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1.  Physical health indicators among lesbian, gay, and bisexual U.S. Veterans 
Annals of epidemiology  2013;23(7):448-451.
To provide information about lesbian, gay and bisexual (LGB) veterans’ health status, diagnoses, and health screening behaviors compared with heterosexual veterans.
Data are from ten states’ 2010 Behavioral Risk Factor Surveillance System (BRFSS) surveys that contained sexual orientation data for veterans (n=11,665). Chi-square tests and multiple logistic regression were used to examine outcomes among LGB and heterosexual veterans.
More LGB veterans than heterosexual veterans reported current smoking, not seeking medical care due to cost, and activity limitations. Compared with heterosexual veterans, LGB veterans had greater odds of ever having an HIV test (OR=5.42; 95%CI: 3.28–8.96) but lower odds of diabetes diagnosis (0.55 (0.34–0.89).
Findings from this sample suggest patterns of health behaviors and outcomes among LGB veterans that are both unique from and similar to results from general samples of LGB persons. With the formal end of the “Don’t Ask, Don’t Tell” policy that discriminated against LGB people in the military, institutions such as the Department of Veterans Affairs (VA) are likely to see an increase in its current population of LGB veterans. The VA stands in a unique place to meet the health equity needs of this minority population.
PMCID: PMC3698572  PMID: 23688720
2.  Adverse Childhood Experiences and Adult Health Outcomes Among Veteran and Non-Veteran Women 
Journal of Women's Health  2015;24(9):723-729.
Background: Women veterans represent a vulnerable population with unique health needs and disparities in access to care. One constellation of exposures related to subsequent poor health includes adverse childhood experiences (ACEs; e.g., physical and sexual child abuse), though research on impacts of ACEs among women veterans is limited.
Methods: Data were drawn from the 2010 Behavioral Risk Factor Surveillance System for the 11 states that included the ACE module (n=36,485). Weighted chi-squared tests and multivariable logistic regression were used to assess the prevalence of ACEs among women veterans compared with women non-veterans and differences in the following outcomes, controlling for ACEs: social support, inadequate sleep, life satisfaction, mental distress, smoking, heavy alcohol use, obesity, diabetes, cardiovascular disease symptoms, asthma, and disability.
Results: Women veterans (1.6% of the total sample) reported a higher prevalence of 7 out of 11 childhood adversities and higher mean ACE score than women non-veterans. Women veterans were more likely to be current smokers and report a disability, associations which were attenuated when controlling for ACE.
Conclusions: Despite women veterans' higher prevalence of ACE, their health outcomes did not differ substantially from non-veterans. Further research is needed to understand the intersections of traumatic experiences and sources of resilience over the lifecourse among women veterans.
PMCID: PMC4589327  PMID: 26390379
3.  Sexual Victimization, Health Status, and VA Healthcare Utilization Among Lesbian and Bisexual OEF/OIF Veterans 
Journal of General Internal Medicine  2013;28(Suppl 2):604-608.
Many lesbian and bisexual (LB) women veterans may have been targets of victimization in the military based on their gender and presumed sexual orientation, and yet little is known regarding the health or mental health of LB veterans, nor the degree to which they feel comfortable receiving care in the VA.
The purpose of this study was to examine the prevalence of mental health and gender-specific conditions, VA healthcare satisfaction and trauma exposure among LB veterans receiving VA care compared with heterosexually-identified women veterans receiving.
Prospective cohort study of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) women veterans at two large VA facilities.
Three hundred and sixty five women veterans that completed a baseline survey. Thirty-five veterans (9.6 %) identified as gay or lesbian (4.7 %), or bisexual (4.9 %).
Main Measures
Measures included sexual orientation, military sexual trauma, mental and gender-specific health diagnoses, and VA healthcare utilization and satisfaction.
Key Results
LB OEF/OIF veterans were significantly more likely to have experienced both military and childhood sexual trauma than heterosexual women (MST: 31 % vs. 13 %, p < .001; childhood sexual trauma: 60 % vs. 36 %, p = .01), to be hazardous drinkers (32 % vs. 16 %, p = .03) and rate their current mental health as worse than before deployment (35 % vs. 16 %, p < .001).
Many LB veterans have experienced sexual victimization, both within the military and as children, and struggle with substance abuse and poor mental health. Health care providers working with female Veterans should be aware of high rates of military sexual trauma and childhood abuse and refer women to appropriate VA treatment and support groups for sequelae of these experiences. Future research should focus on expanding this study to include a larger and more diverse sample of lesbian, gay, bisexual, and transgender veterans receiving care at VA facilities across the country.
