Differences in medically assisted reproduction use by sexual identity and partnership: a prospective cohort of cisgender women.

STUDY QUESTION: Does medically assisted reproduction (MAR) use among cisgender women differ among those with same-sex partners or lesbian/bisexual identities compared to peers with different-sex partners or heterosexual identities? SUMMARY ANSWER: Women with same-sex partners or lesbian/bisexual identities are more likely to utilize any MAR but are no more likely to use ART (i.e. IVF, reciprocal IVF, embryo transfer, unspecified ART, ICSI, and gamete or zygote intrafallopian transfer) compared to non-ART MAR (i.e. IUI, ovulation induction, and intravaginal or intracervical insemination) than their different-sex partnered and completely heterosexual peers. WHAT IS KNOWN ALREADY: Sexual minority women (SMW) form families in myriad ways, including through fostering, adoption, genetic, and/or biological routes. Emerging evidence suggests this population increasingly wants to form genetic and/or biological families, yet little is known about their family formation processes and conception needs. STUDY DESIGN, SIZE, DURATION: The Growing Up Today Study is a US-based prospective cohort (n = 27 805). Participants were 9-17 years of age at enrollment (1996 and 2004). Biennial follow-up is ongoing, with data collected through 2021. PARTICIPANTS/MATERIALS, SETTING, METHODS: Cisgender women who met the following criteria were included in this sample: endorsed ever being pregnant; attempted a pregnancy in 2019 or 2021; and endorsed either a male- or female-sex partner OR responded to questions regarding their sexual identity during their conception window. The main outcome was any MAR use including ART (i.e. procedures involving micromanipulation of gametes) and non-ART MAR (i.e. nonmanipulation of gametes). Secondary outcomes included specific MAR procedures, time to conception, and trends across time. We assessed differences in any MAR use using weighted modified Poisson generalized estimating equations. MAIN RESULTS AND THE ROLE OF CHANCE: Among 3519 participants, there were 6935 pregnancies/pregnancy attempts and 19.4% involved MAR. A total of 47 pregnancies or pregnancy attempts were among the same-sex partnered participants, while 91 were among bisexual participants and 37 among lesbian participants. Participants with same-sex, compared to different-sex partners were almost five times as likely to use MAR (risk ratio [95% CI]: 4.78 [4.06, 5.61]). Compared to completely heterosexual participants, there was greater MAR use among lesbian (4.00 [3.10, 5.16]) and bisexual (2.22 [1.60, 3.07]) participants compared to no MAR use; mostly heterosexual participants were also more likely to use ART (1.42 [1.11, 1.82]) compared to non-ART MAR. Among first pregnancies conceived using MAR, conception pathways differed by partnership and sexual identity groups; differences were largest for IUI, intravaginal insemination, and timed intercourse with ovulation induction. From 2002 to 2021, MAR use increased proportionally to total pregnancies/pregnancy attempts; ART use was increasingly common in later years among same-sex partnered and lesbian participants. LIMITATIONS, REASONS FOR CAUTION: Our results are limited by the small number of SMW, the homogenous sample of mostly White, educated participants, the potential misclassification of MAR use when creating conception pathways unique to SMW, and the questionnaire's skip logic, which excluded certain participants from receiving MAR questions. WIDER IMPLICATIONS OF THE FINDINGS: Previous studies on SMW family formation have primarily focused on clinical outcomes from ART procedures and perinatal outcomes by conception method, and have been almost exclusively limited to European, clinical samples that relied on partnership data only. Despite the small sample of SMW within a nonrepresentative study, this is the first study to our knowledge to use a nonclinical sample of cisgender women from across the USA to elucidate family formation pathways by partnership as well as sexual identity, including pathways that may be unique to SMW. This was made possible by our innovative approach to MAR categorization within a large, prospective dataset that collected detailed sexual orientation data. Specifically, lesbian, bisexual, and same-sex partnered participants used both ART and non-ART MAR at similar frequencies compared to heterosexual and different-sex partnered participants. This may signal differential access to conception pathways owing to structural barriers, emerging conception trends as family formation among SMW has increased, and a need for conception support beyond specialized providers and fertility clinics. STUDY FUNDING/COMPETING INTEREST(S): The research reported in this publication was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health (NIH), under award number R01MD015256. Additionally, KRSS is supported by NCI grant T32CA009001, AKH by the NCI T32CA057711, PC by the NHLBI T32HL098048, BM by the Stanford Maternal Child Health Research Institute Clinical Trainee Support Grant and the Diversity Fellowship from the American Society for Reproductive Medicine Research Institute, BGE by NICHD R01HD091405, and SM by the Thomas O. Pyle Fellowship through the Harvard Pilgrim Health Care Foundation and Harvard University, NHLBI T32HL098048, NIMH R01MH112384, and the William T. Grant Foundation grant number 187958. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The first author recently had a leadership role in the not-for-profit program, The Lesbian Health Fund, a research fund focused on improving the health and wellbeing of LGBTQ+ women and girls. The fund did not have any role in this study and the author's relationship with the fund did not bias the findings of this manuscript. TRIAL REGISTRATION NUMBER: N/A.

