Sexual Orientation Disparities in Papanicolaou Test Use Among US Women: The Role of Sexual and Reproductive Health Services

We investigated sexual orientation disparities in Papanicolaou screening among US women aged 21 to 44 years (n = 9581) in the 2006 to 2010 National Survey of Family Growth. The odds ratios for lesbian versus heterosexual women and women with no versus only male sexual partners were 0.40 and 0.32, respectively, and were attenuated after adjustment for sexual and reproductive health (SRH) care indicators. Administering Papanicolaou tests through mechanisms other than SRH services would promote cervical cancer screening among all women.Cervical cancer, a deadly disease primarily caused by human papillomavirus infection,1 can be prevented through regular Papanicolaou (Pap) test use and appropriate follow-up.2,3 Although lesbians and women who have sex with women are at risk for human papillomavirus4–14 from both past and present sexual partners, limited evidence derived from convenience15,16 and subnational population-based16,17 samples suggests that they are less likely than heterosexual women and women with only male sexual partners, respectively, to receive Pap tests.8,9,15,17–22 We accordingly investigated sexual orientation disparities in Pap test use in a large US national probability sample, which no previous study has done, and assessed the contribution of sexual and reproductive health (SRH) services to sexual orientation disparities in Pap test use.     

Demonstrating the Importance and Feasibility of Including Sexual Orientation in Public Health Surveys: Health Disparities in the Pacific Northwest

Objectives. We identified health disparities for a statewide population of lesbian, gay, and bisexual (LGB) men and women compared with their heterosexual counterparts.Methods. We used data from the 2003–2006 Washington State Behavioral Risk Factor Surveillance System to examine associations between sexual orientation and chronic health conditions, health risk behaviors, access to care, and preventive services.Results. Lesbian and bisexual women were more likely than were heterosexual women to have poor physical and mental health, asthma, and diabetes (bisexuals only), to be overweight, to smoke, and to drink excess alcohol. They were also less likely to have access to care and to use preventive services. Gay and bisexual men were more likely than were heterosexual men to have poor mental health, poor health-limited activities, and to smoke. Bisexuals of both genders had the greatest number and magnitude of disparities compared with heterosexuals.Conclusions. Important health disparities exist for LGB adults. Sexual orientation can be effectively included as a standard demographic variable in public health surveillance systems to provide data that support planning interventions and progress toward improving LGB health.A limited number of studies have described chronic disease health risks among lesbian, gay, and bisexual (LGB) adults. Few of these studies have been population based, and those were often conducted in limited geographic areas or did not include a heterosexual comparison group. Most have relied on convenience samples or other targeted study designs and studied only specific health issues such as smoking or HIV risk factors.The patchwork of available studies indicates that LGB adults have important health disparities. Compared with heterosexual women, lesbian and bisexual women have been shown to have poorer overall health and mental health^1–3; higher rates of smoking,^4–11 alcohol consumption,^8,11–13 asthma,^3,13 and obesity²; and less access to health care,¹² including routine preventive screenings such as Papanicolaou (Pap) tests or mammograms,^14–16 although they were more likely to have had HIV tests.¹⁵ Gay and bisexual men have reported higher rates of smoking^4–6,9 and alcohol use⁸ and poorer general health and mental health^1,3 compared with heterosexual men. An LGB companion document to the Healthy People 2010 initiative identified 29 specific objectives that prioritized sexual minorities, but data by sexual orientation were not available in public health surveillance systems to track most of those objectives.¹⁷ In a recent review of sexual and gender minority health issues, Mayer et al.¹⁸ called for more inclusion of sexual minority identifiers in national data sets as a necessary next step in elimination of health disparities.In 2003, Washington began to include a question about sexual orientation in its Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS is a telephone-based survey of adults that is sponsored by the Centers for Disease Control and Prevention (CDC) and implemented throughout the United States.¹⁹For previous analyses, we combined data from 2 states (Washington and Oregon) collecting LGB information in BRFSS since 2003 into a single data set to gain sufficient numbers to describe LGB smoking behaviors.⁶ After 4 years of data collection, we now have enough LGB respondents from Washington alone to examine a variety of indicators. The purpose of this study was to describe a variety of health indicators for a statewide population of LGB men and women compared with their heterosexual counterparts. By demonstrating the feasibility and relevance of collecting information on sexual orientation in the BRFSS, we provide justification for public health surveillance systems to progress beyond “don''t ask, don''t tell” policies.     

Let’s Get Physical: Sexual Orientation Disparities in Physical Activity,Sports Involvement,and Obesity Among a Population-Based Sample of Adolescents

