Women's Health Issues 25-5 (2015) 509–516

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Original article

Cancer Risk Factors, Diagnosis and Sexual Identity in the Australian Longitudinal Study of Women’s Health Rhonda Brown, PhD a,*, Ruth McNair, PhD b, Laura Szalacha, PhD c, Patricia M. Livingston, PhD d, Tonda Hughes, PhD e a

School of Nursing and Midwifery, Deakin University, Melbourne, Australia Department of General Practice, University of Melbourne, Melbourne, Australia College of Nursing, Ohio State University, Columbus, Ohio d Faculty of Public Health, Deakin University, Melbourne, Australia e College of Nursing, University of Illinois Chicago, Chicago, Illinois b c

Article history: Received 27 May 2014; Received in revised form 29 March 2015; Accepted 6 April 2015

a b s t r a c t Purpose: We sought to examine cancer diagnosis, cancer treatment, and related risk factors among Australian, middleaged, exclusively heterosexual women compared with sexual minority women (SMW; mainly heterosexual, bisexual, mainly lesbian, and lesbian). Methods: Secondary data analysis of the Australian Longitudinal Study of Women’s Health for women born in 1946 through 1951 (n ¼ 10,451) included bivariate tests (i.e., contingency table analyses, independent t tests). Results: SMW did not have significantly higher cancer diagnoses compared with exclusively heterosexual women, although they were more likely to report never having had a mammogram or pap smear. SMW were also significantly more likely to be high-risk drinkers (11.1% vs. 6.8%; p < .05), current smokers (15.1% vs. 8.3%; p < .001), report significantly higher rates of depression (mean  SD; 6.4  5.5 vs. 5.4  5.1; p < .01.), have experienced physical abuse (10.2% vs. 5.1%; p < .001), and been in a violent relationship (27.2% vs. 12.8%; p < .001). Conclusion: SMW had higher rates of several known cancer risk factors, ostensibly placing them at higher risk of cancer as well as chronic health conditions. Further research is needed to determine whether increased risk results in increased cancer as these women age, and to inform the development of interventions to reduce the risk of disease for SMW. Copyright Ó 2015 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.

Cancer is a leading cause of illness in Australia with around 50,000 new cases of cancer diagnosed in women each year, of which 25% is breast cancer (Australian Institute of Health and Welfare & Australasian Association of Cancer Registries, 2012). Despite state and national surveillance on cancer prevalence no data are collected about sexual minority women (SMW). To date, there has been limited research on the prevalence of cancer and related risk factors among Australian lesbians and bisexual women. A recent populationbased Australian study of the health status of young women aged 25 to 30 years (n ¼ 8,850) found that young lesbian and bisexual women reported significantly poorer mental health * Correspondence to: Rhonda Brown, PhD, Senior Lecturer, School of Nursing and Midwifery, Deakin University, 221 Burwood Highway, Burwood 3125, Victoria, Australia. Phone: þ 61 3 92517026; fax: þ 61 3 92447026. E-mail address: [email protected] (R. Brown).

and higher rates of asthma, and were significantly more likely to report a cancer diagnosis (3% of lesbians, compared with 1.1% of heterosexual women and 1% of bisexual women; p < .05; McNair, Szalacha, & Hughes, 2011). These young lesbians were also significantly less likely to have ever had a Pap test and lesbian and bisexual women more likely to be under screened for breast cancer. McNair et al. (2011) argued that although the cancer diagnosis rates were predictably low given their relatively young age, the higher rates of cancer in lesbians compared with heterosexual and bisexual women was of concern and that higher cancer risk factors pointed to the need for additional research to more fully understand cancer outcomes for SMW. Several studies have demonstrated significantly greater cancer risk factors for lesbians and bisexual women than for heterosexual women in the United States (Brandenburg, Matthews, Johnson, & Hughes, 2007; Cochran et al., 2001), in Britain (King &

