heterosexual groups, but these were restricted to general population studies, thereby excluding individuals sampled through LGB community venues. Each sampling strategy, however, has particular methodological strengths and limitations. For instance, general population probability studies have defined sampling frames but are prone to information bias associated with underreporting of LGB identities. By contrast, LGB community surveys may support disclosure of sexuality but overrepresent individuals with strong LGB community attachment. OBJECTIVES To reassess the burden of suicide-related behavior among LGB adults, directly comparing estimates derived from population- versus LGB community-based samples. SEARCH METHODS In 2014, we searched MEDLINE, EMBASE, PsycInfo, CINAHL, and Scopus databases for articles addressing suicide-related behavior (ideation, attempts) among sexual minorities. SELECTION CRITERIA We selected quantitative studies of sexual minority adults conducted in nonclinical settings in the United States, Canada, Europe, Australia, and New Zealand. DATA COLLECTION AND ANALYSIS Random effects meta-analysis and meta-regression assessed for a difference in prevalence of suicide-related behavior by sample type, adjusted for study or sample-level variables, including context (year, country), methods (medium, response rate), and subgroup characteristics (age, gender, sexual minority construct). We examined residual heterogeneity by using τ(2). MAIN RESULTS We pooled 30 cross-sectional studies, including 21,201 sexual minority adults, generating the following lifetime prevalence estimates of suicide attempts: 4% (95% confidence interval [CI] = 3%, 5%) for heterosexual respondents to population surveys, 11% (95% CI = 8%, 15%) for LGB respondents to population surveys, and 20% (95% CI = 18%, 22%) for LGB respondents to community surveys (Figure 1). The difference in LGB estimates by sample type persisted after we accounted for covariates with meta-regression. Sample type explained 33% of the between-study variability. AUTHOR'S CONCLUSIONS Regardless of sample type examined, sexual minorities had a higher lifetime prevalence of suicide attempts than heterosexual persons; however, the magnitude of this disparity was contingent upon sample type. Community-based surveys of LGB people suggest that 20% of sexual minority adults have attempted suicide. PUBLIC HEALTH IMPLICATIONS Accurate estimates of sexual minority health disparities are necessary for public health monitoring and research. Most data describing these disparities are derived from 2 sample types, which yield different estimates of the lifetime prevalence of suicide attempts. Additional studies should explore the differential effects of selection and information biases on the 2 predominant sampling approaches used to understand sexual minority health.
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Affiliation(s)
- Travis Salway Hottes
- Travis Salway Hottes, Laura Bogaert, and Dionne Gesink are with the Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Anne E. Rhodes is with the Division of Epidemiology, Dalla Lana School of Public Health, and Department of Psychiatry, University of Toronto; and the Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario. David J. Brennan is with the Factor-Inwentash Faculty of Social Work, University of Toronto
| | - Laura Bogaert
- Travis Salway Hottes, Laura Bogaert, and Dionne Gesink are with the Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Anne E. Rhodes is with the Division of Epidemiology, Dalla Lana School of Public Health, and Department of Psychiatry, University of Toronto; and the Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario. David J. Brennan is with the Factor-Inwentash Faculty of Social Work, University of Toronto
| | - Anne E Rhodes
- Travis Salway Hottes, Laura Bogaert, and Dionne Gesink are with the Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Anne E. Rhodes is with the Division of Epidemiology, Dalla Lana School of Public Health, and Department of Psychiatry, University of Toronto; and the Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario. David J. Brennan is with the Factor-Inwentash Faculty of Social Work, University of Toronto
| | - David J Brennan
- Travis Salway Hottes, Laura Bogaert, and Dionne Gesink are with the Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Anne E. Rhodes is with the Division of Epidemiology, Dalla Lana School of Public Health, and Department of Psychiatry, University of Toronto; and the Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario. David J. Brennan is with the Factor-Inwentash Faculty of Social Work, University of Toronto
| | - Dionne Gesink
- Travis Salway Hottes, Laura Bogaert, and Dionne Gesink are with the Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Anne E. Rhodes is with the Division of Epidemiology, Dalla Lana School of Public Health, and Department of Psychiatry, University of Toronto; and the Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario. David J. Brennan is with the Factor-Inwentash Faculty of Social Work, University of Toronto
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Suicide in married couples in Sweden: Is the risk greater in same-sex couples? Eur J Epidemiol 2016; 31:685-90. [PMID: 27168192 DOI: 10.1007/s10654-016-0154-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 04/27/2016] [Indexed: 10/21/2022]