Examining Differences in Alcohol and Smoking Behaviors between Parenting and Nonparenting Lesbian Women.

BACKGROUND: The transition to parenthood is a significant life event that has implications for health behaviors and health. Few studies have examined alcohol use and smoking by parenthood status (nonparent vs. parent) among women who identify as lesbian. METHODS: This study used data from two longitudinal studies, the Chicago Health and Life Experiences of Women Study (n = 135) and the U.S. National Longitudinal Lesbian Family Study (n = 116), to compare problem drinking and cigarette smoking trajectories among lesbian-identified women by parenthood status. We used mixed models to investigate differences in problem drinking and cigarette smoking in three waves of data in each study. RESULTS: Lesbian parents reported significantly less problem drinking, but not cigarette smoking, than nonparent lesbian women. When considering the interaction between parental status and time, problem drinking was significantly higher among nonparents than parents at each time interval. CONCLUSIONS: Parenthood was associated with positive changes in drinking among lesbian women; however, more research is needed to understand how to support smoking cessation among parenting lesbian women.

Disparities in smoking during pregnancy by sexual orientation and race-ethnicity.

The intersection between sexual orientation and race-ethnicity is emerging as an important dynamic for health. Prior research indicates that sexual orientation can have very different health implications for White, Black, and Latina individuals and that these patterns are unpredictable. Here we use U.S. data from the National Survey of Family Growth (2006-2019, n = 15,163 pregnancies) to examine how an important health indicator - smoking during pregnancy - is shaped jointly by sexual orientation and race-ethnicity. Smoking during pregnancy was more common among sexual minority women (both bisexual-identified and heterosexual-identified who expressed same-gender attraction/behavior), compared to heterosexual women. Second, the association between sexual orientation and smoking during pregnancy differed by race-ethnicity: sexual minority status was more strongly associated with smoking among Latina women, compared to White women. Finally, the subgroup with the highest rates of smoking during pregnancy was bisexual White women. These findings indicate that smoking rates among pregnant sexual minority women warrant attention (regardless of race-ethnicity), particularly as births within this group are rising. It is important to address structural factors that may create more stress for sexual minority women, since smoking is often a response to stress. These findings also highlight the role of heterogeneity: low smoking rates among pregnant Latina women mask within-group disparities.

Differences in Perinatal Outcomes of Birthing People in Same-Sex and Different-Sex Marriages.

It is unknown whether people in same-sex relationships who give birth have different perinatal outcomes than people in different-sex relationships, despite differences in risk factors such as use of assisted reproductive technologies, obesity, smoking, and poor mental health. Marriage equality has established birth certificates as a promising new source of population-based data on births to same-sex married parents. We used birth certificate data from Massachusetts for 201,873 singletons born to married parents from 2012 to 2016. We estimated the associations of several birth outcomes with having a birth parent in a same-sex marriage using propensity score-matched and -unmatched samples. We also tested whether these associations were modified by the use of assisted reproductive technologies. People in same-sex marriages who gave birth had perinatal outcomes related to decreased fetal growth and preterm birth that were similar to those of their peers in different-sex marriages. Use of assisted reproductive technology was associated with decreased fetal growth and increased risk of preterm birth for infants with different-sex parents but not for infants with same-sex parents. More research is needed across other states and to understand why use of assisted reproductive technology is not a risk factor for poor birth outcomes for those in same-sex marriages.

Do Sexual Minorities Receive Appropriate Sexual and Reproductive Health Care and Counseling?

