Sexual Health Behaviors and Sexual Orientation in a U.S. National Sample of College Students

Many studies have examined differences in sexual behavior based on sexual orientation with results often indicating that those with same-sex partners engage in higher risk sexual behavior than people with opposite sex partners. However, few of these studies were large, national sample studies that also include those identifying as unsure. To address that gap, this study examined the relationship of sexual orientation and sexual health outcomes in a national sample of U.S. college students. The Fall 2009 American College Health Association–National College Health Assessment was used to examine sexual health related responses from heterosexual, gay, lesbian, bisexual, and unsure students (N = 25,553). Responses related to sexual behavior, safer sex behaviors, prevention and screening behaviors, and diagnosis of sexual health related conditions were examined. The findings indicated that sexual orientation was significantly associated with engaging in sexual behavior in the last 30 days. Sexual orientation was also significantly associated with the number of sexual partners in the previous 12 months, with unsure men having significantly more partners than gay, bisexual and heterosexual men and heterosexual men having significantly less partners than gay, bisexual and unsure men. Bisexual women had significantly more partners than females reporting other sexual orientations. Results examining the associations between sexual orientation and safer sex, prevention behaviors, and screening behaviors were mixed. Implications for practice, including specific programmatic ideas, were discussed.     

Trends in Sexual Orientation Missing Data Over a Decade of the California Health Interview Survey

Objectives. We explored changes in sexual orientation question item completion in a large statewide health survey.Methods. We used 2003 to 2011 California Health Interview Survey data to investigate sexual orientation item nonresponse and sexual minority self-identification trends in a cross-sectional sample representing the noninstitutionalized California household population aged 18 to 70 years (n = 182 812 adults).Results. Asians, Hispanics, limited-English-proficient respondents, and those interviewed in non-English languages showed the greatest declines in sexual orientation item nonresponse. Asian women, regardless of English-proficiency status, had the highest odds of item nonresponse. Spanish interviews produced more nonresponse than English interviews and Asian-language interviews produced less nonresponse when we controlled for demographic factors and survey cycle. Sexual minority self-identification increased in concert with the item nonresponse decline.Conclusions. Sexual orientation nonresponse declines and the increase in sexual minority identification suggest greater acceptability of sexual orientation assessment in surveys. Item nonresponse rate convergence among races/ethnicities, language proficiency groups, and interview languages shows that sexual orientation can be measured in surveys of diverse populations.Measuring sexual orientation in health surveys facilitates comprehensive public health surveillance. Accumulating evidence suggests that some lesbians, gay men, and bisexual individuals, compared with heterosexual persons, have higher smoking rates,1,2 greater second-hand smoke exposure,3 more psychological distress4–6 and depression,7 higher suicide attempt rates,8 worse general health status9 and higher disability rates,10 and lower preventive care use.11 As a reflection on these emerging findings, calls for greater collection of sexual orientation data abound,12–17 but the validity of sexual-minority research is threatened if survey respondents cannot or will not provide these data.Several large health surveys now routinely measure sexual orientation. Since 2001, the California Health Interview Survey (CHIS) has included questions assessing self-identified sexual orientation.18 Twelve Behavioral Risk Factor Surveillance System state surveys also asked sexual orientation questions at least once between 2000 and 2014.19 Other large-scale surveys currently asking sexual orientation include the Los Angeles County Health Survey,20 National Health Interview Survey (NHIS),21 National Health and Nutrition Examination Survey,22 and General Social Survey.23Results from these surveys indicate that most respondents provide a codeable sexual orientation response. One percent of NHIS respondents in 2013 did not respond when asked their sexual orientation. “Don’t know” responses comprised 0.4% and refusals made up 0.6%.24 In 2003 to 2010 Washington State Behavioral Risk Factor Surveillance System data, 0.74% responded “don’t know” or “not sure,” and 1.12% refused.25 Yet, African Americans, Asian Americans, and Hispanics in that study had higher odds of nonresponse than Whites. This raises questions about possible sociodemographic differences in sexual orientation measurement, but there have been few assessments of the combined roles of race/ethnicity and language in sexual orientation item nonresponse, and changes in those effects over time.25,26 The independent effects of English proficiency and interview language remain largely unexplored as well. Linguistic and ethnic minorities who are also sexual minorities may be underrepresented in routine public health surveillance efforts if they are differentially likely to answer sexual orientation questions.25 Understanding the relationship among sexual orientation item nonresponse, race/ethnicity, and language proficiency is important because these sociodemographic domains correlate with health disparities.27-29Sexual orientation nonresponse is likely attributable to social stigma of identification and a lack of understanding of the terminology used to discuss the topic.30 Secular trends in lesbian, gay, and bisexual (LGB) social and legal recognition31 may increase LGB individuals’ willingness to disclose their sexual orientation in surveys. The non-LGB public may also become more comfortable with and knowledgeable about the topic as a result. Public opinion surveys now show majority support for gay marriage and LGB people in general.32,33 Sexual orientation item nonresponse should decline, and the percentage of respondents identifying as LGB may increase as stigma recedes and familiarity grows. These potential effects may be more pronounced among racial, ethnic, and linguistic minorities.25,26Two primary research questions guided this study:

