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1.  Reports of parental maltreatment during childhood in a United States population-based survey of homosexual, bisexual, and heterosexual adults☆ 
Child abuse & neglect  2002;26(11):1165-1178.
Objective
The study objective was to determine the nature and prevalence of childhood maltreatment experiences among lesbian, gay, and bisexual adults and to compare findings to those obtained from similar heterosexual adults.
Method
Data from the National Survey of Midlife Development in the United States (MIDUS), which measured both childhood experiences with parental emotional and physical maltreatment and adult sexual orientation, were used to compare childhood maltreatment experiences of 2917 heterosexual, homosexual, and bisexual individuals, age 25–74 years, separately by gender.
Results
Homosexual/bisexual men reported higher rates than heterosexual men of childhood emotional and any physical maltreatment (including major physical maltreatment) by their mother/maternal guardian and major physical maltreatment by their father/paternal guardian. In contrast, homosexual/bisexual women, as compared to heterosexual women, reported higher rates of major physical maltreatment by both their mother/maternal guardian and their father/paternal guardian. Differences among individuals with differing sexual orientations were most pronounced for the more extreme forms of physical maltreatment.
Conclusions
Adult minority sexual orientation is a risk indicator for positive histories of experiencing parental maltreatment during childhood. While the reasons for this are beyond the scope of the current study, previous research suggests that childhood individual differences, including possibly gender atypicality, may be a causal factor.
PMCID: PMC4194076  PMID: 12398854
Child maltreatment; Child abuse; Homosexuality
2.  Disproportionate Exposure to Early-Life Adversity and Sexual Orientation Disparities in Psychiatric Morbidity 
Child abuse & neglect  2012;36(9):645-655.
Objectives
Lesbian, gay, and bisexual (LGB) populations exhibit elevated rates of psychiatric disorders compared to heterosexuals, and these disparities emerge early in the life course. We examined the role of exposure to early-life victimization and adversity—including physical and sexual abuse, homelessness, and intimate partner violence—in explaining sexual orientation disparities in mental health among adolescents and young adults.
Methods
Data were drawn from the National Longitudinal Study of Adolescent Health, Wave 3 (2001–2002), a nationally representative survey of adolescents. Participants included gay/lesbian (n=227), bisexual (n=245), and heterosexual (n=13,490) youths, ages 18–27. We examined differences in the prevalence of exposure to child physical or sexual abuse, homelessness or expulsion from one’s home by caregivers, and physical and sexual intimate partner violence according to sexual orientation. Next we examined the associations of these exposures with symptoms of psychopathology including suicidal ideation and attempts, depression, binge drinking, illicit drug use, tobacco use, alcohol abuse, and drug abuse. Finally, we determined whether exposure to victimization and adversity explained the association between sexual orientation and psychopathology.
Results
Gay/lesbian and bisexual respondents had higher levels of psychopathology than heterosexuals across all outcomes. Gay/lesbian respondents had higher odds of exposure to child abuse and housing adversity, and bisexual respondents had higher odds of exposure to child abuse, housing adversity, and intimate partner violence, than heterosexuals. Greater exposure to these adversities explained between 10–20% of the relative excess of suicidality, depression, tobacco use, and symptoms of alcohol and drug abuse among LGB youths compared to heterosexuals. Exposure to victimization and adversity experiences in childhood and adolescence significantly mediated the association of both gay/lesbian and bisexual orientation with suicidality, depressive symptoms, tobacco use, and alcohol abuse.
Conclusions
Exposure to victimization in early-life family and romantic relationships explains, in part, sexual orientation disparities in a wide range of mental health and substance use outcomes, highlighting novel targets for preventive interventions aimed at reducing these disparities.
doi:10.1016/j.chiabu.2012.07.004
PMCID: PMC3445753  PMID: 22964371
3.  Victimization and substance use disorders in a national sample of heterosexual and sexual minority women and men 
Addiction (Abingdon, England)  2010;105(12):2130-2140.
Context
There is consensus in the research literature that substance use disparities exist among sexual minority women and men; however, few studies have examined risk factors that may contribute to these disparities.
Aims
To compare reports of life-time victimization experiences in a US national sample of adult heterosexual and sexual minority women and men and to examine the relationships between victimization experiences and past-year substance use disorders.
Design, participants, measurements
The secondary data analyses used 2004–05 (wave 2) National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) data collected in structured diagnostic face-to-face interviews in the United States. Substance use disorders (SUDs) were defined according to DSM-IV criteria and included past-year alcohol abuse, alcohol dependence, drug abuse and drug dependence. The sample consisted of 34 653 adults aged 20 years and older; approximately 2% of the respondents self-identified as sexual minority (lesbian, gay or bisexual).
Findings
Results showed strong associations between victimization and any past-year SUDs and confirmed findings from several previous studies indicating that, compared with heterosexuals, sexual minority women and men are at heightened risk for life-time victimization. However, prevalence of the seven victimization experiences and the degree of association between individual victimization experiences and SUDs varied substantially across sexual minority subgroups. The childhood victimization variables—especially childhood neglect—showed the strongest and most consistent associations with SUDs. Odds of SUDs were generally higher among both female and male respondents, regardless of sexual identity, who reported multiple (two or more) victimization experiences than among those who reported no life-time victimization, suggesting a possible cumulative effect of multiple victimization experiences.
Conclusions
Higher rates of life-time victimization, particularly victimization experienced in childhood, may help to explain higher rates of substance use disorders among sexual minorities. However, more research is needed to understand better the complex relationships among sexual orientation, victimization and substance use.
doi:10.1111/j.1360-0443.2010.03088.x
PMCID: PMC3006226  PMID: 20840174
DSM-IV substance use disorders; epidemiology; sexual identity; sexual orientation; victimization
4.  Associations between Intimate Partner Violence and Health among Men Who Have Sex with Men: A Systematic Review and Meta-Analysis 
PLoS Medicine  2014;11(3):e1001609.
Ana Maria Buller and colleagues review 19 studies and estimate the associations between the experience and perpetration of intimate partner violence and various health conditions and sexual risk behaviors among men who have sex with men.
Please see later in the article for the Editors' Summary
Background
Intimate partner violence (IPV) among men who have sex with men (MSM) is a significant problem. Little is known about the association between IPV and health for MSM. We aimed to estimate the association between experience and perpetration of IPV, and various health conditions and sexual risk behaviours among MSM.
