Men's sexual orientation and health in Canada.
Until recently, no population-based data have been available to determine whether these types of health disparities exist for gay and bisexual men in Canada. In the current study, we have conducted a detailed analysis of the data available from the Canadian Community Health Survey (CCHS, 2003)--which for the first time included a question about sexual orientation in its 2003 data collection (Cycle 2.1)--to determine whether health status and health risk behaviours of Canadian men vary based on sexual orientation identity.
Our study is a cross-sectional analysis of data from the CCHS: Cycle 2.1 (2003). The CCHS is a national population-based survey designed to gather cross-sectional health data on a representative sample of Canadians. In Cycle 2.1, trained interviewers conducted extensive computer-assisted interviews with over 135,000 Canadians. The sampling frame for CCHS 2.1 included 98% of the Canadian population and the sampling methods are described by Statistics Canada. (23) The overall response rate was 80.7%. (23) For our study, we limited the sample to respondents 18 years of age and older.
The CCHS measured respondents' sexual orientation by asking "Do you consider yourself to be: 1) heterosexual? (sexual relations with people of the opposite sex); 2) homosexual? that is lesbian or gay (sexual relations with people of your own sex); 3) bisexual? (sexual relations with people of both sexes)". Hence the CCHS 2.1 measured the proportion of Canadians who self-identified as belonging to a sexual minority.
Socio-demographic variables included age (continuous), sex, recent immigration (born outside of Canada and moved to Canada within 5 years of participating in survey), education level (high school diploma or no high school diploma), low income adequacy (a dichotomous measure
based on total household income and the number of people in the household), employment status (currently employed or not) and race/ethnicity. We were obliged to aggregate ethnicity data into a binary variable ("white" or "non-white") in order to avoid small cells.
Measures of health status included respiratory disease, hypertension, and mood or anxiety disorders. Reports of life-time suicidality, self-perceived physical health status and self-perceived mental health status were also included. The self-report global health status variables were measured using a 5-point global assessment scale (excellent, very good, good, fair, or poor). We also compared the likelihood of having an overweight or obese Body Mass Index (BMI) between sexual orientation groups.
Health Risk Behaviours
We examined health risk behaviours including tobacco use (current daily smoker or not), high-risk alcohol consumption (>8 drinks per week), and, of those who reported any sexual intercourse, any lifetime diagnosis with a sexually transmitted disease (STD).
We described respondents' demographic characteristics by sexual orientation group. Next we conducted bivariate analyses to describe self-reported rates of outcomes and identify potential associations between gay or bisexual orientation and our outcomes relative to heterosexual men (with separate comparisons calculated for each of gay and bisexual men with heterosexual men as the referent group). Finally, we used multivariable logistic regression to assess the independent effects of sexual orientation on health status and health risk behaviours. We adjusted our analyses of health status for age, immigration, education, household income, employment level, and relevant health risk behaviours (e.g., smoking for respiratory disease, BMI for hypertension). We adjusted our health risk behaviours analyses for age (linear and quadratic terms), immigration, education level, household income, employment level and self-perceived health status.
For all logistic regression models, we calculated odds ratios, p-values, standard errors, and 95% confidence intervals (CIs) using the bootstrap re-sampling procedure recommended by Statistics Canada. All analyses were performed using Stata 10SE.
Using preliminary data provided by Statistics Canada, we assumed a sample of 536 gay men, 300 bisexual men, and 49,065 heterosexual male respondents. For each dependent variable, the range of responses varied because not all questions were asked of all participants (Range Gay men: 128-536; Bisexual men: 91-300; Heterosexual men: 18,944-49,065).
Table 1 shows the demographic characteristics of our sample by sexual orientation. Among the 18-59 year age group, 1.3% of Canadian men reported that they self-identified as homosexual and 0.6% of men reported that they self-identified as bisexual. (24) Heterosexual men were significantly older, on average, than gay or bisexual men and gay men were significantly less likely to be immigrants or to have lower education levels than both heterosexual and bisexual men.
