Oct 052015
 

480px-RGB_LED_Rainbow_from_7th_symmetry_cylindrical_gratingI’ve been saying for years now that the phrase “LGBT community” is insufficient when it comes to health. It’s not one community — it is multiple communities. The social issues and health issues that a gay transgender man faces every day are different from the issues a bisexual cisgender woman faces every day. There are some similarities and grouping the communities together has been politically useful. But it should never be forgotten that L, G, B, and T all face different types of health concerns and have different civil rights battles to face.

A study came out in August that has to be one of my favorites this year. Researchers in Georgia surveyed over three thousand lesbian, gay, bisexual, pansexual, transgender, gender non-conforming, and queer people. They asked about health behaviors of all kinds. And then they did statistical analysis, comparing the various genders (cis male, cis female, trans male, trans female, genderqueer) and sexual orientations (lesbian, gay, bisexual, pansexual, queer, straight). Let’s look at what they found!

  • Diet and exercise: The researchers asked about fatty foods, eating while not hungry, quantity of vegetables and fruits eaten, and about hours and types of exercise. Transgender women had the least healthy diet of all genders. As a group, they were less likely to eat many fruits and vegetables, and more likely to drink sugared drinks and eat when they weren’t hungry. Both cisgender and transgender men were also less likely to eat many vegetables compared with other groups. Genderqueer people and gay cisgender men were most likely to exercise.
  • Substance use: The researchers asked about smoking tobacco and alcohol consumption. Cisgender men were the most likely to drink alcohol, binge drink, and to drink even when they didn’t want to. Participants who identified as queer were also more likely to drink. When it came to tobacco, transgender men and straight participants were the most likely to smoke.
  • Motor vehicle risk: The researchers asked about seatbelt use, speeding, and texting while driving. No clear differences for speeding were noted. Transgender men and straight participants were most likely to drive without a seatbelt. Texting while driving varied considerably; gay and lesbian drivers were most likely to text while driving.
  • Sexual behaviors: The researchers asked about frequency of unprotected sex and sex while intoxicated. Gay men were least likely to have unprotected sex while lesbian women were most likely to have unprotected sex. When it came to sex while intoxicated, only the bisexual participants stood out as being most likely among the groups to have sex while intoxicated.
  • Violence: The researchers asked about self harm and expressing anger at others. Overall rates of interpersonal anger were very low. Transgender men and pansexual people were most likely to self harm.
  • Medical risk taking: The researchers asked about delaying medical care and not following physician advice. Transgender women were least likely to seek care; 1/3 reported that they regularly delayed seeking medical care. Both transgender women and transgender men were more likely to not follow medical advice when it was given. Bisexual people were also more likely to delay seeking medical care compared to lesbian and gay participants.

That’s a mouthful, right? There are a lot of details I left out of this summary and it still threatens to be overwhelming with detail. So how we can break this down even more simply? By talking about the conclusions.

The researchers go into some possible causes for all these different results. Maybe gay men are safer about sex because of HIV risk. Maybe transgender men eat few vegetables because of cultural expectations that “men eat lots of meat and not many vegetables.” Maybe gay and lesbian people text more while driving because of the lack of community-specific messages.

Maybe. And they’re all good thoughts.

I tend to look forward more to what we can do with these data. I’m pretty happy with this study — it’s one of the broadest I’ve seen for inclusion. Few health-oriented pieces of research include pansexual and genderqueer individuals.

It’s important to remember that these results are at the group level. Any individual person who is a gender/sexual minority will have their own health behaviors and risks. They should be evaluated and treated as individuals. From a public health perspective though, this research brings valuable data. Only by knowing what each group faces can prevention, screening, and treatment campaigns be created. Only by knowing, for example, that transgender and bisexual people avoid seeking medical care can we then examine “why?” and act to remove the barriers so that appropriate, respectful medical care is available.

So — can we change the conversation? Instead of talking about “the LGBT community”, let’s talk about “the LGBT communities”. Or, even better, “gender and sexual minority communities” — removing the alphabet soup and expanding the definitions at the same time. This research is only the tip of the iceberg. We have so much more to explore.

The paper is published online ahead of print. The abstract is publicly available.

Aug 102015
 

Rainbow ribbon for LGBT+ cancer awarenessGender and sexual minority health isn’t just about HIV/AIDS, sexually transmitted infections, and mental health. It’s also about cancers, and our exposures to risk factors for cancers. Why? Because everyone can get cancer, and we all need both preventative and therapeutic health care.