Abstract
Minority sexual orientation is a predictor of suicide ideation and attempts, though its association with suicide mortality is less clear. We capitalize on Sweden's extensively linked databases, to investigate whether, among married individuals, same-sex marriage is associated with suicide. Using a population-based register design, we analyzed suicide risk among same-sex married women and men (n = 6456), as compared to different-sex married women and men (n = 1181723) in Sweden. We selected all newly partnered or married individuals in the intervening time between 1/1/1996 and 12/31/2009 and followed them with regard to suicide until 12/31/2011. Multivariate Poisson regression was used to calculate adjusted incidence risk ratios (IRR) with 95 % confidence intervals (CI). The risk of suicide was higher among same-sex married individuals as compared to different-sex married individuals (IRR 2.7, 95 % CI 1.5-4.8), after adjustment for time at risk and socioeconomic confounding. Sex-stratified analyses showed a tentatively elevated risk for same-sex married women (IRR 2.5, 95 % CI 0.8-7.7) as compared to different-sex married women. Among same-sex married men the suicide risk was nearly three-fold greater as compared to different-sex married (IRR 2.895 % CI 1.5-5.5). This holds true also after adjustment for HIV status. Even in a country with a comparatively tolerant climate regarding homosexuality such as Sweden, same-sex married individuals evidence a higher risk for suicide than other married individuals.
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Grey JA, Bernstein KT, Sullivan PS, Purcell DW, Chesson HW, Gift TL, Rosenberg ES. Estimating the Population Sizes of Men Who Have Sex With Men in US States and Counties Using Data From the American Community Survey. JMIR Public Health Surveill 2016; 2:e14. [PMID: 27227149 PMCID: PMC4873305 DOI: 10.2196/publichealth.5365] [Citation(s) in RCA: 151] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 12/15/2015] [Accepted: 01/21/2016] [Indexed: 01/29/2023] Open
Abstract
Background In the United States, male-to-male sexual transmission accounts for the greatest number of new human immunodeficiency virus (HIV) diagnoses and a substantial number of sexually transmitted infections (STI) annually. However, the prevalence and annual incidence of HIV and other STIs among men who have sex with men (MSM) cannot be estimated in local contexts because demographic data on sexual behavior, particularly same-sex behavior, are not routinely collected by large-scale surveys that allow analysis at state, county, or finer levels, such as the US decennial census or the American Community Survey (ACS). Therefore, techniques for indirectly estimating population sizes of MSM are necessary to supply denominators for rates at various geographic levels. Objective Our objectives were to indirectly estimate MSM population sizes at the county level to incorporate recent data estimates and to aggregate county-level estimates to states and core-based statistical areas (CBSAs). Methods We used data from the ACS to calculate a weight for each county in the United States based on its relative proportion of households that were headed by a male who lived with a male partner, compared with the overall proportion among counties at the same level of urbanicity (ie, large central metropolitan county, large fringe metropolitan county, medium/small metropolitan county, or nonmetropolitan county). We then used this weight to adjust the urbanicity-stratified percentage of adult men who had sex with a man in the past year, according to estimates derived from the National Health and Nutrition Examination Survey (NHANES), for each county. We multiplied the weighted percentages by the number of adult men in each county to estimate its number of MSM, summing county-level estimates to create state- and CBSA-level estimates. Finally, we scaled our estimated MSM population sizes to a meta-analytic estimate of the percentage of US MSM in the past 5 years (3.9%). Results We found that the percentage of MSM among adult men ranged from 1.5% (Wyoming) to 6.0% (Rhode Island) among states. Over one-quarter of MSM in the United States resided in 1 of 13 counties. Among counties with over 300,000 residents, the five highest county-level percentages of MSM were San Francisco County, California at 18.5% (66,586/359,566); New York County, New York at 13.8% (87,556/635,847); Denver County, Colorado at 10.5% (25,465/243,002); Multnomah County, Oregon at 9.9% (28,949/292,450); and Suffolk County, Massachusetts at 9.1% (26,338/289,634). Although California (n=792,750) and Los Angeles County (n=251,521) had the largest MSM populations of states and counties, respectively, the New York City-Newark-Jersey City CBSA had the most MSM of all CBSAs (n=397,399). Conclusions We used a new method to generate small-area estimates of MSM populations, incorporating prior work, recent data, and urbanicity-specific parameters. We also used an imputation approach to estimate MSM in rural areas, where same-sex sexual behavior may be underreported. Our approach yielded estimates of MSM population sizes within states, counties, and metropolitan areas in the United States, which provide denominators for calculation of HIV and STI prevalence and incidence at those geographic levels.
