In this issue of AJPH, Bender and Lauritsen (p. 318) use the National Crime Victimization Survey (NCVS) since it began including sexual orientation and gender identity data in 2017 to detail sobering ...findings about violence endured by sexual minorities in the United States. For example, compared with heterosexual women, gay and bisexual men and lesbian and bisexual women all had greater odds-ranging from 90% to 261% increased odds-of reporting violent victimization in the last six months, including serious crimes like sexual and physical assault. Such a clear, nationally representative picture of how the wicked problem of violence disproportionately burdens sexual minority communities has, heretofore, been largely elusive, although the study results are not entirely surprising.
Adverse childhood experiences (ACEs) are associated with several adulthood health problems, such as self-directed violence. For some individuals, enlistment in the military may be an instrumental act ...to escape adverse household environments; however, to our knowledge prevalence of ACEs among persons with a history of military service has not been documented in the United States using population-based data.
To compare the prevalence of ACEs among individuals with and without a history of military service.
Data are from the 2010 Behavioral Risk Factor Surveillance System. Computer-assisted telephone interviews were conducted with population-based samples of noninstitutionalized US adults from January 1 through December 31, 2010. Analyses were limited to respondents who received the ACE module (n = 60,598). Participants were categorized by history of military service and whether a respondent was 18 years of age in 1973.
History of military service was defined by active duty service, veteran status, or training for the Reserves or National Guard. The ACE inventory assessed 11 negative experiences before the age of 18 years. Weighted χ2 tests and multiple logistic regression analyses were used to examine differences in ACEs by history of military service, era of service, and sex.
Those with military experience had greater odds of any difference in prevalence of ACEs. In the all-volunteer era, men with military service had a higher prevalence of ACEs in all 11 categories than men without military service. Notably, in the all-volunteer era, men with military service had twice the odds of reporting forced sex before the age of 18 years (odds ratio, 2.19; 95% CI, 1.34-3.57) compared with men without military service. In the draft era, the only difference among men was household drug use, in which men with a history of military service had a significantly lower prevalence than men without a history of military service (2.1% vs. 3.3%; P = .003). Fewer differences were observed among women in the all-volunteer and draft eras.
Differences in ACEs by era and sex lend preliminary support that enlistment may serve as an escape from adversity for some individuals, at least among men. Further research is needed to understand how best to support service members and veterans who may have experienced ACEs.
Adverse childhood experiences portend vulnerability to numerous physical and mental health concerns across the lifespan. Separate bodies of work suggest that both lesbian, gay, bisexual, and queer ...individuals and military veterans are more likely to report adverse childhood experiences than their non−lesbian, gay, bisexual, and queer and non-veteran counterparts, respectively. Although lesbian, gay, bisexual, and queer veterans experience health disparities compared with non−lesbian, gay, bisexual, and queer veterans, the prevalence of adverse childhood experiences among individuals with both lesbian, gay, bisexual, and queer and veteran identities is yet unknown.
Participants were U.S. military veterans (N=14,461) from 18 states that included Sexual Orientation and Gender Identity and adverse childhood experiences modules in the 2019 and 2020 Behavioral Risk Factor Surveillance System survey. Multivariable logistic regression was used to determine the odds of adverse childhood experiences reported by lesbian, gay, bisexual, and queer veterans compared with those reported by non−lesbian, gay, bisexual, and queer veterans. Analyses were conducted in 2023.
While accounting for sociodemographic factors, lesbian, gay, bisexual, and queer veterans were more likely to report living with someone who experienced mental illness (AOR=2.17, 95% CI=1.35, 3.51), emotional abuse (AOR=1.58, 95% CI=1.11, 2.25), and sexual abuse (AOR=2.21, 95% CI=1.29, 3.76) than non−lesbian, gay, bisexual, and queer veterans.
With past work indicating that childhood abuse experiences are especially predictive of adverse health in adulthood, these findings suggest that a higher prevalence of adverse childhood experiences among lesbian, gay, bisexual, and queer veterans may contribute to health disparities among this population.
Disclosure of suicidal thoughts and behaviors represents an opportunity to intervene before suicide mortality, representing a cornerstone for suicide prevention. Sexual minority (e.g., lesbian/gay, ...bisexual) people experience sharply elevated suicide risk, yet there is scant research on patterns of disclosure of suicidal thoughts and behaviors before suicide that might uncover missed opportunities for suicide prevention. Thus, authors leveraged postmortem suicide data to evaluate associations among sexual orientation, sex, and disclosure of suicidal thoughts and behaviors in the month preceding death.
