Jun 262017
 

All lesbian, gay, and bisexual (LGB)* people are not the same. I’ve long been an advocate that it’s not “the LGB community”, it’s “the LGB communities“. Even within just the lesbian “community”, there are subgroups. Everyone has different experiences, needs, and expectations. There is no one universal experience, and no monolithic community.

The easiest example is gender nonconformity. Within lesbian and female bisexual communities, for example, there are women who dress and act more masculine (“butch”) and women who dress and act more feminine (“femme”). The same is true for gay and male bisexual communities. Another example is “coming out”. While it’s a common experience, it’s not universal. I myself never had to “come out” to my family because my family was very accepting.. Bisexual people who date/marry opposite sex partners may also not choose to come out.

Despite differences, we know that there are some generalities about LGB communities. We know that LGB people, as a whole, have higher rates of depression than their straight peers. But we also know that not all LGB people have depression. Could gender nonconformity be the key?

Portrait of a boy, c. 1800. A boy who looked like this might well end up with depression after being teased and bullied.

Portrait of a boy, c. 1800. A boy who looked like this might well end up with depression after being teased and bullied.

Today’s study looked at depression, gender nonconformity, and LGB status among young adults in the United States. They used data from the Add Health study. Add Health was a study that started in schools and continued through until the participants were up to 32. The participants in today’s study were age 18-32. 86.7-93.1% of the sample (women-men range) were heterosexual. The rest were mostly heterosexual, bisexual, mostly lesbian/gay, or lesbian/gay. Depression was measured with a validated scale. Sexual orientation was rated on a Kinsey-type scale. And gender non-conformity was measured with a scale of activities, including team sports, religious activities, video game use, housework, and social activities.

What were the results?

At first, it looked like all the non-heterosexual participants were at higher risk for depression. Bisexuals had more depressive symptoms than lesbian and gay participants. However once they controlled for gender nonconformity, lesbians and gay men did not have more depression symptoms than heterosexuals. Bisexual participants continued to have higher rates of depression and controlling for gender nonconformity.

Who tended to be gender nonconforming? Young men were more nonconforming than young women. Lesbians and gay men were more nonconforming than all the bisexuals (including mostly straight and mostly gay), who were about as nonconforming as straight participants.

And the depression? Young women were more depressed than men. Black, Latino, and Asian participants were also more likely to have it. The same was true for those with low parental education levels and families with financial problems. Participants who were gender nonconforming reported more symptoms of depression than those who were conforming.

Lastly, the researchers looked at whether that depression held over time. Gender nonconformity did not predict depression in the future. Bisexuals, lesbian, and gay young adults were also not at risk for future depression; only depression in the moment. However individuals who identified as mostly heterosexual continued to have higher rates of symptoms. Individuals who are Black, Asian, female, had low parental education levels, or severe family financial problems, continued to have depression symptoms.

What does this really mean?

LGB young adults as a whole continue to be at higher risk for depression. However, that risk appears to mostly be an effect of gender nonconformity as a young adult. Those who are gender nonconforming as young adults are at higher risk for depression as young adults, but six years later that risk goes away. Why? Gender nonconformity is visible, and likely to result in the individual being a target for discrimination, which can result in depression. But then why doesn’t it continue six years later? Either the discrimination reduces (teenagers can be notoriously mean to each other), or the individuals develop coping skills or move into a more accepting community.

Additionally, bisexuals and mostly heterosexuals are at higher risk for depression than lesbians and gay men. Why? Well, it might be because they can “hide” and look heterosexual. That means they don’t need to “come out”. But it also means there’s less acceptance and acknowledgement of their orientation. That could have big effects.

What do we do with this information?

First, we can keep an eye out for the gender nonconforming young adults in our communities, whether they’re straight, bisexual, gay, or somewhere in between. We can support them when they need it. And second, we can create a more accepting environment. The less discrimination and the more acceptance of gender nonconformity, the less depression we are likely to see. We can make the world a positive place to be for everyone.

Want to read the abstract for yourself? The abstract is publicly available.

*: Please note that although today’s article does not use the word “cis” throughout despite the implication. The study in question examined cis individuals. However in my language, I use “men/male” and “women/female” to refer to gender identity, not biologic sex. So the general statements I make are intended to be inclusive of both cis and trans individuals, who can be lesbian/gay, bisexual, or straight.

Mar 062017
 

Lesbian, gay and bisexual (LGB) high school students are at higher risk for suicide than their heterosexual peers. The reasons are complex. The facts are simple. In the US in 2015, 29% of LGB youth report attempting suicide in the past year compared to 6% of their heterosexual peers. LGB youth also have higher rates of depression, anxiety, and non-suicidal self injury. Why? One of the main culprits is stigma.

