Annals of Epidemiology 25 (2015) 661e667

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Original article

Associations of sexual and gender minority status with health indicators, health risk factors, and social stressors in a national sample of young adults with military experience John R. Blosnich PhD, MPH a, b, *, Adam J. Gordon MD, MPH a, c, d, Michael J. Fine MD, MSc a, c a

Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA Division of General Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA d Mental Illness Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA b c

a r t i c l e i n f o

a b s t r a c t

Article history: Received 26 January 2015 Accepted 3 June 2015 Available online 19 June 2015

Purpose: To assess the associations of self-identified lesbian, gay, bisexual, and questioning sexual orientation or transgender status (LGBTQ) and military experience with health indicators. Methods: We used data from the Fall 2012 National College Health Assessment. The survey included self-identified sociodemographic characteristics, mental (e.g., depression) and physical (e.g., human immunodeficiency virus) conditions, health risk behaviors (e.g., smoking), and social stressors (e.g., victimization). We used modified Poisson regression models, stratified by self-reported military service, to examine LGBTQ-related differences in health indicators, whereas adjusting for sociodemographic characteristics. Results: Of 27,176 in the sample, among the military-experienced group, LGBTQ individuals had increased adjusted risks of reporting a past-year suicide attempt (adjusted risk ratio [aRR] ¼ 4.37; 95% confidence interval [CI] ¼ 1.39e13.67), human immunodeficiency virus (aRR ¼ 9.90; 95% CI ¼ 1.04e79.67), and discrimination (aRR ¼ 4.67; 95% CI ¼ 2.05e10.66) than their non-LGBTQ peers. Among LGBTQ individuals, military experience was associated with a nearly four-fold increased risk of reporting a pastyear suicide attempt (aRR ¼ 3.61; 95% CI ¼ 1.46e8.91) adjusting for age, sex, race and ethnicity, marital status, depression, and other psychiatric diagnoses. Conclusions: Military experience may moderate health indicators among LGBTQ populations, and likewise, LGBTQ status likely modifies health conditions among military-experienced populations. Results suggest that agencies serving military populations should assess how and if the health needs of LGBTQ individuals are met. Published by Elsevier Inc.

Keywords: Veterans health Sexuality Transgendered persons Health surveys Minority health Mental health Military personnel

Introduction In the United States, an estimated 9 million adults identify as lesbian, gay, bisexual, or transgender (LGBT or sexual and gender minority) [1]. These groups are vulnerable to disparities in several health risk behaviors, such as cigarette smoking [2], substance use [3], violence [4], and discrimination [5], and in adverse health outcomes, such as depression [6], respiratory illnesses [7], and

* Corresponding author. Department of Veterans Affairs, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive C (151C-U), Building 30, Pittsburgh, PA 15240-1001. Tel.: þ1-412-360-2138; fax: þ1412-360-2284. E-mail address: [email protected] (J.R. Blosnich). http://dx.doi.org/10.1016/j.annepidem.2015.06.001 1047-2797/Published by Elsevier Inc.

sexually transmitted diseases [8]. In 2011, the Institute of Medicine recommended further research to explore how specific sociodemographic factors may further influence health among LGBT populations [9]. Current and former military experience is one example of a characteristic that may influence health because of the unique stressors (e.g., combat exposure, military sexual trauma, transitions between deployments [10e12]) and culture (e.g., norms and beliefs [13,14]) of military service. Several studies document elevated burdens of mental health problems among individuals with military service history, including suicide risk [15] and post-traumatic stress disorder (PTSD) [16]. LGBT persons who served in the U.S. military may have experienced more stressors, such as discrimination and harassment, than their non-LGBT peers because of the

