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.     

Hispanic lesbians and bisexual women at heightened risk for [corrected] health disparities

Objectives. We investigated whether elevated risks of health disparities exist in Hispanic lesbians and bisexual women aged 18 years and older compared with non-Hispanic White lesbians and bisexual women and Hispanic heterosexual women.Methods. We analyzed population-based data from the Washington State Behavioral Risk Factor Surveillance System (2003–2009) using adjusted logistic regressions.Results. Hispanic lesbians and bisexual women, compared with Hispanic heterosexual women, were at elevated risk for disparities in smoking, asthma, and disability. Hispanic bisexual women also showed higher odds of arthritis, acute drinking, poor general health, and frequent mental distress compared with Hispanic heterosexual women. In addition, Hispanic bisexual women were more likely to report frequent mental distress than were non-Hispanic White bisexual women. Hispanic lesbians were more likely to report asthma than were non-Hispanic White lesbians.Conclusions. The elevated risk of health disparities in Hispanic lesbians and bisexual women are primarily associated with sexual orientation. Yet, the elevated prevalence of mental distress for Hispanic bisexual women and asthma for Hispanic lesbians appears to result from the cumulative risk of doubly disadvantaged statuses. Efforts are needed to address unique health concerns of diverse lesbians and bisexual women.Equity in health and health care is of critical societal importance given its ethical and social justice implications. Despite tremendous advancements in medicine and improved health for many Americans, historically disadvantaged and underserved communities continue to bear higher levels of illness, disability, and premature death. The National Institutes of Health affirms a commitment to reducing and eliminating health disparities affecting disadvantaged populations across the country.1 In addition, Healthy People 2020 has specifically recognized racial/ethnic minorities and sexual minorities as primary targets of health disparity reduction.2A growing body of literature endorses such federal initiatives’ recognition of health disparities by race/ethnicity and sexual orientation. Health disparities among the Hispanic population, for example, have been well documented. Higher death rates from stroke, chronic liver disease, diabetes, and HIV/AIDS have been observed among Hispanics compared with non-Hispanic Whites, and Hispanics are more likely to be obese and less likely to participate in regular physical activities.3,4 Furthermore, the Hispanic population is at increased risk for limited health care access.5–7 The likelihood of Hispanics not having health insurance is almost twice as high as that of the general population.8The evidence of health disparities affecting sexual minority women is also growing. According to previous studies based on probability samples, sexual minority women, compared with heterosexual women, report experiencing higher levels of poor physical and general health,9–11 mental distress,9,11–13 and higher prevalence rates of asthma10,11,13 and disability.10,11 In terms of health risk behaviors, lesbians and bisexual women are more likely to smoke9–11,13,14 and to consume higher quantities of alcohol.9,11,13,14 Sexual minority women are also at increased risk for poor health care access.10,14,15 Emerging research has also found within-group differences among sexual minority women; for example, lesbians, but not bisexual women, are more likely to be obese10,16 and have arthritis12 than are heterosexual women, whereas bisexual women are more likely to report poor general health and mental distress than are lesbians.17Yet, the evidence of health disparities by race/ethnicity and sexual orientation might not be generalized to sexual minorities of color,18 and knowledge regarding health among Hispanic sexual minorities is still limited. Without better understanding the potential interplay between these marginalized statuses, it remains difficult, if not impossible, to develop culturally sensitive health services that are responsive to the needs of the Hispanic sexual minority population.19The possibility of cumulative risks resulting from multiple disadvantaged statuses affecting health among Hispanic sexual minorities has been raised in the literature. It has been suggested that Hispanic sexual minorities experience heightened risks of poor physical and mental health compared with non-Hispanic White sexual minorities and Hispanic heterosexuals. According to a comprehensive review on racial/ethnic disparities in health, racial discrimination and related stressors have an inverse relationship to physical and mental health and health care access.20 Previous studies also have emphasized that health disparities among sexual minorities likely result from exposure to life stressors, including stigmatization, victimization, and discrimination.21–23 The consequences of multiple stressors, such as racial/ethnic discrimination within sexual minority communities and antigay values within Hispanic communities, may lead to an increased risk of poor physical and mental health.18,24,25 Furthermore, Hispanic sexual minority women may experience additional stressors if they are perceived to violate conventional feminine norms in Hispanic communities.26A few studies have assessed health-related concerns among Hispanic sexual minority women. One study found that Hispanic sexual minority women had increased psychiatric morbidity risk compared with Hispanic heterosexual women.27 Another study found that among sexual minority women, Hispanic women were more likely than were non-Hispanic White women to report depressive symptoms.28 In terms of physical health status and behaviors, Hispanic lesbians and bisexual women have shown elevated risks and higher prevalences of obesity, smoking, and drinking than have Hispanic heterosexual women.29Yet, to identify the potentially cumulative impact of multiple disadvantaged statuses on health disparities, the prevalence of health indicators for Hispanic sexual minority women must be compared with Hispanic heterosexual women as well as non-Hispanic White lesbians and bisexual women within the same sample. Furthermore, because the patterns and extents of health disparities may be dissimilar between lesbians and bisexual women, the cumulative effects should be tested separately among lesbians and bisexual women. Disaggregating groups of sexual minorities is an important stage in developing tailored interventions to respond to the unique health-related needs of these subgroups.17The Washington State Behavioral Risk Factor Surveillance System (BRFSS) provides population-based data that allow us to examine indicators of health disparities. In this study, we compared the unadjusted and adjusted prevalence of health disparities including health status, health risk behaviors, health care access, and health outcomes by Hispanic lesbians (the reference group), non-Hispanic White lesbians, and Hispanic heterosexual women as well as by Hispanic bisexual women (the reference group), non-Hispanic White bisexual women, and Hispanic heterosexual women. We hypothesized that Hispanic lesbians and bisexual women would experience higher risks of health disparities than would non-Hispanic White lesbians and bisexual women as well as Hispanic heterosexual women.     

Health Disparities Among Lesbian,Gay, and Bisexual Older Adults: Results From a Population-Based Study