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Affiliation(s)
- Jeremy A Grey
- Department of Epidemiology Rollins School of Public Health Emory University Atlanta, GA United States
| | - Kyle T Bernstein
- Division of STD Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Centers for Disease Control and Prevention Atlanta, GA United States
| | - Patrick S Sullivan
- Department of Epidemiology Rollins School of Public Health Emory University Atlanta, GA United States
| | - David W Purcell
- Division of HIV/AIDS Prevention National Center for HIV, Viral Hepatitis, STD, and TB Prevention Centers for Disease Control and Prevention Atlanta, GA United States
| | - Harrell W Chesson
- Division of STD Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Centers for Disease Control and Prevention Atlanta, GA United States
| | - Thomas L Gift
- Division of STD Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Centers for Disease Control and Prevention Atlanta, GA United States
| | - Eli S Rosenberg
- Department of Epidemiology Rollins School of Public Health Emory University Atlanta, GA United States
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Padula WV, Heru S, Campbell JD. Societal Implications of Health Insurance Coverage for Medically Necessary Services in the U.S. Transgender Population: A Cost-Effectiveness Analysis. J Gen Intern Med 2016; 31:394-401. [PMID: 26481647 PMCID: PMC4803686 DOI: 10.1007/s11606-015-3529-6] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 06/16/2015] [Accepted: 09/24/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND Recently, the Massachusetts Group Insurance Commission (GIC) prioritized research on the implications of a clause expressly prohibiting the denial of health insurance coverage for transgender-related services. These medically necessary services include primary and preventive care as well as transitional therapy. OBJECTIVE To analyze the cost-effectiveness of insurance coverage for medically necessary transgender-related services. DESIGN Markov model with 5- and 10-year time horizons from a U.S. societal perspective, discounted at 3% (USD 2013). Data on outcomes were abstracted from the 2011 National Transgender Discrimination Survey (NTDS). PATIENTS U.S. transgender population starting before transitional therapy. INTERVENTIONS No health benefits compared to health insurance coverage for medically necessary services. This coverage can lead to hormone replacement therapy, sex reassignment surgery, or both. MAIN MEASURES Cost per quality-adjusted life year (QALY) for successful transition or negative outcomes (e.g. HIV, depression, suicidality, drug abuse, mortality) dependent on insurance coverage or no health benefit at a willingness-to-pay threshold of $100,000/QALY. Budget impact interpreted as the U.S. per-member-per-month cost. KEY RESULTS Compared to no health benefits for transgender patients ($23,619; 6.49 QALYs), insurance coverage for medically necessary services came at a greater cost and effectiveness ($31,816; 7.37 QALYs), with an incremental cost-effectiveness ratio (ICER) of $9314/QALY. The budget impact of this coverage is approximately $0.016 per member per month. Although the cost for transitions is $10,000-22,000 and the cost of provider coverage is $2175/year, these additional expenses hold good value for reducing the risk of negative endpoints--HIV, depression, suicidality, and drug abuse. Results were robust to uncertainty. The probabilistic sensitivity analysis showed that provider coverage was cost-effective in 85% of simulations. CONCLUSIONS Health insurance coverage for the U.S. transgender population is affordable and cost-effective, and has a low budget impact on U.S. society. Organizations such as the GIC should consider these results when examining policies regarding coverage exclusions.