Methods and Findings
We searched 13 electronic databases up to 23 October 2013 to identify research studies reporting the odds of health conditions or sexual risk behaviours for MSM experiencing or perpetrating IPV. Nineteen studies with 13,797 participants were included in the review. Random effects meta-analyses were performed to estimate pooled odds ratios (ORs). Exposure to IPV as a victim was associated with increased odds of substance use (OR = 1.88, 95% CIOR 1.59–2.22, I2 = 46.9%, 95% CII2 0%–78%), being HIV positive (OR = 1.46, 95% CIOR 1.26–1.69, I2 = 0.0%, 95% CII2 0%–62%), reporting depressive symptoms (OR = 1.52, 95% CIOR 1.24–1.86, I2 = 9.9%, 95% CII2 0%–91%), and engagement in unprotected anal sex (OR = 1.72, 95% CIOR 1.44–2.05, I2 = 0.0%, 95% CII2 0%–68%). Perpetration of IPV was associated with increased odds of substance use (OR = 1.99, 95% CIOR 1.33–2.99, I2 = 73.1%). These results should be interpreted with caution because of methodological weaknesses such as the lack of validated tools to measure IPV in this population and the diversity of recall periods and key outcomes in the identified studies.
Conclusions
MSM who are victims of IPV are more likely to engage in substance use, suffer from depressive symptoms, be HIV positive, and engage in unprotected anal sex. MSM who perpetrate IPV are more likely to engage in substance use. Our results highlight the need for research into effective interventions to prevent IPV in MSM, as well as the importance of providing health care professionals with training in how to address issues of IPV among MSM and the need to raise awareness of local and national support services.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Intimate partner violence (IPV, also called domestic violence) is a common and widespread problem. Globally, nearly a third of women are affected by IPV at some time in their life, but the prevalence of IPV (the proportion of the population affected by IPV) varies widely between countries. In central sub-Saharan Africa, for example, nearly two-thirds of women experience IPV during their lifetime, whereas in East Asia only one-sixth of women are affected. IPV is defined as physical, sexual, or emotional harm that is perpetrated on an individual by a current or former partner or spouse. Physical violence includes hitting, kicking, and other types of physical force; sexual violence means forcing a partner to take part in a sex act when the partner does not consent; and emotional abuse includes threatening a partner by, for example, stalking them or preventing them from seeing their family. The adverse effects of IPV for women include physical injury, depression and suicidal behaviour, and sexual and reproductive health problems such as HIV infection and unwanted pregnancies.
Why Was This Study Done?
IPV affects men as well as women. Men can be subjected to IPV either by a female partner or by a male partner in the case of men who have sex with men (MSM, a term that encompasses homosexual, bisexual, and transgender men, and heterosexual men who sometimes have sex with men). Recent reviews suggest that the prevalence of IPV in same-sex couples is as high as the prevalence of IPV for women in opposite-sex relationships: reported lifetime prevalences of IPV in homosexual male relationships range between 15.4% and 51%. Little is known, however, about the adverse health effects of IPV on MSM. It is important to understand how IPV affects the health of MSM so that appropriate services and interventions can be provided to support MSM who experience IPV. In this systematic review (a study that identifies all the research on a given topic using predefined criteria) and meta-analysis (a study that combines the results of several studies using statistical methods), the researchers investigate the associations between the experience and perpetration of IPV and various health conditions and sexual risk behaviours among MSM.
What Did the Researchers Do and Find?
The researchers identified 19 studies that investigated associations between IPV and various health conditions or sexual risk behaviours (for example, unprotected anal sex, a risk factor for HIV infection) among MSM. The associations were expressed as odds ratios (ORs); an OR represents the odds (chances) that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure. The researchers estimated pooled ORs from the data in the individual studies using meta-analysis. The pooled lifetime prevalence of experiencing any IPV (which was measured in six studies) was 48%. Exposure to IPV as a victim was associated with an increased risk of substance (alcohol or drug) use (OR = 1.88, data from nine studies), reporting depressive symptoms (OR = 1.52, data from three studies), being HIV positive (OR = 1.46, data from ten studies), and engagement in unprotected sex (OR = 1.72, data from eight studies). Perpetration of IPV was associated with an increased risk of substance abuse (OR = 1.99, data from six studies).
What Do These Findings Mean?
These findings suggest that MSM frequently experience IPV and that exposure to IPV is associated with several adverse health conditions and sexual risk behaviours. There were insufficient data to estimate the lifetime prevalence of IPV perpetration among MSM, but these findings also reveal an association between IPV perpetration and substance use. The accuracy of these findings is limited by heterogeneity (variability) between the studies included in the meta-analyses, by the design of these studies, and by the small number of studies. Despite these and other limitations, these findings highlight the need to undertake research to identify interventions to prevent IPV among MSM and to learn more about the health effects of IPV among MSM. They highlight the importance of health care professionals being aware that IPV is a problem for MSM and of training these professionals to assess MSM for IPV. Finally, these results highlight the need to improve the availability and effectiveness of support services to which health care professionals can refer MSM experiencing or perpetrating IPV.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001609.
The World Health Organization provides detailed information on intimate partner violence
The US Centers for Disease Control and Prevention provides information about IPV and a fact sheet on understanding IPV that includes links to further resources
The UK National Health Service Choices website has a webpage about domestic violence, which includes descriptions of personal experiences
The US National Domestic Violence Hotline provides confidential help and support to people experiencing IPV, including MSM; its website includes personal stories of IPV
The US Gay Men's Domestic Violence Project/GLBTQ Domestic Violence Project provides support and services to MSM experiencing IPV; its website includes some personal stories
The UK not-for-profit organization Respect runs two advice lines: the Men's Advice Line provides advice and support for men experiencing domestic violence and abuse and the Respect Phoneline provides advice for domestic violence perpetrators and for professionals who would like further information about services for those using violence/abuse in their intimate partner relationships
The UK not-for-profit organization ManKind Initiative also provides support for male victims of IPV
The UK not-for-profit organization Broken Rainbow UK provides help and support for lesbians and MSM experiencing IPV
MedlinePlus provides links to other resources about domestic violence (in English and Spanish)
The UK charity Galop gives advice and support to people who have experienced biphobia, homophobia, transphobia, sexual violence, or domestic abuse
doi:10.1371/journal.pmed.1001609
PMCID: PMC3942318  PMID: 24594975
5.  Mental health, sexual identity, and interpersonal violence: Findings from the Australian longitudinal Women’s health study 
BMC Women's Health  2017;17:94.
