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1.  Sexual Orientation Differences in Complementary Health Approaches Among Young Adults in the United States 
Purpose
Lesbian, gay, and bisexual (LGB) young adults experience a wide range of health disparities, compared to heterosexuals. However, LGBs also experience many barriers to conventional healthcare, including social stigma, lack of LGB-specific knowledge among providers, and lower rates of health insurance coverage, which may limit utilization of traditional health services. Complementary health approaches (CHA) may represent an alternative to conventional care, but very little is currently known about CHA use in this population. We examined whether and how LGB young adults differed from heterosexual young adults in use of CHA.
Methods
Data were from Wave III of the National Longitudinal Study of Adolescent to Adult Health (2001-02). Fifteen types of CHA were considered. Descriptive and bivariate statistics were computed using design-based F-tests and logistic regression was used. Analyses were weighted and gender-stratified.
Results
Almost 46% of gay/bisexual men used CHA in the past 12 months versus 26% of heterosexual men (p<0.001) and 50% of lesbian/bisexual women versus 30% of heterosexual women (p<0.001). LGBs also differed significantly on demographics, access to conventional care, and health behaviors. Multivariate results showed higher odds of CHA among LGBs relative to heterosexuals (AOR = 2.37 for men, AOR = 1.98 for women, both p<0.001).
Conclusions
This is the first study to systematically demonstrate sexual orientation differences in CHA in a nationally representative sample of young adults. Public health wellness initiatives for sexual minorities should include evidence-based CHA in addition to traditional health services.
doi:10.1016/j.jadohealth.2016.07.001
PMCID: PMC5077684  PMID: 27567062
sexual orientation; lesbian, gay, bisexual; young adults; complementary and alternative medicine; health care utilization
2.  Sexual orientation disparities in physical health: age and gender effects in a population-based study 
Background
Recent studies have identified substantial health disparities between lesbian, gay, and bisexual (LGB) individuals compared to heterosexuals. However, possible variation in sexual orientation health disparities by age and according to gender remains largely unexplored.
Purpose
To examine physical health disparities between LGB and heterosexual individuals in a general population sample in Sweden, to explore potential age and gender differences in these disparities, and to test potential mechanisms underlying any observed disparities.
Method
Between 2008 and 2013, 60,922 individuals (16–84 years of age) responded to nationwide population-based health surveys. In the sample, 430 (0.7 %) individuals self-identified as gay/lesbian and 757 (1.3 %) self-identified as bisexual. Logistic and negative binomial regression analyses were used to explore health disparities based on sexual orientation.
Results
Overall, LGB individuals were more likely to report worse self-rated health as well as more physical health symptoms (e.g., pain, insomnia, dermatitis, tinnitus, intestinal problems) and conditions (e.g., diabetes, asthma, high blood pressure) compared to heterosexuals. However, these physical health disparities differed by age. Disparities were largest among adolescents and young adults and generally smallest in older age groups. Health behaviors and elevated reports of exposure to perceived discrimination, victimization, and threats of violence among sexual minorities partially explained the sexual orientation disparities in physical health.
Conclusions
Age emerged as an important effect modifier of physical health disparities based on sexual orientation. Gender-specific findings suggest that sexual orientation disparities persist into adulthood for women but are gradually attenuated for older age groups; in contrast, for men, these disparities disappear starting with young adults. These results support a developmental model of minority stress and physical health among LGB individuals.
doi:10.1007/s00127-015-1116-0
PMCID: PMC4747986  PMID: 26298574
Self-rated health; Minority stress; Health behaviors; Gay/bisexual; Sexual orientation; Life span
3.  Substance Use among Lesbian, Gay, and Bisexual Clients Entering Substance Abuse Treatment: Comparisons to Heterosexual Clients 
Objective
This study evaluated whether sexual orientation-specific differences in substance use behaviors exist among adults entering substance abuse treatment.
Method
Admissions records (July 2007-December 2009) were examined for treatment programs in San Francisco, California receiving government funding. Lesbian, gay, and bisexual (LGB) persons (n=1441) were compared to heterosexual persons (n=11770) separately by sex, examining primary problem substance of abuse, route of administration, age of first use, and frequency of use prior to treatment.
