Abstract
Purpose:
Skin cancer is prevalent in sexual minority men but little is known about risk factors and screening specifically among couples in same-sex relationships (SSR). We aimed to compare sunburns, sun-protective behaviors, indoor tanning, and total body skin examinations (TBSEs) between people in SSR with those in opposite-sex relationships (OSR).
Methods:
We conducted a pooled cross-sectional analysis of 2000–2015 data from the National Health Interview Survey, a nationally representative survey of the United States civilian population.
Results:
Of 102,365 adults with a spouse or married partner, 448 (0.4%) were men in SSR, 48,312 (48.1%) men in OSR, 497 (0.5%) women in SSR, and 53,108 women in OSR (51.9%). Men in SSR were more likely than men in OSR to seek shade (adjusted odds ratio [aOR] = 1.41; 95% confidence interval [CI] = 1.07–1.85), tan indoors (aOR = 3.71; 95% CI = 2.38–5.78), and receive any TBSE (aOR = 2.45; 95% CI = 1.69–3.54) after adjusting for sociodemographic factors, health insurance status, and health behaviors. Men in SSR were less likely than men in OSR to wear long pants (aOR = 0.63; 95% CI = 0.46–0.85) and caps or visors (aOR = 0.50; 95% CI = 0.36–0.69). No differences in sunburns, sun-protective behaviors, indoor tanning, and TBSE between women in SSR and OSR were observed after multivariable adjustment.
Conclusion:
Patterns of sun-protective behaviors and indoor tanning among men in SSR, compared with men in OSR, demonstrate modifiable behaviors that may mitigate skin cancer risk. Dyadic counseling and public health interventions geared toward men in SSR may promote sun-protective behaviors and reduce indoor tanning.
Keywords: epidemiology, risk factors, same-sex relationships, sexual and gender minority, skin cancer, tanning
Introduction
Gay and bisexual men have higher lifetime prevalence of indoor tanning and skin cancer when compared with heterosexual men.1–4 Indoor tanning, and other skin cancer behavioral risk factors such as lack of use of protective clothing, may be prominent among sexual minority men because of perceived associations between tanned skin and attractiveness.4,5 Although sun-protective behaviors and indoor tanning may be motivated by dating and relationships, there is limited research on skin cancer behavioral risk factors, indoor tanning, and skin cancer screening practices among sexual minority populations in long-term relationships.5
Skin cancer risk factors and clinical screening correlate well among romantic couples, and prior studies suggest similarities in behavior may be more pronounced among gay and lesbian couples than heterosexual couples.6,7 Gay and lesbian couples reported lower engagement in skin self examinations (SSEs) and total body skin examinations (TBSEs) than heterosexual couples.8 Importantly, behavioral concordance was higher among gay and lesbian couples, regardless of whether couples were both engaging or not engaging in SSE or TBSE.8 Understanding skin cancer risk factors among sexual minority individuals in relationships may help identify distinct patterns of behavior that can be leveraged through dyadic interventions targeting couples rather than separate individuals.9
In this study, we aim to investigate prevalence of sunburns, sun-protective behaviors, indoor tanning, and skin cancer screening practices between individuals in same-sex relationships (SSR) compared with those in opposite-sex relationships (OSR) using data collected from a large, nationally representative, population-based survey.
Methods
Data source
The National Health Interview Survey (NHIS) is an annual, population-based, cross-sectional survey designed to be representative of the civilian, noninstitutionalized United States population. Data are collected through a personal household interview survey systematically administered by trained interviewers from the U.S. Census Bureau. The survey contains detailed information on sociodemographics, health conditions and behaviors, and health care access and utilization. We pooled NHIS data from years 2000, 2003, 2005, 2008, 2010, 2013, and 2015 as those years contained supplemental data on skin cancer risk factors and screening utilization. This study was exempted from review by the Emory University Institutional Review Board and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology Statement guidelines.10
Participant selection
Participants included adults ≥18 years old living with either a spouse or unmarried partner during the 7-year period of data collection with available skin cancer-related outcomes. In NHIS, an adult reference person within a sampled family of a sampled household was randomly selected to complete an in-depth interview. For all other persons within that family, their sex and relationship with the reference person were recorded. Reference persons living in a SSR or an OSR—through identification of a husband, wife, or unmarried partner of either sex—were elicited. Therefore, adults with a spouse or unmarried partner who did not live together were not included.
