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Indoor Tanning among Sexual and Gender Minority Adolescents and Adults: Results from the 2020 Pennsylvania LGBT Health Needs Assessment

Indoor Tanning among Sexual and Gender Minority Adolescents and Adults: Results from the 2020... Hindawi Journal of Skin Cancer Volume 2023, Article ID 3953951, 6 pages https://doi.org/10.1155/2023/3953951 Research Article Indoor Tanning among Sexual and Gender Minority Adolescents and Adults: Results from the 2020 Pennsylvania LGBT Health Needs Assessment 1 2 Christopher W. Wheldon and Joshua Zhi Hao Spradau Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia, PA, USA College of Science and Technology, Temple University, Philadelphia, PA, USA Correspondence should be addressed to Christopher W. Wheldon; chris.wheldon@temple.edu Received 17 February 2023; Revised 25 April 2023; Accepted 4 May 2023; Published 17 May 2023 Academic Editor: Eugenio Vocaturo Copyright © 2023 Christopher W. Wheldon and Joshua Zhi Hao Spradau. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Sexual and gender minority (SGM) populations include individuals whose sexual orientation, gender identity, or reproductive development is characterized by nonbinary sexual constructs (e.g., lesbian, gay, bisexual, and transgender (LGBT) individuals). Previous research suggests that some SGM populations have higher rates of skin cancer. Te purpose of this study was to assess the association of diverse SGM identities with indoor tanning, a risk factor for skin cancer, while exploring other relevant co- occurring risk factors. A secondary analysis was performed on the 2020 LGBT Health Needs Assessment collected by the Pennsylvania Department of Health. Measures included sexual orientation, gender identity, healthcare utilization, and cancer risk factors. Cisgender SGM men are more likely to use indoor tanning devices (adjusted odds ratio (aOR) � 1.79; 95% CI: 1.31–2.44) compared to other SGM subpopulations independent of sexual orientation. Indoor tanning was also associated with alcohol (aOR � 1.94; 95% CI: 1.50–2.51) and tobacco use (aOR � 1.64; 95% CI: 1.21–2.21). Findings suggest that targeted screening for skin cancer risk behaviors could accompany standard tobacco and alcohol screenings in clinical practice. basal cell carcinomas were attributable to excess UV radi- 1. Introduction ation exposure [6]. Indoor tanning devices expose users to Sexual and gender minority (SGM) populations include high doses of radiation, making them dangerous enough that individuals whose sexual orientation, gender identity, or they are classifed as a group I carcinogen [7]. Studies have reproductive development is characterized by nonbinary shown that SGM males were 2.9–5.8 times more likely to sexual constructs (e.g., lesbian, gay, bisexual, and trans- have tanned indoors when compared to heterosexual males. gender (LGBT) individuals) [1]. SGM populations have been Past studies found no diference in other UV-related risk shown to have an increased risk of developing certain types factors between SGM samples and the general population, including outdoor sun exposure and infrequent sunscreen of cancer compared to heterosexual and cisgender in- dividuals [2]. Among these, skin cancer is of particular use [3]. Tus, it is likely that the use of indoor tanning concern, as studies suggest that lifetime risk of skin cancer devices contributes to the skin cancer disparity between was 1.3–2.1 times higher among SGM males when compared these groups [4, 5]. to heterosexual males [3–5]. Existing behavioral research focused on the use of indoor Tanning behaviors, particularly the use of indoor tan- tanning devices in SGM populations is limited. In these ning devices, are a likely contributing factor to skin cancer studies, either gender was measured as a binary variable disparities. A past meta-analysis found that almost 90% of all confating sex at birth and gender identity or SGM sub- melanomas, 85% of squamous cell carcinomas, and 82% of groups were aggregated into one group, concealing 2 Journal of Skin Cancer variations across sexual and gender identities. SGM pop- including spray-on tans, during the past 12 months, how ulations are heterogenous, and there are likely important many times have you used an indoor tanning device such as psychosocial diferences across SGM subgroups related to a sunlamp, tanning bed, or booth?” Responses were di- the use of indoor tanning devices. Appearance-based mo- chotomized to refect any past 12-month indoor tanning. tivations have been found to be particularly important in Participants were also asked the following question about cisgender gay and bisexual men, but this research was not their history of skin cancer: “At any time in your life, have diverse with regard to gender and sexual identities [8]. you received a skin cancer diagnosis?” Te response options Problem behavior theory (PBT) posits that risk behav- were “Yes” or “No.” iors cluster because of latent personality characteristics that enable the behaviors, which are reinforced