Abstract
Perceptions of the importance of health problems can drive advocacy, policy change, resource distribution, and individual behaviors. However, little is known about how lesbian, gay, bisexual, and transgender (LGBT), that is, sexual and gender minority (SGM) adults view the health problems facing SGM populations. In a 2017 national, probability-based survey of U.S. SGM adults (N = 453), we asked respondents to identify the most serious health problem facing SGM people today. Participants also rated the seriousness of five specific health problems (HIV/AIDS, suicide, hate crimes, harmful alcohol use, tobacco use). Analyses accounted for the complex sampling design and were stratified by gender identity. One quarter of U.S. SGM adults identified the most serious health problem facing SGM people to be HIV/AIDS (95% confidence interval [20.3, 31.2]). More respondents stated there were no serious LGBT health differences compared with straight/cisgender adults (4.2%, confidence interval [2.6, 5.9]) than identified tobacco use, hate crimes, chronic diseases, cancer, or suicide as the most serious. Importance ratings differed by gender and tobacco/alcohol use were perceived as less serious compared with HIV/AIDS, suicide, and hate crimes. Attention paid to HIV/AIDS by the SGM public, while important, may hinder efforts to address chronic diseases and other health issues affecting SGM people.
Introduction
There are substantial differences in health by sexual orientation and gender identity that disadvantage sexual and gender minority (SGM, e.g., lesbian, gay, bisexual, and transgender) populations. To address these inequities, SGM communities have organized to improve health care, develop health centers that serve SGM populations, adapt interventions for SGM communities, and build networks and coalitions to address specific health topics (e.g., HIV/AIDS, tobacco control, violence, cancer). Prominent have been efforts to address HIV and AIDS, including iconic activism by the AIDS Coalition to Unleash Power (ACT-UP) and others (Halcli, 1999). Similarly, community and public attention to SGM suicide and hate crimes have been driven by attention to problems in communities and coverage in the media (Savage & Miller, 2012).
Several theoretical and conceptual approaches illustrate why public attention to a health problem matters to addressing inequities. Theories of agenda setting suggest that policy agendas are driven in part by attention and media coverage (Scheufele, 2000). Similarly, the “issue attention cycle” posits that attention to a problem can drive interventions (Downs, 2016). Finally, public health practice recognizes the importance of media advocacy to drive changes (Drabble et al., 2006). In addition to mobilizing communities and driving policy agendas, perceptions of health issues important to SGM communities can also influence individual health behaviors. The importance of HIV to the SGM community may drive individual testing behaviors and safer-sex practices by, for example, changing individuals’ perceived vulnerability and motivation to protect oneself.
Despite the historic and current importance of SGM communities’ perceptions of health problems, there is little data regarding what health issues SGM communities view as most salient. Only limited evidence is available about what those perceptions are. For example, one venue-based (i.e., bar and club) study (N = 660) found HIV and sexually transmitted infections were rated highest of issues of importance among gay and bisexual men and smoking was rated least important (Grov et al., 2013). In a Houston, Texas, convenience sample (N = 99), just 6% of participants listed smoking or secondhand smoke exposure as a top-three health problem (Tami-Maury et al., 2015).
It is important to understand where perceptions of problems may not align with premature death and disease. That is, not all problems receive attention proportionate to their actual contribution to premature death and diseases. For example, SGM populations smoke at much higher rates than other groups (Buchting et al., 2017; Wheldon et al., 2018). As such, tobacco use is a leading cause of death among SGM people given existing disparities (Max et al., 2020). Nonetheless, the disproportionate effect of tobacco use on the SGM community has received scant media attention and is not viewed as an important community issue by community members (Smith et al., 2008).
Given the theoretical and practical importance of media and public attention to health problems, substantial health inequities for SGM populations, and limited probability-based data, we sought to (1) assess the salience of health issues relevant to SGM adults, and (2) assess how tobacco use is perceived in relation to other key health issues in a national, probability-based survey.
Method
From July to October 2017 we administered a cross-sectional phone survey to a sample of English speaking SGM adults living in the United States (Lee et al., 2020) who were recruited as a follow-up to a larger, probability-based tobacco use survey study implemented in two waves of data collection (Boynton et al., 2016; Jeong et al., 2020). SGM individuals were recruited to the parent tobacco use survey as part of the probability-based sampling procedure or as part of a supplemental respondent-driven sampling chain. In all cases, participants had a known probability of selection and therefore weights could be constructed to generate nationally representative estimates. A minimum of six call attempts were made to contact every eligible SGM participant, yielding a final sample of 453 SGM adults.
After the screening and consent process was complete the interviewer made the statement, I’d like to start by asking you about issues important to the LGBT community. I will be using the term LGBT throughout this survey to refer to anyone who is lesbian, gay, bisexual, transgender, or queer. I appreciate your understanding if the term LGBT does not completely capture your identity.
The interviewer then asked, “What do you think is the most serious
Because there are substantial differences by gender in SGM health and because HIV/AIDS disproportionately affects sexual minority men and transgender women, we conducted analyses stratified by gender identity. The University of North Carolina at Chapel Hill Institutional Review Board reviewed and approved the study protocol (No. 13-2779).