Objectives. We examined sexual orientation disparities in physical activity, sports involvement, and obesity among a population-based adolescent sample.Methods. We analyzed data from the 2012 Dane County Youth Assessment for 13 933 students in grades 9 through 12 in 22 Wisconsin high schools. We conducted logistic regressions to examine sexual orientation disparities in physical activity, sports involvement, and body mass index among male and female adolescents.Results. When we accounted for several covariates, compared with heterosexual females, sexual minority females were less likely to participate in team sports (adjusted odds ratio [AOR] = 0.44; 95% confidence interval [CI] = 0.37, 0.53) and more likely to be overweight (AOR = 1.28; 95% CI = 1.02, 1.62) or obese (AOR = 1.88; 95% CI = 1.43, 2.48). Sexual minority males were less likely than heterosexual males to be physically active (AOR = 0.62; 95% CI = 0.46, 0.83) or to participate in team sports (AOR = 0.26; 95% CI = 0.20, 0.32), but the 2 groups did not differ in their risk of obesity.Conclusions. Sexual orientation health disparities in physical activity and obesity are evident during adolescence. Culturally affirming research, interventions, and policies are needed for sexual minority youths.Obesity is an increasing and serious health problem among adolescents.1,2 This is of major concern because obesity has many health and social consequences and it affects adolescents’ overall well-being.3,4 Obesity among adolescents also has a high likelihood of continuing into adulthood.5 Recent population-based and longitudinal research has demonstrated that there are disparities in obesity between sexual minority and heterosexual adolescents.6–8 Research has also documented sexual orientation disparities in physical activity and sports involvement in adolescence.9,10 Despite this increased attention, the overall empirical base remains limited, and findings also suggest some gender nuances that need further exploration. More population-based research is needed to investigate these disparities, consistent with federal health priorities.7,11There are sexual orientation–based disparities in physical activity and sports involvement among adolescents; however, there are mixed findings for females. One study reported that sexual minority females are less likely than heterosexual females to participate in moderate to vigorous physical activity and team sports,9 whereas another study found no such differences in physical activity.10 Findings are more consistent for sexual minority male adolescents, who are less likely than heterosexual males to engage in moderate to vigorous physical activity, to engage in recommended levels of physical activity, and to participate in team sports.9,10 More research is needed because of the paucity of studies and mixed results. This is especially important given that adolescents’ physical activity has been shown to relieve stress and protect against many mental and physical health conditions, including obesity,12,13 for which sexual minority adolescents are at greater risk.Research on sexual orientation disparities in obesity suggests that there are some gender nuances. Many studies have found that sexual minority female adolescents have higher risk of obesity than heterosexual females (e.g., higher body mass index [BMI], defined as weight in kilograms divided by the square of height in meters).6,8,10,14 These sexual orientation disparities in obesity among adolescent females parallel those among sexual minority adult women.15,16Findings of elevated obesity risk among sexual minority male adolescents are mixed. Some studies show that sexual minority males, specifically bisexual males, have higher odds of obesity than heterosexuals,14 whereas other studies have documented no differences.10 By contrast, some studies have found that heterosexual males have increases in BMI during adolescence compared with sexual minority males.6,8 These mixed findings for sexual minority males might be attributed to physical maturation and developmental changes in adolescence that some of the cross-sectional studies could not examine.10,14 Specifically, one study found that sexual minority males had higher obesity risk than heterosexual males in early adolescence, but their risk of obesity became lower than for heterosexual males later in adolescence.6 The authors postulated that, compared with heterosexual males, sexual minority males reach puberty maturation earlier in adolescence but make less substantial weight gains later in adolescence.6Sexual orientation health disparities have been explained through the minority stress model: sexual minority youths experience unique stressors and stigma related to their sexual identity (e.g., homophobic bullying), which lead to poorer health.17 Sexual minority adolescents might therefore be less likely to be physically active or involved in team sports because of potential minority stressors that they often experience at school, especially bias and heightened discrimination experienced in the context of sports or in their communities.18–20 More recently, the negative effects of minority stress and stigma on physical health disparities have been documented,21,22 including their effects on obesity for sexual minority women.23 However, the minority stress model is not sufficient in explaining how sexual minority adolescent females, but not males, are at greater risk for obesity compared with their heterosexual peers.Another potential explanation of these obesity disparities is related to cultural norms and sexual minority females’ experiences of internalizing ideals for femininity and appearance8 and sexual minority males’ ideals for muscularity and body image.24 For instance, compared with heterosexual women, sexual minority women are more likely to be satisfied with their bodies and attracted to women with greater body mass,25,26 whereas sexual minority men are less likely to be satisfied with their bodies compared with heterosexual men and are more likely to be attracted to muscular men.25,27 Therefore, these 2 groups might engage (or not engage) in differing body weight management and dieting behaviors compared with their heterosexual peers; concomitantly, these behaviors might render differing risks for obesity.Sexual minority adolescents’ lack of physical activity and sports involvement might be influenced by traditional gender norms associated with athleticism and sports, which has implications for their athletic self-esteem and involvement. For adolescent males, team sports are a means to define masculinity28; however, adolescent males often engage in homophobic banter to prove their masculinity and heterosexuality and to enforce traditional gender norms.29,30 Sexual prejudice is pervasive in athletic settings,19,20 making sports contexts unwelcoming and unsafe for many sexual minority males. Traditional feminine gender norms and homophobia also affect sexual minority females’ involvement in sports.31 However, sexual minority adolescent females have unique gendered experiences in relation to sports. Because women’s athleticism can be a stereotype for being a lesbian,32 sexual minority females might avoid sports involvement. Expecting or experiencing exclusion in sports settings might also affect sexual minority adolescents’ athletic self-esteem, consequently preventing them from engaging in future sports or physical activity.9 In fact, athletic self-esteem has been found to contribute to sexual orientation disparities in sports involvement and physical activity.9Emerging evidence of sexual orientation disparities in physical activity, sports involvement, and obesity among adolescents, in addition to potential gender nuances in these disparities, points to the need for more population-based research in this area. We therefore examined sexual orientation disparities among a large adolescent population-based sample and tested for gender differences. While accounting for variables commonly associated with physical activity and obesity among adolescents,4,33 we hypothesized that sexual minority adolescents would be less likely to report physical activity and sports involvement than would their heterosexual peers. We also hypothesized that sexual minority females would be at higher risk for being overweight and obese than their heterosexual peers. Because of mixed findings in existing sexual orientation disparities research among adolescent males, we hypothesized that sexual minority males would be at equal risk for being overweight and obese than their heterosexual male peers.     

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.     

