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Sexual minorities face significant health disparities

Sexual minorities were more likely to experience drug and alcohol use disorders, anxiety and depressive disorders, and cardiovascular disease, among other negative health outcomes. And increased stress stemming from discrimination and prejudice could be a potential reason for these disparities.

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Sexual minorities – or people who are attracted to members of the same sex or who identify as gay, lesbian or bisexual (LGB) – are at a higher risk for several different health problems at different points in their lives.

This is according to Penn State researchers who found that sexual minorities were more likely to experience drug and alcohol use disorders, anxiety and depressive disorders, and cardiovascular disease, among other negative health outcomes.

Cara Rice, assistant research professor in Penn State’s Methodology Center, said increased stress stemming from discrimination and prejudice could be a potential reason for these disparities.

“It’s generally believed that sexual minorities experience increased levels of stress throughout their lives as a result of discrimination, microaggressions, stigma and prejudicial policies,” Rice said. “Those increased stress levels may then result in poor health in a variety of ways, like unhealthy eating or excessive alcohol use.”

Stephanie Lanza, professor of biobehavioral health and director of the Edna Bennett Pierce Prevention Research Center, said the results — recently published in Annals of Epidemiology — help shed light on health risks that have been historically understudied.

“Discussions about health disparities often focus on the differences between men and women, across racial and ethnic groups, or between people of different socioeconomic backgrounds,” Lanza said. “However, sexual minority groups suffer substantially disproportionate health burdens across a range of outcomes including poor mental health and problematic substance use behaviors.”

While previous research has shown that sexual minorities are more likely to experience health problems like substance use disorders and mood or anxiety disorders, Rice said it is not as well known if those risks remain constant across age.

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“As we try to develop programs to prevent these disparities, it would be helpful to know which specific ages we should be targeting,” Rice said. “Are there ages where sexual minorities are more at risk for these health disparities, or are the disparities constant across adulthood?”

For the study, the researchers used data from about 30,999 participants between the ages of 18 and 65 from the National Epidemiologic Survey of Alcohol and Related Conditions-III. Data included information about past-year alcohol, tobacco, and drug use disorders, as well whether they had a history of depression, anxiety, sexually transmitted infections (STIs), or cardiovascular disease.

Lanza said the researchers used a method developed at Penn State, called time-varying effect modeling, to analyze the information.

“Using the time-varying effect model, we revealed specific age periods at which sexual minority adults in the U.S. were more likely to experience various poor health outcomes,” Lanza said, “even after accounting for one’s sex, race or ethnicity, education level, income, and region of the country in which they reside.”

The researchers found that overall, sexual minorities were more likely to experience all the health outcomes. Nearly a quarter — 24 percent — of sexual minorities had an alcohol use disorder in the year prior to the survey, compared to 15 percent of heterosexuals. Sexual minorities were also about twice as likely to experience anxiety, depression, and STIs in the previous year.

Additionally, risks for some health problems were higher at different ages. For example, the increased odds for anxiety and depression among sexual minorities was highest in their early twenties, while increased odds for poor cardiovascular health was higher in their forties and fifties.

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“We also observed that odds of substance use disorders remained constant across age for sexual minorities, while in the general population they tend to be concentrated in certain age groups,” Rice said. “We saw that sexual minorities were more likely to have these substance use disorders even in their forties and fifties when we see in the general population that drug use and alcohol use start to taper off.”

Rice said the findings could potentially be used to develop programs to help prevent these health problems before they start.

“A necessary first step was to understand how health disparities affecting sexual minorities vary across age,” Rice said. “These findings shed light on periods of adulthood during which intervention programs may have the largest public health impact. Additionally, future studies that examine possible drivers of these age-varying disparities, such as daily experiences of discrimination, will inform the development of intervention content that holds promise to promote health equity for all people.”

Sara A. Vasilenko, Syracuse University, and Jessica N. Fish, University of Maryland, also worked on this research.

Health & Wellness

Lesbian and bi women at increased risk of being overweight

Gay men however are less likely to be overweight than their straight counterparts, and more at risk of being underweight.