It is still not a “good” or “normal” thing to be LGB in the United States. LGB people are very much in the minority. They are targets for discrimination and violence. All of this is part of stigma. There are different types of stigma. Structural stigma is policy, rule, and law based discrimination. Marriage inequality was one of the most talked-about forms of structural stigma.

If poor mental health outcomes like suicide attempts are partially because of stigma then we would expect changes in those mental health outcomes after a change in stigma. In other words, if marriage inequality is one way that society says “LGB is bad” and drives adolescents toward suicide, then when marriage inequality goes away adolescents should have fewer suicide attempts.

And that’s what the researchers in this week’s study looked at. They asked: Did youth suicide attempts go down after legalization of marriage equality?

The Study

The researchers looked at data from the Youth Risk Behavior Surveillance System (YRBSS). The YRBSS is a survey done by the Centers for Disease Control every 2 years. It’s conducted in 47 of the 50 United States.Among other things, the YRBSS asks about number of suicide attempts in the past 12 months.

They looked at data from 1999-2015. 2015 is before country-wide marriage equality. So instead of looking at national data, they looked state by state. They compared suicide attempts before and after legalization in that state. They also compared suicide attempts in states that legalized and in states that did not legalize in the same year.

In addition they compared straight suicide attempts to LGB suicide attempts. Only 25 states were actually asking about sexual orientation by 2015, so this part of the study was limited.

In total there were data from roughly 760 thousand adolescents. 12.7% of students in states that asked about sexual orientation identified as LGB. 2.3% were gay/lesbian, 6.4% were bisexual, and 4% were uncertain.

8.6% of all students had attempted suicide in the past year before marriage equality. That dropped by 0.6% to 8.0% after same-sex marriage was legalized. If we extrapolate out, that’s roughly 134 thousand adolescents who did not attempt suicide after marriage equality.

For LGB students the difference was even more impressive. Out of 231 thousand adolescents, 28.5% had attempted suicide in the past year prior to legalization. After marriage equality it dropped by 4.0% to 24.5%. That’s a relative reduction of 14%.

And for the statistically nerdy folks among us, those results were statistically significant at the p = 0.05 level.

Nice data, but what does it mean?

Here’s the bottom line. There were fewer suicide attempts in all high school students after marriage equality. This was especially true among LGB youth, but the effect was seen in all youth.

There’s a very important lesson in these results. Legal policies and the message those policies convey have very real effects on health. And it’s not just as simple as policies like mandatory vaccination and the resulting drop in infectious diseases. Denying same sex couples the right to marry and all the legal protections associated with marriage sends the message that LGB people are inferior. And our youth hear that. It has very real effects on their health. It’s behooves us as a society to examine other policies like employment and school protections to see if they send the same message.

From a personal perspective, these results are not surprising. While the Defense of Marriage Act was still law, even as a teenager I was very aware of what that meant for my legal rights. I knew about, and was distressed by, the lack of hospital visitation rights and insurance coverage. As an adult the knowledge that I have the legal right to make medical decisions for my wife without question is immensely comforting. We have a long way to go on other matters, but this one small step makes a difference.

Lastly, never underestimate suicidality. If you or someone you love is in crisis, the Trevor Project is an LGBT friendly suicide hotline for youth. Adults who need assistance can find the right hotline for them here.

Want to read the study for yourself? The abstract is publicly available.

Jan 092017
 

Most people today know that cigarette smoking is bad for you. The mantra is drilled into children in school. Tobacco causes COPD and the vast majority of cancers, especially lung cancers. It raises the risk for heart disease. Asthma, diabetes, and osteoporosis are made worse by tobacco. And for pregnant women, tobacco causes birth defects. Children exposed to tobacco are more prone to asthma, ear infectious, and death by Sudden Infant Death Syndrome. (Source)

The negative effects of cigarettes comes from the chemicals in the tobacco plant plus chemicals added by the cigarette manufacturer. It’s not all added by the manufacturer. Hand-made cigarettes, snuff, and cigars still cause disease. Unfortunately tobacco also contains nicotine. Nicotine by itself is relatively harmless, but it is highly addictive. It’s also a stimulant, giving a “high” of its own that many find temporarily helpful as they deal with the stresses of life. Physical and psychological addiction together make it very difficult to quit smoking.

A nicotine patch, one of the main aids in quitting smoking

A nicotine patch, one of the main aids in quitting smoking

Quitting is possible. No matter how many packs a smoker has smoked, their health improves when they quit. For many it can take multiple tries before they’re able to quit for good. And I’m sure you’ve seen the advertisements; there are medications and therapies out there to help those who are interested.