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Affiliation(s)
- William V Padula
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA.
| | - Shiona Heru
- Commonwealth of Massachusetts Group Insurance Commission (GIC), Boston, MA, USA
| | - Jonathan D Campbell
- Center for Pharmaceutical Outcomes Research (CePOR), Department of Clinical Pharmacy, University of Colorado, Aurora, CO, USA
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Cochran SD, Björkenstam C, Mays VM. Sexual Orientation and All-Cause Mortality Among US Adults Aged 18 to 59 Years, 2001-2011. Am J Public Health 2016; 106:918-20. [PMID: 26985610 DOI: 10.2105/ajph.2016.303052] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
To determine whether sexual minorities have an earlier mortality than do heterosexuals, we investigated associations between sexual orientation assessed in the 2001 to 2010 National Health and Nutrition Examination Surveys (NHANES) and mortality in the 2011 NHANES-linked mortality file. Mortality follow-up time averaged 69.6 months after NHANES. By 2011, 338 individuals had died. Sexual minorities evidenced greater all-cause mortality than did heterosexuals after adjusting for demographic confounding. These effects generally disappeared with further adjustment for NHANES-detected health and behavioral differences.
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Affiliation(s)
- Susan D Cochran
- Susan D. Cochran is with the Department of Epidemiology, University of California, Los Angeles Fielding School of Public Health and the Department of Statistics, University of California, Los Angeles. Charlotte Björkenstam is with the Department of Epidemiology, University of California, Los Angeles Fielding School of Public Health and the Department of Sociology, Stockholm University, Stockholm, Sweden. Vickie M. Mays is with the Department of Health Policy and Management, University of California, Los Angeles Fielding School of Public Health and the Department of Psychology, University of California, Los Angeles
| | - Charlotte Björkenstam
- Susan D. Cochran is with the Department of Epidemiology, University of California, Los Angeles Fielding School of Public Health and the Department of Statistics, University of California, Los Angeles. Charlotte Björkenstam is with the Department of Epidemiology, University of California, Los Angeles Fielding School of Public Health and the Department of Sociology, Stockholm University, Stockholm, Sweden. Vickie M. Mays is with the Department of Health Policy and Management, University of California, Los Angeles Fielding School of Public Health and the Department of Psychology, University of California, Los Angeles
| | - Vickie M Mays
- Susan D. Cochran is with the Department of Epidemiology, University of California, Los Angeles Fielding School of Public Health and the Department of Statistics, University of California, Los Angeles. Charlotte Björkenstam is with the Department of Epidemiology, University of California, Los Angeles Fielding School of Public Health and the Department of Sociology, Stockholm University, Stockholm, Sweden. Vickie M. Mays is with the Department of Health Policy and Management, University of California, Los Angeles Fielding School of Public Health and the Department of Psychology, University of California, Los Angeles
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Björkenstam C, Kosidou K, Björkenstam E, Dalman C, Andersson G, Cochran S. Self-reported suicide ideation and attempts, and medical care for intentional self-harm in lesbians, gays and bisexuals in Sweden. J Epidemiol Community Health 2016; 70:895-901. [PMID: 26945095 DOI: 10.1136/jech-2015-206884] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 02/19/2016] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Charlotte Björkenstam
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, USA Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden Department of Sociology, Stockholm University, Stockholm, Sweden
| | - Kyriaki Kosidou
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Emma Björkenstam
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden Department of Community Health Sciences, Fielding School of Public Health and California Center for Population Research, University of California Los Angeles, Los Angeles, USA
| | - Christina Dalman
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Gunnar Andersson
- Department of Sociology, Stockholm University, Stockholm, Sweden
| | - Susan Cochran
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, USA
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Lehavot K, Rillamas-Sun E, Weitlauf J, Kimerling R, Wallace RB, Sadler AG, Woods NF, Shipherd JC, Mattocks K, Cirillo DJ, Stefanick ML, Simpson TL. Mortality in Postmenopausal Women by Sexual Orientation and Veteran Status. THE GERONTOLOGIST 2016; 56 Suppl 1:S150-62. [PMID: 26768389 PMCID: PMC5881613 DOI: 10.1093/geront/gnv125] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 07/27/2015] [Indexed: 01/11/2023] Open