Results
Regarding bisexual males, the only significant finding of note was greater prevalence of methamphetamine as the primary substance of abuse. When compared to heterosexual men, gay and bisexual men evidenced greater rates of primary problem methamphetamine use (44.5% and 21.8% respectively versus 7.7%, adjusted odds ratios [ORs] 6.43 and 2.94), and there was lower primary heroin use among gay men (9.3% vs. 25.8%,OR 0.35). Among LGB individuals, race and ethnicity did not predict primary problem substance, except that among LGB men and women, a non-White race predicted cocaine use (OR 4.83 and 6.40, respectively), and among lesbian and bisexual women, Hispanic ethnicity predicted lower odds of primary cocaine use (OR 0.24). When compared to heterosexual men, gay men were more likely to smoke their primary problem substance (OR 1.61), first used this substance at an older age (M = 23.16 versus M=18.55, p<.001), and used this substance fewer days prior to treatment (M=8.75 versus M=11.41, p<.001). There were no differences between heterosexual and lesbian or bisexual women.
Conclusions
There wereunique patterns of substance use for gay and bisexual men entering substance abuse treatment, but women did not evidence differences. Gay men evidenced unique factors that may reflect less severity of use when entering treatment including fewer days of use and a later age of initiation of their primary problem substances. The results underscore the importance of being sensitive to differences between gay, bisexual and heterosexual males when considering substance use disorders.
Public Health Significance Statement
This study suggests that it is important to consider the sexual orientation of individuals entering substance abuse treatment as it may be an indicator of different patterns of substance use, particularly among gay men.
doi:10.1037/a0038724
PMCID: PMC4380585  PMID: 25622196
Sexual minority; lesbian; gay; bisexual; substance abuse treatment
4.  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
5.  Chronic Health Conditions and Key Health Indicators Among Lesbian, Gay, and Bisexual Older US Adults, 2013–2014 
American journal of public health  2017;107(8):1332-1338.
Objectives
To examine disparities in chronic conditions and health indicators among lesbian, gay, and bisexual (LGB) adults aged 50 years or older in the United States.
Methods
We used data from the 2013 and 2014 National Health Interview Survey to compare disparities in chronic conditions, health outcomes and behaviors, health care access, and preventive health care by sexual orientation and gender.
Results
LGB older adults were significantly more likely than heterosexual older adults to have a weakened immune system and low back or neck pain. In addition, sexual minority older women were more likely than their heterosexual counterparts to report having arthritis, asthma, a heart attack, a stroke, a higher number of chronic conditions, and poor general health. Sexual minority older men were more likely to report having angina pectoris or cancer. Rates of disability and mental distress were higher among LGB older adults.
Conclusions
At substantial cost to society, many disparities in chronic conditions, disability, and mental distress observed in younger LGB adults persist, whereas others, such as cardiovascular disease risks, present in later life. Interventions are needed to maximize LGB health.
doi:10.2105/AJPH.2017.303922
PMCID: PMC5508186  PMID: 28700299
6.  Sexual Orientation and Sex Differences in Adult Chronic Conditions, Health Risk Factors, and Protective Health Practices, Oregon, 2005–2008 
Introduction
Research on lesbian, gay, and bisexual (LGB) individuals’ health and health practices has primarily consisted of convenience studies focused on HIV/AIDS, substance use, or mental illness. We examined health-related disparities among Oregon LGB men and women compared with heterosexual men and women using data from a population-based survey.
Methods
Data from the 2005 through 2008 Oregon Behavioral Risk Factor Surveillance System were used to examine associations between sexual orientation and chronic conditions, health limitations, health risk factors, and protective health practices.
Results
Compared with heterosexual women, lesbian and bisexual women were significantly more likely to smoke cigarettes, be obese, binge drink, and have chronic conditions, and less likely to engage in protective health practices. Compared with heterosexual men, gay men were significantly less likely to be obese, more likely to binge drink, and more likely to engage in protective health practices. Compared with heterosexual men, bisexual men were significantly more likely to have a physical disability, smoke cigarettes, binge drink, and more likely to get an HIV test.