PMCID: PMC3695265  PMID: 23807072
lesbian; health services research; Veterans; women
4.  Health Care Utilization and Health Indicators Among a National Sample of U.S. Veterans in Same-Sex Partnerships 
Military medicine  2013;178(2):207-212.
To examine health indicators of same-sex partnered veterans as compared with their opposite-sex partnered veteran and nonveteran peers.
Same-sex partner status was derived by self-reported same-sex partnerships in data from the 2004 Behavioral Risk Factor Surveillance System. Outcome variables included health risk disparities associated with sexual minority status (e.g., frequent mental distress) and veteran status (e.g., firearm ownership). Stratified multiple logistic regression models were used to examine the association of same-sex partnered veteran status with health indicators.
Same-sex partnered veterans had higher odds of being overweight and keeping firearms in the house compared with same-sex partnered nonveterans. Same-sex partnered veterans were less likely than opposite-sex partnered veterans to be overweight, and they were more than twice as likely to be current smokers when compared with opposite-sex partnered nonveterans.
Findings suggest both that some health disparities patterns identified by same-sex partnership status among the general population also exist among veteran populations, and that some unique distinctions may exist, particularly related to BMI and firearm ownership. Collection of information about sexual minority status within Department of Veterans Affairs data sources is needed to more accurately assess the health of this minority population.
PMCID: PMC3725588  PMID: 23495467
5.  Experiences with VHA care: a qualitative study of U.S. women veterans with self-reported trauma histories 
BMC Women's Health  2017;17:38.
Women veterans in the United States, particularly those with posttraumatic stress disorder (PTSD) or a history of military sexual assault, have unique health care needs, but their minority status in the US Veterans Health Administration (VHA) has led to documented healthcare disparities when compared to men. This study’s objective was to obtain a richer understanding of the challenges and successes encountered by women veterans with self-reported service-related trauma histories (particularly those with a history of military sexual assault and/or posttraumatic stress symptomology) receiving VHA care.
Thirty-seven female Vietnam and post-Vietnam (1975–1998) era veterans were randomly selected from a cohort of PTSD disability benefit applicants to complete semi-structured interviews in 2011–2012. Grounded-theory informed procedures were used to identify interview themes; differences between veterans with and without a history of military sexual assault were examined through constant comparison.
At the time of the interviews, many women believed that VHA was falling short of meeting women veterans’ needs (e.g., lack of women-only mental health programming). Also common, but particularly among those with a military sexual assault history, was the perception that VHA’s environment was unwelcoming; being “surrounded by men” yielded emotions ranging from discomfort and mistrust to severe anxiety. A few veterans reported recent positive changes and offered additional suggestions for improvement.
Findings suggest that while at the time of the interviews gains had been made in the delivery of gender-sensitive outpatient medical care, women veterans with a history of military sexual assault and/or posttraumatic stress symptomology perceived that they were not receiving the same quality of care as male veterans.
PMCID: PMC5450063  PMID: 28558740
Women; Veterans; Qualitative research; Patient satisfaction; Posttraumatic stress disorder; Military sexual assault
6.  Older Age Associated with Mental Health Resiliency in Sexual Minority US Veterans 
Objectives were to: (a) identify the mental health needs of older and younger sexual minority and heterosexual US veterans and (b) examine whether sexual minority status confers vulnerability or resiliency in older adulthood. Support and trauma exposure were examined as potential mechanisms for age by sexual orientation differences.
Participants were a nationally representative sample of 3,095 US veterans (ages 21 to 96 years). Measures included demographics, military characteristics, sexual orientation (lesbian, gay, or bisexual; LGB), social support, trauma, and mental health indicators (lifetime and present depression and posttraumatic stress disorder (PTSD); lifetime anxiety and suicidal ideation).
Younger LGB veterans were most likely to report lifetime depression and/or PTSD and current depression compared to older LGB and younger and older heterosexual veterans. Older LGB veterans had low levels of mental health problems, but they reported the smallest social support networks.
Older and younger LGB veterans have different mental health challenges. Younger LGB veterans are more vulnerable to mental health problems than their older LGB peers. Older LGB veterans are resilient, but they may be at greater risk of social isolation than their younger LGB peers.