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Lesbian and bisexual women are at increased risk of being overweight or obese compared to heterosexual women, according to new research from the University of East Anglia and UCL.

Gay men however are less likely to be overweight than their straight counterparts, and more at risk of being underweight.

The study (‘Sexual orientation identity in relation to unhealthy body mass index (BMI): Individual participant data meta-analysis of 93,429 individuals from 12 UK health surveys’), published in the Journal of Public Health, is the first to investigate the relationship between sexual orientation and body mass index (BMI) using population data in the UK.

The findings support the argument that sexual identity should be considered as a social determinant of health.

The research team pooled data from 12 UK national health surveys involving 93,429 participants and studied the relationship between sexual orientation and BMI.

Lead researcher Dr. Joanna Semlyen, from UEA’s Norwich Medical School, said: “We found that women who identify as lesbian or bisexual are at an increased risk of being overweight or obese, compared to heterosexual women. This is worrying because being overweight and obese are known risk factors for a number of conditions including coronary heart disease, stroke, cancer and early death. Conversely, gay and bisexual men are more likely than heterosexual men to be underweight, and there is growing evidence that being underweight is linked to a range of health problems too, including excess deaths.”

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The study also found that gay men are significantly less likely than straight men to be overweight or obese.

According to the researchers, this study demonstrates that there is a relationship between sexual identity and BMI and that this link appears to be different for men and women.

“There are a number of possible explanations for these findings. We know that sexual minority groups are more likely to be exposed to psychosocial stressors, which impacts on their mental health and their health behaviours such as smoking and alcohol use and which may influence their health behaviours such as diet or physical activity,” Semlyen said. “These stressors include homophobia and heterosexism, negative experiences that are experienced by the lesbian, bisexual and gay population as a result of their sexual orientation identity and are known to be linked to health.”

Until 2008, sexual orientation wasn’t recorded in health surveys. This means that until recently it has not been possible to determine health inequalities affecting lesbian, gay and bisexual people.

The researchers hope that policy makers and clinicians will be able to use this evidence “to provide better healthcare and tailored advice and interventions for lesbian, gay and bisexual people.”

“We need longitudinal research to understand the factors underlying the relationship between sexual orientation and BMI, and research to understand more about being underweight, especially in this population,” Semlyen ended.

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Health & Wellness

Trans patients have 70% lower odds of breast cancer screening

Transgender patients had 70% lower odds of being screened for breast cancer, 60% lower odds of being screened for cervical cancer, and 50% lower odds of being screened for colorectal cancer.

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Patients who identify as transgender have lower odds of being screened for cancer. This was suggested by a new study from St. Michael’s Hospital, which also explored how doctors can address the disparity.

The study assessed screening rates for cervical, breast and colorectal cancer among 120 transgender patients eligible for screening and compared these with screening rates among the cisgender (i.e. non-transgender) patient population at the St. Michael’s Hospital Academic Family Health Team.

The study found that transgender patients had 70% lower odds of being screened for breast cancer, 60% lower odds of being screened for cervical cancer, and 50% lower odds of being screened for colorectal cancer. And this is even after accounting for other factors like age and the number of visits to the team.

“Our overall cancer screening rates were improving and if we hadn’t thought to look at this particular patient population we would have been happy with our results,” said Dr. Tara Kiran, a family physician and a researcher at the Centre for Urban Health Solutions of St. Michael’s. “This study stemmed from a realization that our system had the potential to miss patients whose gender had changed on their health card but who still required screening,” Dr. Kiran said. “Our findings have prompted us to develop a system to include transgender patients in the outreach we do to patients overdue for cancer screening so that we’re not missing anyone.”

Patients who have transitioned from female to male and still require cervical cancer screening are often missed when provincial agencies send reminders to those overdue.

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This analysis of cancer screening rates at the Family Health Team led Dr. Kiran and her colleagues to embark on a quality improvement project to learn more about perspectives towards cancer screening among transgender patients.

“In many cases, physicians had discussed cancer screening with patients and patients had made an informed decision not to get screened,” Kiran said. “That was really important for us to understand. For people who have transitioned from female to male, having a Pap test can be upsetting as it can sometimes be gender dysphoric.”

