Palliative and end-of-life care needs, experiences, and preferences of LGBTQ+ individuals with serious illness: A systematic mixed-methods review.

BACKGROUND: Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) individuals experience discrimination throughout the care continuum, including during serious illness and at end of life. High-quality palliative care requires that health professionals deliver individualized services that reflect the needs, experiences, and preferences of LGBTQ+ persons. AIM: To identify and appraise existing evidence related to the needs, experiences, and preferences for palliative and end of life care among LGBTQ+ individuals with serious illness. DESIGN: Data-based convergent synthesis design reported per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES: PubMed, Embase, Cochrane CENTRAL, PsycINFO, CINAHL, and Scopus from January 1, 2010 to November 6, 2020. RESULTS: Of 4875 results captured, 69 articles underwent full-text review and 13 were retained for analysis. Most studies were from North America with trans individuals represented in 10 of 13 studies. Needs (n = 6) included increased social support, institutional safety, economic and legal supports, and advocacy to mitigate health barriers.Experiences (n = 12) were driven by fear and worry associated with discrimination/stigma,providers' hetero-/cisnormative assumptions, homophobia and transphobia, social isolation, and an undignified death. Preferences (n = 6) pertained to inclusion of chosen families in decision-making, disclosure of LGBTQ+ identity based on safety of the clinical environment, and a desire to maintain autonomy. CONCLUSIONS: The robustness of the science has improved regarding the needs, experiences, and preferences of trans individuals. Actionable, inclusive policies coupled with sustained and integrated cultural sensitivity training for health workers are mandatory. Interventional research is critical to enhance tailored palliative care for LGBTQ+ people and their chosen families.

Comparing substance use outcomes by sexual identity among women: Differences using propensity score methods.

BACKGROUND: Differences in alcohol, tobacco, and other drug (ATOD) use by sexual identity vary across samples of women recruited using different sampling methods. We used propensity score (PS) weighting methods to address two methodological questions: (1) Do disparities between sexual minority women (SMW) and heterosexual women persist when differences in risk and protective factors are similarly distributed between groups, and (2) Does accounting for SMW-specific resiliency factors impact differences between non-probability samples of SMW? METHODS: Four samples included SMW from a longitudinal study with a nonprobability sample (n = 373), a national general population panel sample (n = 373), and a national LGBTQ-specific panel sample (n = 311), as well as a national probability sample of heterosexual women (n = 446). Between-groups analyses using double-robust PS weighted models estimated differences in ATOD use under hypothetical conditions in which samples have similar risk and protective factors. RESULTS: After PS weighting, imbalance in confounders between SMW and heterosexual samples was substantially reduced, but not eliminated. In double-robust PS weighted models, SMW samples consistently had significantly greater odds of drug use than heterosexuals, with odds from 8.8 to 5.6 times greater for frequent marijuana use and 4.8-3.2 greater for other drug use. Few differences between SMW samples in ATOD outcomes or other variables remained after PS weighting. CONCLUSION: Relative to heterosexual women, disparities in marijuana and other drug use among SMW are evident regardless of sampling strategy. The results provide some reassurance about the validity of large nonprobability samples, which remain an important recruitment strategy in research with SMW.

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.

A scoping review of alcohol, tobacco, and other drug use treatment interventions for sexual and gender minority populations.

BACKGROUND: Alcohol, tobacco, and other drug use are among the most prevalent and important health disparities affecting sexual and gender minority (SGM; e.g., lesbian, gay, bisexual, transgender) populations. Although numerous government agencies and health experts have called for substance use intervention studies to address these disparities, such studies continue to be relatively rare. METHOD: We conducted a scoping review of prevention and drug treatment intervention studies for alcohol, tobacco, and other drug use that were conducted with SGM adults. We searched three databases to identify pertinent English-language, peer-reviewed articles published between 1985 and 2019. RESULTS: Our search yielded 71 articles. The majority focused on sexual minority men and studied individual or group psychotherapies for alcohol, tobacco, or methamphetamine use. CONCLUSION: Our findings highlight the need for intervention research focused on sexual minority women and gender minority individuals and on cannabis and opioid use. There is also a need for more research that evaluates dyadic, population-level, and medication interventions.

International consensus-based policy recommendations to advance universal palliative care access from the American Academy of Nursing Expert Panels.