PMCID: PMC5291307  PMID: 27769835
sexual minority status; veterans; mental health; aging
7.  Mental health, sexual identity, and interpersonal violence: Findings from the Australian longitudinal Women’s health study 
BMC Women's Health  2017;17:94.
We examined the relationships among experiences of interpersonal violence, mental health, and sexual identity in a national sample of young adult women in Australia.
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.
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.
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.
PMCID: PMC5622594  PMID: 28964264
Interpersonal violence; Female sexual identity; Stress; Depression; Australian longitudinal Women’s health study
8.  Racial/ethnic differences in contraceptive preferences, beliefs, and self-efficacy among women veterans 
American journal of obstetrics and gynecology  2017;216(5):504.e1-504.e10.
Significant racial/ethnic disparities in unintended pregnancy persist in the United States, with the highest rates observed among low-income black and Hispanic women. Differences in contraceptive preferences, beliefs, and self-efficacy may be instrumental in understanding contraceptive behaviors that underlie higher rates of unintended pregnancy among racial/ethnic minorities.
Our objective was to understand how contraceptive preferences, beliefs, and self-efficacy vary by race and ethnicity among women veterans.
We analyzed data from the Examining Contraceptive Use and Unmet Need Study, a national telephone survey of women veterans aged 18–44 years who had received primary care at the Veterans Administration in the prior 12 months. Participants rated the importance of various contraceptive characteristics and described their level of agreement with contraceptive beliefs using Likert scales. Contraceptive self-efficacy was assessed by asking participants to rate their certainty that they could use contraception consistently and as indicated over time using a Likert scale. Multivariable logistic regression was used to examine associations between race/ethnicity and contraceptive attitudes, controlling for age, marital status, education, income, religion, parity, deployment history, and history of medical and mental health conditions.
Among the 2302 women veterans who completed a survey, 52% were non-Hispanic white, 29% were non-Hispanic black, and 12% were Hispanic. In adjusted analyses, compared with whites, blacks had lower odds of considering contraceptive effectiveness extremely important (adjusted odds ratio; 0.55, 95% confidence interval, 0.40–0.74) and higher odds of considering the categories of does not contain any hormones and prevents sexually transmitted infections extremely important (adjusted odds ratio, 1.94, 95% confidence interval, 1.56–2.41, and adjusted odds ratio; 1.99, 95% confidence interval, 1.57–2.51, respectively). Hispanics also had higher odds than whites of considering the category of does not contain any hormones and prevents sexually transmitted infections extremely important (adjusted odds ratio, 1.72, 95% confidence interval, 1.29–2.28, and adjusted odds ratio, 1.63; 95% confidence interval, 1.21–2.19, respectively). Compared with whites, blacks and Hispanics had higher odds of expressing fatalistic beliefs about pregnancy (adjusted odds ratio, 1.79, 95% confidence interval, 1.35–2.39, and adjusted odds ratio, 1.48, 95% confidence interval, 1.01–2.17, respectively); higher odds of viewing contraception as primarily a woman’s responsibility (adjusted odds ratio, 1.92, 95% confidence interval, 1.45–2.55, and adjusted odds ratio, 1.77; 95% confidence interval, 1.23–2.54, respectively); and lower odds of being very sure that they could use a contraceptive method as indicated over the course of a year (adjusted odds ratio, 0.73, 95% confidence interval, 0.54–0.98, and adjusted odds ratio, 0.66, 95% confidence interval, 0.46–0.96, respectively).
Women veterans’ contraceptive preferences, beliefs, and self-efficacy varied by race/ethnicity, which may help explain observed racial/ethnic disparities in contraceptive use and unintended pregnancy. These differences underscore the need to elicit women’s individual values and preferences when providing patient-centered contraceptive counseling.
PMCID: PMC5502093  PMID: 28063910
attitudes; beliefs; contraception; fatalism; health equity; preferences; racial disparities; self-efficacy; unintended pregnancy; veteran health; women veterans
9.  Sexual and Behavioral Health Disparities Among Sexual Minority Hispanics/Latinos: Findings From the National Health and Nutrition Examination Survey, 2001–2014 
Hispanics/Latinos (henceforth, Latinos) are the largest minority group in the U.S. With growing health disparities among this group, the highest burden remains among sexual and gender minority Latinos. Differences regarding sexual orientation have not been fully explored within this group using national representative samples. This study analyzed sexual and behavioral health disparities associated with sexual minority status among Latinos in the U.S.