The research team is still investigating reasons to explain the lower rates of colorectal cancer screening among transgender patients.

Kiran and her team hope this research helps increase awareness among primary care providers of the unique health needs of transgender patients and helps prompt decision-makers to address systems that overlook these unique needs.

“This study shows the importance of an equity approach,” Kiran said. “Improvements in care may not reach everyone and we need to have targeted strategies to reach those with unique needs. Our research also highlights the importance of tracking not just whether patients have had a test but whether they have had an informed discussion… Improved shared decision-making may be a more appropriate quality improvement goal than increasing cancer screening rates. We are hopeful that engaging trans patients in our quality improvement efforts will help us challenge our assumptions and provide better care to the trans population.”

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Health & Wellness

Most oncologists don’t know how to treat patients with different SOGI, but most interested to learn

Most oncologists don’t know enough about treating patients with differences in sexual orientation or identity, according to a study that also – fortunately – found that most are also interested in learning more.

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Most oncologists don’t know enough about treating patients with differences in sexual orientation or identity, according to a study that also – fortunately – found that most are also interested in learning more.

Led by researchers from NYU School of Medicine and Moffitt Cancer Center, the study reported that the majority of oncologists were comfortable treating individuals who identify as lesbian, gay or bisexual, but only half expressed confidence in their knowledge of these patients’ health needs. Fewer of those surveyed (nearly 83%) said they were comfortable treating transgender individuals, and only 37% felt they knew enough to do so.

Members of the lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) community are at greater risk for certain types of cancer such as, cervical or oral, say the study authors. Furthermore, they cite studies showing that LGBTQ individuals are less likely to get screened for cancer but more like to engage in behaviors that increase cancer risk, such as drinking or smoking.

“Cancer care within the LGBTQ community is a largely ignored public health issue,” says Gwendolyn Quinn, PhD, a professor in the Departments of Obstetrics and Gynecology, and Population Health at NYU Langone Health. “To address this problem, we have to start by understanding the gaps in knowledge among physicians.”

Published online Jan. 16 in the Journal of Clinical on Oncology – the first-of-its-kind study surveyed 450 oncologists from the 45 NCI designated cancer centers in the US to assess their knowledge, attitudes, behaviors, and willingness to be educated about LGBTQ cancer patients.

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Besides Quinn, another NYU Langone researcher involved in the study is Megan E. Sutter, PhD. Other study authors include Matthew B. Schabath, Catherine A. Blackburn, Peter A. Kanetsky, Susan T. Vadaparampil, Vani N. Simmons, Julian A. Sanchez, and Steven K. Sutton, from Moffit Cancer Center in Tampa.

Interestingly, oncologists’ confidence in their ability to treat LGBTQ patients–when asked about it at the start of the survey and again at the end–dropped 20%, with the survey- serving as a process of identifying knowledge gaps.

Political affiliation and having LGBTQ friends or family were associated with both higher knowledge and interest in education.

As a result of their findings, researchers recommend cancer centers not only create an environment safe for patients to disclose their sexual orientation and gender identity, but also establish protocols for treating LGBTQ cancer patients.

“Oncologists and other cancer care providers need to consider sexual orientation and gender identity when assessing the needs of a patient,” says Quinn. “At the institutional level, education and further training should be offered to physicians so they can be both culturally sensitive and clinically informed about LGBTQ cancer issues.”

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Health & Wellness

One in five contract STI from somebody they met on a dating app

85% of 18-24 year olds have used dating apps. Unfortunately, of 2,000 respondents, 18% said they had caught an STI from someone they had met online.

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The sexual health risks for young adults are increasing through the use of dating websites and apps.

This is according to an original research by Zava, which found that 85% of 18-24 year olds have used dating apps. Unfortunately, of 2,000 respondents, 18% said they had caught an STI from someone they had met online, with chlamydia being the most common STI, with 10% of 18-24 year-olds catching the infection as a result of a meeting arranged through a dating app.

