RESEARCH AND PRACTICE
Skin Cancer Risk Behaviors Among US Men: The Role of Sexual Orientation Aaron J. Blashill, PhD, and Steven A. Safren, PhD
The current study assessed skin cancer risk behaviors by sexual orientation in a nationally representative prospective sample of US men (n = 1767), sampled at ages 16 and 29 years. At age 16 years, sexual minority men were 3.9 times as likely as heterosexual men to indoor tan. Participants did not significantly differ in the use of sunscreen or the frequency of outdoor tanning. Thus, sexual minority men might be an at-risk group for developing skin cancers because of their indoor tanning behaviors. (Am J Public Health. 2014;104:1640–1641. doi:10.2105/ AJPH.2014.301993)
Skin cancers (i.e., melanoma, basal cell, and squamous cell carcinomas) disproportionally affect men in the United States. In 2013, the American Cancer Society estimated that men would have a 40% increased risk of being diagnosed with and have nearly a 100% increased risk of dying from skin cancers, compared with women.1 Despite awareness of these gender differences, to date, there have been limited investigations of demographic characteristic differences among men regarding skin cancer risk behaviors. Sexual minority (i.e., gay and bisexual) men may represent a group that is at increased risk for skin cancer. Behaviors such as indoor and outdoor tanning and use of sunscreen are strongly related to appearance concerns,2 and sexual minority men report elevated body dissatisfaction compared with heterosexual men.3 Our aim in the present study was to test, in a US nationally representative sample of men, differences in skin cancer
risk behaviors as a function of sexual orientation. We hypothesized that sexual minority men would report greater skin cancer risk behaviors compared with heterosexual men.
METHODS Data included wave 2 and wave 4 from a nationally representative, longitudinal data set of US adolescents (the National Longitudinal Study of Adolescent Health; “Add Health”),4 with data from 1996 (wave 2) to 2008 (wave 4). Data from wave 1 were not included, because skin cancer risk behaviors were not introduced until wave 2, and wave 3 did not include skin cancer risk behaviors. Participants’ average age at wave 2 and wave 4 was 16 (SD = 1.6) and 29 (SD = 1.6) years, respectively. Initially, a sample of 80 high schools and 52 middle schools from the United States was selected with unequal probability of selection. Incorporating systematic sampling methods and implicit stratification into the Add Health study design ensured this sample was representative of US schools with respect to region of the country, urbanicity, school size, school type, and ethnicity/race. Furthermore, we used complex samples (in SPSS version 22, IBM, Armonk, NY) to account for weighting and clustering. Only male participants were included in the present study, and the final sample was n = 1767. Sexual minority status was operationally defined by responses to 2 individual items at age 29 years. Same-sex attraction was assessed via the question, “Are you romantically attracted to males?” Sexual identity was assessed via the question, “Please choose the description that best fits how you think about yourself.” Responses of “yes” to the attraction item or “bisexual,” “mostly homosexual,” or “100% homosexual” to the identity item were included as sexual minorities. This strategy was taken because the aim of our study was to present a broad epidemiological view of skin cancer risk as a function of sexual orientation. Using a composite variable aided us in generating the largest possible group of sexual minority men. This is also a current approach that was established in large epidemiological samples.5,6 Use of sunscreen was assessed at ages 16 and 29 years with the question, “When you go outside on a sunny day for more than one
1640 | Research and Practice | Peer Reviewed | Blashill and Safren
hour, how likely are you to use sunscreen or sunblock?” Responses were bifurcated into “unlikely versus very/somewhat likely.” Sunbathing was assessed at age 16 years with the item, “During the summer, how often do you sunbathe, or lie in the sun, to get a tan?” with response options bifurcated into “frequently/ occasionally versus rarely/never.” Indoor tanning was assessed at age 16 years with the item, “How many times in your life have you used a sunlamp or a tanning booth or a tanning parlor or salon?” with response options dichotomized into “one or more versus never.”
RESULTS Table 1 lists the participant demographic characteristics of the sample. We conducted a series of v2 tests of independence with sexual minority status (yes/no) and each of the dichotomous skin cancer risk behaviors (Table 2). Sexual minority men reported more frequent indoor tanning (27%) compared with heterosexual men (8.6%; v2[1, 131] = 17.3; F = 10.1; P = .002; odd ratio [OR] = 3.9; 95% confidence interval [CI] = 1.6, 9.8). Although outdoor tanning did not reach statistical significance, sexual minority men also reported more frequent outdoor tanning (22.3%) compared with heterosexual men (14.5%; v2[1, 131] = 2.0; F = 1.3; P = .26; OR = 1.7; 95% CI = 0.67, 4.3). Furthermore, groups did not significantly differ on either sunscreen use at age 16 years or at age 29 years.
