Does sexual orientation impact mortality in females? Healthcare data collection and research on sexual orientation is in its nascent stages of development. Yet, sexual orientation has clear implications on an individual’s health stemming from “chronic and cumulative exposure to stressors” (McKett et al., 2024). This is an area in dire need of attention and further investigation. While not designed specifically to study the influences of sexual orientation on health, researchers on the Nurses’ Health Study revealed that it can negatively impact mortality.
The Nurses’ Health Study History (NHS3, n.d.)
The Nurses’ Health Study (NHS) was established in 1976 as a long-term, questionnaire-based study on women’s health. Funded by the National Institutes of Health, several prospective cohort studies have been conducted over the last three decades.
- NHS: began in 1976 and included 121,700 female registered nurses in the U.S. between the ages of 30 and 55 at baseline. It focused on the long-term risk factors for cancer and cardiovascular disease in females.
- NHS II: began in 1989 and included 116,429 female registered nurses in the U.S. between the ages of 25 and 42 at baseline. This study focused on diet and lifestyle risk factors in females who were younger than the original NHS participants.
- Growing up Today Study (GUTS): began in 1996 and included 27,706 male and female children of NHS II participants between the ages of 9 and 14 at baseline. This study evaluated aspects that affect weight change, substance use, eating disorders, gender, sexual orientation, genetics, and environmental factors.
- GUTS2: began in 2004, the second phase of GUTS, and included 10,923 children of NHS II participants between the ages of 10 and 17 at baseline.
- NHS3: began in 2010 and includes over 40,000 male and female nurses and nursing students in the U.S. and Canada who are at least 19 years old at baseline. It was designed to address public health issues directly related to nurses’ health including chemical exposures and fertility. Recruitment is ongoing.
Expanding upon the original NHS study, NHS II evolved to address additional factors such as silicone implants, air pollution, and shift work. Every two years, participants in NHS II received a follow-up survey with questions about diseases and health-related topics such as smoking, hormone use, pregnancy history, and menopausal status. Although gender was not assessed in the sample, all participants were recruited based on female sex or self-report as being female. In 1995, the questionnaire included information on sexual orientation or identity with the following response options: heterosexual; lesbian, gay, or homosexual; bisexual; none of these; or prefer not to answer. McKetta et al. (2024) sought to examine the data to determine the differences in mortality based on sexual orientation. Among the 116,149 eligible participants, almost 91,000 (78%) data points were assessed: 98.9% identified as heterosexual, 0.8% identified as lesbian, and 0.4% identified as bisexual.
Results (McKetta et al., 2024)
The researchers of the NHS II found the following:
- Cumulative mortality was 4.6% for heterosexual participants and 8.0% for lesbian, gay, bisexual (LGB) participants (7.0% for lesbian participants and 10.1% for bisexual participants).
- LGB females died 26% earlier than heterosexual females after follow-up for three decades.
- Bisexual participants died 37% earlier.
- Lesbian participants died 20% earlier.
- Leading causes of death for LGB females were cancer, respiratory disease, suicide, and cardiovascular disease.
- Risk factors for breast cancer and cardiovascular disease were increased as both lesbian and bisexual participants reported twice as much alcohol and tobacco use as heterosexual participants.
- Bisexual participants had a 50% higher prevalence of hypertension than heterosexuals in the study.
- LGB females had a higher risk of depression.
The study investigators were able to differentiate risks for bisexual and lesbian females. In general, they found bisexual individuals have a higher incidence of substance use and worse physical and mental health compared to lesbian females. Bisexuals experience specific stressors related to a hesitancy to disclose their sexual orientation which can significantly compound their stress. LGB females that do disclose their orientation experience several detrimental biases such as:
- Discrimination by health care clinicians making them less likely to seek preventative care.
- Prejudice from employers, landlords and services providers that can lead to financial, housing, and food insecurity.
- Disapproval or rejection from family and unstable relationships may limit access to social resources.
Strategies to Mitigate Challenges (McKetta et al., 2024)
Chronic stress can lead to cardiovascular, metabolic, and immune system disorders making LGB females vulnerable to disease and increased mortality. Strategies to off-set these challenges include:
- Implementing preventive screening for LGB females.
- Screening and treatment for tobacco, alcohol, and other substance use.
- Instituting mandatory, cultural competency training for all health care providers to help facilitate open communication regarding risk assessment.
Conclusion
There are a few limitations to the study, one of which is the composition of participants, a racially homogenous educated group of individuals with high socioeconomic status. In addition, the proportion of lesbian (0.8%) and bisexual (0.3%) females in the research sample is lower than the current population of adults identifying as lesbian (1%) and bisexual (4.2%) in the U.S. Despite these constraints, this important investigation emphasizes the need to address racial inequities, health care disparities, and modifiable risks in the LGB population.
Consult the
National Institute of Mental Health, a division of the National Institute of Health, for information and resources on crisis intervention and suicide hotlines.
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