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recently rescinded “Don’t Ask, Don’t Tell” policy that banned openly lesbian, gay, and bisexual people from military service [17,18]. Individuals can still be discharged from the U.S. military if they are transgender [19]. Despite these potential unique experiences and health needs, there is a paucity of health information about LGBT persons who have served in the U.S. military. Data from the U.S. Census and general population surveys suggest that nearly 1 million U.S. military veterans identify as lesbian, gay, bisexual individuals, and recent findings suggest that more than 70,000 lesbian, gay, bisexual individuals and 15,500 transgender individuals serve in active duty, the guard, or the reserves [20,21]. To some extent, the sexual orientationerelated and transgenderrelated health differences observed in general samples have also been documented in studies with veteran populations. For instance, studies comparing sexual minority with heterosexual veterans have documented higher prevalence of smoking [22,23], suicidal ideation [24e27], PTSD [28], and victimization [29,30]. There are, however, studies that suggest veteran status may moderate differences among sexual minority individuals. Blosnich et al. [31] noted that sexual minority veterans had twice the odds of keeping firearms in the home compared with their sexual minority nonveteran peers. In another study, lesbian and bisexual women veterans had significantly greater prevalence of mental distress, sleep disturbances, current smoking, and poor physical health than lesbian and bisexual nonveterans [22]. The few empirical studies about transgender veterans note a substantially higher burden of poor mental health compared with nontransgender veterans [32e34]. Relatively, very little is known about health risk behaviors and social stressors (e.g., violence and discrimination) among sexual and gender minority individuals with military experience. Research efforts have been hampered by the relative rarity of LGBT status in data collection systems.[35,36]. When LGBT status is collected, large sample sizes are necessary to find analyzable groups of persons who report both LGBT status and military experience. Moreover, many extant studies of LGBT veterans lack direct comparison groups of non-LGBT veterans or LGBT nonveterans groups. To address these gaps, we examine differences in a variety of health indicators (i.e., physical and mental health, health risk behaviors, and social stressors) by sexual and gender minority status among persons reporting a military experience in a large national sample of young adults. Material and methods Data Data are from the National College Health Assessment Fall 2012 survey sponsored by the American College Health Association (ACHA). Postsecondary educational institutions purchase the National College Health Assessment, and ACHA aggregates data collected from institutions that use probability-based sampling methods. The Fall 2012 data set had a total of 28,237 respondents from 51 institutions in the United States. Most institutions (n ¼ 48) used Web-based surveys and three used paper administration. The mean response rate was 20%. Further details about the Fall 2012 survey administration and survey items have been published previously by ACHA [37]. Sociodemographic information Our two independent variables of interest were military experience and sexual or gender minority status. Military experience was assessed with the item: “Are you currently or have you been a member of the United States Armed Services (Active Duty, Reserve, or National Guard)?” Response categories were as follows: no; yes

and I have deployed to an area of hazardous duty; and yes and I have not deployed to an area of hazardous duty. We dichotomized these response categories as yes versus no. Sexual minority status was assessed with the item: “What is your sexual orientation?” to which respondents could indicate heterosexual, gay or lesbian, bisexual, or unsure (i.e., questioning). In a separate item, respondents indicated their gender as female, male, or transgender. Because of the small sample of persons with military experience who identified as having lesbian, gay, bisexual, or questioning (LGBQ) sexual orientation or having a gender identity of transgender, the sexual orientation and gender identity responses were classified as any person who identified as lesbian, gay, bisexual, and questioning sexual orientation or transgender (LGBTQ). We abstracted additional sociodemographic covariates, including age, race and ethnicity, and relationship status. Race and ethnicity were categorized as nonminority (white, non-Hispanic) versus minority (African American or black; Hispanic or Latino and/or Latina; Asian or Pacific Islander; American Indian, Alaskan Native, or Native Hawaiian; biracial or multiracial; or other). Relationship status was classified as married or partnered versus not partnered or married. Health indicators We assessed several self-reported indicators of mental health, physical health, health risk behaviors, and social stressors. Mental health indicators were self-reported as follows: (1) lifetime diagnosis of depression; (2) past 12 months diagnosis or treatment for depression; and (3) past 12 months diagnosis or treatment of other psychiatric conditions (i.e., anorexia, anxiety, attention deficit and hyperactivity disorder, bipolar disorder, bulimia, insomnia, other sleep disorder, obsessive compulsive disorder, panic attacks, phobia, schizophrenia, substance abuse or addiction, other addiction, or other mental health condition). We also included two items about suicidal ideation and suicide attempt in the past 12 months. Each of the five mental health indicators was dichotomously coded as yes or no. We assessed six physical health indicators based on previous literature suggesting sexual or gender minority-based disparities for the following medical conditions: asthma [38], acute respiratory infections (i.e., bronchitis, sinus infection, or strep throat) [7], sexually transmitted diseases (i.e., chlamydia, herpes, human papilloma virus, or gonorrhea), hepatitis B or C [39e41], human immunodeficiency virus (HIV) [42e44], and cardiovascular risk factors (i.e., high blood pressure, high cholesterol) [45e47]. Participants indicated if they have been diagnosed or treated by a professional in the past 12 months for each condition, with response categories of yes versus no. Health risk behaviors included alcohol, tobacco, and illicit drug use. Binge drinking was defined as at least one episode of consuming five alcoholic drinks or more in one sitting in the past 2 weeks. We assessed three types of tobacco use in the past 30 days: (1) cigarettes; (2) cigars, cigarillos, or clove cigarettes; or (3) hookah. We created a global measure of any of these types of tobacco use. Smokeless tobacco use was coded as a separate category of any use versus no use in the past 30 days. We assessed three types of illicit drug use in the past 30 days: (1) marijuana, (2) other drugs (i.e., cocaine, methamphetamines, sedatives, hallucinogens, steroids, opiates, inhalants, ecstasy, other club drugs, and other illegal drugs), and (3) prescription misuse. Prescription drug misuse was defined as any use in the last 12 months of prescription drugs that were not prescribed to the respondent, including antidepressants, drugs for erectile dysfunction, pain relievers, sedatives, or stimulants. We created a global measure of any of the three categories of illicit drug use. We assessed four social stressors based on sexual and gender minority individuals’ high risk of experiencing discrimination and violence [4,48e50]. These included self-reported (1) physical