DISCUSSION The current study provided the first evidence, to our knowledge, that sexual minority men engaged in elevated skin cancer risk behaviors compared with heterosexual men. Sexual minority men reported higher levels of indoor and outdoor tanning as adolescents compared with their heterosexual male counterparts. Although we noted nonsignificant differences with regard to use of sunscreen at age 16 and 29 years, rates were low among both groups, and substantially lower than that of women.7 In addition, tanning before the age of 35 years is a known risk factor for developing skin cancers.8 Thus, these findings, taken together, suggested that sexual minority men might be an at-risk group for developing skin cancers; however,
American Journal of Public Health | September 2014, Vol 104, No. 9
RESEARCH AND PRACTICE
Contributors TABLE 1—Ethnicity/Race, Education, and Income by Sexual Orientation: Add Health, United States, 2008 Frequency (%) or Mean 6SD Variable Sample size
Total
Sexual Minority
Heterosexual
1767 (100)
78 (4)
1689 (96)
Ethnicity/race White
1266 (72)
48 (64)
1218 (73)
Black/African-American Hispanic/Latino
383 (22) 198 (11)
23 (30) 14 (18)
360 (21) 184 (11)
Asian/Pacific Islander
87 (5)
3 (4)
84 (5)
Native American
83 (5)
4 (5)
79 (5)
< high school
188 (11)
11 (14)
177 (11)
High school
346 (20)
8 (10)
338 (20)
Some college/college
1080 (61)
51 (65)
1029 (61)
Some graduate/graduate Income, $
153 (9) 40 267 647 995
8 (10) 33 636 627 086
145 (9) 40 573 648 728
Education
Note. Variables assessed at wave 4 (mean age = 29 years). Ethnicity/race frequencies sum to greater than 100% because some participants selected more than 1 response. No significant (P < .05) group differences emerged on ethnicity/race, education, or income.
additional research is needed to explore possible competing risks with regard to morbidity and mortality among this population. The current study was limited in several important ways. Because this was the first study, to our knowledge, to examine sexual
TABLE 2—Prevalence and Odds Ratios of Skin Cancer Risk Behaviors by Sexual Orientation: Add Health, United States, 1996–2008 Skin Cancer Risk Behavior/Sexual Orientation
PR, %
OR (95% CI)
Sunbathing age 16 y Sexual minority Heterosexual Indoor tanning age 16 y Sexual minority Heterosexual
22.3
1.7 (0.7, 4.3)
14.5
1.0 (Ref)
27.0
3.9 (1.6, 9.8)
8.6
1.0 (Ref)
No sunscreen age 16 y Sexual minority
70.5
0.9 (0.4, 2.0)
Heterosexual
73.5
1.0 (Ref)
75.9 75.2
1.0 (0.4, 3.0) 1.0 (Ref)
No sunscreen age 29 y Sexual minority Heterosexual
Note. CI = confidence interval; OR = odds ratio; PR = prevalence rate.
orientation and skin cancer risk, we used a broad term of sexual minority status to assess sexual orientation. Future research might benefit from exploring how these behaviors might vary as a function of domain of sexual orientation (e.g., identity, attraction, and behavior). Analyses also did not focus on prospective changes in skin cancer risk behaviors across time. Thus, future research might also benefit from methods that assess skin cancer risk and sexual orientation over at least 3 or more assessment waves. To date, there are no known skin cancer prevention interventions adapted for gay men, and this might prove to be a fruitful area for future research endeavors. It would likely be particularly helpful to better understand the mechanisms of why being a sexual minority man leads to increased skin cancer risk behaviors. By identifying these salient pathways, interventions can tailor content to this at-risk group. j
About the Authors Aaron J. Blashill and Steven A. Safren are with the Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston. Correspondence should be sent to Aaron J. Blashill, PhD, 1 Bowdoin Square, 7th Floor, Boston, MA 02118 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted March 27, 2014.
September 2014, Vol 104, No. 9 | American Journal of Public Health
A. J. Blashill originated the study, and was chiefly responsible for data analysis and writing of the article. S. A. Safren provided supervision and editorial comments on analysis, writing, and implications.