Skin cancer behavioral risk factors
In years 2000, 2005, 2010, and 2015, NHIS sampled adults were asked the number of sunburns they experienced in the past 12 months; whether they had a TBSE by a dermatologist or other doctors, and the timing of their last TBSE. In 2000–2015, participants were also asked frequency of sun-protective behaviors when outside on a sunny day for ≥1 hour, including how often they stay in the shade, wear a wide-brimmed hat, wear a long-sleeved shirt, use sunscreen, as well as the sun protection factor (SPF) of the sunscreen they usually use. In 2005–2015, the question “Is the SPF usually 1–14 or 15–50?” was added. In 2005–2015, additional questions were included on how often they wore long clothing to the ankles, or wore a baseball cap or sun visor for sun protection. In 2005–2013, questions about frequency of indoor tanning device use in the past 12 months were added (Supplementary Table S1).
Consistent with prior studies, outcomes were defined as the prevalence of individuals reporting: (1) ≥1 sunburn in the past 12 months; (2) “always” or “most of the time” engaging in sun-protective behaviors, as opposed to “sometimes,” “rarely,” or “never”; (3) any use or frequent (≥10) use of indoor tanning device (including sunlamps, sunbeds, or tanning booths, but not spray-on tans) in the past 12 months; and (4) having a history of TBSE ever and in the past 12 months (Supplementary Table S1).11–14 Small percentages of individuals responded to the sun-protective behavior questions by saying that they “don't go out in the sun”; these responses were considered as frequent engagement in sun-protective behavior (Supplementary Table S1). Participants with missing data were only excluded from analyses that required the missing data and were included in other analyses where the same participant had data available.
Statistical analysis
All analyses reflected the multistage, complex survey design of NHIS using appropriate sampling weights to produce nationally representative estimates with appropriate subpopulation variance. Relative standard errors for all outcome estimates were tested and all met the a priori reliability threshold of <30% in accordance with NHIS guidelines.15 Weighted prevalence estimates of sociodemographic and health characteristics were summarized descriptively and compared between individuals in SSR and OSR using Rao–Scott χ2 tests. Given potential interaction between sex and sexual orientation on outcome prevalence, analyses were stratified by sex.
Associations between sexual orientation and each outcome variable were modeled using individual bivariate logistic regression models. Multivariable models adjusted for survey year, sociodemographic factors, health insurance status, cancer-related health behaviors, and personal history of any skin cancer. The Benjamini–Hochberg procedure was used to adjust for multiple testing with 10 outcomes and a false discovery rate of 5%, with p < 0.05 in two-sided tests considered significant.16
Sensitivity analysis on the prevalence of sunscreen use restricting to known SPF 15+ was performed and did not significantly affect our results (data not shown). NHIS began collecting data on sexual orientation in 2013, so sensitivity analyses were performed using 2013–2015 data comparing skin cancer risk factors among men and women in SSR with men and women who identified as gay, lesbian, and bisexual not living with a romantic partner. Wearing long-sleeved shirts, hats, and indoor tanning were not included in sensitivity analyses as coefficient of variance did not meet reliability thresholds. All analyses were performed using Stata IC 12.1 (StataCorp LLC, College Station, TX).
Results
Across the 7 pooled years of the NHIS from 2000 to 2015, 211,821 sampled adults completed the survey. From 102,365 adult respondents with a spouse or married partner, 448 (0.4%) were men in SSR, 48,312 (48.1%) men in OSR, 497 (0.5%) women in SSR, and 53,108 women in OSR (51.9%) (Table 1). In the 2013–2015 subset that self-reported sexual orientation, 86.0% (95% confidence interval [CI] = 83.5–94.7) of men in SSR identified as gay, 0.9% (95% CI = 0.2–4.3) as bisexual, and 3.6% (95% CI = 1.3–9.7) as something else, whereas 99.4% (95% CI = 99.2–99.6) of men in OSR identified as straight. A total of 82.8% (95% CI = 75.9–88.0) of women in SSR identified as lesbian, 6.3% (95% CI = 3.5–11.1) as bisexual, 1.4% (95% CI = 0.2–9.4) as something else, and 9.4% (95% CI = 5.9–14.8) as straight, whereas 99.1% (95% CI = 98.9–99.3) of women in OSR identified as straight.
Table 1.