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assault (not including sexual assault), (2) sexual assault (touched sexually without consent, attempted sexual penetration without consent, or sexual penetration without consent), (3) intimate partner violence (IPV; including emotional, physical, or sexual abuse), and (4) discrimination within the past 12 months. Discrimination was specifically described in the survey with “(e.g., homophobia, racism, sexism).” Respondents had six response options as follows: (1) this did not happen to me and/or not applicable; (2) I have experienced this issue but my academics have not been affected; (3) received a lower grade on an examination or important project; (4) received a lower grade in the course; (5) received an incomplete or dropped the course; or (6) significant disruptions in thesis, dissertation, research, or practicum work. Responses were coded as did not experience discrimination (response 1) versus experienced discrimination (responses 2e6). Analyses To produce specific estimates of direct comparisons between individual groups, we conducted stratified analysis. After stratification based on self-reported military experience, we used c2 and Fisher’s exact tests to examine differences in LGBTQ and nonLGBTQ individuals. We also conducted analyses focused on the LGBTQ sample to assess the associations of military experience with the study outcomes. We used modified Poisson regression models with robust standard errors, controlling for age, race and ethnicity, and partnership status and to estimate adjusted risk ratios (aRRs) with 95% confidence intervals (CIs) for the independent variables of interest (i.e., LGBTQ status and military experience) [51,52]. Analyses of past-year suicidal ideation and attempted suicide were adjusted for depression and other psychiatric diagnoses in the past year. We decided not to adjust for multiple comparisons because of the increased risk of inflating type II error [53,54], especially in light of the existing limited statistical power given the relatively small sample of LGBTQ veterans in this data set (n ¼ 48). All analyses were conducted using Stata/SE, version 13.1 (StataCorp, College Station, TX). This study was approved by the institutional review board of the VA Pittsburgh Healthcare System. Results Sociodemographics Our analytic sample included individuals who indicated their sexual orientation, gender identity, and military experience