Because smoking is such a huge public health issue, the United States government included tobacco use in its Healthy People 2020 project. Healthy People is a set of goals to improve the health of the US population. In 2008 when the project started 20.8% of US adults smoked. They want to reduce that number to 12% by the year 2020.

Sound ambitious? Perhaps. But on November 11th, 2016 the Centers for Disease Control released new data on smoking rates in the US. This included data from 2005 to the 2015 National Health Interview Survey. So we can see the progress for ourselves!

But wait, why am I talking about smoking on a blog dedicated to gender and sexual minority healthy? Because LGBT people smoke more than our heterosexual and cisgender neighbors. And in this new report, the CDC actually included information on LGB smoking. Let’s take a look!

The Data

Good news, everyone!

Graph of the decline in smoking rate20.9% of adults in the United States smoked in 2005. By 2014, only 16.8% smoked. That fell to 15.1% by 2015! And among those who currently smoke, fewer reported smoking every day; from 80.8% of smokers being daily smokers in 2005 to 75.7% in 2015. And the number of cigarettes smoked per day dropped too; from 16.7 in 2005 to 14.2 in 2015. So not only are fewer people smoking overall, but those who are smokers are smoking less.

Unfortunately smoking is not so low in all groups. When the CDC looked at subgroups, there were some stark differences. Here are the groups who smoked the most in their analysis:

  • Individuals experiencing serious psychological distress: 40.6% vs 14% who did not
  • Those with a GED: 34.1% vs 3.6% of those with a college degree
  • Medicaid enrollees (27.8%) and people without insurance (27.4%), vs those with private insurance (11.1%) or Medicare only (8.9%). A reminder for international audiences — Medicaid is the US public health insurance for the poor. Medicare is the equivalent for those over the age of 65 or with certain health conditions
  • The poor: 26.1% vs 13.9%
  • People with disabilities: 21.5% vs 13.8%
  • Lesbian, gay, and bisexual people: 20.6% vs 14.9%. (Transgender people were not included in this analysis)
  • Men more than women: 16.7% vs 13.6%

In other words: People with poor mental health, the poor, the undereducated, the disabled, and minorities are more likely to be smokers. And lesbian, gay, and bisexual people are more likely to be smokers than their heterosexual neighbors. 1 in 5 LGB people smoke. 1 in 6 heterosexual people smoke.

Unfortunately we can’t see how the percentages have changed for LGB people. The survey in 2005 did not include sexual orientation. But even from this one snippet of data we know that LGB people are indeed at risk.

But why?

Why is there this difference in smoking rates?

The truth is that we don’t know for certain. But here are some possibilities:

  • Stress. Smoking, like other substance use, is something that many people try to use to control the stress in their lives. The brief “high” of the nicotine helps for a short time. Unfortunately it’s not the most effective long-term solution. But being part of a minority is stressful, so we’d expect to see more minorities smoking simply because of that stress.
  • Advertising. The LGBT community has been specifically targeted in some smoking advertisements.
  • Lack of targeted anti-smoking campaigns and resources
  • Lack of health insurance and access to physicians in order to access help in quitting

And likely there are many other reasons.

What can we do about smoking?
One LGBT-targeted ad to quit smoking

One LGBT-targeted ad to quit smoking

First, and most importantly, is to quit smoking yourself if you smoke. Resources specific to LGBT communities include smokefree.gov and lgbttobacco.org. If you don’t smoke but a loved one does, support them in their efforts to quit.

As a community we can provide smoke-free spaces. Smoke-free bars are important, as are social events that aren’t in bars. We can choose imagery without cigarettes and remove cigarette-including glamour shots from our community spaces.

More broadly, emotional and financial support are important factors involved with smoking. As we saw, people who are emotionally struggling are more likely to be smokers. Supporting each other as a community may help, and with that help preventing smoking and quitting may become more feasible.

Lastly, vote if you can. Policy-level decisions can and do impact smoking rates! For example, raising taxes on cigarettes increases the number of people who quit in a community. And funding for quitting programs often comes from government sources. So make sure you vote (if you can)!

Want to read more on the topic? The original CDC paper is publicly available. Healthy People 2020 also has more information on smoking.

Jun 272016
 

Welcome back to Open Minded Health Promotion! This week is all about how cisgender women who have sex with women, including lesbian and bisexual women, can maximize their health. As a reminder — these are all in addition to health promotion activities that apply to most people, like colon cancer screening at age 50.

