Heterogeneity of health disparities among African American, Hispanic, and Asian American women: unrecognized influences of sexual orientation

Exploring pathways to successful aging among older black lesbians and sexual minority women: A focus on life satisfaction and intersectional factors

PURPOSE

Satisfaction with life is a core aspect of successful aging, which is influenced by a broad range of factors, including health, socioeconomic status, and social relationships. Black lesbians experience various social challenges, including racism, sexism, ageism, and heterosexualism, that may present as deterrents to aging successfully. To develop better policies and programs in support of successful aging among all adults, an understanding of the unique components associated with their intersecting identities must be explored. This study was carried out to gain a better understanding of how Black lesbians and other Black sexual minority women (BSMW) view successful aging within the context of life satisfaction.

METHODS

Inferential statistics were used to determine relationships between satisfaction with life (SWLS-3) and selected independent variables. Backward stepwise regression was conducted to ascertain significant relationships of the study outcome variable.

RESULTS

The respondents were 118 Black lesbians and other BSMW aged 50 and above. Independent t-tests showed that those living with a partner had a significantly higher SWLS-3. Backwards stepwise regression indicated the predictor variables for higher rates of SWLS-3 to be harmony in life, annual household income, and provider sensitivity/cultural competence to their patient being Black.

CONCLUSION

This study provides insight on factors increasing and diminishing satisfaction with life for aging Black lesbians and other BSMW. Future research should replicate this study with a more diverse and nationally representative sample, especially given the study limitations of having recruited a highly educated sample during a global pandemic.

Neurological Health in Sexual and Gender Minority Individuals

Despite representing a significant proportion of the U.S. population, there is a paucity of population-based research on the health status and health needs of sexual and gender minority (SGM) individuals in neurology. Compared with heterosexual peers, some SGM populations have a higher burden of chronic health conditions. In parallel, SGM individuals are more likely to experience stigma and discrimination producing psychological distress, which may contribute to and be compounded by reduced health care access and utilization. In this narrative review, we summarize the existing literature on common neurological health conditions such as stroke, headache, epilepsy, movement disorders, and traumatic brain injury through the lens of intersection of SGM identity. Special focus is attuned to social determinants of health and gender-affirming hormonal therapy. Given the limitations in the available literature, there is an urgent unmet need for datasets that include sexual orientation and gender identity information, as well as funding for research that will characterize the prevalence of neurological conditions, unique risk factors, and health outcomes in SGM populations. In the health care community, providers should address deficiencies in their professional training and integrate inclusive language into their clinical skillset to build trust with SGM patients. There is an opportunity in neurology to proactively engage SGM communities, collaborate to remove barriers to care, promote resilience, and develop targeted interventions to ensure high-quality, culturally competent care for SGM populations to improve neurological health for all.

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

BACKGROUND AND OBJECTIVES

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

DISCUSSION AND IMPLICATIONS

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

Scholarly literature in HIV-related lesbian, gay, bisexual, and transgender studies: A bibliometric analysis

Introduction

Lesbian, gay, bisexual, and transgendered (LGBT) people are marginalized and understudied. Analyzing research activity worldwide is vital to better understand their needs in confronting the HIV epidemic. This study aimed to evaluate the global literature to identify the research collaboration, content, and tendency in HIV-related issues among the LGBT populations.

Methods

Peer-reviewed original articles and reviews were achieved from the Web of Science Core Collection database. Country's collaborations and co-occurrence of most frequent terms were illustrated by VOSviewer software. The Latent Dirichlet Allocation (LDA) and the linear regression model were utilized to uncover the hidden topics and examine the research trend.

Results

From 1990 to 2019, a total of 13,096 publications were found. Stigma, sexual risk behaviors and HIV testing were the major topics in the LGBT research during the study period. Among 15 topics, topics about HIV/Sexually transmitted infections (STIs) prevalence, Outcomes of HIV/AIDS care and treatment, and Opportunistic infections in HIV-positive LGBT people showed decreasing attention over years, while other topics had a slight to moderate increase.

Discussion

Our study underlined the exponential growth of publications on the LGBT population in HIV research, and suggested the importance of performing regional collaborations in improving research capacity. Moreover, further research should focus on examining the manner to increase the coverage of HIV testing and treatment, as well as implement HIV-interventions with low cost and easy to scale-up.

Exploring Factors Affecting Patient-Provider Interactions and Healthcare Engagement Among a Diverse Sample of Women Who Have Sex with Women in New York City

Women who have sex with women (WSW) have lower rates of engagement in health care and preventive screenings than women who have sex exclusively with men. Existing literature provides limited insight into how intersecting and overlapping identities, such as race, ethnicity, sexual orientation, gender identity, and identities related to gender expression, may shape individuals' experiences within health care. We conducted qualitative interviews in New York City with 30 people who identified as women, reported sex with people who identify as women, were age 18-65, and were diverse in race, ethnicity, and sexual orientation and gender identity. The semi-structured questionnaire asked participants about positive and negative healthcare experiences to elicit what could encourage or prevent seeking care, with a focus on provider-related factors. Factors that led to positive healthcare experiences included having a provider who was knowledgeable about LGBTQ experience and health and who affirmed their sexuality, gender identity, and other intersecting identities. Factors that contributed to negative healthcare experiences included poor interactions with providers, and providers' perceived heteronormativity and lack of awareness of WSW healthcare needs. WSW of different races, ethnicities, sexual orientations, and gender identities seek validating healthcare experiences that acknowledge and affirm their identities. We present a visual summary of the main thematic factors that contributed to positive and negative WSW healthcare experiences. Increasing access to care requires training providers on how to engage WSW patients, including WSW of diverse race/ethnicity and gender identity and expression.

Eliminating Disparities in Cardiovascular Disease for Black Women: JACC Review Topic of the Week

Black women are disproportionately affected by cardiovascular disease with an excess burden of cardiovascular morbidity and mortality. In addition, the racialized structure of the United States shapes cardiovascular disease research and health care delivery for Black women. Given the indisputable evidence of the disparities in health care delivery, research, and cardiovascular outcomes, there is an urgent need to develop and implement effective and sustainable solutions to advance cardiovascular health equity for Black women while considering their ethnic diversity, regions of origin, and acculturation. Innovative and culturally tailored strategies that consider the differential impact of social determinants of health and the unique challenges that shape their health-seeking behaviors should be implemented. A patient-centered framework that involves collaboration among clinicians, health care systems, professional societies, and government agencies is required to improve cardiovascular outcomes for Black women. The time is "now" to achieve health equity for all Black women.

The association of sexual orientation with prostate, breast, and cervical cancer screening and diagnosis

PURPOSE

Data on heterogeneity in cancer screening and diagnosis rates among lesbians/gays and bisexuals (LGBs) is lacking. Recent studies showed that LGBs have decreased healthcare utilization compared to heterosexual counterparts. Few studies have examined how sexual orientation impacts cancer screening and prevalence. We, therefore, investigated the association between sexual orientation and prevalent sex-specific cancer including prostate (PCa), breast (BC), and cervical (CC) cancer.

METHODS

This was a cross-sectional survey-based US study, including men and women aged 18 + from the Health Information National Trends Survey (HINTS) database between 2017 and 2019. The primary endpoint was individual-reported prostate, breast, and cervical cancer screening and prevalence rates among heterosexual and LGB men and women. Multivariable logistic regression analyses assessed association of various covariates with undergoing screening and diagnosis of these cancers.