Cancer is not just one disease, which is why it’s been so difficult to “cure”. Cancer is when a cell mutates and grows out of control. The cells begin to invade other tissues, and can spread throughout the body. Any cell can become cancerous. And different cancers are caused by different things and have different treatments.

A recent paper, published online ahead of print, looked at the data surrounding lesbian, gay, bisexual and transgender/transsexual (LGBT) populations and cancers. They specifically looked at cancers which may be more common in LGBT communities: anal, breast, cervical, colon/rectal, endometrial, lung, and prostate cancers.

Why might these cancers be more common in LGBT communities? Perhaps because of higher levels of risk factors like obesity, smoking, and certain infections. Or perhaps because of lack of preventative health care.

But what do the data say? What data do we even have? So far it looks like we don’t have much information. Most studies about cancers don’t ask about sexual orientation or gender identity. But let’s take the data one cancer type at a time, just as the paper did…

Anal cancer is a rare cancer of the anus. It’s primarily associated with HIV infection and HPV infection. Men who have sex with men, because they are at high risk for HIV and HPV infections, are at higher risk for anal cancer. The risks for women and transgender people are unknown. The best prevention for anal cancer is the HPV vaccine and consistent use of condoms to prevent HPV and HIV infections. Screening, to catch cancers in their most treatable state, can be done through the anal pap test. However there are no guidelines for the anal pap test and its value as a screening tool is uncertain. Treatment for anal cancer can impact not only general quality of life for survivors but sexual quality of life for men who have sex with men. The effects on sexual quality of life may be under appreciated by physicians.

Breast cancer is among the most frequently diagnosed cancers in women. Unlike with anal cancer, there are no obvious risk factors beyond being a cisgender woman. There are no data on how rates of breast cancer differ between heterosexual, bisexual and lesbian women. It is thought that bisexual/lesbian women may be at higher risk of breast cancer because of high rates of smoking, alcohol use, and obesity. Lesbian/bisexual women are also less likely to carry a pregnancy. However, it’s not known if those risk factors are actually associated with higher rates of disease. There are no data on cis or trans male breast cancer. Trans women were thought to potentially be at higher risk because of the hormones they take, but data so far seem to indicate that they’re at low risk. When it comes to screening, the best screenings so far are clinical breast exams and mammography. Women who have sex with women are less likely to receive either. Once they survive a breast cancer, women who have sex with women may be at risk for sexual side effects more than heterosexual women.

Cervical cancer is a cancer that exclusively affects cisgender women, pre-op trans men and others who have a cervix. There are no data describing how the risk for cervical cancer may be different for bisexual/lesbian women and trans men. The biggest risk for cervical cancer is HPV infection. The best prevention of cervical cancer includes the HPV vaccine and the use of barriers to prevent HPV infection. For screening, pelvic exam with pap smear at a regular interval is recommended. Women who have sex with women are less likely to receive the vaccine and less likely to receive regular screenings. Anecdotal evidence suggests that the same is true for trans men. This would leave both bisexual/lesbian women and trans men at higher risk for cervical cancer, and higher risk that if there is cancer it will be discovered at a later stage. No studies have been performed examining how women who have sex with women and trans men fare after a cervical cancer diagnosis.

Colon cancer is the third most common cancer in both men and women. Preliminary studies indicate that lesbian, gay, and bisexual cisgender people are not being diagnosed with colon cancer more frequently than heterosexual people are. There are no data on trans people. However, LGB people are more likely to have risk factors like obesity, smoking, and alcohol use. On the whole, they are also less likely to receive screenings for colon cancer. The exception is gay and bisexual men, who receive colonoscopy and sigmoidoscopy more often than heterosexual men (the authors theorize that this may be because colonoscopy and sigmoidoscopy are used to diagnose difficulties with receptive anal sex). No studies have compared side effects in LGBT survivors. However, clinicians should advise men who have receptive anal sex that treatment may impact their sexual life.

Endometrial cancer is a cancer of the lining of the uterus, which can affect any individual with that lining. There are no data on lesbian, bisexual, or transgender populations nor are there recommendations for prevention and screening for endometrial cancer. Survivor outcomes are similarly murky. However the authors note that lesbian and bisexual women, because of stigma, may seek medical care later than heterosexual women. The authors advocate for a welcoming LGBT environment for patients to facilitate early detection and treatment.