Conclusions
Health disparities among Oregon LGB individuals were most prominent among lesbian and bisexual women. Gay men had the most protective health practices, but they were more likely than heterosexual men to engage in risky behaviors that lead to chronic diseases later in life. Targeted public health interventions should be provided in environments that avoid stigmatizing and discriminating against LGB individuals where they live, work, learn, and socialize.
doi:10.5888/pcd11.140126
PMCID: PMC4723300  PMID: 25101493
7.  Health Inequities among Lesbian, Gay, and Bisexual Adults in North Carolina, 2011–2014 
Inequalities in health have been identified for lesbian, gay, and bisexual (LGB) populations nationally. Policies in the U.S. South offer fewer protections for LGB people than in other regions, yet, limited data exist for this region. North Carolina (NC) BRFSS data from 2011 to 2014 were combined (LGB n = 604; heterosexual n = 33,170) and analyzed using SAS survey procedures to estimate health characteristics by sexual orientation within gender. Many examined indicators were not different by sexual orientation, however, other results were significant and consistent with findings from state population surveys in other regions of the country. Both genders showed inequities in mental health, having over twice the odds of five or more poor mental health days in the past month and of having ever been diagnosed with a depressive disorder. Sexual minority women had higher odds compared with heterosexual women for ever having smoked cigarettes, current smoking, exposure to secondhand smoke both in the workplace and at home, and both alcohol risk factors, binge and heavy drinking. Being part of the LGB population in NC is associated with worse health. The implementation of anti-LGB policies in the NC warrants ongoing monitoring of LGB health inequities in NC and in other southeastern states for potential effects on the health and well-being of sexual minorities.
doi:10.3390/ijerph14080835
PMCID: PMC5580539  PMID: 28757566
homosexuality; Behavioral Risk Factor Surveillance System; public health surveillance; North Carolina; sexual minority; health status disparities
8.  Sexual orientation and self-reported mood disorder diagnosis among Canadian adults 
BMC Public Health  2013;13:209.
Background
The prevalence and correlates of mood disorders among people who self-identify as lesbian, gay or bisexual (LGB) are not well understood. Therefore, the current analysis was undertaken to estimate the prevalence and correlates of self-reported mood disorders among a nationally representative sample of Canadian adults (ages 18 to 59 years). Stratified analyses by age and sex were also performed.
Methods
Using data from the 2007–2008 Canadian Community Health Survey, logistic regression techniques were used to determine whether sexual orientation was associated with self-reported mood disorders.
Results
Among respondents who identified as LGB, 17.1% self-reported having a current mood disorder while 6.9% of heterosexuals reported having a current mood disorder. After adjusting for potential confounders, LGB-respondents remained more likely to report mood disorder as compared to heterosexual respondents (AOR: 2.93; 95% CI: 2.55-3.37). Gay and bisexual males were at elevated odds of reporting mood disorders (3.48; 95% CI: 2.81–4.31), compared to heterosexual males. Young LGB respondents (ages 18–29) had higher odds (3.75; 95% CI: 2.96–4.74), compared to same-age heterosexuals.
Conclusions
These results demonstrate elevated prevalence of mood disorders among LGB survey respondents compared to heterosexual respondents. Interventions and programming are needed to promote the mental health and well being of people who identify as LGB, especially those who belong to particular subgroups (e.g., men who are gay or bisexual; young people who are LGB).
doi:10.1186/1471-2458-13-209
PMCID: PMC3599883  PMID: 23510500
Mood disorders; Mental health; Sexual orientation; Sexual minority
9.  Individual trajectories of substance use in lesbian, gay and bisexual youth and heterosexual youth 
Addiction (Abingdon, England)  2009;104(6):974-981.
Aims
Several decades of research have shown that lesbian, gay and bisexual (LGB) adults are at high risk for substance use and substance use disorders, and a recent meta-analysis shows that these disparities most probably begin in adolescence; however, no studies to date have examined longitudinal growth in substance use in LGB youth and heterosexual youth to determine if they follow different trajectories into young adulthood. The primary aims of this paper were to estimate individual trajectories of substance use in youth and examine differences between self-identified LGB and heterosexual subsamples.