Data on suicides from the 2013-2019 National Violent Death Reporting System (N=155,516) were classified for sexual orientation and denoted disclosure of suicidal thoughts and behaviors and to whom suicidal thoughts and behaviors were disclosed in the month preceding death. Logistic regression models stratified by sex and adjusted for sociodemographic covariates assessed the associations between sexual orientation and suicidal thoughts and behaviors disclosure. Analyses were conducted from October 2022 to February 2023.
Among females, sexual minority decedents were 65% more likely to disclose suicidal thoughts and behaviors than heterosexual decedents (95% CI=37%, 99%, p<0.001). No difference in suicidal thoughts and behaviors disclosure was observed between sexual minority and heterosexual men. Of decedents who disclosed suicidal thoughts and behaviors, one in five sexual minority decedents disclosed to a friend/colleague, whereas fewer than 5% disclosed to a healthcare professional. Among sexual minority females, younger age, intimate partner problems, and physical health problems were positively associated with disclosing suicidal thoughts and behaviors.
These findings suggest that reducing suicide mortality in sexual minority populations will require considering contexts beyond the healthcare system, including engaging peer networks. Gatekeeper training for suicide prevention may be an especially promising approach for reducing suicide among sexual minority women.
Purpose
Social determinants of health (SDoH) refer to the conditions in the environments in which people live that affect health outcomes and risks. SDoH may provide proximal, actionable targets for ...interventions. This study examined how SDoH are associated with posttraumatic stress disorder (PTSD) and depression symptoms among Veterans and non-Veterans with probable PTSD or depression.
Methods
Four multiple regressions were conducted. Two multiple regressions with Veterans examined the impact of SDoH on PTSD symptoms and on depression symptoms. Two multiple regressions with non-Veterans examined the impact of SDoH on PTSD symptoms and on depression symptoms. Independent variables included demographic characteristics, adverse experiences (in childhood and adulthood), and SDoH (discrimination, education, employment, economic instability, homelessness, justice involvement, and social support). Correlates that were statistically significant (
p
< 0.05) and clinically meaningful (
r
part
>|0.10|) were interpreted.
Results
For Veterans, lower social support (
r
part
= − 0.14) and unemployment (
r
part
= 0.12) were associated with greater PTSD symptoms. Among non-Veterans, greater economic instability (
r
part
= 0.19) was associated with greater PTSD symptoms. In the depression models, lower social support (
r
part
= − 0.23) and greater economic instability (
r
part
= 0.12) were associated with greater depression for Veterans, while only lower social support was associated with greater depression for non-Veterans (
r
part
= − 0.14).
Conclusion
Among Veterans and non-Veterans with probable PTSD or depression, SDoH were associated with PTSD and depression symptoms, particularly social support, economic instability, and employment. Beyond direct treatment of mental health symptoms, addressing social support and economic factors such as instability and employment in the context of PTSD and depression are potential intervention targets that would benefit from future research.
To examine how sexual orientation change efforts (SOCE) are associated with suicide morbidity after controlling for adverse childhood experiences (ACEs).
Cross-sectional survey data are from the ...Generations survey, a nationally representative sample of 1518 nontransgender sexual minority adults recruited between March 28, 2016, and March 30, 2018, in the United States. Self-identified transgender individuals were included in a separate, related TransPop study. We used weighted multiple logistic regression analyses to assess the independent association of SOCE with suicidal ideation and suicide attempt while controlling for demographics and ACEs.
Approximately 7% experienced SOCE; of them, 80.8% reported SOCE from a religious leader. After adjusting for demographics and ACEs, sexual minorities exposed to SOCE had nearly twice the odds of lifetime suicidal ideation, 75% increased odds of planning to attempt suicide, and 88% increased odds of a suicide attempt with minor injury compared with sexual minorities who did not experience SOCE.
Over the lifetime, sexual minorities who experienced SOCE reported a higher prevalence of suicidal ideation and attempts than did sexual minorities who did not experience SOCE.
Evidence supports minimizing exposure of sexual minorities to SOCE and providing affirming care with SOCE-exposed sexual minorities. (
. Published online ahead of print May 21, 2020: e1-e7. doi:10.2105/AJPH.2020.305637).
Rising US suicide rates are particularly notable among military veterans, especially women. It is unknown whether these differences extend to suicidal ideation (SI) and suicide attempts (SA), which ...are major predictors of suicide. Literature comparing SI and SA prevalence and timing of onset between veterans and nonveterans is limited.