Weighted Prevalence of Sociodemographic and Health Characteristics Among U.S. Adults in Same-Sex and Opposite-Sex Relationships
| Prevalence % (95% CI) | Men |
Women |
||||
|---|---|---|---|---|---|---|
| SSR | OSR | p | SSR | OSR | p | |
| Age, years | ||||||
| 18–29 | 14.5 (10.8–19.2) | 11.1 (10.7–11.5) | <0.001 | 22.5 (17.8–27.9) | 15.0 (14.6–15.4) | <0.001 |
| 30–39 | 24.2 (19.7–29.3) | 20.8 (20.3–21.2) | 25.5 (20.4–31.4) | 21.9 (21.4–22.3) | ||
| 40–49 | 29.7 (24.8–35.1) | 23.1 (22.6–23.6) | 24.9 (20.6–29.7) | 23.1 (22.6–23.6) | ||
| 50–64 | 27.4 (22.3–33.1) | 27.7 (27.2–28.3) | 24.1 (19.4–29.4) | 26.5 (26.0–27.0) | ||
| 65+ | 4.3 (2.6–6.9) | 17.4 (16.9–17.8) | 3.1 (1.7–5.6) | 13.6 (13.2–14.0) | ||
| Race/ethnicity | ||||||
| White | 78.2 (73.4–82.3) | 73.8 (73.2–74.5) | 0.15 | 75.9 (70.8–80.3) | 75.3 (74.7–75.9) | 0.13 |
| Black | 8.0 (5.5–11.7) | 8.4 (8.0–8.8) | 9.8 (6.9–13.6) | 7.1 (6.8–7.5) | ||
| Hispanic | 9.6 (7.0–13.0) | 13.0 (12.5–13.5) | 10.8 (8.0–14.4) | 12.2 (11.8–12.6) | ||
| Other | 4.2 (2.5–6.9) | 4.8 (4.6–5.1) | 3.5 (2.0–6.3) | 5.4 (5.1–5.7) | ||
| Education level | ||||||
| Below high school | 6.5 (4.5–9.4) | 14.3 (13.8–14.7) | <0.001 | 6.3 (4.1–9.6) | 12.3 (11.9–12.8) | <0.001 |
| High school | 17.3 (13.1–22.4) | 27.5 (26.9–28.0) | 21.0 (17.0–25.7) | 28.5 (27.9–29.0) | ||
| Some college | 27.7 (22.7–33.3) | 26.7 (26.2–27.2) | 28.0 (22.7–33.9) | 29.7 (29.2–30.2) | ||
| College graduate or above | 48.5 (42.5–54.6) | 31.6 (30.9–32.2) | 44.7 (39.0–50.5) | 29.5 (28.9–30.1) | ||
| Income levela | ||||||
| Below or equal 2 × FPL | 14.4 (10.4–19.7) | 21.7 (21.2–22.4) | 0.003 | 20.9 (16.1–26.6) | 21.9 (21.4–22.5) | 0.69 |
| Above 2 × FPL | 85.6 (80.3–89.6) | 78.3 (77.6–78.9) | 79.1 (73.4–83.9) | 78.1 (77.5–786) | ||
| Health insurance status | ||||||
| Uninsured/unknown | 18.4 (14.4–23.2) | 13.6 (13.1–14.0) | 0.04 | 15.7 (11.8–20.5) | 13.0 (12.6–13.4) | 0.23 |
| Insured | 81.6 (76.8–85.6) | 86.4 (86.0–86.9) | 84.3 (79.5–88.2) | 87.0 (86.6–87.4) | ||
| History of any skin cancer | ||||||
| No/unknown | 96.6 (93.7–98.1) | 96.6 (96.4–96.8) | 0.96 | 97.8 (95.3–99.0) | 97.4 (97.2–97.6) | 0.67 |
| Yes | 3.4 (1.9–6.3) | 3.4 (3.2–3.6) | 2.2 (1.0–4.7) | 2.6 (2.4–2.8) | ||
| Smoking | ||||||
| Never | 43.2 (37.5–49.0) | 50.2 (49.6–50.9) | <0.001 | 50.4 (44.5–56.3) | 63.6 (63.1–64.2) | <0.001 |
| Former | 25.0 (20.4–30.2) | 29.7 (29.1–30.2) | 25.7 (20.9–31.3) | 19.8 (19.3–20.2) | ||
| Current | 31.8 (26.5–37.7) | 20.1 (19.6–20.6) | 23.9 (19.3–29.2) | 16.6 (16.2–17.0) | ||
| Heavy alcohol useb | ||||||
| No/unknown | 56.9 (50.4–63.3) | 61.0 (60.3–61.7) | 0.23 | 72.5 (65.7–78.4) | 79.7 (79.1–80.3) | 0.03 |
| Yes | 43.1 (36.7–49.6) | 39.0 (38.3–39.7) | 27.5 (21.6–34.3) | 20.3 (19.7–20.9) | ||
| Body mass index | ||||||
| <25 or unknown | 46.8 (41.1–52.5) | 27.5 (27.0–28.0) | <0.001 | 38.0 (32.3–44.2) | 49.9 (49.4–50.5) | <0.001 |
| 25–29.9 | 34.6 (29.3–40.4) | 44.7 (44.1–45.2) | 25.1 (20.3–30.7) | 27.2 (26.7–27.6) | ||
| 30+ | 18.6 (14.3–23.8) | 27.8 (27.3–28.3) | 36.8 (31.5–42.5) | 22.9 (22.4–23.4) | ||
Low-income status was defined as family income below or equal to double the federal poverty level.