RESULTS

Overall, 4,441 and 6,333 heterosexual men and women, respectively, were compared to 225 and 213 LGB men and women, respectively. LGBs were younger and less likely to be screened for PCa, BC, and CC than heterosexuals. A higher proportion of heterosexual women than lesbian and bisexual women were screened for CC with pap smears (95.36% vs. 90.48% and 86.11%, p ≤ 0.001) and BC with mammograms (80.74% vs. 63.81% and 45.37%, p ≤ 0.001). Similarly, a higher proportion of heterosexual men than gay and bisexual men were screened for PCa with PSA blood tests (41.27% vs. 30.53% and 27.58%, p ≤ 0.001).

CONCLUSION

There were more heterosexuals than LGBs screened for CC, BC, and PCa. However, no association between sexual orientation and cancer diagnosis was found. Healthcare professionals should be encouraged to improve cancer screening among LGBs.

A population-based study of the intersection of sexual identity and race/ethnicity on physiological risk factors for CVD among U.S. adults (ages 18-59)

Objectives: Sexual minorities face significant psychosocial stressors (such as discrimination and violence) that impact their health. Several studies indicate that sexual minority women (SMW) and bisexual men may be at highest risk for cardiovascular disease (CVD), but limited research has examined physiological CVD risk or racial/ethnic differences. This study sought to examine racial/ethnic differences in physiological risk factors for CVD among sexual minority and heterosexual adults.Design: We analyzed data from the National Health and Nutrition Examination Survey (2001-2016) using sex-stratified multiple linear regression models to estimate differences in physiological CVD risk. We compared sexual minorities (gay/lesbian, bisexual, 'not sure') to heterosexual participants first without regard to race/ethnicity. Then we compared sexual minorities by race/ethnicity to White heterosexual participants.Results: The sample included 22,305 participants (ages 18-59). Lesbian women had higher body mass index (BMI) but lower total cholesterol than heterosexual women. Bisexual women had higher systolic blood pressure (SBP). Gay men had lower BMI and glycosylated hemoglobin (HbA1c) relative to heterosexual men. White and Black lesbian women and bisexual women of all races/ethnicities had higher BMI than White heterosexual women; Black bisexual women had higher SBP and HbA1c. Black sexual minority men had higher HbA1c relative to White heterosexual men. Latino 'not sure' men also had higher SBP, HbA1c, and total cholesterol than White heterosexual men.Conclusions: Given evidence of higher CVD risk in sexual minority people of color relative to White heterosexuals, there is a need for health promotion initiatives to address these disparities. Additional research that incorporates longitudinal designs and examines the influence of psychosocial stressors on CVD risk in sexual minorities is recommended. Findings have implications for clinical and policy efforts to promote the cardiovascular health of sexual minorities.

The Intersection of Sexual and Racial/Ethnic Identity Centrality and Mental Well-Being among Black and Latinx Sexual Minority Adults

Studies document how identity related processes, including identity centrality, shape mental well being. More research, however, is needed that considers how identity centrality impacts well being for people with more than one marginalized identity. Drawing from data from 1,571 black and Latinx sexual minorities included in the Social Justice Sexuality Project, I apply an intercategorical intersectional approach to examine the association between the intersection of sexual and racial/ethnic identity centrality and mental well being. Ordinary least squares regression models show three key findings. First, I found a significant association between both racial/ethnic and sexual identity centrality and mental well being. Second, my results highlight a significant interaction effect between sexual and racial/ethnic identity centrality, indicating the relationship between centrality and well being varies across different levels of centrality. Finally, my results indicate that after adjusting for identity centrality, other predictors remain significantly associated with well being.

Disparities in food insecurity at the intersection of race and sexual orientation: A population-based study of adult women in the United States

Food insecurity affects 1 in 8 American adults annually, and is more prevalent in Black and sexual minority women. We applied an intersectional approach to investigate food insecurity prevalence in women with intersecting minority race and sexual orientation. We used two United States surveillance systems-National Health Interview Survey (NHIS) 2013-2018 and National Health and Nutrition Examination Survey (NHANES) 2005-2014, to estimate how race and sexual orientation jointly influence food insecurity prevalence in women aged 18-59 years (NHIS: N = 47596; NHANES: N = 5106). All analyses were stratified for Supplemental Nutrition Assistance Program (SNAP) use. Relative measures estimated weighted prevalence ratios (PR) comparing Black and White sexual minority women (SMW) to heterosexual White women. Absolute prevalence measures estimated the excess prevalence of food insecurity due to multiple marginalization. Patterns of food insecurity prevalence were similar across NHIS and NHANES, and differed only for non-SNAP users. Relative prevalence of food insecurity was greater in Black SMW than heterosexual White women in NHIS (PR: 2.16; 95% confidence interval [CI], 1.41-3.30) and NHANES (PR: 2.79; 95% CI, 1.73-4.51). The strength of the association between multiple marginalization and food insecurity was stronger for Black SMW than White SMW. Absolute measures were significant only for NHIS and did not support our a priori hypothesis: For non-SNAP users, being Black and sexual minority reduced the joint disparity in food insecurity by approximately 50% (Synergy Index: 0.52; 95% CI, 0.11-0.93). Overall, our study illuminated population-level differences in food insecurity among women of diverse minority races and sexual orientations. Black SMW experienced high rates of food insecurity, which may contribute to chronic disease disparities. Yet, intersecting minority social positions (race and sexual orientation) reduced food insecurity; these findings are unexpected and must be further investigated. Increasing SNAP use among multiply marginalized women may attenuate food insecurity disparities.

Health Disparities Among Sexual Gender Minority Women in the United States: A Population-Based Study

There is a paucity of population-based research to identify health disparities experienced by sexual gender minority (SGM) women. The purpose of this study was to use a population-based data set to understand disparities in access to healthcare, preventive care, and health risk behaviors of lesbian and bisexual women compared to their straight counterparts and to each other. This was a cross-sectional study using the 2016 Behavioral Risk Factor Surveillance System data. SPSS with complex samples was used to calculate weighted descriptive statistics. Logistic regression was used to calculate odds and adjusted odds ratios. 9016 women were included in the analyses. Women who identified as lesbian were more likely to be from a minority group. Bisexual women were more likely to be in the younger age groups and were less likely to be college graduates or report a higher income. Lesbian and bisexual women were more likely to report depression, smoking, and heavy/binge drinking compared to straight women. They were also less likely to have received a pap test. Compare to lesbian women, bisexual women were more likely to report depression and poorer health. SGM women are at greater risk of depression and risky coping behaviors such as smoking and heavy/binge drinking. Within the SGM subgroup, bisexual women have a higher risk for depression and worse general health. Health promotion programs and interventions must be tailored to account for the unique stressors SGM women encounter and associated negative health outcomes.

