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1.  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
2.  Health Inequalities Among Sexual Minority Adults 
Background
Improving the health of lesbian, gay, and bisexual (LGB) individuals is a Healthy People 2020 goal; however, the IOM highlighted the paucity of information currently available about LGB populations.
Purpose
To compare health indicators by gender and sexual orientation statuses.
Methods
Data are from Behavioral Risk Factor Surveillance System surveys conducted January–December of 2010 with population-based samples of non-institutionalized U.S. adults aged over 18 years (N=93,414) in ten states that asked about respondents’ sexual orientation (response rates=41.1%–65.6%). Analyses were stratified by gender and sexual orientation to compare indicators of mental health, physical health, risk behaviors, preventive health behaviors, screening tests, health care utilization, and medical diagnoses. Analyses were conducted in March 2013.
Results
Overall, 2.4% (95% CI=2.2, 2.7) of the sample identified as LGB. All sexual minority groups were more likely to be current smokers than their heterosexual peers. Compared with heterosexual women, lesbian women had over 30% decreased odds of having an annual routine physical exam, and bisexual women had over 2.5 times the odds of not seeking medical care owing to cost. Compared with heterosexual men, gay men were less likely to be overweight or obese, and bisexual men were twice as likely to report a lifetime asthma diagnosis.
Conclusions
This study represents one of the largest samples of LGB adults and finds important health inequalities, including that bisexual women bear particularly high burdens of health disparities. Further work is needed to identify causes of and intervention for these disparities.
doi:10.1016/j.amepre.2013.11.010
PMCID: PMC4102129  PMID: 24650836
3.  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
4.  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
5.  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
6.  Sexual-Orientation Disparities in Substance Use in Emerging Adults: A Function of Stress and Attachment Paradigms 
More lesbian, gay, and bisexual (LGB) youths than heterosexuals report substance use. We examined a theoretical model to understand these disparities in lifetime and past-year substance use by means of stress and attachment paradigms, using the longitudinal Growing Up Today Study (GUTS) and Nurses’ Health Study II (NHSII). GUTS participants are the children of participants in NHSII; thus, child and maternal data are available. In addition, GUTS contains siblings, allowing for comparisons of LGB and heterosexual siblings. Of 5,647 GUTS youths (M = 20.6 years old in 2005), 1.6% were lesbian/gay (LG), 1.6% bisexual (BI), 9.9% mostly heterosexual (MH), and 86.9% completely heterosexual (CH). After adjusting for sibling clustering in GUTS and covariates, significantly more sexual minorities (LGs, BIs, and MHs) than CHs reported lifetime and past-year smoking, non-marijuana illicit drug use, and prescription drug misuse. More sexual minorities also reported marijuana use in the past year. The relations between sexual orientation and substance use were moderated by the stress markers: As mother's discomfort with homosexuality increased, more BIs and MHs than CHs used substances. As childhood gender nonconforming behaviors increased, more LGs than CHs used substances. The relations between sexual orientation and substance use were mediated by attachment and maternal affection (percent of effect mediated ranged from 5.6%–16.8%% for lifetime substance use and 4.9%–24.5% for past-year use). In addition, sibling comparisons found that sexual minorities reported more substance use, more childhood gender nonconforming behaviors, and less secure attachment than CH siblings; mothers reported less affection for their sexual-minority than CH offspring. The findings indicate the importance of stress and attachment paradigms for understanding sexual-orientation disparities in substance use.
doi:10.1037/a0035499
PMCID: PMC4203310  PMID: 25134050
Sexual orientation; substance use; attachment; stress; youth
7.  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
8.  Screening for Sexual Orientation in Psychiatric Emergency Departments 
Introduction
Our goal was to explore whether emergency department (ED) patients would disclose their sexual orientation in a research evaluation and to examine demographic and clinical characteristics of patients by self-identified sexual orientation.
Methods
Participants (n=177) presented for psychiatric treatment at three urban EDs in New York City, Rochester, NY, and Philadelphia, PA. Participants were interviewed in the context of a larger study of a standardized suicide risk assessment. We assessed participants’ willingness to answer questions regarding sexual orientation along three dimensions: a self-description of sexual orientation, a self-description of sexual attraction, and the gender of any prior sexual partners.
Results
No participants (0/177) refused to respond to the categorical question about sexual orientation, 168/177 (94.9%) agreed to provide information about prior sexual partners, and 100/109 (91.7%) provided information about current sexual attraction toward either gender. Of all 177 participants, 154 (87.0%) self-identified as heterosexual, 11 (6.2%) as bisexual, 10 (5.6%) as gay or lesbian, and 2 (1.1%) indicated they were not sure. As compared with heterosexual patients, lesbian, gay and bisexual (LGB) patients were significantly younger and more likely to be non-white, but did not differ significantly in terms of education, income, employment, or religious affiliation or participation. Further, LGB participants did not differ from self-identified heterosexual participants for lifetime suicide attempt rate or lifetime history of any mood, substance-related, psychotic spectrum, or other Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) Axis I disorder. Of self-identified heterosexual participants 5.6% (5/89) reported sexual attraction as other than ‘only opposite sex,’ and 10.3% (15/142) of sexually active ‘heterosexual’ participants reported previous same-gender sexual partners.