Heavy alcohol use was defined as having 5+ alcoholic drinks in one or more days in the past year.
CI, confidence interval; FPL, federal poverty level; OSR, opposite-sex relationship; SSR, same-sex relationship.
Men in SSR were more likely than men in OSR to seek shade (adjusted odds ratio [aOR] = 1.41; 95% CI = 1.07–1.85) and less likely to wear long pants (aOR = 0.63; 95% CI = 0.46–0.85) and caps or visors (aOR = 0.50; 95% CI = 0.36–0.69) after adjusting for sociodemographic factors, health insurance status, and health behaviors (Table 2). Men in SSR were also more likely than men in OSR to have tanned indoors (aOR = 3.71; 95% CI = 2.38–5.78) and frequently tanned indoors (aOR = 7.98; 95% CI = 3.22–19.77) in the last year (Table 2). Men in SSR were also more likely than men in OSR to have received any TBSE in their lifetime (aOR = 2.45; 95% CI = 1.69–3.54).
Table 2.
Weighted Prevalence of Skin Cancer-Related Behavioral Risk Factors Among Men in Same-Sex and Opposite-Sex Relationships
| Variables | Men in SSR |
Men in OSR |
Bivariable model |
Multivariable modela,b |
||
|---|---|---|---|---|---|---|
| N | Prevalence % (95% CI) | N | Prevalence % (95% CI) | OR (95% CI) | OR (95% CI) | |
| Sunburns | ||||||
| Once or more | 105 | 39.1 (32.7–45.8) | 9505 | 37.9 (37.2–38.6) | 1.05 (0.80–1.39) | 0.82 (0.60–1.13) |
| None | 167 | 60.9 (54.2–67.3) | 17,128 | 62.1 (61.4–62.8) | ||
| Seeking shade | ||||||
| Frequent | 115 | 31.2 (26.2–36.8) | 10,232 | 25.8 (25.3–26.4) | 1.30 (1.02–1.67) | 1.41 (1.07–1.85) |
| Not frequent | 240 | 68.8 (63.2–73.8) | 28,243 | 74.2 (73.6–74.7) | ||
| Long-sleeved shirts | ||||||
| Frequent | 28 | 8.1 (5.5–11.7) | 5491 | 12.9 (12.5–13.4) | 0.59 (0.39–0.89) | 0.70 (0.45–1.08) |
| Not frequent | 328 | 91.9 (88.3–94.5) | 33,066 | 87.1 (86.6–87.5) | ||
| Long pants | ||||||
| Frequent | 70 | 23.6 (18.9–29.1) | 9444 | 36.6 (35.8–37.4) | 0.54 (0.40–0.71) | 0.63 (0.46–0.85) |
| Not frequent | 199 | 76.4 (70.9–81.1) | 15,034 | 63.4 (62.6–64.2) | ||
| Wide-brimmed hats | ||||||
| Frequent | 53 | 14.4 (10.6–19.2) | 8948 | 21.8 (21.3–22.3) | 0.60 (0.43–0.85) | 0.72 (0.49–1.06) |
| Not frequent | 303 | 85.6 (80.8–89.4) | 29,619 | 78.2 (77.7–78.7) | ||
| Caps or visors | ||||||
| Frequent | 91 | 32.2 (26.3–38.8) | 12,090 | 48.9 (48.1–49.7) | 0.50 (0.37–0.66) | 0.50 (0.36–0.69) |
| Not frequent | 177 | 67.8 (61.2–73.7) | 12,399 | 51.1 (50.3–51.9) | ||
| Sunscreen | ||||||
| Frequent | 119 | 31.7 (26.8–37.1) | 8589 | 23.3 (22.8–23.8) | 1.53 (1.20–1.94) | 1.26 (0.95–1.68) |
| Not frequent | 235 | 68.3 (62.9–73.2) | 29,984 | 76.7 (76.2–77.2) | ||
| Sun-protective behaviors | ||||||
| ≥1 | 215 | 57.9 (52.0–63.5) | 23,562 | 60.7 (60.1–61.3) | 0.89 (0.70–1.13) | 0.87 (0.67–1.14) |
| 0 | 142 | 42.1 (36.5–48.0) | 15,057 | 39.3 (38.7–39.9) | ||
| Indoor tanning | ||||||
| Once or more | 40 | 13.3 (9.4–18.5) | 1536 | 5.3 (4.9–5.6) | 2.76 (1.85–4.11) | 3.71 (2.38–5.78) |
| None | 300 | 86.7 (81.5–90.6) | 30,490 | 94.7 (94.4–95.1) | ||
| Frequent tanning | ||||||
| Yes | 5 | 2.5 (1.0–5.9) | 111 | 0.3 (0.3–0.4) | 7.46 (3.01–18.48) | 7.98 (3.22–19.77) |