Method
A school-based, longitudinal study of health-related behaviors of adolescents and their outcomes in young adulthood was used to test our hypotheses (The National Longitudinal Study of Adolescent Health). Participants were included if they were interviewed at all three waves and were not missing information regarding self-identified sexual orientation (n = 10 670).
Results
Latent curve models (LCMs) showed that LGB identity was associated significantly with individual variability in substance use intercepts and slopes, above and beyond age, race and gender. Self-identified LGB youth reported higher initial rates of substance use and on average their substance use increased over time more rapidly than did substance use by heterosexual youth. Two other indicators of sexual orientation (same-sex romantic attraction and same-sex sexual behavior) were also associated with substance use trajectories, and differential results were found for youth who identified as ‘mostly heterosexual’ and bisexual compared with youth who identified as completely heterosexual or homosexual.
Conclusions
Sexual orientation is an important risk marker for growth in adolescent substance use, and the disparity between LGB and heterosexual adolescents increases as they transition into young adulthood. More research is needed in order to examine: causal mechanisms, protective factors, important age-related trends (using a cohort-sequential design), the influence of gay-related developmental milestones, curvilinear effects over time and long-term health outcomes.
doi:10.1111/j.1360-0443.2009.02531.x
PMCID: PMC3649139  PMID: 19344440
Bisexual; gay; lesbian; longitudinal; substance use; youth
10.  Differences in Chronic Disease Behavioral Indicators by Sexual Orientation and Sex 
Context
Lesbian, gay, and bisexual (LGB) populations experience significant health inequities in preventive behaviors and chronic disease compared with non-LGB populations.
Objectives
To examine differences in physical activity and diet by sexual orientation and sex subgroups and to assess the influences of home and neighborhood environments on these relationships.
Design
A population-based survey conducted in 2013–2014.
Setting
A stratified, simple, random sample of households in 20 sites in the United States.
Participants
A total of 21 322 adult LGB and straight-identified men and women.
Outcome Measures
Any leisure-time physical activity in the past month; physical activity 150 min/wk or more; daily frequency of consumption of vegetables, fruit, water, and sugar-sweetened beverages; and the number of meals prepared away from home in the past 7 days.
Results
Physical activity and diet varied by sexual orientation and sex; differences persisted after adjusting for sociodemographic factors and household and community environments. Bisexual men reported a higher odds of engaging in frequent physical activity than straight men (odds ratio [OR] = 3.10; 95% confidence interval [CI], 1.57–6.14), as did bisexual women compared with straight women (OR = 1.84; 95% CI, 1.20–2.80). LGB subgroups reported residing in more favorable walking and cycling environments. In contrast, gay men and lesbian and bisexual women reported a less favorable community eating environment (availability, affordability, and quality of fruit and vegetables) and a lower frequency of having fruit or vegetables in the home. Lesbian women reported lower daily vegetable consumption (1.79 vs 2.00 mean times per day; difference = −0.21; 95% CI, −0.03 to −0.38), and gay men reported consumption of more meals prepared away from home (3.17 vs 2.63; difference = 0.53; 95% CI, 0.11–0.95) than straight women and men, respectively. Gay men and lesbian and bisexual women reported a higher odds of sugar-sweetened beverage consumption than straight men and women.
Conclusions
Findings highlight opportunities for targeted approaches to promote physical activity and mitigate differences in diet to reduce health inequities.
doi:10.1097/PHH.0000000000000350
PMCID: PMC4784428  PMID: 26599026
diet; health inequities; physical activity; sexual orientation
11.  Gay Acres: Sexual Orientation Differences in Health Indicators Among Rural and Non-rural Individuals 
Purpose
Geographic location is a significant factor that influences health status and health disparities. Yet, little is known about the relationship between geographic location and health and health disparities among lesbian, gay, and bisexual (LGB) persons. This study used a US population-based sample to evaluate the associations of sexual orientation with health indicators by rural/non-rural residence.