Objectives. We investigated health disparities among lesbian, gay, and bisexual (LGB) adults aged 50 years and older.Methods. We analyzed data from the 2003–2010 Washington State Behavioral Risk Factor Surveillance System (n = 96 992) on health outcomes, chronic conditions, access to care, behaviors, and screening by gender and sexual orientation with adjusted logistic regressions.Results. LGB older adults had higher risk of disability, poor mental health, smoking, and excessive drinking than did heterosexuals. Lesbians and bisexual women had higher risk of cardiovascular disease and obesity, and gay and bisexual men had higher risk of poor physical health and living alone than did heterosexuals. Lesbians reported a higher rate of excessive drinking than did bisexual women; bisexual men reported a higher rate of diabetes and a lower rate of being tested for HIV than did gay men.Conclusions. Tailored interventions are needed to address the health disparities and unique health needs of LGB older adults. Research across the life course is needed to better understand health disparities by sexual orientation and age, and to assess subgroup differences within these communities.Changing demographics will make population aging a defining feature of the 21st century. Not only is the population older, it is becoming increasingly diverse.1 Existing research illustrates that older adults from socially and economically disadvantaged populations are at high risk of poor health and premature death.2 A commitment of the National Institutes of Health is to reduce and eliminate health disparities,3 which have been defined as differences in health outcomes for communities that have encountered systematic obstacles to health as a result of social, economic, and environmental disadvantage.4Social determinants of health disparities among older adults include age, race/ethnicity, and socioeconomic status.5 Centers for Disease Control and Prevention (CDC) and Healthy People 2020 identify health disparities related to sexual orientation as one of the main gaps in current health research.6 The Institute of Medicine identifies lesbian, gay, and bisexual (LGB) older adults as a population whose health needs are understudied.7 The institute has called for population-based studies to better assess the impact of background characteristics such as age on health outcomes among LGB adults. A review of 25 years of literature on LGB aging found that health research is glaringly sparse for this population and that most aging-related studies have used small, non-population-based samples.8Several important studies have begun to document health disparities by sexual orientation in population-based data and have revealed important differences in health between LGB adults and their heterosexual counterparts, including higher risks of poor mental health, smoking, and limitations in activities.9,10 Studies have found higher rates of excessive drinking among lesbians and bisexual women9,10 and higher rates of obesity among lesbians10,11 than among heterosexual women; bisexual men and women are at higher risk of limited health care access than are heterosexuals. In addition, important subgroup differences in health are beginning to be documented among LGB adults. For example, bisexual women are at higher risk than lesbians for mental distress and poor general health.12 A primary limitation of most existing population-based research is a failure to identify the specific health needs of LGB older adults. Most studies to date address the health needs of LGB adults aged 18 years and older9 or those younger than 65 years.10 This lack of attention to older adult health leaves unclear whether disparities diminish or persist or even become more pronounced in later life.A few studies have begun to examine health disparities among LGB adults aged 50 years and older.13,14 Wallace et al. analyzed data from the California Health Interview Survey and found that LGB adults aged 50 to 70 years report higher rates of mental distress, physical limitations, and poor general health than do their heterosexual counterparts. The researchers also found that older gay and bisexual men report higher rates of hypertension and diabetes than do heterosexual men.14 To better address the needs of an increasingly diverse older adult population and to develop responsive interventions and public health policies, health disparities research is needed for this at-risk group.Examining to what extent sexual orientation is related to health disparities among LGB older adults is a first step toward developing a more comprehensive understanding of their health and aging needs. We analyzed population-based data from the Washington State Behavioral Risk Factor Surveillance System (WA-BRFSS) to compare lesbians and bisexual women and gay and bisexual men with their heterosexual counterparts aged 50 years and older on key health indicators: outcomes, chronic conditions, access to care, behaviors, and screening. We also compared subgroups to identify differences in health disparities by sexual orientation among LGB older adults.     

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

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

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.     

Disparities in Health-Related Quality of Life: A Comparison of Lesbians and Bisexual Women

Objectives. We investigated the association of health-related quality of life (HRQOL) with sexual orientation among lesbians and bisexual women and compared the predictors of HRQOL between the 2 groups.Methods. We used multivariate logistic regression to analyze Washington State Behavioral Risk Factor Surveillance System population-based data (2003 to 2007) in a sample of 1496 lesbians and bisexual women and examined determinants of HRQOL among lesbians and bisexual women.Results. For lesbians and bisexual women, frequent mental distress and poor general health were associated with poverty and lack of exercise; poor general health was associated with obesity and mental distress. Bisexual women showed a higher likelihood of frequent mental distress and poor general health than did lesbians. The odds of mental distress were higher for bisexual women living in urban areas as compared with nonurban areas. Lesbians had an elevated risk of poor general health and mental distress during midlife.Conclusions. Despite the standard practice of collapsing sexual minority women into a single group, lesbian and bisexual women in this study emerge as distinct groups that merit specific attention. Bisexual women are at elevated risk for poor HRQOL.Sexual minority women (SMW) were acknowledged as a health disparate population in Healthy People 2010.¹ Despite many recent advances in sociopolitical and cultural acceptance for sexual minorities in the United States, these women continue to live in a society in which their lives run counter to the dominant culture. Meyer''s² model of minority stress attributes health disparities to the greater exposure to life stressors that accompanies minority status among this population. Such stressors include victimization, discrimination, stigmatization, expectations of rejection, and vigilance and are well documented in some empirical studies.^2–4According to the minority stress model, disparities in health outcomes are expected between lesbians and bisexual women and heterosexual women. The inclusion of questions about sexual orientation on some epidemiological health surveys such as the National Comorbidity Survey, the National Health and Nutrition Examination Survey, the National Household Survey on Drug Abuse, and the Midlife in the United States Survey has allowed researchers interested in this population to conduct such between-group research.^5–9 Overall, these data suggest that SMW are at higher risk for mental health disorders, particularly depression and anxiety (see Cochran¹⁰ and Meyer² for reviews). Relative to mental health outcomes, less research has been published focusing on physical health outcomes among SMW. There is evidence, however, that SMW are more likely to be obese, which puts them at greater risk for major health problems such as cancer and heart disease.¹¹ Other studies have demonstrated higher rates of health risk behaviors such as alcohol and drug abuse¹⁰ and smoking¹² among SMW compared with their heterosexual counterparts. Differences in physical health outcomes may be confounded by mental health problems; for example, Cochran and Mays¹³ found that differences in physical health between SMW and heterosexual women were no longer significant when psychological distress was taken into account.Although some studies document differences between SMW and heterosexual women,^14–18 relatively few studies look within SMW subpopulations to examine determinants of health for these populations. Because of small numbers of participants, most studies combine lesbians and bisexual women into a single group for analysis, thereby obscuring potentially important differences. Yet, bisexual women may face additional stressors associated with lack of support from both lesbian and heterosexual communities. Indeed, studies that examine bisexuals as a separate group suggest that this group may have even greater health disparities relative to heterosexual women than do lesbians. For example, in Cochran and Mays''s study,¹³ bisexual women, but not lesbians, were significantly more likely to report a functional health limitation, poor overall physical health, and a greater number of physical health conditions than were heterosexual women. In a recent study, Dilley et al.¹⁹ suggested that bisexual women may have more health risks relative to both heterosexual women and lesbians, although heterosexual women again served as the referent group. Because these prior studies do not report statistically based comparisons of lesbians and bisexual women, we know little about how these 2 groups of women may differ in terms of health.Another limitation of the existing literature on SMW is the inconsistent use of measures across studies, making comparisons difficult. For example, although health-related quality of life (HRQOL) has received much attention in recent health research and has been used extensively to track population trends and assess health disparities,^20,21 HRQOL has not been used in studies of sexual minority health. Moreover, there is little research specifically examining determinants of health and HRQOL among lesbians and bisexual women. Such within-group analyses are the next step in advancing our understanding of minority stress² by highlighting the factors within a minority population that make individuals relatively more vulnerable to poor health outcomes. To date, little is known about whether and how such determinants of health and HRQOL are similar or different for lesbians versus for bisexual women. Hence, we have little information on how best to focus preventive intervention efforts for these groups.In this population-based study, we used Behavioral Risk Factor Surveillance System data from Washington State (WA-BRFSS) to examine the relationship between HRQOL and sociodemographic characteristics, access to health care, and health risk behaviors among lesbians and bisexual women. We hypothesized that compared with lesbians, bisexual women would have lower levels of HRQOL, after controlling for the other health-related factors. We also examined similarities and differences in the predictors of HRQOL between these 2 groups.     