in the social 2.1.2. Sexual Orientation and Gender Identity (SOGI). environment [9]. Personality factors, such as sensation Current gender was determined using both sex at birth and seeking and low inhibitory control, were associated with current gender identity; for example, male sex at birth and binge drinking and tobacco use in cisgender SGM men in current female was coded as transgender female and male previous research [10–12]. Based on PBT, we would expect sex at birth and current man was coded as cisgender male. that skin cancer risk behaviors, such as the use of indoor Te response options for sex at birth were “Male” and tanning devices, would correlate with other cancer risk “Female,” and the response options for current gender behaviors found to be prevalent in SGM populations (e.g., identity included the following: “Man,” “Woman,” “Gen- tobacco and alcohol use); however, co-occurring cancer risk derqueer,” “Nonbinary,” “Genderfuid,” and “Another behaviors were not considered in previous studies on indoor gender.” Tose who selected the last option were asked to fll tanning in SGM populations [5, 13, 14]. in the blank to specify their gender identity. Te Surgeon General’s Call to Action to Prevent Skin Participants were asked, “Which of the following best Cancer was released in 2014, which outlined fve strategic describes your sexual orientation?” Te response options objectives for preventing skin cancer [15]. Among these, one were “Bisexual,” “Gay,” “Lesbian,” “Pansexual,” “Asexual,” was to equip individuals with the necessary knowledge to “Demisexual,” “Queer,” or “Another sexual orientation.” make informed and healthy decisions about their exposure Due to low cell sizes, “Asexual” and “Demisexual” were to UV rays. A national study of the U.S. primary care combined into the same category with “Another sexual providers found that over a quarter regularly counseled their orientation.” patients on indoor tanning [16]. Given that SGM pop- ulations face barriers to accessing primary care [17], the role of primary care in ameliorating skin cancer disparities is 2.1.3. Cancer Risk Behaviors. Current smoking was assessed signifcant. with a single item: “How often do you currently smoke Te purpose of this study was to assess the use of indoor cigarettes?” Responses were dichotomized as “not at all” tanning devices among a heterogenous sample of SGM compared to “some days” or “every day.” Binge drinking was adolescents and adults. We sought to answer the following assessed with a single item: “In the past 30 days, how often research questions: (RQ1) Which SGM subgroups were did you drink 5 or more alcoholic drinks in a day? (One most likely to use indoor tanning devices? (RQ2) How was drink is equivalent to a 12-ounce beer, a 5-ounce glass of healthcare utilization associated with the use of indoor wine, or a drink with one shot of liquor).” Responses were tanning devices? (RQ3) What was the association of cancer dichotomized as “never” compared to those reporting binge risk behaviors with the use of indoor tanning devices? drinking at least once in the past 30 days. 2. Methods 2.1.4. Sociodemographics. Demographic measures included current age in years, Hispanic or Latin ethnicity (no versus Tis was a secondary analysis of the 2020 LGBT Health yes), race (“White,” “Black/African American,” “Asian,” Needs Assessment collected by the Pennsylvania De- “American Indian, Native American, or Alaskan native,” partment of Health [18]. Respondents were SGM residents “Pacifc Islander,” or “Another race”), and educational at- of Pennsylvania aged thirteen and older. Tey were recruited tainment. Participants also reported their county of resi- through a nonprobability community-based approach. Re- dence, which was used to classify them as rural or urban cruitment materials were distributed in English and Spanish based on the Center for Rural Pennsylvania’s defnition of by community organizations over a wide range of platforms, population density. including e-mail, mailed postcards, websites, mobile phone applications, and social media. Te 15-minute questionnaire was available in both Spanish and English. Inclusion criteria 2.2. Analyses. All analyses were conducted in SAS 9.4 (SAS included responding yes to “Do you identify as LGBTQ?” Institute, Cary, NC). Bivariate diferences were examined and “Do you live in Pennsylvania?” using chi-square test of independence. Te following four hierarchical logistic regression models were estimated: un- adjusted (model 1), demographics and SOGI (model 2), 2.1. Measures healthcare utilization (model 3), and the full model with the addition of cancer risk factors (model 4). Adjusted odds 2.1.1. Indoor Tanning and Skin Cancer History. Indoor tanning use was measured with the following item: “Not ratios with 95% confdence intervals were reported as the Journal of Skin Cancer 3 measure of association. List wise deletion was used for men is not inclusive enough. A growing percentage of SGM missing data on predictor variables (<2% for any given youth is identifed as pansexual (along with other identity labels) [21]. In this study, gender was predictive of indoor variable). Missing data resulted from participants exiting the survey before reaching the end and did not appear to be tanning regardless of sexual identity (e.g., gay, bisexual, systematic for any one variable. pansexual, or other) with one exception (e.g., queer). Queer identifed persons in this study were less likely to use indoor tanning devices. Future research should attempt to recruit 3. Results cisgender males with diverse sexual identities to help elu- Characteristics of the study sample are described in Table 1 cidate these diferences. (N � 5,192). Overall, 2.8% (n � 143) of participants had Recent binge drinking and tobacco use were also found a previous skin cancer diagnosis. Past year indoor tanning to have a positive and independent association with indoor was reported by 5.5% (n � 286) of participants with the usage tanning. Tese fndings support propositions from the rate by cisgender men being 9.5% (n � 4906). Bivariate Problem Behavior Teory [13, 14] and align with evidence correlates of indoor tanning were age, sexual identity, from qualitative research that demonstrated how the social gender, binge drinking, and tobacco use (Table 1). environment promotes tanning behaviors for many cis- Tere were minimal diferences in the unadjusted and gender SGM men [8]. It also provides an opportunity for adjusted models (Table 2). In the unadjusted models, all interventions. Addressing multiple risk factors simulta- sexual identities were negatively associated with indoor neously has long been shown to be more efective than tanning when compared to gay/lesbian; however, only queer addressing any one alone, since individuals participating in identity (aOR � 0.39; 95% CI: 0.19–0.79) and being a trans- a given category of risky behaviors are likely to be partici- gender woman (aOR � 0.29; 95% CI: 0.11–0.82) remained pating in other risky behaviors as well [22]. Future research signifcant in the fully adjusted model. Black race should investigate the specifc intra- and interpersonal de- (aOR � 0.35; 95% CI: 0.14–0.88) and being <18 years old terminants of indoor tanning among cisgender SGM men (aOR � 0.33; 95% CI: 0.13–0.85) were also negatively asso- across diverse sexual identities. ciated with indoor tanning in the adjusted models. After adjusting for all variables, the following were independently associated with indoor tanning: cisgender men (aOR � 1.79; 4.1. Implications. Overall, these fndings suggest important 95% CI: 1.31–2.44), binge drinking (aOR � 1.94; 95% CI: implications for future intervention research. First, cis- 1.50–2.51), and tobacco use (aOR � 1.64; 95% CI: 1.21–2.21). gender SGM males (inclusive of diverse sexual identities) Of note, the transgender male demographic was not asso- should be targeted for intervention. Second, the null fndings ciated with indoor tanning. regarding healthcare utilization and prior skin cancer di- agnosis suggest that patient-provider discussion regarding skin cancer prevention can be strengthened. Future research 4. Discussion should determine if physicians are discussing the risks from Cisgender men showed the greatest prevalence of indoor indoor tanning devices with SGM patients and ways to tanning independent of sexual identity (RQ1), while indoor improve SGM culturally responsive skin cancer risk com- tanning was otherwise equivalent across sexual and gender munication. Lastly, given the association of indoor tanning identities with a few exceptions: queer-identifed, nonbinary with alcohol and tobacco use behaviors, physicians should individuals, and transgender women were less likely to have consider screening for indoor tanning along with these other used an indoor tanning device. Black respondents and those risk behaviors—particularly among SGM men. Focusing on less than eighteen years of age were also less likely to have co-occuring risk behaviors is especially important consid- tanned indoors in the adjusted models. Tese fndings add to ering that alcohol and tobacco screenings are already existing research in a few important ways. standard in clinical practice and these behaviors are asso- Participnts aged eighteen and younger had far lower ciated with indoor tanning in this study and in the general rates of indoor tanning, suggesting that legal age restrictions population [23]. may have their intended efects. In Pennsylvania, indoor tanning is prohibited for youth sixteen years and younger 4.2. Limitations. Tis study is limited in which the partic- and parental consent is required for those seventeen years of age [19, 20]. Implementing this type of legislation in other ipants were recruited through nonprobability community- based sampling. Data were also self-reported, and a single states may help to reduce the use of indoor tanning devices among SGM youth more broadly. measure of indoor tanning was used. As participants resided in Pennsylvania, results may not apply to the residents of Te strong and independent association of cisgender male identity