• (1) Does the sexual orientation item nonresponse rate change over time?
• a. If so, is this change constant across races/ethnicities, English proficiency levels, and interview languages?
• b. How strongly do race/ethnicity, English proficiency, and interview language predict sexual orientation nonresponse?
• (2) Does LGB identification vary over the same time period?

     

Teaching About Sexual Orientation by Secondary Health Teachers

ABSTRACT: Less than half of a random sample (N = 211) of high school health teachers formally teach about homosexuality. When taught, it most commonly is taught for less than one class period. Only one-in-four teachers perceived themselves as very competent in teaching about homosexuality. This is not surprising given the fact that teachers were most likely to identify the mass media as the most commonly used source of information regarding homosexuality. One-in-five teachers claimed students in their classes often used abusive language when describing homosexuals. One-third of health teachers indicated gay and lesbian rights are a threat to the American family and its values. However, one-third of the health teachers perceived the schools were not doing enough to help homosexual adolescents. Finally, more than half the health teachers indicated gay/lesbian support groups would not be supported by their school administrator. Perceptions and behaviors regarding adolescent homosexuality varied by the teachers' gender, age, educational level, and teaching status regarding homosexuality.     

A Population-Based Study of Sexual Orientation Identity and Gender Differences in Adult Health

Objectives. We provide estimates of several leading US adult health indicators by sexual orientation identity and gender to fill gaps in the current literature.Methods. We aggregated data from the 2001–2008 Massachusetts Behavioral Risk Factor Surveillance surveys (N = 67 359) to examine patterns in self-reported health by sexual orientation identity and gender, using multivariable logistic regression.Results. Compared with heterosexuals, sexual minorities (i.e., gays/lesbians, 2% of sample; bisexuals, 1%) were more likely to report activity limitation, tension or worry, smoking, drug use, asthma, lifetime sexual victimization, and HIV testing, but did not differ on 3-year Papanicolaou tests, lifetime mammography, diabetes, or heart disease. Compared with heterosexuals, bisexuals reported more barriers to health care, current sadness, past-year suicidal ideation, and cardiovascular disease risk. Gay men were less likely to be overweight or obese and to obtain prostate-specific antigen tests, and lesbians were more likely to be obese and to report multiple risks for cardiovascular disease. Binge drinking and lifetime physical intimate partner victimization were more common among bisexual women.Conclusions. Sexual orientation disparities in chronic disease risk, victimization, health care access, mental health, and smoking merit increased attention. More research on heterogeneity in health and health determinants among sexual minorities is needed.Most research on sexual minority health in the United States has been conducted using convenience samples. Although the findings of this research have made significant contributions to the literature, data collected from nonprobability samples have limited utility for public health planning because of concerns regarding selection bias and external validity. Population-based health statistics play a key role in informing the prioritization of public health problems and public investment in health promotion activity.Relatively recent inclusion of sexual orientation measures in a few federal and state health surveillance surveys is enabling the production of population-based information about sexual minority health and its status relative to that of the heterosexual majority. Although the amount of sexual orientation data collected with known probability is increasing, published studies of such data are limited in number and scope. To date, most have reported on sexual orientation differences in the prevalence of psychiatric disorders,^1–5 and a handful have explored other health issues (e.g., tobacco use, health care access, violence victimization, and chronic disease risk).^6–11Examination of variability within the sexual minority population is another limitation of the current population-based literature. Few studies have been adequately powered to investigate variability in health by sexual orientation, let alone by orientation and other key social characteristics (e.g., gender, race/ethnicity, socioeconomic status); yet research suggests heterogeneity in sexual minority health. For instance, lesbians who participated in the National Survey of Family Growth were much more likely to be overweight than were heterosexual women, but the same was not true of bisexual women.⁶ Bisexual women and gay male participants in the representative California Quality of Life Survey (QLS) were more likely to report digestive problems than were their same-gender, heterosexual peers, whereas lesbians and bisexual men were not.¹²This study extends the literature by providing estimates of several leading US health indicators by both sexual orientation identity and gender. To our knowledge, ours is one of few studies to do so and is the first to report on a US East Coast sample. As Healthy People 2020 priorities are established, information about sexual orientation differences across a spectrum of health issues and geographic regions is greatly needed.     