The purpose of this consensus paper was to convene leaders and scholars from eight Expert Panels of the American Academy of Nursing and provide recommendations to advance nursing's roles and responsibility to ensure universal access to palliative care. On behalf of the Academy, these evidence-based recommendations will guide nurses, policy makers, government representatives, professional associations, and interdisciplinary and community partners to integrate palliative nursing services across health and social care settings. Through improved palliative nursing education, nurse-led research, nurse engagement in policy making, enhanced intersectoral partnerships with nursing, and an increased profile and visibility of palliative care nurses worldwide, nurses can assume leading roles in delivering high-quality palliative care globally, particularly for minoritized, marginalized, and other at-risk populations. Part II herein provides a summary of international responses and policy options that have sought to enhance universal palliative care and palliative nursing access to date. Additionally, we provide ten policy, education, research, and clinical practice recommendations based on the rationale and background information found in Part I. The consensus paper's 43 authors represent eight countries (Australia, Canada, England, Kenya, Lebanon, Liberia, South Africa, United States of America) and extensive international health experience, thus providing a global context for the subject matter.

Sexual orientation differences in childhood sexual abuse, suicide attempts, and DSM-5 alcohol, tobacco, other drug use, and mental health disorders in the US.

BACKGROUND: Childhood sexual abuse (CSA) contributes to increased risk of substance use and mental health disorders in the general population. OBJECTIVE: To assess the prevalence and associations of CSA and suicide attempts, substance use, and mental health disorders as a function of sex (female, male) and sexual orientation (lesbian, gay, bisexual, heterosexual-identified with same-sex attraction and/or behavior, heterosexual-identified without same-sex attraction and/or behavior, and unsure). PARTICIPANTS AND SETTING: Data were collected using structured diagnostic face-to-face interviews in a nationally representative sample of 36,309 US adults. METHODS: We used descriptive statistics and logistic regression modeling to analyze data from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III). RESULTS: Childhood sexual abuse was most prevalent among sexual minorities, especially bisexual females. Nearly one-third of bisexual females (30.6%) reported experiencing two or more types of CSA, p < .001. Among all participants, exposure to one or more types of CSA was associated with greater odds of lifetime suicide attempts, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) alcohol, tobacco or other drug use disorder, and mental health disorders, after adjusting for other childhood adversity/maltreatment and general life stressors. CONCLUSIONS: Sexual minority females and males in the US are more likely than their heterosexual counterparts to report CSA. Higher risk of suicide attempts and DSM-5 alcohol, tobacco, other drug use, and mental health disorders in adulthood was directly associated with CSA, particularly among bisexual females. Health professionals working with individuals who have experienced CSA should assess these risks and intervene as needed.

Sexual and gender minority health in Chile: findings from the 2016-2017 Health Survey

ABSTRACT OBJECTIVE To expose visibility of the health concerns of sexual and gender minority groups in Chile, as well as to provide a platform to advocate for policies that support the health and well-being of sexual and gender minority people in the country. METHODS The health conditions and risk factors of participants identified as sexual and gender minority were compared to those identified as cisgender heterosexual using data from the 2016-2017 National Health Survey. RESULTS Despite reporting higher self-rated health than heterosexual men, gay men had a higher risk of lifetime diagnosis of sexually transmitted infections. Compared to heterosexual women, the prevalence of depression was higher among bisexual women, who were also less likely to have been tested for HIV. Moreover, transgender participants were more likely to report depression and worse self-rated health than cisgender heterosexual participants. CONCLUSION Small sample sizes of sexual and gender minority subgroups might have obscured some differences that would have been observable in larger samples. Despite this, we found statistically significant sexual and/or gender identity differences in several health areas, especially mental, sexual, and overall health.

Sexual Identity Differences in Health Behaviors and Weight Status among Urban High School Students.

Although racial/ethnic disparities in childhood obesity are well documented in the United States (U.S.), fewer studies have investigated elevated body mass index (BMI) and related health behaviors among sexual minority youth (SMY; gay/lesbian, bisexual, not sure). We examined pooled data from the 2009-2017 Youth Risk Behavior Surveys, which included high school students from 12 urban U.S. school districts. We used sex-stratified logistic regression models to estimate the association of sexual identity with health behaviors and elevated BMI (reference = heterosexual participants). A total of 133,615 participants were included. Sexual minority boys were more likely to report physical inactivity than heterosexual boys. Gay and not sure boys were also less likely to consume the recommended daily intake of fruit. Bisexual girls were more likely than heterosexual girls to report watching television ≥ 3 hours on a school day and to consume sugar-sweetened beverages (AOR 1.30, 95% CI= 1.18-1.43). All SMY reported higher rates of current tobacco use than their heterosexual peers. Sexual minority girls and bisexual boys had significantly higher rates of obesity than their heterosexual counterparts. These findings can inform tailored health promotion initiatives to reduce obesity risk in SMY.