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Nazareth, 2006), and Australia (Hyde, Comfort, McManus, Brown, & Howat, 2009; McNair et al., 2011). The prevalence of cancer is therefore posited to be higher among SMW (Brown & Tracy, 2008), owing to higher risk factors, including smoking, alcohol, obesity (Aaron et al., 2001), nulliparity, and reduced contraceptive pill use (Cochran et al., 2001; Dibble, Roberts, & Nussey, 2004), and lower rates of screening for breast and/or nor, Kriegger, Austin, Haneuse, & Gottlieb, cervical cancer (Age 2014; Charlton et al., 2011; Cochran et al., 2001; Diamant, Wold, Spritzer, & Gelberg, 2000; McNair et al., 2011; Tjepkema, 2008). High levels of stress in this population are associated with experiences of sexuality-based stigma, victimization, and discrimination (Meyer, 2003; McCabe, Bostwick, Hughes, West & Boyd, 2010). Meyer’s conceptual framework of minority stress explains how these experiences create a hostile social environment that leads to development of mental health problems (Meyer, 2003), including depression and anxiety (Carr, 2010; Chakraborty, McManus, Brugha, Bebbington & King, 2011). Stress, depression, and anxiety have been found to be an important contributing factor to hazardous drinking and high rates of smoking among lesbian and bisexual women (Hughes, McNair, & Szalacha, 2010). SMW have also been found to have higher prevalence of childhood sexual and physical abuse (McLaughlin, Hatzenbuehler, Xuan, & Conron, 2012). There is increasing evidence that a history of physical or sexual violence is associated with increased cancer risk factors including higher rates of smoking and lower rates of preventative screening (Jun et al., 2010; Loxton, Powers, Schofield, Hussain, & Hosking, 2009; Modesitt et al., 2006). Studies have found that women diagnosed with cancer are twice as likely to have experienced intimate partner violence (Coker, Sanderson, Fadden, & Lucia, 2000). In addition, history of intimate partner violence and childhood sexual assault are negatively associated with cancer well-being (Conron, Mimiaga, & Landers, 2010). Based on these risk factors, SMW have been identified as a group that may have higher rates of cancer (Aaron et al., 2001). However, current literature predominantly focuses on breast (Cochran et al., 2001; Diamant et al., 2000; Fobair et al., 2001; Matthews, Brandenburg, Johnson, & Hughes, 2004; Meads & Moore, 2013) and cervical/ovarian cancer risk (Aaron et al., 2001; Brandenburg et al., 2007; Brown & Tracy, 2008), and there has been little research of overall cancer prevalence, incidence, or mortality among SMW. A notable exception is a Danish study that included 1,640 SMW (Frisch, Smith, Grulich, & Johansen, 2003). This study found no differences in cancer prevalence among SMW and heterosexual women. Similarly, a Californian study also found no differences in cancer prevalence in women by sexual orientation (Boehmer, Miao, & Ozonoff, 2011). However, another American study of breast cancer mortality found that women in same-sex relationships had more than a three times greater age-adjusted hazard of dying from breast cancer than those living with a male partner (Cochran & Mays, 2012). Although previous research has made an important contribution to understanding cancer risks in this population, much of the research has been based in the United States and many of the studies have been limited by numerous methodological issues, including small, homogenous convenience samples (i.e., little variation in ethnicity, race, education, income, sexual identities) and a lack of appropriate comparison groups (Hughes, Wilsnack, & Johnson, 2005). Our study aimed to address some of these limitations.

Study Aim The aim of the study was to compare cancer risk factors and rates of various types of cancer, in a population-based sample of middle-aged Australian women of varying sexual identities. We examined cancer diagnosis, cancer treatment, cancer screening, risk factors (for example physical activity, body mass index (BMI), smoking, alcohol use, stress, and violence) and cancer treatment among women who identified as exclusively heterosexual, mainly heterosexual, lesbian, bisexual, and exclusively lesbian to better understand the cancer risk and prevalence of SMW relative to exclusively heterosexual women. Hypothesis Our hypotheses were that compared with exclusively heterosexual women (reference group), SMW would have 1) higher rates of cancer risk factors (higher levels of stress, alcohol and tobacco use, lower cancer screening) and 2) higher rates of cancer diagnosis. We expected that the study outcomes would highlight health inequalities related to cancer risk among SMW and guide the development of additional research and interventions to more fully understand reasons underlying risk factors among this population. Methods We analyzed population-based data from the Australian Longitudinal Study of Women’s Health (ALSWH). The ALSWH is a prospective study, commenced in 1996, that will track the health of women in three age cohorts (ages 18–23, 45–50, and 70–75 at baseline) for at least two decades (Lee et al., 2005). Sampling from the population was random within each age group, with oversampling from rural and remote areas to allow for statistical comparisons of the circumstances and health of urban and rural participants. Mailed surveys were completed every 3 years. Details of the study design and methods have been reported elsewhere (Brown & Tracy, 2008; Lee et al., 2005). The current analyses focused on data from the third through to the sixth survey of the mid-aged cohort born between 1941 and 1946. A total of 10,845 participants completed survey 3 in 2001, which included a sexual identity question. This question was answered by 10,451 women, who serve as the analytic sample for this study. Measures Sexual identity Women were asked which of the following best described their sexual orientation: exclusively heterosexual, mainly heterosexual, bisexual, mainly lesbian, or exclusively lesbian. For the current analyses, women who identified as anything other than exclusively heterosexual (i.e., mainly heterosexual, bisexual, mainly lesbian and lesbian) were categorized as sexual minority. Participants who indicated uncertainty about their sexual identity or declined to answer the question (n ¼ 394) were excluded from analyses. Cancer diagnosis and screening Respondents were asked whether in the past 3 years they had been diagnosed with cancer, conducted self-breast examinations, and had a mammogram, Pap test, or tests for bowel cancer, as well as the results of these screening tests. Cancer diagnoses were analyzed for each of surveys 3, 4, 5, and 6. Screening and all other cancer risk factors were analyzed using survey 3.