Disparities in Weight and Weight Behaviors by Sexual Orientation in College Students

Objectives. We assessed disparities in weight and weight-related behaviors among college students by sexual orientation and gender.Methods. We performed cross-sectional analyses of pooled annual data (2007–2011; n = 33 907) from students participating in a Minnesota state-based survey of 40 two- and four-year colleges and universities. Sexual orientation included heterosexual, gay or lesbian, bisexual, unsure, and discordant heterosexual (heterosexuals engaging in same-sex sexual experiences). Dependent variables included weight status (derived from self-reported weight and height), diet (fruits, vegetables, soda, fast food, restaurant meals, breakfast), physical activity, screen time, unhealthy weight control, and body satisfaction.Results. Bisexual and lesbian women were more likely to be obese than heterosexual and discordant heterosexual women. Bisexual women were at high risk for unhealthy weight, diet, physical activity, and weight control behaviors. Gay and bisexual men exhibited poor activity patterns, though gay men consumed significantly less regular soda (and significantly more diet soda) than heterosexual men.Conclusions. We observed disparities in weight-, diet-, and physical activity–related factors across sexual orientation among college youths. Additional research is needed to better understand these disparities and the most appropriate intervention strategies to address them.In 2011, the Institute of Medicine highlighted the significant lack of research on the health of lesbian, gay, and bisexual (LGB) groups.1 Research has indicated that LGB adults experience worse health outcomes than their heterosexual peers.2–11 These disparities may be attributable to an array of factors, including stigmatization, stress, and limited access to and use of health services.1,12,13 Specific areas of potential disparities among LGB groups lacking substantial research evidence include obesity, diet, physical activity patterns, unhealthy weight control behaviors, and body image. With two thirds of US adults now overweight or obese,14 obesity prevention is a national health priority. Findings from studies examining adult weight disparities by sexual orientation have consistently indicated that lesbian women are more likely to be overweight than heterosexual women.2,11,15–19 Several recent population-based studies have suggested that gay men may be less likely to be overweight than heterosexual men,2,18,20 and additional studies have highlighted concerns regarding body image and unhealthy weight control behaviors among gay men.21–24 Disparities in other behaviors, such as dietary intake and physical activity patterns, have not been studied extensively using population-based samples and, when studied, have yielded inconsistent findings.11,25,26Furthermore, much of the work in this area to date has not focused on the college years. Because nearly half of US high school graduates up to age 24 years are enrolled in postsecondary education,27 colleges and universities offer unique environments for addressing health disparities among young people, including those of LGB students. For many, the college years represent a time during which health disparities emerge28,29 and adverse changes occur in weight, dietary quality, physical activity, and other behaviors.30–38 For LGB people, this age is commonly when sexual identity is declared and assimilation into the LGB community occurs.39 Important postsecondary institutions that could act as platforms for intervention delivery include not only traditional 4-year universities but also 2-year community and technical colleges, which serve millions of students, particularly those from lower income and minority backgrounds.40,41The objective of this study was to characterize gender-specific weight-related disparities among college students by sexual orientation. We analyzed state survey data of nearly 34 000 students attending a wide array of 2- and 4-year colleges and universities in 2007 to 2011, including a subsample of more than 2000 LGB-identified and LGB-questioning participants. This research was intended to fill several gaps in the literature. For example, although a recent wave of studies11,19,22–25 were published after the release of the Institute of Medicine report,1 most of these studies used data from 1999 to 2007 and thus were not able to characterize disparities during the past 5 to 8 years (when important societal shifts in weight-related factors42,43 and social shifts regarding LGB issues occurred). Moreover, a majority of these studies focused not on the college years but rather on adulthood overall (e.g., 18–74 years) or on adolescence (e.g., 9th–12th grade). Finally, only a small number of studies have examined population-level LGB disparities in dietary intake or physical activity,11,20,25,26 which are critical factors to address in weight-related intervention strategies. Among the few population-based studies that have addressed diet and activity, unidimensional indicators have been used to assess fruit and vegetable consumption or moderate to vigorous intensity physical activity, but these studies have generally lacked characterization of other important dietary factors (e.g., frequency of soda, fast food, away-from-home eating, or breakfast consumption) or activities (e.g., strengthening activities, screen time).     

