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PURPOSE: We developed a multiyear database of sexual orientation- and gender identity-related U.S. state laws to advance sexual and gender minority (SGM) health research and practice and assessed variability in U.S. state laws from 1996 through 2016 across all U.S. states and D.C. METHODS: Between 2014 and 2016, a multidisciplinary group of SGM health researchers and legal experts used secondary and primary legal sources and policy surveillance methods to systematically develop a state-level legal database of 30 sexual orientation- and gender identity-related U.S. state laws in 9 legal domains from 1996 through 2016. We calculated descriptive statistics and created maps to observe the distribution of these laws over both time and space. RESULTS: Although progress has occurred in some domains, such as same-sex marriage, adoption, and employment discrimination, significant challenges to SGM rights remain, especially with regard to HIV criminalization, transgender rights, and discrimination in health care settings. Further, notable variation exists in the presence of protective lesbian, gay, bisexual, transgender, queer (LGBTQ) state laws across U.S. states and D.C. CONCLUSION: Efforts to repeal harmful U.S. state laws are needed, as are new laws, policies, regulations, practices, and norms that advance social justice and health equity for all SGM people.

PURPOSE: Extensive prior research has shown that sexual minority women are more likely to have a number of cancer risk factors, thereby putting them at higher risk for cancer than heterosexual women. However, there has been little research evaluating the association between sexual orientation and diet quality. METHODS: Data come from participants (aged 24–54 years) enrolled in Nurses’ Health Study 3, an ongoing, U.S.-based cohort study (N=15,941). We measured diet using recommendations from the Dietary Approach to Stop Hypertension (DASH) and American Health Association (AHA) 2020 Strategic Impact Goals. RESULTS: We found limited evidence of differences across diet quality by sexual orientation. When examining predicted DASH scores, mostly heterosexual [predicted mean score (95% confidence interval), 24.0 (23.8, 24.3)] and lesbian [24.3 (23.8, 24.9)] women had healthier predicted DASH scores than the reference group of completely heterosexual women with no same-sex partners [23.6 (23.5, 23.7)]. Even though certain sexual minority women had overall healthier predict DASH scores, their consumption of certain food groups—low-fat dairy and fruit—was lower than completely heterosexual women with no same-sex partners. When measuring AHA scores, most sexual minority groups (completely heterosexual women with same-sex partners, mostly heterosexual women, and lesbian women) had higher diet quality compared to the reference group of completely heterosexual women with no same-sex partners. CONCLUSION: Sexual minority women, particularly mostly heterosexual women and lesbian women, had healthier diet quality than completely heterosexual women with no same-sex partners. These data suggest that cancer risk factors (e.g., smoking, drinking, and inactivity) other than diet would drive higher cancer rates among sexual minority compared to heterosexual women. Nonetheless, it is critical for all women to improve their diet quality since diet quality was poor among participants of all sexual orientations.

Prior research shows the importance of internalized sexual prejudice and participation in health indicators for sexual minority people, yet no research has used prospective measures or differentiat...

This study examines the mental health significance of Barack Obama’s 2008 presidential election for black adults. His election was a milestone moment. Hence, we expect black adults would experience improved mental health after the first self-identified black person wins election to the most powerful position in the United States. Using nationally representative survey data from the Behavioral Risk Factor Surveillance System (BRFSS), we address this expectation by predicting poor mental health days that black adults report preelection and postelection. We find no overall difference in poor mental health days between the time periods. However, a statistical interaction between gender and time period demonstrates black men report 1.01 fewer poor mental health days after the election, whereas black women report .45 more poor mental health days after the election.

