Key takeaways:

• A new study led by the Harvard Pilgrim Health Care Institute examined differences in premature mortality by sexual orientation among a large group of women followed for three decades.
• Findings show that sexual minority women died much sooner than heterosexual women, with bisexual women having the most pronounced differences.
• This work highlights the urgent need to address sexual orientation-related inequities in preventable illness, including a focus on the systems and laws that drive health inequities.

Boston, MA - Compared to heterosexual women, bisexual women died 37% sooner and lesbian women 20% sooner, according to results from one of the largest studies to examine sexual orientation-related inequities in mortality and the first to differentiate between lesbians and bisexual women.

The findings are published April 25 in JAMA. 

Decades of research have documented that sexual minority women have worse health—across various physical and mental health outcomes—relative to their heterosexual peers. However, few studies examined inequities in mortality, and none have been able to differentiate mortality inequities amongst sexual minority subgroups in women. 

The new findings, led by investigators from the Harvard Pilgrim Health Care Institute with collaborators from Harvard T.H. Chan School of Public Health, the University of Utah, Boston Children’s Hospital, and Columbia University reveal these health inequities are leading to dramatic differences in mortality.

The sexual orientation-related inequities in mortality highlight the urgent need to address preventable causes, particularly given the increasingly hostile policy climate for LGBTQ people in the U.S.

-Sarah McKetta, MD, PhD

“The sexual orientation-related inequities in mortality highlight the urgent need to address preventable causes, particularly given the increasingly hostile policy climate for LGBTQ people in the U.S.,” said lead author Sarah McKetta, Research Fellow at the Harvard Pilgrim Health Care Institute. Adds Dr. McKetta, “LGBTQ people are subjected to unique forms of stigma, prejudice, and discrimination that ‘get under the skin’ in a myriad of ways. These toxic social forces result in chronic stress and unhealthy coping mechanisms, which make this population vulnerable to worse health and premature mortality.”

The researchers used data from the Nurses’ Health Study II, a cohort of over 100,000 female nurses born between 1945–1964 and surveyed prospectively since 1989. Eligible participants were those alive in 1995 when sexual orientation was first assessed. The study team linked participant-reported sexual orientation to nearly 30 years of death records. Results showed that sexual minority women died, on average, 26% sooner than heterosexual women. These disparities were driven by both bisexual women—who died 37% sooner—and lesbian women—who died 20% sooner. 

The more pronounced premature mortality rate among bisexual women is troubling, and underscores the need for targeted interventions to reduce these disparities among all sexual minority groups.

- Brittany Charlton, MSc, ScD

The ability to stratify results by sexual orientation subgroup, researchers say, was a key strength in the study. “Bisexual women face distinct stressors from outside, as well as within, the LGBTQ community that are rooted in biphobia. Additionally, bisexual people are often excluded from various communities because they’re assumed to be straight or gay based on their partner’s gender,” said senior author Brittany Charlton, Harvard Medical School associate professor of population medicine at the Harvard Pilgrim Health Care Institute. “The more pronounced premature mortality rate among bisexual women is troubling, and underscores the need for targeted interventions to reduce these disparities among all sexual minority groups.”
 

The researchers make suggestions for actionable first steps that can be implemented throughout the care continuum. They include evidence-based preventive screening for sexual minority women without assumptions based on identity, increased screening and treatment referral for tobacco, alcohol, and other substance use, and mandatory, culturally-informed training for healthcare providers caring for sexual minority patients.
 

It is imperative that we work to address the systems and structures that undermine the well-being and dignity of LGBTQ people.

“While our findings are striking on their own, they just might underscore the true disparity in the general United States population. Study participants were all nurses and therefore have many protective factors that the general population doesn’t have,” remarked Dr. McKetta. “Future research needs to examine the specific factors that exacerbate or ameliorate these risks, so we can develop targeted interventions to ensure all people have the opportunity to live long, healthy lives.” Adds Dr. Charlton, “It is imperative that we work to address the systems and structures that undermine the well-being and dignity of LGBTQ people.”

About the Harvard Pilgrim Health Care Institute’s Department of Population Medicine

The Harvard Pilgrim Health Care Institute's Department of Population Medicine is a unique collaboration between Harvard Pilgrim Health Care and Harvard Medical School. Created in 1992, it is the first appointing medical school department in the United States based in a health plan. The Institute focuses on improving health care delivery and population health through innovative research and education, in partnership with health plans, delivery systems, and public health agencies. Point32Health is the parent company of Harvard Pilgrim Health Care and Tufts Health Plan. Follow us on Twitter and LinkedIn.

Paper cited:
McKetta, S., Hoatson, T., Hughes, L.D., Everett, B., Haneuse, S., Austin, S.B., Hughes, T.L., Charlton, B.M. Disparities in mortality by sexual orientation in a large, prospective cohort of female nurses (In Press). JAMA.