Almost no public health research has examined the differences in risk behavior or health outcomes between urban and suburban/rural LGBT populations. Furthermore, few studies explore the interaction between sexual orientation, sexual behavior, gender identity and membership in other groups at higher risk for morbidity and mortality (e.g., being a racial minority or belonging to a low income group). Nonetheless, a growing body of research has made clear that LGBT people are disproportionately affected by a number of health problems. This literature has been well summarized elsewhere (Dean, et al., 2000), and a comprehensive review of these issues is beyond the scope of this chapter. However, knowledge and understanding of these health issues, which are certainly more concentrated in cities with large LGBT populations, are critical for planning effective urban health strategies and interventions. Some LGBT health problems are the result of unique exposures to risks related to sexual behavior, but many appear to be related to social conditions characterized by prejudice, stigmatization and discrimination (Meyer, 2001).
Of those health problems related directly to sexual behavior, HIV is currently the one most closely identified with the gay community, though it was foreshadowed by hepatitis B. The clinical and epidemiological evidence that hepatitis B was prevalent among gay men resulted in landmark hepatitis B vaccine trials in New York City in the late 70's and early 80's (Dienstag, et al., 1982; Stevens and Taylor, 1986; Szmuness, et al., 1980; Szmuness, et al., 1981). Ironically, an epidemiological study tracking the incidence of gay hepatitis B among gay men in three gay urban areas (San Francisco, New York, and Amsterdam) provided some of the earliest evidence about the emergence and progression of HIV (Hessol, et al., 1994; Van Griensven, et al., 1993). HIV has profoundly affected the LGBT community, both in terms of the unprecedented loss of community members and in terms of the community mobilization and institution-building it engendered. Despite advances in treatment and a broad-based change in community norms governing sexual behavior, HIV remains a serious threat to the health of men who have sex with men. Almost 60% of all cases of HIV among men are due to exposure through sex with other men (CDC, 2003). In addition to HIV, men who have sex with men are at increased risk for other sexually transmitted infections (STIs), including viral hepatitis (Dean, et al., 2000; Schreeder, et al., 1982). Some communities, in fact, are reporting recent increases incidence of other STIs among MSM (CDC, 1997; 1999a; 1999b; 2001; 2001a; 2002b). The impact of HIV and other STIs on lesbians and bisexual women remains under-researched, although most studies suggest a higher HIV sero-prevalance among women who have sex with women compared to heterosexual women (Office on Women's Health, 2000). While female-to-female transmission of HIV is a biological possibility, transmission is more likely a result of injecting drug use and/or sex with men (Young, et al., 1992). HPV, bacterial vaginosis and candidiasis do occur in lesbians and can be transmitted between women; in general, however, lesbians appear to be at less risk for STIs than any other sexually active group (Dean, et al., 2000).
Some preliminary studies have suggested that gay men and lesbians may be at increased risk for certain types of cancer (Dean, et al., 2000), though the reasons for these elevated risks are generally due to variables other than sexual behavior. For instance, the higher incidence of breast cancer among lesbians is likely attributable to increased rates of obesity, alcohol consumption, nulliparity and smoking and lower rates of breast cancer screening, gynecological care, and hormone exposure through oral contraceptives (Dean, et al., 2000; Office on Women's Health, 2000). Lesbians are also less likely than heterosexual women to have a Pap test (Aaron, et al., 2001), although no studies have documented higher rates of cervical cancer. Studies have found higher rates of Kaposi's sarcoma, non-Hodgkins lymphoma, Hodgkin's disease, and anal cancer among gay men, but all of these, except anal cancer, have been attributed to increased incidence of HIV/AIDS (Dean, et al., 2000; Hessol, et al., 1992; Katz, et al., 1994; Koblin, et al., 1996; Lifson, et al., 1990).