Acknowledgments This research uses data from Add Health, a program project directed by Kathleen Mullan Harris and designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris at the University of North Carolina at Chapel Hill, and funded by grant P01-HD31921 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, with cooperative funding from 23 other federal agencies and foundations. No direct support was received from grant P01-HD31921 for this analysis. Research reported in this publication was supported by the National Institute of Mental Health of the National Institutes of Health under award numbers K23MH096647, to A. J. Blashill, and K24MH094214, to S. A. Safren. Information on how to obtain the Add Health data files is available on the Add Health Web site (http:// www.cpc.unc.edu/addhealth). We would like to thank Ronald R. Rindfuss and Barbara Entwisle for assistance in the original design. Note. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Human Participant Protection The parent Add Health study was approved by the University of North Carolina, Chapel Hill institutional review board.
References 1. American Cancer Society. Cancer Facts & Figures 2013. Atlanta, GA: American Cancer Society; 2013. 2. Cafri G, Thompson JK, Jacobsen PB, Hillhouse J. Investigating the role of appearance-based factors in predicting sunbathing and tanning salon use. J Behav Med. 2009;32(6):532---544. 3. Morrison MA, Morrison RG, Sager CL. Does body satisfaction differ between gay men and lesbian women and heterosexual men and women? A meta-analytic review. Body Image. 2004;1(2):127---138. 4. Harris KM, Halpern CT, Whitsel E, et al. Add Health: Study design. Available at: http://www.cpc.unc. edu/projects/addhealth/design. Accessed April 25, 2013. 5. Mustanski B, Van Wagenen A, Birkett M, Eyster S, Corliss H. Identifying sexual orientation health disparities in adolescents: analysis of pooled data from the Youth Risk Behavior Survey, 2005 and 2007. Am J Public Health. 2014;104(2):211---217. 6. Blashill AJ, Safren SA. Sexual orientation and anabolic-androgenic steroid use in US adolescent boys. Pediatrics. 2014;133(3):469---475. 7. Zhang M, Qureshi AA, Geller AC, et al. Use of tanning beds and incident of skin cancer. J Clin Oncol. 2012;30(14):1588---1593. 8. Geller AC, Colditz G, Oliveria S, et al. Use of sunscreen, sunburning rates, and tanning bed use among more than 10000 US children and adolescents. Pediatrics. 2002;109(6):1009---1014.
Blashill and Safren | Peer Reviewed | Research and Practice | 1641
Skin Cancer Risk Behaviors Among US Men: The Role of Sexual Orientation Aaron J. Blashill, PhD, and Steven A. Safren, PhD
The current study assessed skin cancer risk behaviors by sexual orientation in a nationally representative prospective sample of US men (n = 1767), sampled at ages 16 and 29 years. At age 16 years, sexual minority men were 3.9 times as likely as heterosexual men to indoor tan. Participants did not significantly differ in the use of sunscreen or the frequency of outdoor tanning. Thus, sexual minority men might be an at-risk group for developing skin cancers because of their indoor tanning behaviors. (Am J Public Health. 2014;104:1640–1641. doi:10.2105/ AJPH.2014.301993)
Skin cancers (i.e., melanoma, basal cell, and squamous cell carcinomas) disproportionally affect men in the United States. In 2013, the American Cancer Society estimated that men would have a 40% increased risk of being diagnosed with and have nearly a 100% increased risk of dying from skin cancers, compared with women.1 Despite awareness of these gender differences, to date, there have been limited investigations of demographic characteristic differences among men regarding skin cancer risk behaviors. Sexual minority (i.e., gay and bisexual) men may represent a group that is at increased risk for skin cancer. Behaviors such as indoor and outdoor tanning and use of sunscreen are strongly related to appearance concerns,2 and sexual minority men report elevated body dissatisfaction compared with heterosexual men.3 Our aim in the present study was to test, in a US nationally representative sample of men, differences in skin cancer
risk behaviors as a function of sexual orientation. We hypothesized that sexual minority men would report greater skin cancer risk behaviors compared with heterosexual men.