Methods
Data were pooled from the 10 states that collected sexual orientation in the 2010 Behavioral Risk Factor Surveillance System (BRFSS) surveys. Rural status was defined using metropolitan statistical area (MSA), and group differences by sexual orientation were stratified by gender and rural/non-rural status. Chi-square tests for categorical variables were used to assess bivariate relationships. Multivariable logistic regression models stratified by gender and rural/non-rural status were used to assess the association of sexual orientation to health indicators, while adjusting for age, race/ethnicity, education, and partnership status. All analyses were weighted to adjust for the complex sampling design.
Findings
Significant differences between LGB and heterosexual participants emerged for several health indicators, with bisexuals having a greater number of differences than gay men/lesbians. There were fewer differences in health indicators for rural LGB participants compared to heterosexuals than non-rural participants.
Conclusions
Rural residence appears to influence the pattern of LGB health disparities. Future work is needed to confirm and identify the exact etiology or rural/non-rural differences in LGB health.
doi:10.1111/jrh.12161
PMCID: PMC4887433  PMID: 26625172
bisexuality; health disparities; homosexuality; rural health; sexual orientation
12.  Sexual Orientation Modulates Endocrine Stress Reactivity 
Biological psychiatry  2014;77(7):668-676.
BACKGROUND
Biological sex differences and sociocultural gender diversity influence endocrine stress reactivity. Although numerous studies have shown that men typically activate stronger stress responses than women when exposed to laboratory-based psychosocial stressors, it is unclear whether sexual orientation further modulates stress reactivity. Given that lesbian, gay, and bisexual (LGB) individuals frequently report heightened distress secondary to stigma-related stressors, we investigated whether cortisol stress reactivity differs between LGB individuals and heterosexual individuals in response to a well-validated psychosocial stressor.
METHODS
The study population comprised 87 healthy adults (mean age, 25 years) who were grouped according to their biological sex and their gendered sexual orientation: lesbian/bisexual women (n = 20), heterosexual women (n = 21), gay/bisexual men (n = 26), and heterosexual men (n = 20). Investigators collected 10 salivary cortisol samples throughout a 2-hour afternoon visit involving exposure to the Trier Social Stress Test modified to maximize between-sex differences.
RESULTS
Relative to heterosexual women, lesbian/bisexual women showed higher cortisol stress reactivity 40 min after exposure to the stressor. In contrast, gay/bisexual men displayed lower overall cortisol concentrations throughout testing compared with heterosexual men. Main findings were significant while adjusting for sex hormones (estradiol-to-progesterone ratio in women and testosterone in men), age, self-esteem, and disclosure status (whether LGB participants had completed their “coming out”).
CONCLUSIONS
Our results provide novel evidence for gender-based modulation of cortisol stress reactivity based on sexual orientation that goes beyond well-established between-sex differences. This study raises several important avenues for future research related to the physiologic functioning of LGB populations and gender diversity more broadly.
doi:10.1016/j.biopsych.2014.08.013
PMCID: PMC4434405  PMID: 25444167
Cortisol; Gender diversity; Sex differences; Sexual orientation; Stress reactivity; Trier Social Stress Test
13.  Minority stress factors as mediators of sexual orientation disparities in mental health treatment: a longitudinal population-based study 
Background
Substantial mental health disparities between lesbian, gay and bisexual (LGB) individuals compared with heterosexuals have been identified. The aim was to examine potential sexual orientation-based disparities in mental health treatment in a prospectively analysed population-based sample in Sweden and to explore potential moderators and mediators.
Method
30 730 individuals from the Stockholm Public Health Cohort were followed up with questionnaires and registry-based health record data on psychiatric healthcare visits and prescription drug use between 1 January 2011 and 31 December 2011.