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Cancer-related treatment Respondents were asked whether they had undergone any of the following cancer-related surgical procedures in the previous 3 years: both ovaries removed, breast biopsy, mastectomy, lumpectomy, removal of skin cancer, or any other cancer surgery. They were also asked about undergoing chemotherapy and/or radiotherapy for cancer. Behavioral cancer risk factors Respondents were also asked about a number of behavioral risk factors. BMI was assessed based on height and weight and coded as 1) less than 18.5 kg/m2 (underweight), 2) between 18.6 and 25.0 (healthy weight), 3) between 25.1 and 30.0 (overweight), and 4) above 30.1 (obese). Alcohol drinking pattern was assessed by how often the respondent usually consumed alcohol (seven precoded responses, ranging from never drink alcohol to drink every day), and how many drinks they usually had on the days when they consumed alcohol (four precoded responses, ranging from one to two standard drinks to nine or more). Frequency/quantity responses were combined and women were categorized according to alcohol-use associated risk. Those who did not drink were classified as abstainers. Low-risk drinkers were those who consumed up to 2 drinks per day but fewer than 12 standard drinks per week, or up to 4 standard drinks on any single occasion but less than three times per week. Those who consumed 15 or more standard drinks per week, or 5 or more drinks on a single occasion one or more times a week, were defined as ‘at-risk’ drinkers (National Health and Medical Research Council, 2001). Tobacco use was coded into five categories, ranging from never smoked to smoking more than 20 cigarettes a day. Hormone replacement therapy questions assessed whether respondents were currently using hormone replacement therapy. Physical and mental health Women completed the well-validated Short Form 36 (SF36) health survey (Ware & Sherbourne, 1992). We used eight subscales in the current analyses: 1) physical functioning, 2) role physical, 3) pain index, 4) general health, 5) vitality, 6) social functioning, 7) role emotional, and overall 8) mental health index. Participants were asked to “give the one answer that comes closest to the way you’ve been feeling during the past 4 weeks.” Response options were on a 6-point Likert-type scale ranging from none of the time to all of the time. Summed scores ranged from 0 to 100, with higher scores indicating better overall mental health status. Depression A 10-item version of the Center for Epidemiologic Studies Depression Scale (CES-D) was used to assess current depression (past 4 weeks). The CES-D was developed specifically to identify depressive symptoms and screen for depression in nonclinical populations. Scale scores range from 0 to 30. Responses ranged from 0 to 10, with higher scores indicating greater levels of depressive symptoms. The 10-item version of the CES-D used in the ALSWH (Andresen, Malmgren, Carter, & Patrick, 1994) demonstrated good internal consistency (Cronbach’s alpha ¼ 0.80) and validity. Stress The Perceived Stress Questionnaire for Younger Women was developed specifically for the ALSWH. Studies of the younger cohort conducted by Bell and Lee (2002) have demonstrated that the scale is valid and reliable (Cronbach’s alpha ¼ 0.74).

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Respondents were asked 11 questions about how stressed they have felt over the previous 12 months in relationship to several life domains, such as family of origin, relationships with partner/ spouse and others, health, work/employment, study, and motherhood/children. Responses were on a Likert-type scale ranging from 0 (not at all stressed or not applicable) to 4 (extremely stressed), with higher scores indicating greater levels of stress. Anxiety Women were asked how often in the previous 12 months they had experienced episodes of intense anxiety (anxiety symptoms; on a scale of 0 [never] to 3 [often]).

Demographic Characteristics All of the demographic characteristics were operationalized as categorical: education (1 [no formal], 2 [school certificate], 3 [high school certificate], 4 [trade/diploma], 5 [university degree], and 6 [graduate degree]), employment (1 [employed], 2 [unemployed], 3 [not in the labor force]), Health Care card (1 [yes], 0 [no]), private insurance for hospital (1 [yes], 0 [no]), ancillary insurance (1 [yes], 0 [no]), relationship status (1 [single], 2 [married], 3 [living in a de facto relationship, opposite sex], 4 [living in a de facto relationship, same sex], 3 [separated, divorced, or widowed]), parental status (0 [no children], 1 [one or more children]), and region of residence (1 [urban], 0 [rural/ remote]).