Interestingly, the rise in STIs like chlamydia and gonorrhea ought to be linked to lower levels of sexual health education; but as per Zava’s research, the opposite is true, with almost two thirds saying they feel informed about STIs.

The study also noted that young adults in rural areas are more likely to have been diagnosed with an STI as a result of their online activity than those in urban areas. Also, people who identify as gay are also more likely to have contracted an STI, with a third of young gay people testing positive for a sexually transmitted infections after meeting a partner online.

38% of people with an STI found out about the infection by noticing the symptoms, particularly for common STIs like chlamydia and gonorrhea rather than being told by the person they caught it from. Healthcare professionals suggest this could be partly due to the practice of people deleting the profiles of their previous partners, so they can’t always inform them if they are diagnosed with an infection later on.

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As an FYI: The most popular dating app among the respondents was Tinder, with 70% having used it, way ahead of Bumble (6%), Grindr (4%), Happn (2%) and Hinge (1%).

In terms of STI testing, it seems that for young people, the decision to get tested isn’t related to public service advertising. Only 5% of the general population and 12% of people who identify as gay reported that public service advertisements were their primary reason for getting tested. Overall, people who identify as gay or bisexual are more likely to get tested for STIs (34% and 33% respectively) than their straight counterparts (28%).

Commenting on the findings, Dr Kathryn Basford of Zava, said: “Both gonorrhoea and chlamydia are bacterial infections that can have serious health consequences if they remain untreated. Prevention is much better than treatment, so we advise all young adults meeting people online to use a barrier contraceptive like condoms, femidoms, or dental dams. Not only can barrier contraceptives prevent unwanted pregnancies, unlike other forms of contraception they also reduce the risk of contracting an STI.”

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Health & Wellness

Trans hormone therapy less risky than birth control pills, according to studies

A study suggests that hormone therapy for transgender people increases the risk of blood clots less than birth control pills and does not increase the risk of cardiovascular disease at all.

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Studies published in the Men’s Health Issue of AACC’s journal Clinical Chemistry suggest that hormone therapy for transgender people increases the risk of blood clots less than birth control pills and does not increase the risk of cardiovascular disease at all. These preliminary results could help more transgender individuals to access essential hormone therapy by increasing physician comfort with prescribing it.

Major medical associations agree that transgender individuals need to be able to express their gender in ways with which they feel comfortable and that this is the most effective treatment for psychological distress caused by incongruence between sex assigned at birth and gender.

For many transgender individuals, expressing their gender involves physically changing their body through medical steps such as taking hormone therapy.

However, transgender patients often experience difficulty getting hormone therapy prescriptions, to the point that one in four transgender women have to resort to illegally obtaining cross-sex hormones. Part of this is because existing research on transgender hormone therapy is limited and conflicting, which has led to some physicians denying patients this treatment out of concern that it could significantly increase the risk of health problems such as blood clots and cardiovascular disease.

A team of researchers led by Dina N. Greene, PhD, of the University of Washington in Seattle in the US estimated that in transgender women prescribed estrogen, blood clots only occur at a rate of 2.3 per 1,000 person-years. While this is higher than the estimated incidence rate of blood clots in the general population (1.0-1.8 per 1,000 person-years), it is less than the estimated rate in premenopausal women taking oral contraceptives (3.5 per 1,000 person-years), which means that it is an acceptable level of risk.

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In order to determine this, Greene’s team performed a systematic review of all studies that have included the incidence rate of blood clots in transgender women receiving estrogen therapy, identifying 12 that were most relevant. The researchers then used meta-analysis to combine the results of these 12 studies and calculate a risk estimate that is based on all available evidence to date.  

“Documenting the risks associated with hormone treatment may allow for prescribers to feel more comfortable with prescribing practices, allowing for better overall management of transgender people,” said Greene. “Our data support the risk of thrombotic events in transgender women taking estrogen therapy being roughly comparable to the risk of thrombotic risks associated with oral contraceptives in premenopausal women. Given the widespread use of oral contraception, this level of risk appears to be broadly accepted.”