The Relationship Between Discrimination and Substance Use Disorders Among Lesbian, Gay, and Bisexual Adults in the United States

Objectives. We examined the associations between 3 types of discrimination (sexual orientation, race, and gender) and substance use disorders in a large national sample in the United States that included 577 lesbian, gay, and bisexual (LGB) adults.Methods. Data were collected from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions, which used structured diagnostic face-to-face interviews.Results. More than two thirds of LGB adults reported at least 1 type of discrimination in their lifetimes. Multivariate analyses indicated that the odds of past-year substance use disorders were nearly 4 times greater among LGB adults who reported all 3 types of discrimination prior to the past year than for LGB adults who did not report discrimination (adjusted odds ratio = 3.85; 95% confidence interval = 1.71, 8.66).Conclusions. Health professionals should consider the role multiple types of discrimination plays in the development and treatment of substance use disorders among LGB adults.Substance use disorders have been shown to be more prevalent among lesbian, gay, and bisexual (LGB) adults than among heterosexual adults in the United States.^1–6 Despite this evidence, little empirical work has focused on why such differences exist between LGB and heterosexual adults. Many studies have posited that differences in rates of mental health problems and substance abuse are related to social stressors such as discrimination,^7–11 yet no large-scale national studies have examined the relationship between multiple types of discrimination and substance use disorders. Meyer''s minority stress model posits that discrimination, internalized homophobia, and social stigma can create a hostile and stressful social environment for LGB adults that contributes to mental health problems, including substance use disorders.^10,11 An assumption of this model is that minority stress is unique and additive to general stressors that all people experience.Meyer''s model connects the literature demonstrating higher odds of mental health problems and substance use disorders among LGB populations with well-established social science research that demonstrates the link between stress or stressful life events and poor health outcomes.^12–15 Lesbian, gay, and bisexual adults experience discrimination at the structural and institutional level, such as in access to housing, employment, medical care, and basic civil rights,^16,17 as well as at the individual level in the form of harassment and violence.^18–22 Discriminatory experiences have been shown to operate as stressors in the lives of LGB people and, in turn, they are significantly associated with psychiatric disorders,⁹ psychological distress,^9,20,23 and depressive symptoms.^20,24Although the minority stress model provides a useful theoretical framework for understanding health disparities among LGB adults, only a handful of studies have directly assessed discrimination among LGB populations, and even fewer have examined the relationships between discrimination and health outcomes. Extant research on health outcomes related to discrimination has focused on blood pressure,¹⁷ psychological distress,^24,25 mental health disorders,⁹ and general psychological and physical health.²⁶ Given that exposure to both acute and chronic stress has long been associated with substance abuse and relapse in the general population,^26,27 research on the association between experiences of discrimination and substance use disorders among LGB adults is warranted.In our investigation, we assumed that LGB adults are at heightened risk for substance use disorders as a consequence of cultural and environmental factors associated with being part of a stigmatized and marginalized population, not because of their sexual orientation. Building on previous work documenting the impact of multiple stigmatized statuses among sexual minority people^11,28,29 as well as the work of Krieger et al.,¹⁶ we sought to examine the relationships between 3 types of discrimination (sexual orientation, race/ethnicity, and gender) and substance use disorders. We used data from wave 2 of the 2004–2005 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) to test the hypothesis that LGB adults who reported more types of discrimination would be more likely to meet criteria for substance use disorders than would those who reported fewer types or who did not report discrimination.     

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.     

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?

     

A Systematic Review of Neighborhood Disparities in Point-of-Sale Tobacco Marketing

We systematically reviewed evidence of disparities in tobacco marketing at tobacco retailers by sociodemographic neighborhood characteristics. We identified 43 relevant articles from 893 results of a systematic search in 10 databases updated May 28, 2014. We found 148 associations of marketing (price, placement, promotion, or product availability) with a neighborhood demographic of interest (socioeconomic disadvantage, race, ethnicity, and urbanicity).Neighborhoods with lower income have more tobacco marketing. There is more menthol marketing targeting urban neighborhoods and neighborhoods with more Black residents. Smokeless tobacco products are targeted more toward rural neighborhoods and neighborhoods with more White residents. Differences in store type partially explain these disparities.There are more inducements to start and continue smoking in lower-income neighborhoods and in neighborhoods with more Black residents. Retailer marketing may contribute to disparities in tobacco use. Clinicians should be aware of the pervasiveness of these environmental cues.Tobacco products and their marketing materials are ubiquitous in US retailers from pharmacies to corner stores.1 A similar presence is found across the globe, except in countries that ban point-of-sale (POS) tobacco marketing (e.g., Australia, Canada, Thailand2). In the United States, the POS has become the main communications channel for tobacco marketing3,4 and is reported as a source of exposure to tobacco marketing by more than 75% of US youths.5 Burgeoning evidence6,7 suggests that marketing at the POS is associated with youths’ brand preference,8 smoking initiation,9 impulse purchases,10,11 and compromised quit attempts.12,13The marketing of tobacco products is not uniform; it is clear from industry documents that the tobacco industry has calibrated its marketing to target specific demographic groups defined by race,14 ethnicity,15 income,16 mental health status,17 gender,18,19 and sexual orientation.20 Framed as an issue of social and environmental justice,14 research has documented historical racial, ethnic, and socioeconomic disparities in the presence of tobacco billboards,21–25 racial disparities in total tobacco marketing volume,24 and targeting of menthol cigarettes to communities with more Black residents.25,26 Targeted marketing of a consumer product that kills up to half27 of its users when used as directed exacerbates inequities in morbidity and mortality. Smoking is estimated to be responsible for close to half of the difference in mortality between men in the lowest and highest socioeconomic groups.28 However, evidence of marketing disparities is scattered across multiple disciplines and marketing outcomes, such as product availability, advertising quantity, presence of promotional discounts, and price. A synthesis of this literature would provide valuable information for intervention on tobacco marketing in the retail environment and inform etiological research on health disparities.To address this gap in the literature, we systematically reviewed observational studies that examined the presence and quantity of POS tobacco marketing to determine the extent to which marketing disparities exist by neighborhood demographic characteristic (i.e., socioeconomic disadvantage, race, ethnicity, and urbanicity).     