Table 2 shows the unadjusted rates of self-reported health conditions by sexual orientation. Prevalence rates of hypertension before adjustment were slightly higher among heterosexual and bisexual men than among gay men. For respiratory conditions, prevalence rates were very similar across sexual orientation groups. Bisexual men were slightly more likely to report fair or poor physical health in our bivariate analyses than either gay or heterosexual men. Gay and bisexual men were less likely than heterosexual men to report overweight BMI. The results of our logistic regression analyses are presented in Table 3. After adjusting for potential confounders, there were no significant differences between the 3 sexual orientation groups for reporting respiratory conditions, hypertension, or global physical health status. Differences in overweight BMI, however, remained significant after adjustment for covariates.
In the area of mental health, both gay and bisexual men reported markedly higher rates of mood and anxiety disorder compared to heterosexual men (Table 2). Gay and bisexual men were also more likely than heterosexual men to self-report their overall mental health as fair or poor. Moreover, both bisexual and gay men were much more likely than heterosexual men to report having ever seriously considered suicide in their lifetime. After adjustment for potential confounders (Table 3), differences in self-reported mental health were not significant; however, gay men were 3.1 times more likely and bisexual men 2.4 times more likely than heterosexual men to report a mood or anxiety disorder. Also after adjustment for potential confounders, gay men were 4.1 times more likely and bisexual men 6.3 times more likely than heterosexual men to report lifetime suicidality.
Health Risk Behaviours
In our bivariate analyses, unadjusted prevalence rates of daily smoking were slightly higher for gay and bisexual men than for heterosexual men, while prevalence rates of risky drinking were highest for bisexual men and lowest for gay men (Table 2). However, after adjusting for potential confounders, there were no statistically significant differences between the 3 groups for either daily smoking or risky drinking (Table 4). Gay and bisexual men had significantly higher reported rates of ever having been diagnosed with an STD compared to heterosexual men. After adjustment for potential confounders, the difference between gay men and heterosexual men was significant with gay men being 5.8 times more likely to have been diagnosed with an STD. There was no significant difference in STD history between bisexual and heterosexual men after adjustment.
This study represents the first opportunity to examine disparities for men of differing sexual orientations related to health status and health risks using a large Canadian population-based dataset. The findings of this study show evidence of significant differences in the health status and health behaviours of Canadian men of different sexual orientations.
In terms of physical health, and in contrast to some previous research, (1) gay and bisexual men did not report more respiratory conditions than heterosexual men. There was a clear difference between heterosexual men and sexual minority men with regard to BMI, with gay and bisexual men having lower rates of obesity and overweight BMI.
Our data provide evidence of poorer mental health among gay and bisexual men when compared to heterosexual men. In particular, both gay and bisexual men reported significantly higher prevalence of mood or anxiety disorders, and were significantly more likely to report a history of lifetime suicidality. These findings corroborate other evidence that gay and bisexual men report higher rates of anxiety and depression (2-5,7,9,17,25,26) and lifetime suicidality (4,7,9) than heterosexual men. Within this data set, gay men were four times more likely to have ever seriously considered suicide, and bisexual men reported a six-fold increase in risk for having ever seriously considered suicide compared to heterosexual men. These findings highlight the significant mental health disparities affecting bisexual men in particular.
In terms of health risk behaviours, gay and bisexual men in our study did not report higher rates of daily smoking or risky drinking. Several previous studies have reported higher rates of smoking for gay men. (1,11,12,14,15) The limited research that has included bisexual men when comparing rates of smoking has shown that bisexual men's smoking rates tend to be similar to those of heterosexual men. (14,15) Our findings appear to corroborate these studies on bisexual men's smoking rates, but show a different picture for gay men. Though some previous research has shown an increased risk for alcohol use among gay and bisexual men, (1,13,16,18) our findings appear to validate the majority of research in this area that reports no increase of risky drinking for gay and bisexual men. (1,3,5,11,17,27) Finally, our findings suggest that gay men have a dramatically elevated lifetime prevalence of STDs. These findings are consistent with much previous research. (21,22)
This study represents the largest population-based sample size (n>135,000) that has looked at sexual orientation and health risks and behaviours among men. Much of the previous research also problematically combined non-heterosexually identified men into one group. The CCHS design provides the necessary sample size to examine groups of self-identified gay and bisexual men separately.