Background
We examined the relationships among experiences of interpersonal violence, mental health, and sexual identity in a national sample of young adult women in Australia.
Methods
We used existing data from the third (2003) wave of young adult women (aged 25–30) in the Australian Longitudinal Study on Women’s Health (ALSWH). We conducted bivariate analyses and fit multiple and logistic regression models to test experiences of six types of interpersonal violence (physical abuse, severe physical abuse, emotional abuse, sexual abuse, harassment, and being in a violent relationship), and the number of types of violence experienced, as predictors of mental health. We compared types and number of types of violence across sexual identity subgroups.
Results
Experiences of interpersonal violence varied significantly by sexual identity. Controlling for demographic characteristics, compared to exclusively heterosexual women, mainly heterosexual and bisexual women were significantly more likely to report physical, sexual, and emotional abuse. Mainly heterosexual and lesbian women were more likely to report severe physical abuse. Mainly heterosexual women were more than three times as likely to have been in a violent relationship in the past three years, and all three sexual minority subgroups were two to three times as likely to have experienced harassment. Bisexual women reported significantly higher levels of depression than any of the other sexual identity groups and scored lower on mental health than did exclusively heterosexual women. In linear regression models, interpersonal violence strongly predicted poorer mental health for lesbian and bisexual women. Notably, mental health indicators were similar for exclusively heterosexual and sexual minority women who did not report interpersonal violence. Experiencing multiple types of interpersonal violence was the strongest predictor of stress, anxiety and depression.
Conclusions
Interpersonal violence is a key contributor to mental health disparities, especially among women who identify as mainly heterosexual or bisexual. More research is needed that examines within-group differences to determine which subgroups are at greatest risk for various types of interpersonal violence. Such information is critical to the development of effective prevention and intervention strategies.
doi:10.1186/s12905-017-0452-5
PMCID: PMC5622594  PMID: 28964264
Interpersonal violence; Female sexual identity; Stress; Depression; Australian longitudinal Women’s health study
6.  Disparities in Child Abuse Victimization in Lesbian, Bisexual, and Heterosexual Women in the Nurses’ Health Study II 
Journal of women's health (2002)  2008;17(4):597-606.
A growing body of research documents multiple health disparities by sexual orientation among women, yet little is known about the possible causes of these disparities. One underlying factor may be heightened risk for abuse victimization in childhood in lesbian and bisexual women. Using survey data from 63,028 women participating in the Nurses’ Health Study II, we investigated sexual orientation group differences in emotional, physical, and sexual abuse in childhood and adolescence. Multivariable log-binomial and linear regression models were used to examine orientation group differences in prevalence and severity of abuse, with heterosexual as the referent and controlling for sociodemographics. Results showed strong evidence of elevated frequency, severity, and persistence of abuse experienced by lesbian and bisexual women. Comparing physical abuse victimization occurring in both childhood and adolescence, lesbian (30%; prevalence ratio [PR] 1.61; 95% confidence interval [CI] 1.40, 1.84) and bisexual (24%; PR 1.26; 95% CI 1.00, 1.60) women were more likely to report victimization than were heterosexual women (19%). Similarly, comparing sexual abuse victimization occurring in both age periods, lesbian (19%; PR 2.16; 95% CI 1.80, 2.60) and bisexual (20%; PR 2.29; 95% CI 1.76, 2.98) women were more likely to report victimization than were heterosexual women (9%). This study documents prevalent and persistent abuse disproportionately experienced by lesbian and bisexual women.
doi:10.1089/jwh.2007.0450
PMCID: PMC3912575  PMID: 18447763
bisexual; child abuse; lesbian; sexual orientation; victimization
7.  Childhood Victimization, Internalizing Symptoms, and Substance Use Among Women Who Identify as Mostly Heterosexual 
LGBT Health  2016;3(4):266-274.
Abstract
Purpose: The current article examines substance use behavior and associated factors that contribute to risk of substance misuse, such as history of childhood victimization and reports of internalizing symptoms among women from various sexual identity subgroups.
Methods: We recruited a convenience sample of 332 community and university student women (M age = 20.88). Approximately 61.1% of the sample (n = 203) identified as exclusively heterosexual (or “straight”; EH) at the time of the survey, whereas 21.4% (n = 71) identified as primarily heterosexual (or “mostly heterosexual”), 6.6% (n = 22) as bisexual (or “equally gay/lesbian and heterosexual”), 3.0% (n = 10) as primarily gay/lesbian (or “mostly gay/lesbian”) and 7.8% (n = 26) as exclusively gay/lesbian.
Results: Mostly heterosexual women were more likely than EH women to report childhood physical abuse and lifetime tobacco and marijuana use. Mostly heterosexual women also had higher levels of past-year alcohol use disorder symptomology, recent tobacco and marijuana use, and depressive symptoms. Mostly heterosexual women were more likely than bisexual women to have ever tried marijuana, although, among lifetime users, bisexual women reported more frequent recent use.
Conclusion: Mostly heterosexual women reported levels of pathological alcohol use, lifetime rates of tobacco and marijuana use, and recent depressive symptoms that were higher than EH women and relatively similar to lesbian and mostly lesbian women. Bisexual women reported heavier current use of marijuana and were more likely than mostly heterosexual women to report childhood sexual abuse. Implications for mental health services for clients who identify as non-EH are discussed.
doi:10.1089/lgbt.2015.0073
PMCID: PMC4976251  PMID: 27269733
sexuality; sexual minority; substance use; women
8.  Sexual Orientation Disparities in Cardiovascular Biomarkers Among Young Adults 
Background
Emerging evidence from general population studies suggests that lesbian, gay and bisexual (LGB) adults are more likely to experience adverse cardiovascular outcomes relative to heterosexuals. No studies have examined whether sexual orientation disparities exist in biomarkers of early cardiovascular disease risk.
Purpose
To determine whether sexual orientation disparities in biomarkers of early cardiovascular risk are present among young adults.