and indoor tanning device not only supports other states. Also, measures of risk behaviors, personality, a targeted focus on this group for prevention [3] but also and social environment were limited given that this was suggests that limiting inclusion to gay or bisexual identifed a secondary analysis of existing data. 4 Journal of Skin Cancer Table 1: Sample characteristics stratifed by sun protective behaviors (N � 5,192). Stratifed by indoor Chi-square test of tanning Variable Total sample N (%) diference p value % Yes % No Total 5.5 94.5 Demographics Age <0.01 13–18 451 (8.9) 2.0 98.0 18–29 1778 (34.2) 4.6 95.4 30–40 1238 (23.8) 7.2 92.8 40+ 1725 (33.2) 6.1 93.9 County 0.50 Urban 4193 (81.8) 5.3 94.7 Rural 936 (18.2) 5.9 94.1 Race 0.08 White 4413 (85.4) 5.6 94.4 Black/African American 210 (4.1) 2.4 97.6 Asian 92 (1.8) 2.2 97.8 Another race 455 (8.8) 6.5 9.5 Hispanic 0.37 No 4841 (93.4) 5.4 94.6 Yes 343 (6.6) 6.6 93.5 Education level 0.25 Less than college 2389 (46.1) 5.1 94.9 College or higher 2792 (53.9) 5.8 94.2 SOGI Sex at birth <0.01 Female 2831 (54.7) 3.4 96.6 Male 2347 (45.3) 8.1 91.9 Sexual orientation <0.01 Gay/lesbian 2777 (53.6) 7.2 92.8 Bisexual 1017 (19.6) 4.9 95.1 Pansexual 468 (9.0) 3.9 96.1 Queer 575 (11.1) 1.6 98.4 Another sexual orientation 347 (6.7) 2.3 97.7 Current gender <0.01 Cisgender man 1874 (36.1) 9.5 90.5 Cisgender woman 1802 (34.7) 4.2 95.8 Transgender woman 293 (5.7) 2.1 97.9 Transgender man 338 (6.5) 2.7 97.3 Nonbinary 882 (17.0) 1.9 98.1 Healthcare utilization Usual place of care 0.45 Yes 4219 (81.6) 5.4 94.6 No 954 (18.4) 6.0 94.0 Cancer risk Binge drinking (past 30 days) <0.01 Yes 1789 (34.6) 8.9 91.1 No 3387 (65.4) 3.7 96.3 Tobacco cigarette user <0.01 Yes 751 (14.5) 9.7 90.3 No 4439 (85.5) 4.8 95.2 Cancer history Previous skin cancer diagnosis 0.12 Yes 143 (2.8) 8.4 91.6 No 5027 (97.2) 5.4 94.6 Note. SOGI: sexual orientation and gender identity. Tere were minimal amounts of missing data so not all frequencies add up to 5,192. Bolded values are statistically signifcant, p< 0.05. Journal of Skin Cancer 5 Table 2: Correlates of tanning bed use among sexual and gender minority adolescents and adults (N � 5,034). Tanning bed use Model 4 Model 1 Model 2 Model 3 Variable (demographics + SOGI + (unadjusted) OR (demographics + SOGI) (demographics + SOGI + healthcare + cancer risk) (95% CI) aOR (95% CI) healthcare) aOR (95% CI) aOR (95% CI) Demographics Age 13–18 0.19 (0.08, 0.46) 0.28 (0.11, 0.71) 0.27 (0.11, 0.70) 0.33 (0.13, 0.85) 18–29 0.77 (0.57, 1.03) 1.07 (0.78, 1.48) 1.04 (0.75, 1.44) 0.94 (0.67, 1.31) 30–40 1.18 (0.88, 1.59) 1.46 (1.07, 1.98) 1.42 (1.04, 1.94) 1.27 (0.92, 1.75) 40+ 1.00 1.00 1.00 1.00 County Urban 0.89 (0.66, 1.20) 0.86 (0.63, 1.18) 0.86 (0.63, 1.18) 0.86 (0.62, 1.18) Rural 1.00 1.00 1.00 1.00 Race White 1.00 1.00 1.00 1.00 Black/African 0.44 (0.18, 1.07) 0.38 (0.16, 0.95) 0.38 (0.15, 0.94) 0.35 (0.14, 0.88) American Asian 0.40 (0.10–1.61) 0.40 (0.10, 1.66) 0.40 (0.10, 1.66) 0.46 (0.11, 1.90) Another race 1.13 (0.75, 1.70) 1.19 (0.71, 2.01) 1.18 (0.70, 1.98) 1.15 (0.68, 1.94) Hispanic No 1.00 1.00 1.00 1.00 Yes 1.31 (0.83, 2.05) 1.14 (0.65, 2.02) 1.14 (0.65, 2.00) 1.12 (0.64, 1.97) Education level Less than college 1.00 1.00 1.00 1.00 College or higher 1.12 (0.88, 1.43) 0.91 (0.70, 1.18) 0.91 (0.70, 1.19) 0.97 (0.74, 1.26) SOGI Sexual orientation Gay/lesbian 1.00 1.00 1.00 1.00 Bisexual 0.68 (0.50, 0.94) 1.07 (0.75, 1.52) 1.06 (0.74, 1.51) 1.08 (0.76, 1.55) Pansexual 0.44 (0.26, 0.75) 0.88 (0.49, 1.59) 0.89 (0.50, 1.59) 0.88 (0.49, 1.56) Queer 0.21 (0.11, 0.41) 0.40 (0.20, 0.83) 0.40 (0.19, 0.82) 0.39 (0.19, 0.81) Other 0.28 (0.13, 0.59) 0.62 (0.27, 1.41) 0.62 (0.27, 1.41) 0.69 (0.30, 1.57) Current gender Cisgender man 2.31 (1.71, 3.05) 2.05 (1.51, 2.79) 2.05 (1.51, 2.79) 1.81 (1.32, 2.47) Cisgender woman 1.00 1.00 1.00 1.00 Transgender 0.32 (0.12, 0.88) 0.30 (0.11, 0.83) 0.30 (0.11, 0.83) 0.29 (0.11, 0.82) woman Transgender man 0.61 (0.30, 1.23) 0.78 (0.38, 1.64) 0.80 (0.38, 1.66) 0.78 (0.37, 1.65) Nonbinary 0.40 (0.23, 0.70) 0.52 (0.29, 0.93) 0.51 (0.29, 0.93) 0.51 (0.28, 0.92) Healthcare utilization Usual place of care Yes 0.89 (0.66, 1.21) 0.85 (0.61, 1.17) 0.92 (0.67, 1.28) No 1.00 1.00 1.00 Cancer risk Binge drinking (past 30 days) Yes 2.44 (1.91, 3.12) 1.93 (1.49, 2.50) No 1.00 1.00 Tobacco cigarette user Yes 2.11 (1.59, 2.81) 1.67 (1.23, 2.25) No 1.00 1.00 Cancer history Any previous cancer diagnosis Yes 1.42 (0.91, 2.21) 1.21 (0.63, 2.32) No 1.00 1.00 Previous skin cancer diagnosis Yes 1.53 (0.81, 2.86) 1.09 (0.48, 2.49) No 1.00 1.00 Note. OR: odds ratio; aOR: adjusted odds ratio; SOGI: sexual orientation and gender identity. Bolded values are statistically signifcant, p< 0.05. 6 Journal of Skin Cancer tanning,” British Journal of Dermatology, vol. 180, no. 6, 5. Conclusions pp. 1529-1530, 2019. [9] R. Jessor, “Problem behavior theory: a half-century of research Cisgender SGM men are more likely to use indoor tanning on adolescent behavior and development,” in Te De- devices compared to other SGM subpopulations. Because velopmental Science of Adolescence: History through Autobi- indoor tanning is associated with alcohol and tobacco use, ography, pp. 239–256, Psychology Press, London, UK, 2014. screening for skin cancer risk behaviors should accompany [10] C. F. Wong, M. D. Kipke, and G. Weiss, “Risk factors for standard tobacco and alcohol screenings in clinical alcohol use, frequent use, and binge drinking among young practice. men who have sex with men,” Addictive Behaviors, vol. 33, no. 8, pp. 1012–1020, 2008. 6. 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Indoor Tanning among Sexual and Gender Minority Adolescents and Adults: Results from the 2020 Pennsylvania LGBT Health Needs Assessment