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.     

Sex and Gender in the US Health Surveillance System: A Call to Action

Youth Risk Behavior Survey (YRBS) data have exposed significant sexual orientation disparities in health. Interest in examining the health of transgender youths, whose gender identities or expressions are not fully congruent with their assigned sex at birth, highlights limitations of the YRBS and the broader US health surveillance system.In 2009, we conducted the mixed-methods Massachusetts Gender Measures Project to develop and cognitively test measures for adolescent health surveillance surveys. A promising measure of transgender status emerged through this work.Further research is needed to produce accurate measures of assigned sex at birth and several dimensions of gender to further our understanding of determinants of gender disparities in health and enable strategic responses to address them.Healthy People 2020 extends a commitment to

assess health disparities in the US population by tracking rates of illness, death, chronic conditions, behaviors, and other types of outcomes in relation to demographic factors1

and aims to “achieve health equity, eliminate disparities, and improve the health of all groups.”2 Youth Risk Behavior Survey data have exposed significant sexual orientation disparities3–8 in health in jurisdictions that included measures of sexual orientation on their surveys.However, gaps in the US health surveillance system inhibit efforts to improve the health of both transgender people9–11 and the nontransgender (cisgender) majority. Demographic measures that would enable the population to be classified as trans- or cisgender are rarely included in the health surveillance system. Such measures, often used in combination, include sex (assigned at birth), gender identity (current), and transgender status (transgender is an identity for some individuals and an adjective or status for others). Data about additional dimensions of gender (e.g., expression, beliefs about gender) that could be used to tackle persistent health disparities are also not collected, and these gaps represent untapped potential to improve population health.Although sex and gender identity are often static and concordant for the vast majority of Americans, both sex and gender (more broadly) are multidimensional constructs and can vary over time—particularly for transgender people. The term sex refers to biological differences between male, female, and intersex people (hormones, secondary sex characteristics, reproductive anatomy) that can be altered through the use of hormones and surgical interventions.12 The assignment of individuals to a sex category by medical practitioners at birth is typically based on the appearance of external genitalia and is recorded on the birth certificate as male or female (and assumes a legal status). Legal sex can sometimes be changed on legal documents (e.g., birth certificate, driver’s license, passport) through a complex set of legal procedures. Gender has psychological (identity—an internal sense of being a boy or girl, genderqueer, etc.), social (beliefs about gender, the roles that one assumes, community affiliation), and behavioral (gender expression, how one expresses one’s identity through appearance and actions and is perceived by others) dimensions.13Unfortunately, sex and gender are rarely explicitly measured, and when data are collected, a range of measures and approaches are used. In recognition of the importance of sex and gender identity as demographic characteristics of the US population, and variability in their measurement, the Institute of Medicine,14 US Department of Health and Human Services,15 and Centers for Disease Control and Prevention16 have called for a national data standard for sex and research to create valid measures of gender identity. Although the Youth Risk Behavior Survey relies on self-reported sex, other health surveillance surveys, such as the Behavioral Risk Factor Surveillance System,17 are telephone administered and classify respondents as male or female according to the sound of their voice, or, as in the in-person National Health Interview Survey,18 use visual appearance, with direct questioning about the respondent’s sex by the interviewer “if necessary”17 or “not apparent,”18 respectively. These data are used as measures of both sex and gender identity19,20; however, they actually measure the interviewer’s perception of the respondent’s gender identity.Data about other dimensions of gender, such as gender expression and beliefs about gender (the individual-level analog to gender norms, a societal-level construct), are not collected in the health surveillance system, despite growing bodies of research that highlight their importance as health determinants. Research conducted in lesbian, gay, and bisexual, as well as general, primarily heterosexual cisgender samples, indicates that individuals whose gender expression fails to conform to sex-linked social expectations (e.g., masculine girls and women, feminine boys and men) are at increased risk for violence,21–28 discrimination,23 posttraumatic stress disorder,28 and depression.29 Violence23,30–38 and discrimination39–41 against transgender people, who are gender nonconforming by identity or expression in relation to their assigned sex at birth, is commonplace.Research conducted in the general population shows that beliefs about gender (e.g., violence is acceptable, exercising caution is not masculine, being assertive is not feminine)42 are associated with aggression43–47 and alcohol use.44,48 Thus, strategies to ameliorate persistent public health problems, such as high mortality among men from injury, homicide, and suicide,49 might be advanced by the collection of gender data. Long-standing disparities in depression that disfavor women50,51 might also be addressed by reducing girls’ and women’s exposure to violence52 and by modifying emotional coping styles (e.g., rumination is more common among girls and women,53 whereas problem solving is positively associated with masculine traits and negatively associated with depression54).     

