Sexual Minority Health Disparities Research Articles

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

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

Invited Perspective: Moving from Characterizing to Addressing Racial/Ethnic Disparities in Air Pollution Exposure.

Invited Perspective: Moving from Characterizing to Addressing Racial/Ethnic Disparities in Air Pollution Exposure.

Differences in how spouses influence each other's alcohol use in same- and different-sex marriages: A daily diary study.

Different-sex spouses influence each other's alcohol consumption, with women having more influence on their spouses than men. Because women drink less than men, this long-term influence partly explains why married men and women consume less alcohol than their unmarried peers. However, much less is known about possible gender differences in the ways spouses influence each other's alcohol use on a day-to-day basis in same-compared to different-sex marriages. Because sexual minority people are at higher risk for alcohol use disorders compared to their heterosexual counterparts, such knowledge could shed light on ways to reduce this risk and alcohol use disparities between sexual minority and heterosexual people. We use 10 days of diary data collected in 2014-2015 in the United States from 157 female same-sex, 106 male same-sex, and 115 different-sex married couples in midlife (ages 35-65) to examine how one spouse's drinking influences how much the other spouse drinks on the following day. Men reported higher levels of daily drinking than women; after including covariates, men in different-sex marriages reported drinking at the highest levels. Results from actor-partner interdependence models show that men in same- and different-sex marriages drink more, and women in different-sex marriages drink less when their spouse drinks more the previous day. Female same-sex spouses did not change their drinking behaviors in response to their spouse's drinking. Overall higher rates of drinking among men in same-sex marriages suggest an accumulation effect of drinking that may contribute to sexual minority health disparities. Women and men in different-sex marriages may be engaging in social control or navigating masculinity norms. Women in same-sex marriages may not feel the need to adjust to low levels of drinking by their spouses. Findings suggest that spousal influence over alcohol consumption unfolds differently in same-sex compared to different-sex marriages.

Increased Reporting of Sexual Minority Orientation from 2009 to 2017 in England and Implications for Measuring Sexual Minority Health Disparities.

Purpose: Sexual minority adults experience considerable mental and physical health disparities compared to their heterosexual counterparts, but changes in these disparities over time may, in part, reflect changes in how the same people self-identify their sexual orientation. Therefore, we estimated between-cohort and within-person changes in self-identified sexual orientation to better understand changes in sexual orientation-based health disparities over the life course. Methods: We examined 2009 to 2015 changes among 5712 adults 19-25 years of age from the Longitudinal Study of Young People in England (LSYPE) to validate a synthetic cohort approach applied to cross-sectional data on 1,168,346 adults 18-74 years of age (n = 29,677 sexual minority adults) from the General Practice Patient Survey (GPPS), estimating 2009 to 2017 changes in sexual orientation identification. Results: Heterosexual identification for adults 18-24 years of age fell three percentage points from 2009 to 2017. Approximately half of those 26-32 years of age, who identified as sexual minority adults in 2017, may not have identified as such 8 years earlier. LSYPE and GPPS results were similar, validating the synthetic cohort application. Within-cohort analyses estimated that 2.1% and 2.7% of heterosexual-identified women and men 18-24 years of age in 2009, respectively, changed identification by 2017. Smaller changes occurred for adults 25-34 years of age (1.0% and 1.2%, respectively), with still smaller differences at older ages. Conclusion: Changes in health disparities may reflect people newly identifying as a sexual minority as well as longitudinal changes in those long identifying as sexual minority adults. Future research should measure the health of both early- and late-identifying sexual minority adults, as their health care and policy needs may differ.

Sexual Orientation and Diabetes During the Transition to Adulthood.

Purpose: The purpose of this study was to examine how sexual orientation in adolescence and young adulthood was linked to diabetes risk. Methods: Data were drawn from the 1994-2008 National Longitudinal Study of Adolescent to Adult Health. The baseline sample included 4330 girls and 3510 boys ages 12-18. Guided by the life course approach, we considered both the timing and continuity of sexual orientation-broadly defined by sexual identity, sexual attraction, sexual contact, and romantic/sexual relationships-by differentiating respondents into four categories: sexual minority in both adolescence and adulthood, sexual minority in adulthood only, sexual minority in adolescence only, and heterosexual in both adolescence and young adulthood. Diabetes was identified using A1c and glucose biomarkers and self-reports of diabetes diagnosis or medication use. Results: Results from logistic regression models indicated that in comparison with their continuously heterosexual counterparts, respondents reporting sexual minority status in adulthood only or continuously in both adolescence and adulthood had higher diabetes risk in adulthood. However, respondents reporting sexual minority status in adolescence only were not different in diabetes risk in adulthood. The association between diabetes risk and continuous sexual minority status was stronger among women than among men. Conclusions: Sexual minority health disparities emerge early in the life course during adolescence and young adulthood. These findings highlight the importance of designing and implementing policies and public programs to alleviate minority stress early in life to reduce health disparities.