Lung cancer is the leading cause of cancer death worldwide and is primarily caused by tobacco smoke. There are no direct studies of lung cancer in LGBT populations, but LGBT people are far more likely than heterosexual/cisgender people to smoke. LGBT people, as a whole, are thus at higher risk for lung cancer. While an annual screening (via low-dose CT scan) is recommended for some long term smokers, the guidelines were not intended for LGBT patients and may not be appropriate. Outcomes and side effects are unknown for LGBT people.

Prostate cancer is a cancer that exclusively affects cisgender men and transgender women (regardless of surgical status — the prostate is not removed in surgery). HIV+ men may be at lower risk for prostate cancer, though that may be an artifact of testing. The risk of prostate cancer for trans women is unknown, but is not zero. The screening test for prostate cancer, prostate specific antigen (PSA), is of limited value, but it appears that there are no differences in screening based on sexual orientation. Treatment for prostate cancer often has sexual and bowel side effects which may affect men who have sex with men differently (particularly men who prefer receptive anal sex).

Astute readers may have noticed a trend: There are not enough data. This is a huge problem in gender and sexual minority health. We just do not know enough, particularly about topics other than HIV. While some research is going on now to try to tackle these issues, it will be a while before those results come out and get validated.

So in the mean time, what is an LGBT+ person, worried about cancer, to do? You have options! You can…

  • Find a medical provider whom you feel safe and comfortable with, and make sure you come out to them. Ask them about screening schedules for you, given your own set of risk factors. Screenings will not prevent cancer, but they will allow your physician to detect cancer in its earliest, most curable stages and could save your life.
  • Exercise, achieve/maintain as healthy a weight as you can, and eat a varied diet. All of these things will help reduce your risks.
  • Quit smoking, if you currently use tobacco. Don’t start to use tobacco if you currently don’t. All forms of tobacco cause cancer, including chew and snuff.
  • Limit alcohol consumption. Drinking a lot is associated with higher rates of some cancers.
  • Be HPV-aware, and get vaccinated if you can. Use barriers in sexual encounters to prevent both HPV and HIV infection.
  • Be as familiar with your body as you can, so that you can detect changes and notify your physician.

Want to read the study for yourself? It’s publicly available!

Aug 152013
 

Rope (often used in BDSM ) smiley face - CC BY 3.0 Rose Lovell

A new psychological study of BDSM practitioners has just been published. This is the first such research to specifically examine the “Big Five” personality characteristics.

For those of you not interested in the nitty-gritty, here’s the digest: As a group, people who practice BDSM report a better sense of well-being and are more open to new experiences, extraverted, conscientious, and less sensitive to rejection than people who don’t practice BDSM. As with all correlations, this does not mean that BDSM activities caused these differences. Rather, people with these characteristics may be more likely to investigate BDSM.

Are you interested in the details? Cool! Let’s break this study down then.

First, some basics on BDSM. As some readers may remember, BDSM is an acronym standing for: Bondage, Dominance/Submission, SadoMasochism… and probably a few others besides. BDSM is considered an “alternative” sexuality and is highly stigmatized here in the United States. BDSM is often misrepresented as a purely sexual practice focused on pain. In truth, it’s often more sensual than sexual or painful. Many forms of BDSM “play” involve no sex or pain at all. Specific practices vary a lot depending on the people involved**.

Within BDSM, a person is typically in one of three roles: dominant (dom/domme), submissive (sub), or switch. The terms are fairly self explanatory. Dominant “has” control, submissive “gives” control, a switch is someone who switches roles*. Sometimes being a dom/sub/switch is referred to as an orientation, sometimes it’s a role for a particular activity (“scene”)***.

What about these personality characteristics? In personality psychology, there’s the concept of the “big five” personality characteristics, OCEAN: Openness, Conscientiousness, Extraversion, Agreeableness, and Neuroticism. Personality characteristics are thought to be innate. You’re born with a certain personality, and it’s relatively unchangeable. Each of the “big five” can be thought of as a line, and each person falls somewhere along that line. To wit….

  • Openness: How open to new experiences are you? Open vs cautious
  • Conscientiousness: How tidy, thorough and responsible are you? Organized vs careless
  • Extraversion: How much do you enjoy being around other people? Extravert vs introvert
  • Agreeableness: How trusting and cooperative are you? Friendly vs cold
  • Neuroticism: How easily do things tip you emotionally off balance? Easily upset vs steady

Some of these traits are associated with greater happiness and resiliency (e.g., Openness, Agreeableness and Extraversion) whereas others are associated with mental instability or illness (e.g., Neuroticism). There are nuances, overlaps, and arguments over these concepts that I won’t address here, but I hope that gives you a good starting place for understanding the study results. Let me know in the comments if it doesn’t and I’ll gladly expand. This study looked at more than just the “big five”. It also included measures of rejection sensitivity, attachment style, and subjective well being.