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.     

Adult Health Behaviors Over the Life Course by Sexual Orientation

Objectives. We estimated differences in health behaviors among adults by sexual orientation.Methods. We pooled 4 years of data (2001, 2003, 2005, and 2007) from the California Health Interview Survey. We estimated the frequency of smoking, alcohol use, healthy dietary behaviors, physical activity, and health care utilization, and we used logistic regression modeling to determine the odds of each behavior with increasing age and for 2 age groups: younger than 50 years and 50 years old or older.Results. At any adult age, lesbians had greater odds of smoking and binge drinking than did heterosexual women, and gay and bisexual men had greater health care utilization than did heterosexual men. Other risk behaviors differed with age.Conclusions. Some behavioral change interventions should target lesbians, gays, and bisexuals at all ages, whereas other interventions should specifically target individuals at younger ages.Researchers have identified differences in negative health behaviors by sexual orientation. For example, population-based data show that gay men, lesbians, and bisexual women are more likely than are heterosexual men and women to be smokers.¹ Lesbians and bisexual women have lower alcohol abstention rates and are more likely to report alcohol-related social consequences, alcohol dependence, and past help-seeking for an alcohol problem.² Among men, sexual orientation is linked to fewer differences in alcohol use.² In addition, several studies indicate that sexual minorities (e.g., lesbians, gays, bisexuals) are not receiving regular medical care and are more frequently utilizing the emergency room (ER).^3–5 Parallel to the literature showing sexual minority individuals exhibiting riskier behaviors is a body of literature linking risky behaviors to minority stress and more experiences of discrimination.^6,7Despite the emergence of an increasing number of studies indicating differences in risk behaviors by sexual orientation and describing the societal conditions that contribute to these risk behaviors, there is still no certainty about the extent to which risky behaviors are consistent across age cohorts. To date, alcohol use among women is highest among sexual minority women aged 26 to 35 years.⁸ Similarly, Hughes concluded that rates of drinking, heavy drinking, and problem drinking among lesbians and gay men decline less with age compared with declines among heterosexual women and men.⁹ However, other studies have suggested that although lesbians smoke more than do heterosexual women at younger ages, the difference is not significant at older ages.^10,11Research that assesses risk behaviors across age cohorts is lacking because of a number of barriers, including data sets with small subsamples of lesbian, gay, and bisexual individuals, which do not allow for further detailed analyses by age. We suggest that understanding risk behaviors by age is important to determine the extent to which there are age and sexual orientation disparities in risk behaviors and to inform interventions to reduce these risk behavior disparities. Therefore, we sought to determine the extent to which risk behaviors of lesbian, gay, and bisexual individuals differed from those of heterosexual populations across age cohorts. We tested 2 hypotheses for each gender: (1) risk behaviors are more prevalent among younger sexual minorities compared with same-aged heterosexuals, and (2) risk behavior disparities by sexual orientation are reduced at older ages.     

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

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

Effect of health care system distrust on breast and cervical cancer screening in Philadelphia, Pennsylvania

Objectives. We investigated whether health care system distrust is a barrier to breast and cervical cancer screening and whether different dimensions of distrust—values and competence—have different impacts on cancer screening.Methods. We utilized data on 5268 women aged 18 years and older living in Philadelphia, Pennsylvania, and analyzed their use of screening services via logistic and multinomial logistic regression.Results. High levels of health care system distrust were associated with lower utilization of breast and cervical cancer screening services. The associations differed by dimensions of distrust. Specifically, a high level of competence distrust was associated with a reduced likelihood of having Papanicolaou tests, and women with high levels of values distrust were less likely to have breast examinations within the recommended time period. Independent of other covariates, individual health care resources and health status were associated with utilization of cancer screening.Conclusions. Health care system distrust is a barrier to breast and cervical cancer screening even after control for demographic and socioeconomic determinants. Rebuilding confidence in the health care system may improve personal and public health by increasing the utilization of preventive health services.Cancer is a leading cause of death in the United States. Approximately 1.5 million Americans are diagnosed with cancer per year and 1 in 4 deaths are attributed to cancer.¹ Among women, an estimated 192 000 breast and 11 000 cervical cancer cases are detected each year, and in 2009 more than 40 000 women died of breast cancer and approximately 4000 of cervical cancer.¹ To effectively reduce the morbidity and mortality resulting from breast and cervical cancer, efforts need to be made to increase the proportion of women who comply with screening recommendations²; according to a recent report, a third of women are not in compliance with screening guidelines for breast cancer, and more than a fifth are not in compliance for cervical cancer.³ Our goal was to investigate whether health care system distrust (hereafter referred to as distrust) is a barrier to breast and cervical cancer screening.The late 20th century saw many changes in the theoretical underpinnings of research on health in general and women''s health in particular. The prevailing biomedical model was criticized for ignoring social determinants of health, such as social class, gender roles, and poverty,⁴ and health determinants models that incorporated multiple social, economic, and demographic dimensions were embraced.^5–7 The multiple determinants of health perspective emphasizes the relationships between socioeconomic factors and health outcomes,⁴ but the role of psychological factors (i.e., depression and distrust) in cancer screening has only recently been recognized.^8–11 Relatively little is known about whether distrust affects health outcomes, and specifically whether it influences cancer screening behaviors among women.¹¹Americans’ overall confidence in their health care system has declined markedly in recent decades. In 2010, only 34% of adults reported “a great deal” of confidence in the health system, down from over 70% in 1966.¹² More than 80% of Americans, however, held high levels of trust in their personal physicians or providers,¹³ a paradox that has been widely documented in the literature.^14–17 Previous studies suggest that trust in physicians is associated with seeking timely medical care, maintaining appropriate health care, and adhering to medical advice,^18–20 but it is unclear whether trust or its converse, distrust, affects the adoption of preventive health services among women.¹¹The emerging distrust research in health care shows that distrust is a multidimensional concept.^21–23 For example, Shea et al. used focus groups, pilot testing, and a telephone survey to develop a highly reliable 9-item distrust scale that includes 2 subscales: competence distrust and values distrust.²² Competence distrust is expected to be high when the quality of service fails to meet patient expectations and does not improve health. Values distrust is expected to be high when the integrity of the health care system is questioned (e.g., ethical issues, financial priorities, transparency of care). Although dimensions of distrust may influence the use of preventive health services in different ways, little research has addressed this issue explicitly.A range of individual characteristics has been found to be associated with the use of breast and cervical cancer screening, including age,^5,24 race/ethnicity,^11,25 socioeconomic factors,^5,24 marital status,^5,11,24 and availability and utilization of health care resources.^11,24 Access to insurance and health care providers is associated with higher likelihood of interaction with the health care system and has been hypothesized to be related to levels of distrust and to individuals’ health-related behaviors.²⁶ Personal health status has been found to be related to levels of distrust,²⁷ although the underlying causal mechanisms have not been well documented. Evidence concerning the association of health status with use of preventive health services is inconclusive.¹¹ An important contribution of our study is the investigation of the association of distinct aspects of distrust—values distrust and competence distrust—with receipt of 2 preventive health services for adult women: the Papanicolaou (Pap) test for cervical cancer and clinical breast examination to screen for breast cancer. We tested the following 2 hypotheses: after we controlled for individual socioeconomic and demographic characteristics, (1) high levels of distrust are associated with low utilization of cancer screening services and (2) the negative relationship between distrust and cancer screening utilization holds for the values and competence dimensions of distrust.     

