Sex and gender in the US health surveillance system: a call to action.

Youth Risk Behavior Survey (YRBS) data have exposed significant sexual orientation disparities in health. Interest in examining the health of transgender youths, whose gender identities or expressions are not fully congruent with their assigned sex at birth, highlights limitations of the YRBS and the broader US health surveillance system. In 2009, we conducted the mixed-methods Massachusetts Gender Measures Project to develop and cognitively test measures for adolescent health surveillance surveys. A promising measure of transgender status emerged through this work. Further research is needed to produce accurate measures of assigned sex at birth and several dimensions of gender to further our understanding of determinants of gender disparities in health and enable strategic responses to address them.

Monitoring the health of transgender and other gender minority populations: validity of natal sex and gender identity survey items in a U.S. national cohort of young adults.

BACKGROUND: A barrier to monitoring the health of gender minority (transgender) populations is the lack of brief, validated tools with which to identify participants in surveillance systems. METHODS: We used the Growing Up Today Study (GUTS), a prospective cohort study of U.S. young adults (mean age = 20.7 years in 2005), to assess the validity of self-report measures and implement a two-step method to measure gender minority status (step 1: assigned sex at birth, step 2: current gender identity). A mixed-methods study was conducted in 2013. Construct validity was evaluated in secondary data analysis of the 2010 wave (n = 7,831). Cognitive testing interviews of close-ended measures were conducted with a subsample of participants (n = 39). RESULTS: Compared to cisgender (non-transgender) participants, transgender participants had higher levels of recalled childhood gender nonconformity age < 11 years and current socially assigned gender nonconformity and were more likely to have ever identified as not completely heterosexual (p < 0.001). No problems with item comprehension were found for cisgender or gender minority participants. Assigned sex at birth was interpreted as sex designated on a birth certificate; transgender was understood to be a difference between a person's natal sex and gender identity. Participants were correctly classified as male, female, or transgender. CONCLUSIONS: The survey items performed well in this sample and are recommended for further evaluation in languages other than English and with diverse samples in terms of age, race/ethnicity, and socioeconomic status.

Willingness of Pharmacists to Prescribe Medication Abortion in California.

Importance: Nearly half of US states have restricted abortion access. Policy makers are exploring pathways to increase access to abortion and reproductive health care more broadly. Since 2016, California pharmacists could prescribe hormonal birth control, providing an opportunity to learn about the implementation of pharmacist-provided reproductive health care. Objective: To explore the feasibility of broadening pharmacist scope of practice to include prescribing medication abortion. Design, Setting, and Participants: A cross-sectional online survey was conducted from October 11 to December 20, 2022, among a convenience sample of California licensed community pharmacists to examine their attitudes toward, knowledge of, and confidence in prescribing hormonal birth control and reports of pharmacy-level practices. Main Outcomes and Measures: Descriptive analyses and log-binomial regression models were used to compare medication abortion and contraceptive provision attitudes by pharmacist and pharmacy characteristics. Results: Among the 316 pharmacists included in the analysis who worked at community pharmacies across California (mean [SD] age, 40.9 [12.0] years; 169 of 285 [59.3%] cisgender women; and 159 of 272 [58.5%] non-Hispanic Asian individuals), most (193 of 280 [68.9%]) indicated willingness to prescribe medication abortion to pharmacy clients if allowed by law. However, less than half were confident in their knowledge of medication abortion (139 of 288 [48.3%]) or their ability to prescribe it (115 of 285 [40.4%]). Pharmacists who indicated that providing access to hormonal birth control as a prescribing provider was important (263 of 289 [91.0%]) and were confident in their ability to prescribe it (207 of 290 [71.4%]) were 3.96 (95% CI, 1.80-8.73) times and 2.44 (95% CI, 1.56-3.82) times more likely to be willing to prescribe medication abortion and to express confidence in doing so, respectively. Although most pharmacists held favorable attitudes toward hormonal birth control, less than half (144 of 308 [46.8%]) worked in a pharmacy that provided prescriptions for hormonal birth control, and 149 who did not reported barriers such as lack of knowledge or training (65 [43.6%]), insufficient staff or time to add new services (58 [38.9%]), and lack of coverage for services (50 [33.6%]). Conclusions and Relevance: The findings of this cross-sectional survey study of California pharmacists suggest that most pharmacists were willing to prescribe medication abortion. However, future efforts to expand pharmacists' scope of practice should include training to increase knowledge and confidence in prescribing medication abortion. Pharmacy-level barriers to hormonal birth control prescription, such as insurance coverage for pharmacist effort, should also be addressed, as they may serve as barriers to medication abortion access.

Sexual orientation, gender expression and socioeconomic status in the National Longitudinal Study of Adolescent to Adult Health.

