Abstract
This cross-sectional analysis assesses the impact of sexual orientation on indoor tanning, sunless tanning, and sun-protection behaviors among men.
Sexual minority men (SMM), including gay and bisexual men, report increased rates of skin cancer and indoor tanning, whereas sexual minority women report decreased rates of skin cancer and indoor tanning. Indoor tanning has been associated with other risky behaviors, including decreased use of protective clothing and shade when outdoors. However, no data exist on these other skin cancer risk behaviors among SMM. This study assesses the impact of sexual orientation on indoor tanning, sunless tanning, and sun-protection behaviors among men.
Methods
This cross-sectional study including 13 698 adult men used data from the 2015 National Health Interview Surveys. We calculated the age-adjusted prevalence rates and multivariable-adjusted odds ratios (aOR) by sexual orientation for indoor tanning, sunless tanning, sunburn, and sun avoidance. In a subpopulation analysis of sun-exposed individuals, we calculated mean behavioral scores and multivariable-adjusted regression coefficients (using linear regression) by sexual orientation for sun-protection behaviors, including a composite measure. As a secondary outcome, we assessed frequent indoor tanning (≥10 sessions annually) by sexual orientation among current indoor tanners. Multivariable analyses controlled for age, race/ethnicity, region, education level, body mass index (calculated as weight in kilograms divided by height in meters squared), sun sensitivity, and personal and family history of skin cancer. Analyses were weighted and performed using STATA version 13.1 (Stata Corp). This study was exempt from institutional board review at the University of Minnesota.
Results
Our study included 370 SMM and 13 328 heterosexual men; SMM, compared with heterosexual men, had increased odds of reporting indoor tanning (both ever and in the last year), sunless tanning, and sun avoidance. There were no differences in sunburn rates (Table 1). Among current indoor tanners, frequent indoor tanning did not differ between SMM and heterosexual men (mean [SE] 37.0% [5.9%] vs 33.9% [6.6%], respectively; aOR, 0.66; 95% CI, 0.19-2.31). Among sun-exposed individuals, SMM were more likely to use sunscreen and seek shade but less likely to use protective clothing when outdoors, and their composite sun protection scores were lower (Table 2).
Table 1. Indoor Tanning, Sunless Tanning, Sunburn, and Sun Avoidance, by Sexual Orientation of US Adult Men According to NHIS 2015.
| Characteristic | Heterosexual (n = 13 328)a |
Sexual Minority (n = 370)a |
P Value |
|---|---|---|---|
| Indoor tanning (ever)b | |||
| Weighted, % (SE)c | 9.1 (0.4) | 22.1 (2.7) | |
| aPOR (95% CI)d | 1 [Reference] | 3.14 (2.14-4.60) | <.001 |
| Indoor tanning (last 12 mo)b | |||
| Weighted, % (SE) | 1.5 (0.1) | 6.6 (1.5) | |
| aPOR (95% CI)b | 1 [Reference] | 5.85 (3.48-9.83) | <.001 |
| Sunless tanning (last 12 mo)e | |||
| Weighted, % (SE) | 1.0 (0.1) | 7.6 (1.8) | |
| aPOR (95% CI)b | 1 [Reference] | 7.58 (4.46-12.91) | <.001 |
| Sunburn (last 12 mo)f | |||
| Weighted, % (SE) | 35.1 (0.6) | 36.1 (3.5) | |
| aPOR (95% CI)b | 1 [Reference] | 0.95 (0.67-1.32) | .73 |
| Sun avoidance (last 12 mo)g | |||
| Weighted, % (SE) | 6.7 (0.3) | 9.6 (2.2) | |
| aPOR (95% CI)b | 1 [Reference] | 3.25 (1.21-8.70) | .02 |
Abbreviations: aPOR, multivariable-adjusted prevalence odds ratio; NHIS, National Health Interview Survey; SE, standard error.
Unweighted sample size for reference. 1373 of 15 071 (9.1%) total male respondents were excluded owing to missing data on any covariate or primary outcome.
Defined as self-reported use (yes or no) of an indoor tanning device (sunlamp, sunbed, or tanning booth, excluding spray-on tans) either (1) ever or (2) in the last 12 mo.
Age-adjusted weighted prevalence rates standardized against the age distribution of adult men in the general population (based on 2015 NHIS estimates) using the direct method for age standardization.
Multivariable-adjusted odds ratio calculated using logistic regression analyses controlling for age, race, region, education level, body mass index (calculated as weight in kilograms divided by height in meters squared), sun sensitivity, personal history of skin cancer, and family history of skin cancer.
Defined as self-reported use (yes or no) of (1) “spray-on” or mist tans at a tanning salon, or (2) self-applied sunless or fake tanning products in the last 12 mo.
Defined as self-reported sunburn (at least 1 sunburn) in the last 12 mo.
Defined based on self-reported response of “do not go out in the sun on a warm sunny day for more than 1 hour” to at least 1 question assessing sun sensitivity or sun-protection behaviors (use of sunscreen, shade, long sleeves, long pants, baseball cap or visor, and wide-brimmed hat).