Differences by Sexual Orientation in Expectations About Future Long-Term Care Needs Among Adults 40 to 65 Years Old

Objectives. We examined whether and how lesbian, gay, and bisexual (LGB) adults between 40 and 65 years of age differ from heterosexual adults in long-term care (LTC) expectations.Methods. Our data were derived from the 2013 National Health Interview Survey. We used ordered logistic regression to compare the odds of expected future use of LTC among LGB (n = 297) and heterosexual (n = 13 120) adults. We also used logistic regression models to assess the odds of expecting to use specific sources of care. All models controlled for key socioeconomic characteristics.Results. Although LGB adults had greater expectations of needing LTC in the future than their heterosexual counterparts, that association was largely explained by sociodemographic and health differences. After control for these differentials, LGB adults were less likely to expect care from family and more likely to expect to use institutional care in old age.Conclusions. LGB adults may rely more heavily than heterosexual adults on formal systems of care. As the older population continues to diversify, nursing homes and assisted living facilities should work to ensure safety and culturally sensitive best practices for older LGB groups.According to some estimates, approximately 4% of American adults aged 18 years or older self-identify as lesbian, gay, or bisexual (LGB),1 including more than 1.5 million LGB adults aged 65 years or older.2 This number is projected to grow to nearly 3 million by 2030.2 Research has shown that LGB individuals report worse physical and mental health outcomes and are more likely to engage in harmful health behaviors than their heterosexual peers.3,4 Public health studies often attribute LGB health disparities to minority stress, or the chronic stress associated with being a member of a marginalized minority group.5–9Elderly LGB individuals are particularly vulnerable to poor health outcomes owing to minority stress because of their experiences of stigma, discrimination, and violence.10–12 Recent studies involving data from California and Washington State indicate that LGB adults aged 50 years or older are more likely than their heterosexual counterparts to report symptoms of psychological distress, physical disability, and chronic disease; they are also more likely to report that their overall health status is poor.13–15Older LGB adults in same-gender relationships, especially women, are more likely than older heterosexual adults to need assistance with activities of daily living (ADLs) such as dressing, bathing, and doing errands alone,16 signaling a greater need for long-term care (LTC) services and support in later life.17 Such services and support might include assistance with ADLs (e.g., dressing, bathing, eating), instrumental ADLs (e.g., running errands, managing medications, preparing meals), and clinical or nursing tasks (e.g., pain management, physical or occupational therapy, management of incontinence). LTC may be provided in the home or community setting, by paid or unpaid caregivers, or in institutional settings. Although LGB individuals may have an elevated need for LTC services in later life, we are not aware of any studies examining differences in LTC expectations according to sexual orientation.Most Americans will need LTC at some point in their lives.18 According to current projections, nearly three quarters of all Americans will use LTC during their lives, and nearly half of Americans aged 65 years or older will spend time in a nursing home.18,19 However, middle-aged Americans have unrealistically low expectations of needing LTC,20 and very few people plan for it by either purchasing LTC insurance or making other advanced arrangements.21 This situation may be partly attributable to the high cost of LTC insurance premiums.22 Another major reason why people may not plan ahead for LTC is that they expect family members or close relatives to step in and provide care should they need it.20 This aligns with current use of unpaid caregivers, with approximately 80% of older adults reporting that family members provide the majority of their noninstitutional care.23However, older LGB adults may have different family structures than older heterosexual adults1; for example, they are less likely to be married, less likely to have children, and more likely to experience conflict with their family of origin.2,24,25 Older LGB adults, especially men, are more likely than their heterosexual counterparts to live alone,13,15,26,27 which is a major risk factor for both needing LTC and having unmet care needs.28–30Furthermore, although LGB individuals often exhibit distrust in formal LTC systems,31,32 one study showed that older LGB adults are only half as likely as older heterosexual adults to depend on close relatives for help.2 More than a quarter of LGB older adults report apprehension about discrimination as they age and how it may be manifested in institutional discrimination on the part of health care providers, including LTC providers.33 This should concern practitioners and policymakers given that the older LGB population is growing and our current system of LTC may be inappropriate to meet the needs of this group.Unfortunately, very little is known about LTC expectations among LGB populations. Research on the general population has shown that LTC expectations and planning behaviors are patterned according to demographic characteristics. Characteristics that may promote LTC planning include older age, female gender, being married, being White, having a college education or above, and having previous experience with LTC.21 Research suggests that LGB older adults are poorer and less financially secure than heterosexual older adults, in part because of limited employment opportunities resulting from institutional and personal discrimination34 and limited (or lack of) ability to receive partner benefits or property inheritances.35 Yet, as noted, there is a dearth of literature examining differences in LTC expectations by sexual orientation.3The few studies that have examined LTC expectations in older LGB populations indicate that these individuals may use nursing homes sooner than the general population owing to a lack of caregivers at home.2,33 LGB older adults in institutional facilities may be at heightened risk of neglect and abuse as a result of limited knowledge and training among providers and, sometimes, blatant discrimination on the part of staff and fellow residents.36One survey of LGB older adults and their families indicated that LGB adults were more likely than heterosexual adults to be harassed or mistreated in LTC facilities.37 Altogether, 328 respondents reported 853 instances of mistreatment among LGB older adults in LTC settings.37 Thus, some LGB older adults may avoid nursing homes because of barriers such as fear of discrimination and abuse, concerns about going “back into the closet,” and a reluctance to be separated from their partners.2,32 Instead of using formal LTC settings, some older LGB adults rely on friends and LGB-specific community organizations for assistance in later life.33 Older LGB adults who do reside in institutional settings may keep their sexual orientation a secret or seek out welcoming service providers.In this study, we sought to fill gaps in existing research by comparing LTC expectations among LGB and heterosexual adults aged 40 to 65 years. Whereas older heterosexual adults may expect to rely on their children and spouses for support in later life, the same may not be true for LGB adults. The findings of this study will be especially important for public health practitioners and policymakers planning for future LTC needs in aging populations.     