Purpose: We investigated associations between maternal comfort with lesbian, gay, and bisexual (LGB) people during the participant's adolescence and their health indicators in adulthood. Methods: Data came from a prospective cohort, Growing Up Today Study (N = 7476), limited to men and women who provided information during their adulthood about recent binge drinking, cigarette smoking, or disordered weight control behaviors (DWCB) and whose mothers provided information during the participant's adolescence about her comfort with LGB people. Results: Increased maternal comfort with LGB people was associated with increased engagement in health indicators for heterosexual but not sexual minority adults (binge drinking, cigarette smoking, and DWCB for women; binge drinking for men). No association existed between maternal comfort with LGB people and binge drinking or cigarette smoking for sexual minority women, and binge drinking for sexual minority men. This resulted in statistically smaller differences across sexual orientation in cigarette smoking for women when their mothers were highly comfortable with LGB people compared with those whose mothers were uncomfortable with LGB people. There were no differences in binge drinking (women and men) and DWCB (women only) across sexual orientation when mothers were highly comfortable with LGB people. Conclusion: Maternal comfort with LGB people is associated with certain sexual orientation-related disparities in health indicators through adulthood, due to increased engagement in health indicators by heterosexual adults. Exposure to sexual orientation stigma in adolescence, measured as maternal comfort with LGB people, possibly drives well-known differences in drinking, smoking, and DWCB during adulthood between heterosexual and sexual minority adults.

Background Although much has been published in recent years on differences in Papanicolaou (Pap) tests across sexual orientation, other aspects of cervical cancer prevention remain underexplored, such as human papillomavirus (HPV) vaccination, HPV co-tests, or abnormal Pap tests. Methods Data came from participants (aged 24–54 years) enrolled in an ongoing, longitudinal, U.S.-based cohort study, the Nurses’ Health Study 3 (N = 12,175). Analyses were restricted to participants who met the current guidelines for care (e.g., ≥21 years of age for Pap tests). Results Mostly heterosexual women were more likely to initiate HPV vaccination than completely heterosexual women with no same-sex partners. All other comparisons across sexual orientation for HPV vaccination initiation and completion and the age of initiation were not statistically significant. Compared with completely heterosexual women with no same-sex partners, mostly heterosexual and lesbian women had lower odds of having a Pap test within the past 2 years. Completely heterosexual women with same-sex partners, mostly heterosexual women, and bisexual women had their first Pap test at an earlier age, had higher odds of having an HPV co-test, and had higher odds of having a positive HPV or abnormal Pap test compared with completely heterosexual women with no same-sex partners. In contrast, lesbian women had lower odds of having positive HPV or abnormal Pap results (odds ratio, 0.65; 95% confidence interval, 0.49–0.86) than completely heterosexual women with no same-sex partners. Conclusions There are significant differences across sexual orientation groups in cervical cancer prevention for Pap test timing and positive HPV and abnormal Pap tests, but few differences in HPV vaccination initiation, completion, and age at initiation. Interventions should focus on increasing routine Pap testing among mostly heterosexual and lesbian women.

The number of regulations surrounding abortion has increased drastically in recent years. It is important to assess how these laws relate to abortion timing, since the cost, safety, and accessibility of abortion varies by how many weeks pregnant a woman is when the procedure occurs. Research examining how state laws relate to abortion timing generally use rates or data from vital statistics; while informative, such methods do not allow researchers to examine how these laws may be disproportionately associated with abortion timing among select groups of women, including poor and nonwhite women. To fill this research gap, I analyze data from the nationally representative 2008 Abortion Patient Survey, with appended information on state laws regarding abortion in 2008. I find that laws requiring second trimester abortions be performed in a hospital and both in-person counselling and waiting periods have different associations with abortion timing based on race and income-to-poverty status. Predicted abortion timing for black and Hispanic women differs based on state laws and their income-to-poverty status, while for white women, models show that the association between state laws and abortion timing is not dependent on their income-to-poverty status. Overall, this research illustrates the relevance of state-level abortion laws for shaping abortion timing among women, highlighting how these relationships differ across racial and socioeconomic groups in the United States.