Health Among Caregivers of Children With Health Problems: Findings From a Canadian Population-Based Study

Objectives. We used population-based data to evaluate whether caring for a child with health problems had implications for caregiver health after we controlled for relevant covariates.Methods. We used data on 9401 children and their caregivers from a population-based Canadian study. We performed analyses to compare 3633 healthy children with 2485 children with health problems. Caregiver health outcomes included chronic conditions, activity limitations, self-reported general health, depressive symptoms, social support, family functioning, and marital satisfaction. Covariates included family (single-parent status, number of children, income adequacy), caregiver (gender, age, education, smoking status, biological relationship to child), and child (age, gender) characteristics.Results. Logistic regression showed that caregivers of children with health problems had more than twice the odds of reporting chronic conditions, activity limitations, and elevated depressive symptoms, and had greater odds of reporting poorer general health than did caregivers of healthy children.Conclusions. Caregivers of children with health problems had substantially greater odds of health problems than did caregivers of healthy children. The findings are consistent with the movement toward family-centered services recognizing the link between caregivers'' health and health of the children for whom they care.Caring for a child with health problems can entail greater than average time demands,^1,2 medical costs,^3,4 employment constraints,^5,6 and childcare challenges.^6–8 These demands may affect the health of caregivers, a notion supported by a variety of small-scale observational studies that have shown increased levels of stress, distress, emotional problems, and depression among caregivers of children with health problems.^1,2,5,9–12Whether these problems are caused by the additional demands of caring for children with health problems or by confounding variables is difficult to answer definitively. The literature reports the identification of a variety of factors purported to be associated with caregiver health, including contextual factors such as socioeconomic status^13–17; child factors such as level of disability,^{1,11,13,18–21} presence of behavior problems,^22–25 and overall child adjustment²⁶; and caregiver-related characteristics such as coping strategies^11,22,27 and support from friends and family.^15,17,28,29 In general, this work has been based on small clinic-based samples^9,30 or specific child populations (e.g., cerebral palsy,^5,25 attention-deficit/hyperactivity disorder^31,32), and typically has been hampered by limited generalizability and a lack of careful, multivariate analysis. Furthermore, most studies have focused on caregivers'' psychological health,^1,2,5,9–12 although physical health effects may also exist among caregivers.^5,19,25,33One of the few studies to involve large-scale, population-based data compared the health of 468 caregivers of children with cerebral palsy to the health of a population-based sample of Canadian parents.⁵ The study showed that caregivers of children with cerebral palsy had poorer health on a variety of physical and psychological health measures. Furthermore, the data were consistent with a stress process model,^5,25 which proposes that additional stresses associated with caring for a child with cerebral palsy directly contribute to poorer caregiver health. However, these findings were based on a specific subpopulation of caregivers and univariate comparisons that could not control for potentially important confounders such as variation in caregiver education, income, and other demographic factors.We used population-based data to test the hypothesis that the health of caregivers of children with health problems would be significantly poorer than that of caregivers of healthy children, even after we controlled for relevant covariates. Our approach of using large-scale, population-based data representing a broad spectrum of childhood health problems³⁴ makes 4 key contributions to the current literature. First, our use of population-based data rather than small-scale, clinic-based studies yielded results that are potentially generalizable to a wide group of caregivers caring for children with health problems. Second, our examination of children with and without health problems allowed us to examine caregiver health effects across a wide variety of caregiving situations. Third, consideration of physical health outcomes (in addition to more regularly studied psychological outcomes) increased our knowledge of the breadth of caregiver health issues. Finally, controlling for relevant covariates allowed us to rule out a number of alternative explanations for caregiver health effects.     

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     

The association between perceived discrimination and obesity in a population-based multiracial and multiethnic adult sample

Objectives. We examined whether perceived chronic discrimination was related to excess body fat accumulation in a random, multiethnic, population-based sample of US adults.Methods. We used multivariate multinomial logistic regression and logistic regression analyses to examine the relationship between interpersonal experiences of perceived chronic discrimination and body mass index and high-risk waist circumference.Results. Consistent with other studies, our analyses showed that perceived unfair treatment was associated with increased abdominal obesity. Compared with Irish, Jewish, Polish, and Italian Whites who did not experience perceived chronic discrimination, Irish, Jewish, Polish, and Italian Whites who perceived chronic discrimination were 2 to 6 times more likely to have a high-risk waist circumference. No significant relationship between perceived discrimination and the obesity measures was found among the other Whites, Blacks, or Hispanics.Conclusions. These findings are not completely unsupported. White ethnic groups including Polish, Italians, Jews, and Irish have historically been discriminated against in the United States, and other recent research suggests that they experience higher levels of perceived discrimination than do other Whites and that these experiences adversely affect their health.It is estimated that 2 of every 3 adults in the United States are overweight or obese.^1,2 Obesity is a major risk factor for chronic health conditions, such as type 2 diabetes, coronary heart disease, hypertension, stroke, some forms of cancer, and osteoarthritis.³ Although it is widely accepted that high-fat diets and physical inactivity are preventable risk factors,⁴ obesity continues to increase.^1,2,5There is a growing interest in the relationship between psychosocial risk factors and excess body fat accumulation.^6–16 In particular, some evidence suggests that psychosocial stressors may play a role in disease progression in general and in excess body fat in particular.^7,8,17 The key factors underlying physiological reactions to psychosocial stress have not been completely elucidated, but McEwen and Seeman¹⁷ and others^7,18,19 posit that the continued adaptation of the physiological system to external challenges alters the normal physiological stress reaction pathways and that these changes are related to adverse health outcomes.^8,17,18,20 For example, in examining the association between psychosocial stress and excess body fat accumulation, Björntorp and others have suggested that psychosocial stress is linked to obesity, especially in the abdominal area.^7,8Perceived discrimination, as a psychosocial stressor, is now receiving increased attention in the empirical health literature.^21–24 Such studies suggest perceived discrimination is inversely related to poor mental and physical health outcomes and risk factors, including hypertension,^24,25 depressive symptoms,^26–28 smoking,^29–31 alcohol drinking,^32,33 low birthweight,^34,35 and cardiovascular outcomes.^36–38Internalized racism, the acceptance of negative stereotypes by the stigmatized group,³⁹ has also been recognized as a race-related psychosocial risk factor.⁴⁰ Recent studies have also suggested that race-related beliefs and experiences including perceived discrimination might be potentially related to excess body fat accumulation. Three of these studies^9,13,41 showed that internalized racism was associated with an increased likelihood of overweight or abdominal obesity among Black Caribbean women in Dominica⁴¹ and Barbados¹³ and adolescent girls in Barbados.⁹ These researchers posit that individuals with relatively high levels of internalized racism have adopted a defeatist mindset, which is believed to be related to the physiological pathway associated with excess body fat accumulation. However, Vines et al.¹⁶ found that perceived racism was associated with lower waist-to-hip ratios among Black women in the United States. Although the assessment of race-related risk factors varied across these studies, the findings suggest that the salience of race-related beliefs and experiences may be related to excess body fat accumulation.Collectively, the results of these studies are limited. First, because they examined the relationship between race-related beliefs and experiences and excess body fat only among women, we do not know if this relationship is generalizable to men.^13,16,41 Second, these studies only examined this relationship among Blacks, even though perceived unfair treatment because of race/ethnicity has been shown to be adversely related to the health of multiple racial/ethnic population groups in the United States^42–49 and internationally.^27,50–55 Third, none of the studies have examined the relationship between excess body fat accumulation and perceived nonracial/nonethnic experiences of interpersonal discrimination. Some evidence suggests that the generic perception of unfair treatment or bias is adversely related to health, regardless of whether it is attributed to race, ethnicity, or some other reason.^45,55,56 Fourth, none of these studies included other measures of stress. We do not know if the association between race-related risk factors and obesity is independent of other traditional indicators of stress.Using a multiethnic, population-based sample of adults, we examined the association of perceived discrimination and obesity independent of other known risk factors for obesity, including stressful major life events. Additionally, because reports of perceived racial/ethnic discrimination and non-racial/ethnic discrimination vary by racial/ethnic groups^24,45,46,57 and because Whites tend to have less excess body fat than do Blacks and Hispanics,^1,3 we examined the relationships between perceived discrimination and excess body fat accumulation among Hispanics, non-Hispanic Whites, and non-Hispanic Blacks.     