American Academy of Nursing Expert Panel consensus statement on nursing's roles in ensuring universal palliative care access.

The purpose of this consensus paper was to convene leaders and scholars from eight Expert Panels of the American Academy of Nursing and provide recommendations to advance nursing's roles and responsibility to ensure universal access to palliative care. Part I of this consensus paper herein provides the rationale and background to support the policy, education, research, and clinical practice recommendations put forward in Part II. On behalf of the Academy, the evidence-based recommendations will guide nurses, policy makers, government representatives, professional associations, and interdisciplinary and community partners to integrate palliative nursing services across health and social care settings. The consensus paper's 43 authors represent eight countries (Australia, Canada, England, Kenya, Lebanon, Liberia, South Africa, United States of America) and extensive international health experience, thus providing a global context for the subject matter. The authors recommend greater investments in palliative nursing education and nurse-led research, nurse engagement in policy making, enhanced intersectoral partnerships with nursing, and an increased profile and visibility of palliative nurses worldwide. By enacting these recommendations, nurses working in all settings can assume leading roles in delivering high-quality palliative care globally, particularly for minoritized, marginalized, and other at-risk populations.

Past-year discrimination and cigarette smoking among sexual minority women: investigating racial/ethnic and sexual identity differences.

Although findings are mixed, discrimination has been identified as a risk factor for smoking in sexual minority women (SMW; e.g., lesbian and bisexual). We examined associations between past-year discrimination and cigarette smoking among SMW. Using regression analyses we examined associations of past-year discrimination including count of types of discriminatory experiences and attributions of the main reason for discrimination (i.e., sexual orientation, race/ethnicity, gender) with smoking outcomes (e.g., current smoking, nicotine dependence, smoking more cigarettes now than 12 months ago). We conducted exploratory analyses to examine whether race/ethnicity and sexual identity moderated the associations of past-year discrimination with smoking outcomes. The sample included 619 SMW. Most identified as lesbian (74.3%) and non-White (61.1%). SMW who reported a higher count of types of discriminatory experiences (AOR 1.54, 95% CI 1.12-2.12) and any gender-based discrimination in the past year (AOR 4.79, 95% CI 1.39-16.45) reported smoking more cigarettes now than 12 months ago. Associations of other past-year discrimination measures with other smoking outcomes were not significant. Compared to White SMW, any discrimination [B (SD) = 2.56 (0.83)] and a higher count of types of discriminatory experiences in the past year [B (SD) = 0.88 (0.31)] were associated with higher nicotine dependence scores in Black/African American SMW. Past-year discrimination are associated with smoking outcomes in SMW. Black/African American race moderated the associations of any past-year discrimination and a higher count of types of discriminatory experiences with nicotine dependence scores in SMW. Targeted interventions to mitigate the influence of discrimination on smoking among SMW are needed.

Sexual Orientation, Tobacco Use, and Tobacco Cessation Treatment-Seeking: Results From a National U.S. Survey.

Despite higher rates of tobacco use and smoking-related diseases among sexual minorities, tobacco cessation treatment-seeking behaviors (e.g., medication, nicotine replacement products) remain poorly understood across sexual orientation subgroups. This study examines tobacco cessation treatment-seeking behaviors associated with Diagnostic and Statistical Manual of Mental Disorders, 5th Edition tobacco use disorder (TUD) across the three major sexual orientation dimensions (identity, attraction, behavior) in U.S. adults. Prevalence estimates reflect data collected from a 2012-2013 national sample of adults 18 years and older. More than three-fourths of U.S. adults with TUD had never engaged in tobacco cessation treatment-seeking behaviors, regardless of sexual orientation. Despite having the highest rates of TUD, bisexual men and women had some of the lowest rates of tobacco cessation treatment-seeking. Men who identified as gay, reported same-sex attraction, or reported same-sex behaviors had the highest rates of tobacco cessation treatment-seeking. In contrast, women with same-sex attraction or same-sex behavior had higher rates of TUD but were less likely to engage in tobacco cessation treatment-seeking behaviors than women with only other-sex attraction or other-sex behavior, respectively. Heterosexual women were more likely to engage in tobacco cessation treatment-seeking than heterosexual men; this sex difference was not present for sexual minorities. Medications and nicotine replacement therapy products were the most prevalent forms of treatment-seeking. There were notable differences in tobacco cessation treatment-seeking behaviors based on sex and sexual orientation. Findings highlight the underutilization of tobacco cessation treatment-seeking among all U.S. adults and point to important factors to consider when working with sexual minorities who are trying to reduce or stop using tobacco.

