To the editor:
Sexual minority persons – including lesbian, gay, bisexual persons – face unequal cancer risks and are a National Institutes of Health-designated health disparity population.1 While multiple studies demonstrated higher prevalence of skin cancer and associated risk factors in gay and bisexual men,2–4 two studies showed that sexual minority women (SMW) had lower prevalence of indoor tanning and skin cancers as compared with heterosexual women.4,5 Scant data exist on additional skin cancer risk behaviors among sexual minority women.
To address this critical knowledge gap, our study examines the prevalence of multiple skin cancer risk factors and screening in SMW using the 2015 National Health Interview Survey, a cross-sectional survey representative of the US civilian population. Emory University institutional review exemption was obtained. We restricted analysis to adult women age ≥18 self-identifying as “lesbian or gay” or “bisexual” (SMW) and as “straight, that is, not lesbian or gay” (heterosexual women). Prevalence of ≥1 sunburns, indoor tanning device use, and skin cancer screening examination within the past 12 months were compared between SMW and heterosexual women using Rao-Scott χ2 tests and benchmarked against Healthy People 2020 targets. Survey sample weights were applied and all estimates met a priori reliability standards. Multivariable logistic regression adjusted for significant sociodemographic confounders. Two-sided tests with Bonferroni-corrected P < .005 were considered significant for 9 outcomes (STATA software, version 12.1; StataCorp).
Among 18,601 women respondents, 464 SMW (2.5%; 263 [1.4%] gay or lesbian and 201 [1.1%] bisexual) and 17,340 (93.2%) heterosexual women were identified. SMW were more likely to report younger age, non-Hispanic ethnicity, obesity, current or former smoker, heavy alcohol use, and lower income level than heterosexual women (Table 1). No significant difference in geographic region, educational attainment, health insurance status, and personal or family history of skin cancers were found. Although SMW reported more sunburns on univariate analysis, there was no statistically significant difference in reported sunburns after adjustment for sociodemographic differences (Table 2). No differences in indoor tanning, skin cancer screening examinations, and frequent sun-protective behaviors were noted by sexual minority status. Healthy People 2020 prevalence targets were met for sunburns (33.8%) in heterosexual women but not in SMW; targets for indoor tanning (3.6%) and sun-protective behaviors (73.7%) remain unmet for both groups.
Table 1.
Sociodemographic characteristics of sexual minority and heterosexual women.
| N (weight prevalence %) | Sexual minority women (N = 464) |
Heterosexual women (N = 17,340) |
P |
|---|---|---|---|
| Age | |||
| 18–39 | 263 (59.8%) | 5,618 (36.6%) | < 0.001 |
| 40–64 | 158 (32.4%) | 7,054 (42.5%) | |
| 65+ | 43 (7.8%) | 4,668 (20.9%) | |
| Race/ethnicity | |||
| Non-Hispanic White | 307 (67.6%) | 10,645 (65.2%) | 0.048 |
| Non-Hispanic Black | 77 (16.0%) | 2,576 (12.6%) | |
| Hispanic | 56 (10.5%) | 2,944 (15.2%) | |
| Other | 24 (5.9%) | 1,175 (7.0%) | |
| Educational attainment | |||
| Below high school | 48 (9.5%) | 2,365 (12.1%) | 0.15 |
| High school or equivalent | 83 (19.4%) | 4,199 (23.9%) | |
| Some college | 161 (36.1%) | 5,606 (32.3%) | |
| College graduate or above | 172 (35.1%) | 5,096 (31.7%) | |
| Family income level | |||
| ≥200% federal poverty level | 247 (57.9%) | 9,661 (61.8%) | < 0.001 |
| ≥200% federal poverty level | 205 (39.9%) | 6,541 (31.1%) | |
| Missing | 12 (2.2%) | 1,138 (7.1%) | |
| Geographic region | |||
| Northeast | 78 (14.1%) | 2,925 (17.9%) | 0.47 |
| Midwest | 87 (22.4%) | 3,568 (21.8%) | |
| South | 167 (38.5%) | 6,179 (38.1%) | |
| West | 132 (25.0%) | 4,668 (22.2%) | |
| Smoking status | |||
| Never smoker a | 238 (55.8%) | 11,429 (67.7%) | 0.001 |
| Former smoker | 111 (19.8%) | 2,436 (13.4%) | |
| Current smoker | 114 (24.4%) | 3,450 (18.9%) | |
| Heavy alcohol use b | 176 (35.3%) | 2,887 (17.1%) | < 0.001 |
| Body mass index | |||
| Underweight / Normal | 159 (36.4%) | 6,631 (42.2%) | 0.003 |
| Overweight | 118 (23.4%) | 4,826 (28.5%) | |
| Obese | 179 (40.2%) | 5,173 (29.3%) | |
| Has health insurance | 411 (89.9%) | 15,692 (90.5%) | 0.70 |
| Personal history of skin cancer | 11 (2.2%) | 496 (2.7%) | 0.54 |
| Family history of skin cancer | 41 (9.4%) | 1,346 (7.6%) | 0.36 |
Defined as smoking fewer than 100 cigarettes in lifetime
Defined as reporting any day with 5+ drinks in the past year
Table 2.