Physical Size and Sexual Orientation: Analysis of the Chinese Health and Family Life Survey

In the present study, the relationship between physical size and sexual orientation was examined. Participants were men and women comprising the Chinese Health and Family Life Survey (N > 3,500), which employed a national probability sample from China. This survey is important because no research has examined these issues in a representative, non-Western sample. Participants completed self-report measures of height, weight, and sexual orientation. Some evidence was found that men with same-sex inclinations were significantly shorter than heterosexual men. The evidence that women with same-sex inclinations were significantly taller and heavier than heterosexual women was equivocal. The results add modest support to some prior research suggesting that men with same-sex inclinations have a different pattern of growth and development relative to heterosexual comparisons.     

Family Poverty Over the Early Life Course and Recurrent Adolescent and Young Adult Anxiety and Depression: A Longitudinal Study

Objectives. We determined whether exposure to family poverty over a child''s early life course predicts adolescent and young adult anxiety and depression.Methods. We used a birth cohort study of a sample of women in Brisbane, Australia, who were recruited in early pregnancy and whose children were followed up on at ages 14 and 21 years. Some 2609 mothers and adolescents provided usable data at the 14- and 21-year follow-ups.Results. After adjustment for poverty at other phases, poverty at the 14-year follow-up was the strongest predictor of adolescent and young adult anxiety and depression. The more frequently the child was exposed to poverty, the greater was the risk of that individual being anxious and depressed at both the 14- and 21-year follow-ups.Conclusions. Family poverty predicts higher rates of adolescent and young adult anxiety and depression. Increased frequency of child exposure to poverty is a consistent predictor of adolescent and young adult anxiety and depression. Repeated experiences of poverty over a child''s early life course are associated with increased levels of poor mental health.Family poverty has been associated with a variety of adverse health outcomes,^1–6 including poor mental health. Relatively little, however, is known about the extent to which poverty and socioeconomic disadvantage experienced early in the life course (e.g., fetal, childhood, or adolescent period) may have long-term consequences. Poverty experienced in early childhood has been found to affect cognitive and other health and developmental outcomes.^7–9 Little is known, however, about whether there may be critical periods during gestation, childhood, or adolescence when exposures to poverty may have major and irreversible consequences.The notion of critical or sensitive periods has a long history.¹⁰ The concept of sensitive periods must be distinguished from the effects of the intensity, duration, or frequency of exposure to a stimulus (i.e., the cumulative level of exposure). Generally, periods over the life course that might be characterized as critical or sensitive are periods when those exposed are experiencing important biological changes, and when the exposure modifies these ongoing biological changes.^11,12 Gestation, early childhood, and adolescence are stages of the life course during which the fetus, child, or adolescent is experiencing rapid biological change. Although the specific mechanisms involved in the finding of critical or sensitive periods remain a matter of debate, they are likely to include the concept of brain plasticity and epigenetic processes.¹³Whether there are critical or sensitive periods for the impact of family poverty on the development of childhood mental illness (specifically, anxiety and depression) does not appear to have been a subject of previous research. In some of the few studies that have tracked the impact of early life-course experiences of poverty on adult chronic diseases, the observation of statistically significant associations has not been accompanied by a focus on differences in life-course stage in the experience of poverty.^8,14We examined 3 specific questions concerning the association between family poverty and anxiety and depression among adolescents and young adults: Does family poverty experienced at different points over the early life course affect anxiety and depression at the 14-year (adolescent) and 21-year (young adult) follow-ups? Does recurrent exposure to family poverty have a cumulative effect on adolescent and young adult anxiety and depression? Is the association between family poverty and anxiety and depression in children and young adults independent of some possible confounding factors—specifically, mother''s age at time of pregnancy, mother''s marital status, mother''s anxiety and depression, and offspring''s income in adulthood?     

Influence of Life Course Socioeconomic Position on Older Women's Health Behaviors: Findings From the British Women's Heart and Health Study