Sexual Minority Women's Sexual and Reproductive Health Literacy: A Qualitative Descriptive Study.

Although sexual minority women (SMW) are at risk for cervical cancer and sexually transmitted infections (STIs), they may not seek preventative sexual and reproductive health care at the same rates as their heterosexual peers. We conducted a qualitative descriptive study of 22 adult SMW, a subsample of participants enrolled in the Chicago Health and Life Experiences of Women study. The aim was to describe the sexual and reproductive health literacy of this community sample based on qualitative themes, using an integrated model of health literacy. This model considers not only access to information but also understanding, appraisal, and application of information. We found that family of origin, health care providers, and school-based sexual education were the most important sources of sexual and reproductive health information. Participants described their understanding, appraisal, and application of sexual and reproductive health information as interdependent concepts. Pap test literacy and decision making were strongly independent, with SMW seeking various sources of information, or were driven by health care providers, with SMW following instructions and trusting provider advice. STI-related literacy hinged on whether the participant perceived SMW as at risk for STIs. Our findings reinforce that simply having access to information is insufficient to enact health behaviors that reflect full literacy. Findings have implications for health care providers, who should provide evidence-based recommendations for their SMW clients, and for public health practitioners and educators, who could make sexual health education more inclusive of and specific to the needs of SMW.

Associations Among Childhood Household Dysfunction, Sexual Orientation, and DSM-5 Alcohol, Tobacco and Other Substance Use Disorders in Adulthood: Evidence From a National U.S. Survey.

OBJECTIVES: This study examined the associations between childhood household dysfunction and adulthood past-year DSM-5 alcohol, tobacco, and other substance use disorders across sexual orientation subgroups (eg, lesbian/gay, bisexual, and heterosexual). METHODS: Prevalence estimates were based on National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III) data collected from structured diagnostic face-to-face interviews in a nationally representative sample of 36,309 U.S. adults. Multivariable regression was used to examine associations between childhood household dysfunction and past-year substance use disorders in adulthood. RESULTS: Sexual minorities, particularly sexual minority women, reported higher rates of childhood household dysfunction (eg, parental/household history of substance-related problems) and adulthood DSM-5 alcohol, tobacco, and substance use disorders. Results of multivariable analyses indicated that childhood histories of parental/household substance-related problems were associated with greater odds of past-year substance use disorders among sexual minorities than heterosexuals, and that such histories may moderate differences among sexual orientation subgroups. The risk of substance use disorders among sexual minority women relative to exclusively heterosexual women (ie, heterosexual-identified women without same-sex attraction or behavior) remained high, even when accounting for household dysfunction. In contrast, there were no such differences between sexual minority men and exclusively heterosexual men. CONCLUSIONS: Sexual minorities are more likely to have childhood household dysfunction which in turn is associated with a higher risk of developing DSM-5 alcohol, tobacco, and substance use disorders in adulthood, especially among sexual minority women. Healthcare providers who care for individuals raised in dysfunctional households should carefully assess risk for substance use disorders and intervene as needed.

Associations between sexual orientation discrimination and substance use disorders: differences by age in US adults.

PURPOSE: Sexual minorities are at heightened risk for substance use disorders (SUDs). Discrimination based on sexual orientation may be an important factor in this increased risk, but differences across age have not been systematically examined. We examined age-varying associations of sexual orientation discrimination with alcohol use disorder (AUD), tobacco use disorder (TUD), and drug use disorder (DUD). METHODS: We used data from US participants aged 18-50 years who reported non-heterosexual identity, attraction, or behavior (N = 2375) in a nationally representative survey. We examined the prevalence of sexual orientation discrimination across age and its salience as a risk factor for AUD, TUD, and DUD for gay/lesbian, bisexual, and heterosexual identifying individuals using time-varying effect modeling. RESULTS: Sexual orientation discrimination was most prevalent in early young adulthood but was positively associated with greater odds of AUD, TUD, and DUD only at later ages. We found statistically significant associations at ages 24.5-40.0 for AUD, ages 32.5-42.9 for DUD, and ages 39.3-43.2 for TUD. For example, discrimination at age 30 was associated with 2.1 times greater odds of AUD (95% CI 1.3, 3.3) compared to those who reported no discrimination at that age. Discrimination at age 35 was associated with 2.8 times greater odds of DUD (95% CI 1.2, 6.6) relative to no discrimination. CONCLUSIONS: Sexual orientation discrimination is significantly associated with SUDs and risk varies across age. Thus, age should be considered in the development of prevention and treatment of AUD, TUD, and DUD, particularly for sexual minorities.