| No | 328 | 97.5 (94.1–99.0) | 31,803 | 99.7 (99.6–99.7) | ||
| TBSE in lifetime | ||||||
| Yes | 93 | 36.2 (29.9–42.9) | 5544 | 21.7 (21.1–22.3) | 2.05 (1.54–2.73) | 2.45 (1.69–3.54) |
| No | 180 | 63.8 (57.1–70.1) | 21,427 | 78.3 (77.7–78.9) | ||
Significance of bold values indicate adjusted p < 0.05.
Multivariable logistic regression models adjusted for survey year, age, race/ethnicity, education, poverty, geographic region, and health insurance, smoking status, heavy alcohol use, obesity, and personal history of any skin cancer. Men in OSR were used as the reference group.
Adjusted p < 0.05; p values in multivariable models adjusted for multiple comparisons with 10 outcomes using the Benjamini–Hochberg procedure.
OR, odds ratio; TBSE, total body skin examination.
There were no differences in sunburns, sun-protective behaviors, indoor tanning, and TBSE between women in SSR and OSR after adjusting for sociodemographic factors, health insurance status, and health behaviors (Table 3).
Table 3.
Weighted Prevalence of Skin Cancer-Related Behavioral Risk Factors Among Women in Same-Sex and Opposite-Sex Relationships
| Variables | Women in SSR |
Women in OSR |
Bivariable model |
Multivariable modela,b |
||
|---|---|---|---|---|---|---|
| N | Prevalence % (95% CI) | N | Prevalence % (95% CI) | OR (95% CI) | OR (95% CI) | |
| Sunburns | ||||||
| Once or more | 134 | 48.0 (42.2–53.9) | 10,377 | 37.3 (36.6–38.0) | 1.55 (1.22–1.97) | 1.20 (0.89–1.61) |
| None | 154 | 52.0 (46.1–57.8) | 18,874 | 62.7 (62.0–63.4) | ||
| Seeking shade | ||||||
| Frequent | 136 | 34.0 (28.8–39.5) | 16,661 | 37.8 (37.2–38.4) | 0.85 (0.67–1.08) | 0.82 (0.64–1.06) |
| Not frequent | 242 | 66.0 (60.5–71.2) | 26,083 | 62.2 (61.6–62.8) | ||
| Long-sleeved shirts | ||||||
| Frequent | 31 | 8.0 (5.4–11.6) | 4627 | 10.0 (9.6–10.4) | 0.78 (0.52–1.18) | 1.00 (0.66–1.51) |
| Not frequent | 347 | 92.0 (88.4–94.6) | 38,151 | 90.0 (89.6–90.4) | ||
| Long pants | ||||||
| Frequent | 54 | 20.1 (15.1–26.4) | 6093 | 21.6 (20.9–22.2) | 0.92 (0.64–1.31) | 0.98 (0.67–1.42) |
| Not frequent | 229 | 79.9 (73.6–84.9) | 20,716 | 78.4 (77.8–79.1) | ||
| Wide-brimmed hats | ||||||
| Frequent | 55 | 13.3 (10.0–17.4) | 6961 | 15.6 (15.2–16.1) | 0.83 (0.60–1.14) | 0.94 (0.65–1.37) |
| Not frequent | 323 | 86.7 (82.6–90.0) | 35,818 | 84.4 (83.9–84.8) | ||
| Caps or visors | ||||||
| Frequent | 73 | 26.8 (21.2–33.3) | 5529 | 20.6 (19.9–21.2) | 1.42 (1.04–1.93) | 1.41 (1.00–1.98) |
| Not frequent | 210 | 73.2 (66.7–78.8) | 21,288 | 79.4 (78.8–80.1) | ||
| Sunscreen | ||||||
| Frequent | 155 | 42.5 (36.8–48.4) | 18,299 | 44.5 (43.9–45.1) | 0.92 (0.73–1.17) | 0.81 (0.63–1.04) |
| Not frequent | 224 | 57.5 (51.6–63.2) | 24,493 | 55.5 (54.9–56.1) | ||
| Sun-protective behaviors | ||||||
| ≥1 | 249 | 66.0 (60.5–71.2) | 28,164 | 66.1 (65.5–66.7) | 1.00 (0.79–1.27) | 0.95 (0.73–1.24) |
| 0 | 131 | 34.0 (28.8–39.5) | 14,676 | 33.9 (33.3–34.5) | ||
| Indoor tanning | ||||||
| Once or more | 40 | 9.7 (6.4–14.3) | 1536 | 11.0 (10.6–11.4) | 0.87 (0.55–1.36) | 0.70 (0.41–1.18) |
| None | 300 | 90.3 (85.7–93.6) | 30,490 | 89.0 (88.6–89.4) | ||
| Frequent tanning | ||||||
