Sexual Orientation Disparities in Sexually Transmitted Infection Risk Behaviors and Risk Determinants Among Sexually Active Adolescent Males: Results From a School-Based Sample

Objectives. We examined disparities in risk determinants and risk behaviors for sexually transmitted infections (STIs) between gay-identified, bisexual-identified, and heterosexual-identified young men who have sex with men (YMSM) and heterosexual-identified young men who have sex with women (YMSW) using a school-based sample of US sexually active adolescent males.Methods. We analyzed a pooled data set of Youth Risk Behavior Surveys from 2005 and 2007 that included information on sexual orientation identity, sexual behaviors, and multiple STI risk factors.Results. Bisexual-identified adolescents were more likely to report multiple STI risk behaviors (number of sex partners, concurrent sex partners, and age of sexual debut) compared with heterosexual YMSW as well as heterosexual YMSM and gay-identified respondents. Gay, bisexual, and heterosexual YMSM were significantly more likely to report forced sex compared with heterosexual YMSW.Conclusions. Our results provide evidence that sexual health disparities emerge early in the life course and vary by both sexual orientation identity and sexual behaviors. In particular, they show that bisexual-identified adolescent males exhibit a unique risk profile that warrants targeted sexual health interventions.Several studies have documented an elevated risk of acquiring sexually transmitted infections (STIs), including HIV/AIDS, among young men who have sex with men (YMSM).1 In recent years, HIV/AIDS infection rates have actually increased among this population.2,3 To develop more effective and targeted STI prevention programs, researchers have suggested using multiple measures of sexual minority status when examining disparities in STI risk by sexual orientation.4–8 Existing research on sexual health disparities among adolescents often uses community-based samples that rarely yield large enough sample sizes to examine multiple sexual minority statuses in any given study.6,9 This gap in the literature is particularly problematic given the documented incongruence between sexual orientation identity and sexual behaviors among sexual minority adolescents.10–12 Thus, although studies have demonstrated that both YMSM1,13–15 and bisexual- and gay-identified male adolescent16,17 are more likely to report a variety of STI risk factors, to our knowledge, no studies to date have used both indicators of sexual orientation identity and sexual behaviors to examine disparities in STI risk factors among adolescents.Elevated rates of STI among sexual minority adolescent males are due to a variety of factors, including social conditions, sexual networks, and, in particular, the excess biological risk associated with anal sex.1,18 Elevated STI risk, however, has also been attributed to sexual orientation disparities in a variety of risk behaviors, including earlier age of sexual debut, more sex partners,14,17,19 higher rates of substance use during sex,15 and lower rates of condom use.13,20 These disparities have been documented through use of sexual behaviors1,13–15 or sexual orientation identity16,17 to capture sexual minority status. As a result, STI risk interventions based on studies that use sexual orientation identity alone may not reach adolescents who engage in same-sex behavior but identify as heterosexual.1 Alternatively, focusing exclusively on sexual behavior obscures potentially important differences across social identities, which are critical for understanding and eliminating disparities in STIs.5 Studies that use either sexual orientation identity or behavior are therefore likely to capture different populations and provide an incomplete portrait of STI risk among sexual minority adolescents.21To develop appropriate STI intervention strategies, it is also critical to understand what factors might lead to risk-taking behaviors among sexual minority populations. Studies have shown that sexual minority adolescent males are more likely to report multiple sources of victimization, including forced sex16,22 and intimate partner violence (IPV),23–25 compared with their sexual nonminority peers. Forced sex may directly expose young men to STIs, but it also may have long-lasting implications for the development of sexual self-efficacy, safe sex communication skills, and normative attitudes surrounding sexual risk behaviors.26,27 IPV has been identified as a significant barrier to effective communication about safer sex behaviors and is linked to elevated STI risk among adolescents.28 Similar to the literature on STI risk behaviors, existing studies on forced sex and IPV among sexual minorities rely on single indicators of sexual orientation—either sexual orientation identity16,23 or the sex of sex partners.25 Given the stigma associated with gay or bisexual identity, sexual minority–identified respondents may be more likely to be targeted for victimization than YMSM who identify as heterosexual.Understanding which aspects of sexual minority status (e.g., sexual orientation identity, sex of sex partners) are related to STI risk factors during adolescence is critical for developing targeted prevention efforts to curb rising STI infection rates. New evidence suggests that STI risk varies by both sexual orientation identity and behaviors among young adult men.4 It is unclear whether similar patterns in STI risk behaviors and risk behavior determinants emerge during adolescence. Using a school-based sample of adolescent males, we aimed to determine whether sexual risk behaviors, including age of sexual debut, number of sex partners, concurrent sex partners, condom use, and drug and alcohol during sex, as well 2 indicators of risk behavior determinants (forced sex and IPV) vary at the intersection of sexual orientation identity and sexual behaviors.     

Asthma Disparities and Within-Group Differences in a National,Probability Sample of Same-Sex Partnered Adults

Objectives. We examined the prevalence and correlates of self-reported lifetime diagnosis of asthma and current asthma among same-sex and opposite-sex partnered adults.Methods. Data were from the 2004 Behavioral Risk Factor Surveillance System, in which same-sex partnership was a response option to a family planning item in the core questionnaire. Self-reported lifetime diagnosis of asthma and current asthma were examined in logistic regression models adjusted for demographic characteristics and asthma-related confounding factors and stratified by both gender and same-sex partnership status.Results. Significantly higher proportions of same-sex partnered male and female respondents reported lifetime and current asthma compared with their opposite-sex partnered peers. In adjusted analyses, same-sex partnership status remained significantly associated with asthma outcomes among men and women, with odds ratios ranging from 1.57 to 2.34.Conclusions. Results corroborated past studies that indicated asthma disproportionately affects sexual minority populations. The addition of sexual minority status questions to federal survey projects is key to further exploring health disparities in this population. Future studies are needed to investigate the etiology of this disparity.Nearly 25 million Americans currently have asthma,1 resulting in health care and absenteeism costs estimated at $56 billion annually.1 In addition to disparities in asthma identified by race/ethnicity,2,3 gender,4 and socioeconomic indicators,2 developing literature also suggests a higher prevalence of asthma among gay, lesbian, and bisexual (i.e., sexual minority) populations.5–8 However, most of the existing literature examining asthma in sexual minority populations is derived from state-based5–7,9 or local surveys.10 For example, in a population-based sample of Massachusetts adults, Conron et al.9 found that self-identified gay or lesbian and bisexual individuals had a 48% and 39% increase, respectively, in odds of a lifetime diagnosis of asthma compared with their heterosexual peers.To our knowledge, only 1 study has used a nationally drawn sample to examine asthma among persons in same-sex relationships. Heck and Jacobson8 examined self-identified same-sex partnered adults in data from the National Health Interview Survey. Results showed significantly increased odds of self-reported lifetime asthma diagnosis and past-year asthma among same-sex partnered men and women, respectively, compared with heterosexually partnered persons. Although the National Health Interview Survey study provides key evidence of sexual minority asthma disparities compared with heterosexuals, it focused on between-group differences (same-sex partnered vs opposite-sex partnered). Further study is needed to explore possible differences among sexual minority populations, which is one of the recommendations in a recent Institute of Medicine report on lesbian, gay, bisexual, and transgender health. Additionally, the Institute of Medicine report calls for corroboration of findings that indicate disparity by examining health indicators from different population-based data sources.11To these ends, the key aims of this study were to (1) examine the association between same-sex partnership status and prevalence of self-reported asthma within a representative, national sample of adults in the 2004 Behavioral Risk Factor Surveillance System (BRFSS), and (2) examine within-group differences by both gender and partnership status.     

Increased Risks of Needing Long-Term Care Among Older Adults Living With Same-Sex Partners

Objectives. We examined whether older individuals living with same-sex partners face greater risks of needing long-term care than their counterparts living with different-sex partners or spouses.Methods. With data on older couples (at least 1 individual aged 60 years or older) from the 2009 American Community Survey, we estimated logistic regression models of 2 activity limitations that signal a long-term care need: difficulty dressing or bathing and difficulty doing errands alone.Results. When we controlled for age, race/ethnicity, and education, older women who lived with female partners were statistically significantly more likely than those who lived with male partners or spouses to have difficulty dressing or bathing. Older men who lived with male partners were statistically significantly more likely than those who lived with female spouses or partners to need assistance with errands.Conclusions. Older individuals living with same-sex partners face greater risks of needing long-term care than those living with different-sex partners or spouses, but the role of relationship status differs by gender. These findings suggest more broadly that older gay men and lesbians may face greater risks of needing long-term care than their heterosexual counterparts.In light of population aging1,2 and the substantial number of individuals identifying as gay, lesbian, or bisexual,3 understanding the relationship between long-term care needs and sexual orientation has become increasingly important. Several factors may contribute to health limitations among sexual minorities: (1) a history of stigma, prejudice, and discrimination4–9; (2) discriminatory public policies10–18; and (3) sexual and reproductive histories.19–22First, experiences of discrimination, anticipation of rejection, concealment or disclosure of a stigmatized identity, and internalized negative views of oneself contribute to minority stress, the chronic stress that accompanies a stigmatized social status.4–6,8 A growing body of literature provides evidence that minority stressors adversely affect the mental and physical health of lesbians and gay men.4,6,8,9 Minority stressors are linked to higher psychological distress,6 depressive symptoms,8 and serious physical health problems.9 Second, public policies that limit access to health care, employment, housing, public benefits, and legal marriage on the basis of sexual orientation may also have negative health consequences for sexual minorities.13 For example, several studies provide evidence of health benefits associated with marriage,23,24 and a recent study showed that legal marriage to a same-sex partner significantly enhances mental health.18 Negative health impacts have been found for sexual minorities living in states with public policies that fail to protect them from employment discrimination or hate crimes.13 Third, men who have sex with men face greater risks of HIV than do men who have sex with women,20 and differences in reproductive histories combined with minority stressors and discriminatory public policies may cause lesbians to suffer from higher rates of breast cancer than do heterosexual women.21,22 The cumulative health consequences of these 3 factors may increase the risks of disability among sexual minorities and, in particular, may lead to greater risks of needing long-term care in old age.Although a growing body of literature provides evidence of mental15,25–29 and physical7,30–33 health differences by sexual orientation, collectively this literature offers scant evidence concerning activity limitations among older adults. One recent study begins to fill this gap. Using data from the California Health Interview Survey on individuals aged 50 to 70 years, Wallace et al.34 examined whether a variety of chronic health conditions—including physical disability—varied by sexual identity. The study found that lesbian, gay, and bisexual older adults experienced higher levels of chronic health conditions, including psychological distress and physical disabilities, than did their older heterosexual counterparts.Our study contributes to this literature by examining whether older individuals in same-sex relationships are more likely than their counterparts in different-sex relationships to experience activity limitations that specifically signal a need for long-term care.35 Long-term care is generally defined as

a range of services and supports [a person] may need to meet health or personal needs over a long period of time. Most long-term care is not medical care, but rather assistance with the basic personal tasks of everyday life.36

We hypothesized that older gay men and lesbians would face greater risks of needing long-term care than their heterosexual counterparts. Without access to federally recognized marriage, we expected gay men and lesbians to be particularly disadvantaged relative to married heterosexuals. With data from the Public Use Microdata Sample of the 2009 American Community Survey (ACS), we focused on 2 activity limitations: (1) self-care difficulty (difficulty dressing or bathing) and (2) difficulty living independently (difficulty doing errands alone). We used logistic regression to compare men living with male partners to men living with female partners or spouses; likewise, we compared women living with female partners to women living with male partners or spouses. Our approach differs from that of Wallace et al.34 in 3 key respects: (1) the use of nationally representative rather than state-level data, (2) the focus on measures that signal a need for long-term care rather than a broad range of chronic health conditions, and (3) the use of a behavioral measure of sexual orientation rather than sexual identity. Thus, our study both broadens the findings of the California study to a national sample and focuses on the implications for older gays and lesbians who have disabilities that could result in a need for a specific type of health care service—long-term care.     