Vulvodynia, "A Really Great Torturer": A Mixed Methods Pilot Study Examining Pain Experiences and Drug/Non-drug Pain Relief Strategies.

BACKGROUND: Women with vulvodynia, a chronic pain condition, experience vulvar pain and dyspareunia. Few studies examine the range and combination of treatment strategies that women are actually using to reduce vulvodynia. AIM: To describe pain experiences and pain relief strategies of women with vulvodynia. METHODS: Convenience sample, 60 women with vulvodynia (median age 32.5 [interquartile range {IQR} 8.5] years; 50 white, 10 racial/ethnic minorities) completed PAINReportIt and reported use of drugs and alcohol and responded to open-ended questions. Univariate descriptive statistics and bivariate inferential tests were used to describe average pain intensity scores, alcohol use, smoking, number of pain relief strategies, and their associations. Women's open-ended responses about their pain experiences and drug and non-drug pain relief strategies (NDPRS) were analyzed for patterns. OUTCOMES: Our mixed methods analysis connected data from pain measures, prescribed treatments and self-reported behaviors with women's free responses. This enabled nuanced insights into women's vulvodynia pain experiences. RESULTS: Women's descriptions of their pain and suffering aligned with their reported severe pain and attempts to control their pain, with a median pain intensity of 6.7 (IQR 2.0) despite use of adjuvant drugs (median 2.0 [IQR 2.0]), and opioids (median 1.0 [IQR 2.0]). 36 women (60%) used alcohol to lessen their pain. 26 women (43%) listed combining analgesics and alcohol to relieve their pain. 30 women (50%) smoked cigarettes. 54 women (90%) used ≥1 NDPRS. The mean number of NDPRS used was 2.1 ± 1.3 (range 0-6). The 5 most common NDPRS from women's comments were herbal medicine (40%), acupuncture (27%), massage (22%), hypnosis (15%), and mental healthcare (13%). CLINICAL IMPLICATIONS: Severe pain in women with vulvodynia may be a clinical indicator of those at higher risk of combining prescription pain medications with alcohol, which are all central nervous system depressants and may potentiate overdose. STRENGTHS AND LIMITATIONS: This pilot study demonstrated that the mixed methods approach to help understand the complexity of vulvodynia was feasible. We identified data showing a reliance on a high-risk mix of prescriptions and alcohol to reduce vulvodynia pain and a high prevalence of cigarette smoking. However, as a pilot study, these results are considered preliminary; the sample may not be representative. Perhaps only women at the extreme end of the pain continuum participated, or women took the survey twice because identifiers were not collected. CONCLUSION: Despite attempts to reduce pain using multiple therapies, including alcohol, women's vulvodynia pain is severe and not controlled. Schlaeger JM, Pauls HA, Powell-Roach KL, et al. Vulvodynia, "A Really Great Torturer": A Mixed Methods Pilot Study Examining Pain Experiences and Drug/Non-drug Pain Relief Strategies. J Sex Med 2019;16:1255-1263.

Sexual Identity, Adverse Life Experiences, and Cardiovascular Health in Women.

