John R. Blosnich

A systematic review of the aetiology of tobacco disparities for sexual minorities

Objective To conduct a systematic review of the literature examining risk factors/correlates of cigarette smoking among lesbian, gay and bisexual (ie, sexual minority) populations. Methods Sets of terms relevant to sexual minority populations and cigarette smoking were used in a simultaneous search of 10 databases through EBSCOhost. The search was limited to the peer-reviewed literature up to January 2011, using no geographic or language limits. For inclusion, the paper was required to: (1) have been written in English, (2) have sexual minorities (defined by either attraction, behaviour, or identity) included in the study population and (3) have examined some form of magnitude of association for risk factors/correlates of any definition of cigarette smoking. A total of 386 abstracts were reviewed independently, with 26 papers meeting all inclusion criteria. Abstracts were reviewed and coded independently by authors JB and JGLL using nine codes derived from the inclusion/exclusion criteria. Results Studies used various measures of sexual orientation and of smoking. Risk factors that could be considered unique to sexual minorities included internalised homophobia and reactions to disclosure of sexual orientation. Some studies also indicated common smoking risk factors experienced at higher rates among sexual minorities, including stress, depression, alcohol use and victimisation. Conclusions This review identified risks that were associated with sexual minority status and common to the general population but experienced at potentially higher rates by sexual minorities. Government and foundation funds should be directed towards research on the origins of this disparity.

Prevalence of Gender Identity Disorder and Suicide Risk Among Transgender Veterans Utilizing Veterans Health Administration Care

OBJECTIVES We estimated the prevalence and incidence of gender identity disorder (GID) diagnoses among veterans in the Veterans Health Administration (VHA) health care system and examined suicide risk among veterans with a GID diagnosis. METHODS We examined VHA electronic medical records from 2000 through 2011 for 2 official ICD-9 diagnosis codes that indicate transgender status. We generated annual period prevalence estimates and calculated incidence using the prevalence of GID at 2000 as the baseline year. We cross-referenced GID cases with available data (2009-2011) of suicide-related events among all VHA users to examine suicide risk. RESULTS GID prevalence in the VHA is higher (22.9/100 000 persons) than are previous estimates of GID in the general US population (4.3/100 000 persons). The rate of suicide-related events among GID-diagnosed VHA veterans was more than 20 times higher than were rates for the general VHA population. CONCLUSIONS The prevalence of GID diagnosis nearly doubled over 10 years among VHA veterans. Research is needed to examine suicide risk among transgender veterans and how their VHA utilization may be enhanced by new VA initiatives on transgender care.

Disparities in Adverse Childhood Experiences Among Individuals With a History of Military Service

IMPORTANCE Adverse childhood experiences (ACEs) are associated with several adulthood health problems, such as self-directed violence. For some individuals, enlistment in the military may be an instrumental act to escape adverse household environments; however, to our knowledge prevalence of ACEs among persons with a history of military service has not been documented in the United States using population-based data. OBJECTIVE To compare the prevalence of ACEs among individuals with and without a history of military service. DESIGN, SETTING, AND PARTICIPANTS Data are from the 2010 Behavioral Risk Factor Surveillance System. Computer-assisted telephone interviews were conducted with population-based samples of noninstitutionalized US adults from January 1 through December 31, 2010. Analyses were limited to respondents who received the ACE module (n = 60,598). Participants were categorized by history of military service and whether a respondent was 18 years of age in 1973. MAIN OUTCOMES AND MEASURES History of military service was defined by active duty service, veteran status, or training for the Reserves or National Guard. The ACE inventory assessed 11 negative experiences before the age of 18 years. Weighted χ2 tests and multiple logistic regression analyses were used to examine differences in ACEs by history of military service, era of service, and sex. RESULTS Those with military experience had greater odds of any difference in prevalence of ACEs. In the all-volunteer era, men with military service had a higher prevalence of ACEs in all 11 categories than men without military service. Notably, in the all-volunteer era, men with military service had twice the odds of reporting forced sex before the age of 18 years (odds ratio, 2.19; 95% CI, 1.34-3.57) compared with men without military service. In the draft era, the only difference among men was household drug use, in which men with a history of military service had a significantly lower prevalence than men without a history of military service (2.1% vs. 3.3%; P = .003). Fewer differences were observed among women in the all-volunteer and draft eras. CONCLUSIONS AND RELEVANCE Differences in ACEs by era and sex lend preliminary support that enlistment may serve as an escape from adversity for some individuals, at least among men. Further research is needed to understand how best to support service members and veterans who may have experienced ACEs.

Disparities in Adverse Childhood Experiences among Sexual Minority and Heterosexual Adults: Results from a Multi-State Probability-Based Sample

Background Adverse childhood experiences (e.g., physical, sexual and emotional abuse, neglect, exposure to domestic violence, parental discord, familial mental illness, incarceration and substance abuse) constitute a major public health problem in the United States. The Adverse Childhood Experiences (ACE) scale is a standardized measure that captures multiple developmental risk factors beyond sexual, physical and emotional abuse. Lesbian, gay, and bisexual (i.e., sexual minority) individuals may experience disproportionately higher prevalence of adverse childhood experiences. Purpose To examine, using the ACE scale, prevalence of childhood physical, emotional, and sexual abuse and childhood household dysfunction among sexual minority and heterosexual adults. Methods Analyses were conducted using a probability-based sample of data pooled from three U.S. states’ Behavioral Risk Factor Surveillance System (BRFSS) surveys (Maine, Washington, Wisconsin) that administered the ACE scale and collected information on sexual identity (n = 22,071). Results Compared with heterosexual respondents, gay/lesbian and bisexual individuals experienced increased odds of six of eight and seven of eight adverse childhood experiences, respectively. Sexual minority persons had higher rates of adverse childhood experiences (IRR = 1.66 gay/lesbian; 1.58 bisexual) compared to their heterosexual peers. Conclusions Sexual minority individuals have increased exposure to multiple developmental risk factors beyond physical, sexual and emotional abuse. We recommend the use of the Adverse Childhood Experiences scale in future research examining health disparities among this minority population.

