To the Editor:
Sexual minority women (SMW; e.g., lesbian, bisexual), a National Institutes of Health U.S. health disparity population,1 may have a lower prevalence of indoor tanning and skin cancers compared to heterosexual women;2,3 however, the relationship between sun protective behaviors (SPB), sexual orientation, and sexual behavior is not well-studied. This cross-sectional study compared SPBs in women by sexual orientation and sexual behavior using nationally representative National Health and Nutrition Examination Survey (NHANES) data pooled from 2009–2016.
Self-reported sexual orientation was dichotomized into SMW (lesbian, bisexual) and heterosexual; sexual behavior was dichotomized into women-who-have-sex-with-women (WSW) and non-WSW. Frequent SPB was defined as “always” or “most of the time” responses on using sunscreen, wearing long-sleeves, or seeking shade. Outdoor sun exposure between 9AM-5PM during workdays and non-workdays was evaluated using a threshold of 3 hours. Spending at least 3 hours outdoors during workdays is a known risk factor for skin cancer.4 SPBs and outdoor sun exposure were compared by sexual orientation and sexual behavior using Rao-Scott χ2 tests with standard sample weights. Adjustments for sociodemographic confounders (age, race/ethnicity, relationship status, education, household income, sun reactivity) were modeled using multivariable logistic regression using Stata 17.0 (StataCorp LLC, Collage Station, TX).
The NHANES Sexual Behavior Questionnaire response rates in 2009–2016 ranged from 85.5% (2011–2012) to 89.4% (2013–2014). Among 8,799 women, 773 were WSW and 8,026 were non-WSW. WSW tended to be younger, non-Hispanic white, and reported lower rates of college graduation and household income compared to non-WSW (Table 1). Mean time spent outdoors was higher for WSW compared to non-WSW on workdays (difference 23.3 minutes, 95%CI 15.0–31.7) and non-workdays (difference 26.0 minutes, 95%CI 16.9–35.0, Table 2). WSW also had an increased odds of spending at least 3 hours outdoors during workdays (aOR 1.56, 95%CI 1.22–1.99) and non-workdays (aOR 1.41, 95%CI 1.18–1.67).
Table 1.
Sociodemographic characteristics of women respondents to National Health and Nutrition Examination Survey (NHANES) Sexual Behavior Interview (2009–2016).
| Characteristic | Non-WSW No. (%)3 | WSW1 No. (%)3 | P-Value | Heterosexual Women No. (%)3 | SMW2 No. (%)3 | P-Value |
|---|---|---|---|---|---|---|
| N=8,026 | N=773 | N=6,378 | N=510 | |||
| Age | ||||||
| 20–29 | 1,435 (19) | 261 (36) | <0.001 | 1,452 (25) | 204 (45) | <0.001 |
| 30–39 | 1,402 (19) | 181 (25) | 1,426 (24) | 106 (23) | ||
| 40–49 | 1,619 (21) | 128 (18) | 1,596 (27) | 79 (17) | ||
| 50–59 | 1,489 (20) | 103 (14) | 1,434 (24) | 63 (14) | ||
| 60–69 | 1,593 (21) | 46 (6) | NA | NA | ||
| Race/Ethnicity | ||||||
| Non-Hispanic White | 2,929 (36) | 332 (43) | <0.001 | 2,436 (38) | 201 (39) | 0.002 |
| Hispanic | 2,363 (29) | 137 (18) | 1,748 (27) | 102 (20) | ||
| Non-Hispanic Black | 1,753 (22) | 227 (29) | 1,420 (22) | 138 (27) | ||
| Other | 981 (12) | 77 (10) | 774 (12) | 69 (14) | ||
| Educational Attainment | ||||||
| Below High School | 1,561 (21) | 105 (15) | <0.001 | 1,015 (17) | 88 (19) | 0.001 |
| High School or Equivalent | 1,517 (20) | 157 (22) | 1,140 (19) | 108 (24) | ||
| Some College | 2,493 (33) | 297 (41) | 2,076 (35) | 165 (37) | ||
| College Graduate or Above | 1,963 (26) | 160 (22) | 1,674 (28) | 91 (20) | ||
| Household Income Level | ||||||
| Less than $20,000 | 1,632 (21) | 224 (30) | <0.001 | 1,213 (20) | 135 (27) | <0.001 |
| At least $20,000 | 6,015 (79) | 534 (70) | 4,909 (80) | 361 (73) | ||
| Relationship Status | ||||||
| Never Married/Single | 1,499 (20) | 267 (37) | <0.001 | 1,384 (23) | 195 (43) | <0.001 |
| Living with Partner/Married | 4,368 (58) | 288 (40) | 3,471 (59) | 186 (41) | ||
| Widowed/Divorced/Separated | 1,667 (22) | 164 (23) | 1,051 (18) | 71 (16) | ||
| Sun Reactivity 4 | ||||||
| No Reaction | 2,223 (38) | 242 (36) | 0.525 | 2,168 (37) | 177 (40) | 0.038 |
| Tanning | 1,359 (23) | 157 (24) | 1,362 (23) | 90 (20) | ||
| Mild Burn and Some Tanning | 1,557 (27) | 172 (26) | 1,572 (27) | 107 (24) | ||
| Severe Burn +/− Blistering | 718 (12) | 94 (14) | 723 (12) | 72 (16) | ||
Abbreviations: WSW, women who have sex with women; SMW, sexual minority women
Respondents who answered “yes” to the NHANES Sexual Behavior Interview question “Have you ever had any kind of sex with a woman? By sex, we mean sexual contact with another woman’s vagina or genitals” were considered women who have sex with women.