Racial disparities in health and health behaviors among gay, lesbian, bisexual and heterosexual men and women in the BRFSS-SOP

Objectives: Research on sexual minority health lack examinations of how sexual orientation intersects with other identities, including racial/ethnic identity, to shape health outcomes among U.S. adults. This study examines how health status and health behavior varies for gay, lesbian, and bisexual men and women who identify as non-Hispanic white, non-Hispanic black, Latino, Asian/Pacific Islander, and American Indian/Alaskan Native. By examining health and health behaviors within and across sexual minority subgroups, our study reports on race/ethnic, gender, and sexual orientation specific health risks.Methods: We respond to shortcomings in current data by utilizing aggregated data from fourteen states from the Behavioral Risk Factor Surveillance System (BRFSS) collected between 2005 and 2010 (n = 557,773). We investigated the odds of reporting poorer health, current cigarette smoking, and obesity by sexual orientation within race/ethnic and gender subgroups; all statistical analyses were performed in 2016.Results: Results suggest persistent health and behavior disadvantages for lesbian and bisexual women of all racial and ethnic identities, relative to heterosexuals. Some of the heightened odds are extreme. Asian/Pacific Islander lesbian (OR = 3.92) and bisexual (OR = 4.61) women, for example, have 4.0 times higher odds of smoking than heterosexual A/PI women. Results for men are more variable. To illustrate, the odds of obesity for White and A/PI men are indistinguishable between bisexuals and heterosexuals, and Black and American Indian/Alaskan Native bisexuals have lower odds of obesity than their heterosexual counterparts.Conclusion: These findings highlight the need for policy efforts aimed at improving health and health behaviors among lesbian and bisexual women across groups, and more targeted efforts among sexual minority men.

Disparities in Health Insurance Coverage and Access to Care for Children By Mother's Sexual Orientation

OBJECTIVE

Few population-based studies have examined the health care experiences of children with sexual minority parents. The purpose of this study was to compare health insurance status, access to care, and health services utilization for children by mother's sexual orientation.

METHODS

We used data on children with lesbian mothers (n = 195), bisexual mothers (n = 299), and heterosexual mothers (n = 23,772) in the 2013-2017 National Health Interview Survey. Logistic regression models were used to compare health insurance status, access to care, and health services utilization while adjusting for demographic and socioeconomic characteristics of the child, mother, and household.

RESULTS

After controlling for sociodemographic factors, there were no statistically significant differences in health insurance coverage, access to care, or health services utilization between children of lesbian mothers and children of heterosexual mothers. Compared to children with heterosexual mothers, children with bisexual mothers were more likely to have public health insurance (OR 2.33; 95% CI 1.07-7.68), delayed medical care due to cost (OR 2.33; 95% CI 1.12-4.86), unmet medical care due to cost (OR 2.86; 95% CI 1.07-7.68), and a visit to the emergency room (OR 1.74; 95% CI 1.27-2.39) in the prior year after controlling for child-level characteristics. Some of these differences were attenuated after controlling for maternal demographics and household characteristics.

CONCLUSIONS FOR PRACTICE

Children with bisexual mothers experience barriers to routine medical care. Addressing socioeconomic dimensions of health care access and targeted outreach to bisexual parents will help promote health equity for children growing up in sexual minority households.

Racial/Ethnic Differences in Cardiometabolic Risk in a Community Sample of Sexual Minority Women

Purpose: To examine the intersection of sexual identity and race/ethnicity on self-reported cardiometabolic risk in sexual minority women (SMW). Methods: Data from the Chicago Health and Life Experiences of Women study were analyzed. Logistic regression models examined racial/ethnic differences in cardiometabolic risk (including obesity, hypertension, and diabetes) in SMW, accounting for psychosocial and behavioral factors. A variable accounting for the intersection of sexual identity and race/ethnicity was added to regression models (White lesbian women were the reference group). Results: The analytic sample included 601 SMW (237 White, 219 Black, 145 Latina). Black (adjusted odds ratio [AOR] 2.96, 95% confidence interval [CI]=1.48-5.94) and Latina (AOR 2.30, 95% CI=1.18-4.48) SMW had higher rates of lifetime trauma than White SMW. Black SMW reported higher rates of obesity (AOR 3.05, 95% CI=1.91-4.88), hypertension (AOR 1.99, 95% CI=1.08-3.66), and diabetes (AOR 3.77, 95% CI=1.46-9.74) relative to White SMW. Intersectional analyses revealed that Black lesbian (AOR 2.94, 95% CI=1.74-4.97) and Black bisexual (AOR 3.43, 95% CI=1.69-6.96) women were more likely to be obese than White lesbian women. Black lesbian women also reported higher rates of hypertension (AOR 2.09, 95% CI=1.08-4.04) and diabetes (AOR 3.31, 95% CI=1.26-8.67) than White lesbian women. No differences in cardiometabolic risk were found between Latina and White SMW. Conclusion: This study extends previous research on racial/ethnic differences in cardiometabolic risk among SMW. Prevention strategies are needed to reduce cardiometabolic risk in Black SMW. Findings highlight the need for cardiovascular disease research in SMW that incorporates longitudinal designs and objective measures.

Vaccination differences among U.S. adults by their self-identified sexual orientation, National Health Interview Survey, 2013-2015

Introduction

Very few studies have explored the associations between self-identified sexual orientation and comprehensive vaccination coverage. Most of the previous studies that reported health disparities among lesbian, gay and bisexual populations were not based on a nationally representative sample of U.S. adults, limiting the generalizability of the findings. Starting in 2013, the National Health Interview Survey (NHIS) included questions to ascertain the adult’s self-identified sexual orientation that allowed national level vaccination estimation by sexual orientation. This study examined associations of self-reported vaccination coverage for selected vaccines among U.S. adults by their sexual orientation.

Methods

We analyzed combined data from 2013–2015 NHIS, a nationally representative probability-based health survey of the noninstitutionalized U.S. population ≥18 years. For vaccines other than influenza, weighted proportions were calculated. Influenza coverage was calculated using the Kaplan-Meier procedure. Multivariable logistic regression models were used to calculate adjusted prevalence differences for each vaccine overall and stratified by sexual orientation and to identify factors independently associated with vaccination.

Results

Significant differences were observed by sexual orientation for self-reported receipt of human papillomavirus (HPV), hepatitis A (HepA), hepatitis B (HepB), and influenza vaccination. Bisexual females (51.6%) had higher HPV coverage than heterosexual females (40.2%). Gay males (40.3% and 53.6%, respectively) had higher HepA and HepB coverage than heterosexual males (25.4% and 32.6%, respectively). Bisexual females (33.9% and 58.5%, respectively) had higher HepA and HepB coverage than heterosexual females (23.5% and 38.4%, respectively) and higher HepB coverage than lesbian females (45.4%). Bisexual adults (34.1%) had lower influenza coverage than gay/lesbian (48.5%) and heterosexual adults (43.8%). Except for the association of having self-identified as gay/lesbian orientation with greater likelihood of HepA, HepB, and influenza vaccination, sexual orientation was not associated with higher or lower likelihood of vaccination. Health status or other behavioral characteristics studied had no consistent relationship with vaccination among all populations.

Conclusion

Differences were identified in vaccination coverage among the U.S. adult population by self-reported sexual orientation. This study is the first to assess associations of sexual orientation with a comprehensive list of vaccinations. Findings from this study can serve as a baseline for monitoring changes over time. All populations could benefit from improved vaccination.