The study included data from 5,598 Latino adults who participated in the 2001–2014 waves of the National Health and Nutrition Examination Survey. Data analysis was conducted in 2016. Bivariate and multivariable logistic regression analyses examined the prevalence of HIV, sexually transmitted infections, mental health problems, cigarette smoking, and alcohol/illicit drug use among sexual minorities and heterosexual Latino adults. Sexual minorities were defined as “gay, lesbian, and bisexual” (GLB) and “other” non-heterosexual groups.
GLB Latinos reported higher prevalence of mental health problems and cigarette smoking compared with heterosexuals. After adjusting for covariates, GLB Latinos had greater odds of testing positive for HIV, lifetime diagnosis of sexually transmitted infections, poor mental health outcomes, cigarette smoking (including lifetime and current smoking status), and illicit drug use than heterosexuals.
The disproportionate impact of health disparities among Latinos varies significantly by sexual orientation, with GLB individuals facing elevated prevalence. In particular, elevated odds for HIV/sexually transmitted infections, mental health problems, smoking, and illicit substance use were found. Further research, including longitudinal studies to understand the trajectories of risks, is needed to identify intervention opportunities in this population.
PMCID: PMC5567737  PMID: 28284748
10.  Military Sexual Trauma Among Homeless Veterans 
Journal of General Internal Medicine  2013;28(Suppl 2):536-541.
Military sexual trauma (MST) is the Veteran Health Administration’s (VHA) term for sexual assault and/or sexual harassment that occurs during military service. The experience of MST is associated with a variety of mental health conditions. Preliminary research suggests that MST may be associated with homelessness among female Veterans, although to date MST has not been examined in a national study of both female and male homeless Veterans.
To estimate the prevalence of MST, examine the association between MST and mental health conditions, and describe mental health utilization among homeless women and men.
National, cross-sectional study of 126,598 homeless Veterans who used VHA outpatient care in fiscal year 2010.
All variables were obtained from VHA administrative databases, including MST screening status, ICD-9-CM codes to determine mental health diagnoses, and VHA utilization.
Of homeless Veterans in VHA, 39.7 % of females and 3.3 % of males experienced MST. Homeless Veterans who experienced MST demonstrated a significantly higher likelihood of almost all mental health conditions examined as compared to other homeless women and men, including depression, posttraumatic stress disorder, other anxiety disorders, substance use disorders, bipolar disorders, personality disorders, suicide, and, among men only, schizophrenia and psychotic disorders. Nearly all homeless Veterans had at least one mental health visit and Veterans who experienced MST utilized significantly more mental health visits compared to Veterans who did not experience MST.
A substantial proportion of homeless Veterans using VHA services have experienced MST, and those who experienced MST had increased odds of mental health diagnoses. Homeless Veterans who had experienced MST had higher intensity of mental health care utilization and high rates of MST-related mental health care. This study highlights the importance of trauma-informed care among homeless Veterans and the success of VHA homeless programs in providing mental health care to homeless Veterans.
PMCID: PMC3695264  PMID: 23807062
Veterans; homelessness; sexual assault; mental health
11.  Cigarette smoking disparities among sexual minority cancer survivors 
Preventive Medicine Reports  2015;2:283-286.
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.
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.
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.
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.
•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.
PMCID: PMC4430723  PMID: 25984441
Smoking; Neoplasms; Sexuality; Homosexuality; Female; Homosexuality; Male; Minority health
12.  Discrimination, Mental Health, and Substance Use Disorders Among Sexual Minority Populations 
LGBT Health  2016;3(4):258-265.
Purpose: Sexual minority (lesbian, gay, bisexual) populations have a higher prevalence of mental health and substance use disorders compared to their heterosexual counterparts. Such disparities have been attributed, in part, to minority stressors, including distal stressors such as discrimination. However, few studies have examined associations between discrimination, mental health, and substance use disorders by gender among sexual minority populations.
Methods: We analyzed data from 577 adult men and women who self-identified as lesbian, gay, or bisexual and participated in Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Six questions assessed discrimination due to sexual orientation. Weighted multivariable logistic regression examined associations between experiences of sexual orientation discrimination and both mental health and substance use disorders. Analyses were conducted separately for sexual minority men and women, adjusting for sociodemographic covariates.
Results: Sexual minority men who ever experienced discrimination (57.4%) reported higher odds of any lifetime drug use disorder and cannabis use disorder compared to sexual minority men who never experienced discrimination. Sexual minority women who ever experienced discrimination (42.9%) reported higher odds of any lifetime mood disorder and any lifetime anxiety disorder compared to sexual minority women who never experienced discrimination.