BACKGROUND: Socioeconomic status (SES) is a fundamental contributor to health, yet it is rarely examined relative to gender expression, particularly gender non-conformity and sexual orientation. METHODS: We use data from 11 242 Wave V respondents (aged 33-44) in the National Longitudinal Study of Adolescent to Adult Health (2016-2018) to examine associations between socially assigned gender expression, sexual orientation and SES, in logistic and multinomial regression models stratified by sex assigned at birth. RESULTS: Among both women and men a general pattern of heightened risk for lower SES among gender non-conforming sexual minorities relative to gender conforming heterosexuals was observed. Gender non-conforming heterosexuals were also at elevated risk of lower SES compared with their conforming heterosexual peers. CONCLUSION: Socioeconomic differences by sexual orientation and gender expression have important implications for understanding health disparities among gender non-conforming sexual minorities and their gender conforming heterosexual counterparts.

Transgender health in Massachusetts: results from a household probability sample of adults.

Despite higher rates of unemployment and poverty among transgender adults (n = 131; 0.5% weighted) than among nontransgender adults (n = 28,045) in our population-based Massachusetts household sample, few health differences were observed between transgender and nontransgender adults. Transgender adults who are stably housed and participated in a telephone health survey may represent the healthiest segment of the transgender population. Our findings demonstrate a need for diverse sampling approaches to monitor transgender health, including adding transgender measures to population-based surveys, and further highlight economic inequities that warrant intervention.

Sexual orientation differences in asthma correlates in a population-based sample of adults.

To understand what conditions may correlate with asthma diagnoses in the lesbian, gay, and bisexual (LGB) population, we used Massachusetts Behavioral Risk Factor Surveillance System data to construct multivariable logistic regression models separately for LGB individuals and heterosexuals. Current or former smoking and obesity were positively associated with history of an asthma diagnosis among both LGB individuals and heterosexuals. Being underweight (negative correlation) and overweight and reporting frequent symptoms of depression in the preceding 30 days also predicted a history of asthma diagnosis among heterosexuals.

Perspectives on Sexual Health, Sexual Health Education, and HIV Prevention From Adolescent (13-18 Years) Sexual Minority Males.

INTRODUCTION: Adolescent sexual minority males (ASMM) are at disproportionate risk of HIV infection. The purpose of this study was to assess ASMM's attitudes about sexual health, barriers/facilitators to accessing HIV prevention, and actual versus ideal interactions for receiving sexual health care and information. METHOD: Two online and two in-person focus groups were conducted with ASMM from across the United States. Qualitative data were analyzed using content analysis. RESULTS: Twenty-one racially diverse ASMM participated (average age = 16.4 years). Online focus groups were superior for reaching the target population. Four themes emerged: 1: identity formation and sources of support, 2: challenges to obtaining sexual health information, 3: attitudes/beliefs about sex and sexual behaviors, and 4: barriers to HIV prevention. DISCUSSION: These findings illustrate current gaps in sexual health knowledge, as well as barriers and facilitators to obtaining sexual health information, sexual health care, and affirming education and support for ASMM.

A population-based study of sexual orientation identity and gender differences in adult health.

OBJECTIVES: We provide estimates of several leading US adult health indicators by sexual orientation identity and gender to fill gaps in the current literature. METHODS: We aggregated data from the 2001-2008 Massachusetts Behavioral Risk Factor Surveillance surveys (N = 67,359) to examine patterns in self-reported health by sexual orientation identity and gender, using multivariable logistic regression. RESULTS: Compared with heterosexuals, sexual minorities (i.e., gays/lesbians, 2% of sample; bisexuals, 1%) were more likely to report activity limitation, tension or worry, smoking, drug use, asthma, lifetime sexual victimization, and HIV testing, but did not differ on 3-year Papanicolaou tests, lifetime mammography, diabetes, or heart disease. Compared with heterosexuals, bisexuals reported more barriers to health care, current sadness, past-year suicidal ideation, and cardiovascular disease risk. Gay men were less likely to be overweight or obese and to obtain prostate-specific antigen tests, and lesbians were more likely to be obese and to report multiple risks for cardiovascular disease. Binge drinking and lifetime physical intimate partner victimization were more common among bisexual women. CONCLUSIONS: Sexual orientation disparities in chronic disease risk, victimization, health care access, mental health, and smoking merit increased attention. More research on heterogeneity in health and health determinants among sexual minorities is needed.

Metabolic Syndrome and Economic Strain Among Sexual Minority Young Adults.

PURPOSE: The study tested if sexual orientation is associated with metabolic syndrome (MetS) in young adulthood (ages 24-32), and if economic strain impacts associations. METHODS: Gender-stratified logistic regressions were fit among 11,575 young adults (1644 sexual minority [SM]) in Wave IV of The National Longitudinal Study of Adolescent to Adult Health. RESULTS: MetS was not associated with sexual orientation for either gender, yet economic strain was more prevalent among both SM males and females. Additional MetS risk factors (smoking, binge drinking, and lower education) emerged for SM females. CONCLUSION: Although MetS did not differ by sexual orientation, emergent sexual orientation disparities among females suggest increased future risk.