The use of a single identity variable to measure sexual orientation is an important limitation to our study. As many as 24% of men who have sex with other men do not self-identify as gay or bisexual. (28) As a result, this question may obscure health disparities between men who have sex with men and others. Recent evidence suggests that those who do not self-identify as gay or bisexual but engage in same-sex activity are likely to be at highest risk for poor health outcomes. (26) Recent advances in methodology have suggested that in addition to the use of a sexual orientation identity variable, it is useful to measure sexual behaviour and, in some populations (such as youth), desire/attraction as well, in order to fully capture the experience of sexual minorities. (29)
This study's findings suggest that current Canadian health practice and policy are not ameliorating the effects of stigma and discrimination on the marginalization of gay and bisexual men. Further research is required to understand the mechanisms that influence these health disparities in order that effective interventions and policies to address these health disparities are developed and evaluated.
Acknowledgements: This research was supported by grants from the Institute of Gender and Health (IGH), Canadian Institutes of Health Research (CIHR 2005-11HOA-1988-721), the Fonds Quebecois de Recherche sur la Societe et la Culture (FQRSC 111796) awarded to the research team SVR (www.svr.uqam.ca) and a Janus Grant from the College of Family Physicians of Canada. Dr. Steele is funded as a career scientist by the Ontario Ministry of Health and Long-Term Care. Dr. Ross is supported as a New Investigator by the Canadian Institutes of Health Research and Ontario Women's Health Council (Award NOW-84656).
Received: August 6, 2009
Accepted: February 5, 2010
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David J. Brennan, PhD,  Lori E. Ross, PhD,  Cheryl Dobinson, MA,  Scott Veldhuizen, MA,  Leah S. Steele, MD, PhD 
[1.] Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON
[2.] Social Equity & Health Research Section, Centre for Addiction & Mental Health, Toronto, ON
[3.] Department of Family and Community Medicine, University of Toronto, Toronto, ON
Correspondence: Dr. David J. Brennan, Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, ON M5S 1A1, Tel: 416-978-3273, Fax: 416-978-7072, E-mail: firstname.lastname@example.org
Conflict of Interest: None to declare.
Table 1. Demographics by Sexual Orientation Heterosexual Men Mean/% 95% CI Age (mean yrs) 44.4 44.3-44.5 Immigrant (%) 21.9 21.3-22.5 < High school Education (%) 18.1 17.6-18.5 Annual household income ($CAD) $72,700 $71,700-$73,700 Currently working (%) 69.9 69.3-70.5 Gay Men Mean/% 95% CI Age (mean yrs) 39.9 38.4-41.4 Immigrant (%) 12.0 7.8-16.3 < High school Education (%) 7.7 4.9-10.6 Annual household income ($CAD) $69,100 $61,500-$76,600 Currently working (%) 72.7 67.8-77.7 Bisexual Men Mean/% 95% CI Age (mean yrs) 39.3 36.5-42.1 Immigrant (%) 18.6 11.1-26 < High school Education (%) 20.7 14.7-26.7 Annual household income ($CAD) $67,400 $26,200-$108,700 Currently working (%) 66.8 58.6-75.1 Note: 