Conclusion: The findings suggest that discrimination is differentially associated with internalizing (mental health) and externalizing (substance use) disorders for sexual minority men and women. These findings indicate a need to consider how homophobia and heteronormative discrimination may contribute to distinct health outcomes for lesbian and bisexual women compared with gay and bisexual men.
PMCID: PMC4976222  PMID: 27383512
discrimination; gender; mental health; sexual minorities; substance use
13.  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.
PMCID: PMC3823232  PMID: 23438246
Sexual minority women; hazardous drinking; alcohol consumption; childhood sexual abuse; childhood physical abuse; adult victimization
14.  Sexual orientation identity disparities in health behaviors, outcomes, and services use among men and women in the United States: a cross-sectional study 
BMC Public Health  2016;16:807.
Research shows that sexual minorities (e.g., lesbian, gay, and bisexual individuals) experience higher levels of discrimination, stigma, and stress and are at higher risk of some poor health outcomes and health behaviors compared to their heterosexual counterparts. However, the majority of studies have examined sexual orientation disparities in a narrow range of health outcomes and behaviors using convenience samples comprised of either men or women living in restricted geographic areas.
To investigate the relationship between sexual orientation identity and health among U.S. women and men, we used Poisson regression with robust variance to estimate prevalence ratios for health behaviors, outcomes, and services use comparing sexual minorities to heterosexual individuals using 2013 and 2014 National Health Interview Survey data (N = 69,270).
Three percent of the sample identified as sexual minorities. Compared to heterosexual women, lesbian (prevalence ratio (PR) = 1.65 [95 % confidence interval (CI): 1.14, 2.37]) and bisexual (PR = 2.16 [1.46, 3.18]) women were more likely to report heavy drinking. Lesbians had a higher prevalence of obesity (PR = 1.20 [1.02, 1.42]), stroke (PR = 1.96 [1.14, 3.39]), and functional limitation (PR = 1.17 [1.02, 1.34] than heterosexual women. Gay men were more likely to have hypertension (PR = 1.21 [1.03, 1.43]) and heart disease (PR = 1.39 [1.02, 1.88]). Despite no difference in health insurance status, sexual minorities were more likely than heterosexual individuals to delay seeking healthcare because of cost; however, members of this group were also  more likely to have received an HIV test and initiated HPV vaccination.
Sexual minorities had a higher prevalence of some poor health behaviors and outcomes.
PMCID: PMC4989521  PMID: 27534616
Sexual orientation; Health behaviors; Health outcomes; United States
15.  Health Risk Behaviors of Afghanistan and Iraq War Veterans Attending College 
The population military veterans attending college is rapidly growing as veterans return from Operations Enduring Freedom and Iraqi Freedom (OEF/OIF). We sought to describe patterns of student veterans’ health-related behaviors and how they might differ from their non-veteran peers.
We analyzed data from the 2008 Boynton College Student Health Survey (CSHS).
CSHS participants completed an anonymous online survey.
The CSHS sampled students (n=8,651) attending public, private, two-, and four-year postsecondary educational institutions in Minnesota.
The CSHS included items on substance use (including alcohol and tobacco), safety, nutrition, and physical activity.
We described demographics of OEF/OIF veteran, non-OEF/OIF veteran, and non-veteran students and used poisson regression to compute adjusted relative risks (ARR) with 95% confidence intervals to characterize associations between veteran status and health behaviors.
After controlling for demographics, veteran students reported more safety-, tobacco-, and alcohol-related risk behaviors compared to non-veteran students. For instance, compared to the non-veteran reference group, the ARR for past year smokeless tobacco use and physical fighting among for OEF/OIF veterans was 1.76 [CI: 1.31–2.35] and 1.48 [CI: 1.22–1.79] respectively. Veteran and non-veteran students display similar weight-related behaviors, though OEF/OIF veteran students were more likely to engage in strengthening exercises.
There are specific health risk behaviors which are particularly relevant for veterans attending postsecondary institutions. As veterans enroll in postsecondary education there is a unique window of opportunity for health promotion in this population.
PMCID: PMC3579508  PMID: 22040391
Veterans; Young Adult; Tobacco; Substance Abuse; Obesity; Safety
16.  Hispanic Lesbians and Bisexual Women at Heightened Risk or Health Disparities 
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.