Methods
Data come from Wave IV (2008–2009) of the National Longitudinal Study for Adolescent Health (N=12,451), a prospective nationally representative study of U.S. adolescents followed into young adulthood (mean age: 28.9 years). A total of 520 respondents identified as lesbian, gay, or bisexual. Biomarkers included C-reactive protein, glycosylated hemoglobin, systolic and diastolic blood pressure, and pulse rate. Analyses were conducted in 2012.
Results
In gender-stratified models adjusted for demographics (age, race/ethnicity); SES (income, education); health behaviors (smoking, regular physical activity, alcohol consumption); and BMI, gay and bisexual men had significant elevations in C-reactive protein, diastolic blood pressure, and pulse rate, compared to heterosexual men. Despite having more risk factors for cardiovascular disease, including smoking, heavy alcohol consumption, and higher BMI, lesbians and bisexual women had lower levels of C-reactive protein than heterosexual women in fully adjusted models.
Conclusions
Evidence was found for sexual orientation disparities in biomarkers of cardiovascular risk among young adults, particularly in gay and bisexual men. These findings, if confirmed in other studies, suggest that disruptions in core physiologic processes that ultimately confer risk for cardiovascular disease may occur early in the life course for sexual minority men.
doi:10.1016/j.amepre.2013.01.027
PMCID: PMC3659331  PMID: 23683979
9.  FROM BIAS TO BISEXUAL HEALTH DISPARITIES: ATTITUDES TOWARD BISEXUAL MEN AND WOMEN IN THE UNITED STATES 
LGBT health  2014;1(4):309-318.
PUROPSE
A newly emergent literature suggest that bisexual men and women face profound health disparities in comparison to both heterosexual and homosexual individuals. Additionally, bisexual individuals often experience prejudice, stigma, and discrimination from both gay/lesbian and straight communities, termed “biphobia.” However, only limited research exists that empirically tests the extent and predictors of this double discrimination. The Bisexualities: Indiana Attitudes Survey (BIAS) was developed to test associations between biphobia and sexual identity.
METHODS
Using standard techniques, we developed and administered a scale to a purposive online sample of adults from a wide range of social networking websites. We conducted exploratory factor analysis to refine scales assessing attitudes toward bisexual men and bisexual women, respectively. Using generalized linear modeling, we assessed relationships between BIAS scores and sexual identity, adjusting for covariates.
RESULTS
Two separately gendered scales were developed, administered, and refined: BIAS-m (n=645), focusing on attitudes toward bisexual men; and BIAS-f (n=631), focusing on attitudes toward bisexual women. Across scales, sexual identity significantly predicted response variance. Lesbian/gay respondents had lower levels of bi-negative attitudes than their heterosexual counterparts (all p-values <.05); bisexual respondents had lower levels of bi-negative attitudes than their straight counterparts (all p-values <.001); and bisexual respondents had lower levels of bi-negative attitudes than their lesbian/gay counterparts (all p-values <.05). Within racial/ethnic minority respondents, biracial/multiracial status was associated with lower bi-negativity scores (all p-values <.05).
CONCLUSION
This study provides important quantitative support for theories related to biphobia and double discrimination. Our findings provide strong evidence for understanding how stereotypes and stigma may lead to dramatic disparities in depression, anxiety, stress, and other health outcomes among bisexual individuals in comparison to their heterosexual and homosexual counterparts. Our results yield valuable data for informing social awareness and intervention efforts that aim to decrease bi-negative attitudes within both straight and gay/lesbian communities, with the ultimate goal of alleviating health disparities among bisexual men and women.
PMCID: PMC4283842  PMID: 25568885
Bisexuality; attitudes; bisexual men; bisexual women; stigma
10.  Sexual Orientation and Functional Pain in U.S. Young Adults: The Mediating Role of Childhood Abuse 
PLoS ONE  2013;8(1):e54702.
Objective
Pain without known pathology, termed “functional pain,” causes much school absenteeism, medication usage, and medical visits. Yet which adolescents are at risk is not well understood. Functional pain has been linked to childhood abuse, and sexual orientation minority youth (gay, lesbian, bisexual, “mostly heterosexual,” and heterosexual with same-sex sexual contact) are more likely to be victims of childhood abuse than heterosexuals, thus may be at greater risk of functional pain.
Methods
We examined sexual orientation differences in past-year prevalence of functional headache, pelvic, and abdominal pain and multiple sites of pain in 9,864 young adults (mean age = 23 years) from a large U.S. cohort. We examined whether childhood abuse accounted for possible increased risk of functional pain in sexual minority youth.
Results
Sexual minority youth, except for gays and lesbians, were at higher risk of functional pelvic and abdominal pain and multiple sites of pain than heterosexuals. Gay and lesbian youth had elevated prevalence only of abdominal pain. Childhood abuse accounted for 14% to 33% of increased experience of multiple sites of pain in minority youth.
Conclusions
Youth who identify as “mostly heterosexual” or bisexual or who identify as heterosexual and have had same-sex partners comprised 18% of our sample. Clinicians should be aware that patients with these orientations are at elevated risk of functional pain and may be in need of treatment for sequelae of childhood abuse. Conventional categorization of sexual orientation as heterosexual or homosexual may fail to distinguish a large number of youth who do not wholly identify with either group and may be at elevated risk of health problems.
doi:10.1371/journal.pone.0054702
PMCID: PMC3552856  PMID: 23355890
11.  Attitudes toward Bisexual Men and Women among a Nationally Representative Probability Sample of Adults in the United States 
PLoS ONE  2016;11(10):e0164430.