So why look at the “big five” and all those others in the context of BDSM? The arguments of the researchers make some sense. While BDSM and the “big five” have not been directly compared before, there is some evidence that the “big five” is associated with certain sexual attitudes. The more open you are, the more permissive your attitudes around sex. The more neurotic you are, the less stable your relationships, thus impacting your sexual life. And so on. Similarly, people with secure attachment styles are more likely to have a wide variety of sexual behaviors and better trust with partner(s) than people with insecure attachment styles.

So we have our variables: the “big five”, rejection sensitivity, attachment style, subjective well-being. What about our participants?

BDSM participants were 902 Dutch people, 464 male and 438 female (no mention of trans or genderqueer folks), recruited from one Dutch BDSM forum. Control participants were 434 Dutch people screened for BDSM behavior, 129 male and 305 female, recruited from magazine ads or websites having to do with “secrets”. Men in the study were older than women. I’m really not sure this control is an adequate control for this study because of the recruitment methods… but I’m not sure it’s not either. Differences between the groups? There certainly were some other than the practice of BDSM. There were significantly more women in the control group than the BDSM group. The control group was younger and less well educated than the BDSM group, although both were more well educated than the average Dutch citizen. Whether these differences affected the study results is unknown, but a possibility.

The researchers also note a gender difference between roles in the BDSM group. Men were 33.4% submissive, 18.3% switch, and 48.3% dominant identified. Women, on the other hand, were 75.6% submissive, 16.4% switch, and 8% dominant. This is certainly reflected in the stereotypes associated with BDSM activities.

Results included:

  • People who practice BDSM were more Open, Extraverted, and Conscientious than the control participants.
  • People who practice BDSM were less Neurotic and Agreeable than the control participants
  • People who practice BDSM were less sensitive to rejection than people who didn’t practice BDSM. Within the BDSM participants, submissives were more sensitive to rejection than dominants
  • People who practice BDSM had a greater sense of well-being than control participants. Dominants scored the highest on well-being.
  • Relatively few differences between BDSM participants and control participants was found when attachment styles were examined. When there was a difference, BDSM participants had a more secure attachment than control participants.

Effect sizes were small to medium. That is about average for a psychological study.

The OCEAN results make sense within the context of BDSM. In order to even try BDSM activities, you’d need to be open to new experiences. Conscientiousness is also valued, in order to be safe. Extraversion is helpful within a community setting. The rejection sensitivity results also make sense to me – a timid person may not continue to explore BDSM after one or two rejections. But this is all after-the-fact reasoning, and not particularly predictive or scientific.

The authors note that these results contradict the long-standing assumption that women who participate in BDSM so do because they were abused as children. But they didn’t ask directly about childhood sexual abuse. Rather, they draw this conclusion from the established relationship between attachment styles and abuse history. Childhood abuse is associated with insecure attachment. But in this study, BDSM folk were more likely to have a secure attachment than the control group. I think this logic is fairly sound, though a definitive answer will need to wait for a study where childhood abuse is specifically asked about.

The most obvious limitations to this study are the participants. The BDSM and control participants were not necessarily comparable, and there were significant known differences between the groups. Those differences could have affected the study’s results. Also, as usual, this study’s results may not be generalizable to BDSM communities in other countries (e.g., the United States).

Despite the limitations, these results are a delightful breath of fresh air, when so much of the literature treats BDSM as psychopathology. People who practice BDSM has long argued that there is nothing inherently “wrong”, “sick” or “dangerous” about their sexuality. These results absolutely support their assertion. The study authors state “We therefore conclude that these results favor the view […] that BDSM may be thought of as a recreational leisure, rather than the expression of psychopathological processes.” Yes, yes and yes.

The study was published in the Journal of Sexual Medicine. The abstract is publicly available.

* This is a highly simplified description. Power, and the exchange of power, is complex.

** It’s important to note, though, that for many people who participate in BDSM pain is very important, if not the central experience.

*** In addition to Dom/Sub/Switch, there’s also the idea of “topping” and “bottoming”. Topping and bottoming are much more transitory than Dom/Sub/Switch. In any particular activity, the Top is the “do-er” and the Bottom is the “do-ee”. But being Top or Bottom is activity specific and not as much of an orientation as Dom/Sub/Switch.