Woman-and-woman-icon.svgAll cisgender women who have sex with women should consider…

  • Talk with their physician about their physical and mental health
  • Practice safer sex where possible to prevent pregnancy and sexually transmitted infections. Some sexually transmitted infections can be passed between women. If sexual toys are shared, consider using barriers or cleaning them between uses.
  • If under the age of 26, get the HPV vaccine. This will reduce the chance for cervical, vaginal, anal, and oral cancers.
  • Avoid tobacco, limit alcohol, and limit/avoid other drugs. If you choose to use substances and are unwilling to stop, consider using them in the safest ways possible. For example, consider vaporizing marijuana instead of smoking, or participate in a clean needle program.
  • Maintain a healthy weight. Women who have sex with women are more likely to be overweight than their heterosexual peers. Being overweight is associated with heart disease and a lower quality of life.
  • Exercise regularly. Weight bearing exercise, like walking and running, is best for bone health. But anything that gets your heart rate up and gets you moving is good for your body and mind!
  • Seek help if you’re struggling with self injury, anorexia, or bulimia. These issues are much more common in women than in men, and can be particularly challenging to deal with.
  • Consider taking folic acid supplements if pregnancy is a possibility. Folic acid prevents some birth defects.
  • Discuss their family’s cancer history with their physician.

Your physician may wish to do other tests, including…

  • Cervical cancer screening/Pap smear. All women with a cervix, starting at age 21, should get a pap smear every 3-5 years at minimum. Human papilloma virus (HPV) testing may also be included. More frequent pap smears may be recommended if one comes back positive or abnormal.
  • Pregnancy testing, even if you have not had contact with semen. Emergency situations are where testing is most likely to be urged. Physicians are, to some extent, trained to assume a cisgender woman is pregnant until proven otherwise. If you feel strongly that you do not want to get tested, please discuss this with your physician.
  • BRCA screening to determine your breast cancer risk, if breast cancer runs in your family. They may wish to perform other genetic testing as well, and may refer you to a geneticist.
  • If you’re between the ages of 50 and 74, mammography every other year is recommended. Mammography is a screening test for breast cancer. Breast self exams are no longer recommended.

One note on sexually transmitted infections… some lesbian and bisexual women may feel that they are not at risk for sexually transmitted infections because they don’t have contact with men. This is simply not true. The specific STIs are different, but there are still serious infections that can be spread from cis woman to cis woman. Infections that cis lesbians and bisexual women are at risk for include: chlamydia, herpes, HPV, pubic lice, trichomoniasis, and bacterial vaginosis (Source). Other infections such as gonorrhea, HIV, and syphilis are less likely but could still be spread. Please play safe and seek treatment if you are exposed or having symptoms.

Want more information? You can read more from the CDC, Gay and Lesbian Medical Association, and the United States Preventative Services Task Force.

Mar 072016
 

Double_mars_symbol.svgGay and bisexual cisgender men (men who have sex with men) have their own health needs…and unlike what the popular media would suggest, it’s not all about HIV.

All men who have sex with men should…

  • Talk with their physician about their physical and mental health
  • Talk with their physician about their risk for HIV infection and discuss pre-/post- exposure prophylaxis, in case prophylaxis is ever needed
  • Avoid the use of steroids
  • Practice safer sex where possible. Barrier methods such as condoms and dental dams are best.
  • Receive the Hepatitis A and Hepatitis B vaccines. If you are HIV+, you may also need additional immunizations depending on your T cell count. Those additional vaccines include measles/mumps/rubella, pneumococcus, and varicella (chicken pox).
  • If under the age of 26, get the HPV vaccine. This will reduce the chance for anal, oral, and penile cancer.
  • Talk with their physician about substance use, if relevant. If you choose to use substances (e.g., “poppers” during sex) and are unwilling to stop, consider using them in the safest ways possible. As always, it’s best to avoid tobacco, limit alcohol, and limit/avoid other drugs as much as possible
  • Take special care to maximize your mental health. Get a support network in place.
  • Get help if you’re experience domestic violence.
  • See your physician regularly to maintain your health

Your physician may wish to do other tests, including:Emoji_u1f46c.svg

  • Anal pap smear. This is a test to screen for anal cancer.
  • PSA blood test or digital rectal exam. These are screening tests for prostate cancer. The PSA, however, is not recommended routinely by the USPSTF because it is often positive even when there is no cancer. Talk with your physician about the pros/cons about the PSA before getting it.

If you have unprotected anal sex, especially with multiple partners, you should be checked for the following infections and health conditions:

  • Hepatitis B and Hepatitis C
  • HIV
  • Syphilis
  • Other sexually transmitted infections

Your physician may wish to screen you for these infections even if you do not have unprotected anal sex.

If you are HIV+ it is extremely important that you continue to receive medical care for HIV. This can be through specialized infectious disease physicians or your primary care. Keeping the HIV viral load low is the best way to live a long and healthy life and avoid spreading the virus to others.

Need more information? Check out the CDC, USPSTF, and GLMA webpages.