Sexual Identity,Partner Gender,and Sexual Health Among Adolescent Girls in the United States

Objectives. We examined associations between adolescent girls’ sexual identity and the gender of their sexual partners, on one hand, and their reports of sexual health behaviors and reproductive health outcomes, on the other.Methods. We analyzed weighted data from pooled Youth Risk Behavior Surveys (2005 and 2007) representative of 13 US jurisdictions, focusing on sexually experienced girls in 8th through 12th grade (weighted n = 6879.56). We used logistic regression with hierarchical linear modeling to examine the strength of associations between reports about sexual orientation and sexual and reproductive health.Results. Sexual minority girls consistently reported riskier behaviors than did other girls. Lesbian girls’ reports of risky sexual behaviors (e.g., sex under the influence of drugs or alcohol) and negative reproductive health outcomes (e.g., pregnancy) were similar to those of bisexual girls. Partner gender and sexual identity were similarly strong predictors of all of the sexual behaviors and reproductive health outcomes we examined.Conclusions. Many sexual minority girls, whether categorized according to sexual identity or partner gender, are vulnerable to sexual and reproductive health risks. Attention to these risks is needed to help sexual minority girls receive necessary services.Sexual minority adolescent girls in the United States and Canada have been found to suffer from a number of sexual and reproductive health disparities.1,2 However, previous research in this area has consisted of only a handful of studies, and these investigations have generally focused on regional or convenience samples.2 Thus, there is a need for studies of large, national samples.It is also unclear which sexual minority girls are most at risk. Studies have generally lacked the sample size necessary to differentiate between lesbian and bisexual girls.3–5 Moreover, the sexual minority umbrella includes girls whose sexual behaviors might vary considerably, particularly because their sexual identity and behavior do not always coincide. For example, in a study representative of Massachusetts high school students, more than half of all girls self-identifying as lesbians reported sexual experiences with both male and female partners.6Much previous research on adolescent sexual health has focused on sexual identity, often collapsing girls who identify as lesbian, bisexual, or “mostly heterosexual” into a single category and comparing them with girls identifying as heterosexual. These comparisons have shown that girls self-identifying as sexual minorities have higher rates of alcohol or drug use during sex,3–5 lower rates of birth control or condom use during sex with male partners,4,5,7 and similar8 or higher5,7 rates of pregnancy. In other words, adolescent girls who identify as lesbian, bisexual, or mostly heterosexual, as a group, experience greater sexual health risks and more negative reproductive outcomes than do heterosexual girls.However, a sexual history that includes both female and male partners may be a stronger sexual health indicator than self-identification as lesbian or bisexual.6 Some research in this area has compared girls who report male partners only with girls who report both female and male partners (i.e., those who are bisexually experienced), excluding girls with female partners only. These studies have shown that rates of condom use during sex with male partners among bisexually experienced girls are similar to6 or lower than9,10 rates among girls who report only male partners. Also, these investigations have shown that rates of pregnancy are higher among bisexually experienced girls.6,10 Only 1 published study included a group of girls with female partners only.6 In this study, bisexually experienced girls were more likely than girls with male or female partners only to report using alcohol or drugs during their most recent sexual encounter.6In summary, bisexually experienced adolescent girls seem to have greater sexual health risks and more negative reproductive outcomes than do heterosexually experienced girls, and bisexual girls may experience greater risks than girls with female partners only. However, further research is needed.As a result of these sexual, reproductive, and other health risks, the American Academy of Pediatrics recommended in 2004 that care providers discuss sexual orientation with their adolescent patients.11 However, data from a 2005 survey suggest that few of the academy’s members routinely discuss sexual orientation with patients during preventive care visits.12 Furthermore, it is unclear what questions care providers should ask to identify at-risk sexual minority girls. The American Academy of Pediatrics and others have suggested possible patient interview questions that address sexual identity, sexual attraction, romantic behavior, or sexual behavior.11,13 It is unclear, however, which of these types of questions would best predict sexual risk and reproductive health outcomes.In this context, reliable information from large-scale surveys could be useful. We used Youth Risk Behavior Survey (YRBS) data from 13 US jurisdictions to assess several hypotheses. Our initial hypothesis was that girls who self-identified as lesbian or bisexual would report more risky sexual behaviors and more negative reproductive outcomes than would girls who self-identified as heterosexual. Similarly, we hypothesized that sexual and reproductive health differences would also occur as a function of partner gender. Specifically, we hypothesized that girls who reported engaging in sex with both male and female partners would report more risky sexual behavior and more negative reproductive health outcomes than would girls who reported male partners only. Further, although girls with only female partners are not at risk for adolescent pregnancy, we hypothesized that they would report more risky sexual behaviors than girls with male partners only. Finally, we hypothesized that partner gender would be a stronger predictor of sexual and reproductive health outcomes than sexual identity.     

The Association Between Sexual Orientation Identity and Behavior Across Race/Ethnicity,Sex, and Age in a Probability Sample of High School Students

Objectives. We examined the prevalence and associations between behavioral and identity dimensions of sexual orientation among adolescents in the United States, with consideration of differences associated with race/ethnicity, sex, and age.Methods. We used pooled data from 2005 and 2007 Youth Risk Behavior Surveys to estimate prevalence of sexual orientation variables within demographic sub-groups. We used multilevel logistic regression models to test differences in the association between sexual orientation identity and sexual behavior across groups.Results. There was substantial incongruence between behavioral and identity dimensions of sexual orientation, which varied across sex and race/ethnicity. Whereas girls were more likely to identify as bisexual, boys showed a stronger association between same-sex behavior and a bisexual identity. The pattern of association of age with sexual orientation differed between boys and girls.Conclusions. Our results highlight demographic differences between 2 sexual orientation dimensions, and their congruence, among 13- to 18-year-old adolescents. Future research is needed to better understand the implications of such differences, particularly in the realm of health and health disparities.The Institute of Medicine (IOM) recently called for increased data collection on the lesbian, gay, and bisexual (LGB) community in population health studies.1 Although numerous studies have identified sexual orientation health disparities among youths,2–9 researchers have only more recently begun to question if there is variation in prevalence of health outcomes among LGB populations depending on which dimension of sexual orientation is used (i.e., identity, behavior, or attraction).10 Sexual orientation is a multidimensional construct,11,12 and how it is measured changes the prevalence of nonheterosexual orientations.13,14 Large studies of probability samples of youths typically only include 1 item assessing a single dimension of sexual orientation,15 and, therefore, it is important to understand the level of congruency across these items.The IOM report also called for the use of an intersectional perspective, which is one that recognizes an individual’s co-occurring social identities and how they interact with sexual orientation.1 Along these lines, there is much interest in the basic question of how different dimensions of sexual orientation are interrelated and if these relationships vary across development, sex, and race/ethnicity.11,12,16 Understanding how various dimensions of sexual orientation are interrelated, and if this varies across demographic groups, has important implications for our basic understanding of the development of sexual orientation and its measurement in future adolescent health research.There is a growing body of research on incongruence between sexual orientation identity and sexual behaviors.13,17,18 A Canadian study found that 12% of 1878 adolescents endorsed at least 1 dimension of nonheterosexuality.13 Of these students, discrepancies were evident in their reports of sexual identity, attraction, and behavior; the majority only selected a single item (62%) whereas only 15% endorsed all items. The second-largest group (35%) was youths who reported same-sex attractions but no same-sex behavior or minority identity labels. From a developmental perspective it is important to recognize that sexual attractions typically emerge during early adolescence, whereas sexual behavior and internal adoption of identity labels occur during middle-to-late adolescence.11 These patterns reflect the complexity in researching youths’ sexual orientation as adolescents’ identity may be in flux and opportunities for sexual expression may not exist.11,12A number of studies have found that girls are more likely to adopt both-sex–oriented identities (i.e., bisexual or mostly heterosexual) and to report same-sex attraction and same-sex sexual behavior.13,19,20 Studies have also found lower levels of congruence between identity and behavior among adult women compared with men,21,22 leading some to hypothesize that female sexual orientation is more fluid or plastic.23,24 Studies of sex differences in sexual orientation stability across development have not been fully supportive of this hypothesis as results have been inconsistent, with some studies finding greater stability of identity among sexual-minority girls,25,26 no sex differences among sexual minorities,27 or that it depends on sexual orientation.20There has been limited research on how the experience of being LGB varies across racial or ethnic groups. Lack of significant differences in the timing of psychosexual milestones or in sexual identity formation among Black, Asian, Latino, and White youths has been reported,28–30 whereas others have found differences.31,32 Factors such as internalized homophobia, perceptions of rejection, and limited availability of support resources have been hypothesized to delay the timing of identity labeling and disclosure among racial/ethnic minority youths and thereby potentially produce less concordance among dimensions of sexual orientation.33,34 However, little research has examined how associations among different dimensions of sexual orientation may differ by race/ethnicity among adolescents.There are crucial gaps in our knowledge of the congruence among the dimensions of sexual orientation among youths, which have an impact on our understanding of measurement of sexual orientation and, by extension, characterization of health disparities. This is primarily attributable to the small number of sexual minority individuals in most probability samples, which typically do not permit exploring variation within the LGB sample. The objective of this study was to examine the congruency of sexual orientation identity and behavior across sex, race/ethnicity, and development in a probability sample of adolescents achieved through pooling Youth Risk Behavior Survey (YRBS) data.35     

Mediation by Peer Violence Victimization of Sexual Orientation Disparities in Cancer-Related Tobacco,Alcohol, and Sexual Risk Behaviors: Pooled Youth Risk Behavior Surveys

