DEAR EDITOR, Sexual-minority men (SMM, including men who identify as homosexual, gay, bisexual or other) are more likely than heterosexual men to have had skin cancer1–3 and to have tanned indoors.1 While motivations for tanning have been explored for young women, limited research has examined the motivations for SMM to stop indoor tanning.3 Given the increasing evidence that tanning itself may even be classifiable as addictive behaviour,4 understanding the motivations for tanning in this high-risk population is pressing. The goal of this study is to understand motivations for starting and stopping indoor tanning among SMM.
We conducted 10 semi structured focus groups (2-h each), with a median of five (range, 2–8) participants, from June to July 2017. Participants were recruited through online advertisements, flyers and participant referrals. Eligible participants included self-identified SMM 18 years of age and older, who reported indoor tanning at least once, and who used social media.
We audio-recorded and transcribed all focus group discussions, and team members (N.A., M.A.P. and N.P.) used the mixed-method analytic software Dedoose (www.dedoose.com) to create a preliminary list of codes representing reasons participants started and stopped indoor tanning. Codes were refined using Dedoose’s interrater reliability testing feature, which assesses interrater agreement using Cohen’s K coefficient. Final coding began when the pooled K across coders was > 0–80, indicating consistent code application by all coders. N.A. and M.A.P. then reviewed the data and applied codes to organize text and identify overarching themes and relevant subthemes (i.e. exploratory thematic analysis), which team members then reviewed and finalized.5 This study was approved by the University of California San Francisco Institutional Review Board.
The median age of the 48 participants was 49–5 (range 21–76) years, and 38 (79%) identified as gay, seven (15%) as bisexual, three (6%) as other. Thirty-four (71%) men identified as non-Hispanic white, eight (17%) Asian, four (8%) Hispanic, one (2%) Black and one (2%) multiracial. Among these, 35 (73%) began tanning before age 25 years, 25 (52%) tanned indoors weekly when they were tanning, and 18 (38%) reported more than 30 lifetime indoor tanning experiences.
Reasons for starting and stopping indoor tanning were categorized into themes (Table 1). Appearance was a primary driver of tanning behaviour. Skin was perceived as more appealing, appearing more toned and muscular while tan. Men repeatedly used the word ‘healthy’ to describe a tan appearance, with at least one participant making reference to ‘HIV culture’ and the desire to not appear sickly. Participants also described the role of their community, and particularly their female friends, in promoting tanning as a group activity. When discussing reasons for stopping tanning, participants primarily focused on worry about wrinkles and looking older. Fear of skin cancer seemed particularly impactful when a certain event (e.g. a skin cancer diagnosis in a family member) raised their awareness to this risk. Maturity also emerged as a reason to stop tanning: participants’ life priorities shifting away from dating as they grew older made tanning less appealing. Finally, just as participants noted that they were more likely to tan when it was inexpensive or free, they also cited cost as deterring them from continuing to tan.
Table 1.
Reasons for starting and stopping indoor tanning among sexual-minority mena
| Theme | Selected quotations |
|---|---|
| Reasons for starting | |
| Appearance | It’s easier to feel better about your body. When you’re tan and not in great shape it’s like, oh but at least I’m tan. Focus group 7, age 29, participant 33 |
| Community | I think tanning relates to being gay.. . it was a way to congregate with my female friends who were open minded and things like that. Focus group 7, age 23, participant 32 |
| Pleasure | [In] the winter time when it’s cold, and you start your session, you’re warmed and you just feel good. Focus group 7, age 51, participant 26 |
| Convenience | It’s a convenient way to get the tan without spending hours on the beach or the sun deck. Focus group 7, age 57, participant 30 |
| Reasons for stopping | |
| Skin ageing | I started grad school at 22 and 3 years later I looked like I was in my mid to late thirties and started getting carded at the clubs. Focus group 5, age 60, participant 15 |
| Fear of getting skin cancer | I stopped using it as soon as my grandma was diagnosed with cancer. Focus group 5, age 30, participant 1 8 |
| Maturity | When you’re young and you’re gay and in the dating game, you want to look attractive. When you get older, and you’re not in that dating game anymore, then it’s not so important. Focus group 3, age 76, participant 12 |
| Cost | It’s a serious waste of money and it is really expensive. Focus group 2, age 56, participant 6 |
A larger version of Table 1 is available to readers on direct application to the corresponding author.
This study is one of the first to report on motivations to start and stop indoor tanning among SMM. Gay men report sixfold higher rates of tanning bed use and over double the odds of skin cancer compared with heterosexual men.1 In addition, these cancers are both more common and more aggressive in HIV-infected vs. uninfected persons,6 making prevention a priority given the higher HIV prevalence in the SMM community. Our study is limited in its generalizability because it uses a small, single-city sample, which may primarily reflect the social norms of San Francisco SMM.
Our findings directly inform future skin cancer prevention approaches for this community. Firstly, cancer prevention messages that emphasize the risk of wrinkles and skin ageing may be effective deterrents for SMM. Loss-framed, appearance-focused messages have been shown to be effective in interventions targeting young women who tan.7 Secondly, messages that highlight indoor tanning and skin cancer as an LGBTQ community issue by describing the disproportionate impact of indoor tanning and skin cancer on this community may be effective. This approach has been successfully used by the Truth Initiative to highlight the impact of tobacco on the LGBT community.8 Thirdly, policy efforts are essential to make access to this carcinogen less convenient and accessible. These policies can include (i) taxation of indoor tanning; (ii) enforcement of minimum age restriction on indoor tanning use. Overall, our study contributes to our understanding of ways to reduce indoor tanning among SMM.
Acknowledgments
We are indebted to Mary-Margaret Chren MD, from University of California San Francisco and Vanderbilt Department of Dermatology for her thoughtful discussions, and Yi Gao BS, from Cleveland Clinic for his role in recruitment. M.M.C. and Y.G. were not compensated for their roles in this study.
Funding sources: This study was supported in part by the NIH
(R21CA212201 and DP2CA225433) and UCSF Department of Dermatology (UCSF Medical Student Summer Research Fellowship).
Footnotes
Conflicts of interest: none to declare.
References
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