Sexual minority men (SMM) report higher risk of skin cancer and indoor tanning than heterosexual men[1]. Time spent outdoors and other skin cancer risk behaviors in SMM have not been well investigated. To tailor future skin cancer prevention efforts for SMM, this cross-sectional study compared the prevalence of sun protective behaviors (SPBs) and time spent outdoors by sexual orientation and sexual behavior in US men aged 20–59 years in the National Health and Nutrition Examination Survey (NHANES) during 2009–2016.
Analyses were restricted to men; data comparing SPBs in sexual minority women using NHANES data has been investigated[2]. Self-reported gay or bisexual men were categorized as SMM, while straight men were categorized as heterosexual. Sexual behavior was categorized into men-who-have-sex-with-men (MSM) and non-MSM. Frequent SPBs were defined as responses “always” or “most of the time” in using sunscreen, wearing long-sleeves, or seeking shade. Outdoor sun exposure during workdays and non-workdays was assessed using a three-hour threshold. Spending 3+ hours outdoors per day is a recognized risk factor for skin cancer[3]. SPBs and time spent outdoors were compared by sexual orientation and sexual behavior using Rao-Scott χ2 tests. Adjustments for confounders (age, race/ethnicity, marital status, education level, income, sun reactivity, HIV antibody test, past skin cancer diagnosis) were made using multivariable logistic regression. Analyses were performed in R Statistical Software (v4.3.1; R Core Team 2023).
The NHANES Sexual Behavior Questionnaire response rates in 2009–2016 ranged from 85.5% to 89.4%. Among the 6,449 respondents, 339 were MSM and 6,110 non-MSM. MSM and non-MSM differed by marital status, education level, and race/ethnicity (Table 1). Compared to non-MSM, MSM were less likely to spend 3+ hours outdoors during workdays (aOR: 0.63, CI 0.48–0.81) and non-workdays (aOR: 0.65, CI 0.51–0.83) (Table 2).
Table 1.
Demographic characteristics of male respondents to National Health and Nutrition Examination Survey Sexual Behavior Interview (2009–2016)
| Characteristic | Non-MSM No. (%) n = 6,110 |
MSM+ No. (%) n = 339 |
P value | Heterosexual Men No. (%) n = 6,002 |
SMM* No. (%) n = 269 |
P value |
|---|---|---|---|---|---|---|
| Age | ||||||
| 20–29 | 1,587 (26) | 89 (26) | 0.172 | 1,561 (26) | 89 (33) | 0.003 |
| 30–39 | 1,574 (26) | 85 (25) | 1,559 (26) | 63 (23) | ||
| 40–49 | 1,494 (24) | 69 (20) | 1,465 (24) | 44 (16) | ||
| 50–59 | 1,455 (24) | 96 (28) | 1,417 (24) | 73 (27) | ||
| Race/Ethnicity | ||||||
| Hispanic | 1,597 (26) | 68 (20) | <0.001 | 1,513 (25) | 57 (21) | 0.374 |
| Non-Hispanic Black | 1,262 (21) | 71 (21) | 1,255 (21) | 54 (20) | ||
| Non-Hispanic White | 2,370 (39) | 169 (50) | 2,401 (40) | 120 (45) | ||
| Other | 881 (14) | 31 (9) | 833 (14) | 38 (14) | ||
| Education level | ||||||
| Below high school | 1,366 (22) | 35 (10) | <0.001 | 1,260 (21) | 35 (13) | 0.005 |
| High school or equivalent | 1,473 (24) | 80 (24) | 1,458 (24) | 61 (23) | ||
| Some college | 1,777 (29) | 120 (35) | 1,785 (30) | 96 (36) | ||
| College graduate or above | 1,491 (24) | 104 (31) | 1,496 (25) | 77 (29) | ||
| Household income level | ||||||
| Less than $20,000 | 998 (17) | 66 (20) | 0.238 | 965 (17) | 58 (23) | 0.022 |
| At least $20,000 | 4,804 (83) | 266 (80) | 4,751 (83) | 199 (77) | ||
| HIV antibody test | ||||||
| Negative | 5,797 (99.7) | 295 (89) | <0.001 | 5,700 (99.7) | 227 (87) | <0.001 |
| Positive | 17 (0.3) | 35 (11) | 16 (0.3) | 35 (13) | ||