Objectives. We examined the role of adolescent peer violence victimization (PVV) in sexual orientation disparities in cancer-related tobacco, alcohol, and sexual risk behaviors.Methods. We pooled data from the 2005 and 2007 Youth Risk Behavior Surveys. We classified youths with any same-sex sexual attraction, partners, or identity as sexual minority and the remainder as heterosexual. We had 4 indicators of tobacco and alcohol use and 4 of sexual risk and 2 PVV factors: victimization at school and carrying weapons. We stratified associations by gender and race/ethnicity.Results. PVV was related to disparities in cancer-related risk behaviors of substance use and sexual risk, with odds ratios (ORs) of 1.3 (95% confidence interval [CI] = 1.03, 1.6) to 11.3 (95% CI = 6.2, 20.8), and to being a sexual minority, with ORs of 1.4 (95% CI = 1.1, 1.9) to 5.6 (95% CI = 3.5, 8.9). PVV mediated sexual orientation disparities in substance use and sexual risk behaviors. Findings were pronounced for adolescent girls and Asian/Pacific Islanders.Conclusions. Interventions are needed to reduce PVV in schools as a way to reduce sexual orientation disparities in cancer risk across the life span.The Institute of Medicine recently reviewed the research literature on health disparities between lesbian, gay, bisexual, and transgender individuals and heterosexuals across the life span.1 It identified the significant role of stigma in the health of lesbian, gay, bisexual, and transgender individuals and areas in need of research, including disparities in cancer between sexual minorities (lesbian, gay, and bisexual persons) and heterosexuals. Behaviors that increase cancer risk (e.g., tobacco and alcohol use, unprotected sexual intercourse) may be initiated during adolescence. For sexual minorities, peer violence victimization (PVV) may partly explain disparities in cancer-related risk behaviors because such disparities between sexual minorities and heterosexuals have been attributed to the differential burden of stigma experienced by sexual minorities.1Certain behaviors place one at risk for cancer, and sexual orientation disparities exist in those cancer-related risk behaviors. Tobacco and alcohol use are risk factors for various types of cancers, such as lung, esophageal, oropharyngeal, and colon.2–8 More sexual minority adults and youths than their heterosexual peers report tobacco and alcohol use.9–18Several sexual risk behaviors (number of partners, early age of first intercourse, concurrent sexual partners, lack of condom use, and substance use during intercourse) are known to increase vulnerability to infection with, for example, human papillomavirus (HPV)19–29 and hepatitis B.30,31 Women who have sex with women have elevated rates of such sexual risk behaviors relative to women who only have sex with men.32–34 Women who only have sex with women are less likely to be screened for sexually transmitted infections,33,35,36 despite the risk of HPV transmission during female-to-female sexual intercourse.37 HPV in men is important because it is linked to anal, oral, and penile cancers.24,38 The risk of cancer-related sexual behaviors may be elevated among sexual minority men, because of the links between anal intercourse, HPV, and anal cancer,39 especially among men who are HIV positive.40 Hepatitis B has been linked to liver cancer41 and increased risk of anal HPV among men.31     

Mental Health and Suicidality Among Racially/Ethnically Diverse Sexual Minority Youths

Objectives. We examined the relationships among sexual minority status, sex, and mental health and suicidality, in a racially/ethnically diverse sample of adolescents.Methods. Using pooled data from 2005 and 2007 Youth Risk Behavior Surveys within 14 jurisdictions, we used hierarchical linear modeling to examine 6 mental health outcomes across 6 racial/ethnic groups, intersecting with sexual minority status and sex. Based on an omnibus measure of sexual minority status, there were 6245 sexual minority adolescents in the current study. The total sample was n = 72 691.Results. Compared with heterosexual peers, sexual minorities reported higher odds of feeling sad; suicidal ideation, planning and attempts; suicide attempt treated by a doctor or nurse, and self-harm. Among sexual minorities, compared with White youths, Asian and Black youths had lower odds of many outcomes, whereas American Native/Pacific Islander, Latino, and Multiracial youths had higher odds.Conclusions. Although in general, sexual minority youths were at heightened risk for suicidal outcomes, risk varied based on sex and on race/ethnicity. More research is needed to better understand the manner in which sex and race/ethnicity intersect among sexual minorities to influence risk and protective factors, and ultimately, mental health outcomes.Over the past 20 years, research has documented elevated suicidality1—defined as behavior related to contemplating, attempting, or completing suicide2—among sexual minority youths (an umbrella term, generally including those who identify as lesbian, gay, bisexual, or transgender [LGBT]; engage in same-sex sexual behavior; or have same-sex attractions). This research has consistently demonstrated substantial sexual orientation disparities in suicidality, with sexual minority youths having higher prevalence of suicidality than their heterosexual peers.3–6 A recent review of the literature indicated that sexual minority youths are at least twice as likely as heterosexual youths to contemplate suicide, and 2 to 7 times as likely to attempt suicide.7 A meta-analysis found that 28% of sexual minority youths had a history of suicidality, compared with 12% of their heterosexual peers.8Despite the development of knowledge about suicidality among sexual minority youths, little is known about suicidality in sexual minority youths of color. To the extent that existing researchers have explored racial/ethnic differences, analyses have rarely gone beyond dichotomous (White vs “youths of color”) or trichotomous (White vs Black vs Latino) comparisons. As a result, there exists scant literature exploring the full spectrum of racial/ethnic differences in suicidality among sexual minority youths.The literature on suicide in the general adolescent population demonstrates racial/ethnic differences in suicide ideation and attempts. For example, prevalence of suicide among Native American and Alaska Native youths is twice that of other youths,9 and Latino youths are more likely than either Black or White youths to have considered and attempted suicide.10 Differences are further moderated by participants’ gender: girls are more likely to consider suicide and attempt suicide than boys,10 although boys are more likely to complete suicide.11Studies that have considered racial/ethnic differences in suicidality among sexual minority youths have found differences, though the patterns have been inconsistent. A study based on Youth Risk Behavior Survey (YRBS) data from Massachusetts, reported that among self-identified lesbian, gay, or bisexual (LGB) youths3 Latinos were significantly more likely than Whites to report past-year suicide attempt. Another study found that same-sex–attracted Black and White youths were more likely than their other-sex–attracted peers to report suicidal ideation, whereas same-sex–attracted Latino and Asian/Pacific Islander youths did not differ from other-sex–attracted peers.12 In a nonprobability sample of urban LGBT youths,13 Black and White youths were more likely to report suicidal ideation than Latinos; however, Latinos reported the highest frequency of suicide attempts. A study of New York City adults found that Latino and Black LGB participants were more likely to report serious suicide attempts than were White LGB participants, with most reported attempts occurring during adolescence and young adulthood.14 These conflicting results suggest that there are important differences in suicidality at the intersections of sexual minority status and race/ethnicity, yet further study requires data of sufficient scale and scope to enable analyses of low-prevalence behaviors across small subgroups of youths.To address the need for information about suicidality among racially/ethnically diverse sexual minority populations, we assess suicidality patterns among youths based on sexual orientation, race/ethnicity, and sex. With this, we respond to calls for public health to utilize minority stress and intersectional frameworks as potential lenses through which to understand health and health disparities among sexual minority populations.15,16 Rather than treating social identities as separate and discrete phenomena, our inquiry allows that co-occurring minority identities operate together. An intersectional approach suggests that sexual identity–race–sex intersections are informed by unique cultural, historical, social, and political factors that differentially influence life experiences, including discrimination based on such identities.17–19 In turn, minority stress theory posits that discriminatory experiences predispose populations to stress and adverse mental health outcomes, including suicidality.20The focus on health differences among sexual minority youths across race/ethnicity and sex is vital to creating effective health interventions and programs. Such a focus is particularly relevant within the context of youth suicide, as risk and protective factors associated with suicidality vary across both racial/ethnic and sexual minority groups, and there is a need to better integrate these bodies of research.21     

Sexual Minority Women and Depressive Symptoms Throughout Adulthood

Objectives. We examined the associations between depressive symptoms and sexual identity and behavior among women with or at risk for HIV.Methods. We analyzed longitudinal data from 1811 participants in the Women’s Interagency HIV Study (WIHS) from 1994 to 2013 in Brooklyn and the Bronx, New York; Chicago, Illinois; Washington, DC; and Los Angeles and San Francisco, California, by comparing depressive symptoms by baseline sexual identity and ongoing sexual behavior. We controlled for age, socioeconomic status, violence history, and substance use.Results. In separate analyses, bisexual women and women who reported having sex with both men and women during follow-up had higher unadjusted odds of depressive symptoms compared with heterosexuals and women who reported only having male sexual partners (adjusted odd ratio [AOR] = 1.36; 95% confidence interval [CI]  = 1.10, 1.69 and AOR = 1.21; 95% CI = 1.06, 1.37, respectively). Age was a significant effect modifier in multivariable analysis; sexual minority women had increased odds of depressive symptoms in early adulthood, but they did not have these odds at midlife. Odds of depressive symptoms were lower among some sexual minority women at older ages.Conclusions. Patterns of depressive symptoms over the life course of sexual minority women with or at risk for HIV might differ from heterosexual women and from patterns observed in the general aging population.Depression is a major health concern for women. According to the Centers for Disease Control and Prevention (CDC), 10% of US women reported any depression and 5% reported major depression in the previous 2 weeks.1 Depression has been reported in 19% to 62%2–4 of HIV-infected women and is associated with reduced cognitive function,5 decreased adherence to highly active antiretroviral therapy (HAART),6 higher rates of unprotected sex among substance users,7 and increased mortality.2,6Women with or at risk for HIV are often exposed to factors such as poverty,8 substance use, and violence,9–11 which can independently and jointly contribute to depression. A recent study found that any combination of intimate partner violence (IPV), substance use, and HIV infection increased the odds of depression.12 Lower socioeconomic status (SES) in women12 and HIV infection4,5 were also independently associated with depression. However, studies showed no association among HIV stage, HAART use,4,8 CD4 count,8,13 or viral load and depression.4,8,13There is a strong association between sexual minority status (i.e., women who identify as lesbian or bisexual or have female sex partners) and poor mental health. In a US survey, lifetime major depression was reported by 42% of lesbians, 52% of bisexuals, and 27% of heterosexual women (P < .01); in the same study, major depression was reported by 15% of women who have sex with women (WSW), 51% of women who have sex with men and women (WSMW), and 27% of women who have sex with men (WSM; P < .01).14 In this study, we examined 2 aspects of sexual orientation15–17: sexual identity and sexual behavior. Although sexual attraction is also considered part of an individual’s sexual orientation, data on attraction was not collected in the original study.Despite the strong association between sexual minority status and depression, it is unknown whether sexual minority status acts as an independent predictor or effect modifier of depressive symptoms among women affected by HIV, substance use, and violence. Our original hypothesis was that lesbian, bisexual, and WSMW (but not WSW) would have higher odds of depression, with race/ethnicity acting as a potential effect modifier.     