As bisexual individuals in the United States (U.S.) face significant health disparities, researchers have posited that these differences may be fueled, at least in part, by negative attitudes, prejudice, stigma, and discrimination toward bisexual individuals from heterosexual and gay/lesbian individuals. Previous studies of individual and social attitudes toward bisexual men and women have been conducted almost exclusively with convenience samples, with limited generalizability to the broader U.S. population. Our study provides an assessment of attitudes toward bisexual men and women among a nationally representative probability sample of heterosexual, gay, lesbian, and other-identified adults in the U.S. Data were collected from the 2015 National Survey of Sexual Health and Behavior (NSSHB), via an online questionnaire with a probability sample of adults (18 years and over) from throughout the U.S. We included two modified 5-item versions of the Bisexualities: Indiana Attitudes Scale (BIAS), validated sub-scales that were developed to measure attitudes toward bisexual men and women. Data were analyzed using descriptive statistics, gamma regression, and paired t-tests. Gender, sexual identity, age, race/ethnicity, income, and educational attainment were all significantly associated with participants' attitudes toward bisexual individuals. In terms of responses to individual scale items, participants were most likely to “neither agree nor disagree” with all attitudinal statements. Across sexual identities, self-identified other participants reported the most positive attitudes, while heterosexual male participants reported the least positive attitudes. As in previous research on convenience samples, we found a wide range of demographic characteristics were related with attitudes toward bisexual individuals in our nationally-representative study of heterosexual, gay/lesbian, and other-identified adults in the U.S. In particular, gender emerged as a significant characteristic; female participants’ attitudes were more positive than male participants’ attitudes, and all participants’ attitudes were generally more positive toward bisexual women than bisexual men. While recent population data suggest a marked shift in more positive attitudes toward gay men and lesbian women in the general population of the U.S., the largest proportions of participants in our study reported a relative lack of agreement or disagreement with all affective-evaluative statements in the BIAS scales. Findings document the relative lack of positive attitudes toward bisexual individuals among the general population of adults in the U.S. and highlight the need for developing intervention approaches to promote more positive attitudes toward bisexual individuals, targeted toward not only heterosexual but also gay/lesbian individuals and communities.
doi:10.1371/journal.pone.0164430
PMCID: PMC5082634  PMID: 27783644
12.  Do shared etiological factors contribute to the relationship between sexual orientation and depression? 
Psychological medicine  2011;42(3):521-532.
Background
Gays, lesbians, and bisexuals (i.e. nonheterosexuals) have been found to be at much greater risk for many psychiatric symptoms and disorders, including depression. This may be due in part to prejudice and discrimination experienced by nonheterosexuals, but studies controlling for minority stress, or performed in very socially liberal countries, suggest that other mechanisms must also play a role. Here we test the viability of common cause (shared genetic or environmental etiology) explanations of elevated depression rates in nonheterosexuals.
Method
A community-based sample of adult twins (N=9884 individuals) completed surveys investigating the genetics of psychiatric disorder, and were also asked about their sexual orientation. Large subsets of the sample were asked about adverse childhood experiences such as sexual abuse, physical abuse, and risky family environment, and also about number of older brothers, paternal and maternal age, and number of close friends. Data were analysed using the classical twin design.
Results
Nonheterosexual males and females had higher rates of lifetime depression than their heterosexual counterparts. Genetic factors accounted for 31% and 44% of variation in sexual orientation and depression, respectively. Bivariate analysis revealed that genetic factors accounted for a majority (60%) of the correlation between sexual orientation and depression. In addition, childhood sexual abuse and risky family environment were significant predictors of both sexual orientation and depression, further contributing to their correlation.
Conclusions
Nonheterosexual men and women had elevated rates of lifetime depression, partly due to shared etiological factors, although causality cannot be definitively resolved.
doi:10.1017/S0033291711001577
PMCID: PMC3594769  PMID: 21867592
sexual orientation; childhood abuse; depression; twins; genetics
13.  Cigarette smoking disparities among sexual minority cancer survivors 
Preventive Medicine Reports  2015;2:283-286.
Objective
Sexual minority (i.e., lesbian, gay, and bisexual) adults smoke cigarettes at higher rates than heterosexual adults. Smoking after receiving a cancer diagnosis is a major health concern, yet risk of continued smoking among sexual minority cancer survivors is as yet unknown. The current study examines current smoking among sexual minority vs. heterosexual adult cancer survivors.
Method
Data drawn from the 2010 Behavioral Risk Factor Surveillance System survey in five states (Alaska, California, Massachusetts, New Mexico, and Wisconsin) included items about sexual orientation, cancer diagnosis, and tobacco use. The analytic sample included 124 sexual minority and 248 propensity score matched heterosexual adult cancer survivors.
Results
Bivariate analysis showed that sexual minority cancer survivors had twice the odds of current smoking as their heterosexual counterparts (OR = 2.03, 95%CI:1.09–3.80). In exploratory analyses stratified by sex, sexual minority disparities in prevalence of smoking post-cancer showed a trend toward significance among females, not males.
Conclusion
The current study offers preliminary evidence that sexual minority status is one variable among many that must be taken into account when assessing health behaviors post-cancer diagnosis. Future research should identify mechanisms leading from sexual minority status to increased rates of smoking and develop tailored smoking cessation interventions.
Highlights
•We examine cigarette smoking in sexual minority vs. heterosexual cancer survivors in the BRFSS.•We use propensity score matching to control for confounding demographic variables.•Rates of continued smoking are higher in sexual minority survivors.•Analyses stratified by sex show disparities at a trend level among sexual minority females, not males.
doi:10.1016/j.pmedr.2015.04.004
PMCID: PMC4430723  PMID: 25984441
Smoking; Neoplasms; Sexuality; Homosexuality; Female; Homosexuality; Male; Minority health
14.  Childhood Abuse and Mental Health Indicators among Ethnically Diverse Lesbian, Gay, and Bisexual Adults 
Objective
Prior research has established that lesbian, gay, and bisexual (LGB) people experience higher rates of childhood abuse compared to heterosexuals. However, there has been little research on the mental health impact of these experiences, or how race/ethnicity might influence prevalence and mental health impact of childhood abuse in this population. The study’s objective was to examine the relationships between race/ethnicity and childhood abuse and their effect on mental health indicators in a national sample of LGB adults.
Method
Participants were recruited via the internet using snowball and targeted sampling methods. 669 LGB adults, 21% of whom were people of color, participated in an online survey. Participants completed the Childhood Trauma Questionnaire-Short Form, the Center for Epidemiologic Studies Depression Scale, the Patient Health Questionnaire Generalized Anxiety Disorder Scale, the PTSD Checklist-Civilian Version, and the Perceived Stress Scale Short-Form.