Education Attainment and Obesity：Differential Returns Based on Sexual Orientation

Background: Although high educational attainment is linked to better health and lower health risk behaviors, this effect may be systemically smaller for racial and ethnic minority groups compared to Whites. However, it is still unknown whether these diminished returns also apply to marginalization based on sexual orientation. Aims: In a national sample of adults which was composed of people of color, we compared straight and homosexual people for the association between education attainment and obesity. Methods: The Social Justice Sexuality Project (SJS-2010) is a cross-sectional national survey of health and wellbeing of predominantly people of color who identify as homosexual. The current analysis included 2884 adults (age 24 or more) who were either heterosexual (n = 260) or homosexual (n = 2624). The predictor variable was education attainment, and the outcome variable was obesity status (body mass index larger than 30 kg/m² [kilograms per meter squared]). Demographic factors (age and gender), household income, nativity (US born vs. immigrant), and health (self-rated health and current smoking) were the covariates. Sexual orientation was the moderator. Results: In the pooled sample, high education attainment was protective against obesity status. Sexual orientation interacted with education attainment on odds of obesity, which was suggestive of stronger protective effects of high education attainment against obesity for heterosexual than homosexual individuals. Conclusion: High education attainment better protects heterosexual than homosexual people against obesity, a pattern similar to what has been observed for comparison of Whites and non-Whites. Smaller protective effects of education attainment on health behaviors of marginalized people are possibly, due to prejudice and discrimination that they experience. Discrimination may minimize stigmatized individuals' abilities to mobilize their economic and human resources and translate them to tangible outcomes. This finding extends the Minorities' Diminished Returns theory, suggesting that it is not just race/ethnicity but possibly any marginalizing and stigmatizing social identity that results in diminished returns of socioeconomic status resources.

Quantifying Sexual Orientation Among Homeless and Unstably Housed Women in a Longitudinal Study: Identity, Behavior, and Fluctuations Over a Three-Year Period

Sexual orientation has been linked to certain health conditions, and yet quantifying sexual orientation in longitudinal studies is challenging. This study examined different methods of accounting for sexual orientation in a cohort study of 300 homeless and unstably housed women followed every 6 months over 3 years. Altogether, 39.7% (n = 119) could be considered sexual minority at one or more time points based on identity and/or behavior; 16.3% (n = 49) reported shifts in sexual identity. Only 24.0% (n = 72) were identified as sexual minority through a single measure of sexual identity, 27.0% (n = 81) were identified with a single measure of identity and behavior, 33.0% (n = 99) were identified through annual measures of identity and behavior, and 22.0%-22.3% (n = 66-67) were identified through latent class analysis including all identity/behavior measures. This study found that sexual fluidity is common in unstably housed women, and many sexual minority women would be missed in longitudinal studies with different methods of accounting for sexual orientation.

Health-related Quality of Life Among Black Sexual Minority Women

INTRODUCTION

It is well established that socially marginalized groups experience worse health than dominant groups. However, many questions remain about the health of members of multiple marginalized groups, such as black sexual minority women. The purpose of this study was to examine the relationship between health-related quality of life (HRQOL), race, and sexual orientation identity among a general population sample of black and white women and to assess additive interaction between sexual orientation identity and race.

METHODS

This study used cross-sectional 2014 and 2015 Behavioral Risk Factor Surveillance System data from 154,995 women residing in 20 U.S. states. G-computation was used to estimate age-adjusted prevalence differences for nine dichotomized measures of HRQOL. The HRQOL of black sexual minority women was compared with the HRQOL of black heterosexual women, white sexual minority women, and white heterosexual women. Analyses were conducted in 2017.

RESULTS

Age-adjusted prevalence differences for all measures suggested worse HRQOL among black sexual minority women, compared with most of the other groups (e.g., frequent poor mental health comparing black lesbian and heterosexual women: 0.083, 95% CI= -0.017, 0.183); HRQOL among black bisexual women was often similar to or worse than white bisexual women. Most prevalence differences comparing black sexual minority women with white heterosexual women suggested additive interaction that led to stronger or weaker associations than expected. Although many point estimates suggested meaningful differences, many 95% CIs for prevalence differences, and when assessing for interaction, included 0.

CONCLUSIONS

Having two marginalized identities compared with one is often associated with worse HRQOL. In addition, race and sexual orientation identity may interact in their relationship to HRQOL, such that black sexual minority women have worse or better HRQOL than expected.

Healthcare Experiences of Underrepresented Lesbian and Bisexual Women: A Focus Group Qualitative Study

Purpose: To understand the complex healthcare experiences of women identifying as lesbian or bisexual. who are also women of color, veterans, and/or 65 years of age and older. Methods: Inclusion criteria were age 25 or older, Los Angeles County resident, self-identification as a lesbian or bisexual woman, and as an African American, Latina, Asian-Pacific Islander, and/or a veteran. For the age 65 years and older group, participants were eligible regardless of their veteran status or race/ethnicity. Five focus groups were conducted (n=35) and the same questions were asked addressing their comfort interacting with healthcare providers, the provider knowing their sexual orientation, characteristics of a perfect provider, and barriers to care. Structured qualitative analyses were performed. Results: Participants identified concerns that providers often hold to heterosexual cultural norms. Participants varied on preferences for providers of the same race/ethnicity as themselves. Lesbians who are 65 years and older identified legal barriers as major concerns. All groups identified incorrect provider assumptions about sexual orientation and sexual practices as frequently compromising their care. Participants supported the idea of certification for providers skilled in lesbian, gay, bisexual, transgender, and queer (LGBTQ) health, but expressed skepticism that such programs would necessarily result in better care. Conclusion: Healthcare provider trainings need to address the specific concerns and experiences of underrepresented lesbian and bisexual women. Healthcare environments must be transformed to effectively address their needs. More research is needed on the separate healthcare experiences of specific marginalized populations related to their sexual orientation and/or gender identity.

Tobacco Use and Sexual Orientation in a National Cross-sectional Study: Age, Race/Ethnicity, and Sexual Identity-Attraction Differences

INTRODUCTION

The purpose of this study is to determine the past-year prevalence estimates of any nicotine/tobacco use, cigarette smoking, and DSM-5 tobacco use disorder based on sexual identity among U.S. adults, and to examine potential variations in these estimates by age, race/ethnicity, and sexual identity-attraction concordance/discordance.

METHODS

The 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions collected data via in-person interviews with a cross-sectional nationally representative sample of non-institutionalized adults (response rate=60.1%) and analyses for the present study were conducted in 2017.

RESULTS

Any past-year nicotine/tobacco use, cigarette smoking, and DSM-5 tobacco use disorder were most prevalent among sexual minority-identified adults compared with heterosexual-identified adults, with notable variations based on sex, age, race/ethnicity, and sexual identity-attraction discordance. Elevated rates of any nicotine/tobacco use, cigarette smoking, and DSM-5 tobacco use disorder among sexual minorities were most prevalent among younger lesbian women and gay men, and all age groups of bisexual men and women. The odds of any nicotine/tobacco use, cigarette smoking, and DSM-5 tobacco use disorder were significantly greater among sexual identity-attraction discordant women and significantly lower among sexual identity-attraction discordant men.

CONCLUSIONS

These findings provide valuable new information about sexual minority subgroups, such as self-identified bisexual older adults and sexual identity-attraction discordant women, that appear to be at higher risk for adverse smoking-related health consequences as a result of their elevated rates of cigarette smoking. Additional attention is warranted to examine these high-risk subpopulations prospectively and, if the results are replicated with larger samples, this information can be used to target smoking-cessation and lung cancer screening efforts.

Health and healthcare disparities among U.S. women and men at the intersection of sexual orientation and race/ethnicity: a nationally representative cross-sectional study

Background

Research has shown that sexual minorities (SMs) (e.g. lesbian, gay, and bisexual individuals), compared to their heterosexual counterparts, may engage in riskier health behaviors, are at higher risk of some adverse health outcomes, and are more likely to experience reduced health care access and utilization. However, few studies have examined how the interplay between race and sexual orientation impacts a range of health measures in a nationally representative sample of the U.S. population.