95% CI = 95% confidence interval Table 2. Unadjusted Prevalence Rates of Self-reported Health Status and Health Risk Behaviours by Sexual Orientation Heterosexual Men % 95% CI Respiratory condition 8.2 7.8-8.6 Hypertension 14.5 14.1-15.0 Physical health fair or poor 10.2 9.8-10.6 Overweight/Obese BMI 57.4 56.7-58.0 Mood or anxiety disorder 5.1 4.8-5.5 Mental health fair or poor 4.2 4.0-4.5 Life-time suicidality 7.4 6.8-7.9 Daily smoker 21.1 20.5-21.6 Risky drinking 13.3 12.7-13.8 Ever diagnosed with STD 5.4 5.0-5.8 Gay Men % 95% CI Respiratory condition 9.6 6.3-12.8 Hypertension 9.6 6.7-12.6 Physical health fair or poor 11.9 8.0-15.8 Overweight/Obese BMI 39.3 33.4-45.2 Mood or anxiety disorder 15.8 12.0-19.6 Mental health fair or poor 7.3 3.9-10.7 Life-time suicidality 25.2 14.6-35.8 Daily smoker 26.2 20.7-31.7 Risky drinking 11.1 7.1-15.1 Ever diagnosed with STD 26.6 19.4-33.7 Bisexual Men % 95% CI Respiratory condition 8.2 3.9-12.5 Hypertension 13.2 8.7-17.6 Physical health fair or poor 14.8 9.0-20.6 Overweight/Obese BMI 43.3 34.4-52.1 Mood or anxiety disorder 13.8 8.5-19.1 Mental health fair or poor 8.6 5.0-12.3 Life-time suicidality 34.8 13.6-56.0 Daily smoker 27.2 20.1-34.4 Risky drinking 16.3 9.3-23.3 Ever diagnosed with STD 9.4 3.3-15.5 Note: 95% CI = 95% confidence interval; BMI = Body Mass Index; STD = Sexually Transmitted Disease. Table 3. Health Status of Gay and Bisexual Men When Compared to Heterosexual Men Using Logistic Regression * Gay Men OR (95% CI) p-value Respiratory condition ([dagger]) 1.19 (0.80-1.77) 0.40 Hypertension ([double dagger]) 1.01 (0.72-1.43) 0.94 Physical health fair or poor 1.43 (0.96-2.14) 0.08 Overweight/Obese BMI 0.43 (0.33-0.56) <0.01 Mood or anxiety disorder 3.06 (2.20-4.25) <0.01 Mental health fair or poor 1.55 (0.85-2.82) 0.15 Life-time suicidality 4.13 (2.13-8.01) <0.01 Bisexual Men OR (95% CI) p-value Respiratory condition ([dagger]) 0.87 (0.47-1.59) 0.65 Hypertension ([double dagger]) 1.17 (0.72-1.89) 0.54 Physical health fair or poor 1.50 (0.95-2.36) 0.08 Overweight/Obese BMI 0.61 (0.40-0.93) 0.02 Mood or anxiety disorder 2.38 (1.45-3.90) <0.01 Mental health fair or poor 1.53 (0.91-2.59) 0.11 Life-time suicidality 6.32 (2.08-19.15) <0.01 * all regressions adjusted for age, immigration, education, household income, employment level. ([dagger]) also adjusted for smoking. ([double dagger]) also adjusted for BMI. OR = Odds Ratio; BMI = Body Mass Index; STD = Sexually Transmitted Disease Table 4. Health Behaviours of Gay and Bisexual Men When Compared to Heterosexual Men Using Logistic Regression Gay Men OR (95% CI) p-value Daily smoker 1.15 (0.86-1.54) 0.35 Risky drinking 0.71 (0.47-1.08) 0.11 Ever diagnosed with STD 5.80 (3.92-8.57) <0.01 Bisexual Men OR (95% CI) p-value Daily smoker 1.24 (0.86-1.80) 0.25 Risky drinking 1.27 (0.74-2.20) 0.38 Ever diagnosed with STD 2.19 (0.97-4.93) 0.06 OR = Odds Ratio
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|Author:||Brennan, David J.; Ross, Lori E.; Dobinson, Cheryl; Veldhuizen, Scott; Steele, Leah S.|
|Publication:||Canadian Journal of Public Health|
|Date:||May 1, 2010|
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