Table 2. Sun-Protection Behaviors by Sexual Orientation of Sun-Exposed US Adult Men According to NHIS 2015.
| Sun-Protection Behavior | Heterosexual (n = 12 350)a |
Sexual Minority (n = 341)a |
P Value |
|---|---|---|---|
| Sunscreen use | |||
| Behavioral score, mean (SE)b | 2.4 (0.02) | 2.8 (0.1) | |
| Coefficient (95% CI)c | 0 [Reference] | 0.17 (0.01 to 0.33) | .04 |
| Shade | |||
| Behavioral score, mean (SE)b | 3.0 (0.02) | 3.2 (0.1) | |
| Coefficient (95% CI)c | 0 [Reference] | 0.18 (0.02 to 0.33) | .03 |
| Long pants | |||
| Behavioral score, mean (SE)b | 2.6 (0.02) | 2.4 (0.1) | |
| Coefficient (95% CI)c | 0 [Reference] | −0.17 (−0.36 to −0.01) | .04 |
| Long sleeves | |||
| Behavioral score, mean (SE)b | 2.0 (0.02) | 1.8 (0.1) | |
| Coefficient (95% CI)c | 0 [Reference] | −0.27 (−0.42 to −0.13) | <.001 |
| Baseball cap or visor | |||
| Behavioral score, mean (SE)b | 3.2 (0.02) | 2.6 (0.1) | |
| Coefficient (95% CI)c | 0 [Reference] | −0.70 (−0.91 to −0.49) | <.001 |
| Wide-brimmed hat | |||
| Behavioral score, mean (SE)b | 1.9 (0.02) | 1.6 (0.1) | |
| Coefficient (95% CI)c | 0 [Reference] | −0.33 (−0.48 to −0.19) | <.001 |
| Multimodal sun protection | |||
| Composite score, mean (SE)d | 2.5 (0.01) | 2.4 (0.05) | |
| Coefficient (95% CI)c | 0 [Reference] | −0.19 (−0.28 to −0.10) | <.001 |
Abbreviations: NHIS, National Health Interview Survey; SE, standard error.
Unweighted sample size for reference. 1373 of 15 071 (9.1%) total male respondents were excluded owing to missing data on any covariate or primary outcome. 1007 of 13 686 (7.4%) of remaining male respondents were excluded who reported no significant outdoor sun exposure (self-reported response of “do not go out in the sun on a warm sunny day for more than one hour”).
Age-adjusted weighted mean behavioral score standardized against the age distribution of adult men in the general population (based on 2015 NHIS estimates) using the direct method for age standardization. Individual participants were assigned a behavioral score between 1 (never use) and 5 (always use) based on a Likert scale for self-reported use of each sun protection method when outdoors on a sunny day for more than 1 h.
Coefficient calculated using multivariable-adjusted linear regression analyses controlling for age, race, region, education level, body mass index (calculated as weight in kilograms divided by height in meters squared), sun sensitivity, personal history of skin cancer, and family history of skin cancer.
Age-adjusted weighted mean composite score standardized against the age distribution of adult men in the general population (based on 2015 NHIS estimates) using the direct method for age standardization. Composite score of multimodal sun protection calculated for each participant as the average of the mean behavioral scores for each of the sun protective behaviors.
Discussion
This study demonstrates that indoor tanning, sunless tanning, and sun-protection behaviors differ by sexual orientation among men in the United States. Sexual minority men report increased indoor and sunless tanning and decreased use of sun-protective clothing when outdoors, but are more likely to avoid sun exposure and, if sun-exposed, to use sunscreen and seek shade when outdoors.
These findings have important implications for skin cancer prevention in SMM. Higher rates of indoor and sunless tanning suggest an increased desire for tanned skin in SMM. This likely relates to increased emphasis on body image and appearance concerns, which has been associated with indoor tanning use among SMM. While SMM are more likely to avoid sun exposure, seek shade, and use sunscreen when outdoors, their composite sun protection scores were lower, and it is possible that lower rates of protective clothing may lead to increased chronic sun exposure among SMM. Furthermore, frequent use of sunscreen and indoor tanning have both been correlated with increased outdoor sun exposure, which may also be elevated in SMM. Study strengths include the use of a nationally representative data set. Limitations include self-reported data, the relatively small number of SMM, and the lack of data on outdoor sun exposure. Gay and bisexual men were analyzed together to increase statistical power. This may limit the generalizability of our results when applied individually across these heterogeneous populations.
Dermatologists should be aware that indoor tanning, sunless tanning, and sun-protection behaviors are different in SMM and should consider routine assessment of sexual orientation in clinical settings to help guide behavioral screening and counseling. Future studies should investigate the motivations contributing to these differences and outdoor sun exposure behaviors in SMM. Targeted interventions designed to change behaviors could help reduce the risk of skin cancer among SMM.
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