Sample The majority of participants in the sample identified as exclusively heterosexual, 98% (n ¼ 10,200) and 2% (n ¼ 251) were sexual minority (mainly heterosexual, n ¼ 117; bisexual, n ¼ 18; mainly lesbian, n ¼ 16; or exclusively lesbian, n ¼ 100). Owing to the relatively small numbers in some of the identity groupsdparticularly bisexual and mainly lesbiandwe collapsed respondents who identified as mainly heterosexual, bisexual, mainly lesbian, and lesbian into one sexual minority category. The distribution of exclusively heterosexual and sexual minority groups in this study is consistent with the prevalence of sexuality minority identity and heterosexual identity in Australia (Smith, Rissel, Richters, Grulich, & de Visser, 2003). Overall, sexual minority respondents were slightly more likely than exclusively heterosexual respondents to be employed, have private insurance (both hospital and ancillary), and to live in urban areas, but not significantly so (Table 1). Three sociodemographic characteristics differed significantly by sexual identity. Exclusively heterosexual women were more likely to be married (73%) and to have children (83%), whereas SMW were more likely to have a university or graduate degree (40%).

Data Analysis We used contingency table analyses for the categorical variables and analysis of variance and analysis of covariance models for the continuous variables. The data were analyzed using Stata 10 (Stata Corporation, College Station, TX) with an a priori significance level of alpha  0.05 for all statistical tests.

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Table 1 Sociodemographic Characteristics Stratified by Sexual Identity: Australian Longitudinal Study of Women’s Health Mid-life Cohort (n ¼ 10,451) Characteristic

Education No formal School certificate Higher school certificate Trade/diploma University degree Graduate degree Labor force Employed Unemployed Not in labor force Health care card Private insurance Hospital Ancillary Relationship status Single Married De facto opposite sex De facto same sex Separated/divorced/widowed Parental status No children Have children Residence Urban Rural/remote

Exclusively Heterosexual (n ¼ 10,200), n (%)

Sexual Minority (n ¼ 251), n (%)

c2 Test Statistic

1,041 2,045 1,592 1,787 987 692

(12.8) (25.1) (19.5) (22.0) (12.1) (8.5)

22 29 31 41 36 47

(10.7) (14.1) (15.0) (19.9) (17.5) (22.8)

(df ¼ 5) 64.29**

5,023 47 3,431 2,685

(59.1) (0.6) (40.4) (31.5)

143 0 74 74

(65.9) (0) (34.1) (33.9)

(df ¼ 2) ns (df ¼ 1) ns

5,819 (68.3) 5,233 (61.4) 192 6,217 398 2 1,692

(2.3) (73.1) (4.7) (0.1) (19.9)

127 (58.8) 124 (57.7) 21 93 13 32 57

(df ¼ 1) 8.73* (df ¼ 1) ns

(9.7) (43.1) (6.0) (14.8) (26.4)

(df ¼ 4) 1261.1**

1,785 (17.5) 8,412 (82.5)

75 (29.9) 176 (70.1)

(df ¼ 1) 25.65**

6,657 (79.1) 1,759 (20.9)

181 (84.2) 34 (15.8)

(df ¼ 1) ns

significantly poorer social functioning (mean  SD; 79.4  25.9 vs. 84.1  23.0; t ¼ 2.64; p < .01), lower emotional role functioning (78.5  24.6 vs. 84.4  31.7; t ¼ 2.47; p < .05), and higher levels of depression (6.4  5.5 vs. 5.4  5.1; t ¼ 2.78; p < .01) than did exclusively heterosexual women (Table 3). Experiences of violence Compared with exclusively heterosexual women, SMW reported almost twice the number of violent experiences (Table 3). Overall, 27% of SMW reported having been in violent relationship with a partner/spouse (vs. 13% of exclusively heterosexual women, c2 (df ¼ 1) ¼ 24.87, p < .001, and 27% reported being uncomfortable with a family member recently (vs. 20%), c2 (df ¼ 1) ¼ 6.90, p < .001; 10% reported being pushed, grabbed, shoved, kicked, or hit (10% vs. 5%), c2 (df ¼ 1) ¼ 10.95, p < .001, and 8% reported being forced to do things they did not want to do (vs. 5%), c2 (df ¼ 1) ¼ 5.83, p < .001. The gender of the perpetrating partner was not identified in the survey. In analysis of the relationship between cancer risk factors and cancer diagnosis, cancer risk factors did not predict cancer in a future wave, nor was there any significance by sexual identity. Although SMW reported significantly more hazardous drinking and smoking than did exclusively heterosexual women, there was no difference by sexual identity, nor any significant relationship between hazardous drinking or smoking and any cancer diagnosis. Discussion

Abbreviation: ns, not significant. * p < .01; **p < .001.