METHODS Data included wave 2 and wave 4 from a nationally representative, longitudinal data set of US adolescents (the National Longitudinal Study of Adolescent Health; “Add Health”),4 with data from 1996 (wave 2) to 2008 (wave 4). Data from wave 1 were not included, because skin cancer risk behaviors were not introduced until wave 2, and wave 3 did not include skin cancer risk behaviors. Participants’ average age at wave 2 and wave 4 was 16 (SD = 1.6) and 29 (SD = 1.6) years, respectively. Initially, a sample of 80 high schools and 52 middle schools from the United States was selected with unequal probability of selection. Incorporating systematic sampling methods and implicit stratification into the Add Health study design ensured this sample was representative of US schools with respect to region of the country, urbanicity, school size, school type, and ethnicity/race. Furthermore, we used complex samples (in SPSS version 22, IBM, Armonk, NY) to account for weighting and clustering. Only male participants were included in the present study, and the final sample was n = 1767. Sexual minority status was operationally defined by responses to 2 individual items at age 29 years. Same-sex attraction was assessed via the question, “Are you romantically attracted to males?” Sexual identity was assessed via the question, “Please choose the description that best fits how you think about yourself.” Responses of “yes” to the attraction item or “bisexual,” “mostly homosexual,” or “100% homosexual” to the identity item were included as sexual minorities. This strategy was taken because the aim of our study was to present a broad epidemiological view of skin cancer risk as a function of sexual orientation. Using a composite variable aided us in generating the largest possible group of sexual minority men. This is also a current approach that was established in large epidemiological samples.5,6 Use of sunscreen was assessed at ages 16 and 29 years with the question, “When you go outside on a sunny day for more than one
1640 | Research and Practice | Peer Reviewed | Blashill and Safren
hour, how likely are you to use sunscreen or sunblock?” Responses were bifurcated into “unlikely versus very/somewhat likely.” Sunbathing was assessed at age 16 years with the item, “During the summer, how often do you sunbathe, or lie in the sun, to get a tan?” with response options bifurcated into “frequently/ occasionally versus rarely/never.” Indoor tanning was assessed at age 16 years with the item, “How many times in your life have you used a sunlamp or a tanning booth or a tanning parlor or salon?” with response options dichotomized into “one or more versus never.”
RESULTS Table 1 lists the participant demographic characteristics of the sample. We conducted a series of v2 tests of independence with sexual minority status (yes/no) and each of the dichotomous skin cancer risk behaviors (Table 2). Sexual minority men reported more frequent indoor tanning (27%) compared with heterosexual men (8.6%; v2[1, 131] = 17.3; F = 10.1; P = .002; odd ratio [OR] = 3.9; 95% confidence interval [CI] = 1.6, 9.8). Although outdoor tanning did not reach statistical significance, sexual minority men also reported more frequent outdoor tanning (22.3%) compared with heterosexual men (14.5%; v2[1, 131] = 2.0; F = 1.3; P = .26; OR = 1.7; 95% CI = 0.67, 4.3). Furthermore, groups did not significantly differ on either sunscreen use at age 16 years or at age 29 years.
DISCUSSION The current study provided the first evidence, to our knowledge, that sexual minority men engaged in elevated skin cancer risk behaviors compared with heterosexual men. Sexual minority men reported higher levels of indoor and outdoor tanning as adolescents compared with their heterosexual male counterparts. Although we noted nonsignificant differences with regard to use of sunscreen at age 16 and 29 years, rates were low among both groups, and substantially lower than that of women.7 In addition, tanning before the age of 35 years is a known risk factor for developing skin cancers.8 Thus, these findings, taken together, suggested that sexual minority men might be an at-risk group for developing skin cancers; however,
American Journal of Public Health | September 2014, Vol 104, No. 9
RESEARCH AND PRACTICE
Contributors TABLE 1—Ethnicity/Race, Education, and Income by Sexual Orientation: Add Health, United States, 2008 Frequency (%) or Mean 6SD Variable Sample size
Total
Sexual Minority
Heterosexual
1767 (100)
78 (4)
1689 (96)
Ethnicity/race White
1266 (72)
48 (64)
1218 (73)
Black/African-American Hispanic/Latino
383 (22) 198 (11)
23 (30) 14 (18)
360 (21) 184 (11)
Asian/Pacific Islander
87 (5)
3 (4)
84 (5)
Native American
83 (5)
4 (5)
79 (5)
< high school
188 (11)
11 (14)
177 (11)
High school
346 (20)
8 (10)
338 (20)
Some college/college
1080 (61)
51 (65)
1029 (61)
Some graduate/graduate Income, $
153 (9) 40 267 647 995
8 (10) 33 636 627 086
145 (9) 40 573 648 728
Education
Note. Variables assessed at wave 4 (mean age = 29 years). Ethnicity/race frequencies sum to greater than 100% because some participants selected more than 1 response. No significant (P < .05) group differences emerged on ethnicity/race, education, or income.