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(n ¼ 27,176). Of the survey respondents, 2316 (8.5%) self-identified as LGBTQ, and 587 (2.2%) indicated military experience. Because sexual orientation and gender identity were assessed separately, we examined a cross-tabulation to assure that LGBTQ persons were only counted once when coding LGBTQ individuals with military service. Among LGBTQ persons with military experience, 47 individuals identified as LGBQ and six individuals identified as transgender. Five transgender individuals with military experience also identified as having an LGBQ sexual orientation, and one transgender person indicated being heterosexual. This resulted in 48 LGBTQ individuals with military service, which represented 8.2% among all persons with military experience. Military-experienced LGBTQ individuals were significantly younger and had lower proportions of men, white non-Hispanic individuals, and married or partnered individuals than their nonLGBTQ military-experienced peers (Table 1). Aside from age, the same LGBTQ-related differences in sociodemographic characteristics were observed among the participants without military experience. Prevalence of military experience was significantly higher among transgender individuals than among persons who reported being male or female (9.4% vs. 2.1%, P < .001, data not shown), which has been documented both among Department of Veterans Affairs (VA) samples [34] and among community samples of transgender individuals [32,55]. However, LGBQ and heterosexual individuals had similar prevalence of military experience (2.1% vs. 2.2%, P ¼ .72, data not shown). Differences between LGBTQ and non-LGBTQ individuals In terms of mental health indicators, greater proportions of military-experienced LGBTQ individuals than non-LGBTQ individuals reported lifetime depression, past 12 months depression, and having other psychiatric diagnoses (Table 2). Although the elevated prevalence of suicidal ideation among militaryexperienced LGBTQ individuals was not statistically different from their non-LGBTQ peers, they had nearly 10 times the crude prevalence of their military-experienced non-LGBTQ counterparts in reporting a suicide attempt in the last 12 months (12.5% vs. 1.3%, respectively). Among the nonmilitary groups, LGBTQ individuals had greater crude prevalence of all five mental health indicators. Military-experienced LGBTQ individuals also reported greater burdens of all physical health conditions except for acute respiratory infections; the greatest disparities were in HIV (12.8% vs. 0.8%) and hepatitis (12.8% vs. 1.1%). A slightly different pattern of differences emerged among the nonmilitary groups: LGBTQ individuals

Table 1 Respondent sociodemographic characteristics, stratified by military experience and LGBTQ status Characteristic

Age, M (SE) Gender, n (%) Male Female Transgender Race/ethnicity, n (%) White, non-Hispanic Racial/ethnic minority Black or African American Hispanic, Latino/a Other Marital status, n (%) Married or partnered Neither married nor partnered

Military experience

No military experience

LGBTQ (n ¼ 48)

Non-LGBTQ (n ¼ 539)

27.4 (1.94)*,y

29.6 (0.43)

21.8 (0.12)

20 (41.7)*,y 22 (45.8) 6 (12.5)

385 (71.4) 154 (28.6) d

769 (34.2)* 1421 (63.2) 57 (2.5)

375 163 28 36 99

1373 861 126 188 547

19 28 7 5 16

(40.4)*,y (59.6) (14.9) (10.6) (34.0)

8 (16.7)*,y 40 (83.3)

(69.7) (30.3) (5.2) (6.7) (18.4)

180 (33.6) 356 (66.4)

LGBTQ (n ¼ 2247)

(61.5)* (38.5) (5.6) (8.4) (24.5)

144 (6.4)* 2090 (93.6)

M ¼ mean; SE ¼ standard error. * P < .05 in comparisons of LGBTQ and non-LGBTQ within groups with military experience and with no military experience. y P < .05 in comparisons of LGBTQ with military service history versus LGBTQ without military service history.

Non-LGBTQ (n ¼ 24,342) 21.8 (0.04) 7701 (31.6) 16,641 (68.4) d 16,131 8100 1165 1823 5112

(66.6) (33.4) (4.8) (7.5) (21.1)

2022 (8.4) 22,203 (91.6)

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Table 2 Unadjusted prevalence of mental and physical health indicators, health risk behaviors, and social stressors, stratified by military experience and LGBTQ status Dependent variable

Mental health indicator Lifetime depression diagnosis Depression in past 12 mo Other psychiatric diagnosis Suicidal ideation Suicide attempt Physical health indicator Asthma Acute respiratory infections Sexually transmitted diseases Hepatitis B or C HIV Cardiovascular risk factors Health risk behaviors Binge drinking in past 2 wk Any smoked tobacco Cigarettes Cigars, cigarillos, cloves Hookah Smokeless tobacco Any illicit drug use Marijuana Other illicit drugs Prescription drug misuse Social stressors Discrimination Intimate partner violence Physical assault Sexual assault * y