Results
Latina/o and Asian American participants reported the highest levels of physical abuse (p < .01), and Latina/o and African American participants reported the highest levels of sexual abuse (p < .01). Childhood emotional abuse was the strongest predictor of current psychopathology symptoms for all participants (ps < .01). Relative to White participants, emotional abuse showed a stronger relationship with current PTSD and anxiety symptoms for African American participants (ps < .01), and physical abuse showed a stronger relationship with current PTSD and anxiety symptoms for Latina/o participants (ps < .05).
Conclusions
Findings suggest that race/ethnicity may be an important factor when examining childhood abuse and mental health correlates among LGB populations.
doi:10.1037/a0018661
PMCID: PMC2911995  PMID: 20658803
Sexual orientation; race; child abuse; gay; lesbian
15.  The Social Environment and Suicide Attempts in Lesbian, Gay, and Bisexual Youth 
Pediatrics  2011;127(5):896-903.
OBJECTIVE:
To determine whether the social environment surrounding lesbian, gay, and bisexual youth may contribute to their higher rates of suicide attempts, controlling for individual-level risk factors.
METHODS:
A total of 31 852 11th grade students (1413 [4.4%] lesbian, gay, and bisexual individuals) in Oregon completed the Oregon Healthy Teens survey in 2006–2008. We created a composite index of the social environment in 34 counties, including (1) the proportion of same-sex couples, (2) the proportion of registered Democrats, (3) the presence of gay-straight alliances in schools, and (4) school policies (nondiscrimination and antibullying) that specifically protected lesbian, gay, and bisexual students.
RESULTS:
Lesbian, gay, and bisexual youth were significantly more likely to attempt suicide in the previous 12 months, compared with heterosexuals (21.5% vs 4.2%). Among lesbian, gay, and bisexual youth, the risk of attempting suicide was 20% greater in unsupportive environments compared to supportive environments. A more supportive social environment was significantly associated with fewer suicide attempts, controlling for sociodemographic variables and multiple risk factors for suicide attempts, including depressive symptoms, binge drinking, peer victimization, and physical abuse by an adult (odds ratio: 0.97 [95% confidence interval: 0.96–0.99]).
CONCLUSIONS:
This study documents an association between an objective measure of the social environment and suicide attempts among lesbian, gay, and bisexual youth. The social environment appears to confer risk for suicide attempts over and above individual-level risk factors. These results have important implications for the development of policies and interventions to reduce sexual orientation–related disparities in suicide attempts.
doi:10.1542/peds.2010-3020
PMCID: PMC3081186  PMID: 21502225
suicide attempts; sexual orientation; disparities; social determinants of health
16.  A Meta-Analysis of Disparities in Childhood Sexual Abuse, Parental Physical Abuse, and Peer Victimization Among Sexual Minority and Sexual Nonminority Individuals 
American journal of public health  2011;101(8):1481-1494.
Objectives
We compared the likelihood of childhood (i.e., <18 years) sexual abuse, parental physical abuse, and peer victimization based on sexual orientation.
Methods
We conducted a meta-analysis of adolescent school-based studies that compared the likelihood of childhood abuse among sexual minorities vs sexual nonminorities.
Results
Sexual minority individuals were on average 3.8, 1.2, 1.7, and 2.4 times more likely to experience sexual abuse, parental physical abuse, or assault at school or to miss school through fear, respectively. Moderation analysis showed that disparities between sexual minority and sexual nonminority individuals were larger for (1) males than females for sexual abuse, (2) females than males for assault at school, and (3) bisexual than gay and lesbian for both parental physical abuse and missing school through fear. Disparities did not change between the 1990s and the 2000s.
Conclusions
The higher rates of abuse experienced by sexual minority youths may be one of the driving mechanisms underlying higher rates of mental health problems, substance use, risky sexual behavior, and HIV reported by sexual minority adults.
doi:10.2105/AJPH.2009.190009
PMCID: PMC3134495  PMID: 21680921
17.  The health of people classified as lesbian, gay and bisexual attending family practitioners in London: a controlled study 
BMC Public Health  2006;6:127.
Background
The morbidity of gay, lesbian or bisexual people attending family practice has not been previously assessed. We compared health measures of family practice attendees classified as lesbian, gay and bisexual.
Methods
We conducted a cross-sectional, controlled study conducted in 13 London family practices and compared the responses of 26 lesbian and 85 bisexual classified women, with that of 934 heterosexual classified women and 38 gay and 23 bisexual classified men with that of 373 heterosexual classified men. Our outcomes of interest were: General health questionnaire; CAGE questionnaire; short form12; smoking status; sexual experiences during childhood; number of sexual partners and sexual function and satisfaction.
Results
In comparison to people classified as heterosexuals: men classified as gay reported higher levels of psychological symptoms (OR 2.48, CI 1.05–5.90); women classified as bisexual were more likely to misuse alcohol (OR 2.73, 1.70–4.40); women classified as bisexual (OR 2.53, 1.60–4.00) and lesbian (OR 3.13, 1.41–6.97) and men classified as bisexual (OR 2.48, 1,04, 5.86) were more likely to be smokers and women classified as bisexual (OR 3.27, 1.97–5.43) and men classified as gay (OR 4.86, 2.28–10.34) were much more likely to report childhood sexual experiences in childhood. Psychological distress was associated with reporting sexual experiences in childhood in men classified as gay and bisexual and women classified as heterosexual. Men classified as bisexual (OR 5.00, 1.73–14.51) and women classified as bisexual (OR 2.88, 1.24- 6.56) were more likely than heterosexuals to report more than one sexual partner in the preceding four weeks. Lesbian, gay and bisexual classified people encountered no more sexual function problems than heterosexuals but men classified as bisexual (OR 2.74, 1.12–6.70) were more dissatisfied with their sex lives.
Conclusion
Bisexual and lesbian classified people attending London general practices were more likely to be smokers and gay classified men were at increased risk of psychological distress in comparison to heterosexual classified people. Increased awareness of the sexuality of people seen in primary care can provide opportunities for health promotion.
doi:10.1186/1471-2458-6-127
PMCID: PMC1475848  PMID: 16681849
18.  Endorsement and Timing of Sexual Orientation Developmental Milestones Among Sexual Minority Young Adults in the Growing Up Today Study 
Journal of sex research  2016;54(2):172-185.