Results Bivariate Analyses Cancer diagnosis and screening As shown in Table 2, cancer diagnosis in the previous 3 years was increasing with advancing age in both exclusively heterosexual and SMW, and there was no difference according to sexual orientation. There were also no sexual identity differences for any of the cancer procedures. Exclusively heterosexual women were significantly more likely than SMW to conduct self-breast examinations (54% vs. 47% of exclusively heterosexual women), c2 (df ¼ 1) ¼ 5.43, p < .05; to have had a mammogram (97% vs. 94%) c2 (df ¼ 1) ¼ 9.38, p < .001, and to report ever having had a Pap smear (98%; Table 2). SMW were significantly more likely to have never had a mammogram (7% vs. 3%), c2 (df ¼ 3) ¼ 4.91, p < .01, and to have never had a Pap test (5% vs. 2%), c2 (df ¼ 3) ¼ 10.57, p < .01. Behavioral cancer risk factors SMW were significantly more likely to be high-risk drinkers (11% vs. 7% for exclusively heterosexual women), c2 (df ¼ 3) ¼ 7.87, p < .05, more likely to smoke (15% vs. 8%), c2 (df ¼ 2) ¼ 20.297, p < .001, whereas only a small number smoked more than 20 cigarettes a day (6% vs. 4%), c2 (df ¼ 4) ¼ 23.88, p < .001. There were no differences in BMI or current hormone replacement therapy based on sexual identity (Table 3). Physical and mental health Although there were no differences in mental health index, life satisfaction, stress, or anxiety scores, SMW reported

This study replicates existing findings about cancer risk in SMW within an Australian context. In this Australian sample of women, one in five exclusively heterosexual women and one in four SMW had been diagnosed with cancer in the previous 3 years when last surveyed. However, cancer risk factors did not predict cancer in a future wave, nor were there any significant differences by sexual identity. Therefore, our second hypothesis that cancer prevalence would be higher among SMW was not demonstrated. We suggest, however, that as these women age into their 70s, SMW cancer prevalence will be more likely to increase faster than that for heterosexual women, in keeping with the findings from our first hypothesis. Although not significant, the rate of cancer diagnosis rose at a higher rate in SMW than exclusively heterosexual women between the ages of 56 and 61 and 59 and 64. The uptake of mammography and Pap tests was relatively high in the sample; however, SMW were more likely to have never had a mammogram or Pap test. This has important health implications for these women given that a lack of screening decreases the chance of cancer detection at an earlier stage (Brown & Tracy, 2008). Studies have found that SMW are less likely than exclusively heterosexual women to have a regular general practitioner and are, therefore, less likely to be reminded about the importance of such screening (McNair et al., 2011; Tjepkema, 2008). In addition, SMW may be reluctant to attend for preventive screening or follow-up care because of perceived or actual experiences of discrimination (Clark, Bonacore, Wright, Armstrong, & Rakowski, 2003). Further, some SMW and some health care providers may themselves be misinformed about the need for such screeningdparticularly Pap tests (Matthews et al., 2004; Tracy, Lydecker, & Ireland, 2010). Given these factors, there may be a need for more culturally targeted health promotion messages about cancer risk factors and preventive screening for this population.

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Table 2 Cancer Diagnosis and Screening Stratified by Sexual Identity: Australian Longitudinal Study of Women’s Health Mid-life Cohort (n ¼ 10,451) Characteristic

Diagnosed cancer Past 3 y Wave 3 (n ¼ 10,346) Past 3 y Wave 4 (n ¼ 9,296) Past 3 y Wave 5 (n ¼ 9,136) Past 3 y Wave 6 (n ¼ 8,687) Ever (across all waves) Cancer screening Breast screening Self-breast examination Clinical breast examination Mammogram In last 2 years Past 2–5 y >5 y Never Ever had mammogram Abnormal result from a mammogram Cervical screening Pap test In last 2 y Past 2–5 y >5 y Never Ever had pap smear Abnormal result from a pap smear Colon screening

Exclusively Heterosexual (n ¼ 10,200), n (%)

339 1,190 1,471 1,853 3,129

(3.4) (13.1) (16.5) (21.9) (30.7)

Sexual Minority (n ¼ 251), n (%)

9 32 31 56 87

(3.6) (14.2) (13.8) (25.9) (34.7)

c2 Test Statistic

Odds Ratio For Sexual Minority (95% CI)

ns ns ns ns ns

1.08 1.09 .811 1.25 1.20

4,665 (54.4) 5,228 (61.3)

102 (46.8) 132 (60.6)