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Hindawi Journal of Skin Cancer Volume 2023, Article ID 3953951, 6 pages https://doi.org/10.1155/2023/3953951 Research Article Indoor Tanning among Sexual and Gender Minority Adolescents and Adults: Results from the 2020 Pennsylvania LGBT Health Needs Assessment 1 2 Christopher W. Wheldon and Joshua Zhi Hao Spradau Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia, PA, USA College of Science and Technology, Temple University, Philadelphia, PA, USA Correspondence should be addressed to Christopher W. Wheldon; chris.wheldon@temple.edu Received 17 February 2023; Revised 25 April 2023; Accepted 4 May 2023; Published 17 May 2023 Academic Editor: Eugenio Vocaturo Copyright © 2023 Christopher W. Wheldon and Joshua Zhi Hao Spradau. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Sexual and gender minority (SGM) populations include individuals whose sexual orientation, gender identity, or reproductive development is characterized by nonbinary sexual constructs (e.g., lesbian, gay, bisexual, and transgender (LGBT) individuals). Previous research suggests that some SGM populations have higher rates of skin cancer. Te purpose of this study was to assess the association of diverse SGM identities with indoor tanning, a risk factor for skin cancer, while exploring other relevant co- occurring risk factors. A secondary analysis was performed on the 2020 LGBT Health Needs Assessment collected by the Pennsylvania Department of Health. Measures included sexual orientation, gender identity, healthcare utilization, and cancer risk factors. Cisgender SGM men are more likely to use indoor tanning devices (adjusted odds ratio (aOR) � 1.79; 95% CI: 1.31–2.44) compared to other SGM subpopulations independent of sexual orientation. Indoor tanning was also associated with alcohol (aOR � 1.94; 95% CI: 1.50–2.51) and tobacco use (aOR � 1.64; 95% CI: 1.21–2.21). Findings suggest that targeted screening for skin cancer risk behaviors could accompany standard tobacco and alcohol screenings in clinical practice. basal cell carcinomas were attributable to excess UV radi- 1. Introduction ation exposure [6]. Indoor tanning devices expose users to Sexual and gender minority (SGM) populations include high doses of radiation, making them dangerous enough that individuals whose sexual orientation, gender identity, or they are classifed as a group I carcinogen [7]. Studies have reproductive development is characterized by nonbinary shown that SGM males were 2.9–5.8 times more likely to sexual constructs (e.g., lesbian, gay, bisexual, and trans- have tanned indoors when compared to heterosexual males. gender (LGBT) individuals) [1]. SGM populations have been Past studies found no diference in other UV-related risk shown to have an increased risk of developing certain types factors between SGM samples and the general population, including outdoor sun exposure and infrequent sunscreen of cancer compared to heterosexual and cisgender in- dividuals [2]. Among these, skin cancer is of particular use [3]. Tus, it is likely that the use of indoor tanning concern, as studies suggest that lifetime risk of skin cancer devices contributes to the skin cancer disparity between was 1.3–2.1 times higher among SGM males when compared these groups [4, 5]. to heterosexual males [3–5]. Existing behavioral research focused on the use of indoor Tanning behaviors, particularly the use of indoor tan- tanning devices in SGM populations is limited. In these ning devices, are a likely contributing factor to skin cancer studies, either gender was measured as a binary variable disparities. A past meta-analysis found that almost 90% of all confating sex at birth and gender identity or SGM sub- melanomas, 85% of squamous cell carcinomas, and 82% of groups were aggregated into one group, concealing 2 Journal of Skin Cancer variations across sexual and gender identities. SGM pop- including spray-on tans, during the past 12 months, how ulations are heterogenous, and there are likely important many times have you used an indoor tanning device such as psychosocial diferences across SGM subgroups related to a sunlamp, tanning bed, or booth?” Responses were di- the use of indoor tanning devices. Appearance-based mo- chotomized to refect any past 12-month indoor tanning. tivations have been found to be particularly important in Participants were