| Yes | 10 | 97.7 (97.5–97.9) | 713 | 2.3 (2.1–2.5) | 1.31 (0.65–2.64) | 1.10 (0.50–2.42) |
| No | 363 | 97.1 (94.3–98.5) | 33,590 | 2.9 (1.5–5.7) | ||
| TBSE in lifetime | ||||||
| Yes | 68 | 24.2 (19.0–30.2) | 6292 | 22.9 (22.3–23.5) | 1.07 (0.79–1.46) | 0.95 (0.68–1.32) |
| No | 220 | 75.8 (69.8–81.0) | 23,442 | 77.1 (76.5–77.7) | ||
Multivariable logistic regression models adjusted for survey year, age, race/ethnicity, education, poverty, geographic region, and health insurance, smoking status, heavy alcohol use, obesity, and personal history of any skin cancer. Women in OSR were used as the reference group.
Adjusted p < 0.05; p values in multivariable models adjusted for multiple comparisons with 10 outcomes using the Benjamini–Hochberg procedure.
In sensitivity analyses with 2013 and 2015 data, men and women in SSR were both more likely to receive TBSE when compared with gay, lesbian, and bisexual individuals not living with a romantic partner in bivariable analyses; associations did not persist after multivariable adjustment (Supplementary Tables S2 and S3). Sunburns and sun-protective behaviors did not differ between groups (Supplementary Tables S2 and S3).
Discussion
Differences in sun-protective behaviors, indoor tanning, and skin cancer screening behaviors among men in SSR were observed when compared with those in OSR using data from a nationally representative survey. Higher prevalence of sunscreen use and indoor tanning, and lower prevalence of wearing long-sleeved shirts, long pants, and caps/visors are consistent with prior studies among sexual minority men regardless of relationship status.1–4
Increased risk of skin cancer among men in SSR resembles patterns of risk factors reported in prior studies. Men in SSR had high prevalence of indoor tanning compared to men in OSR, consistent with prior studies among sexual minority men in general that demonstrated high magnitudes of indoor tanning among self-identified gay and/or bisexual men compared with heterosexual men.2,17–19 Men in SSR were also more likely than those in OSR to have had TBSE, which reinforces prior research suggesting that gay and lesbian couples have higher concordance in skin cancer screening than other couples.8
Dermatologists should be aware that disparities in skin cancer risk factors observed in sexual minority men remain prevalent among men in SSR, but key differences among those in relationships and single individuals may exist. Men and women in SSR were more likely than gay, lesbian, and bisexual individuals not living with a romantic partner to have had TBSE in bivariable analyses, although differences did not remain significant after adjusting for additional sociodemographic covariates. The role of same-sex romantic partnership in facilitating the receipt of clinical skin cancer screening and engaging in partner-facilitated skin examination should be further examined. Future studies in a larger sample of all sexual minority individuals may help elucidate factors associated with skin cancer risk and prevalence to further refine public health programs or clinical screening.