Abstract
PURPOSE OF THE STUDY To examine differences in all-cause and cause-specific mortality by sexual orientation and Veteran status among older women. DESIGN AND METHODS Data were from the Women's Health Initiative, with demographic characteristics, psychosocial factors, and health behaviors assessed at baseline (1993-1998) and mortality status from all available data sources through 2014. Women with baseline information on lifetime sexual behavior and Veteran status were included in the analyses (N = 137,639; 1.4% sexual minority, 2.5% Veteran). The four comparison groups included sexual minority Veterans, sexual minority non-Veterans, heterosexual Veterans, and heterosexual non-Veterans. Cox proportional hazard models were used to estimate mortality risk adjusted for demographic, psychosocial, and health variables. RESULTS Sexual minority women had greater all-cause mortality risk than heterosexual women regardless of Veteran status (hazard ratio [HR] = 1.20, 95% confidence interval [CI]: 1.07-1.36) and women Veterans had greater all-cause mortality risk than non-Veterans regardless of sexual orientation (HR = 1.14, 95% CI: 1.06-1.22), but the interaction between sexual orientation and Veteran status was not significant. Sexual minority women were also at greater risk than heterosexual women for cancer-specific mortality, with effects stronger among Veterans compared to non-Veterans (sexual minority × Veteran HR = 1.70, 95% CI: 1.01-2.85). IMPLICATIONS Postmenopausal sexual minority women in the United States, regardless of Veteran status, may be at higher risk for earlier death compared to heterosexuals. Sexual minority women Veterans may have higher risk of cancer-specific mortality compared to their heterosexual counterparts. Examining social determinants of longevity may be an important step to understanding and reducing these disparities.
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Affiliation(s)
- Keren Lehavot
- Health Services Research & Development, VA Puget Sound Health Care System and Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle.
| | - Eileen Rillamas-Sun
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center and Health Services Research & Development, VA Puget Sound Health Care System, Seattle, Washington
| | - Julie Weitlauf
- Sierra Pacific Mental Illness, Research, Education and Clinical Center and Center for Innovation to Implementation, VA Palo Alto Health Care System, California. Department of Psychiatry & Behavioral Sciences and Stanford Cancer Institute, California
| | | | | | | | | | - Jillian C Shipherd
- VA Boston Healthcare System, National Center for PTSD Women's Health Sciences, Boston University School of Medicine, Massachusetts. LGBT Program Patient Care Services, Washington DC
| | - Kristin Mattocks
- VA Central Western Massachusetts, Leeds. University of Massachusetts Medical School, Worcester
| | - Dominic J Cirillo
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, the University of Iowa Department of Epidemiology, New York
| | - Marcia L Stefanick
- Stanford Prevention Research Center, Stanford University School of Medicine, California
| | - Tracy L Simpson
- Center of Excellence in Substance Abuse Treatment and Education, VA Puget Sound Health Care System and Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
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Velkoff EA, Forrest LN, Dodd DR, Smith AR. Identity, Relationship Satisfaction, and Disclosure. PSYCHOLOGY OF WOMEN QUARTERLY 2015. [DOI: 10.1177/0361684315621496] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We tested the usefulness of combining the Interpersonal–Psychological Theory of Suicide and minority stress models in studying suicidality among sexual minority women. According to the Interpersonal–Psychological Theory of Suicide, perceptions of being a burden on others and feelings of failed belongingness predict suicidal ideation. In a sample of sexual minority women ( n = 51), we tested first, if the interaction of perceived burdensomeness and failed belongingness predicted lifetime suicidal behavior; second, if identity affirmation was negatively related to perceived burdensomeness and if this relation was moderated by disclosure; and third, if relationship satisfaction was negatively related to failed belongingness and if this relation was moderated by acceptance concerns. The proposed interaction of perceived burdensomeness and failed belongingness predicted lifetime suicide attempts. Moreover, among sexual minority women with greater disclosure of their sexual minority identities, low identity affirmation was related to higher perceived burdensomeness. For sexual minority women with high acceptance concerns, relationship satisfaction did not relate to lower feelings of failed belongingness. These findings suggest that sexual minority related stressors moderate risk factors for suicidality—in particular, perceptions of burdensomeness and failed belongingness. We suggest clinicians and others encourage sexual minority individuals to engage in activities that promote effectiveness and interpersonal closeness. Online slides for instructors who want to use this article for teaching are available to PWQ subscribers on PWQ's website at http://pwq.sagepub.com/supplemental