CONTEXT: Sexual minority women (SMW) are less likely to use sexual and reproductive health care services and receive contraceptive counseling than their heterosexual peers. The role of recent sexual partners and the type of information provided when SMW access health services are unclear. METHODS: The National Survey of Family Growth 2006-2015 was used to document sexual orientation disparities in the use of sexual and reproductive health services and counseling in clinical settings among 20,703 women. We incorporate data on sexual partners in the past 12 months to investigate whether recent sex with men was associated with health care seeking behavior and reproductive counseling. RESULTS: Eight-seven percent of the sample reported a male partner in the past 12 months, including 83% of bisexual women and 17% of lesbian women. In clinical settings, 48% of women reported birth control counseling at pregnancy or Pap tests, 49% reported a condom consult at an sexually transmitted diseases (STD) screening, and 9% reported emergency contraception counseling at a Pap test. Logistic regression models show that lesbian women were less likely than heterosexual women to have been given a contraceptive prescription or received contraceptive counseling, but were more likely to have received an STD test. In clinical settings, lesbian women were less likely to receive contraceptive counseling at pregnancy tests, and lesbian women without male partners were less likely to have a counseling about condom use at STD-related visits compared with heterosexual women. CONCLUSIONS: At least some women and providers adjust health care seeking behaviors and information provided to women based upon recent sexual behavior histories. More work is needed to understand why disparities in reproductive health services and contraceptive use persist among SMW who engage in sex with men.

Mediation by peer violence victimization of sexual orientation disparities in cancer-related tobacco, alcohol, and sexual risk behaviors: pooled youth risk behavior surveys.

OBJECTIVES: We examined the role of adolescent peer violence victimization (PVV) in sexual orientation disparities in cancer-related tobacco, alcohol, and sexual risk behaviors. METHODS: We pooled data from the 2005 and 2007 Youth Risk Behavior Surveys. We classified youths with any same-sex sexual attraction, partners, or identity as sexual minority and the remainder as heterosexual. We had 4 indicators of tobacco and alcohol use and 4 of sexual risk and 2 PVV factors: victimization at school and carrying weapons. We stratified associations by gender and race/ethnicity. RESULTS: PVV was related to disparities in cancer-related risk behaviors of substance use and sexual risk, with odds ratios (ORs) of 1.3 (95% confidence interval [CI] = 1.03, 1.6) to 11.3 (95% CI = 6.2, 20.8), and to being a sexual minority, with ORs of 1.4 (95% CI = 1.1, 1.9) to 5.6 (95% CI = 3.5, 8.9). PVV mediated sexual orientation disparities in substance use and sexual risk behaviors. Findings were pronounced for adolescent girls and Asian/Pacific Islanders. CONCLUSIONS: Interventions are needed to reduce PVV in schools as a way to reduce sexual orientation disparities in cancer risk across the life span.

A longitudinal study of the correlates of persistent smoking among sexual minority women.

INTRODUCTION: We conducted a longitudinal evaluation of factors associated with persistent smoking behaviors among sexual minority women (SMW; lesbians and bisexual women). METHODS: Structured interview data were collected as part of a larger longitudinal study of SMW's health: the Chicago Health and Life Experiences of Women study. We conducted multivariate analyses to evaluate the influence of 4 groups of predictor variables on smoking: (a) demographic, (b) childhood victimization, (c) other substance use, and (d) health variables. RESULTS: At Wave 1, 30.9% (n = 138) of participants reported current smoking, with substance-use and demographic factors having the strongest relationships to smoking status. The majority (84.9%) of Wave 1 smokers were also smoking at Wave 2. Among demographic variables, level of education was inversely associated with continued smoking. With respect to substance use, hazardous drinking and cocaine/heroin use were significantly associated with continued smoking. None of the victimization or health variables predicted smoking status. CONCLUSIONS: Consistent with previous studies, smoking rates in this sample of SMW were elevated. Despite intensive efforts to reduce smoking in the general population, 84% of SMW smokers continued smoking from Wave 1 to Wave 2. Findings suggest that the majority of SMW will continue to smoke over time. Additional research is needed to increase motivation and access to smoking cessation resources.

Sexual orientation disparities in cancer-related risk behaviors of tobacco, alcohol, sexual behaviors, and diet and physical activity: pooled Youth Risk Behavior Surveys.