We analyzed population-based data from the Washington State Behavioral Risk Factor Surveillance System (2003–2009) using adjusted logistic regressions.
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.
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.
PMCID: PMC3490549  PMID: 22095348
17.  Self-Reported Mental Disorders and Distress by Sexual Orientation 
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.
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.
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).
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.
PMCID: PMC4476922  PMID: 25997903
18.  Sexual Victimization and Hazardous Drinking Among Heterosexual and Sexual Minority Women 
Addictive Behaviors  2010;35(12):1152-1156.
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.
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.
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.
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.
PMCID: PMC3006188  PMID: 20692771
Adult Sexual Assault; Childhood Sexual Abuse; Hazardous Drinking; Revictimization; Sexual Orientation
19.  Research on PTSD prevalence in OEF/OIF Veterans: expanding investigation of demographic variables 
European Journal of Psychotraumatology  2015;6:10.3402/ejpt.v6.27322.
A series of recent articles has reported on well-designed studies examining base rates of posttraumatic stress disorder (PTSD) screenings within the Operation Enduring Freedom (Afghanistan conflict)/Operation Iraqi Freedom (Iraq conflict) (OEF/OIF) military population. Although these studies have a number of strengths, this line of research points out several key areas in need of further examination.
Many OEF/OIF Veterans do not use available Veterans Affairs (VA) services, especially mental health care. This highlights the need to understand the differences between those who use and do not use the VA, especially as research with pre-OEF/OIF Veterans suggests that these two groups differ in significant ways. The high rates of PTSD-related concerns in non-VA users also points to a need to understand whether—and where—Veterans are seeking care outside the VA and the accessibility of evidence-based, trauma-focused treatments in the community and private sectors. Careful examination of relationship status is also paramount as little research has examined relationship status or other relationship context issues. Social support, especially from a spouse, can buffer the development of PTSD; however, relationship discord has the potential to greatly exacerbate PTSD symptomatology. Furthermore, given the additional risk factors for sexual minority Veterans to be exposed to trauma, the 2011 repeal of the US Military “Don't Ask, Don't Tell” policy, and the emergence of the VA as likely the largest health care provider for sexual minority Veterans, it will be critically important to study the trauma and mental health experiences of this group.
Studies that examine prevalence rates of PTSD in the returning cohort contribute significantly to our understanding of the US OEF/OIF military population. Further study of PTSD in relation to demographic variables such as VA and non-VA use, relationship status, and sexual orientation will provide rich data that will enhance our ability to develop policy and practice to provide the best care to this population.
PMCID: PMC4430556  PMID: 25971312
PTSD; military Veteran; OEF/OIF; prevalence rates; demographics; VA service use; marital status; relationships; Don't Ask, Don't Tell; LGBT
20.  Mental and Physical Health among Homeless Sexual and Gender Minorities in a Major Urban US City 
Sexual and gender minorities have been shown to have greater rates of mental health, substance use disorders, and specific types of health problems compared to heterosexuals. Among the homeless population in several US urban areas, sexual and gender minorities are overrepresented but few studies have examined the mental and physical health status of homeless sexual and gender minorities, with studies on homeless gender minorities being particularly hard to find. Using survey data obtained from the city and county of San Francisco (2015 Homeless Survey), this study examined differences in causes of homelessness, physical and mental health problems, and domestic violence among homeless sexual and gender minorities and their heterosexual and cisgender (i.e., non-transgender) counterparts, respectively. Lesbians and bisexual women, and gay and bisexual men did not differ from their cisgender heterosexual counterparts. Cisgender men who identified as queer or “other” in response to sexual orientation questions had higher rates of psychiatric problems and posttraumatic stress disorder, while cisgender women who identified as queer or “other” had higher rates of psychiatric problems and drug and alcohol use. Transgender men who were homeless were found to be particularly at risk for physical health problems, mental health problems, and domestic violence or abuse. Transgender women were more likely to report posttraumatic stress disorder. This study suggests that transgender men and cisgender sexual minority men and women who identify as queer or “other” are groups among the homeless that may benefit from increased outreach and services.
PMCID: PMC5126021  PMID: 27699581
Sexual minority; Gender minority; Homelessness; Mental health; Physical health; Substance use
21.  Tobacco Product Use Among Sexual Minority Adults 
A growing body of evidence reveals higher rates of tobacco use among sexual minority populations relative to non-minority (“straight”) populations. This study seeks to more fully characterize this disparity by examining tobacco use by distinct sexual identities and gender to better understand patterns of: (1) cigarette smoking and smoking history; and (2) use of other tobacco products including cigars, pipes, hookah, e-cigarettes, and smokeless tobacco.