(df ¼ 1) 5.43* (df ¼ 1) ns

7,086 728 361 269 8,175 1,980

(83.5) (8.6) (4.3) (3.2) (96.8) (23.6)

168 17 16 15 201 38

(77.4) (7.8) (7.4) (6.9) (93.1) (17.9)

(df ¼ 3) 14.91** (df ¼ 1) 9.38*** (df ¼ 1) ns

5,013 1,011 1,996 146 8,020 1,716 2,889

(59.3) (12.0) (23.6) (1.7) (98.2) (20.4) (33.9)

122 23 52 10 197 48 75

(56.7) (10.7) (24.2) (4.7) (95.2) (22.5) (34.4)

(df (df (df (df

¼ ¼ ¼ ¼

3) 1) 1) 1)

(.548–2.11) (.748–1.60) (.553–1.19) (.916–1.70) (.920–1.56)

10.57* 10.22*** ns ns

Abbreviation: ns, not significant. * p < .05; **p < .01; ***p < .001.

Regarding behavioral risk factors, in contrast with previous research (Boehmer, Bowen, & Bauer, 2007; Case et al., 2004; Yancey, Cochran, Corliss, & Mays, 2003), we did not find that SMW were more likely to have a high BMI than exclusively heterosexual women. However, SMW were more likely to smoke and to smoke a greater number of cigarettes per day. In addition, although the majority of both sexual identity groups consumed alcohol, SMW were more likely to drink at risky levels. This finding is consistent with previous research that has found that young Australian SMW smoke and use alcohol at hazardous rates (Hughes et al., 2010; McNair et al., 2011), but extends this research to SMW in their midlife. These factors place SMW at higher risk of lung, breast, mouth, liver, throat, larynx, and esophageal cancers (Danaei, Vander Hoorn, Lopez, Murray, & Ezzati, 2005). Although SMW reported significantly more hazardous drinking and smoking than did exclusively heterosexual women, there was no difference by sexual identity, nor any significant relationship between hazardous drinking or smoking and any cancer diagnosis. Despite consistent research findings indicating that SMW are more likely to be smokers and hazardous drinkers, smoking cessation and alcohol reduction programs have yet to target this population group specifically. In addition to risks associated with health behaviors and lower rates of screening, SMW in the study reported high levels depressive symptoms, poorer social functioning, and lower emotional role. They were also significantly more likely to report experiences of violence than were exclusively heterosexual women. Although we were unable to determine whether intimate partner violence was recent or whether it had occurred in opposite- or same-sex relationships, the high rate of this form of violence reported by SMW is of concern.

Although being sexual minority is not in and of itself a risk factor for cancer, responses to higher rates of perceived or experienced discrimination and exposure to violence are possible reasons for higher use of tobacco and alcohol, poorer mental health, and reduced access to caredall of which are risk factors for cancer. Health care providers need to be aware of these risk factors, actively seek out information about sexual orientation, and screen for risk factors for, and indicators of, cancer among this group of women. Education programs should include information about the health of SMW and provide health care professionals with tools to facilitate targeted interventions to address the health disparities of this population. Strengths and Limitations This study has several strengths and several limitations that should be considered in interpreting the findings. Among the strengths of the study is the fact that it is the first Australian study to specifically investigate cancer diagnosis and cancer risk factors in middle-aged SMW. Second, data were drawn from a national population-based random sample, which distinguishes it from many of the previous studies of cancer risk factors in this population. In addition, women living in rural Australia were sampled at twice the rate of those living in urban areas to capture the health experiences of women living outside urban areas (Lee et al. 2005). Data were drawn from three separate time waves. This study adds to existing literature previous studies by examining a broad range of important cancer risk factors and cancer diagnosis. Limitations of the study include the cross-sectional design and limited assessment of sexual identity. The specific question about sexual orientation was only asked at the third survey in

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Table 3 Behavioral Cancer Risk Factors Stratified by Sexual Identity from the Australian Longitudinal Study of Women’s Health Mid-life Cohort (n ¼ 10,451) Characteristic Body mass index (kg/m2) Underweight (< 18.5) Healthy (18.6–25.0) Overweight (30.1) Hormone replacement therapy Current Alcohol drinking pattern Abstainer Low risk – drinks less than weekly Low risk– drinks more than weekly High risk drinker Tobacco use: smoking status Never Current Ex-smoker 20 cigarettes/d

Exclusively Heterosexual (n ¼ 10,200), n (%) 112 3,009 2,892 2,354

(1.3) (36.0) (34.6) (28.1)

1,014 (11.9)

Sexual Minority (n ¼ 251), n (%) 3 94 67 50

(1.4) (43.9) (31.3) (23.4)

30 (13.9)

1,154 6,602 125 572

(13.6) (78.1) (1.5) (6.8)