Sexual minority health disparities: an examination of age-related trends across adulthood in a national cross-sectional sample

PurposeSexual minorities experience significant health disparities across a variety of mental, behavioral, and physical health indicators. Yet, an understanding of the etiology and progression of sexual minority health disparities across the lifespan is limited. MethodsWe used the U.S. National Epidemiologic Survey of Alcohol and Related Conditions III to evaluate the association between sexual minority status and seven past-year health outcomes (alcohol use disorder, tobacco use disorder, drug use disorder, major depressive episode, generalized anxiety disorder, sexually transmitted infection, and cardiovascular conditions). To do this, we used unadjusted and adjusted logistic regression among our study sample (n = 30,999; aged 18–65 years) and time-varying effect models to evaluate how sexual orientation differences in these outcomes vary across adulthood. ResultsRelative to heterosexuals, sexual minorities had elevated odds of past-year alcohol use disorder and drug use disorder across all ages (18–65 years) although the magnitude of the disparity varies by age. Sexual minorities were also more likely to experience major depressive episode, generalized anxiety disorder, tobacco use disorder, sexually transmitted infection, and cardiovascular disease, but only at specific ages. ConclusionsSexual minority health disparities vary appreciably across the adult lifespan, thus elucidating critical periods for focused prevention efforts.

Are You in, or Are You Out? Implications of Inclusion Criteria in Sexual Minority Health Disparities Research

Those who identify as lesbian, gay, or bisexual are found to be at a heightened risk for problematic health outcomes, including substance use. Sexual minority identities are concealable, multidimensional, exist on a continuum, and develop fluidly. Together, these factors are important predictors of health outcomes, yet they have been neglected in the process of sample identification in health disparity research. Inclusion criteria employed when identifying samples affects research findings and potentially biases results when crucial factors are neglected. Using the National Longitudinal Study of Adolescent to Adult (Add Health), the authors identified four samples of sexual minorities (i.e., broad self-identified, broad multidimensional, narrow self-identified, and narrow multidimensional) based on the continuum of self-identification and multidimensional factors and examined a trajectory of binge drinking predicted by various relevant factors. When the authors defined the samples using different inclusion criteria and examined the results across these samples, differences in the results emerged and fell into four main patterns: (1) sex differences, (2) differences in the average frequency and rate of change in binge drinking, (3) differences in statistical significance, and (4) Implications. Inclusion criteria alone had a significant impact on the health implications for lesbian, gay, and bisexual individuals in this study and thus should encourage cautious interpretation and application of research on sexual minority health by care professionals. The authors discuss research implications for these findings.

Sexual Orientation Group Differences in Perceived Stress and Depressive Symptoms Among Young Adults in the United States.

Overall, sexual minorities have poorer mental health than heterosexual individuals, and stress is thought to underlie such disparities. However, sexual minorities include both those identifying as lesbian, gay, or bisexual (LGB) and many who do not (e.g., individuals identifying as mostly heterosexual, or as heterosexual but with discordant same-sex attractions or behaviors), and little is known about the mental health or stress experiences of non-LGB identified sexual minorities. This study assessed perceived stress and depressive symptom differences between concordant heterosexual individuals and three groups of sexual minority young adults (LGB, mostly heterosexual, and discordant heterosexual individuals). Data were from the National Longitudinal Study of Adolescent to Adult Health, Wave IV (2008-2009). Descriptive and bivariate statistics were estimated. Path analyses assessed whether perceived stress mediated differences in depressive symptomatology. Analyses were weighted and gender-stratified. Mostly heterosexual individuals comprised the largest sexual minority group, for both men (3.58%) and women (15.88%). All sexual minority groups reported significantly more depressive symptoms than concordant heterosexual individuals, for both men and women (all P < 0.05). Among women, all sexual minority groups reported significantly higher perceived stress than concordant heterosexual individuals (all P < 0.05), which partially mediated elevations in depressive symptomatology (all P < 0.05). Mostly-heterosexual-identified men reported significantly higher perceived stress than concordant heterosexual men (P < 0.01), which partially mediated elevations in depressive symptomatology (P < 0.01). Our results underscore the importance of assessing sexual orientation comprehensively to fully understand sexual minority health disparities. Additional research should examine the stressors specific to different sexual minority groups.

Physical Health Disparities Across Dimensions of Sexual Orientation, Race/Ethnicity, and Sex: Evidence for Increased Risk Among Bisexual Adults.

