BY TRISH BENDIX
Among the myths about lesbian and bisexual women that have persisted over the years, few are as based in truth as that they tend to be more at risk for certain health issues. One of those has to do with their physical health, specifically their being at risk for Type 2 diabetes and obesity.
Heather L. Corliss, a professor at San Diego State University’s Graduate School of Public Health, has been working to make sense of why statistics prove this to be the case. In this month’s Diabetes Care, she (along with co-authors Nicole A. VanKim of the Department of Biostatistics and Epidemiology at the University of Massachusetts Amherst; Hee-Jin Jun of SDSU’s Graduate School of Public Health; S. Bryn Austin, Molin Wang and Frank B. Hu, all of the Brigham and Women’s Hospital; and Biling Hong of the Harvard T.H. Chan School of Public Health) published “Risk of Type 2 Diabetes Among Lesbian, Bisexual, and Heterosexual Women: Findings from the Nurses’ Health Study II,” which provided some statistics and context to research taken from over 100,000 women followed since 1989.
“The primary purpose of that cohort study was to sort of understand lifestyle factors that are associated with breast cancer risk, but then they’ve also expanded their focus to look at some chronic diseases more broadly,” Corliss tells INTO. “And then, in 1995, they were one of the few studies that added a question on sexual orientation.”
The NIH was heavily criticized by right-wing conservatives for its funding of the Harvard study in 2013. Most of them were outraged that the government was dedicating more than one million dollars to looking into why “lesbians are fat.” Those studies have provided the preliminary results that show that over a 24-year-time period, lesbian and bisexual women had a 27 percent higher risk of developing type 2 diabetes than heterosexual women. By 2013, 6,399 of the women who had been followed since 1989 had developed Type 2 diabetes, and lesbian and bisexual women bested heterosexual women by 22 percent. Lesbian and bisexual women also developed type 2 diabetes younger and were more prone to having a higher body mass index.
Corliss says that one study is not enough to make succinct conclusions and has plans for follow-ups, but what she does find that most suspected reasons for lesbian and bisexual women’s obesity and propensity for diabetes is due to minority stress. Looking at the women’s physical activity, sedentary behavior, and dietary patterns, as well as other behavioral factors, lesbian and bisexual women helped Corliss and her cohorts find that lesbian and bisexual women were more athletic and active than heterosexual women, and also reported better dietary intake.
“Lesbian and bisexual women are more likely to be in the work force and maybe more likely to be in professions that are contributing to sedentary behaviors, but that in itself is not enough to explain this increase for obesity,” Corliss says. “It might contribute a small proportion to obesity within the nurses health study II, it might contribute a small proportion to increase risk for Type 2 diabetes, but it’s not going to be the main factor right, so what else is going on?”
“We don’t really know,” she continues, “but we can draw on theory and we can draw on literature that really points to minority distress as potentially being an important contributor to this increase risk for obesity and increase risk for chronic disease associated with obesity such as Type 2 diabetes or cardiovascular disease.”
The American Psychological Association defines minority stress as “the relationship between minority and dominant values and resultant conflict with the social environment experienced by minority group members.”
“Our statistical analyses are indicating that it’s an important contributing factor, so I do think that sort of exposure to minority stress and the exposure to stressful situations, whether it be violence or maltreatment or discriminations, we are going to be uncovering evidence in the future,” Corliss says. “This is my hypothesis that that is going to be an important contributing factor to this disparity.”
That minority stress can lead lesbian and bisexual women to drink more heavily, become regular tobacco users, and other stress-related exposures including violence victimization and psychological distress. It is possible that within that subset, women of color, disabled women, and others who might be further marginalized have an even higher propensity for the behaviors that lead to major health conditions.
“There has definitely been a lot of research that has linked racism and disadvantaged social statuses based on race to increase risk for cardiovascular disease and diabetes, yes,” Corliss says. “There just hasn’t been studies that have looked at the specifically within lesbian and bisexual women with good methods; rigorous methods.”
Few studies conducted on women’s health have inquired about sexual orientation, which means there is a lack of data on how lesbian and bisexual women might differ from their heterosexual counterparts. Corliss, who began working on this study as an assistant professor at Harvard Medical School, says the lack of funding and interest in LB women makes it difficult to truly gage community-specific issues. The sample sizes are too small, and the findings are all-too-often provided from cross-sectional studies that don’t allow for additional information about a person, such as class, ethnicity, or region-based statistics.
“Part of it is that researchers in general are reluctant to add questions around sexual orientation to large cohort studies,” she says. “So the data sources are difficult to find. [Having that data] would allow us to investigate these questions and then starting a new cohort from scratch is extremely expensive and it’s not really identified as a priority by [National Institute of Health].”
In addition to asking these more probing questions, Corliss is working on a follow-up paper looking at the contributions of exposure to childhood maltreatment.
“Lesbian and bisexual women are more likely to report child abuse, and then also experience more severe forms of child abuse, child maltreatment,” she says. “Our follow-up paper is going to show that that contributes a little bit to increase risk for obesity in nurses health study II.”
Procuring the support needed for further research has not been easy, Corliss says. She’s been told by program officials at the National Institute of Diabetes and Digestive and Kidney Diseases that lesbian and bisexual women are not a priority.
“But I’m persistent,” she says. “I didn’t take no for an answer from the first program official so I searched around for maybe other program officials who might be more supportive and managed to find one to talk to who was more supportive, and she did say this isn’t something that NIDDK has been interested in or funded in the past but you know we are interested in health disparities and so it is something that you know please submit your grant and if it gets favorably reviewed, then I will support it.”
Corliss says that many gatekeepers find including new questions (such as sexual orientation) to studies as expensive, and also something that might contribute to participant burden (or the amount of time, energy, and vulnerability a participant is asked to contribute).
“You have to balance participant burden with sort of priorities and so researchers will prioritize what they think is most important, and they will put on questions on surveys that they found the research areas that they’re prioritizing,” Corliss says. “And so that’s why there’s then years and years and years and years and years of advocacy within the public health community to include sexual orientation and gender identity questions on these National Center for Health statistic surveillance mechanisms such as national health interview research survey and surveillance systems, youth risk behavior surveys.”
She notes that this kind of erasure is particularly great in conservative, Republican, and/or otherwise red states.
“So you definitely see a disparity in the generation of knowledge, and the generations of information. You hypothesize that LGBT people in these states may even have greater health disparities and greater burdens, but we’re not able to really determine that because data questions has been tampered,” Corliss says. “That’s changing, but it’s only because researchers and public health advocates have been advocating for this for many years.”
Corliss wants not only to shed light on the truth of health disparities and both qualify and quantify those, specifically for lesbian and bi women, but also to change the narrative that these women are more likely to be obese because of stereotypes that they care less about their bodies or physical health or appearances.
“Yes, there is greater disease burden in these populations; greater risk for mental health disorders, greater risk for physical health conditions,” she says. “And you know it is a population, a diverse population that experiences health disparities and that we should focus on that and we should try to figure out ways to refuse health disparities and these populations can improve health, but we also need to recognize that the majority of LGBTQ people are healthy and don’t have these negative health outcomes that we’re talking about, and that it’s a very strong, resilient population, or multiple populations.”
“And so we don’t want our discussion of greater disease burden to kind of further stigmatize or further marginalize these populations,” she continues. “We want to recognize there’s incredible strength and incredible resilience and we should harness those strength and resilience to improve our health, and so I think that researchers don’t want negative messages to further stigmatize populations. I want these messages to be information that we can use to further improve and empower these populations.”