BACKGROUND: Adverse life experiences (ALE; eg, discrimination and sexual abuse) may contribute to cardiovascular disease (CVD) risk in sexual minority women (SMW), but few studies have tested whether ALE explain the association of sexual identity with cardiovascular health (CVH) markers in women. OBJECTIVE: The aim of this study was to examine sexual identity differences in CVH among women and the role of ALE. METHODS: In the Epidemiologic Study of Risk in Women, we used multinomial logistic regression to assess sexual identity differences (SMW vs heterosexual women [reference group]) in CVH markers (ideal vs poor, intermediate vs poor) using the American Heart Association's Life's Simple 7 metric and the total score. Next, we tested whether the association of sexual identity with the total CVH score was attenuated by traditional CVD risk factors or ALE. RESULTS: The sample consisted of 867 women (395 heterosexual, 472 SMW). Sexual minority women were more likely to have experienced discrimination (P < .001) and lifetime sexual abuse (P < .001) than heterosexual women. Sexual minority women were also less likely to meet ideal CVH criteria for current tobacco use (adjusted odds ratio, 0.43; 95% confidence interval, 0.24-0.73) or intermediate CVH criteria for body mass index (adjusted odds ratio, 0.60; 95% confidence interval, 0.40-0.92). Sexual minority women had a lower cumulative CVH score (B [SE] = -0.35 [0.14], P < .01) than heterosexual women. This difference was not explained by traditional CVD risk factors or ALE. CONCLUSIONS: Smoking, body mass index, and fasting glucose accounted for much of the CVH disparity due to sexual identity, but those differences were not explained by ALE. Health behavior interventions tailored to SMW should be considered.

A scoping review of sexual minority women's health in Latin America and the Caribbean.

OBJECTIVES: Despite research documenting significant health disparities among sexual minority women (lesbian, bisexual, and other non-heterosexual women) in high-income countries, few studies of sexual minority women's health have been conducted in low- and middle-income countries. The purpose of this scoping review was to examine the empirical literature related to the health disparities and health needs of sexual minority women in Latin America and the Caribbean (LAC), and to identify research gaps and priorities. DESIGN: A scoping review methodology was used. DATA SOURCES: We conducted a comprehensive search of seven electronic databases. The search strategy combined keywords in three areas: sexual minority women, health, and LAC. English, Spanish, and Portuguese language studies published through 2017 in peer-reviewed journals were included. REVIEW METHODS: A total 1471 articles were retrieved. An additional 5 articles were identified following descendancy search; 3 of these met inclusion criteria. After removal of duplicates and title and abstract screening, we screened the full text of 37 articles, of which 22 (representing 18 distinct studies) met inclusion criteria. At least two authors independently reviewed and abstracted data from all articles. RESULTS: More than half of the studies were conducted in Brazil (n = 9) and Mexico (n = 5). Sexual health was the most studied health issue (n = 11). Sexual minority women were at elevated risk for sexually transmitted infections related to low use of barrier contraceptive methods during sexual encounters with men. Findings suggest that sexual minority women are generally distrustful of healthcare providers and view the healthcare system as heteronormative. Providers are believed to lack the knowledge and skills to provide culturally competent care to sexual minority women. Sexual minority women generally reported low levels of sexual health education and reluctance in seeking preventive screenings due to fear of mistreatment from healthcare providers. Sexual minority women also reported higher rates of poor mental health, disordered eating, and substance use (current tobacco and alcohol use) than heterosexual women. Gender-based violence was identified as a significant concern for sexual minority women in LAC. CONCLUSIONS: Significant knowledge gaps regarding sexual minority women's health in LAC were identified. Additional investigation of understudied areas where health disparities have been observed in other global regions is needed. Future research should explore how the unique social stressors sexual minority women experience impact their health. Nurses and other healthcare providers in the region need training in providing culturally appropriate care for this population.

Severity of Alcohol, Tobacco, and Drug Use Disorders Among Sexual Minority Individuals and Their "Not Sure" Counterparts.

PURPOSE: Sexual minority individuals have heightened risk for substance use; however, previous studies have not assessed severity of alcohol use disorders (AUDs), tobacco use disorders (TUDs), and drug use disorders (DUDs) among lesbian/gay and bisexual individuals and those "not sure" of their sexual identity compared with heterosexual individuals. This study examined how three dimensions of sexual orientation (identity, attraction, and behavior) relate to severity of AUD, TUD, and DUD. METHODS: This study used cross-sectional national data (N = 36,309) from the National Epidemiologic Survey on Alcohol and Related Conditions-III, and well-validated alcohol, tobacco, and drug measures that align with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. Data were collected through in-person interviews in 2012-2013. RESULTS: Sexual minority respondents, based on sexual identity, had higher odds of severe AUD or TUD than heterosexual respondents. Opposite- and same-sex behavior was a predictor of severe AUD (adjusted odds ratio [AOR] = 2.44; 95% confidence interval [CI] = 1.24-4.79) and TUD (AOR = 2.16; 95% CI = 1.19-3.93), but not DUD. Those "not sure" of their sexual identity had higher odds of severe AUD, TUD, and DUD: AUD (AOR = 5.05; 95% CI = 2.78-9.16), TUD (AOR = 4.18; 95% CI = 2.29-7.64), and DUD (AOR = 4.40; 95% CI = 1.72-11.2), than heterosexual respondents. There were few significant differences between "not sure" and bisexual respondents. CONCLUSIONS: These findings provide strong evidence that bisexual and "not sure" U.S. adults are more likely to have a severe AUD and TUD. They also demonstrate the importance of treatment strategies that address sexual minority-specific risks, particularly for bisexual individuals and those "not sure" of their sexual identity.