In a second study, a team of researchers led by Guy G.R. T’Sjoen, MD, PhD, also conducted a systematic review of all studies that measured risk factors for cardiovascular disease in transgender people taking hormone therapy. The researchers identified 77 relevant studies in this area and found that the majority of them report no increase in cardiovascular disease in either transgender men or women after 10 years of hormone therapy. The studies that did indicate a higher cardiovascular disease risk for transgender women in particular mainly involved patients using ethinyl estradiol, a now obsolete estrogen agent, and are therefore no longer valid.

T’Sjoen’s team does state that their results are not conclusive due to the small sample sizes and relatively short duration of the studies in this area (and Greene’s team included a similar caveat for their work). However, it is important to look at Greene and T’Sjoen’s studies in the context of transgender research as a whole. The field only began to receive National Institutes of Health funding in 2017 and is also lagging due to the fact that transgender patients often aren’t identified in medical databases that provide data for research. In light of this, these studies are significant not only because they suggest that transgender hormone therapy is safe, but also because they underscore the need for longer-term, large scale studies involving this underserved population.

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Sexual, gender minority patients report greater comfort when SOGI’s collected via nonverbal self-report

Registrar form collection is the optimal patient-centered approach to collecting sexual orientation and gender identity information in the emergency department.

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Sexual or gender minority patients reported greater comfort and improved communication when SOGI was collected via nonverbal self-report.

This is according to “Assessment of Patient-Centered Approaches to Collect Sexual Orientation and Gender Identity Information in the Emergency Department”, a study done by Adil Haider, MD, MPH; Rachel R. Adler, ScD; Eric Schneider, PhD; et al and publisher din JAMA Network Open.

For this study, the researchers wanted to identify the optimal patient-centered approach to collecting sexual orientation and gender identity information in the emergency department (ED).

So they tapped four EDs on the east coast of the US that sequentially tested two different sexual orientation and gender identity (SOGI) collection approaches between February 2016 and March 2017.

A total of 540 enrolled patients were analyzed; the mean age was 36.4 years and 66.5% of those who identified their gender were female.

In particular, two SOGI collection approaches were tested: nurse verbal collection during the clinical encounter vs nonverbal collection during patient registration. The ED physicians, physician assistants, nurses, and registrars received education and training on sexual or gender minority health disparities and terminology prior to and throughout the intervention period.

Multivariable ordered logistic regression was used to assess whether either SOGI collection method was associated with higher patient satisfaction with their ED experience. Eligible adults older than 18 years who identified as a sexual or gender minority (SGM) were enrolled and then matched 1 to 1 by age (aged ≥5 years) and illness severity (Emergency Severity Index score ±1) to patients who identified as heterosexual and cisgender (non-SGM), and to patients whose SOGI information was missing (blank field). Patients who identified as SGM, non-SGM, or had a blank field were invited to complete surveys about their ED visit. Data analysis was conducted from April 2017 to November 2017.

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The study found that sexual or gender minority patients had significantly better Communication Climate Assessment Toolkit scores with nonverbal registrar form collection compared with nurse verbal collection (mean [SD], 95.6 [11.9] vs 89.5 [20.5]; P = .03). No significant differences between the 2 approaches were found among non-SGM patients (mean [SD], 91.8 [18.9] vs 93.2 [13.6]; P = .59) or those with a blank field (92.7 [15.9] vs 93.6 [14.7]; P = .70). After adjusting for age, race, illness severity, and site, SGM patients had 2.57 (95% CI, 1.13-5.82) increased odds of a better Communication Climate Assessment Toolkit score category during form collection compared with verbal collection.

In a gist (and to emphasize): Registrar form collection is the optimal patient-centered approach to collecting sexual orientation and gender identity information in the emergency department.

“Our interventional study assessing two potential methods to collect SOGI in the ED found that SGM patients reported significantly higher satisfaction with their experience in the ED with registrar nonverbal collection compared with nurse verbal collection,” the researchers stated. “In other words, SGM patients preferred a standardized collection process where all patients could report SOGI along with other demographical information vs being asked by a nurse during a clinical encounter. Non-SGM patients and those without reported SOGI information were no less satisfied with form collection compared with verbal collection.”

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