Existing research on cancer screening utilization among sexual minority women in the U.S. has mostly relied on non-random samples that combine lesbian and bisexual women into a single group. We respond to these limitations by examining the relationship between sexual orientation and cancer screening among a sample of U.S. women from the Behavioral Risk Factor Surveillance System (BRFSS). Our analytic sample includes 2273 lesbian, 1689 bisexual, and 174,839 heterosexual women interviewed in 15 U.S. states between 2000 and 2010. We examine two cancer screening measures: timely mammogram and pap tests, defined as having had a mammogram in the past 2 years for women aged 40 and older, and having had a pap test in the past 3 years for women aged 21–65. For mammogram, results showed that rates of timely use did not significantly differ by sexual orientation. However, lesbian and bisexual women report significantly lower rates of timely pap testing than heterosexual women. Logistic regression results on timely pap testing showed that lower pap test use for bisexual women is primarily driven by their poorer socioeconomic status relative to heterosexual women, while the significantly lower odds of timely pap testing for lesbian women were unaffected by control measures. Better understanding of cancer screening utilization disparities among lesbian and bisexual women is necessary to address morbidity and mortality disparities by sexual orientation.

Purpose The purpose of the study was to test whether those who initiate tanning during adolescence are more likely to continue tanning in young adulthood, potentially increasing their risk for melanoma. Methods The study included prospective data from the Growing Up Today Study, a cohort study started in 1996 (N = 5,882). Results Among men and women who ever indoor UV tanned, those who indoor UV tan by age 17 years consistently indoor tanned at least twice the prevalence as those who did not indoor UV tan by age 17 years. Indoor tanning prevalence at age 27 years was nearly 4 times as high (18.8% vs. 4.8%) among men who started indoor tanning by age 17 years than those who did not indoor tan by age 17 years. These differences persisted through age 27 years and are more pronounced in men (18.8% vs. 4.8%) than in women (30.5% vs. 13.0%). Conclusion Adolescents who indoor UV tan by age 17 years are more likely to continue to indoor tan through young adulthood than those who begin indoor UV tanning at age 18 years or older. Our findings suggest that interventions to prevent indoor UV tanning among minors may substantially reduce years of exposure to this carcinogenic behavior in young adults.

The objective of this study was to quantify sexual orientation differences in insurance access, healthcare utilization, and unmet needs for care. We analyzed cross-sectional data from three longitudinal U.S.-based cohorts (N = 31,172) of adults ages 20–54 years in the Growing Up Today Studies 1 and 2 and the Nurses' Health Study 3 from 2015 to 2019. Adjusted log-binomial models examined sexual orientation differences (reference: completely heterosexual) in insurance access, healthcare utilization, and unmet needs for care. Compared to completely heterosexuals, mostly heterosexual and bisexual adults were more likely to report emergency departments as a usual source of care and less likely to be privately insured. Sexual minorities (mostly heterosexual, bisexual, gay/lesbian) were also more likely than completely heterosexuals to delay needed care for reasons of not wanting to bother a healthcare provider, concerns over cost/insurance, bad prior healthcare experiences, and being unable to get an appointment. Differences by sex and sexual orientation also emerged for healthcare utilization and unmet needs. For example, mostly heterosexual women were more likely than completely heterosexual women to delay care due to perceiving symptoms as not serious enough, while gay men were less likely than lesbian women to delay for this reason. Findings indicate that sexual minorities experience disparities in unmet needs for and continuity of care. Provider education should be attentive to how perceptions, like perceived severity, can shape healthcare access in tandem with socioeconomic barriers.

The human papillomavirus (HPV) vaccination, sexually transmitted infection (STI) tests, and Papanicolaou (Pap) testing rates vary by sexual orientation, which may be due in part to healthcare providers (HCP) recommending this care unevenly. Data (N = 17,675) came from the Growing Up Today Study (GUTS) (N = 8039) and Nurses' Health Study 3 (NHS3) (N = 9636). Among participants who met clinical guidelines to receive the care in question, we estimated the probability of an HCP encouraging participants to have the HPV vaccination, STI tests, or Pap test. Regardless of sexual orientation, participants whose HCP knew their sexual orientation were more likely to have been encouraged to get care compared to those whose HCP did not know the participant's sexual orientation. Sexual minority men and women were more likely to be encouraged to obtain HPV vaccination, STI tests, and Pap test than same-gender, completely heterosexuals with no same-sex partners, with some variation by gender and the care in question. Lesbian women were the sole sexual orientation subgroup that was less likely to be encouraged to receive care (HPV vaccination and Pap test) than their same gender, completely heterosexual counterparts with no same-sex partners (odds ratio [95% confidence interval]: 0.90 [0.80–1.00] and 0.94 [0.91–0.98], respectively). The differences across sexual orientation in HCPs' encouragement of care indicate a possible explanation for differences in utilization across sexual orientation. Across the US, HCPs under-encourage HPV vaccination, STI tests, and Pap test for all sexual orientation groups. Lesbian patients appear to be at high risk of under-encouragement for the Pap test.