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Affiliation(s)
| | | | - Dorian R. Dodd
- Department of Psychology, Miami University, Oxford, OH, USA
| | - April R. Smith
- Department of Psychology, Miami University, Oxford, OH, USA
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Moore CL, Grulich AE, Prestage G, Gidding HF, Jin F, Mao L, Petoumenos K, Zablotska IB, Poynten IM, Law MG, Amin J. Hospitalisation rates and associated factors in community-based cohorts of HIV-infected and -uninfected gay and bisexual men. HIV Med 2015; 17:327-39. [PMID: 26344061 DOI: 10.1111/hiv.12312] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2015] [Indexed: 01/08/2023]
Abstract
OBJECTIVES There is evidence that HIV-positive patients are suffering from a greater burden of morbidity as they age due to nonAIDS-related complications. To date it has been difficult to determine what part of this excess risk is due to the health effects of HIV, its treatment or to lifestyle factors common to gay and bisexual men (GBM). We calculated overall and cause-specific hospitalisation rates and risk factors for hospitalisations in HIV-negative and HIV-positive cohorts of GBM and compare these with rates in the general male population. METHODS We conducted a record linkage study, linking two cohorts of HIV-negative (n = 1325) and HIV-positive (n = 557) GBM recruited in Sydney, New South Wales (NSW), Australia with the NSW hospital discharge data register. We compared rates of hospitalisation in the two cohorts and risk factors for hospitalisation using random-effects Poisson regression methods. Hospitalisation rates for each cohort were further compared with those in the general male population using indirect standardisation. RESULTS We observed 2032 hospitalisations in the HIV-negative cohort during 13,016 person-years (PYs) [crude rate: 15.6/100 PYs (95% CI: 14.9-16.3)] and 2130 hospitalisations in the HIV-positive cohort during 5571 PYs [crude rate: 38.2/100 PYs (95% CI: 36.6-39.9)]. HIV-positive individuals had an increased risk of hospitalisation compared with the HIV-negative individuals [adjusted-IRR: 2.34 (95% CI: 1.91-2.86)] and the general population [SHR: 1.45 (95% CI: 1.33-1.59)]. Hospitalisation rates were lower in the HIV-negative cohort compared with the general population [SHR: 0.72 (95% CI: 0.67-0.78)]. The primary causes of hospitalisation differed between groups. CONCLUSIONS HIV-positive GBM continue to experience excess morbidity compared with HIV-negative GBM men and the general population. HIV-negative GBM had lower morbidity compared with the general male population suggesting that GBM identity does not confer excess risk.
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Affiliation(s)
- C L Moore
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - A E Grulich
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - G Prestage
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia.,Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Vic., Australia
| | - H F Gidding
- School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia
| | - F Jin
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - L Mao
- Centre for Social Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - K Petoumenos
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - I B Zablotska
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - I M Poynten
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - M G Law
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - J Amin
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
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Seeman MV. Sexual Minority Women in Treatment for Serious Mental Illness: A Literature Review. JOURNAL OF GAY & LESBIAN MENTAL HEALTH 2015. [DOI: 10.1080/19359705.2015.1026016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Hottes TS, Ferlatte O, Gilbert M. Misclassification and Undersampling of Sexual Minorities in Population Surveys. Am J Public Health 2015; 105:e5. [PMID: 25393201 DOI: 10.2105/ajph.2014.302408] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Travis S Hottes
- Travis S. Hottes is with the Dalla Lana School of Public Health, University of Toronto, Toronto, ON, and the Community-Based Research Centre for Gay Men's Health, Vancouver, BC. Olivier Ferlatte is with the Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, and the Community-Based Research Centre for Gay Men's Health. Mark Gilbert is with the Ontario HIV Treatment Network, Toronto, and the School of Population and Public Health, University of British Columbia, Vancouver
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