Results
In adjusted analyses, gay and lesbian individuals were more likely to receive treatment for anxiety disorders (adjusted ORs (AOR)=3.80; 95% CI 2.54 to 5.69) and to use antidepressant medication (AOR=2.13; 95% CI 1.62 to 2.79); and bisexuals were more likely to receive treatment for mood disorders (AOR=1.58; 95% CI 1.00 to 2.48), anxiety disorders (AOR=3.23; 95% CI 2.22 to 4.72) and substance use disorders (AOR=1.91; 95% CI 1.12 to 3.25), and to use antidepressant medication (AOR=1.91; 95% CI 1.12 to 3.25) when compared with heterosexuals. The largest mental health treatment disparities based on sexual orientation were found among bisexual women, gay men and younger lesbian women. More frequent experiences of victimisation/threat of violence and lack of social support could partially explain these disparities.
Conclusions
This study shows a substantially elevated risk of poor mental health among LGB individuals as compared with heterosexuals. Findings support several factors outlined in the minority stress theory in explaining the mechanisms behind these disparities.
doi:10.1136/jech-2016-207943
PMCID: PMC5484026  PMID: 28043996
14.  Physical health indicators among lesbian, gay, and bisexual U.S. Veterans 
Annals of epidemiology  2013;23(7):448-451.
Purpose
To provide information about lesbian, gay and bisexual (LGB) veterans’ health status, diagnoses, and health screening behaviors compared with heterosexual veterans.
Methods
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.
Results
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).
Conclusions
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.
doi:10.1016/j.annepidem.2013.04.009
PMCID: PMC3698572  PMID: 23688720
15.  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
16.  Sexual Minorities in England Have Poorer Health and Worse Health Care Experiences: A National Survey 
ABSTRACT
BACKGROUND
The health and healthcare of sexual minorities have recently been identified as priorities for health research and policy.
OBJECTIVE
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.
DESIGN
Multivariate analyses of observational data from the 2009/2010 English General Practice Patient Survey.
PARTICIPANTS
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.
MAIN MEASURES
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).
KEY RESULTS
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.
CONCLUSIONS
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.
doi:10.1007/s11606-014-2905-y
PMCID: PMC4284269  PMID: 25190140
sexual orientation; health care experiences; disparities
17.  Health Disparities Among Lesbian, Gay, and Bisexual Older Adults: Results From a Population-Based Study 
American journal of public health  2013;103(10):1802-1809.
Objectives
We investigated health disparities among lesbian, gay, and bisexual (LGB) adults aged 50 years and older.
Methods
We analyzed data from the 2003–2010 Washington State Behavioral Risk Factor Surveillance System (n = 96 992) on health outcomes, chronic conditions, access to care, behaviors, and screening by gender and sexual orientation with adjusted logistic regressions.
Results
LGB older adults had higher risk of disability, poor mental health, smoking, and excessive drinking than did heterosexuals. Lesbians and bisexual women had higher risk of cardiovascular disease and obesity, and gay and bisexual men had higher risk of poor physical health and living alone than did heterosexuals. Lesbians reported a higher rate of excessive drinking than did bisexual women; bisexual men reported a higher rate of diabetes and a lower rate of being tested for HIV than did gay men.
Conclusions
Tailored interventions are needed to address the health disparities and unique health needs of LGB older adults. Research across the life course is needed to better understand health disparities by sexual orientation and age, and to assess subgroup differences within these communities.
doi:10.2105/AJPH.2012.301110
PMCID: PMC3770805  PMID: 23763391
18.  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
19.  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
20.  An Examination of Health Inequities among College Students by Sexual Orientation Identity and Sex 
Background
Lesbian, gay, and bisexual (LGB) college students may have an increased number of health inequities compared to their heterosexual counterparts. However, to date, no research has provided a comprehensive examination of health-related factors by sexual orientation identity and sex among a national sample of college students. Thus, the purpose of this study was to examine physical, sexual, interpersonal relations/safety, and mental health inequities by sexual orientation identity and sex among a national sample of college students.
Design and methods
Participants (n=39,767) completed the National College Health Assessment II during the fall 2008/spring 2009 academic year. Hierarchical binary logistic regression analyses were used to examine health inequities by sexual orientation identity and sex.
Results
LGB students compared to heterosexual students, experienced multiple health inequities including higher rates of being verbally threatened and lower rates of physical activity and condom use.