Respondents who responded “lesbian or gay”, bisexual,” or “something else” to the NHANES Sexual Behavior Interview question “Which of the following best represents how you think of yourself?” were considered sexual minority women. Those who answered “Straight, that is not lesbian or gay” were considered heterosexual women. Those who responded “I don’t know the answer” or “Not sure” were excluded from analysis.
The percentage indicates the weight prevalence.
Sun reactivity was assessed using the NHANES Dermatology question “If after several months of not being in the sun, you then went out in the sun without sunscreen or protective clothing for a half hour, which one of these would happen to your skin?” Responses included “Get a severe sunburn with blisters,” “A severe sunburn for a few days with peeling,” “Mildly burned with some tanning,” “Turning darker without a sunburn,” Nothing would happen in half an hour.” Those who responded “Other” or “Don’t know” were excluded from analysis.
Table 2.
Prevalence and adjusted odds of engagement in sun protective and sun risk behaviors.
| Outcomes, N(%)1 | Non-WSW | WSW2 | P-Value4 | Heterosexual Women | SMW3 | P-Value4 | |
|---|---|---|---|---|---|---|---|
| N=8,026 | N=773 | N=6,378 | N=510 | ||||
| Sunscreen 5 | Infrequent | 3,960 (67) | 478 (72) | 0.016 | 3,909 (67) | 332 (75) | 0.001 |
| Frequent | 1,918 (33) | 186 (28) | 1,937 (33) | 113 (25) | |||
| aOR (95% CI)6 | Reference | 0.90 (0.74–1.09) | 0.286 | Reference | 0.77 (0.61–0.99) | 0.038 | |
| Long Sleeves 5 | Infrequent | 5,280 (90) | 620 (93) | 0.003 | 5,295 (91) | 409 (92) | 0.345 |
| Frequent | 599 (10) | 44 (7) | 552 (9) | 36 (8) | |||
| aOR (95% CI)6 | Reference | 0.80 (0.57–1.12) | 0.190 | Reference | 0.94 (0.64–1.38) | 0.752 | |
| Seeking Shade 5 | Infrequent | 3,331 (56) | 414 (62) | 0.007 | 3,333 (56) | 269 (60) | 0.203 |
| Frequent | 2,612 (44) | 259 (38) | 2,573 (44) | 183 (40) | |||
| aOR (95% CI)6 | Reference | 0.89 (0.75–1.06) | 0.207 | Reference | 0.95 (0.77–1.17) | 0.646 | |
| Sunburn in Past 12 Months | No | 3,784 (64) | 390 (58) | 0.003 | 3,706 (63) | 263 (58) | 0.055 |
| Yes | 2,147 (36) | 283 (42) | 2,190 (37) | 188 (42) | |||
| aOR (95% CI)6 | Reference | 1.10 (0.90–1.33) | 0.352 | Reference | 1.09 (0.86–1.38) | 0.471 | |
| Time Spent Outdoors (Workday) | Less than 1 hour | 3,079 (62) | 285 (52) | <0.001 | 3,036 (61) | 199 (52) | <0.001 |
| Between 1–2 hours | 1,328 (27) | 165 (30) | 1,354 (27) | 98 (26) | |||
| At Least 3 hours | 581 (12) | 103 (19) | 572 (12) | 86 (22) | |||
| aOR (95% CI)6,7 | Reference | 1.56 (1.22–1.99) | <0.001 | Reference | 1.95 (1.49–2.55) | <0.001 | |
| Minutes, mean (95% CI) | 59.1 (56.5–61.7) | 82.4 (73.0–91.9) | <0.001 | 59.1 (56.5–61.6) | 88.2 (76.0–100) | <0.001 | |
| Time Spent Outdoors (Non-Workday) | Less than 1 hour | 1,755 (30) | 167 (25) | <0.001 | 1,700 (29) | 115 (26) | <0.001 |
| Between 1–2 hours | 2,387 (40) | 234 (35) | 2,374 (40) | 158 (35) | |||
| At Least 3 hours | 1,768 (30) | 266 (40) | 1,796 (31) | 178 (39) | |||
| aOR (95% CI)6,7 | Reference | 1.41 (1.18–1.67) | <0.001 | Reference | 1.38 (1.12–1.69) | 0.002 | |
| Minutes, mean (95% CI) | 118 (115–121) | 144 (134–153) | <0.001 | 120 (117–123) | 145 (133–156) | <0.001 | |
Abbreviations: WSW, women who have sex with women; SMW, sexual minority women; aOR, adjusted prevalence odds ratio; CI, confidence interval
Complete case analysis of 8,799 women who participated in the NHANES sexual behavior questionnaire excluded up to 2,186 (24.8%) who did not have dermatology outcomes.