32 156 5 24

(14.7) (71.9) (2.3) (11.1)

5,227 711 2,596 175 249 287

(61.2) (8.3) (30.4) (2.1) (2.9) (3.8)

105 33 80 11 8 14

(48.2) (15.1) (36.7) (5.0) (3.7) (6.4)

c2 Test Statistic

(df ¼ 3) 6.00, ns (df ¼ 1) ns

(df ¼ 3) 7.87*

20.297***

(df ¼ 4) 23.88***

Physical and Mental Health

Mean  SD

Mean  SD

Independent t Test Statistic

SF36 Physical functioning Role physical Pain index General health Vitality Social functioning Role emotional Mental health index Depression Stress Anxiety

79.31  20.78 74.49  37.68 67.21  23.47 71.08  20.22 61.02  20.98 84.05  23.00 84.39  31.68 77.08  17.07 5.39  5.10 0.50  0.42 3.59  2.65

78.93  20.76 71.14  39.58 65.81  23.85 69.48  21.03 59.98  20.31 79.36  25.86 78.50  24.56 75.36  17.76 6.44  5.46 0.55  0.44 3.58  2.66

ns ns ns ns ns t ¼ 2.64** t ¼ 2.47* ns t ¼ 2.78** ns ns

Experiences of violence

n (%)

n (%)

c2 Test Statistic

Past year Pushed, grabbed, shoved, kicked or hit Forced unwanted sexual activity Ever Pushed, grabbed, shoved, kicked or hit Forced unwanted sexual activity Been in violent relationship with a partner/spouse Recently Uncomfortable with anyone in family Forced you to do things you did not want to do Anyone close tried to hurt or harm you Anyone close called you names/put you down/made you feel bad Afraid of anyone in your family

74 (0.9) 27 (0.3)

3 (1.4) 2 (0.9)

(df ¼ 1) ns (df ¼ 1) ns

432 (5.1) 317 (3.7) 1,091 (12.8)

22 (10.1) 13 (6.0) 53 (27.2)

(df ¼ 1) c2 ¼ 10.95*** (df ¼ 1) ns (df ¼ 1) c2 ¼ 24.87***

1,691 403 181 989 270

59 18 4 25 2

(df (df (df (df (df

(19.9) (4.7) (2.1) (1.6) (3.2)

(27.2) (8.3) (1.9) (11.5) (0.9)

¼ ¼ ¼ ¼ ¼

1) 1) 1) 1) 1)

c2 ¼ 6.90*** c2 ¼ 5.83*** ns ns ns

Abbreviation: ns, not significant. p < .05; **p < .01; ***p < .001.

*

2001 and not in subsequent surveys. Therefore, we are unable to determine if there was any change in sexual orientation after this time. In addition, because of the relatively small numbers of some sexual orientation subgroups, we made the decision to collapse those who did not identify as exclusively heterosexual into a single category of SMW. The very small sizes of some of the subgroups (bisexual, n ¼ 18; mainly lesbian, n ¼ 16) precluded examining any potential differences across sexual minority subgroups. A further limitation is the relative young age of the study sample for whom cancer is not present as yet. Although data were drawn from a longitudinal study, questions about cancer diagnoses were limited to the past 3 years. We were unable to determine lifetime diagnosis of cancer because we were unable able to determine from the available data whether participants were reporting new or recurrent cancers at each timeframe. A potential selection bias in the study is the limited

age range of the sample and it being limited to the Australian context; however, the sample is population based and our findings replicate other studies. Therefore, we believe our study provides generalizable results in particular about cancer risks among SMW. Implications for Practice and/or Policy SMW seem to have higher rates of several known cancer risk factors, which places them at higher risk of cancer as well as a number of other chronic health conditions. However, further research is required to determine whether increased risks relative to exclusively heterosexual women result in higher rates of cancer diagnosis as this group of women moves into older age. Future research should also include comparisons of cancer and cancer risk factors between sexual minority subgroups. Our

