Kerith J. Conron

A Population-Based Study of Sexual Orientation Identity and Gender Differences in Adult Health

OBJECTIVES We provide estimates of several leading US adult health indicators by sexual orientation identity and gender to fill gaps in the current literature. METHODS We aggregated data from the 2001-2008 Massachusetts Behavioral Risk Factor Surveillance surveys (N = 67,359) to examine patterns in self-reported health by sexual orientation identity and gender, using multivariable logistic regression. RESULTS Compared with heterosexuals, sexual minorities (i.e., gays/lesbians, 2% of sample; bisexuals, 1%) were more likely to report activity limitation, tension or worry, smoking, drug use, asthma, lifetime sexual victimization, and HIV testing, but did not differ on 3-year Papanicolaou tests, lifetime mammography, diabetes, or heart disease. Compared with heterosexuals, bisexuals reported more barriers to health care, current sadness, past-year suicidal ideation, and cardiovascular disease risk. Gay men were less likely to be overweight or obese and to obtain prostate-specific antigen tests, and lesbians were more likely to be obese and to report multiple risks for cardiovascular disease. Binge drinking and lifetime physical intimate partner victimization were more common among bisexual women. CONCLUSIONS Sexual orientation disparities in chronic disease risk, victimization, health care access, mental health, and smoking merit increased attention. More research on heterogeneity in health and health determinants among sexual minorities is needed.

Transgender Health in Massachusetts: Results From a Household Probability Sample of Adults

Despite higher rates of unemployment and poverty among transgender adults (n = 131; 0.5% weighted) than among nontransgender adults (n = 28,045) in our population-based Massachusetts household sample, few health differences were observed between transgender and nontransgender adults. Transgender adults who are stably housed and participated in a telephone health survey may represent the healthiest segment of the transgender population. Our findings demonstrate a need for diverse sampling approaches to monitor transgender health, including adding transgender measures to population-based surveys, and further highlight economic inequities that warrant intervention.

Disproportionate exposure to early-life adversity and sexual orientation disparities in psychiatric morbidity

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 ones 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 and 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.

Education and race-ethnicity differences in the lifetime risk of alcohol dependence

Objectives: While lower socioeconomic status (SES) is related to higher risk for alcohol dependence, minority race-ethnicity is often associated with lower risk. This study attempts to clarify the nature and extent of social inequalities in alcohol dependence by investigating the effects of SES and race-ethnicity on the development of alcohol dependence following first alcohol use. Design: Cross-sectional analysis of data from the National Epidemiologic Survey on Alcohol and Related Conditions (n = 43 093). Survival analysis was used to model alcohol dependence onset according to education, race-ethnicity and their interaction. Setting: United States, 2001–2. Results: Compared with non-Hispanic white people, age-adjusted and sex-adjusted risks of alcohol dependence were lower among black people (odds ratio (OR) = 0.70, 95% confidence interval (CI) = 0.63 to 0.78), Asians (OR = 0.65, CI = 0.49 to 0.86) and Hispanics (OR = 0.68, CI = 0.58 to 0.79) and higher among American Indians (OR = 1.37, CI = 1.09 to 1.73). Individuals without a college degree had higher risks of alcohol dependence than individuals with a college degree or more; however, the magnitude of risk varied significantly by race-ethnicity (χ2 for the interaction between education and race-ethnicity = 19.7, df = 10, p = 0.03); odds ratios for less than a college degree were 1.12, 1.46, 2.24, 2.35 and 10.99 among Hispanics, white people, black people, Asians, and American Indians, respectively. There was no association between education and alcohol dependence among Hispanics. Conclusions: Race-ethnicity differences in the magnitude of the association between education and alcohol dependence suggest that aspects of racial-ethnic group membership mitigate or exacerbate the effects of social adversity.

A Longitudinal Study of Maternal Depression and Child Maltreatment in a National Sample of Families Investigated by Child Protective Services

OBJECTIVE To assess whether a change in depression predicts a mothers change in maltreatment. DESIGN Observational, repeated measures study. SETTING National Survey of Child and Adolescent Well-being, 1999 to 2004. PARTICIPANTS Mothers who retained custody of a child aged 0 to 15 years following a maltreatment investigation and completed at least 2 of 3 surveys (n = 2386). MAIN EXPOSURE Change in depression status between baseline and 18- and 36-month follow-ups, assessed with the Composite International Diagnostic Interview Short Form. MAIN OUTCOME MEASURES Change in psychological aggression, physical assault, and neglect between baseline and 18- and 36-month follow-ups, assessed with the Conflict Tactics Scale Parent-Child version. RESULTS One-third (35.5%) of mothers experienced onset or remission of depression. Onset of depression was associated with an increase of 2.3 (95% confidence interval, 0.2-4.4) psychologically aggressive acts in an average 12-month period, but was not statistically significantly associated with change in physical assault or neglect. CONCLUSION Depression is positively associated with maternal perpetration of psychological aggression in high-risk families.