The objective of this study was to estimate and compare SI and SA prevalence and onset timing relative to age and military service between veterans and nonveterans, by gender.
Gender-stratified analysis of cross-sectional data from the Comparative Health Assessment Interview Study. Generalized estimating equations logistic regression was used to compare prevalence and onset of SI and SA between time periods and across groups, controlling for years at risk in each time period.
National sample of 15,082 post-9/11 veterans (36.7% women) and 4638 nonveterans (30.5% women).
Columbia-Suicide Severity Rating Scale adapted to assess SI and SA relative to age (less than 18 y, 18 y and above) and military service (pre-, during, and post-military).
Veteran men experienced significantly higher odds of lifetime SI compared with nonveteran men (odds ratio=1.13), whereas veteran women experienced significantly higher odds of lifetime SA compared with nonveteran women (odds ratio=1.35). SI and SA onset varied considerably for veterans and nonveterans and by gender within veteran groups.
Veterans and nonveterans appear to differ in periods of risk for SI and SA. Furthermore, gender differences in SI and SA onset for veterans highlight the need for gender-informed veteran suicide prevention strategies that target periods of highest risk.
Adverse childhood experiences (ACEs) are robustly associated with physical and mental health problems over the life span. Relatively limited research has examined the breadth of ACEs among military ...veteran populations, for whom ACEs may be premilitary traumas associated with suicidal ideation and attempt. Using data from the Comparative Health Assessment Interview Research Study, a large national survey sponsored by the U.S. Department of Veterans Affairs, this investigation examined the prevalence of 22 self-reported potentially traumatic experiences before the age of 18 (i.e., ACEs) among veterans and nonveterans and estimated the association of ACEs with suicidal ideation and attempt at age 18 or older. All analyses were weighted to account for complex sampling design and stratified by gender. The study sample included 9,571 veteran men, 3,143 nonveteran men, 5,543 veteran women, and 1,364 nonveteran women. Veteran men reported greater average frequency of ACEs than nonveteran men (2.7 ACEs vs. 2.3 ACEs, respectively, p < .001); 11.1% of veteran men indicated >6 ACEs compared with 7.3% of nonveteran men (p < .001). Veteran women reported greater average frequency of ACEs than nonveteran women (3.1 ACEs vs. 2.4 ACEs, respectively, p < .001). Among women, more veterans than nonveterans reported >6 ACEs (14.9% vs. 8.6%, respectively, p < .001). The strongest correlate of suicide attempt at age 18 or older for veteran men was having >6 ACEs (adjusted odds ratio, aOR = 4.20, 95%CI = 2.72-6.49); for veteran women, the strongest correlate was suicidal ideation or attempt before age 18 (aOR = 5.37, 95%CI = 4.11-7.03). Suicide prevention research, policy, and practice should address ACEs among veterans as salient premilitary risk factors.
Public Significance Statement
Study results showed that post-9/11 military veterans are more likely to report adverse childhood experiences (ACEs) than nonveterans. After accounting for demographic factors and suicidal thoughts and behaviors before age 18, ACEs were strongly associated with suicidal thoughts and behaviors after age 18 among veterans. Suicide prevention for veterans is a national priority and must attend to premilitary trauma as a significant risk factor.
Transgender individuals have greater health risks than cisgender individuals, which may bode for greater mortality. However, research is limited by lack of gender identity information at the time of ...death. Novel opportunities to combine administrative data with National Death Index (NDI) data may facilitate mortality research about transgender populations, but binary measures of sex and gender may pose problems for analyses. This study explored differences in sex recorded in Veterans Health Administration (VHA) electronic health record (EHR) and NDI data between transgender and cisgender decedents.
We used VHA EHR data from fiscal years 2000-2016 to identify deaths among a sample of transgender and cisgender patients. We cross-tabulated sex recorded in the NDI with EHR-based sex from VHA EHR data. We extracted data in 2018 and conducted analyses in 2020.
Death occurred for 1109 transgender patients and 7757 cisgender patients. For cisgender decedents, EHR-based sex and NDI-based sex were 100% concordant. For transgender decedents, 46 (4%) were discordant between data sources. Of transgender decedents with female EHR-based sex (n = 259), 17% were indicated as male in NDI data; of those with male EHR-based sex (n = 850), 0.2% were indicated as female in NDI data.
Data linkage between EHR and the NDI can facilitate transgender mortality research, but examining mortality specific to various transgender identities remains difficult. Improved documentation of sex and gender is needed within US mortality surveillance.
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