Stress and Mental Health Among Midlife and Older Gay-Identified Men

Objectives. We investigated associations between stress and mental health (positive affect, depressive symptoms) among HIV-negative and HIV-positive midlife and older gay-identified men, along with the mediating and moderating effects of mastery and emotional support. We also studied the mental health effects of same-sex marriage.Methods. We obtained data from self-administered questionnaires completed in 2009 or 2010 by a subsample (n = 202; average age = 56.91 years; age range = 44–75 years) of participants in the University of California, Los Angeles component of the Multicenter AIDS Cohort Study, one of the largest and longest-running natural-history studies of HIV/AIDS in the United States.Results. Both sexual minority stress (perceived gay-related stigma, excessive HIV bereavements) and aging-related stress (independence and fiscal concerns) appeared to have been detrimental to mental health. Sense of mastery partially mediated these associations. Being legally married was significantly protective net of all covariates, including having a domestic partner but not being married. Education, HIV status, and race/ethnicity had no significant effects.Conclusions. Sexual minority and aging-related stress significantly affected the emotional lives of these men. Personal sense of mastery may help to sustain them as they age. We observed specific mental health benefits of same-sex legal marriage.Classic conceptualizations of social stress theory1–3 posit that social stressors—socioenvironmental demands that tax or exceed individuals’ adaptive capacities or block the attainment of sought-after ends—can be harmful to health, particularly to mental health. Through the stress process, stressors rooted in critical social roles or relationships are conceptualized as primary sources of subsequent difficulties that collectively diminish well-being.3,4 Psychosocial resources that regulate the health impact of stress, such as social support and sense of mastery, are key elements of the stress process because they may disrupt the relationship between stress and distress.1,5Minority stress theory6–8 contends that minority populations also can be exposed to unique stressors that create strains on individuals as they attempt to adapt and function in their everyday environments, which in turn negatively affect well-being. Investigators have found compelling evidence of the negative impact of minority stress on mental health among sexual minority persons, who consistently demonstrate higher rates of mental disorder, substance misuse, suicidal ideation, and deliberate self-harm than heterosexual populations.8–14However, few studies have examined social stress, minority stress, and health among midlife and older sexual minority persons. Such studies are of public health significance because the baby boomer cohort quickly is approaching old age, and embedded in this cohort are midlife and older sexual minority persons who endure common aging-related stressors in addition to the unique challenges that are associated with their sexual minority status.8,13,15,16 These challenges include well-established domains of minority stress associated with stigma, discrimination or prejudice, internalized homophobia, and concealment.8,13 Other stressors include exclusion from legal marriage, limited legal rights for same-sex partners, lack of access to informal care within traditional family networks, insensitivity to sexual minority health issues among care providers, and ostracization in health care and long-term care settings.17,18Midlife and older sexual minority persons also are of particular interest because of their life-course experiences of either being socially invisible during most of the 20th century or of coming of age on the heels of the gay rights movements in the 1960s. They are the first sexual minorities in history to age with an identity that is now socially and politically recognized as they become increasingly enfranchised. A review of the literature on sexual orientation and aging offers further insight into the life-course challenges faced by the estimated 1 to 3 million older sexual minority adults in the United States—a number that is increasing dramatically.19 Within this broad cohort of midlife and older sexual minorities, gay-identified men (hereafter, gay men) are unique because of their additional historical experience of having been in the highest HIV/AIDS risk group when virtually nothing was known about HIV transmission routes, making prevention impossible. The profound impact of the AIDS epidemic on the lives of these men cannot be overstated.19 For example, they have outlived many of their peers lost during the early years of AIDS,20 diminishing their social support networks.21We examined sexual minority stressors8,13 and generally applicable stressors associated with aging22,23 as well as their hypothesized associations with mental health (Figure 1). On the basis of social stress theory1–3 and its empirical operationalization with the elaboration model,24 we also examined the role of psychosocial resources as “third variables” that are hypothesized to offset these associations. Psychosocial resources may mediate or moderate the association between stress and mental health.1–3Open in a separate windowFIGURE 1—Hypothesized associations between social stress and mental health among midlife and older gay-identified men.In this case, mediation occurs when stress influences a psychosocial resource, which, in turn, influences mental health, thereby transmitting the effect.24,25 Moderation occurs when the effect of stress is contingent upon a psychosocial resource (the dashed line in the center of Figure 1) meaning that its effect differs across various values of the psychosocial resource. We controlled for the effects of background factors that may influence observed findings, with a particular focus on relationship status. We chose this focus because research on same-sex marriage and mental health among gay men is virtually nonexistent despite evidence of the ameliorative effects of marriage on mental health among heterosexual persons.26By investigating associations among these key constructs, we sought to broaden understanding of the stress and aging experiences of midlife and older gay men, many of whom enter later life at increased risk for HIV infection or chronic HIV-related comorbidities,27–29 suicidal thoughts or behaviors,12,30 and other health- and disability-related difficulties.31     

A meta-analysis of disparities in childhood sexual abuse, parental physical abuse, and peer victimization among sexual minority and sexual nonminority individuals

Objectives. We compared the likelihood of childhood sexual abuse (under age 18), parental physical abuse, and peer victimization based on sexual orientation.Methods. We conducted a meta-analysis of adolescent school-based studies that compared the likelihood of childhood abuse among sexual minorities vs sexual nonminorities.Results. Sexual minority individuals were on average 3.8, 1.2, 1.7, and 2.4 times more likely to experience sexual abuse, parental physical abuse, or assault at school or to miss school through fear, respectively. Moderation analysis showed that disparities between sexual minority and sexual nonminority individuals were larger for (1) males than females for sexual abuse, (2) females than males for assault at school, and (3) bisexual than gay and lesbian for both parental physical abuse and missing school through fear. Disparities did not change between the 1990s and the 2000s.Conclusions. The higher rates of abuse experienced by sexual minority youths may be one of the driving mechanisms underlying higher rates of mental health problems, substance use, risky sexual behavior, and HIV reported by sexual minority adults.The number of substantiated annual cases of childhood (i.e., under age 18) physical abuse in the United States declined 52% between 1992 and 2007, and cases of childhood sexual abuse declined 53% during the same period.¹ Criminal victimization of students in school declined 60% between 1995 and 2005.² Although these represent public health success stories, the abuse of children and adolescents is still a major problem. Child welfare agencies confirmed 79 866 cases of physical abuse and 56 460 cases of sexual abuse in the United States during 2007.³ One nationally representative sample found that 17% of youths reported having been the victim of moderate or frequent bullying at school during the prior 2 months,⁴ and another found that 13% experienced being hit, kicked, pushed, shoved around or locked indoors during the same time period.⁵Children and adolescents who experience sexual abuse are more likely to experience depression and dysthymia, borderline personality disorder, somatization disorder, substance abuse disorder, posttraumatic stress disorder, dissociative identity disorder, or bulimia nervosa; to attempt suicide; to become pregnant earlier; to engage in HIV sexual risk behaviors; to perform poorly at school; to be arrested for sex crimes; or to commit other criminal offenses.^6–10 Children and adolescents who experience parental physical abuse are more likely to experience similar psychological, substance use, behavioral, and criminal problems.^11–15 Outcomes of peer victimization among children and adolescents include depressive, anxiety, and drug abuse disorders, suicidal ideation, social isolation, psychosomatic symptoms, poor school performance, and delinquency.^16–20 In addition, these types of abuse are associated with negative psychological, behavioral, and physical outcomes in adulthood.^21–23 Risk markers of childhood abuse include the characteristics of parents (e.g., substance abuse, history being victims of physical or sexual abuse, social isolation, low self-esteem), families (e.g., marital conflict, spousal abuse, financial stress), the individuals themselves (e.g., emotional, psychological, or physical disabilities; low self-esteem; an inability to defend oneself; lack of social skills), and environments (e.g., negative school atmosphere, low socioeconomic status).^24–26One risk factor for experiencing these types of abuse may be sexual orientation. Studies suggest that sexual minority youths (i.e., youths who experience same-sex attractions or self-label as gay, lesbian, or bisexual, or who engage in same-sex sexual activity), compared with sexual nonminority youths, are more likely to experience sexual abuse, parental physical abuse, and peer victimization during childhood.^27–42 However, these studies vary in effect sizes, measurement of abuse and sexual orientation, the group being compared with heterosexuals (e.g., gays, lesbians, and bisexuals combined vs comparing groups individually; combining males and females vs comparing gender individually), sampling and recruitment strategies, and the decade in which the studies were conducted. Thus, relying on any one study to determine whether sexual orientation is a risk factor for child abuse, as well as determining the robustness of the difference in child abuse rates, is problematic. However, if sexual minority youths suffer greater rates of violence victimization, this phenomenon could be one explanation for the existence of substantial health disparities that exist among sexual minority adult populations.⁴³This meta-analysis therefore addressed the following question: are sexual minority adolescents more likely than sexual nonminority adolescents to experience childhood sexual abuse, parental physical abuse, and peer victimization? Beyond examining disparities, we tested the possible moderating role of bisexuality status because data suggest that bisexual adolescents are at greater risk than are gay and lesbian adolescents for engaging in certain risk behaviors^44,45; the decade of survey administration because rates of violence perpetrated against sexual minority youths relative to heterosexuals may have decreased over recent decades⁴⁶; the dimension used to measure sexual orientation (i.e., behavior or identity) because disparities in abuse between sexual minority and sexual nonminority individuals may be greater when sexual minority status is based on self-identification as gay, lesbian, or bisexual than when it is based on same-sex or both-sex sexual activity⁴⁴; and gender because this variable has been shown to moderate the association between sexual orientation and both substance use⁴⁴ and suicide attempts⁴⁷ in sexual minority youths.     