Military experience

No military experience

LGBTQ (n ¼ 48)

Non-LGBTQ (n ¼ 539)

LGBTQ (n ¼ 2247)

Non-LGBTQ (n ¼ 24,342)

n (%)

n (%)

n (%)

n (%)

17 14 21 5 6

(37.8)* (29.2)* (46.7)*,y (10.4) (12.5)*,y

124 56 121 23 7

(24.0) (10.5) (23.6) (4.3) (1.3)

676 466 644 395 75

(30.8)* (20.9)* (30.3)* (17.6)* (3.3)*

3950 2342 4064 1445 235

(16.7) (9.7) (17.5) (6.0) (1.0)

8 8 7 6 6 9

(17.0)* (17.0) (14.9)*,y (12.8)*,y (12.8)*,y (18.8)y

27 86 20 6 4 80

(5.1) (16.2) (3.7) (1.1) (0.8) (15.1)

265 608 90 11 21 155

(11.8)* (27.5)* (4.1)* (0.5) (1.0)* (7.0)*

2226 6090 579 66 36 1267

(9.2) (25.4) (2.4) (0.3) (0.2) (5.3)

16 17 14 10 8 6 14 9 5 12

(34.0) (37.0) (30.4) (21.3)*,y (17.0)* (13.0)y (31.8)* (19.6) (10.9) (25.5)*

174 152 107 52 39 59 93 54 24 51

(32.4) (28.7) (20.0) (9.7) (7.3) (11.1) (18.1) (10.1) (4.5) (9.6)

689 650 487 185 244 76 784 581 228 425

(30.7) (29.2)* (21.8)* (8.3)* (10.9)* (3.4) (36.5)* (26.1)* (10.4)* (19.2)*

7670 4680 2960 1450 1988 807 5293 3503 1183 2921

(31.7) (19.4) (12.2) (6.0) (8.2) (3.3) (22.8) (14.5) (5.0) (12.2)

14 10 8 9

(29.2)* (20.8) (16.7)*,y (18.8)*

16 68 29 23

(3.0) (12.8) (5.4) (4.3)

450 309 142 273

(20.3)* (13.9)* (6.3)* (12.3)*

920 2248 891 1473

(3.8) (9.4) (3.7) (6.1)

P < .05 in comparisons of LGBTQ and non-LGBTQ within groups with military experience and with no military experience. P < .05 in comparisons of LGBTQ with military experience versus LGBTQ without military experience.

did have higher crude prevalence of acute respiratory infections than their non-LGBTQ peers (27.5% vs. 25.4%); however, the groups did not differ in crude prevalence of hepatitis (0.5% vs. 0.3%). Among the military-experienced group, there were relatively fewer LGBTQ-related differences in health risk behaviors. For instance, although significantly greater proportions of militaryexperienced LGBTQ persons reported using noncigarette forms of smoking, the prevalence of using any form of smoked tobacco did not significantly differ from military-experienced non-LGBTQ individuals. All the LGBTQ-related differences observed in the military-experienced groups were also observed in the group without military experience along with differences in all categories except binge drinking and smokeless tobacco use. Overall similar patterns of LGBTQ differences in social stressors were observed across both military-experienced and nonmilitaryexperienced groups, with the exception of IPV in the militaryexperienced group. Although more than one-fifth (20.8%) of military-experienced LGBTQ individuals experienced some form of IPV, the prevalence was not significantly different from the 12.8% of non-LGBTQ individuals with military experience who reported IPV (P ¼ 117). After adjusting for age, gender, race and ethnicity, and marital status, military-experienced LGBTQ individuals had significantly greater risk than their non-LGBTQ peers of all mental health indicators except for suicidal ideation (Table 3). Of note, militaryexperienced LGBTQ persons had more than a four-fold increase in risk of attempting suicide in the past 12 months compared with their non-LGBTQ peers with military experience, even after additionally adjusting for past 12-month depression and other psychiatric diagnoses. Many of the crude prevalence differences in other outcomes among the military-experienced group were not significant after