Conclusions
An understanding of health inequities experienced by LGB college students is critical as during these years of transition, students engage in protective (e.g., physical activity) and risky (e.g., lack of condom use) health behaviours, establishing habits that could last a lifetime. Future research should be used to design and implement targeted public health strategies and policies to reduce health inequities and improve health-related quality of life among LGB college students.
Significance for public healthHealth inequities based on sexual orientation identity and sex among college students is a critical public health concern. Based on the results of the current study, lesbian, gay, and bisexual (LGB) college students experienced multiple physical, sexual, interpersonal relations and safety, and mental health inequities. This understanding of health inequities experienced by LGB college students is critical as during these years of transition, students engage in protective (e.g., physical activity) and risky (e.g., lack of condom use) health behaviours, establishing habits that could last a lifetime. By intervening during the college years, targeted public health strategies and policies can be designed and implemented to reduce health inequities and improve health-related quality of life among LGB individuals during mid-to-later adulthood.
doi:10.4081/jphr.2015.414
PMCID: PMC4407041  PMID: 25918696
health inequities; college students; lesbian; gay; bisexual; heterosexual
21.  Social Support Networks Among Diverse Sexual Minority Populations 
This paper reports a study of the function and composition of social support networks among diverse lesbian, gay and bisexual (LGB) men and women (n = 396) in comparison to their heterosexual peers (n = 128). Data were collected using a structured social support network matrix in a community sample recruited in New York City. Our findings show that gay and bisexual men may rely on “chosen families” within LGBT communities more so than lesbian and bisexual women. Both heterosexuals and LGBs relied less on family and more on other people (e.g., friends, co-workers) for everyday social support (e.g., recreational and social activities, talking about problems). Providers of everyday social support were most often of the same sexual orientation and race/ethnicity as participants. In seeking major support (e.g., borrowing large sums of money), heterosexual men and women along with lesbian and bisexual women relied primarily on their families, but gay and bisexual men relied primarily on other LGB individuals. Racial/ethnic minority LGBs relied on LGB similar others at the same rate at White LGBs but, notably, racial/ethnic minority LGBs reported receiving fewer dimensions of support.
doi:10.1037/ort0000117
PMCID: PMC4878705  PMID: 26752447
22.  Mental and Physical Health Needs of Lesbian, Gay, and Bisexual Clients in Substance Abuse Treatment 
Objective
Lesbian, gay, and bisexual (LGB) orientation predicts greater substance use, treatment utilization, and poorer mental and physical health, but health needs of LGB individuals in substance abuse treatment remain largely unknown. The purpose of this study was to identify differences in mental and physical health needs of LGB individuals in substance abuse treatment.
Methods
Substance abuse treatment admissions data from the County of San Francisco were used in this investigation of differences in mental and physical health problems and service utilization between LGB (n=1,441) and heterosexual individuals (n=11,770).
Results
LGB individuals were more likely to have mental health diagnoses (adjORs ranging from 1.86–4.00) and current mental health prescription medications (adjORs from 1.79–4.99) than heterosexual counterparts. Gay and bisexual men and bisexual women but not lesbian women, were more likely to be receiving mental health treatment. Gay men and bisexual women were more likely than heterosexual counterparts to report physical health problems. Gay and bisexual men and bisexual women but not lesbian women were more likely to be receiving health care. There were no differences between LGB individuals and heterosexual counterparts in the number of emergency room visits or hospital overnight stays.
Discussion
This study found that LGB individuals entering substance abuse treatment have greater mental and physical health needs than heterosexual counterparts. Implications for healthcare integration, research, and practice are discussed.
doi:10.1016/j.jsat.2015.06.022
PMCID: PMC4581963  PMID: 26314505
lesbian; gay; bisexual; substance abuse treatment; physical health disparities; mental health disparities
23.  Older Age Associated with Mental Health Resiliency in Sexual Minority US Veterans 
Objectives
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.
Method
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).
Results
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.