Sexual Orientation Discrimination and Tobacco Use Disparities in the United States.

INTRODUCTION: Differences in tobacco/nicotine use by sexual orientation are well documented. Development of interventions requires attention to the etiology of these differences. This study examined associations among sexual orientation discrimination, cigarette smoking, any tobacco/nicotine use, and DSM-5 tobacco use disorder (TUD) in the United States. METHODS: We used data from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions based on in-person interviews with a nationally representative sample of noninstitutionalized US adults. Approximately 8.3% of the target population was estimated to have same-sex sexual attraction, 3.1% had at least one same-sex sexual partner in the past-year, and 2.8% self-identified as lesbian, gay, or bisexual. RESULTS: Sexual attraction, sexual behavior, and sexual identity were significantly associated with cigarette smoking, any tobacco/nicotine use, and DSM-5 TUD. Risk of all tobacco/nicotine outcomes was most pronounced for bisexual adults across all three sexual orientation dimensions. Approximately half of sexual minorities who identified as lesbian or gay and one-fourth of those who identified as bisexual reported past-year sexual orientation discrimination. Sexual minorities who experienced high levels of past-year sexual orientation discrimination had significantly greater probability of past-year cigarette smoking, any tobacco/nicotine use, and TUD relative to sexual minorities who experienced lower levels of sexual orientation discrimination or no discrimination. CONCLUSIONS: Sexual minorities, especially bisexual adults, are at heightened risk of cigarette smoking, any tobacco/nicotine use, and DSM-5 TUD across all three major sexual orientation dimensions. Tobacco prevention and cessation efforts should target bisexual adults and consider the role that sexual orientation discrimination plays in cigarette smoking and treatment of TUD. IMPLICATIONS: Differences in tobacco/nicotine use by sexual orientation are well documented, but little is known about differences across all three sexual orientation dimensions (attraction, behavior, and identity) or the origins of these differences. This study is the first to show that differences in tobacco/nicotine use across the three sexual orientation dimensions for respondents who were exclusively heterosexually-oriented were minimal, but varied more substantially among sexual minority women and men across the three sexual orientation dimensions. Sexual minorities who experienced high levels of past-year sexual orientation discrimination had significantly greater probability of cigarette smoking, any tobacco/nicotine use and DSM-5 tobacco use disorder.

Association of Pregnancy History and Cervical Cancer Screening in a Community Sample of Sexual Minority Women.

BACKGROUND: Sexual minority women (SMW) face barriers to healthcare that may result in lower utilization of cervical cancer screening. Previous experiences with the healthcare system-specifically reproductive health-related encounters-have the potential to affect future use of screening services. This study aimed to examine the association between pregnancy history and cervical cancer screening in a diverse sample of SMW. Anderson's Behavioral Model of Health Services Use guided the selection of variables included in the study. METHODS: We performed a secondary analysis of cross-sectional data from the third wave of the Chicago Health and Life Experiences of Women (CHLEW) Study, a longitudinal study of SMW in the Midwestern United States. We performed multivariable logistic regression to address the study aims, restricting the sample to women ages 21-45 (n = 430). RESULTS: Reporting a previous pregnancy was consistently positively associated with past-year Pap testing. In the multivariable model, bisexual identity and disclosing one's sexual orientation to healthcare providers were also positively associated with past-year Pap test. CONCLUSIONS: This analysis provides preliminary evidence that SMW who have been pregnant are more likely to receive Pap testing and that multiple sociodemographic factors are likely to impact screening in this population. Clinicians should screen all patients with a cervix for cervical cancer and should encourage screening for all SMW. Future studies should prioritize longitudinal analyses to examine the temporality of reproductive history and healthcare seeking, focus on where SMW seek care, and understand how intersecting components of identity may shape the healthcare utilization of this population.