also asked the following question about cisgender gay and bisexual men, but this research was not their history of skin cancer: “At any time in your life, have diverse with regard to gender and sexual identities [8]. you received a skin cancer diagnosis?” Te response options Problem behavior theory (PBT) posits that risk behav- were “Yes” or “No.” iors cluster because of latent personality characteristics that enable the behaviors, which are reinforced in the social 2.1.2. Sexual Orientation and Gender Identity (SOGI). environment [9]. Personality factors, such as sensation Current gender was determined using both sex at birth and seeking and low inhibitory control, were associated with current gender identity; for example, male sex at birth and binge drinking and tobacco use in cisgender SGM men in current female was coded as transgender female and male previous research [10–12]. Based on PBT, we would expect sex at birth and current man was coded as cisgender male. that skin cancer risk behaviors, such as the use of indoor Te response options for sex at birth were “Male” and tanning devices, would correlate with other cancer risk “Female,” and the response options for current gender behaviors found to be prevalent in SGM populations (e.g., identity included the following: “Man,” “Woman,” “Gen- tobacco and alcohol use); however, co-occurring cancer risk derqueer,” “Nonbinary,” “Genderfuid,” and “Another behaviors were not considered in previous studies on indoor gender.” Tose who selected the last option were asked to fll tanning in SGM populations [5, 13, 14]. in the blank to specify their gender identity. Te Surgeon General’s Call to Action to Prevent Skin Participants were asked, “Which of the following best Cancer was released in 2014, which outlined fve strategic describes your sexual orientation?” Te response options objectives for preventing skin cancer [15]. Among these, one were “Bisexual,” “Gay,” “Lesbian,” “Pansexual,” “Asexual,” was to equip individuals with the necessary knowledge to “Demisexual,” “Queer,” or “Another sexual orientation.” make informed and healthy decisions about their exposure Due to low cell sizes, “Asexual” and “Demisexual” were to UV rays. A national study of the U.S. primary care combined into the same category with “Another sexual providers found that over a quarter regularly counseled their orientation.” patients on indoor tanning [16]. Given that SGM pop- ulations face barriers to accessing primary care [17], the role of primary care in ameliorating skin cancer disparities is 2.1.3. Cancer Risk Behaviors. Current smoking was assessed signifcant. with a single item: “How often do you currently smoke Te purpose of this study was to assess the use of indoor cigarettes?” Responses were dichotomized as “not at all” tanning devices among a heterogenous sample of SGM compared to “some days” or “every day.” Binge drinking was adolescents and adults. We sought to answer the following assessed with a single item: “In the past 30 days, how often research questions: (RQ1) Which SGM subgroups were did you drink 5 or more alcoholic drinks in a day? (One most likely to use indoor tanning devices? (RQ2) How was drink is equivalent to a 12-ounce beer, a 5-ounce glass of healthcare utilization associated with the use of indoor wine, or a drink with one shot of liquor).” Responses were tanning devices? (RQ3) What was the association of cancer dichotomized as “never” compared to those reporting binge risk behaviors with the use of indoor tanning devices? drinking at least once in the past 30 days. 2. Methods 2.1.4. Sociodemographics. Demographic measures included current age in years, Hispanic or Latin ethnicity (no versus Tis was a secondary analysis of the 2020 LGBT Health yes), race (“White,” “Black/African American,” “Asian,” Needs Assessment collected by the Pennsylvania De- “American Indian, Native American, or Alaskan native,” partment of Health [18]. Respondents were SGM residents “Pacifc Islander,” or “Another race”), and educational at- of Pennsylvania aged thirteen and older. Tey were recruited tainment. Participants also reported their county of resi- through a nonprobability community-based approach. Re- dence, which was used to classify them as rural or urban cruitment materials were distributed in English and Spanish based on the Center for Rural Pennsylvania’s defnition of by community organizations over a wide range of platforms, population density. including e-mail, mailed postcards, websites, mobile phone applications, and social media. Te 15-minute questionnaire was available in both Spanish and English. Inclusion criteria 2.2. Analyses. All analyses were conducted in SAS 9.4 (SAS included responding yes to “Do you identify as LGBTQ?” Institute, Cary, NC). Bivariate diferences were examined and “Do you live in Pennsylvania?” using chi-square test of independence. Te following four hierarchical logistic regression models were estimated: un- adjusted (model 1), demographics and SOGI (model 2), 2.1. Measures healthcare utilization (model 3), and the full model with