Conclusion
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.
doi:10.1016/j.jagp.2016.09.006
PMCID: PMC5291307  PMID: 27769835
sexual minority status; veterans; mental health; aging
24.  Substance Use in Lesbian, Gay, and Bisexual Populations: An Update on Empirical Research and Implications for Treatment 
Psychology of Addictive Behaviors  2011;26(2):265-278.
Historically, substance use problems were thought to be more prevalent in lesbian, gay, and bisexual (LGB) populations, and correcting skewed perceptions about substance abuse among LGB individuals is critically important. This review provides an update on empirical evidence on LGB substance use patterns and treatment outcome, with specific focus on clinical implications of findings. Compared to earlier studies, the recent research included in this review has used more sophisticated methodologies, more representative samples, and also has investigated multiple dimensions of sexual orientation in relation to substance use patterns. Findings from recent research suggest that lesbians and bisexual women are at greater risk for alcohol and drug use disorders and related problems, and that gay and bisexual men are at greater risk for illicit drug use and related problems. Several sociocultural factors have emerged as correlates of substance use patterns in LGB populations (e.g., affiliation with gay culture, HIV-status), and several demographic characteristics (e.g., female, older age) do not appear to be as robust of protective factors against substance abuse for LGB individuals compared to heterosexual populations. Bisexual identity and/or behavior in particular seem to be related to increased risk for substance abuse. In terms of treatment outcome, limitations of extant research prevent conclusions about the relative impact of LGB-specific interventions, and further research that includes women and uses more equivalent comparison interventions is needed. Clinical implications of research findings are discussed for case identification, selection of treatment goals (e.g., moderation versus abstinence), targets for intervention, and specific treatment modalities.
doi:10.1037/a0025424
PMCID: PMC3288601  PMID: 22061339
substance use; lesbian; gay; bisexual; review; treatment
25.  Sexual orientation and symptoms of common mental disorder or low wellbeing: combined meta-analysis of 12 UK population health surveys 
BMC Psychiatry  2016;16:67.
Background
Previous studies have indicated increased risk of mental disorder symptoms, suicide and substance misuse in lesbian, gay and bisexual (LGB) adults, compared to heterosexual adults. Our aims were to determine an estimate of the association between sexual orientation identity and poor mental health and wellbeing among adults from 12 population surveys in the UK, and to consider whether effects differed for specific subgroups of the population.
Methods
Individual data were pooled from the British Cohort Study 2012, Health Survey for England 2011, 2012 and 2013, Scottish Health Survey 2008 to 2013, Longitudinal Study of Young People in England 2009/10 and Understanding Society 2011/12. Individual participant meta-analysis was used to pool estimates from each study, allowing for between-study variation.
Results
Of 94,818 participants, 1.1 % identified as lesbian/gay, 0.9 % as bisexual, 0.8 % as ‘other’ and 97.2 % as heterosexual. Adjusting for a range of covariates, adults who identified as lesbian/gay had higher prevalence of common mental disorder when compared to heterosexuals, but the association was different in different age groups: apparent for those under 35 (OR = 1.78, 95 % CI 1.40, 2.26), weaker at age 35–54.9 (OR = 1.42, 95 % CI 1.10, 1.84), but strongest at age 55+ (OR = 2.06, 95 % CI 1.29, 3.31). These effects were stronger for bisexual adults, similar for those identifying as ‘other’, and similar for 'low wellbeing'.
Conclusions
In the UK, LGB adults have higher prevalence of poor mental health and low wellbeing when compared to heterosexuals, particularly younger and older LGB adults. Sexual orientation identity should be measured routinely in all health studies and in administrative data in the UK in order to influence national and local policy development and service delivery. These results reiterate the need for local government, NHS providers and public health policy makers to consider how to address inequalities in mental health among these minority groups.
Electronic supplementary material
The online version of this article (doi:10.1186/s12888-016-0767-z) contains supplementary material, which is available to authorized users.
doi:10.1186/s12888-016-0767-z
PMCID: PMC4806482  PMID: 27009565
Anxiety disorders; Depression; Health surveys; Homosexuality; Mental disorders; Meta-analysis; Mood disorders; Neurotic disorders; Sexual orientation; Sexuality

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