adjustment of sociodemographic characteristics, although LGBTQ status was significantly associated with greater risk of HIV (aRR ¼ 9.90, 95% CI ¼ 1.04e79.67); using cigars, cigarillos, and clove cigarettes (aRR ¼ 2.28, 95% CI ¼ 1.14e4.59); and discrimination (aRR ¼ 4.67, 95% CI ¼ 2.05e10.66). Nearly all the crude LGBTQ differences in the nonmilitary group remained significant in the adjusted analyses. Differences among LGBTQ individuals by military experience Among the LGBTQ group, those with military experience had greater prevalence of several health indicators than individuals without military experience (Table 2). For example, although 12.8% of military-experienced LGBTQ individuals reported HIV, only 1.0% of LGBTQ individuals without military experience indicated they were treated or diagnosed with HIV. In analyses adjusting for sociodemographic characteristics among the LGBTQ group, military experienced was significantly associated with several health indicators (Table 4). For instance, after controlling for age, gender, race and ethnicity, marital status, past 12 months depression, and other psychiatric diagnoses, LGBTQ individuals with military experience had more than three times the risk of reporting attempted suicide in the past 12 months (aRR ¼ 3.61, 95% CI ¼ 1.46e8.91), and they had significantly higher risk of reporting hepatitis and HIV infection than LGBTQ individuals without military experience. Discussion These findings contribute to the growing attention of LGBTQ individual with military experience by corroborating results from previous studies, highlighting new areas of focus, and exploring heterogeneity among LGBTQ populations based on military

J.R. Blosnich et al. / Annals of Epidemiology 25 (2015) 661e667 Table 3 aRRs of LGBTQ status with mental and physical health indicators, health risk behaviors, and social stressors, stratified by military experience Dependent variable

Mental health Lifetime depression diagnosis Depression in past 12 mo Other psychiatric diagnosis Suicidal ideationy Suicide attempty Physical health Asthma Acute respiratory infections Sexually transmitted diseases Hepatitis B or C HIV Cardiovascular risk factors Health risk behaviors Binge drinking in past 2 wk Any smoked tobacco Cigarettes Cigars, cigarillos, cloves Hookah Smokeless tobacco Any illicit drug use Marijuana Other illicit drugs Prescription drug misuse Social stressors Discrimination Intimate partner violence Physical assault Sexual assault

Military experience

No military experience

LGBTQ vs. non-LGBTQ

LGBTQ vs. non-LGBTQ

aRR (95% CI)

aRR (95% CI)

1.59* (1.02e2.50)

1.90* (1.78e2.04)

2.29* 1.89* 0.82 4.37*

2.21* 1.77* 2.11* 1.88*

(1.24e4.20) (1.25e2.86) (0.25e2.68) (1.39e13.67)

(2.02e2.42) (1.65e1.90) (1.89e2.35) (1.41e2.51)

2.24 (0.84e5.99) 0.70 (0.29e1.68) 2.08 (0.63e8.97)

1.28* (1.13e1.45) 1.13* (1.05e1.21) 1.59* (1.27e2.00)

3.21 (0.42e24.59) 9.89* (1.70e57.63) 1.18 (0.53e2.61)

0.60 (0.22e1.68) 3.27* (1.70e6.27) 1.21* (1.01e1.45)

1.01 1.23 1.45 2.28* 1.08 1.28 1.32 1.45 1.55 2.03

(0.61e1.69) (0.75e1.97) (0.87e2.42) (1.14e4.59) (0.42e2.81) (0.49e3.35) (0.73e2.41) (0.68e3.09) (0.54e4.42) (1.00e4.11)

0.96 1.48* 1.77* 1.32* 1.30* 0.89 1.59* 1.79* 1.99* 1.56*

(0.90e1.02) (1.38e1.59) (1.62e1.93) (1.13e1.54) (1.15e1.48) (0.69e1.14) (1.49e1.69) (1.65e1.93) (1.73e2.29) (1.42e1.71)

4.67* 1.27 2.41 1.97

(2.05e10.66) (0.61e2.64) (0.91e6.41) (0.66e5.87)

4.96* 1.47* 1.62* 2.01*

(4.44e5.53) (1.31e1.65) (1.36e1.94) (1.77e2.27)