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findings highlight the importance for health care providers to ask about sexual orientation and assess for risk factors among SMW. It is also important that questions that assess sexual orientation are included in all national health surveys to better understand the health risks and health outcomes in this underserved population. In addition, health promotion interventionsdparticularly regarding cancer screening, smoking cessation, and alcohol reductiondshould be designed and specifically targeted to address the unique risk profiles of SMW. Acknowledgments The research on which this paper is based was conducted as part of the Australian Longitudinal Study of Women’s Health (ALSWH), a 20-year longitudinal study of Australian women by The University of Newcastle and The University of Queensland. The ALSWH methods were approved by the Human Research Ethics Committees of The University of Newcastle and The University of Queensland. The ALSWH was funded by the Australian Government Department of Health and Ageing. The authors also acknowledge and thank the Lesbian Health Fund, USA (grant 0000023715), and the Faculty of Health, Deakin University for funding to support our research. Dr Rhonda Brown, the principal investigator, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. No financial interest to disclose. References Aaron, D. J., Markovic, N., Danielson, M. E., Honnold, J. A., Janosky, J. E., & Schmidt, N. J. (2001). Behavioral risk factors for disease and preventive health practices among lesbians. American Journal of Public Health, 91(6), 972–975. nor, M., Krieger, N., Bryn Austin, S., Haneuse, S., & Gottlieb, B. (2014). At the Age intersection of sexual orientation, race/ethnicity, and cervical cancer screening: Assessing Pap test use disparities by sex of sexual partners among black, Latina, and white U.S. women. Social Science & Medicine, 116, 110–118. Andresen, E., Malmgren, J., Carter, W., & Patrick, D. (1994). Screening for depression in well older adults: Evaluation of a short form of the CES-D (Center for Epidemiologic Studies Depression Scale). American Journal of Preventive Medicine, 10, 77–84. Australian Institute of Health and Welfare (AIHW) & Australasian Association of Cancer Registries. (2012). Cancer in Australia: In brief 2012. Canberra: AIHW. Cancer series no. 72. Cat. no. CAN 69. Bell, S., & Lee, C. (2002). Development of the Perceived Stress Questionnaire for Young Women. Psychology, Health & Medicine, 7(2), 189–201. Boehmer, U., Miao, X., & Ozonoff, A. (2011). Cancer survivorship and sexual orientation. Cancer, 117, 3796–3804. Boehmer, U., Bowen, D. J., & Bauer, G. R. (2007). Overweight and obesity in sexual-minority women: Evidence from population-based data. American Journal of Public Health, 97(6), 1134–1140. Brandenburg, D. L., Matthews, A. K., Johnson, T. P., & Hughes, T. L. (2007). Breast cancer risk and screening: A comparison of lesbian and heterosexual women. Women and Health, 45(4), 109–130. Brown, J. P., & Tracy, J. K. (2008). Lesbians and cancer: An overlooked health disparity. Cancer Causes and Control, 19(10), 1009–1020. Carr, S. (2010). Seldom heard or frequently ignored? Lesbian, gay and bisexual (LGB) perspectives on mental health services. Ethnicity and Inequalities in Health and Social Care, 3(3), 14–23. Case, P., Austin, B., Hunter, D., Manson, J. E., Malspeis, S., Willett, W., & Spiegelman, D. (2004). Sexual orientation, health risk factors, and physical functioning in the Nurses’ Health Study II. Journal of Women’s Health, 13(9), 1033–1047. Chakraborty, A., McManus, S., Brugha, T. S., Bebbington, P., & King, M. (2011). Mental health of the non-heterosexual population of England. British Journal of Psychiatry, 198(2), 143–148. Charlton, B. M., Corliss, H. L., Missmer, S. A., Frazier, A. L., Rosario, M., Kahn, J. A., & Austin, S. B. (2011). Reproductive health screening disparities and sexual orientation in a cohort study of U.S. adolescent and young adult females. Journal of Adolescent Health, 2011(49), 505–510. Clark, M. A., Bonacore, L., Wright, S. J., Armstrong, G., & Rakowski, W. (2003). The cancer screening project for women: Experiences of women who partner

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mental health nursing. Her research primarily focuses on sexual minority populations.

Author Descriptions

Tonda Hughes, PhD, is Professor, Department of Health Systems Science and Associate Dean for Global Health, Global Health Leadership Office at University of Illinois at Chicago, College of Nursing, and Research Director for the UIC National Center of Excellence in Women’s Health.

Rhonda Brown, PhD, is Senior Lecturer at the School of Nursing and Midwifery, Deakin University Melbourne, Australia, where she teaches in community and

Ruth McNair, PhD, is Honorary Associate Professor at the Department of General Practice, University of Melbourne, Australia. She is a practicing GP.

Laura Szalacha, PhD, is Associate Director of the Center for Research & Scholarship and Research Associate Professor at The Ohio State University, College of Nursing. She also teaches statistics and research methods.

Patricia M. Livingston, PhD, is Professor, and Faculty of Health and School of Nursing and Midwifery, Deakin University. She is the Associate Dean (Research) in the Faculty of Health and a member of the Quality and Patient Safety (QPS) Strategic Research Centre.

Cancer Risk Factors, Diagnosis and Sexual Identity in the Australian Longitudinal Study of Women's Health.

We sought to examine cancer diagnosis, cancer treatment, and related risk factors among Australian, middle-aged, exclusively heterosexual women compar...
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