1. Wisconsin Department of Health Services January 2014 P-00522W Healthiest Wisconsin 2020 Baseline and Health Disparities Report Lesbian, Gay, Bisexual, and Transgender Population

2. LGBT Background Terminology Overview of Healthiest Wisconsin 2020 Baseline and Health Disparities Report Key points Data Demographic data Risk behaviors among youth Health care coverage and risk behaviors among adults References Links to additional reports and resources Contacts Chapter Outline Chapter outline 2

3. LGBT Terminology The term “sexual minority” refers to: People who identify as lesbian, gay, or bisexual. People who have had same-sex sexual contact. These people may also have had opposite-sex contact. Transgender people. Gender identity is not collected by the data sources included in this report so data on health disparities experienced by transgender people are not reported. Terminology 3

4. LGBT Report Overview This chapter is part of a larger report created by the Wisconsin Department of Health Services to track progress on the objectives of Healthiest Wisconsin 2020 (HW2020) and identify health disparities in the state. The full report is available at: http://www.dhs.wisconsin.gov/publications/P0/p00522.pdf http://www.dhs.wisconsin.gov/publications/P0/p00522.pdf The report is designed to address the Health Focus Areas in HW2020. Where direct measures exist, data are presented; where direct measures are not available, related information may be included. Information about populations experiencing health disparities is provided in the Health Focus Area chapters and is summarized in separate chapters devoted to specific populations. Technical notes are available at: http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf Report overview 4

5. LGBT Report Format Full Report Format: PDF Intended use: reference document Chapters Format: Annotated PowerPoint slide set Intended uses: presentations to –Decision-makers –Service providers –Community leaders –The public Sample annotated slide Report overview 5

6. LGBT Report Outline Executive Summary Section 1: Introduction Section 2: Demographic overview Section 3: Health focus areas Section 4: Infrastructure focus areas Section 5: Data summaries by population Section 6: Technical notes Report overview 6

7. LGBT Report Outline: Detail Section 3: Health focus areas Alcohol and other drug use Chronic disease prevention and management Communicable diseases Environmental and occupational health Healthy growth and development Injury and violence Mental health Nutrition and healthy foods Oral health Physical activity Reproductive and sexual health Tobacco use and exposure Section 4: Infrastructure focus areas Access to health services Report overview 7

8. LGBT Report Outline: Detail Section 5: Data summaries by population  Racial/ethnic minority populations o American Indians o Asians o Blacks o Hispanics  People of lower socioeconomic status  People with disabilities  Lesbian, gay, bisexual, and transgender populations  Geography Report overview 8

9. LGBT Data notes Please refer to the Technical Notes chapter for a more detailed description of limitations and methods: http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf The 95% confidence intervals are denoted by error bars. Where confidence intervals do not overlap, as shown in the example on the right, differences are statistically significant. Larger confidence intervals may indicate less reliable estimates that should be interpreted with caution. Population estimates that are considered unreliable are excluded. Misclassification of racial/ethnic groups may affect the accuracy of rates. Unless otherwise indicated, the Hispanic population may include people of various races; Whites, Blacks, Asians, and American Indians are non- Hispanic. Report overview 9

10. LGBT Factors that influence health Social determinants of health Source: University of Wisconsin Population Health Institute. County Health Rankings 2013, http://www.countyhealthrankings.org/our-approach Report overview 10

11. LGBT Key points Sexual minority youth in Wisconsin 1 in 11 high school students identifies as lesbian, gay, bisexual, or unsure. 1 in 10 sexually active students has had same-sex sexual contact. Compared to sexual majority youth, sexual minority youth have higher rates of: –Lack of physical activity –Tobacco and drug use –Depression and suicide attempts –School violence and lack of sense of safety Compared to sexual majority youth, sexual minority youth have: –Earlier initiation of alcohol, marijuana, and tobacco use and sexual intercourse –Lower rates of school and family support Key Points 11

12. LGBT An estimated 2.4% of Wisconsin adults identify as lesbian, gay, or bisexual. LGB adults are geographically distributed throughout the state. Compared to heterosexual adults, LGB adults –Are more likely to be uninsured –Earn less income and have less education –Have higher rates of tobacco use Compared to heterosexual men, gay and bisexual men –Are more likely to be in HIV high-risk situations –Are less likely to be overweight or obese Key Points 12 Key points Lesbian, gay and bisexual adults in Wisconsin