Methods

To address these gaps in the literature, we sought to investigate associations between sexual orientation identity and health/healthcare outcomes among U.S. women and men within and across racial/ethnic groups. Using 2013–2015 National Health Interview Survey data (N = 91,913) we employed Poisson regression with robust variance to directly estimate prevalence ratios (PR) comparing health and healthcare outcomes among SMs of color to heterosexuals of color and white heterosexuals, stratified by gender and adjusting for potential confounders.

Results

The sample consisted of 52% women, with approximately 2% of each sex identifying as SMs. Compared to their heterosexual counterparts, white (PR = 1.25 [95% confidence interval (CI): 1.08–1.45]) and black (1.54 [1.07, 2.20]) SM women were more likely to report heavy drinking. Hispanic/Latino SM women and men were more likely to experience short sleep duration compared to white heterosexual women (1.33 [1.06, 1.66]) and men (1.51 [1.21, 1.90). Black SM women had a much higher prevalence of stroke compared to black heterosexual women (3.25 [1.63, 6.49]) and white heterosexual women (4.51 [2.16, 9.39]). White SM women were more likely than white heterosexual women to be obese (1.31 [1.15, 1.48]), report cancer (1.40 [1.07, 1.82]) and report stroke (1.91 [1.16, 3.15]. White (2.41 [2.24, 2.59]), black (1.40[1.20, 1.63]), and Hispanic/Latino SM (2.17 [1.98, 2.37]) men were more likely to have been tested for HIV than their heterosexual counterparts.

Conclusions

Sexual minorities had a higher prevalence of some poor health behaviors, health outcomes, and healthcare access issues, and these disparities differed across racial groups. Further research is needed to investigate potential pathways, such as discrimination, in the social environment that may help explain the relationship between sexual orientation and health.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4937-9) contains supplementary material, which is available to authorized users.

Sexual Health in a Social and Cultural Context: a Qualitative Study of Young Latina Lesbian, Bisexual, and Queer Women

Previous research on sexual minority and Latina women suggests that Latina lesbian, bisexual, and queer (LBQ) women may be at high risk for sexually associated and transmitted infections, but research on the sexual health and practices of this population is limited. This qualitative study explored the knowledge, attitudes, and values related to sexual health among a purposive sample of Latina LBQ women living in Seattle, WA. Latina LBQ women (N = 14) were recruited to participate in in-depth interviews about their sexual health through community organizations, flyers posted on college campuses, email and social media advertisements, and participant referrals. In-person semi-structured interviews were conducted and transcribed; transcripts were coded by two independent coders and reviewed for prominent themes. Four main themes emerged: 1) Latina sexual minorities' sexual health is shaped by their social and cultural contexts, 2) they lack needed sexual health knowledge, 3) their sexual health behaviors vary depending on the relationship status and gender of their partners, and 4) they value taking responsibility for their own sexual health. Further research is needed to better understand sexual health among Latina LBQ women and to identify ways in which their values can be leveraged to promote positive sexual health outcomes.

Cancer care in lesbian, gay, bisexual, transgender and queer populations

Lesbian, gay, bisexual, transgender and queer (LGBTQ) populations experience health and healthcare disparities that may place them at higher risk for developing cancer. In addition, LGBTQ communities have psychosocial factors, such as fear of discrimination, that have substantial impacts on their medical care. As a result, these populations have specific needs with regard to cancer screening, treatment and support that must be addressed by cancer care providers. Although much has been done to address cancer care in the general population, more improvement is needed in the care of LGBTQ patients. We aim to present an overview of the current state of LGBTQ cancer care, opportunities for improvement and how cancer centers and providers can create a better future for the care of LGBTQ cancer patients.

A Systematic Review of Cardiovascular Disease in Sexual Minorities

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Multifactorial discrimination as a fundamental cause of mental health inequities

BACKGROUND

The theory of fundamental causes explains why health disparities persist over time, even as risk factors, mechanisms, and diseases change. Using an intersectional framework, we evaluated multifactorial discrimination as a fundamental cause of mental health disparities.

METHODS

Using baseline data from the Project STRIDE: Stress, Identity, and Mental Health study, we examined the health effects of discrimination among individuals who self-identified as lesbian, gay, or bisexual. We used logistic and linear regression to assess whether multifactorial discrimination met the four criteria designating a fundamental cause, namely that the cause: 1) influences multiple health outcomes, 2) affects multiple risk factors, 3) involves access to resources that can be leveraged to reduce consequences of disease, and 4) reproduces itself in varied contexts through changing mechanisms.

RESULTS

Multifactorial discrimination predicted high depression scores, psychological well-being, and substance use disorder diagnosis. Discrimination was positively associated with risk factors for high depression scores: chronic strain and total number of stressful life events. Discrimination was associated with significantly lower levels of mastery and self-esteem, protective factors for depressive symptomatology. Even after controlling for risk factors, discrimination remained a significant predictor for high depression scores. Among subjects with low depression scores, multifactorial discrimination also predicted anxiety and aggregate mental health scores.

CONCLUSIONS

Multifactorial discrimination should be considered a fundamental cause of mental health inequities and may be an important cause of broad health disparities among populations with intersecting social identities.

Dollar for Dollar: Racial and ethnic inequalities in health and health-related outcomes among persons with very high income

Racial and ethnic disparities in health have been well-documented, and low SES is widely considered to be a driver of this relationship. However, the race-social class-health interrelationship is complex, as several studies have found race disparities between racial/ethnic minorities and whites at middle- income levels. Research on higher income persons is complicated by the lack of data for persons with incomes about $75,000. Most national datasets collect income data in categories with the highest income category being $75,000 and above. In our study, we examined racial/ethnic disparities in health status and behaviors among persons of very high income, reported income of $175,000 or above per year. Data are from the Medical Expenditure Panel Surveys (MEPS). Our findings revealed health disparities in 10 of the 16 health-related outcomes selected. African Americans were most dissimilar to whites at this income and with disadvantages on 6 health outcomes relative to whites. While results also showed some disparities for Asian Americans and Hispanic Americans relative to whites, these groups were advantaged, relative to whites on several health outcomes. Our findings indicate that income does not fully explain racial/ethnic disparities in health. Most public interventions are targeted to low income persons. However, public health interventions should target minority individuals of very high income as well, especially African Americans.

Healthcare experiences of a Black lesbian in the United States

Little is known about the healthcare experiences of Black lesbian and bisexual women. This exploratory study examined the healthcare experiences of a 24-year-old Black lesbian and the interconnection between race, ethnicity, gender, and sexual identity in her lived experiences. Data were gathered through an in-depth audio-recorded interview. Findings revealed the risks of and barriers to self-disclosure in healthcare settings, factors that influence the quality of the patient–provider relationship, and the positive and negative healthcare experiences of this Black American lesbian. This study is an important first step in exploring the healthcare experiences of Black lesbian and bisexual women. The findings of this case study highlight themes and avenues for future research. Clinical implications and suggestions for future research are discussed.

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

AIMS AND OBJECTIVES

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

BACKGROUND

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

DESIGN

This paper is a critical review.

METHODS

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

RESULTS

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

CONCLUSIONS

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

RELEVANCE TO CLINICAL PRACTICE

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

Sexual Orientation and Sexual and Reproductive Health among African American Sexual Minority Women in the U.S. South

BACKGROUND

Research on the sexual and reproductive health of sexual minority women, especially those of color, is limited.