Social gradients in oral health in older adults: findings from the English longitudinal survey of aging

Objectives. We examined prospective associations between socioeconomic position (SEP) markers and oral health outcomes in a national sample of older adults in England.Methods. Data were from the English Longitudinal Survey of Aging, a national cohort study of community-dwelling people aged 50 years and older. SEP markers (education, occupation, household income, household wealth, subjective social status, and childhood SEP) and sociodemographic confounders (age, gender, and marital status) were from wave 1. We collected 3 self-reported oral health outcomes at wave 3: having natural teeth (dentate vs edentate), self-rated oral health, and oral impacts on daily life. Using multivariate logistic regression models, we estimated associations between each SEP indicator and each oral health outcome, adjusted for confounders.Results. Irrespective of SEP marker, there were inverse graded associations between SEP and edentulousness, with proportionately more edentate participants at each lower SEP level. Lower SEP was also associated with worse self-rated oral health and oral impacts among dentate, but not among edentate, participants.Conclusions. There are consistent and clear social gradients in the oral health of older adults in England, with disparities evident throughout the SEP hierarchy.The inverse linear relationship between socioeconomic position (SEP) and health is well established.^1–4 The uneven distribution of health across socioeconomic strata has been observed in both industrialized and less developed countries and for most common diseases and causes of death.^1,5–8 In most cases, the association between SEP and health is characterized by a linear graded pattern, with people in each lower SEP category having successively worse levels of health and dying earlier than those that are better off, a characteristic known as the social gradient in health.⁹Although there is clear and consistent evidence about the existence of the social gradient in working-age adults,^10,11 studies in older adults are less consistent, with some showing attenuation of the gradient^12,13 and others reporting that it persisted^14,15 or even increased¹⁶ in magnitude.Oral health is particularly important at older ages with tooth loss shown to be independently associated with disability and mortality.^17–20 Oral health status in older people is also an important determinant of nutritional status.²¹Socioeconomic disparities in oral health have been consistently demonstrated for various indicators, mostly clinical and disease related^22–31 but also subjective measures of oral health and quality of life.^30,32–38 Some of these studies have explicitly assessed the existence of an oral health gradient,^{23,25–31,34–37} but almost all were carried out on adolescents and adults, with very few focusing on older people.^33,36 These few relevant studies are cross-sectional and inconclusive and have used a limited number of SEP indicators (typically, education and occupational class), thereby hindering any comprehensive analysis on the relationship between SEP and oral health.We addressed the gap in the literature about the existence of an oral health gradient at older ages by examining the prospective associations between a wide range of SEP indicators (education, occupation, household income, household wealth, subjective social status [SSS], and childhood SEP) and various oral health outcomes (presence of natural teeth, self-rated oral health, and oral impacts) in a national sample of older adults from the English Longitudinal Survey of Aging (ELSA). We explored whether there are any significant socioeconomic inequalities in oral health among older people in England and, if so, whether these take the form of a gradient.     