Sex and Gender in the US Health Surveillance System: A Call to Action

Youth Risk Behavior Survey (YRBS) data have exposed significant sexual orientation disparities in health. Interest in examining the health of transgender youths, whose gender identities or expressions are not fully congruent with their assigned sex at birth, highlights limitations of the YRBS and the broader US health surveillance system. In 2009, we conducted the mixed-methods Massachusetts Gender Measures Project to develop and cognitively test measures for adolescent health surveillance surveys. A promising measure of transgender status emerged through this work. Further research is needed to produce accurate measures of assigned sex at birth and several dimensions of gender to further our understanding of determinants of gender disparities in health and enable strategic responses to address them.

“Counting” Transgender and Gender-Nonconforming Adults in Health Research Recommendations from the Gender Identity in US Surveillance Group

Gender minority refers to transgender and gender-nonconforming people whose sex assigned at birth is different from their current gender identity. US health surveillance systems do not routinely include questions to identify gender minority respondents, resulting in a lack of representative health data that can be used to evaluate the health of gender minorities. This omission represents a missed opportunity to understand the health and well-being of transgender and gender-nonconforming people as well as to learn more about sex and gender differences that may be relevant for the health of all people—gender minority and majority alike. In 2011, the Williams Institute at the University of California, Los Angeles, School of Law convened the Gender Identity in US Surveillance (GenIUSS) Group, bringing together a multidisciplinary and multi-institutional group of experts to increase population-based data about gender minority people through the inclusion of gender-related measures (e.g., assigned sex at birth, gender identity, transgender status) in surveys, with a particular consideration for publicly funded data-collection efforts. Drawing on the expertise and experience of the GenIUSS Group, this article provides an overview of challenges and opportunities and makes eight recommendations for “counting” gender minority adults in health research, with an emphasis on adult population-based surveys.

Sexual Orientation Differences in Asthma Correlates in a Population-Based Sample of Adults

To understand what conditions may correlate with asthma diagnoses in the lesbian, gay, and bisexual (LGB) population, we used Massachusetts Behavioral Risk Factor Surveillance System data to construct multivariable logistic regression models separately for LGB individuals and heterosexuals. Current or former smoking and obesity were positively associated with history of an asthma diagnosis among both LGB individuals and heterosexuals. Being underweight (negative correlation) and overweight and reporting frequent symptoms of depression in the preceding 30 days also predicted a history of asthma diagnosis among heterosexuals.

“Everyone Has a Right to, Like, Check Their Box:” Findings on a Measure of Gender Identity from a Cognitive Testing Study with Adolescents

Efforts to monitor the health of transgender youth, a small but high-risk population, are hindered by a lack of knowledge about how to accurately measure gender identity. Adolescents (n = 30) participated in semistructured qualitative interviews after completing a close-ended transgender-inclusive measure of gender. Interviews explored item comprehension and respondent burden. Participants, who were diverse in age (range = 15-21), gender identity, sexual orientation, and race-ethnicity, were accurately classified as male, female, or transgender. All youth understood transgender as a difference between the physical body and a persons internal sense of self. Nontransgender youth frequently used an example (a woman in a mans body) in their explanations and were largely supportive of the transgender options. Most transgender youth found a response option that they felt was appropriate. Transgender response options were added to a gender measure without impacting the accuracy of nontransgender responses or burdening the nontransgender adolescents in our sample. A modified measure (Gender: male; female; transgender, male-to-female; transgender, female-to-male; transgender, do not identify as exclusively male or female) is recommended for testing in samples that vary by age, race-ethnicity, socioeconomic status, language, and geography. Additional suggestions for research in this area are provided.

PUBLIC HEALTH INFRASTRUCTURE: BUILDING LGBT COMPETENCY INTO HEALTH CARE, INSTITUTIONS, AND POLICIES

The mission of public health is to fulfill ‘‘society’s interest in assuring conditions in which persons can be healthy.’’ In public health, a strong infrastructure provides the capacity to prepare for and respond to both acute and chronic threats to the Nation’s health, whether they are bioterrorism or weapons of mass destruction attacks, emerging infections, disparities in health status, or increases in chronic disease and injury rates. This article addresses the need to ensure that the public health system infrastructure has the capacity to carry out for LGBT people the three core functions of public health as set forth in the Public Health Infrastructure focus area of Healthy People 2010: