Why do gay men get sick(er)?

Horror stories about same-sex partners being denied hospital visitation rights have become part of our collective consciousness in the LGBT community. For example, just last year a man in Sonoma County, CA, was denied the right to visit his male partner, who was dying in the hospital.

Such stories, in addition to highlighting ongoing issues of discrimination, make me wonder about access to health care among LGBT individuals. If a same-sex couple is worried about being denied visitation rights, is a same-sex attracted man or woman less likely to seek health care in general for fear of discrimination? Taking a step back from that, are LGBT persons less healthy overall than their heterosexual counterparts? Do health disparities exist based on sexual attraction/behavior/identity? (For more on health disparities, you can nerd out and read this article from the National Institutes of Health.)

The topic of health disparities has been on my mind for several weeks now. Just going off of recent RFAs (that's requests for applications, and I really will try to avoid jargon), disparity seems to be a huge buzzword at NIH these days. There’s been a lot of work on health disparities based on race and ethnicity, a bit based on socioeconomic status, and very little based on sexual minority status.

It’s kind of startling, particularly given that recent estimates hold that same-sex attracted individuals make up a considerable minority of the American populace. Just because I think it’s interesting, I’ll link to this article on estimated numbers of LGBT individuals worldwide.

While not quite the 10% estimated by Kinsey, the more recent projection of 8+ million is nothing to scoff at. Further, those numbers indicate that there are more LGBT persons living in the U.S. than persons of Asian descent.

So there is at least an indication of inequality in health care access and (perhaps) physical health among sexual minorities. There are a lot of LGBT individuals potentially impacted by this inequality. But what do I actually mean when I talk about health disparities? What form might these disparities take? I am thinking of two major areas of physical health disparity that are observable in sexual minority populations:

1. Sexually transmitted infections and HIV. This one’s a gimme. Though rates of HIV infection are rising among other populations, including women and African Americans, same-sex male sexual contact remains the #1 vector for HIV transmission in the U.S., and men who have sex with men (or MSM) remain the group most impacted by the HIV epidemic. Beyond just HIV, MSM are more heavily impacted by syphilis (which has been all but eliminated among other sociosexual groups), Hepatitis C, etc. So you have more same-sex attracted men affected by sexually transmitted infections than heterosexual men. A clear disparity.

2. Cancer. This one is more of a surprise. With HIV, the vector of transmission and the increased incidence rate are tightly linked. HIV in the U.S. has historically been viewed as a “gay disease” (and, in the 80’s, a Haitian/hemophiliac/drug use disease). But cancer can strike anyone, at any time, for any reason! California has signs posted everywhere that entering any building (including our apartment complex!) can expose you to known carcinogenic agents!

There is no immediately apparent reason why LGBT individuals would be more likely to be diagnosed with cancer. And yet, according to Ulrike Boehmer, they are.

Gay men are nearly twice as likely to report a cancer diagnosis as heterosexual men, in fact. And though lesbian women are no more likely to report having cancer than heterosexual women, their health post-cancer is worse. Another clear disparity.

I didn’t know what to make of this finding, and so I acquired my own gigantic population-based dataset (albeit not as big as Boehmer’s). And I replicated the finding: gay men are more likely to report a cancer diagnosis than straight men. They are not more likely to report any other health issue, including hypertension, diabetes, high cholesterol…though, of course, they are more likely to report having had an HIV test in the past year.

So what are we to make of this difference? Why would gay men be more likely to report cancer diagnoses than straight men? And what keeps the incidence of HIV infection so disproportionately high among MSM?

Since the work on health disparities among sexual minority populations is still in its infancy, we need to turn to work on ethnic/racial minorities to try to find answers. King and Williams, in their 1995 book on the subject of race and health, outlined five factors that can lead to health disparities between groups. Let’s see how well these factors map onto sexual minorities.

1. Biological factors that predispose individuals to develop or protect them from disease. If you believe that sexuality is biologically determined (and I do, though that is a topic for another post), you might believe that there is some biological predisposition for certain health issues among sexual minority groups. For example, according to another huge study, lesbian women are more likely than straight women to develop arthritis.