Results
Participant characteristics are provided in our online Dataverse repository cited above and in Lee et al. (2020). Table 1 shows frequencies and weighted proportions of responses identifying the most serious health problem facing LGBT people today, stratified by gender identity.
Topic Identified as Most Serious Health Problem Facing LGBT People Today, Coded From Open Responses, Unweighted ns and Weighted Proportions (N = 453), 2017
NOTE: LGBT = lesbian, gay, bisexual, or transgender; STIs = sexually transmitted infections.
For all groups, HIV/AIDS (25.7%) and sexually transmitted infections/unprotected sex (17.6%) were the most common responses; limitations in health services access, care, and information were also commonly cited (11.0%). More participants reported that they thought no disparity existed (4.2%) than those that indicated discrimination/exclusion, tobacco use, hate crimes, chronic diseases, cancer, or suicide.
As shown in our institutional repository supplemental table cited above, when we asked participants to rate the seriousness of five topics presented in random order, participants rated suicide (mean [M] = 2.26, 95% confidence interval [CI; 2.17, 2.36]), hate crimes (M = 2.21, 95% CI [2.11, 2.30]), and HIV (M = 2.12, 95% CI [2.03, 2.21]) as significantly more serious health problems for the LGBT community compared with harmful alcohol use (M = 1.69, 95% CI [1.59, 1.78]) and smoking (M = 1.64, 95% CI [1.54, 1.74]). We identified significant differences in the ratings for hate crimes by gender identity, with cisgender sexual minority women rating hate crimes as a more serious health issue (M = 2.36, 95% CI [2.25, 2.46]) compared with cisgender sexual minority men (M = 2.01, 95% CI [1.85, 2.16]) and cisgender sexual minority women rating smoking as a less serious problem (M = 1.52, 95% CI [1.39, 1.65]) compared with cisgender sexual minority men (M = 1.78, 95% CI [1.64, 1.93]).
Discussion
Our findings suggest that health issues connected to immediate harms (e.g., HIV infection, health services access, violence) are more salient, and therefore perceived as more serious, to SGM adults as compared to health issues associated with more distal harms such as chronic disease. For example, smoking, which is a leading cause of death and disability for U.S. adults and for LGBT individuals (Max et al., 2020), was not generally perceived as a serious health risk to LGBT people.
Access to quality health care is a major concern in the U.S. population and an important political topic. However, our findings suggest that the top health concerns for SGM populations may differ from those of the general public in important ways, specifically, by including a focus on HIV/AIDS. Addressing inequities in HIV/AIDS for SGM men and gender minority women remains an important area of work, given, for example, the striking inequities in HIV prevalence by race and gender identity among SGM populations (Matthews et al., 2016). HIV/AIDS has historically been viewed as a core issue of SGM health; however, improvements in care (e.g., antiretroviral therapy) are resulting in chronic diseases replacing HIV/AIDS as leading causes of death for people living with HIV/AIDS (Helleberg et al., 2015).
Our findings may be of particular concern for advocates working to address chronic diseases among SGM populations. For example, our findings may help explain the lack of traction that SGM tobacco control advocates report when speaking to SGM community leaders (Smith et al., 2008) and why certain messaging around SGM health disparities performs poorly (Lee et al., 2017). Lack of SGM public attention to more distal health issues may, in turn, hinder efforts to successfully encourage SGM organizations to address health issues such as tobacco use and cardiovascular disease and hinder media advocacy efforts (Drabble et al., 2006).
Regarding public health and health promotion practice, our findings suggest the importance of engaging with SGM communities and SGM community organizations on a broad range of health topics. For example, this could include invitations to SGM community leaders to participate in advisory boards and as community partners. The findings also highlight the importance of health advocates working on chronic disease topics participating in community events. And, it suggests the important need for getting chronic disease topics covered by media tailored to SGM populations.
This study’s strengths of probability sampling of a marginalized population and use of an open-ended response option for health problems must be balanced against its limitations. First, our weights are based on the National Health Interview Survey and are thus limited by the ways in which that survey captured SGM identity. Second, we asked our questions in the context of a survey explicitly about tobacco use and SGM health and we used the term “alcohol abuse” as opposed to less potentially stigmatizing terms such as “alcohol use,” “alcohol use disorder,” or “harmful alcohol use.” This measurement approach may have affected the stated levels of concern for smoking and alcohol use in the SGM community. Third, our small sample of transgender/nonbinary adults did not allow for meaningful comparisons with the cisgender groups.
Conclusion
Efforts to address SGM health beyond HIV/AIDS may be hindered by the focus of the SGM public on the importance of HIV and other sexually transmitted infections. Although a continued focus on averting HIV transmission and connecting HIV positive patients with care is essential, a greater emphasis on burgeoning health issues for the SGM community, such as smoking, is needed.
Footnotes
Authors’ Note:
The authors thank Kurt Ribisl, Noel T. Brewer, and Quirina Vallejos for assistance with development of the survey items and Anna Hoffmeyer for her expertise in managing administration of the telephone survey. Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health and Food and Drug Administration Center for Tobacco Products (CTP) under Award Number P50CA180907. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Food and Drug Administration. The funder had no role in the design of the study or in data collection, data analysis, interpretation, and writing of the article.