Influence of Hormonal Contraceptive Use and Health Beliefs on Sexual Orientation Disparities in Papanicolaou Test Use

Objectives. Reproductive health screenings are a necessary part of quality health care. However, sexual minorities underutilize Papanicolaou (Pap) tests more than heterosexuals do, and the reasons are not known. Our objective was to examine if less hormonal contraceptive use or less positive health beliefs about Pap tests explain sexual orientation disparities in Pap test intention and utilization.Methods. We used multivariable regression with prospective data gathered from 3821 females aged 18 to 25 years in the Growing Up Today Study (GUTS).Results. Among lesbians, less hormonal contraceptive use explained 8.6% of the disparities in Pap test intention and 36.1% of the disparities in Pap test utilization. Less positive health beliefs associated with Pap testing explained 19.1% of the disparities in Pap test intention. Together, less hormonal contraceptive use and less positive health beliefs explained 29.3% of the disparities in Pap test intention and 42.2% of the disparities in Pap test utilization.Conclusions. Hormonal contraceptive use and health beliefs, to a lesser extent, help to explain sexual orientation disparities in intention and receipt of a Pap test, especially among lesbians.Reproductive health screenings, such as Papanicolaou (Pap) tests, are a necessary part of quality health care.1 These screenings can detect precancerous conditions that may lead to cervical cancer if not treated. Despite the health benefits, sexual minority (e.g., lesbian, bisexual) female adolescents and young adults underutilize Pap tests.2–7 In a previous study with the cohort employed in this study, sexual minorities, compared to heterosexuals, were less likely to have had a Pap test within the last year or in their lifetime.8 We now extend this finding by exploring how hypothesized determinants of Pap testing intentions and behaviors help to explain sexual orientation disparities. A more thorough understanding of factors that explain underutilization may enable targeted clinical care and public health messages.It has been proposed that lesbians are less likely than heterosexuals to regularly visit a gynecologist because of their lower likelihood of hormonal contraceptive use.6,7 Other factors that may explain screening disparities include lower risk perception3 of cervical cancer and negative attitudes and beliefs toward Pap tests.9 Previous studies report that lesbians, in contrast to heterosexuals, perceive themselves to be at lower risk for contracting the human papillomavirus (HPV) and subsequently developing cervical cancer. Common reasons include the belief that sex between women is intrinsically safe because of limited fluid transmission, feeling invisible in gay male-focused sexual health promotions and therefore feeling “safe” because of a lack of messaging, and the emphasis in the “safer sex” discourse that one needs to only worry about penile penetrative sex.10 Physician recommendations have proved to be the strongest factor associated with Pap test utilization among all women.11 However, 10% of bisexuals and lesbians report being discouraged by physicians from getting a Pap test.12 Sexual minority adolescents may be particularly at risk because negative perceptions and attitudes about HPV are associated with lower screening rates among adolescents.13The Health Belief Model (HBM) is a psychological model that aims to explain and predict health behaviors. To our knowledge, it has yet to be applied to Pap test use within various sexual orientation groups but has effectively explained health disparities in other populations.14 The model includes 4 constructs focused on an individual’s attitudes and beliefs: susceptibility, severity, benefits, and barriers.15 An additional concept, cues to action, is thought to further motivate behavior,16 as are normative beliefs.The Institute of Medicine states that more data on Pap test use among sexual minority women are needed to better inform medical, governmental, and educational policies.17 Therefore, we examined sexual orientation group disparities in hormonal contraceptive use and HBM constructs (i.e., risk perception, attitudes and beliefs, cues to action) as they relate to Pap testing among adolescents and young adults. We hypothesized that unlike completely heterosexuals, sexual minorities

1. use hormonal contraceptives less frequently (and therefore may not see a health care provider as frequently who could provide a Pap test);
2. perceive themselves to be at lower risk for cervical cancer;
3. perceive themselves to be at lower severity of cervical cancer, if a diagnosis did occur;
4. believe there are fewer benefits to Pap test use;
5. believe there are more barriers to Pap test use;
6. hold fewer normative beliefs about Pap test use;
7. receive fewer cues to action for Pap test use; and
8. perceive fewer other individuals utilizing Pap tests.

Additionally, we hypothesized that these factors would partially explain (i.e., mediate) sexual orientation group disparities in Pap test intention and utilization.     

Sexual Minority Status and Self-Rated Health: The Importance of Socioeconomic Status,Age, and Sex

Objectives. I examined how sexual minority status, as indicated by sex of sexual partners, is associated with self-rated health and how socioeconomic status suppresses and age and sex moderate this association.Methods. I used multinomial logistic regression to analyze aggregated data from the 1991 to 2010 General Social Survey, a population-based data set (n = 13 480).Results. Respondents with only different-sex partners or with any same-sex partners reported similar levels of health. With socioeconomic status added to the model, respondents with any same-sex partners reported worse health than those with only different-sex partners, but only if sexual intercourse with same-sex partners occurred in the previous 5 years. Age and sex moderated this relationship: having any same-sex partners was associated with worse health for women but not men and among younger adults only.Conclusions. The relationship between sexual minority status and self-rated health varies across sociodemographic groups. Future research should use population-level data to examine other health outcomes and continue to explore how the intersection of sexual minority status and other sociodemographic indicators shapes health.Sexual minorities, defined as persons who are sexually attracted to people of their own sex; have sexual relations with people of their own sex; or identify as gay, lesbian, bisexual, or queer,1 are disadvantaged in many physical and mental health outcomes, including cancer, depression, HIV/AIDS, obesity, anxiety disorders, cardiovascular disease, and disability, relative to heterosexuals.1–5 Most previous studies did not examine variation in sexual minority health by age or sex nor how the sexual minority health disadvantage might be linked to socioeconomic status (SES), a composite measure of economic status (measured by income or wealth) and social status (measured by education).6Because people occupy many social identities and may possess multiple marginalized statuses that both independently and relatedly influence health, I advocate for an intersectional approach to studying sexual minority health.7,8 I examined how the relationship between sexual minority status and health is suppressed by SES and moderated by age and sex. I assessed suppression by SES because high SES improves health through multiple pathways (e.g., access to care and healthy foods, education, living conditions).6,9 Sexual minorities, on average, report higher SES than do heterosexuals,10,11 and this SES advantage may mask their health disadvantage. I also considered moderation by age and sex. Previous research indicated that both age and sex significantly shape racial, SES, and marital status health disparities.12–14 Thus they likely influence sexual minority health disparities, although this has been largely unexamined.     