Accumulating evidence suggests that sexual minority individuals are at increased risk for physical health conditions compared to heterosexual individuals. However, we know little about physical health disparities affecting bisexual individuals, a population at increased risk for psychiatric and substance use conditions compared to both heterosexual and lesbian/gay populations. Using a large, nationally representative sample, we examined physical health disparities for bisexual individuals. To advance research on sexual minority health disparities, we further: (1) compared prevalence rates of physical health conditions across three dimensions of sexual orientation (i.e., identity, attractions, behavior) and (2) examined whether disparities differed by sex and race/ethnicity. Results indicated that sexual minority individuals were at increased risk for many physical health conditions. Notably, individuals with bisexual identity, attractions, and/or behavior were at increased risk for more physical health conditions than other sexual minority groups. The number and types of physical health disparities affecting bisexually identified individuals and individuals with same- and opposite-sex attractions and/or sexual partners varied across sex and race/ethnicity, with the most consistent disparities emerging for individuals who reported same- and opposite-sex sexual partners. Our findings highlight the substantial physical health disparities affecting sexual minorities and the heightened risk conferred by all facets of bisexuality.

Life Satisfaction Across Adulthood in Bisexual Men and Women: Findings from the Midlife in the United States (MIDUS) Study.

The number of lesbian, gay, and bisexual (LGB) adults aged 50 and older is projected to reach 5 million in the U.S. by 2030 (Fredriksen-Goldsen, Kim, Shiu, Goldsen, & Emlet, 2015). Older bisexuals experience more negative mental and physical health outcomes when compared to both heterosexuals and other sexual minorities (Fredriksen-Goldsen, Shiu, Bryan, Goldsen, & Kim, 2017). As bisexuals are the numeric majority of sexual minorities in the U.S. (Herbenick et al., 2010), bisexual aging processes are critical to understand if researchers wish to reduce sexual minority health disparities and promote healthy aging. In the current study, we use a national probability sample of adults from the Midlife in the United States (MIDUS) study to assess life satisfaction across an 18-year period. We aimed to identify whether life satisfaction-an indicator of psychological health and well-being-is similar for same-age bisexual, lesbian and gay, and heterosexual midlife individuals, and whether sexual orientation predicts change in life satisfaction across adulthood. Further, we tested whether life satisfaction among bisexuals changes at the same rate and in the same pattern as for lesbian, gay, and heterosexual individuals. Overall, we found a linear pattern of increase in life satisfaction across adulthood. However, when we accounted for sexual orientation, a different pattern emerged for bisexuals. Whereas heterosexuals and lesbian and gay individuals experienced increases in life satisfaction across adulthood, bisexuals' life satisfaction did not increase over this period. Implications for bisexual health and well-being are discussed.

Understanding Sexual Minority Health Disparities in Rural Areas

AbstractThis article reviews research from several disciplines including sociology, psychology, and public health to examine recent inconsistencies in findings of rural/urban health disparities among sexual minority populations. Previous work has found that sexual minorities (lesbian, gay, and bisexual individuals) report worse health than their heterosexual counterparts on many physical and mental health measures. To understand this occurrence, scholars have situated these findings most often within either minority stress or fundamental cause frameworks. These theories attribute health differences to unique stressors and stigmatization experienced by sexual minorities within a heteronormative social climate. This review provides an overview of specific health disparities by gender and sexual orientation, critically examines research on rural/urban health differences among sexual minorities, and offers three avenues for future research to help remedy the inconsistent results of previous rural/urban sexual minority health disparities research. Discussions of the ‘rural effect,’ rural social support resources, and the importance of geographic region for health are included as opportunities to further social scientific research on sexual minority health disparities.

Environmental injustice and sexual minority health disparities: A national study of inequitable health risks from air pollution among same-sex partners

Air pollution is deleterious to human health, and numerous studies have documented racial and socioeconomic inequities in air pollution exposures. Despite the marginalized status of lesbian, gay, bisexual, and transgender (LGBT) populations, no national studies have examined if they experience inequitable exposures to air pollution. This cross-sectional study investigated inequities in the exposure of same-sex partner households to hazardous air pollutants (HAPs) in the US. We examined cancer and respiratory risks from HAPs across 71,207 census tracts using National Air Toxics Assessment and US Census data. We calculated population-weighted mean cancer and respiratory risks from HAPs for same-sex male, same-sex female and heterosexual partner households. We used generalized estimating equations (GEEs) to examine multivariate associations between sociodemographics and health risks from HAPs, while focusing on inequities based on the tract composition of same-sex, same-sex male and same-sex female partners. We found that mean cancer and respiratory risks from HAPs for same-sex partners are 12.3% and 23.8% greater, respectively, than for heterosexual partners. GEEs adjusting for racial/ethnic and socioeconomic status, population density, urban location, and geographic clustering show that living in census tracts with high (vs. low) proportions of same-sex partners is associated with significantly greater cancer and respiratory risks from HAPs, and that living in same-sex male partner enclaves is associated with greater risks than living in same-sex female partner enclaves. Results suggest that some health disparities experienced by LGBT populations (e.g. cancer, asthma) may be compounded by environmental exposures. Findings highlight the need to extend the conceptual framework for explaining LGBT health disparities beyond psycho-behavioral mechanisms translating social stress into illness to include environmental mechanisms. Because psycho-behavioral and environmental factors may together exacerbate health disparities, we call for a shift toward interdisciplinary research on LGBT health that takes into account cumulative risks, including the role of environmental exposures.