| Past skin cancer diagnosis | ||||||
| No | 6,040 (99) | 337 (99) | 0.495 | 5,933 (99) | 266 (99) | 1.000 |
| Yes | 70 (1) | 2 (1) | 69 (1) | 3 (1) | ||
| Marital status | ||||||
| Never married/single | 1,593 (26) | 147 (43) | <0.001 | 1,569 (26) | 138 (51) | <0.001 |
| Living with partner/married | 3,820 (63) | 135 (40) | 3,733 (62) | 101 (38) | ||
| Widowed/divorced/separated | 693 (11) | 57 (17) | 696 (12) | 30 (11) | ||
| Sun reactivity # | ||||||
| No reaction | 2,755 (43) | 137 (41) | 0.098 | 2,676 (45) | 107 (41) | 0.183 |
| Tanning | 1,549 (24) | 79 (24) | 1,526 (26) | 62 (24) | ||
| Mild burn and some tanning | 1,326 (21) | 90 (27) | 1,330 (22) | 72 (27) | ||
| Severe burn + blistering | 427 (7) | 28 (8) | 422 (7) | 22 (8) |
MSM = men who have sex with men, SMM = sexual minority men
Respondents who answered “yes” to the National Health and Nutrition Examination Survey Sexual Behavior question “Have you ever had any kind of sex with a man, including oral or anal?” were considered men-who-have-sex-with-men
Respondents who responded “Gay”, “Bisexual”, or “Something else” to the National Health and Nutrition Examination Survey Sexual Behavior question “Which of the following best represents how you think of yourself?” were considered SMM. Those who answered “Straight, that is not gay” were considered heterosexual. Those who responded “I don’t know the answer” or “Not sure” were excluded
Sun reactivity was assessed using the National Health and Nutrition Examination Survey 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 the analysis.
Table 2.
Prevalence and adjusted odds of engagement in sun protective and sun risk behaviors†
| Outcomes* | Non-MSM No. (%) N = 6,110 |
MSMa No. (%) N = 339 |
P value | Heterosexual Men No. (%) N = 6,002 |
SMMb No. (%) N = 269 |
P value |
|---|---|---|---|---|---|---|
| Sunscreen c | ||||||
| Infrequent | 5,191 (86) | 268 (79) | 0.002 | 5,090 (85) | 210 (78) | 0.002 |
| Frequent | 867 (14) | 70 (21) | 868 (15) | 58 (22) | ||
| aOR (95% CI)d | Reference | 1.31 (0.95–1.77) | 0.095 | Reference | 1.47 (1.04–2.05) | 0.026 |
| Long sleeves c | ||||||
| Infrequent | 5,270 (87) | 304 (90) | 0.137 | 5,217 (88) | 234 (87) | 0.939 |
| Frequent | 787 (13) | 34 (10) | 734 (12) | 34 (13) | ||
| aOR (95% CI)d | Reference | 0.96 (0.64–1.40) | 0.826 | Reference | 1.26 (0.83–1.85) | 0.259 |
| Seeking Shade c | ||||||
| Infrequent | 4,395 (73) | 237 (70) | 0.357 | 4,338 (73) | 180 (67) | 0.046 |
| Frequent | 1,661 (27) | 101 (30) | 1,612 (27) | 88 (33) | ||
| aOR (95% CI)d | Reference | 1.13 (0.86–1.47) | 0.376 | Reference | 1.27 (0.95–1.70) | 0.101 |
| Sunburn in past 12 months | ||||||
| No | 3,864 (63) | 191 (57) | 0.013 | 3,746 (63) | 158 (59) | 0.236 |
| Yes | 2,237 (37) | 147 (43) | 2,247 (37) | 111 (41) | ||
| aOR (95% CI)d | Reference | 1.09 (0.82–1.44) | 0.559 | Reference | 0.97 (0.71–1.32) | 0.851 |
| Time spent outdoors (workday) | ||||||
| Less than 1 h | 2,197 (36) | 141 (42) | 0.002 | 2,156 (36) | 113 (42) | 0.004 |
| Between 1–2 h | 769 (13) | 56 (17) | 771 (13) | 45 (17) | ||
| At least 3 h | 3,144 (51) | 142 (42) | 3,075 (51) | 111 (41) | ||
| aOR (95% CI)d,e | Reference | 0.63 (0.48–0.81) | <0.001 | Reference | 0.58 (0.44–0.77) | 0.001 |
| Time spent outdoors (non-workday) | ||||||
| Less than 1 h | 1,134 (19) | 71 (21) | 0.036 | 1,094 (18) | 60 (22) | 0.017 |
| Between 1–2 h | 853 (14) | 61 (18) | 842 (14) | 49 (18) | ||
| At least 3 h | 4,123 (67) | 207 (61) | 4,066 (68) | 160 (59) | ||