Could there be a biological factor at work there, perhaps having to do with hormone levels? Could there similarly be something in gay men’s physiological makeup that predisposes them to developing cancer? It is possible, but it doesn’t seem the likeliest explanation.

2. Cultural factors that influence health behavior. Importantly, this category also includes risk factors. There’s a lot to say here. Another major and oft-replicated health disparity between LGB (and probably T) persons and heterosexuals is prevalence of drug use and abuse, including alcohol and tobacco use. Some studies have cited as much as a 2.5 times increased prevalence of substance use disorders among sexual minorities. There’s certainly an element of culture at work here, with the ubiquity of the bar and club scene as a social outlet for the LGBT community. For gay men, there is also the direct link between drugs and sex in the PnP culture. Given the link between smoking and cancer, cultural factors that lead to increased smoking and substance use may also lead to increased cancer risk.

For HIV, of course, we have to consider the swing of the cultural pendulum regarding condom use. I can summarize the enthusiasm expressed by the HIV+ gay men with whom I work in two words: “condoms suck.” And they do, let’s be honest. They certainly don’t make sex MORE fun. But the cultural ethos surrounding condom use (or non-use) and the eroticization of barebacking has made it less likely that a gay man influenced by gay culture will choose to use a condom when having sex. And so rates of HIV infection among MSM remain high.

I could go on, but suffice to say that if I was a gambling man, I’d put a lot of money on this set of factors in the race to explain health disparities.

3. Socioeconomic factors that affect ability to access care. A recent report by the Institute of Medicine indicated that LGBT individuals may be less able to obtain health insurance, and may therefore have less access to care.

I don’t necessarily buy it. A number of other studies, including those large population-based ones I mentioned earlier, found that there was no difference between sexual minority individuals and heterosexuals in terms of having insurance, and that sexual minorities actually had a higher mean income. However, I can imagine someone trying to get insurance coverage for a same-sex partner and being denied, based on the lack of legal acknowledgement of the relationship. So there are certainly some uninsured or underinsured LGBT persons. I don’t think this is the biggest set of factors, however.

4. Prejudice/discrimination that creates psychological stress and limits access to care. The Institute of Medicine hit this one pretty hard, and I have examined the role of prejudice a good bit in my work as well. The minority stress model (Ilan Meyer, 2003) is my favorite summary of the impact of prejudice and discrimination on the health and functioning of sexual minorities. It basically posits that living in a prejudicial environment engenders constant stress and anxiety, and this stress and anxiety leads a sexual minority individual to develop a host of stress-related issues.

Thus far, the minority stress model has been used primarily to explain psychological difficulties, but the time is right for its framework to be extended. After all, stress has been implicated in a host of physical ailments, including cancer.  If you believe in the mind-body connection (and again, I do), then the cascade of mental badness resulting from discrimination-based stress is going to have a considerable physical impact.  Even accounting for disparities caused by cultural and risk factors, I would bet that exposure to prejudice is responsible for some amount of the health disparity observed between LGBT and heterosexual individuals.

5. Political factors that contribute to policy directly and indirectly affecting health. And here we end up back where we started, with discriminatory policies that can impact access to health care. I’d love to see an in-depth study of this; the only one I know, again by the fabulous Ulrike Boehmer, found that lesbian women with breast cancer reported fearing discrimination when they interacted with their oncologists. Boehmer is so fabulous, I’d encourage you to go check out her other publications, here.

In addition to this fear of discrimination, you have the issue of visitation rights, etc., which can indirectly impact health through access to care.  Policies can also limit access to insurance, through lack of legal recognition of same-sex relationships.

So there you have it. Health disparities exist for LGBT persons, and they exist (I would guess) largely because of the impact of cultural/risk factors and prejudice/discrimination. What do you think? Does this make sense? And the all-important question: if I’m right, then what do we do to reduce these disparities?