Concealment of Sexual Minority Identities in Interviewer-Administered Government Surveys and Its Impact on Estimates of Suicide Ideation Among Bisexual and Gay Men

ABSTRACTBisexual and gay men are at increased risk of suicide ideation. Characterizing this risk requires self-disclosure of sexual identities; however, many will conceal their identity when interviewed. The authors investigated the impact of the resulting information bias within the Canadian Community Health Survey (CCHS). Expected probabilities of disclosure were derived from a community-based survey of bisexual and gay men, stratified by sexual identity and other social characteristics. Forty percent of bisexual men and 86% of gay men were willing to disclose to CCHS interviewers. The odds of suicide ideation were higher for bisexual (odds ratio [OR] = 4.91) and gay (OR = 3.63) men compared to heterosexual men. After bias analysis these disparities remained significant but were attenuated, with greater attenuation for bisexual (adjusted OR = 3.53) than for gay (adjusted OR = 3.52) men. The authors recommend that researchers continue exploring bias in estimated sexual minority health disparities, and that population surveys be more inclusive of bisexual-identified individuals.

The Health Disparities of Same-Sex Cohabitors at the Intersection of Race-Ethnicity and Gender.

We work from a minority stress perspective to theorize health disparities across union status at the intersection of sexual minority status, race-ethnicity, and gender. We use pooled data from the Integrated National Health Interview Surveys (1997–2014) to assess a wide range of health outcomes, including self-rated physical health, psychological distress, and health behaviors. Results suggest that same-sex cohabitors face substantial health disadvantages relative to different-sex married individuals, with little variation by race-ethnicity and gender. Fewer health differences are found for same-sex cohabitors in comparison with both different-sex cohabitors and unpartnered singles, although greater variation by gender and race-ethnicity is found across these comparisons. This study highlights the importance of integrating intersectionality and minority stress theories to guide future research examining sexual minority health disparities. Results suggest that the sexual minority health disadvantage, as well as the potential health boost of same-sex marriage, may depend on the intersection of race-ethnicity and gender.

Lifetime Prevalence of Suicide Attempts Among Sexual Minority Adults by Study Sampling Strategies: A Systematic Review and Meta-Analysis.

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. To reassess the burden of suicide-related behavior among LGB adults, directly comparing estimates derived from population- versus LGB community-based samples. In 2014, we searched MEDLINE, EMBASE, PsycInfo, CINAHL, and Scopus databases for articles addressing suicide-related behavior (ideation, attempts) among sexual minorities. We selected quantitative studies of sexual minority adults conducted in nonclinical settings in the United States, Canada, Europe, Australia, and New Zealand. 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). 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. 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. 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.

Lifetime Prevalence of Suicide Attempts Among Sexual Minority Adults by Study Sampling Strategies: A Systematic Review and Meta-Analysis

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 τ2. 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.

Sexual Minority Health Disparities in Adult Men and Women in the United States: National Health and Nutrition Examination Survey, 2001-2010.

We used nationally representative data to investigate health disparities associated with sexual minority status among adults in the United States. We analyzed data from 11,114 adults who participated in the 2001 to 2010 waves of the National Health and Nutrition Examination Survey. Using multiple logistic regressions, we examined the prevalence of HIV, sexually transmitted infections, mental health problems, cigarette smoking, and alcohol and illicit drug use in sexual minorities and heterosexual adults. After adjusting for sociodemographic characteristics, sexual minority men had greater odds of mental health problems, testing positive for HIV and herpes simplex virus type 2 and self-reported gonorrhea and chlamydia. Sexual minority women had greater odds of mental health problems, testing positive for hepatitis C, smoking, heavy drinking, and illicit drug use. Numerous health disparities continue to face sexual minority men and women in the United States. Notably, health disparities persisted beyond the role of sociodemographic factors, including access to insurance and primary care, suggesting that further research is warranted to identify the determinants of health inequity for sexual minorities.