Drivers of Disparity: Differences in Socially Based Risk Factors of Self-injurious and Suicidal Behaviors Among Sexual Minority College Students

Abstract Lesbian, gay, and bisexual (ie, sexual minority) populations have increased prevalence of both self-injurious and suicidal behaviors, but reasons for these disparities are poorly understood. Objective: To test the association between socially based stressors (eg, victimization, discrimination) and self-injurious behavior, suicide ideation, and suicide attempt. Participants: A national sample of college-attending 18- to 24-year-olds. Methods: Random or census samples from postsecondary educational institutions that administered the National College Health Assessment during the Fall 2008 and Spring 2009 semesters. Results: Sexual minorities reported more socially based stressors than heterosexuals. Bisexuals exhibited greatest prevalence of self-injurious and suicidal behaviors. In adjusted models, intimate partner violence was most consistently associated with self-injurious behaviors. Conclusions: Sexual minorities’ elevated risks of self-injurious and suicidal behaviors may stem from higher exposure to socially based stressors. Within-group differences among sexual minorities offer insight to specific risk factors that may contribute to elevated self-injurious and suicidal behaviors in sexual minority populations.

Suicidal ideation among sexual minority veterans: results from the 2005-2010 Massachusetts Behavioral Risk Factor Surveillance Survey.

Suicide is a public health problem disproportionately associated with some demographic characteristics (e.g., sexual orientation, veteran status). Analyses of the Massachusetts Behavioral Risk Factor Surveillance Survey data revealed that more lesbian, gay, and bisexual (i.e., sexual minority) veterans reported suicidal ideation compared with heterosexual veterans. Decreased social and emotional support contributed to explaining the association between sexual minority status and suicidal ideation. More research is needed about suicide risk among sexual minority veterans; they might be a population for outreach and intervention by the Veterans Health Administration.

Access to Care for Transgender Veterans in the Veterans Health Administration: 2006–2013

A 2011 Veterans Health Administration directive mandated medically necessary care for transgender veterans. Internal education efforts informed staff of the directive and promoted greater access to care. For fiscal years 2006 through 2013, we identified 2662 unique individuals with International Classification of Diseases, Ninth Revision diagnoses related to transgender status in Veterans Health Administration medical records, with 40% of new cases in the 2 years following the directive. A bottom-up push for services by veterans and top-down education likely worked synergistically to speed implementation of the new policy and increase access to care.

Racial and Ethnic Differences in Current Use of Cigarettes, Cigars, and Hookahs Among Lesbian, Gay, and Bisexual Young Adults

INTRODUCTION Research demonstrates that lesbians, gays, and bisexuals (i.e., LGBs or sexual minorities) smoke more than their heterosexual peers, but relatively less is known about the heterogeneity within LGB populations, namely racial/ethnic differences. Moreover, smoking research on sexual minorities has focused mainly on cigarette smoking, with little attention to other forms of smoking, such as hookahs/water pipes. METHODS Using a large national sample of college students, we examined differences by race and sexual orientation in prevalence of smoking cigarettes, cigars/cigarillos/clove cigarettes, and hookahs. RESULTS All LGB racial groups had higher cigarette smoking prevalence than their heterosexual racial group counterparts. Significantly more White and Hispanic LGBs smoked hookahs when compared, respectively, with White and Hispanic heterosexuals. CONCLUSIONS Given the higher prevalence of multiple forms of smoking among sexual minorities, the heterogeneity within sexual minority populations and the nuances of multiple identities (i.e., racial, ethnic, and sexual minority), targeted-if not tailored-prevention and cessation efforts are needed to address smoking disparities in these diverse communities. Prevention, intervention, and epidemiological research on smoking behaviors among college attending young adults should take into account other forms of smoking, such as hookah use.

Associations of Discrimination and Violence With Smoking Among Emerging Adults: Differences by Gender and Sexual Orientation

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.

Health Disparities Among Sexual Minority Women Veterans

BACKGROUND Lesbian and bisexual (i.e., sexual minority) identity is more common among women veterans than among male veterans. Unique health issues have been identified among women veterans and among sexual minority women, but little is known about women who are both sexual minorities and veterans. This study aimed to compare demographic and health information from sexual minority women veterans with sexual minority women non-veterans and heterosexual women veterans. METHODS Behavioral Risk Factor Surveillance Survey data were pooled from ten U.S. states that elected to ask sexual identity during 2010. The analytic sample was comprised of women who identified both their sexual identity and veteran status (n=1,908). Mental health indicators were frequent mental distress, sleep problems, low social/emotional support, and low satisfaction with life. Health risk indicators included current smoking, overweight, and obesity. Physical health status was defined by three components: disability requiring assistive equipment, >14 days of poor physical health in the past 30 days, and activity limitations. RESULTS Compared with heterosexual women veterans, sexual minority women veterans had higher odds of mental distress (odds ratio [OR]=3.03, 95% confidence interval [CI]: 1.61-5.70) and smoking (OR=2.31, 95%CI: 1.19-4.48). After adjusting for demographic correlates, sexual minority women veterans had three times the odds of poor physical health (OR=3.01, 95%CI: 1.51-5.99) than their sexual minority non-veteran peers. CONCLUSIONS Results suggest sexual minority women veterans may experience unique health disparities relevant to provision of care in both Veterans Affairs (VA) and non-VA healthcare systems. Future research requires availability of data that include sexual minority status.