Social support, exposure to violence and transphobia, and correlates of depression among male-to-female transgender women with a history of sex work

Objectives. We determined racial/ethnic differences in social support and exposure to violence and transphobia, and explored correlates of depression among male-to-female transgender women with a history of sex work (THSW).Methods. A total of 573 THSW who worked or resided in San Francisco or Oakland, California, were recruited through street outreach and referrals and completed individual interviews using a structured questionnaire.Results. More than half of Latina and White participants were depressed on the basis of Center For Epidemiologic Studies Depression Scale scores. About three quarters of White participants reported ever having suicidal ideation, of whom 64% reported suicide attempts. Half of the participants reported being physically assaulted, and 38% reported being raped or sexually assaulted before age 18 years. White and African American participants reported transphobia experiences more frequently than did others. Social support, transphobia, suicidal ideation, and levels of income and education were significantly and independently correlated with depression.Conclusions. For THSW, psychological vulnerability must be addressed in counseling, support groups, and health promotion programs specifically tailored to race/ethnicity.The term “transgender” has been used as an umbrella term, capturing people who do not conform with a binary male–female gender category.¹ In this study, we use the term “transgender women” or “male-to-female transgender women” to describe individuals who were born biologically male but self-identify as women and desire to live as women.² Although transgender persons or those who identify their gender other than male or female have been historically reported in many cultures around the world, their social roles, status, and acceptance have varied across time and place.³ In the United States, as part of the gay rights movement in the 1970s, a transgender civil rights movement emerged to advocate for transgender people''s equal rights and to eradicate discrimination and harassment in their daily lives.⁴ However, transphobia—institutional, societal, and individual-level discrimination against transgender persons—is still pervasive in the United States and elsewhere. It often takes the form of laws, regulations, violence (physical, sexual, and verbal), harassment, prejudices, and negative attitudes directed against transgender persons.^5–7Studies have reported that transgender persons lack access to gender-sensitive health care^6,8,9 and often experience transphobia in health care and treatment.^5,9 Transgender persons are frequently exposed to violence, sexual assault, and harassment in everyday life, mainly because of transphobia.^5–7,9–11 Physical and sexual assaults and violence, and verbal and nonphysical harassment, derive from various perpetrators (e.g., strangers, acquaintances, partners, family members, and police officers). Transgender persons suffer from assaults, rape, and harassment at an early age, and these experiences persist throughout life.¹ A number of studies have examined violence and harassment against sexual minorities, although these have mainly focused on gay men.^12–15 A limited literature has described the prevalence of violence, transphobia, and health disparities among transgender persons.^7–9Psychological indicators such as depression and suicidal ideation and attempts have been reported among transgender persons.^{5,6,10,16–18} Transgender women of color, such as African Americans, Latinas, and Asians/Pacific Islanders (APIs), are at high risk for adverse health outcomes because of racial/ethnic minority status and gender identity,⁶ as well as for depression through exposure to transphobia.¹⁹ Although transgender persons have reported relatively high rates of using basic health care services,²⁰gender-appropriate mental health services are needed,⁵ particularly among African Americans.²¹ A lack of social support, specifically from the biological family, is commonly reported among transgender persons and is associated with discomfort and lack of security and safety in public settings.²² Sparse research exists on social support among transgender persons, although such support could ameliorate adverse psychological consequences associated with transphobia and also mitigate racial discrimination for transgender persons of color.Because of relatively high rates of unemployment, lack of career training and education, and discrimination in employment, many transgender women engage in sex work for survival.^23,24 Sex work is linked to high-risk situations, including substance abuse, unsafe sex, and sexual and physical abuse.²⁵ Physical abuse, social isolation, and the social stigma associated with sex work exacerbate transgender women''s vulnerability to mental illness and HIV risk.^5,17 High HIV seroprevalence rates among transgender women have been reported,^5,20,26–28 particularly among racial/ethnic minorities,⁵ substance users,²⁷ and sex workers.^{20,24,25,29–31} Transgender women of color face multiple adversities, such as racial and gender discrimination; transphobia; economic challenges including unemployment, substance abuse, HIV and other sexually transmitted infections; and mental illness. However, few studies have investigated racial/ethnic differences in psychological status among transgender women of color in relation to social support and exposure to transphobia.To develop culturally appropriate and transgender specific mental health promotion programs, we describe the prevalence of violence, transphobia, and social support in relation to racial/ethnic background among transgender women with a history of sex work (THSW). We also investigated the role of social support and exposure to transphobia on participants’ levels of depression.     

Gender-Stratified Models to Examine the Relationship Between Financial Hardship and Self-Reported Oral Health for Older US Men and Women

Objectives. We evaluated the relationship between financial hardship and self-reported oral health for older men and women.Methods. We focused on adults in the 2008 Health and Retirement Study (n = 1359). The predictor variables were 4 financial hardship indicators. We used Poisson regression models to estimate the prevalence ratio of poor self-reported oral health.Results. In the non–gender-stratified model, number of financial hardships was not significantly associated with self-reported oral health. Food insecurity was associated with a 12% greater prevalence of poor self-reported oral health (95% confidence interval [CI] = 1.04, 1.21). In the gender-stratified models, women with 3 or more financial hardships had a 24% greater prevalence of poor self-reported oral health than women with zero (95% CI = 1.09, 1.40). Number of hardships was not associated with self-reported oral health for men. For men, skipping medications was associated with 50% lower prevalence of poor self-reported oral health (95% CI = 0.32, 0.76).Conclusions. Number of financial hardships was differentially associated with self-reported oral health for older men and women. Most financial hardship indicators affected both genders similarly. Future interventions to improve vulnerable older adults’ oral health should account for gender-based heterogeneity in financial hardship experiences.The Institute of Medicine’s 1998 publication Gender Differences in Susceptibility of Environmental Factors called attention to how socioeconomic factors differentially affect health outcomes for men and women.1 Gender-based health disparities are pronounced among older adults.2,3 In 2010, 25% of the US population was aged 55 years or older, a 15% increase from 2000.4 Advances in chronic disease management have improved adult life expectancy,5–12 making older adults the fastest growing subgroup in the United States. The close relationship between oral and systemic health13–15 has motivated interest in addressing oral health disparities in older adults, particularly among those who are financially vulnerable.16Poverty and low socioeconomic status (SES) are associated with tooth decay, gum diseases, and oral cancers—all of which are indicators of poor oral health.17–28 Older men and women are at differential risk for dental diseases and conditions.29,30 For instance, older men are more likely to have untreated tooth decay,31,32 gum disease,33 and oropharyngeal cancer34 whereas older women are more likely to have missing teeth and to be edentulous.29 Dental care use by women partially explains this heterogeneity in disease risk35 although the mechanisms underlying gender-based differences have not been elucidated. Differential risk for dental disease may translate to differences in self-reported oral health. Based on 1999–2004 US National Health and Nutrition Examination Survey data, a larger proportion of men aged 65 years and older reported fair or poor oral health compared with women (40.1% and 36.9%, respectively).29 Although 2 studies suggest that self-reported oral health measures are weakly associated with dental disease status as assessed by a dentist,36,37 most studies have concluded that self-reported oral health is a valid and reliable measure of clinical oral health.38–41There is a growing body of literature on gender, socioeconomic inequality, and health disparities.42–45 Most studies have focused on traditional measures of SES such as education, income, or occupation.46–48 However, these measures do not adequately capture the multiple pathways by which socioeconomic and financial circumstances influence health.49–53 For example, focusing on income alone may not fully capture an individual’s ability to garner resources to meet financial obligations.54 Alternative SES measures such as financial hardship have been shown to have an impact on health over and above traditional measures of SES.55,56 Furthermore, recent studies suggest that alternative SES measures, which account for economic resources, assets, and household material conditions, are moderated by gender on outcomes such as self-rated health, psychological distress, musculoskeletal disorders, and mortality.55–58 This interaction is particularly relevant for older adults, many of whom are retired or are preparing to exit the workforce.59Currently, there is little understanding of how gender and financial hardship interact on oral health outcome measures. In addition, the studies relevant to adult oral health have 2 limitations: (1) the inclusion of both younger and older adults in the same models, which assumes that the relationship between socioeconomic indicators and oral health is homogeneous across the adult life span20,22,27,47; and (2) the lack of gender-stratified models,28 which treats gender as a confounder rather than as an effect modifier.The aim of the present study was to test the hypothesis that the association between financial hardship and self-reported oral health is different for women and men. This research continues the line of work aimed at identifying ways to improve the oral health of vulnerable older adults, and has important implications in the development of interventions and policies that address gender-based disparities in adult oral health.60,61     