Sexual orientation and sex differences in socioeconomic status: a population-based investigation in the National Longitudinal Study of Adolescent to Adult Health.

BACKGROUND: Socioeconomic status (SES) is a fundamental contributor to health; however, limited research has examined sexual orientation differences in SES. METHODS: 2008-2009 data from 14 051 participants (ages 24-32 years) in the US-based, representative, National Longitudinal Study of Adolescent to Adult Health were analysed using multivariable regressions that adjusted for age, race-ethnicity, childhood SES, urbanicity and Census region, separately for females and males. Modification by racial minority status (black or Latino vs white, non-Hispanic) was also explored. RESULTS: Among females, sexual minorities (SM) (10.5% of females) were less likely to graduate college, and were more likely to be unemployed, poor/near poor, to receive public assistance and to report economic hardship and lower social status than heterosexuals. Adjusting for education attenuated many of these differences. Among males, SM (4.2% of males) were more likely than heterosexuals to be college graduates; however, they also had lower personal incomes. Lower rates of homeownership were observed among SM, particularly racial minority SM females. For males, household poverty patterns differed by race-ethnicity: among racial minority males, SM were more likely than heterosexuals to be living at >400% federal poverty level), whereas the pattern was reversed among whites. CONCLUSIONS: Sexual minorities, especially females, are of lower SES than their heterosexual counterparts. SES should be considered a potential mediator of SM stigma on health. Studies of public policies that may produce, as well as mitigate, observed SES inequities, are warranted.

Gender Expression, Violence, and Bullying Victimization: Findings From Probability Samples of High School Students in 4 US School Districts.

BACKGROUND: Young people may experience school-based violence and bullying victimization related to their gender expression, independent of sexual orientation identity. However, the associations between gender expression and bullying and violence have not been examined in racially and ethnically diverse population-based samples of high school students. METHODS: This study includes 5469 students (13-18 years) from the 2013 Youth Risk Behavior Surveys conducted in 4 urban school districts. Respondents were 51% Hispanic/Latino, 21% black/African American, 14% white. Generalized additive models were used to examine the functional form of relationships between self-reported gender expression (range: 1 = Most gender conforming, 7 = Most gender nonconforming) and 5 indicators of violence and bullying victimization. We estimated predicted probabilities across gender expression by sex, adjusting for sexual orientation identity and potential confounders. RESULTS: Statistically significant quadratic associations indicated that girls and boys at the most gender conforming and nonconforming ends of the scale had elevated probabilities of fighting and fighting-related injury, compared to those in the middle of the scale (p < .05). There was a significant linear relationship between gender expression and bullying victimization; every unit increase in gender nonconformity was associated with 15% greater odds of experiencing bullying (p < .0001). CONCLUSIONS: School-based victimization is associated with conformity and nonconformity to gender norms. School violence prevention programs should include gender diversity education.

Does comparing alcohol use along a single dimension obscure within-group differences? Investigating men's hazardous drinking by sexual orientation and race/ethnicity.

BACKGROUND: Some studies have found that gay, bisexual, and other men who have sex with men (MSM) have higher odds of alcohol abuse and dependence than heterosexual men, but others have found no differences. We investigated whether the association between sexual orientation and hazardous drinking varied by race/ethnicity. METHODS: We estimated the odds of past-year heavy daily, heavy weekly, and binge drinking by sexual orientation and race/ethnicity among non-Latino White, non-Latino Black, and Latino (any race) men (n = 9689) who reported current alcohol use in the 2004-2005 National Epidemiological Survey of Alcohol and Related Conditions (NESARC). Interaction terms were included in multivariable logistic regression models to evaluate possible effect modification. RESULTS: In most comparisons, sexual minority men reported equivalent or lower levels of hazardous drinking than heterosexual peers. There was no association between sexual orientation and heavy daily drinking. Sexual minority Black men had lower odds of heavy weekly drinking and binge drinking than both heterosexual White men and heterosexual Black men. Among Latinos, the odds of heavy weekly drinking were higher for sexual minority men than heterosexuals; there was no difference by sexual orientation for binge drinking among Latinos. CONCLUSIONS: With one exception, sexual minority men were at equivalent or lower risk of hazardous drinking than heterosexual men. The Black-White advantage observed in other alcohol studies was observed in our study and was heightened among sexual minority men, suggesting the presence of protective factors that curb hazardous drinking. Additional research is necessary to identify the mechanisms responsible for these patterns.