Objectives. We examined the association between health behaviors and socioeconomic status (SES) in childhood and adult life.Methods. Self-reported diet, smoking, and physical activity were determined among 3523 women aged 60 to 79 years recruited from general practices in 23 British towns from 1999 through 2001.Results. The most affluent women reported eating more fruit, vegetables, chicken, and fish and less red or processed meat than did less affluent women. Affluent women were less likely to smoke and more likely to exercise. Life course SES did not influence the types of fat, bread, and milk consumed. Adult SES predicted consumption of all foods considered and predicted smoking and physical activity habits independently of childhood SES. Childhood SES predicted fruit and vegetable consumption independently of adult SES and, to a lesser extent, predicted physical activity. Downward social mobility over the life course was associated with poorer diets and reduced physical activity.Conclusions. Among older women, healthful eating and physical activity were associated with both current and childhood SES. Interventions designed to improve social inequalities in health behaviors should be applied during both childhood and adult life.In 1977, the United Kingdom Department of Health commissioned an inquiry focusing on health inequalities in the country''s population. The resulting report—the Black Report, published in 1980—highlighted the marked association between adult socioeconomic status (SES) and mortality rates.¹ Such socioeconomic gradients in mortality rates persist today, tracking into old age.²Inequalities in health are a result of clearly identifiable social and economic factors that could potentially be modified to improve people''s quality and length of life. Employment, education, housing, transportation, environment, health care, and “lifestyle” (in particular smoking, exercise, and diet) all affect health and tend to be favorably distributed in advantaged groups.In the United Kingdom, the introduction of the National Service Framework for Coronary Heart Disease in 2000 was intended to reduce the prevalence of and social inequalities in coronary risk factors in the country''s population.³ Achieving these aims requires equitable access to and use of preventive care irrespective of SES, age, and gender. Health promotion initiatives such the “5-a-day” fruit and vegetable diet plan,⁴ smoking cessation clinics, and structured exercise plans have all been part of the drive to reduce the prevalence of coronary risk factors.Recent years have seen increased recognition of the potential implications of life course SES and a deeper understanding of the conceptual framework on which it is based.^5,6 There is growing evidence that coronary heart disease (CHD) risk is associated with life course SES,^7–10 with those in the most disadvantaged SES groups throughout life showing nearly 3 times greater risk than those in more advantaged groups.⁸ This raises the question of the extent to which behavioral CHD risk factors are similarly dependent on life course SES. We examined the effects of childhood and adulthood SES on various health behaviors (diet, smoking, and physical activity) of older British women.     

Sexual Orientation and Sexual and Reproductive Health Among Adolescent Young Women in the United States

PurposeWe studied sexual and reproductive health among self-identified bisexual, lesbian, and heterosexual adolescent young women. Prior research has suggested that bisexual and lesbian young women may be at greater risk for many negative health outcomes, including risky sexual and reproductive health behavior.MethodsUsing data from the U.S. nationally representative 2006–2010 National Survey of Family Growth (NSFG), we examined sexual and reproductive health among young women 15–20 years of age as a function of sexual orientation. We used logistic regression and ANCOVA to examine differences in sexual and reproductive health across groups while controlling for demographic group differences.ResultsBisexual and lesbian young women reported elevated sexual and reproductive health risks. Bisexual and lesbian participants reported being younger at heterosexual sexual debut, and having more male and female sexual partners, than did heterosexual participants. Further, they were more likely than heterosexual young women to report having been forced to have sex by a male partner. Bisexual young women reported the earliest sexual debut, highest numbers of male partners, greatest use of emergency contraception, and highest frequency of pregnancy termination.ConclusionsOverall, sexual minority young women—especially those who identified as bisexual—were at higher sexual and reproductive risk than their heterosexual peers.     

Differences by Sexual Orientation in Perceptions of Neighborhood Cohesion: Implications for Health

A large body of research documents the relationship between health and place, including the positive association between neighborhood cohesion and health. However, very little research has examined neighborhood cohesion by sexual orientation. This paper addresses that gap by examining differences in perceived neighborhood cohesion by sexual orientation. We use data from the 2016 National Health Interview Survey (n?=?28,164 respondents aged 18 years and older) to examine bivariate differences by sexual orientation in four measures of neighborhood cohesion. We then use ordered logistic regression models to assess the relationship between sexual orientation and a scaled measure of neighborhood cohesion, adjusting for socio-demographic characteristics, living arrangements, health status, region, and neighborhood tenure. We find that lesbian, gay, and bisexual (LGB) adults are less likely to say that they live in a close-knit neighborhood (54.6 vs. 65.6%, p?<?0.001), they can count on their neighbors (74.7 vs. 83.1%, p?<?0.001), they trust their neighbors (75.5 vs. 83.7%, p?<?0.001), or people in their neighborhood help each other out (72.9 vs. 83.1%, p?<?0.001), compared to heterosexual adults. Even after controlling for socio-demographic factors, neighborhood cohesion scores are lower for LGB adults compared to heterosexual adults (odds ratio of better perceived neighborhood cohesion for sexual minorities: 0.70, p?<?0.001). Overall, LGB adults report worse neighborhood cohesion across multiple measures, even after adjusting for individual characteristics and neighborhood tenure. Because living in a cohesive neighborhood is associated with better health outcomes, future research, community-level initiatives, and public policy efforts should focus on creating welcoming neighborhood environments for sexual minorities.