LGBTQ ¼ lesbian, gay, bisexual, transgender, or questioning. Calculated using modified Poisson regression; All analyses adjusted for age, gender (male as reference), race and/or ethnicity (white, non-Hispanic as reference), and marital status (married or partnered as reference); *P < .05. y Analyses also adjusted for past 12 months depression and other psychiatric diagnoses.

experience. First, similar to earlier studies, we observed higher prevalence of poor mental health [22,26,28,32] and sexual assault [29,30] among sexual and gender minority veterans in this sample. Second, we noted several differences between LGBTQ and nonLGBTQ individuals with military experience that have not been examined, including higher prevalence of physical conditions, such as hepatitis B or C, and social stressors, such as discrimination. Finally, these findings suggest that military experience may moderate some health indicators among LGBTQ individuals, such as suicide risk, hepatitis, and HIV. Although the causes of LGBTQ-related health disparities are thought to be rooted in minority stress stemming from the stigmatization of LGBTQ status [6], military experience may confer unique stressors as well. For instance, combat exposure in the forms of traumatic brain injury [56], guilt from killing [57], and PTSD [16] have been linked to poor mental health among current and former military personnel. In addition, owing to the U.S. legacy of “Don’t Ask, Don’t Tell,” discrimination and stigma among LGBTQ people who have served in the military may be particularly pernicious for mental health given the persecution they faced in their military occupations during that era [17]. In our sample, militaryexperienced LGBTQ individuals had a risk of recent attempted suicide that not only was higher than their non-LGBTQ militaryexperienced peers, but also higher than their LGBTQ peers without military experience. Although both the U.S. VA and the U.S. Department of Defense have implemented herculean efforts into

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Table 4 aRRs of military experience with mental and physical health indicators, health risk behaviors, and social stressors among LGBTQ individuals Dependent variable

Military experience aRR (95% CI)

Mental health indicators Lifetime depression diagnosis Depression in past 12 mo Other psychiatric diagnosis Suicidal ideationy Suicide attempty Physical health indicators Asthma Acute respiratory infections Sexually transmitted diseases Hepatitis B or C HIV Cardiovascular risk factors Health risk behaviors Binge drinking in past 2 wk Any smoked tobacco Cigarettes Cigars, cigarillos, and cloves Hookah Any illicit drug use Marijuana Other illicit drugs Prescription drug misuse Social stressors Discrimination Intimate partner violence Physical assault Sexual assault

1.08 1.00 1.37 0.52 3.61*

(0.69e1.70) (0.57e1.75) (0.94e2.00) (0.19e1.47) (1.46e8.91)

0.91 0.49 1.56 15.94* 4.39* 1.56

(0.36e2.31) (0.22e1.12) (0.54e4.51) (4.95e51.28) (1.06e18.25) (0.72e3.41)

1.04 1.19 1.25 2.87* 1.45 0.68 0.68 0.79 0.92

(0.64e1.67) (0.75e1.87) (0.77e2.05) (1.51e5.44) (0.64e3.26) (0.38e1.20) (0.32e1.42) (0.28e2.24) (0.47e1.78)

0.84 1.39 2.01 1.48

(0.43e1.65) (0.70e2.76) (0.87e4.67) (0.69e3.19)

Calculated using modified Poisson regression; All analyses adjusted for age, gender (male as reference), race and/or ethnicity (white, non-Hispanic as reference), and marital status (married or partnered as reference); *P < .05. y Analyses also adjusted for past 12 months depression and other psychiatric diagnoses.

suicide prevention [58], research is needed to investigate how and if prevention and intervention efforts reach vulnerable populations like LGBTQ individuals with military experience. We also found significantly greater burdens of several physical health conditions among military-experienced LGBTQ individuals. Even after adjusting for several sociodemographic characteristics highly related to physical health, most notably age and smoking status, military experience was associated with higher risk of reporting hepatitis and HIV among LGBTQ individuals. More specifically, in post hoc analyses using a Fisher’s exact test of persons indicating HIV infection (data not shown), 83.3% (5 of 6) militaryexperienced LGBTQ and 33.3% (7 of 21) nonmilitary-experienced LGBTQ individuals reported also having a hepatitis B or C infection (P ¼ .043). These results invite further questions about why HIV and hepatitis coinfection may be moderated by military experience among LGBTQ populations. Limitations Several limitations must be noted. First, although a national sample, participants were recruited from postsecondary educational institutions, limiting the representativeness of the findings. Furthermore, the survey response rate was relatively low (20%), which may introduce selection bias and limit generalizability. Second, despite the large number of LGBTQ individuals in the overall sample, the sample size of military-experienced LGBTQ individuals was relatively small, resulting in decreased statistical power. Consequently, we combined sexual and gender minority individuals into one group to maximize statistical power, which precluded the ability to examine the uniqueness of each