Disproportionate exposure to early-life adversity and sexual orientation disparities in psychiatric morbidity.

OBJECTIVES: Lesbian, gay, and bisexual (LGB) populations exhibit elevated rates of psychiatric disorders compared to heterosexuals, and these disparities emerge early in the life course. We examined the role of exposure to early-life victimization and adversity-including physical and sexual abuse, homelessness, and intimate partner violence-in explaining sexual orientation disparities in mental health among adolescents and young adults. METHODS: Data were drawn from the National Longitudinal Study of Adolescent Health, Wave 3 (2001-2002), a nationally representative survey of adolescents. Participants included gay/lesbian (n=227), bisexual (n=245), and heterosexual (n=13,490) youths, ages 18-27. We examined differences in the prevalence of exposure to child physical or sexual abuse, homelessness or expulsion from one's home by caregivers, and physical and sexual intimate partner violence according to sexual orientation. Next we examined the associations of these exposures with symptoms of psychopathology including suicidal ideation and attempts, depression, binge drinking, illicit drug use, tobacco use, alcohol abuse, and drug abuse. Finally, we determined whether exposure to victimization and adversity explained the association between sexual orientation and psychopathology. RESULTS: Gay/lesbian and bisexual respondents had higher levels of psychopathology than heterosexuals across all outcomes. Gay/lesbian respondents had higher odds of exposure to child abuse and housing adversity, and bisexual respondents had higher odds of exposure to child abuse, housing adversity, and intimate partner violence, than heterosexuals. Greater exposure to these adversities explained between 10 and 20% of the relative excess of suicidality, depression, tobacco use, and symptoms of alcohol and drug abuse among LGB youths compared to heterosexuals. Exposure to victimization and adversity experiences in childhood and adolescence significantly mediated the association of both gay/lesbian and bisexual orientation with suicidality, depressive symptoms, tobacco use, and alcohol abuse. CONCLUSIONS: Exposure to victimization in early-life family and romantic relationships explains, in part, sexual orientation disparities in a wide range of mental health and substance use outcomes, highlighting novel targets for preventive interventions aimed at reducing these disparities.

Adulthood stressors, history of childhood adversity, and risk of perpetration of intimate partner violence.

BACKGROUND: More than half a million U.S. women and more than 100,000 men are treated for injuries from intimate partner violence (IPV) annually, making IPV perpetration a major public health problem. However, little is known about causes of perpetration across the life course. PURPOSE: This paper examines the role of "stress sensitization," whereby adult stressors increase risk for IPV perpetration most strongly in people with a history of childhood adversity. METHODS: The study investigated a possible interaction effect between adulthood stressors and childhood adversities in risk of IPV perpetration, specifically, whether the difference in risk of IPV perpetration associated with past-year stressors varied by history of exposure to childhood adversity. Analyses were conducted in 2010 using de-identified data from 34,653 U.S. adults from the 2004-2005 follow-up wave of the National Epidemiologic Survey on Alcohol and Related Conditions. RESULTS: There was a significant stress sensitization effect. For men with high-level childhood adversity, past-year stressors were associated with an 8.8 percentage point (pp) increased risk of perpetrating compared to a 2.3 pp increased risk among men with low-level adversity. Women with high-level childhood adversity had a 14.3 pp increased risk compared with a 2.5 pp increased risk in the low-level adversity group. CONCLUSIONS: Individuals with recent stressors and histories of childhood adversity are at particularly elevated risk of IPV perpetration; therefore, prevention efforts should target this population. Treatment programs for IPV perpetrators, which have not been effective in reducing risk of perpetrating, may benefit from further investigating the role of stress and stress reactivity in perpetration.

A longitudinal study of maternal depression and child maltreatment in a national sample of families investigated by child protective services.

OBJECTIVE: To assess whether a change in depression predicts a mother's change in maltreatment. DESIGN: Observational, repeated measures study. SETTING: National Survey of Child and Adolescent Well-being, 1999 to 2004. PARTICIPANTS: Mothers who retained custody of a child aged 0 to 15 years following a maltreatment investigation and completed at least 2 of 3 surveys (n = 2386). MAIN EXPOSURE: Change in depression status between baseline and 18- and 36-month follow-ups, assessed with the Composite International Diagnostic Interview Short Form. MAIN OUTCOME MEASURES: Change in psychological aggression, physical assault, and neglect between baseline and 18- and 36-month follow-ups, assessed with the Conflict Tactics Scale Parent-Child version. RESULTS: One-third (35.5%) of mothers experienced onset or remission of depression. Onset of depression was associated with an increase of 2.3 (95% confidence interval, 0.2-4.4) psychologically aggressive acts in an average 12-month period, but was not statistically significantly associated with change in physical assault or neglect. CONCLUSION: Depression is positively associated with maternal perpetration of psychological aggression in high-risk families.