the addition of cancer risk factors (model 4). Adjusted odds 2.1.1. Indoor Tanning and Skin Cancer History. Indoor tanning use was measured with the following item: “Not ratios with 95% confdence intervals were reported as the Journal of Skin Cancer 3 measure of association. List wise deletion was used for men is not inclusive enough. A growing percentage of SGM missing data on predictor variables (<2% for any given youth is identifed as pansexual (along with other identity labels) [21]. In this study, gender was predictive of indoor variable). Missing data resulted from participants exiting the survey before reaching the end and did not appear to be tanning regardless of sexual identity (e.g., gay, bisexual, systematic for any one variable. pansexual, or other) with one exception (e.g., queer). Queer identifed persons in this study were less likely to use indoor tanning devices. Future research should attempt to recruit 3. Results cisgender males with diverse sexual identities to help elu- Characteristics of the study sample are described in Table 1 cidate these diferences. (N � 5,192). Overall, 2.8% (n � 143) of participants had Recent binge drinking and tobacco use were also found a previous skin cancer diagnosis. Past year indoor tanning to have a positive and independent association with indoor was reported by 5.5% (n � 286) of participants with the usage tanning. Tese fndings support propositions from the rate by cisgender men being 9.5% (n � 4906). Bivariate Problem Behavior Teory [13, 14] and align with evidence correlates of indoor tanning were age, sexual identity, from qualitative research that demonstrated how the social gender, binge drinking, and tobacco use (Table 1). environment promotes tanning behaviors for many cis- Tere were minimal diferences in the unadjusted and gender SGM men [8]. It also provides an opportunity for adjusted models (Table 2). In the unadjusted models, all interventions. Addressing multiple risk factors simulta- sexual identities were negatively associated with indoor neously has long been shown to be more efective than tanning when compared to gay/lesbian; however, only queer addressing any one alone, since individuals participating in identity (aOR � 0.39; 95% CI: 0.19–0.79) and being a trans- a given category of risky behaviors are likely to be partici- gender woman (aOR � 0.29; 95% CI: 0.11–0.82) remained pating in other risky behaviors as well [22]. Future research signifcant in the fully adjusted model. Black race should investigate the specifc intra- and interpersonal de- (aOR � 0.35; 95% CI: 0.14–0.88) and being <18 years old terminants of indoor tanning among cisgender SGM men (aOR � 0.33; 95% CI: 0.13–0.85) were also negatively asso- across diverse sexual identities. ciated with indoor tanning in the adjusted models. After adjusting for all variables, the following were independently associated with indoor tanning: cisgender men (aOR � 1.79; 4.1. Implications. Overall, these fndings suggest important 95% CI: 1.31–2.44), binge drinking (aOR � 1.94; 95% CI: implications for future intervention research. First, cis- 1.50–2.51), and tobacco use (aOR � 1.64; 95% CI: 1.21–2.21). gender SGM males (inclusive of diverse sexual identities) Of note, the transgender male demographic was not asso- should be targeted for intervention. Second, the null fndings ciated with indoor tanning. regarding healthcare utilization and prior skin cancer di- agnosis suggest that patient-provider discussion regarding skin cancer prevention can be strengthened. Future research 4. Discussion should determine if physicians are discussing the risks from Cisgender men showed the greatest prevalence of indoor indoor tanning devices with SGM patients and ways to tanning independent of sexual identity (RQ1), while indoor improve SGM culturally responsive skin cancer risk com- tanning was otherwise equivalent across sexual and gender munication. Lastly, given the association of indoor tanning identities with a few exceptions: queer-identifed, nonbinary with alcohol and tobacco use behaviors, physicians should individuals, and transgender women were less likely to have consider screening for indoor tanning along with these other used an indoor tanning device. Black respondents and those risk behaviors—particularly among SGM men. Focusing on less than eighteen years of age were also less likely to have co-occuring risk behaviors is especially important consid- tanned indoors in the adjusted models. Tese fndings add to ering that alcohol and tobacco screenings are already existing research in a few important ways. standard in clinical practice and these behaviors are asso- Participnts aged eighteen and younger had far lower ciated with indoor tanning in this study and in the general rates of indoor tanning, suggesting that legal age restrictions population [23]. may have their intended efects. In Pennsylvania, indoor tanning is prohibited for youth sixteen years and younger 4.2. Limitations. Tis study is limited in which the partic- and parental consent is required for those seventeen years