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     

Pleasure, power, and inequality: incorporating sexuality into research on contraceptive use

We know surprisingly little about how contraception affects sexual enjoyment and functioning (and vice versa), particularly for women. What do people seek from sex, and how do sexual experiences shape contraceptive use? We draw on qualitative data to make 3 points. First, pleasure varies. Both women and men reported multiple aspects of enjoyment, of which physical pleasure was only one.Second, pleasure matters. Clear links exist between the forms of pleasure respondents seek and their contraceptive practices. Third, pleasure intersects with power and social inequality. Both gender and social class shape sexual preferences and contraceptive use patterns. These findings call for a reframing of behavioral models that explain why people use (or do not use) contraception.Despite the addition of “sexual” to the sexual and reproductive health agenda^1,2 and the increasing attention paid to how gendered power differentials influence sexual behaviors, public health research has yet to adequately explore the needs and purposes that sex fulfills. Research with both heterosexual and homosexual men has taken into account how the goal of physical pleasure shapes risk taking,^3–8 and a parallel body of work for heterosexual women has explored the relative importance of economic need and the desire for intimacy to risk taking.^9–11 Each of these bodies of work, however, are themselves bound by gender stereotypes—specifically by the assumptions that women do not have sex for pleasure and that men do not have sex for intimacy. Unintended pregnancy, sexually transmitted infections (STIs), and HIV are among the most pressing issues in public health both in the United States and abroad. It is more important than ever to understand the array of factors contributing to sexual risk taking and risk reduction, including sexual goals and sexual pleasure.Sexual health research within public health has largely failed to explore how pleasure and positive sexual functioning affect sexual risk and risk-reduction practices,^12,13 particularly for women.^14,15 This void is especially evident in the field''s approach to male condoms and women. Public health programs target women to carry out sexual risk reduction through condom use (even though women do not “use” or “wear” male condoms) despite research showing that women may lack the power to press their partners to use condoms^16–20 and that even when women are able to negotiate for condom use, they may refrain from doing so out of the desire for sex that is “close,” loving, and monogamous.^{10,11,21–23} We still know little, however, about women''s sexual experiences with male condoms and how their perceptions of the way condoms feel physically affect their risk behaviors (for 2 exceptions, see Holland et al.²⁴ and Ehrhardt et al.²⁵). There is a critical need for research that examines how a desire for sexual pleasure—or more broadly, the full range of reasons women have sex—shapes women''s willingness to encourage condom use.Many studies of hormonal contraceptives also fail to systematically assess how these methods affect sexual functioning or pleasure or how women''s sexual goals shape their patterns of use.^26–28 However, several recent studies have suggested that a desire for sexual enjoyment can play a role in women''s contraceptive behaviors. US women and men ranked pleasure as equally important in evaluating a contraceptive''s acceptability in one study.²⁹ Other research associates method continuation to the reductions in or enhancement of sexual experience caused by oral contraceptives,²⁶ injectables,³⁰ tubal ligation,³¹ and especially, the female condom^32–34 and microbicides.^35–39These studies suggest that the initiation and continuation of contraceptive methods (including male and female condoms) is influenced by how they make sex feel and that sexual experience and contraceptive experience may shape each other reciprocally. However, few of these studies have explored multiple forms of contraception simultaneously, and none has gone beyond individual experience to situate pleasure more broadly within social processes. Furthermore, as evident in the data we present, “pleasure” contains multiple overlapping categories. Work to date has not adequately explored variation in people''s ideas about what makes sex feel good or the varying weight given to this “feeling good” relative to other valued qualities in the sexual encounter.We used an ethnographic, inductive approach to explore the range of sexual motivations and goals—that is, what sex is for or what needs it fulfills—expressed by a sample of individuals in urban Atlanta, Georgia, and we analyzed the relationship between these sexual goals and contraceptive practices. We had 3 research questions: (1) What do people seek from and experience within their sexual encounters and relationships? (2) How do these expectations and experiences shape contraceptive use? and (3) How are sexual goals shaped by gender, social class, and other forms of structural social inequality?     

Participatory Design of Mass Health Communication in Three Languages for Seniors and People With Disabilities on Medicaid