Conclusion
Assessing patients’ sexual orientation in the ED by a three-question approach appeared feasible in the ED and acceptable to ED patients. However, since many patients have sexual experiences not suggested by simple labels, self-report of sexual identity alone may not inform clinicians of health risks inherent in same or opposite gender sexual contact.
doi:10.5811/westjem.2014.12.22254
PMCID: PMC4307732  PMID: 25671014
9.  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
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.  Nonevent Stress Contributes to Mental Health Disparities Based on Sexual Orientation: Evidence From a Personal Projects Analysis 
This study examined the role of nonevent stress—in the form of frustrated personal project pursuits in the arenas of relationships and work—as a contributing factor to mental health disparities between heterosexual and lesbian, gay, and bisexual (LGB) populations. A purposive sample of 431 LGB (55%) and heterosexually identified (45%) individuals living in the United States and Canada completed the Personal Project Inventory by describing and rating core personal projects they were pursuing. The intensity of perceived barriers to the achievement of relationship- and work-related personal projects served as indicators nonevent stress. Hierarchical linear regression models tested the hypothesis that nonevent stress contributes to the association between sexual orientation and two indicators of mental health: depressive symptoms and psychological well-being. LGB individuals had significantly more depressive symptoms and lower levels of psychological well-being than heterosexuals. Indicators of nonevent stress were significantly associated with mental health outcomes and their inclusion in models attenuated sexual orientation differences in mental health. The critical indirect pathway leading from sexual minority status to mental health occurred via barriers to relationship projects from interpersonal sources. This research suggests that nonevent stress because of structural and interpersonal stigma may contribute to mental health disparities between LGB and heterosexual individuals. The findings have important implications for policy reform around same-sex relationship recognition and workplace discrimination. Future research and clinical work will benefit by expanding existing foci on stress to include nonevent stressors to better understand and address mental health problems, particularly in LGB populations.
doi:10.1037/ort0000024
PMCID: PMC4313555  PMID: 25265219
mental health disparities; well-being; personal projects; nonevent stress; sexual orientation
12.  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
13.  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
14.  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
15.  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
16.  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
17.  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
18.  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
19.  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
20.  Sexual orientation and smoking history: results from a community-based sample of youth in Shanghai, China 
Objective
Cigarette smoking has been found to be more prevalent among adults and youths with a minority sexual orientation (lesbian, gay, bisexual, LGB) than among the general population, while less is known about smoking among LGB youth in low- and middle-income countries. The goal of the study was to examine cigarette smoking in relation to sexual orientation in a community-based sample of youth in Shanghai, China.
Methods
A multi-center cross-sectional survey of 17,016 youth aged 15–24 years was conducted in rural and urban areas of Hanoi, Vietnam; Taipei, Taiwan; and Shanghai, China in 2006. In this article, analysis was restricted to the 6,299 respondents in Shanghai. Assessments included ever smoking, age at first smoking, frequency of smoking, and number of cigarettes smoked daily. Logistic regression was used to estimate the association between sexual orientation and cigarette smoking.
Results
Nine percent (594/6,299) of eligible participants considered themselves as LGB youths; 34.2 % ever smoked, 14.81 % initiated smoking before age 13, 15.9 % smoked in the past 30 days, and 14.1 % were moderate or heavy smokers. LGB identity predicted moderate or heavy smoking (OR 2.2, 95 % CI 1.3, 3.9). Male LGB youth smoked more cigarettes daily (OR 2.2, 95 % CI 1.3, 3.9) whilst female LGB youth reported less any prior cigarette use (OR 0.7, 95 % CI 0.5, 1.0).
Conclusions
Few meaningful disparities in cigarette smoking were related to sexual orientation, except male LGB youth consumed more cigarettes daily. Prevention and cessation should target this population, especially male LGB youth.
doi:10.1007/s12199-015-0444-8
PMCID: PMC4434233  PMID: 25648257
Sexual orientation; LGB; Smoking; Youth; China
21.  Sexual orientation and adolescent substance use: a meta-analysis and methodological review* 
Addiction (Abingdon, England)  2008;103(4):546-556.
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 (SUDs). These problems may often start prior to young adulthood; however, relatively little is known about risk for substance use in LGB adolescents. The primary aims of this paper were to conduct a meta-analysis of the relationship between sexual orientation and adolescent substance use and a systematic review and critique of the methodological characteristics of this literature.