Pervasive Trauma Exposure Among US Sexual Orientation Minority Adults and Risk of Posttraumatic Stress Disorder

Objectives. We assessed sexual orientation disparities in exposure to violence and other potentially traumatic events and onset of posttraumatic stress disorder (PTSD) in a representative US sample.Methods. We used data from 34 653 noninstitutionalized adult US residents from the 2004 to 2005 wave of the National Epidemiologic Survey on Alcohol and Related Conditions.Results. Lesbians and gay men, bisexuals, and heterosexuals who reported any same-sex sexual partners over their lifetime had greater risk of childhood maltreatment, interpersonal violence, trauma to a close friend or relative, and unexpected death of someone close than did heterosexuals with no same-sex attractions or partners. Risk of onset of PTSD was higher among lesbians and gays (adjusted odds ratio [AOR] = 2.03; 95% confidence interval [CI] = 1.34, 3.06), bisexuals (AOR = 2.13; 95% CI = 1.38, 3.29), and heterosexuals with any same-sex partners (AOR = 2.06; 95% CI = 1.54, 2.74) than it was among the heterosexual reference group. This higher risk was largely accounted for by sexual orientation minorities’ greater exposure to violence, exposure to more potentially traumatic events, and earlier age of trauma exposure.Conclusions. Profound sexual orientation disparities exist in risk of PTSD and in violence exposure, beginning in childhood. Our findings suggest there is an urgent need for public health interventions aimed at preventing violence against individuals with minority sexual orientations and providing follow-up care to cope with the sequelae of violent victimization.Sexual orientation disparities in exposure to violence over the life course are well documented.^1–10 Individuals with minority sexual orientation (e.g., gay, lesbian, bisexual) report elevated frequency, severity, and persistence of physical and sexual abuse in childhood.^1,3,4 Throughout their lives, sexual orientation minorities are more likely to experience violence in their communities, including hate crimes.^5,10–12 Intimate partner violence and sexual assault in adulthood are also disproportionately prevalent among sexual orientation minorities.^3,9 It is unknown whether sexual orientation disparities also exist in exposure to other types of potentially traumatic events.Despite the growing recognition of sexual orientation disparities in violence exposure, population-representative research examining possible sexual orientation differences in risk of posttraumatic stress disorder (PTSD) is very limited. PTSD is a mental disorder that develops in response to exposure to a potentially traumatic event, including violence (e.g., childhood abuse, sexual assault) or other negative life experiences (e.g., disasters, accidents). The disorder is characterized by persistent reexperiencing of the event, persistent avoidance of stimuli associated with the event, emotional numbing, and hyperarousal. For PTSD diagnosis according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, symptoms must be present for at least 1 month and result in functional impairment.¹³The public health consequences of PTSD are staggering and include secondary mental disorders, substance dependence,^14,15 impaired role functioning, health problems,^16–18 and reduced life course opportunities (e.g., higher rates of unemployment).¹⁹ The lack of data on PTSD among sexual orientation minorities is a critical gap because, of all civilian traumas, interpersonal violence is associated with the highest conditional risk of developing PTSD.^20,21 We examined sexual orientation disparities in exposure to violence and other potentially traumatic events and in risk of PTSD in a US representative sample.Previous studies have found elevated rates of PTSD among sexual orientation minorities in comparison with heterosexuals.^6,10,22,23 However, our understanding of the burden of PTSD in this vulnerable population is constrained by 3 limitations of extant research. First, as far as we know, only 1 study compared rates of PTSD across sexual orientation groups in a nationally representative sample.²³ Several studies relied on convenience samples; selection factors in such samples could bias observed associations among sexual orientation, violence exposure, and PTSD. Second, the only study of sexual orientation and PTSD in a nationally representative sample categorized members into a sexual orientation group solely by reports of the gender of their sexual partners. Other dimensions of sexual orientation, such as sexual orientation identity and feelings of sexual attraction, which have been shown to be important correlates of physical and mental health,^24,25 were not measured. Third, no previous study attempted to link possible sexual orientation disparities in PTSD directly to elevated risk of exposure to violence and other traumatic events in the minority sexual orientation population. Type of potentially traumatic event exposure—particularly elevated rates of exposure to violence, exposure to multiple events, and younger age at exposure—are all important determinants of PTSD^{20,21,26–28} that may account for the disparities in PTSD by sexual orientation.We designed our study to document the public health burden of potentially traumatic event exposure and PTSD in US residents with minority sexual orientations. We analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a large, nationally representative survey of US adults.²⁹ Respondents were asked to report on 3 dimensions of sexual orientation: identity (i.e., heterosexual, gay, lesbian, or bisexual), same-sex and opposite-sex attractions, and same-sex and opposite-sex sexual partners. We also investigated the causes of observed disparities in PTSD by analyzing NESARC''s detailed information on type of traumatic events and age at first exposure. These are therefore the most comprehensive data reported to date, derived from a nationally representative sample and aimed at quantifying disparities in potentially traumatic events and associated PTSD by sexual orientation.     

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.Numerous studies have documented robust sexual orientation–related differences in suicide attempts,1–12 tobacco smoking,13–28 HIV infection risk among men,29 and problems in health care access.30–35 However, whether these health differences actually translate into overall greater risk for early mortality among sexual minorities, including among men who have sex with men (MSM) and among women who have sex with women (WSW), is not clear. Persistent methodological barriers have posed a nearly insurmountable obstacle to investigating questions of sexual orientation–related differences in mortality risk.36,37 In the United States, for example, death certificates, a common data source utilized in mortality studies, do not record sexual orientation information. In addition, there are few population-based data sets in which both markers of sexual orientation and mortality-related information are available.However, in recent years, evidence has begun to emerge that anticipated mortality differences might, in fact, exist though results to date are inconclusive. Two ecological studies,38,39 with their attendant methodological weaknesses,40 linked higher rates of lung and colorectal cancer mortality among men to areas of relatively higher residential density of same-sex couples in the US Census. Three studies that we are aware of used newly available information from population registries in Denmark.41–43 One41 compared all-cause mortality rates of individuals in registered same-sex domestic partnerships (RDPs) to those of the Danish population as a whole, finding excess mortality risk for both men and women in RDP relationships. But these sexual orientation differences were most pronounced in individuals who were newly registered. With increasing duration of relationships, sexual orientation–related differences attenuated. Furthermore, information on cause of death was not available. The second 2 studies42,43 investigated differences in suicide mortality between individuals in current or former RDP relationships and heterosexually married or formerly married persons, with the Mathy et al. study43 observing higher rates of suicide mortality among RDP men but not among RDP women. Because suicide mortality is a relatively rare event,44 the small numbers of RDP individuals may have led to insufficient statistical power to detect sexual orientation differences among women.In a fourth study,45 from the United States, we used information available in multiple years of the National Health Interview Survey, and reported that women in same-sex relationships had elevated risk for breast cancer mortality compared with heterosexually married women. This is consistent with persistent concerns that sexual minority women may have elevated risk for breast cancer because of a unique combination of risk factors including lower rates of parity, higher tobacco and alcohol use, and problems in utilizing preventive health care.45 However, an important limitation across all 4 studies that used relationship status to classify for sexual orientation was that comparisons were necessarily limited to partnered sexual minorities who represent but a minority of the sexual minority population.46 Whether these differences or lack of differences are true for sexual minorities in general cannot be determined by these study designs.More recently, 2006 mortality follow-up information obtained for men who were first interviewed in the 1988–1994 National Health and Nutrition Examination Survey III (NHANES III) provided clear evidence that MSM, including men not currently in same-sex relationships, experienced greatly elevated risk for mortality attributable to HIV infection during the 1990s, which appeared to wane somewhat following widespread introduction of highly active antiretroviral therapies (HAART) in 1996.37 In that study, men were asked the gender of their lifetime sexual partners, which was used to classify the sample into MSM versus men who did not report any same-sex partners. Contrary to the robust evidence for excess HIV-related mortality among MSM, the study revealed no evidence of increased risk for suicide-related mortality linked to sexual orientation. But, like the earlier studies, the small number of MSM in the NHANES III sample (n = 85) may have greatly limited power to detect such differences. A further limitation in NHANES III was that markers of sexual orientation were not assessed in female respondents.Thus, at present, although several studies have found hints that sexual orientation might be differentially linked to early mortality, reported findings have not been conclusive and mortality risks among sexual minority women, in particular, have been greatly unexamined. In the current study, we capitalized on information available in the 2008 General Social Survey (GSS)–National Death Index (NDI) data set47 to investigate possible sexual orientation differences in mortality risk among both men and women who vary in their reports of the gender of their lifetime sexual partners. This novel data set combines information obtained from 14 years of data collection for the GSS surveys in which markers of sexual orientation (e.g., gender of lifetime and recent sexual partners) were assessed in a large sample of adults. Mortality data recently linked to these GSS participants provides up to 20 years of mortality follow-up and offers a unique opportunity to investigate possible sexual orientation differences in risk for both all-cause mortality and mortality attributable to the 3 factors that have long raised concerns in these communities: suicide,48 HIV infection among men,37,49 and breast cancer among women.45     

The association of sexual orientation measures with young adults' health-related outcomes