of age [19, 20]. Implementing this type of legislation in other ipants were recruited through nonprobability community- based sampling. Data were also self-reported, and a single states may help to reduce the use of indoor tanning devices among SGM youth more broadly. measure of indoor tanning was used. As participants resided in Pennsylvania, results may not apply to the residents of Te strong and independent association of cisgender male identity and indoor tanning device not only supports other states. Also, measures of risk behaviors, personality, a targeted focus on this group for prevention [3] but also and social environment were limited given that this was suggests that limiting inclusion to gay or bisexual identifed a secondary analysis of existing data. 4 Journal of Skin Cancer Table 1: Sample characteristics stratifed by sun protective behaviors (N � 5,192). Stratifed by indoor Chi-square test of tanning Variable Total sample N (%) diference p value % Yes % No Total 5.5 94.5 Demographics Age <0.01 13–18 451 (8.9) 2.0 98.0 18–29 1778 (34.2) 4.6 95.4 30–40 1238 (23.8) 7.2 92.8 40+ 1725 (33.2) 6.1 93.9 County 0.50 Urban 4193 (81.8) 5.3 94.7 Rural 936 (18.2) 5.9 94.1 Race 0.08 White 4413 (85.4) 5.6 94.4 Black/African American 210 (4.1) 2.4 97.6 Asian 92 (1.8) 2.2 97.8 Another race 455 (8.8) 6.5 9.5 Hispanic 0.37 No 4841 (93.4) 5.4 94.6 Yes 343 (6.6) 6.6 93.5 Education level 0.25 Less than college 2389 (46.1) 5.1 94.9 College or higher 2792 (53.9) 5.8 94.2 SOGI Sex at birth <0.01 Female 2831 (54.7) 3.4 96.6 Male 2347 (45.3) 8.1 91.9 Sexual orientation <0.01 Gay/lesbian 2777 (53.6) 7.2 92.8 Bisexual 1017 (19.6) 4.9 95.1 Pansexual 468 (9.0) 3.9 96.1 Queer 575 (11.1) 1.6 98.4 Another sexual orientation 347 (6.7) 2.3 97.7 Current gender <0.01 Cisgender man 1874 (36.1) 9.5 90.5 Cisgender woman 1802 (34.7) 4.2 95.8 Transgender woman 293 (5.7) 2.1 97.9 Transgender man 338 (6.5) 2.7 97.3 Nonbinary 882 (17.0) 1.9 98.1 Healthcare utilization Usual place of care 0.45 Yes 4219 (81.6) 5.4 94.6 No 954 (18.4) 6.0 94.0 Cancer risk Binge drinking (past 30 days) <0.01 Yes 1789 (34.6) 8.9 91.1 No 3387 (65.4) 3.7 96.3 Tobacco cigarette user <0.01 Yes 751 (14.5) 9.7 90.3 No 4439 (85.5) 4.8 95.2 Cancer history Previous skin cancer diagnosis 0.12 Yes 143 (2.8) 8.4 91.6 No 5027 (97.2) 5.4 94.6 Note. SOGI: sexual orientation and gender identity. Tere were minimal amounts of missing data so not all frequencies add up to 5,192. Bolded values are statistically signifcant, p< 0.05. Journal of Skin Cancer 5 Table 2: Correlates of tanning bed use among sexual and gender minority adolescents and adults (N � 5,034). Tanning bed use Model 4 Model 1 Model 2 Model 3 Variable (demographics + SOGI + (unadjusted) OR (demographics + SOGI) (demographics + SOGI + healthcare + cancer risk) (95% CI) aOR (95% CI) healthcare) aOR (95% CI) aOR (95% CI) Demographics Age 13–18 0.19 (0.08, 0.46) 0.28 (0.11, 0.71) 0.27 (0.11, 0.70) 0.33 (0.13, 0.85) 18–29 0.77 (0.57, 1.03) 1.07 (0.78, 1.48) 1.04 (0.75, 1.44) 0.94 (0.67, 1.31) 30–40 1.18 (0.88, 1.59) 1.46 (1.07, 1.98) 1.42 (1.04, 1.94) 1.27 (0.92, 1.75) 40+ 1.00 1.00 1.00 1.00 County Urban 0.89 (0.66, 1.20) 0.86 (0.63, 1.18) 0.86 (0.63, 1.18) 0.86 (0.62, 1.18) Rural 1.00 1.00 1.00 1.00 Race White 1.00 1.00 1.00 1.00 Black/African 0.44 (0.18, 1.07) 0.38 (0.16, 0.95) 0.38 (0.15, 0.94) 0.35 (0.14, 0.88) American Asian 0.40 (0.10–1.61) 0.40 (0.10, 1.66) 0.40 (0.10, 1.66) 0.46 (0.11, 1.90) Another race 1.13 (0.75, 1.70) 1.19 (0.71, 2.01) 1.18 (0.70, 1.98) 1.15 (0.68, 1.94) Hispanic No 1.00 1.00 1.00 1.00 Yes 1.31 (0.83, 2.05) 1.14 (0.65, 2.02) 1.14 (0.65, 2.00) 1.12 (0.64, 1.97) Education level Less than college 1.00 1.00 1.00 1.00 College or higher 1.12 (0.88, 1.43) 0.91 (0.70, 1.18) 0.91 (0.70, 1.19) 0.97 (0.74, 1.26) SOGI Sexual orientation Gay/lesbian 1.00 1.00 1.00 1.00 Bisexual 0.68 (0.50, 0.94) 1.07 (0.75, 1.52) 1.06 (0.74, 1.51) 1.08 (0.76, 1.55) Pansexual 0.44 (0.26, 0.75) 0.88 (0.49, 1.59) 0.89 (0.50, 1.59) 0.88 (0.49, 1.56) Queer 0.21 (0.11, 0.41) 0.40 (0.20, 0.83) 0.40 (0.19, 0.82) 0.39 (0.19, 0.81) Other 0.28 (0.13, 0.59) 0.62 (0.27, 1.41) 0.62 (0.27, 1.41) 0.69 (0.30, 1.57) Current gender Cisgender man 2.31 (1.71, 3.05) 2.05 (1.51, 2.79) 2.05 (1.51, 2.79) 1.81 (1.32, 2.47) Cisgender woman 1.00 1.00 1.00 1.00 Transgender 0.32 (0.12, 0.88) 0.30 (0.11, 0.83) 0.30 (0.11, 0.83) 0.29 (0.11, 0.82) woman Transgender man 0.61 (0.30, 1.23) 0.78 (0.38, 1.64) 0.80 (0.38, 1.66) 0.78 (0.37, 1.65) Nonbinary 0.40 (0.23, 0.70) 0.52 (0.29, 0.93) 0.51 (0.29, 0.93) 0.51 (0.28, 0.92) Healthcare utilization Usual place of care Yes 0.89 (0.66, 1.21) 0.85 (0.61, 1.17) 0.92 (0.67, 1.28) No 1.00 1.00 1.00 Cancer risk Binge drinking (past 30 days) Yes 2.44 (1.91, 3.12) 1.93 (1.49, 2.50) No 1.00 1.00 Tobacco cigarette user Yes 2.11 (1.59, 2.81) 1.67 (1.23, 2.25) No 1.00 1.00 Cancer history Any previous cancer diagnosis Yes 1.42 (0.91, 2.21) 1.21 (0.63, 2.32) No 1.00 1.00 Previous skin cancer diagnosis Yes 1.53 (0.81, 2.86) 1.09 (0.48, 2.49) No 1.00 1.00 Note. 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