This research examined endorsement and timing of sexual orientation developmental milestones. Participants were 1235 females and 398 males from the Growing Up Today Study, ages 22 to 29 years, who endorsed a sexual minority orientation (lesbian/gay, bisexual, mostly heterosexual) or reported same-gender sexual behavior (heterosexual with same-gender sexual experience). An online survey measured current sexual orientation and endorsement and timing (age first experienced) of five sexual orientation developmental milestones: same-gender attractions, other-gender attractions, same-gender sexual experience, other-gender sexual experience, and sexual minority identification. Descriptive analyses and analyses to test for gender and sexual orientation group differences were conducted. Results indicated that females were more likely than males to endorse same-gender attraction, other-gender attraction, and other-gender sexual experience, with the most gender differences in endorsement among mostly heterosexuals and heterosexuals with same-gender sexual experience. In general, males reached milestones earlier than females, with the most gender differences in timing among lesbian and gay individuals and heterosexuals with same-gender sexual experience. Results suggest that the three sexual minority developmental milestones may best characterize the experiences of lesbians, gay males, and female and male bisexuals. More research is needed to understand sexual orientation development among mostly heterosexuals and heterosexuals with same-gender sexual experience.
doi:10.1080/00224499.2016.1170757
PMCID: PMC5607625  PMID: 27148762
sexual minority development; sexual orientation; sexual identity development; developmental milestones
19.  Self-Reported Mental Disorders and Distress by Sexual Orientation 
Introduction
Sexual minority college students (i.e., those not identifying as heterosexual, or those reporting same-sex sexual activity) may be at increased risk of poor mental health, given factors such as minority stress, stigma, and discrimination. Such disparities could have important implications for students’ academic achievement, future health, and social functioning. This study compares reports of mental disorder diagnoses, stressful life events, and frequent mental distress across five gender-stratified sexual orientation categories.
Methods
Data were from the 2007–2011 College Student Health Survey, which surveyed a random sample of college students (N=34,324) at 40 Minnesota institutions. Data analysis was conducted in 2013–2014. The prevalence of mental disorder diagnoses, frequent mental distress, and stressful life events were calculated for heterosexual, discordant heterosexual, gay or lesbian, bisexual, and unsure students. Logistic regression models were fit to estimate the association between sexual orientation and mental health outcomes.
Results
Lesbian, gay, and bisexual students were more likely to report any mental health disorder diagnosis than heterosexual students (p<0.05). Lesbian, gay, bisexual, and unsure students were significantly more likely to report frequent mental distress compared to heterosexual students (OR range, 1.6–2.7). All sexual minority groups, with the exception of unsure men, had significantly greater odds of experiencing two or more stressful life events (OR range, 1.3–2.8).
Conclusions
Sexual minority college students experience worse mental health than their heterosexual peers. These students may benefit from interventions that target the structural and social causes of these disparities, and individual-level interventions that consider their unique life experiences.
doi:10.1016/j.amepre.2015.01.024
PMCID: PMC4476922  PMID: 25997903
20.  Sexual Identity Group Differences in Child Abuse and Neglect 
Journal of interpersonal violence  2013;28(10):2088-2111.
Research suggests that sexual minority women are more likely than heterosexual women to report childhood abuse, but little is known about potential within-group variations in experiences of abuse among sexual minority women. We investigated rates and characteristics of childhood sexual and physical abuse among women from five sexual identity groups. Our analyses used a pooled sample of women from a national probability study and a large community-based study of sexual minority women designed to replicate the national study’s methodology (pooled n = 953). As predicted, heterosexual women reported significantly less childhood abuse than did women who identified as mostly heterosexual, bisexual, mostly lesbian, or lesbian. There was also considerable variability in abuse rates and characteristics, including severity of abuse, among sexual minority subgroups. To the extent that differences in reports reflect the actual prevalence and severity of abuse experiences, sexual identity subgroup differences in childhood abuse have important clinical and public health implications.
doi:10.1177/0886260512471081
PMCID: PMC3717255  PMID: 23345571
childhood sexual abuse; childhood physical abuse; sexual minority women
21.  Sexual orientation differences in the relationship between victimization and hazardous drinking among women in the National Alcohol Survey 
This study examined relationships between past experiences of victimization (sexual abuse and physical abuse in childhood, sexual abuse and physical abuse in adulthood, and lifetime victimization) and hazardous drinking among sexual minority women compared to exclusively heterosexual women. Data were from 11,169 women responding to sexual identity and sexual behavior questions from three National Alcohol Survey waves: 2000 (n=3,880), 2005 (n=3,464) and 2010 (n=3,825). A hazardous drinking index was constructed from five dichotomous variables (5+ drinking in the past year, drinking two or more drinks daily, drinking to intoxication in the past year, two or more lifetime dependence symptoms and two or more lifetime drinking-related negative consequences). Exclusively heterosexual women were compared to three groups of sexual minority women: lesbian, bisexual, and women who identified as heterosexual but reported same-sex partners. Each of the sexual minority groups reported significantly higher rates of lifetime victimization (59.1% lesbians, 76% bisexuals, and 64.4% heterosexual women reporting same-sex partners) than exclusively heterosexual women (42.3 %). Odds for hazardous drinking among sexual minority women were attenuated when measures of victimization were included in the regression models. Sexual minority groups had significantly higher odds of hazardous drinking, even after controlling for demographic and victimization variables: lesbian (ORadj=2.0, CI=1.1–3.9, p<.01; bisexual (ORadj=1.8, CI=1.0–3.3, p<.05; heterosexual with same-sex partners (ORadj=2.7; CI=1.7–4.3, p<.001). Higher rates of victimization likely contribute to, but do not fully explain, higher rates of hazardous drinking among sexual minority women.
doi:10.1037/a0031486
PMCID: PMC3823232  PMID: 23438246
Sexual minority women; hazardous drinking; alcohol consumption; childhood sexual abuse; childhood physical abuse; adult victimization
22.  Sexual Victimization and Hazardous Drinking Among Heterosexual and Sexual Minority Women 
Addictive Behaviors  2010;35(12):1152-1156.
Aims
Although research shows that sexual minority women report high rates of lifetime sexual victimization and high rates of hazardous drinking, investigators have yet to explore the relationships between sexual victimization and hazardous drinking in this population. In addition, because rates of these problems may vary within the sexual minority population, we examined and compared relationships between sexual victimization and hazardous drinking in exclusively heterosexual and sexual minority (mostly heterosexual, bisexual, mostly lesbian and exclusively lesbian) women.