Suicidal Behavior Among Female Sex Workers in Goa, India: The Silent Epidemic

Objectives. We sought to study suicidal behavior prevalence and its association with social and gender disadvantage, sex work, and health factors among female sex workers in Goa, India.Methods. Using respondent-driven sampling, we recruited 326 sex workers in Goa for an interviewer-administered questionnaire regarding self-harming behaviors, sociodemographics, sex work, gender disadvantage, and health. Participants were tested for sexually transmitted infections. We used multivariate analysis to define suicide attempt determinants.Results. Nineteen percent of sex workers in the sample reported attempted suicide in the past 3 months. Attempts were independently associated with intimate partner violence (adjusted odds ratio [AOR] = 2.70; 95% confidence interval [CI] = 1.38, 5.28), violence from others (AOR = 2.26; 95% CI = 1.15, 4.45), entrapment (AOR = 2.76; 95% CI = 1.11, 6.83), regular customers (AOR = 3.20; 95% CI = 1.61, 6.35), and worsening mental health (AOR = 1.05; 95% CI = 1.01, 1.11). Lower suicide attempt likelihood was associated with Kannad ethnicity, HIV prevention services, and having a child.Conclusions. Suicidal behaviors among sex workers were common and associated with gender disadvantage and poor mental health. India''s widespread HIV-prevention programs for sex workers provide an opportunity for community-based interventions against gender-based violence and for mental health services delivery.Suicide is a public health priority in India. Rates of suicide in India are 5 times higher than in the developed world,^1,2 with particularly high rates of suicide among young women.^3–5 Verbal autopsy surveillance from southern India suggests that suicide accounts for 50% to 75% of all deaths among young women, with average suicide rates of 158 per 100 000.²Common mental disorders such as depressive and anxiety disorders, and social disadvantage such as gender-based violence and poverty, are major risk factors for suicide among women.^1,3,6–8 Although research from high-income countries shows that common mental disorders are a major contributor to the risk of suicidal behavior, their role is less clear in low- and middle-income countries in which social disadvantage has been found to be at least as important.^1,3,6–8 Gender disadvantage is increasingly seen as an important contributing factor to the high rates of suicide seen among women in Asia.^1,3,6,7 Gender-based violence is a common manifestation of gender disadvantage and has been linked with common mental disorders and suicide in population-based studies of women and young adults in Goa, India.^4,5,9 Lack of autonomy, early sexual debut, limited sexual choices, poor reproductive health, and social isolation are other manifestations of gender disadvantage.Sex work in India is common. An estimated 0.6% to 0.7% of the female adult urban population are engaged in commercial sexual transactions.¹⁰ Studies from developed nations have found a high prevalence of self-harming behaviors in people engaged in transactional sexual activity.¹¹ There is also growing evidence suggesting that HIV-positive individuals from traditionally stigmatized groups report higher rates of violence exposure and suicidal ideation.^12,13 Female sex workers in India are a traditionally stigmatized group, with high prevalence of HIV¹⁰ and levels of stigma and violence that relate to the context of their work.¹⁴ Yet, despite substantial investigation of their reproductive and sexual health needs, there is virtually no information on suicide and its determinants among female sex workers from low- and middle-income countries.¹⁵As demonstrated in the hierarchical conceptual framework outlined in Figure 1,^4,5,9 we hypothesized that gender disadvantage, sex work, and health factors together with factors indicative of social disadvantage are distal determinants of female sex workers'' vulnerability to suicidal behaviors,^4,5,9,15 the effects of which would be mediated though poor mental health.³ We studied the burden of suicidal behaviors in a cross-sectional sample of female sex workers in Goa, India. We explored the association of sociodemographic factors, type of sex work, sexual health, and gender disadvantage, with and without measures of poor mental health, on suicide attempts in the past 3 months.Open in a separate windowFIGURE 1A conceptual framework for social risk factors for suicide among female sex workers in India.Note. STI = sexually transmitted infection.     