additional research is needed to explore possible competing risks with regard to morbidity and mortality among this population. The current study was limited in several important ways. Because this was the first study, to our knowledge, to examine sexual
TABLE 2—Prevalence and Odds Ratios of Skin Cancer Risk Behaviors by Sexual Orientation: Add Health, United States, 1996–2008 Skin Cancer Risk Behavior/Sexual Orientation
PR, %
OR (95% CI)
Sunbathing age 16 y Sexual minority Heterosexual Indoor tanning age 16 y Sexual minority Heterosexual
22.3
1.7 (0.7, 4.3)
14.5
1.0 (Ref)
27.0
3.9 (1.6, 9.8)
8.6
1.0 (Ref)
No sunscreen age 16 y Sexual minority
70.5
0.9 (0.4, 2.0)
Heterosexual
73.5
1.0 (Ref)
75.9 75.2
1.0 (0.4, 3.0) 1.0 (Ref)
No sunscreen age 29 y Sexual minority Heterosexual
Note. CI = confidence interval; OR = odds ratio; PR = prevalence rate.
orientation and skin cancer risk, we used a broad term of sexual minority status to assess sexual orientation. Future research might benefit from exploring how these behaviors might vary as a function of domain of sexual orientation (e.g., identity, attraction, and behavior). Analyses also did not focus on prospective changes in skin cancer risk behaviors across time. Thus, future research might also benefit from methods that assess skin cancer risk and sexual orientation over at least 3 or more assessment waves. To date, there are no known skin cancer prevention interventions adapted for gay men, and this might prove to be a fruitful area for future research endeavors. It would likely be particularly helpful to better understand the mechanisms of why being a sexual minority man leads to increased skin cancer risk behaviors. By identifying these salient pathways, interventions can tailor content to this at-risk group. j
About the Authors Aaron J. Blashill and Steven A. Safren are with the Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston. Correspondence should be sent to Aaron J. Blashill, PhD, 1 Bowdoin Square, 7th Floor, Boston, MA 02118 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted March 27, 2014.
September 2014, Vol 104, No. 9 | American Journal of Public Health
A. J. Blashill originated the study, and was chiefly responsible for data analysis and writing of the article. S. A. Safren provided supervision and editorial comments on analysis, writing, and implications.
Acknowledgments This research uses data from Add Health, a program project directed by Kathleen Mullan Harris and designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris at the University of North Carolina at Chapel Hill, and funded by grant P01-HD31921 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, with cooperative funding from 23 other federal agencies and foundations. No direct support was received from grant P01-HD31921 for this analysis. Research reported in this publication was supported by the National Institute of Mental Health of the National Institutes of Health under award numbers K23MH096647, to A. J. Blashill, and K24MH094214, to S. A. Safren. Information on how to obtain the Add Health data files is available on the Add Health Web site (http:// www.cpc.unc.edu/addhealth). We would like to thank Ronald R. Rindfuss and Barbara Entwisle for assistance in the original design. Note. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Human Participant Protection The parent Add Health study was approved by the University of North Carolina, Chapel Hill institutional review board.
References 1. American Cancer Society. Cancer Facts & Figures 2013. Atlanta, GA: American Cancer Society; 2013. 2. Cafri G, Thompson JK, Jacobsen PB, Hillhouse J. Investigating the role of appearance-based factors in predicting sunbathing and tanning salon use. J Behav Med. 2009;32(6):532---544. 3. Morrison MA, Morrison RG, Sager CL. Does body satisfaction differ between gay men and lesbian women and heterosexual men and women? A meta-analytic review. Body Image. 2004;1(2):127---138. 4. Harris KM, Halpern CT, Whitsel E, et al. Add Health: Study design. Available at: http://www.cpc.unc. edu/projects/addhealth/design. Accessed April 25, 2013. 5. Mustanski B, Van Wagenen A, Birkett M, Eyster S, Corliss H. Identifying sexual orientation health disparities in adolescents: analysis of pooled data from the Youth Risk Behavior Survey, 2005 and 2007. Am J Public Health. 2014;104(2):211---217. 6. Blashill AJ, Safren SA. Sexual orientation and anabolic-androgenic steroid use in US adolescent boys. Pediatrics. 2014;133(3):469---475. 7. Zhang M, Qureshi AA, Geller AC, et al. Use of tanning beds and incident of skin cancer. J Clin Oncol. 2012;30(14):1588---1593. 8. Geller AC, Colditz G, Oliveria S, et al. Use of sunscreen, sunburning rates, and tanning bed use among more than 10000 US children and adolescents. Pediatrics. 2002;109(6):1009---1014.
Blashill and Safren | Peer Reviewed | Research and Practice | 1641