Prevalence of sunburns, indoor tanning, skin cancer screening, and frequent sun-protective behaviors among sexual minority and heterosexual women.
| Outcomesa | Sexual minority women (N = 464) |
Heterosexual women (N = 17,340) |
P Value | HP 2020 Targetb |
|---|---|---|---|---|
| Sunburn in the past 12 months | ||||
| Prevalence, % (95% CI) | 43.3 (37.2–49.7) | 33.2 (32.1–34.4) | 0.001 | 33.9 |
| aOR (95% CI) c | 1.08 (0.80–1.48) | 1 [reference] | 0.61 | |
| Indoor tanning in the past 12 months | ||||
| Prevalence, % (95% CI) | 6.6 (4.1–10.3) | 5.2 (4.7–5.8) | 0.34 | 3.6 |
| aOR (95% CI) | 0.88 (0.52–1.48) | 1 [reference] | 0.63 | |
| Skin cancer screening exam in the past 12 months | ||||
| Prevalence, % (95% CI) | 12.5 (9.0–16.9) | 11.6 (11.0–12.3) | 0.68 | N/A |
| aOR (95% CI) | 1.51 (1.03–2.20) | 1 [reference] | 0.03 | |
| Frequent sun-protective behaviors d | ||||
| Prevalence, % (95% CI) | 70.3 (64.5–75.4) | 70.1 (69.1–71.1) | 0.97 | 73.7 |
| aOR (95% CI) | 1.18 (0.89–1.56) | 1 [reference] | 0.26 | |
| 1. Seeking shade | ||||
| Prevalence, % (95% CI) | 41.4 (35.6–47.5) < | 43.2 (42.2–44.3) | 0.57 | N/A |
| aOR (95% CI) | 1.03 (0.79–1.33) | 1 [reference] | 0.85 | |
| 2. Long sleeves | ||||
| Prevalence, % (95% CI) | 8.6 (5.7–12.8) | 11.5 (10.8–12.2) | 0.16 | N/A |
| aOR (95% CI) | 1.06 (0.66–1.68) | 1 [reference] | 0.82 | |
| 3. Long pants | ||||
| Prevalence, % (95% CI) | 25.1 (20.0–31.0) | 22.7 (21.8–23.6) | 0.38 | N/A |
| aOR (95% CI) | 1.41 (1.03–1.94) | 1 [reference] | 0.03 | |
| 4. Wide-brimmed hat | ||||
| Prevalence, % (95% CI) | 12.6 (9.1–17.2) | 14.1 (13.3–14.9) | 0.50 | N/A |
| aOR (95% CI) | 1.19 (0.8–1.76) | 1 [reference] | 0.39 | |
| 5. SPF 15+ sunscreen use | ||||
| Prevalence, % (95% CI) | 39.7 (33.3–46.5) | 39.7 (38.6–40.9) | 0.99 | N/A |
| aOR (95% CI) | 1.07 (0.80–1.42) | 1 [reference] | 0.66 |
Abbreviations: HP 2020, Healt hy People 2020; aOR, adjusted prevalence odds ratio; CI, confidence interval; N/A, not available; SPF, sun protection factor
Complete case analysis excluded up to 1,498 (8.4%) participants with missing outcomes (4.7%) or covariates (4.2%). Missing data were less common in sexual minority women (5.2% vs. 8.5%, P = 0.01).
HP 2020 targets are federal public health goals for year 2020, aimed to reduce the prevalence of sunburns and indoor tanning in the past 12 months and to increase frequent sun-protective behaviors. Skin cancer-related HP 2020 targets are measured by the questions in the National Health Interview Survey. HP 2020 targets have not been set for skin cancer screen or individual sun-protective behaviors.
Multivariable logistic regression models adjusted for age group, race/ethnicity, income level, smoking status, heavy alcohol use, and body mass index. First-order interaction terms between race/ethnicity and sexual minority status were not significant and not included in the final model.
Composite measure defined as “always” or “most of the time” use of staying in the shade, wearing a long-sleeved shirt, long pants, wide-brimmed hat, and/or SPF 15+ sunscreen when going outside on a warm sunny day for more than one hour. Respondents who report they “do not go out into the sun” were not considered to engage in frequent sun-protective behaviors as per the Healthy People 2020 target definitions.
In contrast with prior indoor tanning data,4 the prevalence of skin cancer risk behaviors among sexual minority women are not significantly different from that of heterosexual women in 2015. This may be due to additional adjustments for income, smoking, and alcohol use as potential confounders. Decreasing trends of indoor tanning use seen in heterosexual women may also differ in SMW. Despite the large study sample size, it did not allow further sub-analyses comparing lesbian and bisexual women. Self-reported survey outcomes were subject to information bias. Our results highlighted current unmet targets for skin cancer prevention among SMW and heterosexual women. Future studies are needed to evaluate ongoing public health interventions to reduce indoor tanning and promote sun-protective behaviors in SMW to achieve national skin cancer prevention goals in all women.
Acknowledgments
Funding/Support: Supported in part by the Dermatology Foundation and the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health under award number UL1TR002378 and KL2TR002381 (H.Y.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Funding/Sponsor was involved?
Design and conduct of the study Yes_ No_X_
Collection, management, analysis and interpretation of data Yes_ No_X_
Preparation, review, or approval of the manuscript Yes_ No_X_
Decision to submit the manuscript for publication Yes_ No_X_
Abbreviations and Acronyms:
- SMW
sexual minority women
Footnotes
Prior Presentation: The abstract is presented in part at the International Investigative Dermatology in Orlando, FL on May 16–19, 2018.
Financial Disclosure:
1) Relevant to this manuscript: None reported.
2) All other relationships: Dr. Yeung received honorarium from InVentiv Health. Dr. Chen received honorarium from EB Research Partnership and Leo Pharma and royalties from Unilever, BiopharmX, Trevi, Dermecular, and Phoenix Repair. Ms. Baranowski had no potential conflicts of interest to disclose.
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