METHODS

Using multivariable Poisson regression, we estimated risk ratios for the association between two dimensions of sexual orientation (sexual identity and sexual behavior) and five sexual and reproductive health indicators (pregnancy, contraceptive use, human immunodeficiency virus [HIV] testing, Pap test use, and sexual assault) among African American sexual minority women in the U.S. South (n = 165).

RESULTS

Lesbians were less likely than bisexual women to have ever been pregnant (risk ratio [RR], 0.64; 95% confidence interval [CI], 0.48-0.85), ever received an HIV test (RR, 0.88; 95% CI, 0.80-0.96), obtained a Pap test in the last 3 years (RR, 0.75; 95% CI, 0.61-0.91), and had an abnormal Pap test result in their lifetime (RR, 0.42; 95% CI, 0.24-0.75). Women with only female past-year sexual partners were less likely than women with male and female past-year sexual partners to have ever been pregnant (RR, 0.58; 95% CI, 0.43-0.78), ever received an HIV test (RR, 0.87; 95% CI, 0.79-0.96), obtained a Pap test in the last 3 years (RR, 0.82; 95% CI, 0.67-0.99), and had an abnormal Pap test result in their lifetime (RR, 0.55; 95% CI, 0.32-0.94). Contraceptive use, receiving an abnormal Pap test result at the time of the study visit, and experiencing sexual assault did not differ by sexual identity or behavior.

CONCLUSIONS

Several sexual and reproductive health indicators varied in relation to sexual identity and sexual behavior among Southern African American sexual minority women. Interventions that facilitate access to sexual and reproductive health services and are tailored to the unique needs of sexual orientation subgroups of sexual minority women are needed.

Rates and Predictors of Obesity Among African American Sexual Minority Women

PURPOSE

The purpose of this study is to examine rates of and risk factors for obesity in a community sample of African American sexual minority women (SMW).

METHODS

Data were collected using self-administered paper-and-pencil survey questionnaires (n = 219).

RESULTS

Participants were primarily middle aged (M = 40.1; standard deviation [SD] = 10.5 years), well educated (56.9% with a college education and above), insured (82.3%), and had a median income range from $30,000 to $39,999. The mean body mass index (BMI) of the sample was 31.6 (SD = 8.0). Based on BMI scores, over half of the participants were identified as obese (53.9%) and 25.6% were overweight. A number of comorbid illnesses were reported that could be exacerbated by excess weight, including arthritis (21.3%), adult-onset diabetes (4.9%), back problems (23.2%), high cholesterol (15.3%), high blood pressure (19.2%), and heart disease (12%). Multiple risk factors for obesity were observed, including infrequent exercise (<3 times/week = 50.9%), low levels of fruit/vegetable consumption (≤1 serving daily = 39.9%), and frequent consumption of red meat (≥3 times/week = 21.2%). Psychosocial risk factors were also reported, including "eating in response to stress" (46.0%). Depression scores predicted eating in response to stress. One-third of the sample reported interest in weight management interventions.

CONCLUSIONS

African American SMW report high rates of obesity, chronic health conditions exacerbated by weight, and health and dietary behaviors that increase risk for weight-related health disparities. These study findings have implications for additional research and intervention development.

Importance of Health and Social Care Research into Gender and Sexual Minority Populations in Nepal

Despite progressive legislative developments and increased visibility of sexual and gender minority populations in the general population, mass media often report that this population face a wide range of discrimination and inequalities. LGBT (lesbian, gay, and bisexual, and transgender) populations have not been considered as priority research populations in Nepal. Research in other geographical settings has shown an increased risk of poor mental health, violence, and suicide and higher rates of smoking, as well as alcohol and drugs use among LGBT populations. They are also risk for lifestyle-related illness such as cancer, diabetes, and heart diseases. Currently, in Nepal, there is a lack of understanding of health and well-being, social exclusion, stigma, and discrimination as experienced by these populations. Good-quality public health research can help design and implement targeted interventions to the sexual and gender minority populations of Nepal.

Do lesbians overestimate alcohol use norms? Exploring the potential utility of personalized normative feedback interventions to reduce high-risk drinking in Southern California lesbian communities

This study examines the potential utility of social norms-based approaches to reduce heavy alcohol use in lesbian community settings. In a sample of 278 Southern Californian lesbians recruited from social media networks to complete an online survey, the majority of participants overestimated the quantity of alcohol consumed by their lesbian peers and more frequent lesbian bar attendance was associated with elevated perceptions of how much other lesbians drink. Greater than 90% of participants expressed interest in receiving personalized normative feedback, suggesting that culturally tailored personalized normative feedback interventions focused on correcting perceptions of heavy drinking may be successful in mitigating the alcohol-related risks of lesbians in Southern California, and potentially beyond.

Using the Bem and Klein Grid Scores to Predict Health Services Usage by Men

We examined the association between scores on the Bem Sex Roles Inventory (BSRI), Klein Sexual Orientation Grid, and utilization of hospital inpatient services, emergency departments, and outpatient clinic visits in the past 12 months among 53 men (mean age 39 years). The femininity subscale score on the BSRI, ever having had gonorrhea and age were the three variables identified in a multivariate linear regression significantly predicting use of total health services. This supports the hypothesis that sex roles can assist our understanding of men's use of health services.

Selected Diagnosed Chronic Conditions by Sexual Orientation: A National Study of US Adults, 2013

Introduction

Research is needed on chronic health conditions among lesbian, gay, and bisexual populations. The objective of this study was to examine 10 diagnosed chronic conditions, and multiple (≥2) chronic conditions (MCC), by sexual orientation among US adults.

Methods

The 2013 National Health Interview Survey was used to generate age-adjusted prevalence rates and adjusted odds ratios of diagnosed chronic conditions and MCC for civilian, noninstitutionalized US adults who identified as gay/lesbian, straight, or bisexual, and separately for men and women. Chronic conditions were selected for this study on the basis of previous research.

Results

Hypertension and arthritis were the most prevalent conditions for all groups. Gay/lesbian adults had a 4.7 percentage-point higher prevalence of cancer than bisexual adults, and a 5.6 percentage-point higher prevalence of arthritis and a 2.9 percentage point higher prevalence of hepatitis than straight adults. The prevalence of chronic obstructive pulmonary disease was 8.1 percentage points higher among bisexual adults than among gay/lesbian adults and 7.0 percentage points higher than among straight adults. These differences remained in the multivariate analyses. Additional differences were found in the sex-stratified analyses. No significant differences were found in MCC by sexual orientation.

Conclusion

After age adjustment and controlling for sociodemographic characteristics, only a few significant health disparities for diagnosed chronic conditions were found by sexual orientation, and none for MCC. However, for conditions where differences were found, magnitudes were relatively large. Further examination of these differences among gay/lesbian and bisexual adults could yield a better understanding of why these disparities exist.