Background Prior research has found that education's association with health can differ by social positions such as gender. Yet, none of the existing work has tested whether the relationship between education and self-rated health is equivalent across sexual orientation groups, and additionally, if these associations differ for men and women. Deploying the intersectionality perspective, we expand current debates of education as a resource substitution or multiplication to include sexual orientation. Methods We answer these questions using data from the Behavioral Risk Factor Surveillance System (BRFSS), a probability-based sample of adults living in 44 US states and territories for selected years between 2011 and 2017 (n = 1,219,382). Results Supporting resource multiplication, we find that compared to their same-gender heterosexual counterparts, education is less health-protective for bisexual adults, especially bisexual women. Gay men and lesbian women, on the other hand, seem to have similar associations of education with health as their same-gender heterosexual counterparts. Turning to gender comparisons across sexual identity groups, we find that resource substitution may operate only among heterosexual women when compared with heterosexual men. Conclusions In sum, this study suggests that the relationship between education and health may depend on the intersection of gender and sexual orientation among U.S. adults., Highlights • Education is less health-protective for bisexual adults, especially bisexual women, than for heterosexual adults. • Gay men and lesbian women have similar associations of education with health as their heterosexual counterparts. • Heterosexual women may have a stronger association of education with self-rated health than heterosexual men. • The relationship between education and health does not seem to differ by gender for sexual minority adults. • Heterosexual men without a high school degree may experience unique health challenges.

How social and legal climate influence LGB health is an under-studied topic. In response, this study examines whether the lesbian/gay/bisexual (LGB) climate index and presence of anti-discrimination law show population health significance for U.S. sexual minorities. The LGB climate index uses survey data collected between 2012 and 2013 to gauge states' support of lesbian, gay, and bisexual individuals, whereas anti-discrimination law captures any state-level law that makes it illegal to discriminate because of sexual orientation in employment, housing, and public accommodations. We merge these two contextual measures with 2011-2015 Behavioral Risk Factor Surveillance System (BRFSS) aggregated, individual-level survey data, from which we generate three measures of state-level rates: excellent self-rated health, routine health care utilization, and health insurance among self-identified lesbian/gay and bisexual adults. We find that the LGB climate index associates positively with rates of excellent self-rated health, routine health care utilization, and health insurance-but only for states with anti-discrimination laws, and only among lesbian/gay adults. Analyses confirm salubrious synergism between a sexually-minority-friendly climate and anti-discrimination law-together these two contextual measures interact to protect lesbian/gay population health.

Purpose To determine gendered patterns of preventive medical care (physical and dental/optical) use among pan-ethnic U.S. Asian and Latino adults. Methodology/approach Using National Latino and Asian American Study (2004) data, we apply Andersen’s (1995) Behavioral Model of Health Services Use to assess how preventive care use among Asian and Latino men and women varies as a function of predisposing, enabling, and need-based characteristics. We explore whether adjustment for these factors mediates gender disparities in both physical and dental/optical check-ups, and test whether certain factors operate differently among men versus women. Findings A higher proportion of women reported a routine care visit last year, especially among Latinos. Adjusting for predisposing, enabling, and need-based factors explained the gender difference in reporting a dental/optician check-up, but not a physical check-up, among both Asian and Latino adults. Research limitations/implications Our findings illustrate how gender patterns in routine care use differ by race/ethnicity, and highlight the fundamental importance of enabling characteristics (especially health insurance and having a regular doctor) for shaping routine care use between men and women, both Asian and Latino. Limitations of this chapter are that the data are cross-sectional and were collected before the implementation of the Affordable Care Act, and measures are self-reported. Originality/value This chapter focuses on Asian and Latinos because they represent the fastest growing minority populations in the United States, yet few studies have evaluated gender differences in preventative health care use among these groups.