OBJECTIVES: We examined sexual orientation disparities in cancer-related risk behaviors among adolescents. METHODS: We pooled data from the 2005 and 2007 Youth Risk Behavior Surveys. We classified youths with any same-sex orientation as sexual minority and the remainder as heterosexual. We compared the groups on risk behaviors and stratified by gender, age (< 15 years and > 14 years), and race/ethnicity. RESULTS: Sexual minorities (7.6% of the sample) reported more risk behaviors than heterosexuals for all 12 behaviors (mean = 5.3 vs 3.8; P < .001) and for each risk behavior: odds ratios (ORs) ranged from 1.3 (95% confidence interval [CI] = 1.2, 1.4) to 4.0 (95% CI = 3.6, 4.7), except for a diet low in fruit and vegetables (OR = 0.7; 95% CI = 0.5, 0.8). We found sexual orientation disparities in analyses by gender, followed by age, and then race/ethnicity; they persisted in analyses by gender, age, and race/ethnicity, although findings were nuanced. CONCLUSIONS: Data on cancer risk, morbidity, and mortality by sexual orientation are needed to track the potential but unknown burden of cancer among sexual minorities.

Sexual orientation and gender differences in markers of inflammation and immune functioning.

BACKGROUND: Sexual minorities have documented elevated risk factors that can lead to inflammation and poor immune functioning. PURPOSE: This study aims to investigate disparities in C-reactive protein (CRP) and Epstein-Barr virus (EBV) by gender and sexual orientation. METHODS: We used the National Longitudinal Study of Adolescent Health to examine disparities in CRP (N = 11,462) and EBV (N = 11,812). RESULTS: Among heterosexuals, women had higher levels of CRP and EBV than men. However, sexual minority men had higher levels of CRP and EBV than heterosexual men and sexual minority women. Lesbians had lower levels of CRP than heterosexual women. CONCLUSIONS: Gender differences in CRP and EBV found between men and women who identify as 100 % heterosexual were reversed among sexual minorities and not explained by known risk factors (e.g., victimization, alcohol and tobacco use, and body mass index). More nuanced approaches to addressing gender differences in sexual orientation health disparities that include measures of gender nonconformity and minority stress are needed.

Differences in hypertension by sexual orientation among U.S. young adults.

Using a nationally representative data set, this study provides the first estimates of differences in hypertension by sexual orientation using objective measures of systolic and diastolic blood pressure. Logistic regressions showed that there were no differences in hypertensive risk between mostly heterosexual/bisexual identified-respondents and heterosexual-identified respondents among both men and women. Gay men, however, are almost twice as likely (odds ratio = 1.92, p < .01) to be hypertensive compared to heterosexual men. The elevated risk is not explained by measures of minority stress, nor by cardiovascular disease risk factors such as smoking, alcohol use, drug use, BMI, or physical activity. No differences in hypertension risk by sexual orientation were detected among female respondents. The results suggest that gay men face an excess risk for hypertension compared to heterosexual men that is not explained by differences in measured health behaviors.

Educational differentials in US adult mortality: An examination of mediating factors.

We use human capital theory to develop hypotheses regarding the extent to which the association between educational attainment and US adult mortality is mediated by such economic and social resources as family income and social support; such health behaviors as inactivity, smoking, and excessive drinking; and such physiological measures as obesity, inflammation, and cardiovascular risk factors. We employ the NHANES Linked Mortality File, a large nationally representative prospective data set that includes an extensive number of factors thought to be important in mediating the education-mortality association. We find that educational differences in mortality for the total population and for specific causes of death are most prominently explained by family income and health behaviors. However, there are age-related differences in the effects of the mediating factors. Higher education enables individuals to effectively coalesce and leverage their diverse and substantial resources to reduce their mortality and increase their longevity.

Social, behavioral, and biological factors, and sex differences in mortality.

Few studies have examined whether sex differences in mortality are associated with different distributions of risk factors or result from the unique relationships between risk factors and mortality for men and women. We extend previous research by systematically testing a variety offactors, including health behaviors, social ties, socioeconomic status, and biological indicators of health. We employ the National Health and Nutritional Examination Survey III Linked Mortality File and use Cox proportional hazards models to examine sex diferences in adult mortality in the United States. Our findings document that social and behavioral characteristics are key factors related to the sex gap in mortality. Once we controlfor women's lower levels of marriage, poverty, and exercise, the sex gap in mortality widens; and once we control for women 's greater propensity to visit with friends and relatives, attend religious services, and abstain from smoking, the sex gap in mortality narrows. Biological factors-including indicators of inflammation and cardiovascular risk-also inform sex differences in mortality. Nevertheless, persistent sex differences in mortality remain: compared with women, men have 30% to 83% higher risks of death over the follow-up period, depending on the covariates included in the model. Although the prevalence of risk factors difers by sex, the impact of those risk factors on mortality is similar for men and women.