Respondents who answered “yes” to the NHANES Sexual Behavior Interview question “Have you ever had any kind of sex with a woman? By sex, we mean sexual contact with another woman’s vagina or genitals” were considered women who have sex with women.”
Respondents who responded “lesbian or gay”, bisexual,” or “something else” to the NHANES Sexual Behavior Interview question “Which of the following best represents how you think of yourself?” were considered sexual minority women. Those who answered “Straight, that is not lesbian or gay” were considered heterosexual women. Those who responded “I don’t know the answer” or “Not sure” were excluded from analysis.
All presented data met NHANES reliability threshold including subgroup sample size of at least 30 and relative confidence interval width (<130%). Sensitivity analyses for sun protective behaviors for SMW and WSW as a single group was conducted, with overlapping confidence intervals with the primary analysis. Therefore, we presented the more detailed analysis.
SPBs were assessed by the questions: When you go outside on a very sunny day, for more than one hour, how often do you: (1) Stay in the shade? (2) Wear a long-sleeved shirt? (3) Use sunscreen? Responses of “always” or “most of the time” use were considered frequent, while “sometimes,” “rarely,” or “never” were considered infrequent.
Multivariable logistic regression models were adjusted for age, race/ethnicity, relationship status, education, household income, and sun reactivity.
Adjusted odds of spending at least 3 hours in outdoor sun exposure.
510 women identified as SMW (lesbian [20.4%], bisexual [66.9%], something else [12.7%]) and 6,378 as heterosexual (response rate to SPB questionnaire: 92.3% [6,359/6,888]). Compared to heterosexual women, SMW were less likely to use sunscreen (aOR 0.77, 95%CI 0.61–0.99), but reported similar long-sleeve clothing use and shade-seeking. SMW spent more time outdoors on workdays (difference 29.1 minutes, 95%CI 19.4–38.9) and non-workdays (difference 24.7 minutes, 95%CI 13.8–35.6). SMW also had an increased odds of spending at least 3 hours outdoors during workdays (aOR 1.95, 95%CI 1.49–2.55) and non-workdays (aOR 1.38, 95%CI 1.12–1.69).
SMW were less likely to use sunscreen, suggesting need for targeted SPB education and for future qualitative research exploring reasons underlying differences in sunscreen use in diverse groups of women. Additionally, we demonstrated that SMW spent more time outdoors during the peak hours of sun exposure between 9AM-5PM on workdays and non-workdays. Differences in occupation related to sexual orientation, including increased SMW concentration in construction and protective services, may be contributing factors.5 Study strengths included use of nationally representative data with high survey response rates. Self-reported data were subject to recall bias. Future studies are warranted to examine potential outdoor risk factors for skin cancer among SMW and guide interventions to reduce outdoor UV exposure.
Funding sources:
Dr. Yeung is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases under award numbers L30AR076081 and K23AR075888.
Role of the Funder/Sponsor:
The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Footnotes
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Conflicts of Interest: None.
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