A number of the unique health problems facing LGBT people are related to anti-gay social and cultural forces. Anti-gay violence is perhaps the clearest example. Data on the prevalence of anti-gay hate crimes are scarce, but one report examining hate crimes generally concluded that lesbians and gay men are probably the most frequent victims (Finn and McNeil, 1987). The latest report by the National Coalition of Anti-Violence Programs, which reports hate crimes from 11 cities, shows a continuing rise of hate crimes against LGBT people (Patton, 2004), and a recent study of young urban gay and bisexual men found that 37% had experienced anti-gay verbal harassment and 4.8% reported physical violence in the past six months (Huebner, et al., 2004). Obtaining accurate numbers of hate-motivated violence is complicated by the reluctance of many LGBT people to report incidents and/or disclose their sexual orientation to the police - a reluctance based on a history of police harassment and violence towards LGBT people. One review article concluded that between 16-30% of LGBT hate-crime victims has been victimized by the police (Berrill, 1992).
Intimate partner violence and sexual assault are also health concerns for LGBT people (Burke and Follingstad, 1999). Although empirical evidence is limited, one probability sample of urban MSM found that 22% had experienced physical abuse (Greenwood, et al., 2002), while studies of lesbians have found rates slightly lower than those found for heterosexual women (Dean, et al., 2000). Lifetime prevalence of attempted and completed rape among lesbians is comparable to that among heterosexual women, but gay men appear to be at elevated risk for sexual abuse and assault (Dean, et al., 2000). Fears about homophobic reactions and laws and service systems that presume heterosexuality make it especially difficult for LGBT victims to seek legal assistance, medical treatment, emergency shelter, and support services (Dean, et al., 2000). Clearly, hate crimes and experiences of intimate partner violence and/or sexual assault are likely to place individuals at greater risk for HIV and other STIs as well as impact their emotional and mental health.
Sexual orientation is not intrinsically linked to mental health problems; however, stigma, homophobia, and prejudice may negatively impact the mental health of LGBT individuals (Meyer, 2003). Furthermore, estrangement from family members, adjusting to a LGBT identity, lack of support for relationships and families may be additional stressors. Unfortunately, population-based estimates of prevalence of mental disorders among LGBT people are lacking (Dean, et al., 2000). The few probability based studies that have been done found higher rates of depression, panic attacks syndrome, and psychological distress among MSM (Cochran and Mays, 2000; Cochran, et al., 2003; Mills, et al., 2004), especially among those who had experienced anti-gay harassment (Mills, et al., 2004). Lesbian and bisexual women appear to have higher prevalence of general anxiety disorder compared to heterosexual women (Cochran, et al., 2003). HIV (Bing, et al., 2001; Dickey, et al., 1999) as well as the stress of caring for and losing loved ones to HIV (Sikkema, et al., 2003) have been associated with depressive symptoms and other mental health problems. Others studies found that sexual orientation is a significant predictor of eating disorders among men, though not among women (Dean, et al., 2000). Finally, researchers have found elevated rates of suicidal ideation and attempts, but not completed suicides, among LGB people (Dean, et al., 2000; Matthews, et al., 2002).
In a review of the literature, the Center for Substance Abuse Treatment concluded that "gay men and lesbians were heavier substance and alcohol users than the general populations" (Center for Substance Abuse Treatment, 2001). Although many studies conducted in the past were perceived as biased because they recruited subjects from clubs and bars, some studies with less problematic samples support the finding that LGB people use drugs at higher rates than heterosexuals (Cochran and Mays, 2000; Stall, et al., 2001; Stall and Wiley, 1988; Woody, et al, 2001). A number of studies have also suggested that both gay men and lesbians use tobacco at much higher rates than the national average (Dean, et al., 2000; Office on Women's Health, 2000). Increased rates of substance use adversely impact the health of LGBT people in myriad ways, including interactions with HIV medications and increasing rates of unsafe sexual behavior (Center for Substance Abuse Treatment, 2001; Dean, et al., 2000).
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With all the stresses and strains of modern living, panic attacks are become a common problem for many people. Panic attacks occur when the pressure we are living under starts to creep up and overwhelm us. Often it's a result of running on the treadmill of life and forgetting to watch the signs and symptoms of the effects of excessive stress on our bodies. Thankfully panic attacks are very treatable. Often it is just a matter of learning to recognize the symptoms and learn simple but effective techniques that help you release yourself from the crippling effects a panic attack can bring.