Objectives. We examined associations among 3 dimensions of sexual orientation (identity, behavior, and attraction) and key health-related indicators commonly studied among sexual minority populations: depressive symptoms, perceived stress, smoking, binge drinking, and victimization.Methods. We analyzed data from the National Longitudinal Study of Adolescent Health, Wave IV (2007–2008) when respondents were aged 24 to 32 years (n = 14 412). We used multivariate linear and logistic regressions to examine consistency of associations between sexual orientation measures and health-related indicators.Results. Strength of associations differed by gender and sexual orientation measure. Among women, being attracted to both sexes, identifying as “mostly straight” or “bisexual,” and having mostly opposite-sex sexual partners was associated with greater risk for all indicators. Among men, sexual attraction was unrelated to health indicators. Men who were “mostly straight” were at greater risk for some, but not all, indicators. Men who had sexual partners of the same-sex or both sexes were at lower risk for binge drinking.Conclusions. Using all 3 dimensions of sexual orientation provides a more complete picture of the association between sexual orientation and health among young adults than does using any 1 dimension alone.Sexual orientation is composed of at least 3 dimensions—sexual identity, sexual behavior, and sexual attraction.^1–4 Yet, not until the Williams Institute released its report outlining best practices for asking questions about sexual orientation on surveys did a consensus exist among researchers regarding the best ways to measure these dimensions.⁵ This previous lack of consensus, coupled with the evidence that data sources commonly used to investigate the association between sexual orientation and health do not measure all 3 dimensions, has left the field with an incomplete understanding of health differences not only between heterosexual and sexual minority (nonheterosexual) populations but also within sexual minority populations themselves.Sexual identity is one of the most commonly assessed dimensions of sexual orientation in health research. However, items used to measure sexual identity have been the most difficult for respondents to answer,^1,6–8 not only because some feel discomfort admitting to a nonheterosexual identity but also because sexual minorities increasingly use diverse labels (e.g., two-spirited, same-gender loving, queer), have multiple identities (bilesbian, gay-curious heterosexual, pan-sexual), or use no labels at all when referring to their sexual identity.^9–11 Most measures of sexual identity force individuals to choose among a “heterosexual/straight,” “gay or lesbian,” “bisexual,” or “unsure” identity^1,4–8; whereas others include intermediate options such as “mostly heterosexual/straight” and “mostly homosexual/gay,” which are preferred because they better reflect personal experiences and some view “heterosexual/straight,” “gay or lesbian,” and “bisexual” as static states or permanent identities.^1,4–8Sexual orientation has also been measured by identifying the gender of respondents’ sexual partners. However, terminology used to define “sex” varies considerably, as do respondents’ interpretations of sexual behaviors. For example, the terms “sex” and “sexual intercourse” are often perceived as implicitly heterosexual, referring only to penile penetration. Using these terms may therefore exclude a range of sexual behaviors in which many sexual minorities have engaged.^1,8,12 Moreover, using sexual behavior as the sole measure of sexual orientation is uninformative for individuals who have never had any sexual experience and may misrepresent the sexual orientation of others who have had “sex” with partners of 1 gender but have sexual attractions to the other or both genders.^1,8,12Sexual attraction, or desire for sexual intimacy, is typically considered the defining feature of sexual orientation^13–16 but is the least studied of the 3 sexual dimensions with regard to health outcomes.^17,18 This fact is particularly perplexing given that women show greater variability than do men in the age at which they (1) first become aware of same-gender attractions, (2) consciously question their sexuality, and (3) pursue their first same-gender sexual contact—all of which women tend to experience later in life than do men.^19–25 Moreover, women are more likely than are men to say they become attracted to or fall in love with the person as opposed to the person''s gender^21,26 and to report that their sexuality is fluid over time.^24,26–30Decades of research have documented health disparities between heterosexual and lesbian, gay, and bisexual (LGB) populations,^4,31–46 with minority stress theory frequently used to explain these disparities.⁴⁷ However, Meyer''s minority stress theory conceptualized the LGB population as homogenous; distinctions were not made on the basis of gender or dimension of sexual orientation.⁴⁷ Moreover, few studies have used nationally representative samples or examined all 3 dimensions of sexual orientation.^48–50 Among those that assessed all 3 dimensions, health disparities between LGB populations and heterosexuals differed by dimension of sexual orientation.^17,18For example, Bostwick et al. used nationally representative data to compare clinical measures of mental health among adults aged 20 years and older across all 3 dimensions of sexual orientation and found that adults with an LGB identity had higher odds of having any mood or anxiety disorder than did adults who self-identified as straight.¹⁷ However, women who had only same-sex sexual partners and exclusive same-sex attractions had the lowest rates for most disorders, whereas men who had any same-sex attraction had the highest rates.¹⁷McCabe et al. examined the prevalence of substance use and dependence across all 3 dimensions of sexual orientation using nationally representative data and found that substance use outcomes varied considerably across sexual orientation dimensions and were more pronounced among women than among men.¹⁸ Unlike previous research, the authors found substance use to be less prominent among men and women who identified as bisexual than among those who identified as gay or lesbian.¹⁸ Alternatively, they found greater risk for substance use and dependence among men and women who engaged in bisexual behavior but not among those who engaged in same-sex behavior.¹⁸Few studies using nationally representative samples have assessed associations between health-related outcomes and all 3 dimensions of sexual orientation, and fewer, if any, have explored these associations within an exclusively young adult population—although early adulthood is often accompanied by greater anxiety and uncertainty because of transitions, career entry, and role formations.⁵¹ We examined associations between several health-related indicators commonly used to investigate sexual minority health (i.e., depressive symptoms, perceived stress, smoking, binge drinking, and victimization) and 3 dimensions of sexual orientation (i.e., identity, attraction, and behavior) using a nationally representative sample of young adults. We hypothesized that significant differences would be reported in these health indicators among young adults by gender and the dimension of sexual orientation measured.     

Health status, neighborhood socioeconomic context, and premature mortality in the United States: The National Institutes of Health-AARP Diet and Health Study

Objectives. We examined whether the risk of premature mortality associated with living in socioeconomically deprived neighborhoods varies according to the health status of individuals.Methods. Community-dwelling adults (n = 566 402; age = 50–71 years) in 6 US states and 2 metropolitan areas participated in the ongoing prospective National Institutes of Health–AARP Diet and Health Study, which began in 1995. We used baseline data for 565 679 participants on health behaviors, self-rated health status, and medical history, collected by mailed questionnaires. Participants were linked to 2000 census data for an index of census tract socioeconomic deprivation. The main outcome was all-cause mortality ascertained through 2006.Results. In adjusted survival analyses of persons in good-to-excellent health at baseline, risk of mortality increased with increasing levels of census tract socioeconomic deprivation. Neighborhood socioeconomic mortality disparities among persons in fair-to-poor health were not statistically significant after adjustment for demographic characteristics, educational achievement, lifestyle, and medical conditions.Conclusions. Neighborhood socioeconomic inequalities lead to large disparities in risk of premature mortality among healthy US adults but not among those in poor health.Research dating back to at least the 1920s has shown that the United States has experienced persistent and widening socioeconomic disparities in premature mortality over time.^1–5 However, it has been unclear whether socioeconomic inequalities affect the longevity of persons in good and poor health equally. Socioeconomic status (SES) and health status are interrelated,^6–8 and both are strong independent predictors of mortality.⁹ Low SES is associated with greater risk of ill health and premature death,^{1–5,8,10–13} partly attributable to disproportionately high prevalence of unhealthful lifestyle practices^10,14,15 and physical and mental health conditions.^13,16 Correspondingly, risk of premature mortality is higher in poor than in more affluent areas.^16,17 Although the association between neighborhood poverty and mortality is independent of individual-level SES,^17,18 aggregation of low-SES populations in poor areas may contribute to variations in health outcomes across neighborhoods. Conversely, economic hardships resulting from ill health may lead persons in poor physical or mental health to move to poor neighborhoods.¹⁹ This interrelatedness may create spurious associations between neighborhood poverty and mortality.Although previous studies have found that the risk of premature death associated with poor health status varies according to individuals'' SES,^20,21 no published studies have examined whether the relative risks for premature mortality associated with living in neighborhoods with higher levels of socioeconomic deprivation vary by health status of individuals. Clarifying these relationships will inform social and public health policies and programs that aim to mitigate the health consequences of neighborhood poverty.^22,23We used data from a large prospective study to examine whether the risk of premature mortality associated with neighborhood socioeconomic context differs according to health status at baseline and remains after adjustment for person-level risk factors for mortality, such as SES, lifestyle practices, and chronic medical illnesses.     

Hombres Sanos: evaluation of a social marketing campaign for heterosexually identified Latino men who have sex with men and women

Objectives. We evaluated the effectiveness of Hombres Sanos [Healthy Men] a social marketing campaign to increase condom use and HIV testing among heterosexually identified Latino men, especially among heterosexually identified Latino men who have sex with men and women (MSMW).Methods. Hombres Sanos was implemented in northern San Diego County, California, from June 2006 through December 2006. Every other month we conducted cross-sectional surveys with independent samples of heterosexually identified Latino men before (n = 626), during (n = 752), and after (n = 385) the campaign. Respondents were randomly selected from 12 targeted community venues to complete an anonymous, self-administered survey on sexual practices and testing for HIV and other sexually transmitted infections. About 5.6% of respondents (n = 98) were heterosexually identified Latino MSMW.Results. The intervention was associated with reduced rates of recent unprotected sex with both females and males among heterosexually identified Latino MSMW. The campaign was also associated with increases in perception of HIV risk, knowledge of testing locations, and condom carrying among heterosexual Latinos.Conclusions. Social marketing represents a promising approach for abating HIV transmission among heterosexually identified Latinos, particularly for heterosexually identified Latino MSMW. Given the scarcity of evidence-based HIV prevention interventions for these populations, this prevention strategy warrants further investigation.In the United States, adult and adolescent Latino males represent 5.6% of the total population¹ but 18.7% of HIV/AIDS cases.² Low rates of condom use^3–5 and limited HIV testing^5–7 likely contribute to the risk for infection and transmission among Latinos.Sex between men continues to account for the majority of new HIV infections in the United States.² HIV prevention efforts have traditionally targeted gay and bisexual men. However, individuals’ self-identified sexual orientation frequently does not correspond to their sexual behavior,^8–12 and recent research has been focused on men who self-identify as heterosexual but have sex with men. The results of studies on men who have sex with both men and women (MSMW) suggest that, regardless of sexual identity, this population is at greater risk for HIV than are men who exclusively have sex with men; likewise, MSMW are at greater risk than are men who exclusively have sex with women (MSW).^11,13–16 Reasons for greater risk among MSMW may include lower rates of condom use^11,16 and having sexual partners who engage in high-risk sexual practices.¹¹Previous studies have suggested that Latino men are more likely than are White men to engage in bisexual sexual behavior^9,11,17,18 but less likely than are White men to self-identify as gay or bisexual or to disclose their sexual orientation.^19–23 Cultural factors such as homophobia, social stigma related to same-sex practices, and sexual conservatism may inhibit Latino men from self-identifying as homosexual or bisexual.^{10,13,23–26} The degree to which Latinos integrate same-sex sexual practices into their sexual identities may influence their risk for HIV infection.²⁷ Latino MSMW who identify as heterosexual may perceive that they are at lower risk for sexually transmitted infections (STIs) than are gay or bisexual men, and Latino MSMW may thus be less likely to use condoms to protect themselves or their partners. Latino MSMW who identify as heterosexual may also be more likely to resort to substance use to reduce sexual inhibition, thus increasing the likelihood that they will engage in unsafe sex.^19,27Nondisclosure of same-sex sexual practices among MSMW also has significant implications for the health of their female sexual partners.^9,17 More than 70% of Latinas living with HIV/AIDS in the United States were infected via heterosexual contact.² Most cases of heterosexual transmission to Latinas are related to sex with partners who use injection drugs,²⁸ but unprotected sex with men who have multiple partners, including MSMW, has likely contributed to a subset of HIV cases among Latina women.^2,29Social marketing involves applying the principles and techniques of commercial marketing to the promotion of behavioral change for the good of a target audience.^30,31 Social marketing has been successfully used for HIV prevention with gay and bisexual males,^32,33 racial and ethnic minorities,³⁴ and youths.^35–38 Interventions using social marketing have been associated with improvements in HIV/STI testing^32,34 and condom use.^36,37,39,40 To our knowledge, no social marketing campaigns have been designed to reduce HIV risk among heterosexually identified Latino MSMW. Because of the secrecy of their sexual practices and the perceived association of HIV infection with homosexuality,^24,41,42 heterosexually identified Latino MSMW are difficult to reach with HIV prevention efforts. This population is not likely to be exposed to prevention messages or programs targeted to the gay and bisexual communities.¹⁸ Moreover, interventions requiring active recruitment of heterosexually identified MSMW may fail to reach sufficient numbers or may not reach those who are most secretive about their same-sex sexual practices.⁴¹ We sought to evaluate the effectiveness of a social marketing campaign to increase condom use and HIV testing among heterosexual Latino men in northern San Diego County, California, with a special emphasis on heterosexually identified Latino MSMW.     