Objectives. We used participatory design methods to develop and test guidebooks about health care choices intended for 600 000 English-, Spanish-, and Chinese-speaking seniors and people with disabilities receiving Medicaid in California.Methods. Design and testing processes were conducted with consumers and professionals; they included 24 advisory group interviews, 36 usability tests, 18 focus groups (105 participants), 51 key informant interviews, guidebook readability and suitability testing, linguistic adaptation, and iterative revisions of 4 prototypes.Results. Participatory design processes identified preferences of intended audiences for guidebook content, linguistic adaptation, and format; guidebook readability was scored at the sixth- to eighth-grade level and suitability at 95%. These findings informed the design of a separate efficacy study that showed high guidebook usage and satisfaction, and better gains in knowledge, confidence, and intended behaviors among intervention participants than among control participants.Conclusions. Participatory design can be used effectively in mass communication to inform vulnerable audiences of health care choices. The techniques described can be adapted for a broad range of health communication interventions.Reaching vulnerable populations and communicating effectively with them is a critical public health challenge. The estimated 55.6 million Medicaid beneficiaries¹ are one of the most vulnerable US populations and face serious communication barriers related to limited literacy, language, culture, and disability.^2,3 Of this population, the most at-risk subgroups are the more than 13.5 million seniors and people with disabilities.¹ Their communication barriers are even greater: many have limited health literacy skills (difficulty accessing, understanding, and acting on health information), limited English proficiency,^2,4 or physical or cognitive conditions that impede access to information.With the rapid proliferation of “consumer choice models” in many states, millions of Medicaid beneficiaries are now required to make complex decisions about health plan options and effectively using health care.³ These decisions have important implications for the targeted beneficiaries regarding access to needed preventive, curative, and supportive services.^3,5–9 However, studies show that these populations have difficulty making such decisions—in part because of the poor quality of information they receive.^3–6,8,9 For example, in studies in which seniors on Medicaid used printed materials about health care choices, only 32% of those in Florida³ and 25% of those in California¹⁰ could understand the information. This is not surprising, as more than 250 studies indicate that printed materials related to health are written at reading levels greatly exceeding the average literacy skills of adults in the United States.¹¹Theoretical guidance from socio-ecological,¹² social cognitive,¹³ and transtheoretical models,¹⁴ as well as 40 years of empirical research, suggest that health communication is more effective when it is relevant to people''s personal and social contexts.^15–29 For this reason, interpersonal and tailored computer-mediated communication, which can be personalized, typically show better results than materials-based mass communication.^{18,22,24,25,30–32} However, Medicaid programs primarily communicate with seniors and people with disabilities through printed materials, given the need for low-cost mass distribution and this population''s limited access to both in-person advice and the Internet. Is there a way to reach these highly vulnerable groups effectively and affordably?Research from the past 20 years shows that using strategies to adapt printed mass communication resources more closely to the needs of population subgroups can improve outcomes.^15–29 These design principles include matching readability more closely to users'' literacy levels and using “clear communication” formatting criteria,^33–35 incorporating culturally relevant concepts and graphics,^{4,17,19,23,36–40} and adapting rather than literally translating material into other languages.^{4,19,23,39,41}Such design principles are invaluable, but they can only approximate how real audiences use and react to health communication. For this reason, increasing emphasis is being placed on “participatory” or “user-centered” design—a structured approach that employs varied formative research methods to involve intended consumer and professional audiences as codevelopers of communication.^{4,19,25,42–45}Guidelines from the US Department of Health and Human Services and its centers, including the Centers for Disease Control and Prevention and the National Cancer Institute, recommend participatory design as a primary strategy to develop health communication.^{33–35,43,46} For the past 20 years, our center (Health Research for Action, www.uchealthaction.org) has leveraged such guidance to create large-scale mass communication materials by and for diverse populations.Two decades of studies confirm that when users participate in designing and testing communication, outcomes are more successful, including those for vulnerable groups.^{4,25,28,42,44,47–51} However, limited research is available about the detailed, iterative methods and steps involved in developing user-centered, materials-based mass communication—especially about how to adapt it for specific situations.In California, the Department of Health Care Services (DHCS) was concerned that fewer than 25% of Medicaid beneficiaries who were seniors or people with disabilities made active choices about health plans. By default, many beneficiaries could have plans ill suited for their health care needs. In 2006, the DHCS commissioned our center to use participatory processes to develop and test a guidebook about choosing and navigating health plans, intended for approximately 600 000 statewide Medicaid beneficiaries who were seniors and people with disabilities, in multiple language versions. Our objectives were to determine the (1) importance of participatory design in improving mass communication for diverse and vulnerable audiences, (2) methods to engage consumers and professionals in communication design and testing, (3) processes and outcomes of a project to create a user-designed guidebook for Medicaid beneficiaries, and (4) implications for health communication researchers and practitioners.     

Trust in the health care system and the use of preventive health services by older black and white adults

Objectives. We sought to find racial differences in the effects of trust in the health care system on preventive health service use among older adults.Methods. We conducted a telephone survey with 1681 Black and White older adults. Survey questions explored respondents'' trust in physicians, medical research, and health information sources. We used logistic regression and controlled for covariates to assess effects of race and trust on the use of preventive health services.Results. We identified 4 types of trust through factor analysis: trust in one''s own personal physician, trust in the competence of physicians'' care, and trust in formal and informal health information sources. Blacks had significantly less trust in their own physicians and greater trust in informal health information sources than did Whites. Greater trust in one''s own physician was associated with utilization of routine checkups, prostate-specific antigen tests, and mammograms, but not with flu shots. Greater trust in informal information sources was associated with utilization of mammograms.Conclusions. Trust in one''s own personal physician is associated with utilization of preventive health services. Blacks'' relatively high distrust of their physicians likely contributes to health disparities by causing reduced utilization of preventive services. Health information disseminated to Blacks through informal means is likely to increase Blacks'' utilization of preventive health services.There is strong empirical evidence of health care disparities between Black and White Americans. Blacks are less likely than are Whites to receive many needed services, including routine preventive care.^1–5 The causes of disparities in health care are complex and have been the subject of considerable research; socioeconomic differences and structural characteristics (such as lack of access to care) are important sources of care disparities, and there is significant evidence that racial bias in the health care system is also a major factor in disparities in care between Blacks and Whites.¹Blacks'' distrust of physicians and the health care system may also contribute to health care disparities. Studies have demonstrated that Blacks exhibit less trust in the health care system.^6–9 There are a variety of mechanisms through which this distrust may occur, including Blacks'' personal experiences with racism, their knowledge of a history of racism in the health care system—including circumstances in which Blacks were victimized, such as the Tuskegee Syphilis Study^10–12—and social and cultural distance between Black patients and White physicians.¹³ Taken together, these individual experiences constitute a broader cultural memory of abuse that may contribute to belief in conspiracy theories among Blacks.^14,15 Goertzel reported that belief in conspiracies was correlated with lack of interpersonal trust and that Blacks were more likely to believe in conspiracy theories than were Whites.¹⁶Trust plays a central role in all medical relationships and is an important contributor to positive therapeutic outcomes.^17–20 Lack of patient trust is associated with less doctor–patient interaction, poor clinical relationships that exhibit less continuity, reduced adherence to recommendations, worse self-reported health, and reduced utilization of health care services^17–22; thus, Blacks'' relatively lower trust in the health care system puts them at greater risk of all these negative outcomes. When O''Malley et al.²² evaluated respondents'' answers to a global question assessing overall trust in personal physicians, they found that greater trust was associated with higher overall use of a number of preventive services among low-income Black women 41 years and older.However, little is known about whether distrust affects use of specific preventive services differently. Because trust in the health care system is conceived as consisting of a number of types and dimensions,^17,19,20 it is also possible that different aspects of trust may affect service use differently, thus warranting more detailed study of how the dimensions of trust may affect use of preventive services among various populations. Because of its likely origins in racial bias, Blacks'' health care–related distrust may have somewhat different effects from that of Whites, perhaps manifesting as institutional distrust as opposed to interpersonal distrust.We explored these issues by examining the association of different aspects of health care–related trust with receipt of preventive health services among older Blacks and Whites. We focused on older adults because preventive services such as immunizations, routine physical examinations, and screening for cancer and other diseases can greatly reduce premature mortality and morbidity among this population and are critical to sustaining older adults'' health.²³ Thus, disparities in receipt of preventive services are an especially strong contributor to disparities in health outcomes for older adults.