Center for Population Research in L G B T Health

Featured Findings

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LGB Mental Health Related to State-Level Anti-Discrimination Policies

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A recent analysis of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a large, population-based epidemiological survey of U.S. adults, showed a relationship between state-level policies that protect lesbian, gays and bisexuals (LGBs) from discrimination and hate crimes and the mental health of LGB populations. (more)

As demonstrated in the graph above, the study affirmed the results of previous research by finding a higher prevalence of psychiatric morbidity in LGB populations as compared with heterosexuals. The study further showed that LGBs had a higher prevalence of mental disorders if they lived in a state that did not have one or more of the following protective policies:

  • Hate crime statutes that specify sexual orientation as a protected category
  • Laws banning sexual orientation discrimination in employment

Compared to LGBs living in states with one or more protective policies, LGBs who lived in states with no protective policies were significantly more likely to have generalized anxiety disorder (OR=3.34 compared to 1.86; p>.05), post-traumatic stress disorder (OR=3.64 compared to 1.83; p>.05) and to be diagnosed with two or more mental health disorders (OR=4.76 compared to 2.37; p >.05). (Source: Hatzenbuehler ML, Keyes KM, and Hasin DS, 2009, "State-level policies and psychiatric morbidity in lesbian, gay, and bisexual populations." American Journal of Public Health, Volume 99, Issue 12, pp. 2275-2281.)

For Further Thought

  • The study's findings seem to suggest that protective state-level policies create environments more supportive of LGB mental health. How do you think state level policies work to affect the psyches of LGBs? What are the psychological mechanisms at work?
  • Even with protective state level policies, LGBs were more likely to experience many types of psychiatric disorders. Aside from state policies, what other factors might contribute to disparities in LGB mental health?

Gay and Bisexual Men Have Higher Rates of Disordered Eating

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Confirming results of several other studies, this recent study showed that gay/bisexual men have significantly higher symptoms indicative of eating disorders as compared to heterosexual men. In this study, no significant differences were observed between rates of eating disorders in lesbian/bisexual women and heterosexual women, or between diverse ethnic minorities. (more) The study compared 388 racially diverse LGB men and women with a reference group of 128 white heterosexuals. Participants were sampled from a variety of venues in New York City between February 2004 and January 2005.

  • Full syndrome and subclinical evaluation of eating disorders included: anorexia, bulimia, and binge eating
  • Data was stratified into racial categories, including: white, black, and Latino

The study results found:

  • Gay and bisexual men were 3.8 times (1.1 to 13; 95% CI) more likely to have had any clinical or subclinical symptoms of eating disorders compared to heterosexual men
  • A higher percentage of lesbian and bisexual women reported clinical or subclinical symptoms of eating disorders compared to heterosexual women, but the observed difference was not significant (OR 1.2 (0.4 to 3.5; 95% CI)).
  • Significantly higher rates of bulimia and subclinical bulimia in gay/bisexual men compared to heterosexual men

(Source: Feldman, Matthew & Ilan Meyer, 2007, "Eating Disorders in Diverse Lesbian, Gay, and Bisexual Populations," International Journal of Eating Disorders, Volume 40, Issue 3, pp. 218-226).

For Further Thought

  • What might be some causes of the higher rates of disordered eating among gay and bisexual men? What can be done to address this health disparity?
  • How can we train primary care providers to recognize and address eating disorders in gay and bisexual men?
  • What might be some possible protective factors that explain the lack of disparity in eating for lesbian/bisexual women?

HIV+ Transgender Women Less Likely to Receive Anti-Retroviral Therapy

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A study comparing 59 HIV-positive male-to-female (MTF) transgender persons with a control group of 300 non-transgender HIV positive persons found that fewer in the MTF sample were receiving highly active anti-retroviral therapy (HAART). Only 59% of the MTF sample reported current use of HAART compared with 82% of the control group. (more) Both groups had similar HIV-related health status (i.e., CD4 count, viral load, and AIDS-related symptoms). (Source: Melendez, RM, et al., 2006, "Health and Health Care among Male-to-Female Transgender Persons Who Are HIV Positive," American Journal of Public Health, Volume 96, pp.1034-1037.)

For Further Thought

  • What factors might explain the lower rate of use of anti-retroviral therapy among MTF transgender persons in this sample?

  • Given that a significantly smaller percentage of the MTF study group used HAART, what might explain the similarity in HIV-related health status in the study and control groups?

  • What other health disparities might this HIV-positive MTF transgender sample experience aside from decreased anti-retroviral therapy utilization?

Age of First Anal Intercourse Dropping Among MSM

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Recent evidence suggests that men who have sex with men (MSM) are initiating anal intercourse at earlier ages. A Swiss study reveled that the mean age at first anal intercourse fell from 24.5 years among men born before 1965 to 20.0 years among men born between 1975 and 1984. The study also found that younger cohorts of MSM have been initiating anal intercourse with increasingly older partners. (more) Researchers surveyed 2,200 MSM living in Switzerland in 2004 as part of the nation's HIV behavioral surveillance. Participants were recruited from gay community venues and on-line. The study found the following relationships:

  • Between 20 and 30% of men engage in first anal sex with men 10 or more years older than themselves
  • The younger the age at first anal intercourse, the less likely the use of condoms
  • Use of condoms at first anal intercourse was less likely when the age gap between the partners was greater

(Source: Balthasar, H., Jeannin, A., Dubois-Arber, F., 2008, "First Anal Intercourse and Condom Use among Men Who Have Sex with Men in Switzerland," Archives of Sexual Behavior, June 17).