Community Influences on Young People's Sexual Behavior in 3 African Countries

Objectives. I examined the role of community-level factors in the reporting of risky sexual behaviors among young people aged 15 to 24 years in 3 African countries with varying HIV prevalence rates.Methods. I analyzed demographic and health survey data from Burkina Faso, Ghana, and Zambia during the period 2001 through 2003 to identify individual, household, and community factors associated with reports of risky sexual behaviors.Results. The mechanisms through which the community environment shaped sexual behaviors varied among young men and young women. Community demographic profiles were not associated with reports of risky sexual behavior among young women but were influential in shaping the behavior of young men. Prevailing economic conditions and the behaviors and attitudes of adults in the community were strong influences on young people''s sexual behaviors.Conclusions. These results provide strong support for a focus on community-level influences as an intervention point for behavioral change. Such interventions, however, should recognize specific cultural settings and the different pathways through which the community can shape the sexual behaviors of young men and women.Countries in sub-Saharan Africa are home to only 10% of the world''s population but account for approximately 85% of AIDS deaths worldwide.^1,2 Previous studies have highlighted high levels of sexual activity among young people (i.e., those aged 15–24 years) in many sub-Saharan African countries,^3–7 paralleled by increasing rates of HIV infection among young people.^1,8,9 Although young people in these countries have been shown to have high levels of knowledge regarding HIV/AIDS, studies have demonstrated significant deviation between such knowledge and reported sexual behaviors,^10–12 with high levels of risky sexual activity reported (e.g., failing to use a condom,¹³ engaging in transactional sex,^13,14 having multiple partners.^3,6,15).The health hazards associated with sexual risk taking among young people are well documented, but little is known about the factors associated with sexual behaviors among adolescents in developing countries.^13,15–20 In the few studies that have examined young people''s sexual behavior in these countries, a micro-level approach has been adopted, with a focus on individual characteristics as predictors of behavior²¹ and little consideration of the potential pathways through which the wider community may shape behavior.Condom use has often been the outcome of interest in studies of adolescent sexual behavior,^7,22–25 which is not surprising given the emphasis of many HIV prevention strategies on promoting condom use; other studies have examined factors associated with sexual activity or sexual debut.^1,15,17,26 Higher levels of risky sexual activity have been shown among young people (both male and female) and adult men^24,26 than among adult women.^4,6,27 In many sub-Saharan African countries, young women''s lack of negotiating power in sexual relationships is influenced by the large age differences common in many relationships,^3,14,27,28 the presence of violence or coercion,²⁵ and economic incentives to participate in risky sexual activities.¹⁴Educational attainment has been shown to be associated with young people''s sexual behaviors.^5–7,29 This relationship is more than simply a function of increased knowledge leading to positive health behaviors; the type of educational institution attended and the place of residence of the student have been shown to be influential in determining sexual behaviors,⁵ suggesting that these behaviors are also influenced by the degree of freedom afforded to the young person.Young women from poor households have been shown to be at particular risk of sexual risk taking, with their economic status motivating them to partake in transactional sex and serving as another limitation in their negotiating power with respect to condom use.^6,14 In terms of the influence of knowledge on behavior, some studies have demonstrated a disparity between knowledge regarding HIV risk and sexual behavior^12,22,30 such that many young people, despite knowing the risks associated with unprotected sexual activities, still engage in these activities. There is a limited amount of evidence suggesting that risk knowledge is a more protective factor against risky sexual activity among women than among men,³¹ with fear of unplanned pregnancy providing a greater deterrent for women than for men.Although much is known about the individual characteristics associated with sexual risk taking among young people, the role of the community in shaping such behaviors has been largely overlooked. In a study of adolescents residing in the United States, Billy et al.²¹ suggested that young people''s sexual behavior is strongly influenced by a community''s opportunity structure (i.e., presence of social and economic opportunities), which is composed of 3 key elements. The first element is the presence in the community of reproductive and sexual health services, which determines a young person''s access to information and services. The second element is the demographic profile of the community, which determines the presence of potential sexual partners. The final element is the presence or absence of economic or social opportunities, which influences young people''s perceptions regarding the opportunity costs of sexual behavior.Studies testing the theory of Billy et al. have largely been restricted to developed countries.^21,32 Although some studies have addressed the influence of community factors on young people''s sexual behavior in developing countries, these investigations have focused primarily on indicators of the presence of economic opportunities for young people,^33,34 failing to examine the roles of the cultural and social environments in shaping behavior.I examined community-level factors associated with risky sexual behaviors among young people in the African countries of Burkina Faso, Ghana, and Zambia. The goal of the study was to advance understanding of how the community environment shapes young people''s sexual behavior by considering a broad range of potential community influences, including social, behavioral, and demographic dimensions of the community environment.     

Impact of individual-, environmental-, and policy-level factors on health care utilization among US farmworkers

Objectives. We examined individual-, environmental-, and policy-level correlates of US farmworker health care utilization, guided by the behavioral model for vulnerable populations and the ecological model.Methods. The 2006 and 2007 administrations of the National Agricultural Workers Survey (n = 2884) provided the primary data. Geographic information systems, the 2005 Uniform Data System, and rurality and border proximity indices provided environmental variables. To identify factors associated with health care use, we performed logistic regression using weighted hierarchical linear modeling.Results. Approximately half (55.3%) of farmworkers utilized US health care in the previous 2 years. Several factors were independently associated with use at the individual level (gender, immigration and migrant status, English proficiency, transportation access, health status, and non-US health care utilization), the environmental level (proximity to US–Mexico border), and the policy level (insurance status and workplace payment structure). County Federally Qualified Health Center resources were not independently associated.Conclusions. We identified farmworkers at greatest risk for poor access. We made recommendations for change to farmworker health care access at all 3 levels of influence, emphasizing Federally Qualified Health Center service delivery.US farmworkers face significant disease burden¹ and excessive mortality rates for some diseases (e.g., certain cancers and tuberculosis) and injuries.² Disparities in health outcomes likely stem from occupational exposures and socioeconomic and political vulnerabilities. US farmworkers are typically Hispanic with limited education, income, and English proficiency.³ Approximately half are unauthorized to work in the United States.³ Despite marked disease burden, health care utilization appears to be low.^1,4–9 For example, only approximately half of California farmworkers received medical care in the previous year.⁶ This rate parallels that of health care utilization for US Hispanics, of whom approximately half made an ambulatory care visit in the previous year, compared with 75.7% of non-Hispanic Whites.¹⁰ Disparities in dental care have a comparable pattern.^6,8,11,12 However, utilization of preventive health services is lower for farmworkers^5,7,13,14 than it is for both US Hispanics and non-Hispanic Whites.^15,16Farmworkers face numerous barriers to health care^1,4,17: lack of insurance and knowledge of how to use or obtain it,^6,18 cost,^{5,6,12,13,18–20} lack of transportation,^{6,12,13,19–21} not knowing how to access care,^6,18,20,21 few services in the area or limited hours,^12,20,21 difficulty leaving work,¹⁹ lack of time,^5,13,19 language differences,^6,8,18–20 and fear of the medical system,¹³ losing employment,⁶ and immigration officials.²¹ Few studies have examined correlates of health care use among farmworkers. Those that have are outdated or limited in representativeness.^5,7,14,22,23 Thus, we systematically examined correlates of US health care use in a nationally representative sample of farmworkers, using recently collected data. The sampling strategy and application of postsampling weights enhance generalizability. We selected correlates on the basis of previous literature and the behavioral model for vulnerable populations.²⁴ The behavioral model posits that predisposing, enabling, and need characteristics influence health care use.²⁵ The ecological model, which specifies several levels of influence on behavior (e.g., policy, environmental, intrapersonal),²⁶ provided the overall theoretical framework. To our knowledge, we are the first to extensively examine multilevel correlates of farmworker health care use. We sought to identify farmworkers at greatest risk for low health care use and to suggest areas for intervention at all 3 levels of influence so that farmworker service provision can be improved.