Although prior studies have demonstrated lower prevalence of TBSE, breast cancer, and cervical cancer screening among sexual minority women, the present study of women in SSR demonstrated no differences in skin cancer screening practices compared with women in OSR.20–22 Differences between sexual minority women compared with women in SSR, even within the same dataset, warrant further exploration to determine if being in a relationship is beneficial to health behaviors and outcomes.23 It may be possible that barriers to health care among sexual minority women such as fear of discrimination, negative experience with health care providers, mistrust of the medical community, lack of usual care provider, lack of insurance, and costs may differ by relationship status among sexual minority women.23,24
Dyadic interventions targeting physical activity, diet, and SSEs to detect skin cancer have been shown to improve behaviors, psychological wellbeing, and health outcomes more than if the same interventions were administered to individuals.25–27 The underlying theory behind such interventions is that targeting both members of a dyad promotes increased understanding, motivation, and accountability.28–30 Couples in SSR showed higher concordance in both conducting or not conducting SSEs when compared with couples in OSR.8 Differences in sun-protective behavior, indoor tanning, and clinical surveillance for skin cancer among men in SSR in this study suggest a potential opportunity to develop similar dyadic interventions targeting modifiable skin cancer behavioral risk factors, which may be more efficacious than targeting each member of the dyad alone. In the clinic, providers can encourage their patients to ask loved ones to hold them accountable to sun-protective and sun-avoidant behaviors.
Limitations
Several limitations warrant consideration. Sexual minority individuals may have been underrepresented in this study as sexual orientation information was not collected until 2013 and people in SSR may reflect only a small proportion of all sexual minority individuals. The study was further only able to categorize people in SSR who are living together, which contributed to a low prevalence of people in SSR among NHIS participants that may fail to demonstrate important disparities with smaller effect sizes.
Study data were collected most recently in 2015, so number and demographic composition of couples in SSR may have changed significantly since the landmark Obergefell v. Hodges decision legalizing same-sex marriage in 2015.31 However, our results generate a priori hypothesis testing for future studies that assess skin cancer risk factors and clinical screening among both members in a SSR. Stigma or privacy concerns may lead to underreporting and misclassification of SSR status that might bias our results toward the null. Outcome behaviors were self-reported and subject to recall bias; however, high levels of correlation between self-reported and observed sun-protective behaviors had been demonstrated.32 There may be residual confounding from unmeasured factors such as phototype.
Conclusion
Differences in sun-protective behaviors, indoor tanning, and skin cancer screening among men and women in SSR reflect prior research in sexual minority individuals regardless of relationship status. Clinicians should become familiar with the specific behavioral patterns among same-sex couples to provide effective counseling, deliver tailored interventions, and prevent skin cancers in sexual minority individuals. Public health officials should leverage the influence couples have on each other's health behaviors to develop dyadic interventions that may further reduce skin cancer risk among couples in SSR.
Supplementary Material
Authors' Contributions
K.J.S. and H.Y. had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: H.Y. and S.C.C. Acquisition, analysis, and interpretation of data: H.Y. and K.J.S. Drafting of the article: H.Y. and K.J.S. Critical revision of the article for important intellectual content: H.Y., K.J.S., and S.C.C. Statistical analysis: H.Y. and K.J.S. Obtained funding: N/A. Administrative, technical, or material support: K.J.S. Study supervision: H.Y. and S.C.C.
Disclaimer
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or Department of Veterans Affairs.
Author Disclosure Statement
S.C.C. receives royalties from for-profit companies that license quality of life instruments for which Emory holds copyright. H.Y. and K.J.S. have no conflicts of interest to declare.
Funding Information
H.Y. is supported, in part, by Developmental Funds from the Winship Cancer Institute of Emory University and by the National Institute of Arthritis and Musculoskeletal and Skin Diseases under award numbers L30AR076081 and K23AR075888.
Supplementary Material
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