For Further Thought

  • Do these findings suggest a need for LGBT- specific content in sexual health education for adolescents?
  • What are some obstacles to integrating LGBT-specific content in sex education?

Lesbians Have Lower Rates of Cancer Screening, Higher Risks

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Research evidence from a three city community cancer project shows that lesbian women have higher behavior risk factors for cervical cancer including early onset of sexual activity, more sexual partners, and lower rates of safe sexual practices. The study also found that lesbian women reported less frequent gynecological cancer screening than their heterosexual counterparts. (more) Researchers used data from a survey of 829 women conducted by the Chicago Lesbian Community Cancer Project from 1994 to 1996.

  • Lesbian participants were recruited from Chicago, IL, New York City, NY and Minneapolis/St. Paul, MN
  • Heterosexual participants were recruited via a matched referral method to generate a demographically similar group of heterosexual women for comparison

The study found the following relationships:

  • Lesbians had higher rates of behavior risks for gynecological cancer than heterosexual women, including: onset of sexual activity before age 18, higher number of sexual partners, and lower rates of safer sex practices
  • Lesbians had lower rates of frequent gynecological cancer screening than heterosexual women; 49% of lesbians had annual pap screens compared to 66% of heterosexual women and 81% of lesbians had pap screens at least every 3 years compared to 90% of heterosexual women (p<.001)
  • While not statistically significant, a higher proportion of heterosexual women (31%) reported ever having an abnormal pap result, compared to lesbian women (25%).

(Source: Matthews A.K. et al., 2004, "Correlates of Underutilization of Gynecological Cancer Screening Among Lesbian and Heterosexual Women," Preventative Medicine, Volume 38, pp. 105-113.)

For Further Thought

  • What might contribute to the disparity in cancer screening between lesbian and heterosexual women?
  • Does this study challenge your assumptions about sexual risk behaviors in lesbians?
  • How would you design an intervention to educate the lesbian community about cancer risks and cancer screening?

LGBs More Than Twice as Likely to Smoke

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An analysis comparing gay/lesbian and bisexual survey respondents in Massachusetts to heterosexual counterparts found that gays, lesbians and bisexuals were more than twice as likely to be current smokers (Gay/lesbian OR=2.33, Gay men OR=2.42, Lesbian OR=2.20; Bisexual OR=2.65, Bisexual men OR=2.03, Bisexual women OR=3.00). (more) The study aggregated data from the 2001-2008 population-based Massachusetts Behavioral Risk Factor Surveillance Surveys and examined several socio-economic and health characteristics by sexual orientation and gender. Logistic regression analyses controlled for age, gender, and education. (Source: Conron, KJ, Mimiaga, MJ, & Landers, SJ, 2010, "A Population-Based Study of Sexual Orientation Identity and Gender Differences in Adult Health," American Journal of Public Health, Volume 100, Number 10, pp. 1953-1960.)

For Further Thought

  • As a probability study, the findings of this study are arguably generalizeable to the adult population of the Commonwealth of Massachusetts. Would you expect to find similar LGB smoking disparities in your state? How might the social, political and legal context of Massachusetts impact the observed magnitude of LGB disparities?
  • Bisexual respondents, and bisexual women in particular, appear to be at the greatest risk for current smoking. What factors might put bisexuals at greater risk?

High Rates of Youth Drug Use Observed in Bisexuals and "Mostly Heterosexuals"

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Sexual minority adolescents are at disproportionate risk for using drugs. A recent analysis of a large community-based cohort of U.S. adolescents aged 12-23 revealed that bisexual youth and youth identifying as "mostly heterosexual" were at particularly high risk for using illicit drugs other than marijuana in the past year (more) (Mostly heterosexual females RR: 3.40, CI: 2.91 to 3.97; Bisexual females RR: 5.13, CI: 4.05 to 6.50; Lesbian RR: 3.07, CI: 1.70 to 5.55; Mostly heterosexual males RR: 2.32, CI: 1.78 to 3.03; Bisexual males RR: 2.87, CI: 1.64 to 5.03; Gay male RR: 1.89, CI: 1.17 to 3.06; referent group: heterosexuals). Data came from the longitudinal Growing Up Today Study which has followed children of the Nurses' Health Study II. The three survey waves included data on sexual orientation and drug use and were conducted in 1999, 2001, and 2003. (Source: Corliss, HL, et al., 2010, "Sexual Orientation and Drug Use in a Longitudinal Cohort Study of U.S. Adolescents," Addictive Behaviors, Volume 35, pp. 517-521).