Data from the 2012–2013 National Adult Tobacco Survey, a random-digit dialed landline and cellular telephone survey of U.S. adults aged ≥18 years, were analyzed in 2014. A sexual minority category was created by combining gay, lesbian, and bisexual responses, along with those who selected an option for other non-heterosexual identities.
Smoking prevalence was higher among sexual minority adults (27.4%) than straight adults (17.3%). Cigarette smoking was particularly high among bisexual women (36.0%). Sexual minority women started smoking and transitioned to daily smoking earlier than their straight peers. Use of other tobacco products was higher among sexual minority women: prevalence of e-cigarette (12.4%), hookah (10.3%), and cigar use (7.2%) was more than triple that of their straight female peers (3.4%, 2.5%, and 1.3%, respectively). Likewise, prevalence of sexual minority men’s e-cigarette (7.9%) and hookah (12.8%) use exceeded that of straight men (4.7% and 4.5%, respectively).
Tobacco use is significantly higher among sexual minority than straight adults, particularly among sexual minority women. These findings underscore the importance of tobacco control efforts designed to reach sexual minorities and highlight the heterogeneity of tobacco use within this population.
PMCID: PMC4803352  PMID: 26526162
22.  Disparities in Adverse Childhood Experiences among Sexual Minority and Heterosexual Adults: Results from a Multi-State Probability-Based Sample 
PLoS ONE  2013;8(1):e54691.
Adverse childhood experiences (e.g., physical, sexual and emotional abuse, neglect, exposure to domestic violence, parental discord, familial mental illness, incarceration and substance abuse) constitute a major public health problem in the United States. The Adverse Childhood Experiences (ACE) scale is a standardized measure that captures multiple developmental risk factors beyond sexual, physical and emotional abuse. Lesbian, gay, and bisexual (i.e., sexual minority) individuals may experience disproportionately higher prevalence of adverse childhood experiences.
To examine, using the ACE scale, prevalence of childhood physical, emotional, and sexual abuse and childhood household dysfunction among sexual minority and heterosexual adults.
Analyses were conducted using a probability-based sample of data pooled from three U.S. states’ Behavioral Risk Factor Surveillance System (BRFSS) surveys (Maine, Washington, Wisconsin) that administered the ACE scale and collected information on sexual identity (n = 22,071).
Compared with heterosexual respondents, gay/lesbian and bisexual individuals experienced increased odds of six of eight and seven of eight adverse childhood experiences, respectively. Sexual minority persons had higher rates of adverse childhood experiences (IRR = 1.66 gay/lesbian; 1.58 bisexual) compared to their heterosexual peers.
Sexual minority individuals have increased exposure to multiple developmental risk factors beyond physical, sexual and emotional abuse. We recommend the use of the Adverse Childhood Experiences scale in future research examining health disparities among this minority population.
PMCID: PMC3553068  PMID: 23372755
23.  Longitudinal Cognitive Trajectories of Women Veterans from the Women’s Health Initiative Memory Study 
The Gerontologist  2015;56(1):115-125.
Purpose of the Study:
A comparison of longitudinal global cognitive functioning in women Veteran and non-Veteran participants in the Women’s Health Initiative (WHI).
Design and Methods:
We studied 7,330 women aged 65–79 at baseline who participated in the WHI Hormone Therapy Trial and its ancillary Memory Study (WHIMS). Global cognitive functioning (Modified Mini-Mental State Examination [3MSE]) in Veterans (n = 279) and non-Veterans (n = 7,051) was compared at baseline and annually for 8 years using generalized linear modeling methods.
Compared with non-Veterans, Veteran women were older, more likely to be Caucasian, unmarried, and had higher rates of educational and occupational attainment. Results of unadjusted baseline analyses suggest 3MSE scores were similar between groups. Longitudinal analyses, adjusted for age, education, ethnicity, and WHI trial assignment revealed differences in the rate of cognitive decline between groups over time, such that scores decreased more in Veterans relative to non-Veterans. This relative difference was more pronounced among Veterans who were older, had higher educational/occupational attainment and greater baseline prevalence of cardiovascular risk factors (e.g., smoking) and cardiovascular disease (e.g., angina, stroke).