Racial/ethnic differences in identity and mental health outcomes among young sexual minority women

Previous research suggests that sexual minorities are at greater risk for trauma exposure, mental health problems, and substance use. To date, few studies have examined racial/ethnic differences among sexual minorities in relation to health-related behaviors and outcomes. Furthermore, studies of racial/ethnic differences among young adult sexual minority women (SMW) are virtually nonexistent. The current study adds to the previous literature by exploring differences in trauma exposure, sexual identity, mental health, and substance use in a nonprobability national sample of young adult SMW. A total of 967 self- identified lesbian and bisexual women were recruited via the Internet using social networking sites to participate in a larger longitudinal study on young women's health behaviors. The present study included 730 (76%) White, 108 (10%) African American, 91 (9%) Latina, and 38 (4%) Asian women ages 18 to 25 years. Results revealed differences in socioeconomic variables, degree of outness to family, childhood sexual assault, and forcible rape, but not overall lifetime trauma exposure. Among mental health and health-related behavior variables, few differences between groups emerged. Our findings indicate that both researchers and clinicians should turn their attention to processes of resilience among young SMW, particularly young SMW of color.

Exploring the Cervical Cancer Screening Experiences of Black Lesbian, Bisexual, and Queer Women: The Role of Patient-Provider Communication

Few studies have focused on the health and health care of U.S. black lesbian, bisexual, and queer (LBQ) women. To understand the facilitators of and barriers to cervical cancer screening in this population, focus group discussions were conducted in Boston and Cambridge, Massachusetts between November and December 2012. Using purposive sampling methods, the authors enrolled 18 black LBQ women who participated in one of four focus groups. Using thematic analysis, patient-provider communication was identified, which consisted of four sub-themes--health care provider communication style and demeanor; heteronormative provider assumptions; heterosexism, racism, and classism; and provider professional and sociodemographic background--as the most salient theme. Participants reported fears and experiences of multiple forms of discrimination and preferred receiving care from providers who were knowledgeable about same-sex sexual health and shared their life experiences at the intersection of gender, race/ethnicity, and sexual orientation. The cervical cancer screening experiences of black LBQ women would be improved by training all health care providers in same-sex sexual health, offering opportunities for clinicians to learn about the effects of various forms of discrimination on women's health care, and increasing the presence of LBQ women of color in health care settings.

Trends in sexual orientation missing data over a decade of the California Health Interview Survey

OBJECTIVES

We explored changes in sexual orientation question item completion in a large statewide health survey.

METHODS

We used 2003 to 2011 California Health Interview Survey data to investigate sexual orientation item nonresponse and sexual minority self-identification trends in a cross-sectional sample representing the noninstitutionalized California household population aged 18 to 70 years (n = 182 812 adults).

RESULTS

Asians, Hispanics, limited-English-proficient respondents, and those interviewed in non-English languages showed the greatest declines in sexual orientation item nonresponse. Asian women, regardless of English-proficiency status, had the highest odds of item nonresponse. Spanish interviews produced more nonresponse than English interviews and Asian-language interviews produced less nonresponse when we controlled for demographic factors and survey cycle. Sexual minority self-identification increased in concert with the item nonresponse decline.

CONCLUSIONS

Sexual orientation nonresponse declines and the increase in sexual minority identification suggest greater acceptability of sexual orientation assessment in surveys. Item nonresponse rate convergence among races/ethnicities, language proficiency groups, and interview languages shows that sexual orientation can be measured in surveys of diverse populations.

Mortality risks among persons reporting same-sex sexual partners: evidence from the 2008 General Social Survey-National Death Index data set

OBJECTIVES

We investigated the possibility that men who have sex with men (MSM) and women who have sex with women (WSW) may be at higher risk for early mortality associated with suicide and other sexual orientation-associated health risks.

METHODS

We used data from the 1988-2002 General Social Surveys, with respondents followed up for mortality status as of December 31, 2008. The surveys included 17 886 persons aged 18 years or older, who reported at least 1 lifetime sexual partner. Of these, 853 reported any same-sex partners; 17 033 reported only different-sex partners. Using gender-stratified analyses, we compared these 2 groups for all-cause mortality and HIV-, suicide-, and breast cancer-related mortality.

RESULTS

The WSW evidenced greater risk for suicide mortality than presumptively heterosexual women, but there was no evidence of similar sexual orientation-associated risk among men. All-cause mortality did not appear to differ by sexual orientation among either women or men. HIV-related deaths were not elevated among MSM or breast cancer deaths among WSW.

CONCLUSIONS

The elevated suicide mortality risk observed among WSW partially confirms public health concerns that sexual minorities experience greater burden from suicide-related mortality.

An ecological framework for sexual minority women's health: factors associated with greater body mass

In recent years, many studies have focused on the body of sexual minority women, particularly emphasizing their larger size. These studies rarely offer theoretically based explanations for the increased weight, nor study the potential consequences (or lack thereof) of being heavier. This article provides a brief overview of the multitude of factors that might cause or contribute to larger size of sexual minority women, using an ecological framework that elucidates upstream social determinants of health as well as individual risk factors. This model is infused with a minority stress model, which hypothesizes excess strain resulting from the stigma associated with oppressed minority identities such as woman, lesbian, bisexual, woman of color, and others. We argue that lack of attention to the upstream social determinants of health may result in individual-level victim blaming and interventions that do not address the root causes of minority stress or increased weight.

Bicultural Straddling Among Immigrant Adolescents: A Concept Analysis

BACKGROUND

Increasing population diversity in the United States creates challenges for providing culturally responsive health care to immigrant adolescents. Nursing providers have few effective concepts to guide their understanding of how culturally diverse adolescents handle different cultural influences (between family and society) and how straddling two cultures may influence adolescents' decision making about health.

AIM

Bicultural straddling is defined as an ongoing process of adaptation resulting from living within two different cultural influences. A concept analysis of bicultural straddling is important to nursing professionals in caring for culturally diverse adolescents.

METHOD

Walker and Avant's methodology was used to guide our understanding about how immigrant adolescents straddle cultural influences between their homes and society.

RESULTS

Straddling two different cultures influences adolescents' health-related beliefs, attitudes, perceptions, and behaviors as they navigate everyday struggles to make informed health decisions. Adolescents' ability to achieve active straddling will allow them to experience positive social functioning, psychological development, and health outcomes.

CONCLUSIONS

By understanding the ongoing process of "bicultural straddling" as a balancing act, nurse professionals can develop effective interventions to alleviate stress derived from acculturation among immigrant families and ultimately help adolescents achieve biculturalism.

Chronic Physical Health Problems in Sexual Minority Women: Review of the Literature

Although there is substantial literature about sexual minority women's mental health and use of alcohol, tobacco, and other drugs (ATOD), only recently has attention been focused on chronic physical health disorders thought to stem from stress and exposure to ATOD use. The most extensively studied aspect of physical health has been weight, with the majority of studies reporting higher prevalence of overweight and obesity. In addition, many studies report higher levels of stressful experiences in both childhood and adulthood for sexual minority women. In this paper, the hypothesized relationship between stress, unhealthy behaviors, and five common chronic physical health disorders is explored via review of the literature. Only asthma appeared to be consistently more common in sexual minority women, and few or no differences in diabetes, hypertension, cardiovascular disease, and most cancers were found. The limitations of these studies are reviewed, and the need for studies that directly address the relationships among stress, health-damaging practices, and chronic disorder is emphasized. However, if these findings hold up, and sexual minority women are not more prone to these disorders, the field may need better theoretical frameworks from which to explore potential differences in the manifestation of mental versus chronic physical health disparities.