Health and Health Risks Among Sexual Minority Women: An Examination of 3 Subgroups

We used 2001–2010 National Health and Nutrition Examination Survey data to examine insurance status, source of routine care, cigarette and alcohol use, and self-rated health among lesbian, bisexual, and heterosexual women who have sex with women, compared with heterosexual women who do not have sex with women. We found higher risks of being uninsured among lesbian and bisexual women, worse self-rated health among bisexual women, higher alcohol use among bisexual and heterosexual women who have sex with women, and higher smoking across all subgroups.Sexual minority women (SMW), whether defined by sexual identity (e.g., lesbian or bisexual) or sexual behavior (i.e., same-sex sexual activity), face numerous health risks, including substance use,1–3 mental health disorders,4–6 and poorer physical health,7–10 as well as barriers to quality health care,11,12 compared with sexual nonminority women. Little research, however, has examined the health of different subpopulations of SMW.13 Studies often combine lesbian and bisexual women in analysis, obscuring meaningful differences.14–17 Research also frequently overlooks heterosexual women who have sex with women (WSW), who may experience distinct health risks.18–21In this study, we used information about sexual behavior and sexual identity to further understand differences among SMW. Specifically, we examined health and health risks among 3 subgroups of women: lesbian, bisexual, and heterosexual WSW, compared with heterosexual women who do not have sex with women.     

Dimensions of Sexual Orientation and the Prevalence of Mood and Anxiety Disorders in the United States

Objectives. We used data from a nationally representative sample to examine the associations among 3 dimensions of sexual orientation (identity, attraction, and behavior), lifetime and past-year mood and anxiety disorders, and sex.Methods. We analyzed data from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions.Results. Mental health outcomes differed by sex, dimension of sexual orientation, and sexual minority group. Whereas a lesbian, gay, or bisexual identity was associated with higher odds of any mood or anxiety disorder for both men and women, women reporting only same-sex sexual partners in their lifetime had the lowest rates of most disorders. Higher odds of any lifetime mood or anxiety disorder were more consistent and pronounced among sexual minority men than among sexual minority women. Finally, bisexual behavior conferred the highest odds of any mood or anxiety disorder for both males and females.Conclusions. Findings point to mental health disparities among some, but not all, sexual minority groups and emphasize the importance of including multiple measures of sexual orientation in population-based health studies.In the United States, mental health disorders affect a substantial proportion of the general population.^1,2 Data from the National Comorbidity Study show that approximately 29% of adults meet Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)³ criteria for anxiety disorder and nearly 21% for a mood disorder over their lifetime.¹ Data from the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) indicate that 11% of the US general population met criteria for a DSM-IV independent (nonsubstance-induced) anxiety disorder in the past year and 9.3% met criteria for a DSM-IV mood disorder in the past year.² Given the personal and societal costs associated with mental illness,⁴ it is necessary to understand which groups are at disproportionate risk for mental health disorders so that appropriate prevention and intervention programs can be designed.A growing body of evidence suggests that sexual minorities are at higher risk for mental health disorders than their heterosexual counterparts.^5–8 In a meta-analysis, Meyer⁸ concluded the odds of lifetime mood and anxiety disorders were twice as high for lesbian, gay, and bisexual women and men as for heterosexuals. However, as Meyer and others^9,10 have noted, research on the mental health of sexual minorities has been hampered by methodological limitations, such as nonrandom samples that constrain the generalizability of findings. In addition, many studies contain small samples, which preclude analyses by age, race/ethnicity, and other characteristics that vary with mental health disorders. Lesbian, gay, and bisexual women and men are often combined for analytic reasons, such as the need to increase the overall sample size and corresponding statistical power. This obscures potential differences between lesbians or gays and bisexuals as well as between men and women—and can lead to biased results.Although some researchers have considered how different operationalizations of sexual orientation may affect health outcomes,^11–13 national studies rarely assess sexual orientation and, to date, no national population-based study has compared mental health outcomes across all 3 major dimensions of sexual orientation—identity, behavior, and attraction.¹⁴ As others have noted,^10,15 health risks associated with one dimension of sexual orientation, such as behavior, may differ from those associated with another, such as sexual identity. Furthermore, virtually no population-based health studies of adults have explored associations between sexual attraction and health outcomes. Through the inclusion and measurement of these 3 dimensions in population-based health studies, we can begin to better understand the different dimensions of sexual orientation and their associations with health behaviors and health outcomes.^16–18To address the aforementioned limitations and to contribute to a greater understanding of the prevalence of mental health disorders among sexual minorities, we used data from the 2004–2005 NESARC to assess lifetime and past-year prevalence of DSM-IV mood and anxiety disorders among heterosexual and sexual minority women and men. Our purpose was to answer the following question: does the prevalence of mood and anxiety disorders differ across the 3 major dimensions of sexual orientation and does it differ for women and men?     

Disentangling the Influence of Socioeconomic Status on Differences Between African American and White Women in Unmet Medical Needs

Objectives. We sought to disentangle the relationships between race/ethnicity, socioeconomic status (SES), and unmet medical care needs.Methods. Data from the 2003–2004 Community Tracking Study Household Survey were used to examine associations between unmet medical needs and SES among African American and White women.Results. No significant racial/ethnic differences in unmet medical needs (24.8% of Whites, 25.9% of African Americans; P = .59) were detected in bivariate analyses. However, among women with 12 years of education or less, African Americans were less likely than were Whites to report unmet needs (odds ratio [OR] = 0.57; 95% confidence interval [CI] = 0.42, 0.79). Relative to African American women with 12 years of education or less, the odds of unmet needs were 1.69 (95% CI = 1.24, 2.31) and 2.18 (95% CI = 1.25, 3.82) among African American women with 13 to 15 years of education and 16 years of education or more, respectively. In contrast, the relationship between educational level and unmet needs was nonsignificant among White women.Conclusions. Among African American women, the failure to recognize unmet medical needs is related to educational attainment and may be an important driver of health disparities, representing a fruitful area for future interventions.African Americans are more likely than Whites to have unmet medical care needs according to objective clinical standards such as burden of disease (e.g., higher rates of heart disease and cancer deaths), clinical symptoms of ill health, and preventable hospitalizations.^1,2 Unmet medical need, considered a critical indicator of lack of access to care, is also commonly assessed through subjective indices such as self-reported ability to obtain needed medical care or postponing of needed medical care.^3,4 Studies based on these subjective measures often reveal that African Americans report less need for medical care than Whites,^5–7 but this finding has not been consistent.^8–10 In any event, such a finding suggests that subjective measures capture personal perceptions of need for care rather than (or in addition to) true clinical need.^3,4,11Complex and poorly studied factors influence the link between true medical needs and perceived medical needs, especially among members of racial/ethnic minority groups. Theoretical and empirical research has underscored the limitations of subjective measures of medical need. Signs and symptoms of disease may be a better proxy for unmet medical needs among vulnerable populations.^1,11–14 For example, Cunningham and Hadley¹¹ recently showed that, among members of racial/ethnic minority groups, symptom-specific measures of unmet need were more accurate than general measures.In the United States, race/ethnicity, socioeconomic status (SES), and health have been historically intertwined.¹⁵ SES (e.g., education, occupation, and income) accounts for a large portion of the health disparities observed between members of racial/ethnic minority groups and members of more advantaged groups.^15,16 Also, SES may partly account for differences in how illness severity and risk are perceived. Individuals of low SES, especially members of racial/ethnic minority groups, are more likely than individuals of high SES to underestimate illness severity and the need of medical care for serious conditions such as cancer, stroke, and obesity.^17–21 African Americans and all individuals with low incomes are more likely to underestimate their risk for heart attack, stroke, and cancer than are their counterparts and are less likely to use screening programs and seek appropriate care.^22,23 Thus, perceptions of medical need among members of racial/ethnic minority groups are strongly linked to SES.²⁴Although the literature clearly documents strong links between race/ethnicity, SES, and medical need, the overall picture is not clear. Nationally representative studies with detailed adjustment for SES among specific demographic populations are not available. More specifically, women are more likely than are men to delay or not obtain needed medical care,^25,26 and their unmet needs are more likely to result in mortality.²⁷ The relationship between SES and health may be critically shaped by gender.²⁸ For example, lower SES is associated with poorer health, and, in general, women have lower levels of education than men.^29,30 However, little has been done to disentangle the complex interrelationships among race/ethnicity, SES, and perceptions of unmet or delayed need, especially among women.In an attempt to fill this important gap, we used data from a nationally representative, community-based survey of African American and White women to examine how race/ethnicity and SES are associated with perceived unmet medical care needs. More specifically, we attempted to answer the following question: how does SES influence the relationship between race/ethnicity and perceptions of unmet or delayed need for care among women? Our study was guided by the King and Williams²⁴ conceptual framework for understanding racial differences in health. According to that framework,

race is a proxy variable representing how biological, cultural, socioeconomic, sociopolitical, and discrimination factors … jointly influence health practices, psychosocial and environmental stress, medical care, and ultimately health outcomes.^24(p107)

     

Relation of Childhood Sexual Abuse,Intimate Partner Violence,and Depression to Risk Factors for HIV Among Black Men Who Have Sex With Men in 6 US Cities