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constituent identity. Fourth, some health indicators known to disproportionately affect sexual and gender minority populations, such as syphilis [8], were not included in the survey. Finally, the measure of military experience was self-reported, precluding ascertainment of official enlistment and introducing potential misclassification bias. Conclusion Military experience may be a salient modifier of health indicators among LGBTQ populations, and likewise, LGBTQ status is likely a modifier of health conditions among military-experienced populations. With the recent repeal of “Don’t Ask, Don’t Tell” [5] and ongoing efforts to allow transgender individuals also to serve openly in the U.S. military [59,60] both the Department of Defense and VA are likely to see increases in their current LGBTQ populations. Agencies that serve military and veteran populations should be cognizant of the unique health needs of LGBTQ populations [61,62], as well as promote safe environments and data collection systems (e.g., electronic medical records) that provide LGBTQ individuals the option to disclose their sexual and gender minority status [63]. Acknowledgments The authors thank the American College Health Association for use of the Fall 2012 survey data set. This work was partially supported by a postdoctoral fellowship to J.R. Blosnich through the Department of Veterans Affairs Office of Academic Affiliations and the Center for Health Equity Research and Promotion at the VA Pittsburgh Healthcare System. The opinions expressed in this work are those of the authors and do not represent the funders, institutions, the Department of Veterans Affairs, or the U.S. government. References [1] Gates GJ. How many people are lesbian, gay, bisexual, and transgender?. Los Angeles, CA: The Williams Institute, UCLA School of Law; 2011. [2] Lee JG, Griffin GK, Melvin CL. Tobacco use among sexual minorities, USA, 19872007 (May): a systematic review. Tob Control 2009;18:275e82. [3] Green KE, Feinstein BA. Substance use in lesbian, gay, and bisexual populations: an update on empirical research and implications for treatment. Psychol Addict Behav 2012;26(2):265. [4] Rothman EF, Exner D, Baughman AL. The prevalence of sexual assault against people who identify as gay, lesbian, or bisexual in the United States: a systematic review. Trauma Violence Abuse 2011;12(2):55e66. 1524838010390707. [5] Hatzenbuehler ML, McLaughlin KA, Keyes KM, Hasin DS. The impact of institutional discrimination on psychiatric disorders in lesbian, gay, and bisexual populations: a prospective study. J Inflamm 2010;100(3):452e9. [6] Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull 2003;129(5):674. [7] Blosnich J, Jarrett T, Horn K. Disparities in smoking and acute respiratory illnesses among sexual minority young adults. Lung 2010;188(5):401e7. [8] Centers for Disease Control and Prevention. Sexual transmitted disease surveillance 2012. Atlanta, GA: US Department of Health and Human Services; 2013. [9] Institute of Medicine. The health of lesbian, gay, bisexual, and transgender people: building a foundation for better understanding. Washington, DC: Institute of Medicine; 2011. [10] Hall LK. The importance of understanding military culture. Soc Work Health Care 2011;50(1):4e18. [11] Smith TC, Ryan MA, Wingard DL, Slymen DJ, Sallis JF, Kritz-Silverstein D. New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: prospective population based US military cohort study. BMJ 2008;336(7640):366e71. [12] Suris A, Lind L. Military sexual trauma a review of prevalence and associated health consequences in veterans. Trauma Violence Abuse 2008;9(4):250e69. [13] Reger MA, Etherage JR, Reger GM, Gahm GA. Civilian psychologists in an army culture: the ethical challenge of cultural competence. Mil Psychol 2008;20(1): 21e35.

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