| aOR (95% CI)d,e | Reference | 0.65 (0.51–0.83) | <0.001 | Reference | 0.64 (0.49–0.84) | 0.001 |
aOR = adjusted odds ratio, CI = confidence interval, h = hour(s), MSM = men who have sex with men, SMM = sexual minority male
All presented data met National Health and Nutrition Examination Survey reliability threshold including subgroup sample size of at least 30 and relative confidence interval width (<130%). Sensitivity analyses for sun protective behaviors for SMM and MSM as a single group were conducted, with overlapping confidence intervals with the primary analysis. Therefore, we presented the more detailed analysis.
Complete case analysis of 6,449 men who participated in the National Health and Examination Survey sexual behavior questionnaire excluded up to 178 (2.8%) participants who did not have dermatology outcomes and/or sexual orientation/behavior data.
Respondents who answered “yes” to the National Health and Nutrition Examination Survey Sexual Behavior question “Have you ever had any kind of sex with a man, including oral or anal?” were considered men-who-have-sex-with-men
Respondents who responded “Gay”, “Bisexual”, or “Something else” to the National Health and Nutrition Examination Survey Sexual Behavior question “Which of the following best represents how you think of yourself?” were considered SMM. Those who answered “Straight, that is not gay” were considered heterosexual. Those who responded “I don’t know the answer” or “Not sure” were excluded
SPBs were assessed by the questions: When you go outside on a very sunny day, for more than 1 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, household income, sun reactivity, HIV antibody test, and past skin cancer diagnosis
Adjusted odds of spending at least three hours outdoors per day.
Two hundred sixty-nine men identified as SMM (gay [48.0%], bisexual [36.4%], something else [15.6%]) and 6,002 identified as heterosexual. Similar to MSM, SMM and heterosexual men differed by marital status, education level, and age. Compared to heterosexual men, SMM were more likely to use sunscreen (aOR 1.47, CI 1.04–2.05). SMM were less likely than heterosexual men to spend 3+ hours outdoors during workdays (aOR 0.58, CI 0.44–0.77) and non-workdays (aOR 0.64, CI 0.49–0.84).
Increased sunscreen use and less time outdoors in SMM compared to heterosexual men contrasts with known higher skin cancer risk in SMM[1]. Varying from our results, a previous study reported increased shade seeking behavior and decreased sun-protective clothing use in SMM[4]. The aforementioned study included all men during 2015 compared to our investigation covering 2009–2016 and those aged 20–59 years, potentially contributing to the difference. Limitations include self-reported outcomes which may be subject to misclassification and analyzing SMM together (gay, bisexual, etc.), limiting generalizability to subgroups of SMM. There is evidence of differing skin cancer risk among individual sexual identities[5]. Future research should examine risk factors beyond what is captured by existing surveys and disaggregate analyses by race/ethnicity and individual sexual identities to understand and reduce skin cancer disparities in SMM.
Funding sources:
Dr Yeung is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases under award numbers L30AR076081 and K23AR075888.
Footnotes
Conflicts of Interest: None declared.
IRB approval status: Exempt.
Patient consent on file: Not applicable.
Reprint requests: Howa Yeung
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