Veteran status was associated with higher prevalence of protective factors that may have helped initially preserve cognitive functioning. However, findings ultimately revealed more pronounced cognitive decline among Veteran relative to non-Veteran participants, likely suggesting the presence of risks that may impact neuropathology and the effects of which were initially masked by Veterans’ greater cognitive reserve.
PMCID: PMC4906317  PMID: 26615021
Women; Veterans; Cognition; Cognitive decline; Risk factors
24.  Sexual Minorities in England Have Poorer Health and Worse Health Care Experiences: A National Survey 
The health and healthcare of sexual minorities have recently been identified as priorities for health research and policy.
To compare the health and healthcare experiences of sexual minorities with heterosexual people of the same gender, adjusting for age, race/ethnicity, and socioeconomic status.
Multivariate analyses of observational data from the 2009/2010 English General Practice Patient Survey.
The survey was mailed to 5.56 million randomly sampled adults registered with a National Health Service general practice (representing 99 % of England’s adult population). In all, 2,169,718 people responded (39 % response rate), including 27,497 people who described themselves as gay, lesbian, or bisexual.
Two measures of health status (fair/poor overall self-rated health and self-reported presence of a longstanding psychological condition) and four measures of poor patient experiences (no trust or confidence in the doctor, poor/very poor doctor communication, poor/very poor nurse communication, fairly/very dissatisfied with care overall).
Sexual minorities were two to three times more likely to report having a longstanding psychological or emotional problem than heterosexual counterparts (age-adjusted for 5.2 % heterosexual, 10.9 % gay, 15.0 % bisexual for men; 6.0 % heterosexual, 12.3 % lesbian and 18.8 % bisexual for women; p < 0.001 for each). Sexual minorities were also more likely to report fair/poor health (adjusted 19.6 % heterosexual, 21.8 % gay, 26.4 % bisexual for men; 20.5 % heterosexual, 24.9 % lesbian and 31.6 % bisexual for women; p < 0.001 for each).
Adjusted for sociodemographic characteristics and health status, sexual minorities were about one and one-half times more likely than heterosexual people to report unfavorable experiences with each of four aspects of primary care. Little of the overall disparity reflected concentration of sexual minorities in low-performing practices.
Sexual minorities suffer both poorer health and worse healthcare experiences. Efforts should be made to recognize the needs and improve the experiences of sexual minorities. Examining patient experience disparities by sexual orientation can inform such efforts.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-014-2905-y) contains supplementary material, which is available to authorized users.
PMCID: PMC4284269  PMID: 25190140
sexual orientation; health care experiences; disparities
25.  Sex Differences in Mental Health and Substance Use Disorders and Treatment Entry Among Justice-involved Veterans in the Veterans Health Administration 
Medical care  2015;53(4 Suppl 1):S105-S111.
Over half of veterans in the criminal justice system have mental health or substance use disorders. However, there is a critical lack of information about female veterans in the criminal justice system and how diagnosis prevalence and treatment entry differ by sex.
To document prevalence of mental health and substance use disorder diagnoses and treatment entry rates among female veterans compared with male veterans in the justice system.
Research Design
Retrospective cohort study using national Veterans Health Administration clinical/administrative data from veterans seen by Veterans Justice Outreach Specialists in fiscal years 2010–2012.
A total of 1535 females and 30,478 male veterans were included.
Demographic characteristics (eg, sex, age, residence, homeless status), mental health disorders (eg, depression, posttraumatic stress disorder), substance use disorders (eg, alcohol and opioid use disorders), and treatment entry (eg, outpatient, residential, pharmacotherapy).
Among female veterans, prevalence of mental health and substance use disorders was 88% and 58%, respectively, compared with 76% and 72% among male veterans. Women had higher odds of being diagnosed with a mental health disorder [adjusted odds ratio (AOR) = 1.98; 95% confidence interval (CI), 1.68–2.34] and lower odds of being diagnosed with a substance use disorder (AOR = 0.50; 95% CI, 0.45–0.56) compared with men. Women had lower odds of entering mental health residential treatment (AOR = 0.69; 95% CI, 0.57–0.83).
Female veterans involved in the justice system have a high burden of mental health disorders (88%) and more than half have substance use disorders (58%). Entry to mental health residential treatment for women is an important quality improvement target.
PMCID: PMC5764085  PMID: 25767963
veterans health; sex differences; criminal justice; mental disorders; substance use disorders; mental health services; United States Department of Veterans Affairs

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