Methods
Medical and social science journals were searched using Medline and PsychInfo. Studies were included if they tested the relationship between sexual orientation and adolescent substance use. Eighteen published studies were identified. Data analysis procedures followed expert guidelines, and used National Institutes of Health (NIH)-sponsored meta-analysis software.
Results
LGB adolescents reported higher rates of substance use compared to heterosexual youth (overall odds ratio = 2.89, Cohen's d = 0.59). Effect sizes varied by gender, bisexuality status, sexual orientation definition and recruitment source. None of the studies tested mediation and only one tested moderation. One employed a matched comparison group design, one used a longitudinal design, and very few controlled for possible confounding variables.
Conclusions
The odds of substance use for LGB youth were, on average, 190% higher than for heterosexual youth and substantially higher within some subpopulations of LGB youth (340% higher for bisexual youth, 400% higher for females). Causal mechanisms, protective factors and alternative explanations for this effect, as well as long-term substance use outcomes in LGB youth, remain largely unknown.
doi:10.1111/j.1360-0443.2008.02149.x
PMCID: PMC2680081  PMID: 18339100
Adolescence; alcohol; bisexual; drugs; gay; lesbian; meta-analysis; sexual minority; sexual orientation; youth
22.  Associations of Discrimination and Violence With Smoking Among Emerging Adults: Differences by Gender and Sexual Orientation 
Nicotine & Tobacco Research  2011;13(12):1284-1295.
Introduction:
Lesbian, gay, and bisexual (i.e., sexual minority) populations have higher smoking prevalence than their heterosexual peers, but there is a lack of empirical study into why such disparities exist. This secondary analysis of data sought to examine associations of discrimination and violence victimization with cigarette smoking within sexual orientation groups.
Methods:
Data from the Fall 2008 and Spring 2009 National College Health Assessments were truncated to respondents of 18–24 years of age (n = 92,470). Since heterosexuals comprised over 90% of respondents, a random 5% subsample of heterosexuals was drawn, creating a total analytic sample of 11,046. Smoking status (i.e., never-, ever-, and current smoker) was regressed on general (e.g., not sexual orientation–specific) measures of past-year victimization and discrimination. To examine within-group differences, two sets of multivariate ordered logistic regression analyses were conducted: one set of models stratified by sexual orientation and another set stratified by gender-by-sexual-orientation groups.
Results:
Sexual minorities indicated more experiences of violence victimization and discrimination when compared with their heterosexual counterparts and had nearly twice the current smoking prevalence of heterosexuals. After adjusting for age and race, lesbians/gays who were in physical fights or were physically assaulted had higher proportional odds of being current smokers when compared with their lesbian/gay counterparts who did not experience those stressors.
Conclusions:
When possible, lesbian/gay and bisexual groups should be analyzed separately, as analyses revealed that bisexuals had a higher risk profile than lesbians/gays. Further research is needed with more nuanced measures of smoking (e.g., intensity), as well as examining if victimization may interact with smoking cessation.
doi:10.1093/ntr/ntr183
PMCID: PMC3223581  PMID: 21994344
23.  Sexual orientation disparities in mental health: the moderating role of educational attainment 
Purpose.
Mental health disparities between sexual minorities and heterosexuals remain inadequately understood, especially across levels of educational attainment. The purpose of the present study was to test whether education modifies the association between sexual orientation and mental disorder.
Methods.
We compared the odds of past 12-month and lifetime psychiatric disorder prevalence (any Axis-I, any mood, any anxiety, any substance use, and comorbidity) between lesbian, gay, and bisexual (LGB) and heterosexual individuals by educational attainment (those with and without a bachelor’s degree), adjusting for covariates, and tested for interaction between sexual orientation and educational attainment. Data are drawn from the National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative survey of non-institutionalized US adults (N= 34 653; 577 LGB).
Results.
Sexual orientation disparities in mental health are smaller among those with a college education. Specifically, the disparity in those with versus those without a bachelor’s degree was attenuated by 100% for any current mood disorder, 82% for any current Axis-I disorder, 76% for any current anxiety disorder, and 67% for both any current substance use disorder and any current comorbidity. Further, the interaction between sexual orientation and education was statistically significant for any current Axis-I disorder, any current mood disorder, and any current anxiety disorder. Our findings for lifetime outcomes were similar.
Conclusions.
The attenuated mental health disparity at higher education levels underscores the particular risk for disorder among LGBs with less education. Future studies should consider selection versus causal factors to explain the attenuated disparity we found at higher education levels.
doi:10.1007/s00127-014-0849-5
PMCID: PMC4145056  PMID: 24570204
sexual orientation; disparities; education; psychiatric disorder
24.  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
25.  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

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