Method
Data from 548 participants in the National Study of Health and Life Experiences of Women and 405 participants in the Chicago Health and Life Experiences of Women study were pooled to address these relationships. We compared hazardous drinking, childhood sexual abuse (CSA), adult sexual assault (ASA), and revictimization (both CSA and ASA) across the five sexual identity subgroups. We then fit a multilevel general linear model to examine group differences in the relationships between hazardous drinking and sexual victimization and to test for potential interactions between victimization and identity on hazardous drinking.
Results
Sexual minority women reported higher levels of hazardous drinking and higher rates of CSA and sexual revictimization than did exclusively heterosexual women. Revictimization was the strongest predictor of hazardous drinking among women who identified as mostly heterosexual and mostly lesbian.
Conclusions
This study extends previous research by examining associations between sexual victimization and hazardous drinking in heterosexual and sexual minority women and by exploring within-group variations in these associations among sexual minority women. Higher rates of lifetime sexual victimization and revictimization may help to explain sexual minority women’s heightened risk for hazardous drinking. The findings highlight the need for additional research that examines the meanings of sexual identity labels to more fully understand differences in risk within groups of sexual minority women as well as how sexual identity may affect responses to and interpretations of sexual victimization.
doi:10.1016/j.addbeh.2010.07.004
PMCID: PMC3006188  PMID: 20692771
Adult Sexual Assault; Childhood Sexual Abuse; Hazardous Drinking; Revictimization; Sexual Orientation
23.  Health Disparities Among Sexual Minority Women Veterans 
Journal of Women's Health  2013;22(7):631-636.
Abstract
Background
Lesbian and bisexual (i.e., sexual minority) identity is more common among women veterans than among male veterans. Unique health issues have been identified among women veterans and among sexual minority women, but little is known about women who are both sexual minorities and veterans. This study aimed to compare demographic and health information from sexual minority women veterans with sexual minority women non-veterans and heterosexual women veterans.
Methods
Behavioral Risk Factor Surveillance Survey data were pooled from ten U.S. states that elected to ask sexual identity during 2010. The analytic sample was comprised of women who identified both their sexual identity and veteran status (n=1,908). Mental health indicators were frequent mental distress, sleep problems, low social/emotional support, and low satisfaction with life. Health risk indicators included current smoking, overweight, and obesity. Physical health status was defined by three components: disability requiring assistive equipment, >14 days of poor physical health in the past 30 days, and activity limitations.
Results
Compared with heterosexual women veterans, sexual minority women veterans had higher odds of mental distress (odds ratio [OR]=3.03, 95% confidence interval [CI]: 1.61–5.70) and smoking (OR=2.31, 95%CI: 1.19–4.48). After adjusting for demographic correlates, sexual minority women veterans had three times the odds of poor physical health (OR=3.01, 95%CI: 1.51–5.99) than their sexual minority non-veteran peers.
Conclusions
Results suggest sexual minority women veterans may experience unique health disparities relevant to provision of care in both Veterans Affairs (VA) and non-VA healthcare systems. Future research requires availability of data that include sexual minority status.
doi:10.1089/jwh.2012.4214
PMCID: PMC3761433  PMID: 23746281
24.  Sexual Orientation Trends and Disparities in School Bullying and Violence-Related Experiences, 1999–2013 
Numerous recent studies have demonstrated that schools are often unsafe for lesbian, gay, and bisexual (LGB) adolescents, who are more likely than heterosexual peers to be bullied, harassed, or victimized in school contexts. Virtually all of these studies call for change, yet none investigate whether or not it has occurred.
Using repeated waves of a population-based high school survey, we examine (1) the extent to which sexual orientation differences in school bullying and violence-related experiences are reported by lesbian/gay, bisexual, and heterosexual male and female adolescents; (2) trends in school bullying and violence-related experiences for each gender/orientation group, and (3) whether disparities have changed over time.
Data were drawn from eight Massachusetts biennial Youth Risk Behavior Surveys from 1999 to 2013, grouped into 4 waves totaling 24,845 self-identified heterosexual, 270 lesbian/gay, and 857 bisexual youth. Disparities between LGB and heterosexual peers were found in all indicators. Heterosexual youth and gay males saw significant reductions in every outcome between the first and last waves. Among bisexual males, skipping school due to feeling unsafe, carrying weapons in school, and being bullied all decreased, but among lesbians and bisexual females only fighting in school declined significantly. Improvement trends in school safety were more consistent for heterosexual youth and gay males than for bisexual or lesbian females. Notably, despite these improvements, almost no reduction was seen in sexual orientation disparities. Future research should identify influences leading to reduced school victimization, especially focusing on ways of eliminating persistent sexual orientation disparities.
Future research should identify influences leading to reduced school victimization, especially focusing on ways of eliminating persistent sexual orientation disparities.
doi:10.1037/sgd0000188
PMCID: PMC5758340  CAMSID: cams6912
25.  Mental health and substance use disorders among Latino and Asian American lesbian, gay, and bisexual adults 
Growing evidence suggests that lesbian, gay, and bisexual adults may be at elevated risk for mental health and substance use disorders, possibly due to anti-gay stigma. Little of this work has examined putative excess morbidity among ethnic/racial minorities resulting from the experience of multiple sources of discrimination. We report findings from the National Latino and Asian American Survey (NLAAS), a national household probability psychiatric survey of 4,488 Latino and Asian American adults. Approximately 4.8% of persons interviewed identified as lesbian, gay, bisexual, and/or reported recent same-gender sexual experiences. Although few sexual orientation-related differences were observed, among men, gay/bisexual men were more likely than heterosexual men to report a recent suicide attempt. Among women, lesbian/bisexual women were more likely than heterosexual women to evidence positive 1-year and lifetime histories of depressive disorders. These findings suggest a small elevation in psychiatric morbidity risk among Latino and Asian American individuals with a minority sexual orientation. However, the level of morbidity among sexual orientation minorities in the NLAAS appears similar to or lower than that observed in population-based studies of lesbian, gay, and bisexual adults.
doi:10.1037/0022-006X.75.5.785
PMCID: PMC2676845  PMID: 17907860
gay; lesbian; bisexual; Latino; Asian-American; psychiatric epidemiology

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