Objectives. We assessed the relation of childhood sexual abuse (CSA), intimate partner violence (IPV), and depression to HIV sexual risk behaviors among Black men who have sex with men (MSM).Methods. Participants were 1522 Black MSM recruited from 6 US cities between July 2009 and December 2011. Univariate and multivariable logistic regression models were used.Results. Participants reported sex before age 12 years with someone at least 5 years older (31.1%), unwanted sex when aged 12 to 16 years (30%), IPV (51.8%), and depression (43.8%). Experiencing CSA when aged 12 to 16 years was inversely associated with any receptive condomless anal sex with a male partner (adjusted odds ratio [AOR] = 0.50; 95% confidence interval [CI] = 0.29, 0.86). Pressured or forced sex was positively associated with any receptive anal sex (AOR = 2.24; 95% CI = 1.57, 3.20). Experiencing CSA when younger than 12 years, physical abuse, emotional abuse, having been stalked, and pressured or forced sex were positively associated with having more than 3 male partners in the past 6 months. Among HIV-positive MSM (n = 337), CSA between ages 12 and 16 years was positively associated with having more than 3 male partners in the past 6 months.Conclusions. Rates of CSA, IPV, and depression were high, but associations with HIV sexual risk outcomes were modest.Despite significant medical advances, the HIV epidemic remains a health crisis in Black communities. The Black population represents only 14% of the total US population but accounted for 44% of all new HIV infection (68.9 of 100 000) in 2010.1 Black men who have sex with men (MSM) are disproportionately impacted by HIV compared with other racial/ethnic groups of MSM.1,2 Male-to-male sexual contact accounted for 72% of new infections among all Black men.1 Young Black MSM (aged 13–24 years) have a greater number of new infections than any other age or racial group among MSM.1 Researchers have been challenged with developing HIV prevention strategies for Black MSM.3–7 Higher frequencies of sexual risk behaviors, substance use, and nondisclosure of sexual identities do not adequately explain this disparity.8,9 High rates of sexually transmitted infections (STIs), which facilitate HIV transmission, and undetected or late diagnosis of HIV infection only partially explain disproportionate HIV rates.8Researchers have begun to examine a constellation of health factors that may contribute to HIV among MSM. For example, syndemic theory or the interaction of epidemics synergistically, such as intimate partner violence (IPV) and depression, may help explain HIV-related sexual risk behaviors among Black MSM.9 Childhood sexual abuse (CSA), IPV, and mental health disorders including depression may comprise such a constellation and warrant further exploration.Experiences of CSA have been identified as being associated with negative sexual health outcomes, with MSM reporting higher CSA rates than the general male population.10–12 Men with CSA experiences are more likely than men without CSA experiences to engage in high-risk sexual behaviors,13–21 have more lifetime sexual partners,13–16 use condoms less frequently,13,14,16 and have higher rates of STIs,13,14,17 exchanging sex for drugs or money,13,14,17 HIV,13,14 alcohol and substance use,13–21 and depression.13–15,18,21 Such findings suggest that sexual risk reduction counseling may need to be tailored for MSM with CSA experiences.15Childhood sexual abuse histories have also been correlated with sexual revictimization, including IPV.22–24 One study with population-based estimates of CSA found that gay and bisexually identified men had higher odds of reporting CSA (9.5 and 12.8, respectively) compared with heterosexual men.25 For sexual minority men, CSA histories were associated with higher HIV and STI incidence.25 However, research examining CSA, revictimization, and sexual risk behaviors is lacking among Black MSM.In one existing study, Black and Latino MSM with CSA histories identified their trauma experiences as influencing their adult sexual decision-making.26 Among Black MSM in 2 additional studies, emotional distress and substance use were attributed to having CSA experiences (Leo Wilton, PhD, written communication, October 2, 2013).27 In an ethnically diverse sample of 456 HIV-positive MSM, CSA was associated with insertive and receptive condomless anal sex.19Similar to CSA, IPV has not been extensively examined among MSM or Black MSM,28 but may be associated with sexual risk behaviors. Intimate partner violence is defined as a pattern of controlling, abusive behavior within an intimate relationship that may include physical, psychological or emotional, verbal, or sexual abuse.29 Little research exists on IPV among same-sex couples despite incidence rates being comparable to or greater than that of heterosexual women.28,30–34 Important IPV information comes from the National Intimate Partner and Sexual Violence Survey, a nationally representative survey for experiences of sexual violence, stalking, and IPV among men and women in the United States.28 Among men who experienced rape, physical violence, or stalking by an intimate partner, perpetrator differences by gender were found among gay, bisexual, and heterosexual men; 78% of bisexual and 99.5% of heterosexual men reported having only female perpetrators, and 90.7% of gay men reported having only male perpetrators.28 Being slapped, pushed, or shoved by an intimate partner during their lifetime was reported by gay (24%), bisexual (27%), and heterosexual (26.3%) men.28Intimate partner violence has been linked to condomless anal sex, HIV infection, substance use, CSA, and depression.35–37 Being an HIV-positive MSM has been linked with becoming a victim of IPV.38,39 Welles et al. found that being an African American MSM who initially disclosed having male partners and early life sexual abuse experiences was associated with IPV victimization.39 Wilton found that a high percentage of Black MSM reported IPV histories: emotional abuse (48.3%), physical abuse (28.3%), sexual abuse (21.7%), and stalking abuse (29.2%; Leo Wilton, PhD, written communication, October 2, 2013). Such findings lend to the importance of exploring, both independently and together, the association of CSA and IPV with sexual risk behaviors.Some studies have reported the influence of mental health (e.g., depression) on sexual risk behaviors among MSM,9,40,41 whereas others have not corroborated such findings.42 Greater rates of depression among MSM than among non-MSM samples43–45 and elevated rates of depression and anxiety among Black MSM have been reported.46 The Urban Men’s Health Study, a cross-sectional sample of MSM in 4 US cities, did not find a significant relationship between high depressive symptoms and condomless anal sex.42 However, the EXPLORE study, a randomized behavioral intervention for MSM in 6 US cities, supported the association between moderate depressive symptoms and an increased risk for HIV infection.47 Moderate levels of depression and higher rates of sexual risk were also reported for HIV-infected MSM over time.48 Another study conducted with 197 Black MSM found that moderate depressive symptoms were associated with having condomless anal sex with a serodiscordant casual partner.49 These mixed findings support the need to better understand the relationship between the severity of depression (i.e., moderate vs severe) and HIV risk behaviors.The HIV Prevention Trials Network 061 study, also known as the BROTHERS (Broadening the Reach of Testing, Health Education, Resources, and Services) Project, was a multisite study to determine the feasibility and acceptability of a multicomponent intervention for Black MSM. The current analysis aims to assess the prevalence of CSA, IPV, and depressive symptomology, and examine the relationships between these factors and insertive and receptive condomless anal sex and number of sexual partners in a large cohort of Black MSM.     

Sexual Orientation Disparities in Adolescent Cigarette Smoking: Intersections With Race/Ethnicity,Gender, and Age

Objectives. We examined sexual orientation differences in adolescent smoking and intersections with race/ethnicity, gender, and age.Methods. We pooled Youth Risk Behavior Survey data collected in 2005 and 2007 from 14 jurisdictions; the analytic sample comprised observations from 13 of those jurisdictions (n = 64 397). We compared smoking behaviors of sexual minorities and heterosexuals on 2 dimensions of sexual orientation: identity (heterosexual, gay–lesbian, bisexual, unsure) and gender of lifetime sexual partners (only opposite sex, only same sex, or both sexes). Multivariable regressions examined whether race/ethnicity, gender, and age modified sexual orientation differences in smoking.Results. Sexual minorities smoked more than heterosexuals. Disparities varied by sexual orientation dimension: they were larger when we compared adolescents by identity rather than gender of sexual partners. In some instances race/ethnicity, gender, and age modified smoking disparities: Black lesbians–gays, Asian American and Pacific Islander lesbians–gays and bisexuals, younger bisexuals, and bisexual girls had greater risk.Conclusions. Sexual orientation, race/ethnicity, gender, and age should be considered in research and practice to better understand and reduce disparities in adolescent smoking.Cigarette smoking continues to be the leading cause of preventable morbidity and premature mortality in the United States.1,2 Preventing adolescent smoking is essential to reducing the burden of cigarettes because smoking typically begins during adolescence.3,4 Approximately 88% of adult daily smokers began smoking before their 18th birthday.5 Research has shown that adolescents with a minority sexual orientation (i.e., lesbian, gay, and bisexual [LGB] youths and other adolescents who report same-sex attractions or behavior) are more likely than heterosexual adolescents to smoke cigarettes.6–12 In addition to variation in adolescent smoking by sexual orientation, research has documented variation by race/ethnicity, gender, and age–developmental period.13–17 For instance, national data from the United States collected in 2009 found that White (19.4%) and Hispanic (19.1%) high school students reported higher prevalence of current smoking than Asian (9.7%) and Black (9.1%) students.18 Risk for smoking is typically higher in male than female adolescents and in older than younger adolescents.16,19Although research has shown how sexual orientation, race/ethnicity, gender, and age separately influence variations in adolescent smoking, limited data exist on how sexual orientation differences in adolescent smoking vary across sociodemographic factors such as race/ethnicity, gender, and age. A report published in 2011 by the Institute of Medicine, The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding, argued for the importance of examining the health of sexual minorities in the context of sociodemographic diversity to provide a more complete understanding of health disparities.20 Empirical evidence of this nature can improve understanding of the burden of smoking in specific population subgroups and identify high-risk subgroups to target for research, prevention, and cessation efforts.Existing research to understand how smoking patterns of sexual minority youths vary across gender, age, and race/ethnicity is inconclusive and sometimes contradictory. In addition, few studies have used large, representative samples, which limits the ability to draw inferences about the entire population of sexual minority youths.21 Studies examining how sexual orientation differences in adolescent smoking vary by gender have been the most conclusive and have typically found larger disparities between sexual minority and heterosexual adolescent girls than between sexual minority and heterosexual adolescent boys.6,9,22,23 However, studies examining how sexual orientation differences in adolescent smoking vary by age have been inconclusive. One study of mostly White youths followed between ages 12 and 24 years found that smoking disparities were larger between sexual minorities and heterosexuals during younger than older ages.6 However, a study of Asian Americans and Pacific Islanders (APIs) found that smoking disparities were not present in adolescence but emerged in young adulthood.9In addition, scant data exist on how sexual orientation and race/ethnicity jointly influence risk for adolescent smoking. This is an especially difficult area to investigate because studies with a sample size large enough to examine this question are rare. Some evidence suggests that sexual minority youths who belong to racial/ethnic minority groups are more likely to smoke cigarettes than their heterosexual peers of their same race/ethnicity. For instance, a study of college students found that Black, Asian, Hispanic, and multiracial LGB persons were more likely to smoke than their heterosexual racial/ethnic peers.24 This study also found that Black and Asian LGB persons were less likely to smoke than their White LGB peers, but the same was not true for Hispanics and multiracial LGB persons. However, the study did not describe statistical testing to examine whether race/ethnicity modified sexual orientation disparities in smoking.Another important consideration is the multidimensional nature of sexual orientation (e.g., identity, attractions, behaviors), which in research with adolescents has most often been assessed as how respondents identify or the gender of their sexual attractions or partners. How sexual orientation is operationalized in studies may influence findings and conclusions, but studies infrequently include more than 1 dimension. Studies with adults12,25–27 and adolescents10,23,28 have shown differences in the magnitude of the sexual orientation disparities observed depending on which dimension is considered. For example, a study of Mexican youths aged 18 to 29 years found that self-identified LGB participants had approximately twice the odds of reporting current smoking than did heterosexuals, but differences between participants reporting only same-sex partners and those reporting only opposite-sex partners were negligible.23 Such disparate findings are likely to occur because the dimensions capture somewhat different populations with differing risk and protective factors.29It is especially important to assess multiple dimensions of sexual orientation in adolescence because a same-sex orientation commonly develops during this period, and many adolescents with a same-sex orientation may not identify as LGB.30 In addition, when gender of sexual partners is used as an indicator of sexual orientation, only adolescents who have initiated sexual intercourse (approximately 48% of high school students in 200719) can be identified. Because adolescent smoking is a robust correlate of sexual activity,31 the degree to which the selection of a sexually active subgroup may influence sexual orientation findings warrants consideration. Finally, the extent to which the different dimensions may affect conclusions drawn about smoking disparities arising from sexual orientation when also considering intersections with race/ethnicity, gender, and age remain uncertain. To address these questions, we compared sexual orientation differences in smoking during adolescence with 2 dimensions of sexual orientation (identity and gender of lifetime sexual partners) and investigated how these differences were modified by race/ethnicity, gender, and age in Youth Risk Behavior Survey (YRBS) data pooled from 13 jurisdictions and 2 years.