At the intersection of sexual orientation, race/ethnicity, and cervical cancer screening: assessing Pap test use disparities by sex of sexual partners among black, Latina, and white U.S. women

Understanding how various dimensions of social inequality shape the health of individuals and populations poses a key challenge for public health. Guided by ecosocial theory and intersectionality, we used data from the 2006-2010 National Survey of Family Growth, a national probability sample, to investigate how one dimension of sexual orientation, sex of sexual partners, and race/ethnicity jointly influence Pap test use among black, Latina and white U.S. women aged 21-44 years (N = 8840). We tested for an interaction between sex of sexual partners and race/ethnicity (p = 0.015) and estimated multivariable logistic regression models for each racial/ethnic group, adjusting for socio-demographic factors. The adjusted odds of Pap test use for women with only female sexual partners in the past year were significantly lower than for women with only male sexual partners in the past year among white women (odds ratio [OR] = 0.25, 95% confidence interval [CI]: 0.12,0.52) and may be lower among black women (OR = 0.32, 95% CI: 0.07,1.52); no difference was apparent among Latina women (OR = 1.54, 95% CI: 0.31,7.73). Further, the adjusted odds of Pap test use for women with no sexual partners in the past year were significantly lower than for women with only male sexual partners in the past year among white (OR = 0.30, 95% CI: 0.22,0.41) and black (OR = 0.23, 95% CI: 0.15,0.37) women and marginally lower among Latina women (OR = 0.63, 95% CI: 0.38,1.03). Adding health care indicators to the models completely explained Pap test use disparities for women with only female vs. only male sexual partners among white women and for women with no vs. only male sexual partners among Latina women. Ecosocial theory and intersectionality can be used in tandem to conceptually and operationally elucidate previously unanalyzed health disparities by multiple dimensions of social inequality.

Racial Disparities in Health Behaviors and Conditions Among Lesbian and Bisexual Women: The Role of Internalized Stigma

There are documented disparities in physical health behaviors and conditions, such as physical activity and obesity, with regard to both race/ethnicity and sexual orientation. However, physical health disparities for lesbian and bisexual (LB) women who are also racial minorities are relatively unexplored. Minority stressors, such as internalized stigma, may account for disparities in such multiply marginalized populations. We sought to (1) characterize inequalities among non-Hispanic white and African American LB women and (2) examine the roles of internalized sexism and homophobia in disparities. Data on health behaviors (diet, physical activity); physical health (hypertension, diabetes, overweight/obesity); internalized sexism; and internalized homophobia were collected via a web-based survey. Recruitment ads were sent electronically to over 200 listservs, online groups, and organizations serving the lesbian, gay, and bisexual community in all 50 U.S. states. The analytic sample consisted of 954 white and 75 African American LB women. African American participants were more likely than white participants to report low fruit/vegetable intake and physical activity, a higher body mass index, and a history of diabetes and hypertension. There were no racial differences in internalized homophobia, but African American women reported higher levels of internalized sexism. Internalized sexism partially mediated racial disparities in physical activity and diabetes, but not in the other outcomes. Findings suggest that African American LB women may be at greater risk than their white counterparts for poor health and that internalized sexism may be a mediator of racial differences for certain behaviors and conditions.

Gender expression, sexual orientation and pain sensitivity in women

BACKGROUND

Despite a growing body of literature investigating sex differences with regard to pain, surprisingly little research has been conducted on the influence of various aspects of self-identity, including gender expression and sexual orientation, on pain sensitivity within each sex, particularly among women. In men, dispositional femininity is linked to greater clinical pain and trait masculinity is associated with higher pain thresholds.

OBJECTIVES

To examine whether gender expression and sexual orientation are associated with within-sex differences in ischemic pain sensitivity in healthy young women.

METHODS

A convenience sample of 172 females (mean age 21.4 years; range 18 to 30 years of age; 56.0% white, 89% heterosexual) performed an ischemic pain task in counterbalanced order. Desired levels of dispositional femininity for a preferred romantic partner and self-described levels of personal dispositional femininity were measured.

RESULTS

Compared with heterosexual women, lesbian and bisexual women reported lower pain intensity ratings early in the discomfort task. Irrespective of sexual orientation, attraction to more feminine romantic partners and dispositional masculinity were correlated with lower pain intensity, and with higher pain thresholds and tolerance levels.

DISCUSSION

These preliminary findings suggest that within-sex differences in sexual orientation and other aspects of identity, irrespective of biological sex, may be important to consider when examining experimental pain performance and clinical pain experiences.

CONCLUSION

Larger investigations of the psychophysiological relationships among sexual orientation, gender expression and pain sensitivity are warranted. These findings may have implications for differences in clinical pain sensitivity of lesbian and bisexual women compared with heterosexual women.

Multiple disadvantaged statuses and health: the role of multiple forms of discrimination

The double disadvantage hypothesis predicts that adults who hold more than one disadvantaged status may experience worse health than their singly disadvantaged and privileged counterparts. Research that has tested this thesis has yielded mixed findings due partly to a failure to examine the role of discrimination. This article uses data from the National Survey of Midlife Development in the United States (N = 2,647) to investigate the relationship between multiple disadvantaged statuses and health, and whether multiple forms of interpersonal discrimination contribute to this association. The results suggest that multiply disadvantaged adults are more likely to experience major depression, poor physical health, and functional limitations than their singly disadvantaged and privileged counterparts. Further, multiple forms of discrimination partially mediate the relationship between multiple stigmatized statuses and health. Taken together, these findings suggest that multiply disadvantaged adults do face a "double disadvantage" in health, in part, because of their disproportionate exposure to discrimination.

Demographic, psychosocial, and contextual factors associated with sexual risk behaviors among young sexual minority women

Young sexual minority women are at risk for negative sexual health outcomes, including sexually transmitted infections and unintended pregnancies, yet little is known about these risks. We examined factors that may influence sexual risk from a psychosocial and contextual perspective. Analyses were conducted to examine within group relationships between sexual behaviors, negative outcomes, and related factors in a sample of young sexual minority women. Participants (N = 131) were young (mean = 19.8) and diverse in terms of race/ethnicity (57% non-White). Sex under the influence, having multiple partners, and having unprotected sex were common behaviors, and pregnancy (20%) and sexually transmitted infection (12%) were common outcomes. Risk behaviors were associated with age, alcohol abuse, and older partners. Results support the need for further research to understand how these factors contribute to risk in order to target risk reduction programs for this population.

The relationships of sexual identity, hazardous drinking, and drinking expectancies with risky sexual behaviors in a community sample of lesbian and bisexual women

This study examined the influence of demographic characteristics, sexual identity, hazardous drinking, and sexuality/intimacy enhancement alcohol expectancies on rates of risky sexual behaviors in a community sample of women who self-identified as lesbian, mostly lesbian, and bisexual (N = 349). Structured interview data were collected as part of a larger longitudinal study of sexual minority women's health, the Chicago Health and Life Experiences of Women study. We used structural equation modeling, controlling for demographic characteristics, to evaluate the influence of sexual identity, hazardous drinking, and alcohol-related sexuality/intimacy enhancement expectancies on sexual risk behaviors. Controlling for demographic characteristics and for sexual identity, higher levels of both hazardous drinking and sexuality/intimacy enhancement alcohol expectancies were associated with higher sexual risk scores. The final model predicted 36% of the variance in risky sexual behavior scores. Our findings regarding the central role of alcohol use and sexuality/intimacy enhancement expectancies in sexual risk behaviors among sexual minority women are consistent with previous research focusing on predominantly heterosexual women. Future efforts at sexual risk reduction in sexual minority women will need to address the influences of alcohol use and drinking-related expectancies on sexual behaviors and decision making.