For Further Thought

  • What might substance abuse treatment service providers learn from the results of this study? Do you think substance abuse providers should ask youth about their sexual orientation?
  • This study confirms the results of previous research showing disparities in drug use for sexual minorities. The study further showed that sexual minority females had a higher prevalence of drug use than did sexual minority males - a gender pattern that is the reverse of the findings for heterosexuals. What might account for this reversal? What might this suggest for the development of interventions to reduce drug use in sexual minority youth?

Slow Growth in Published Research Articles in LGBT Health

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While the number of publications in LGBT health indexed in PubMed has increased considerably over the last two decades, growth of the percent of LGBT-related publications in relation to the total number of research publications has been much slower and more uneven. (more) During the decade of the 1990s, the number of publications indexed in PubMed that included one or more LGBT keywords in the title, abstract, or MeSH subject heading remained relatively steady year to year. However, during the same time period the percentage of LGBT publications dropped steadily to a low in 1999 of 0.15%. Since 1999, both the number and percent of LGBT publications have increased; in 2009, 980 (.21%) of publications included an LGBT keyword. While this represents a substantial increase since 1999, the percentage of LGBT publications in 2009 was still smaller than the percentage in 1990 (.24%).

Data was compiled from PubMed searches (limited to journal articles tagged with the MeSH subject heading "humans.") LGBT search terms include variants of the following: gay, bisexual, lesbian, homosexual, queer, transgender, transsexual, transvestite, cross-dresser, sexual minority, gender minority, sexual orientation, sexual identity, same-sex partner, men who have sex with men, women who have sex with women, and women who partner with women. Readers can replicate the search for LGBT health research publications by using the LGBT Pop Center's automated PubMed search link, accessible on the Literature tab.

For Further Thought

  • What contextual factors might account for the decline in the percent of LGBT health publications in the 1990s? Might improvements in HIV/AIDS therapies and perceptions of a declining significance of HIV/AIDS have played a role?
  • Do you expect the percent and number of LGBT health related publications to continue to increase in future years?

Negative Social Environment Related to Suicide Attempts Among LGB Youth

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An analysis of population-based data in Oregon revealed that living in environments that are less supportive of gays and lesbians is associated with greater suicide attempts among LGB youth. Consistent with previous research demonstrating a higher risk of suicide attempts in LGB youth, the study also found that Oregon LGB teens were significantly more likely to have attempted suicide in the past 12 months, compared with heterosexuals (21.5% vs 4.2%). (more) The researchers combined an analysis of data from the Oregon Healthy Teens (OHT) Survey from 2006-2008 with analysis of measures of the social environment, examining differences in the social environment at the county level. The index of the social environment included 5 different items. Each of the 34 Oregon counties that were included in the OHT surveys received a value for each of the 5 items:

  • Proportion of same-sex couples living in the counties
  • Proportion of Democrats living in the counties
  • Proportion of schools with gay-straight alliances
  • Proportion of schools with anti-bullying policies specifically protecting LGB students
  • Proportion of schools with antidiscrimination policies that included sexual orientation
  • As demonstrated in the graph above, the risk of attempting suicide among LGB youth was 20% greater in negative environments compared with positive environments (25.47% of LGB living in negative environments attempted suicide at least once versus 20.37% in positive environments). Among heterosexual youth, the risk of suicide attempts was 9% greater in negative environments. (Source: Hatzenbuehler, M. L., 2011, "The social environment and suicide attempts in lesbian, gay, and bisexual youth," Pediatrics, Volume 127, Issue 5, pp. 896-903.)

For Further Thought

  • What are the implications of this study for prevention of suicide attempts among LGB youth?
  • Aside from the 5 items used to create the social environment index, what other factors would you hypothesize to be associated with a negative social environment for LGBs?
  • Why might a negative climate for LGB students also impact the risk of suicide attempts for heterosexual youths?

25 States Have Included Sexual Orientation Items in the BRFSS

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A review of questionnaires fielded by states in the Behavioral Risk Factor Surveillance System (BRFSS) revealed that twenty-five states and the District of Columbia included at least one item measuring a dimension of sexual orientation at some point during the period between 1995-2011.

  • 9 states (California, Massachusetts, New York, North Carolina, Oregon, Pennsylvania, Vermont, Washington, and Wisconsin) included an item that assessed sexual orientation identity and an item that assessed same-sex sexual behavior.
  • 5 states (Connecticut, Florida, Georgia, Illinois, and Texas) included one item that assessed same-sex sexual behavior. Georgia and Florida did not include sexual orientation items state-wide, but measures were included in some counties.
  • 11 states (Alaska, Arizona, Colorado, Hawaii, Idaho, Maine, Michigan, Montana, New Mexico, North Dakota, Ohio) and the District of Columbia included one item that assessed sexual orientation identity.

In many states, inclusion of sexual orientation items changed over the period examined. Question wording varied across states and within states across years. Leigh Evans conducted the review by searching CDC's BRFSS website and State-Added Questions Database,, and state health department websites for information and questionnaires. When information was unavailable online, she contacted BRFSS State Coordinators.

For Further Thought

  • What are the advantages of included sexual orientation items on BRFSS?
  • Given the variation in question wording, can findings related to sexual and gender minorities be compared across states?
  • Which dimensions of sexual orientation are most important to include in population-based surveys?


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