13. LGBT Key points Transgender adults and youth in Wisconsin Data on transgender adults and youth are very limited. More data are needed to understand the health of transgender-identified adults and youth in Wisconsin. Key Points 13

14. LGBT Demographic data 14

15. LGBT 9% of Wisconsin high school students in Wisconsin identify as lesbian, gay, bisexual, or unsure (2011, YRBS). 10% of Wisconsin high school students who have had sexual contact have had same-sex contact. (2007-2011, YRBS). Demographic data 15 Among high school students in Wisconsin: 1.3% are lesbian or gay 5.1% are bisexual 2.2% are unsure Youth

16. LGBT Adults 2% of Wisconsin adults identify as lesbian, gay or bisexual (BRFS landline sample, 2008-2011). 3% of Wisconsin adults identify as lesbian, gay, bisexual, or transgender (Gallup Poll, 2012). 5% of Wisconsin adult males, age 18 and older, are men who have sex with men, 2007 (White, 5.6%, Black, 4.3%, Hispanic, 5.3%) (Public Health Reports, 2011, V126). Low income (less than $20,000), 2008-2011: LGB adults, 17% (heterosexual adults, 11%) Households 10,863 households (about 1 in 200) in Wisconsin contain a same-sex couple (American Community Survey, 2010). 53% of these are female couples; 47% are male couples (American Community Survey, 2010). 16 Demographic and socioeconomic data

17. LGBT Same-sex-couple households by county, Wisconsin Source: American Community Survey, 2010. Geography 17

18. LGBT Risk behaviors among youth 18

19. LGBT Estimated prevalence of sexual risk behaviors among Wisconsin high school students by sexual minority status, 2007-2011 Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset. Reproductive and sexual health 19

20. LGBT Tobacco use among Wisconsin high school students, by sexual minority status, 2007-2011 Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset. Tobacco 20

21. LGBT Current drinking, binge drinking, and marijuana use among Wisconsin high school students, by sexual minority status, 2007-2011 Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset. Alcohol and other drugs 21

22. LGBT Early initiation of alcohol and marijuana use among Wisconsin high school students, by sexual minority status, 2007-2011 Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset. Alcohol and other drugs 22

23. LGBT Lifetime use of cocaine, inhalants, and heroin among Wisconsin high school students, by sexual minority status, 2007-2011 Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset. Alcohol and other drugs 23

24. LGBT Overweight, obesity, and weight loss attempts among Wisconsin high school students, by sexual minority status, 2007-2011 Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset. Nutrition 24

25. LGBT Physical activity and sedentary behaviors among Wisconsin high school students, by sexual minority status, 2007-2011 Physical activity Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset. 25

26. LGBT Motor vehicle risk behaviors among Wisconsin high school students, by sexual minority status, 2007-2011 Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset. Injury and violence 26

27. LGBT Protective factors among Wisconsin high school students, by sexual minority status, 2007-2011 Mental health 27 Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset.

28. LGBT Depression among Wisconsin high school students, by sexual minority status, 2007-2011 Mental health 28 Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset.

29. LGBT Suicide risk during past 12 months among Wisconsin high school students, by sexual minority status, 2007-2011 Mental health 29 Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset.

30. LGBT Perceptions of school safety among Wisconsin high school students, by sexual minority status, 2007-2011 Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset. Mental health 30

31. LGBT Exposure to school violence among Wisconsin high school students, by sexual minority status, 2007-2011 Injury and violence Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset. 31

32. LGBT Partner violence among Wisconsin high school students, by sexual minority status, 2007-2011 Injury and violence Source: Wisconsin Department of Public Instruction, Youth Risk Behavior Survey (YRBS); 2007, 2009, 2011 combined dataset. 32

33. LGBT Health care access and risk behaviors among adults 33

34. LGBT Lack of health care coverage and Medicaid enrollment among Wisconsin adults, by sexual orientation, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Access to health care 34

35. LGBT Use of and barriers to health care among Wisconsin adults, by sexual orientation, 2009-2011 Access to health care 35 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset.

36. LGBT Indicators of poor health status among Wisconsin adults by sexual orientation, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Physical health and limited activities questions only asked in 2009-2011. Physical health 36

37. LGBT Smoking among Wisconsin adults, by sexual orientation, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Tobacco 37

38. LGBT Binge drinking among Wisconsin adults, by sexual orientation, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Alcohol and other drugs 38

39. LGBT Insufficient sleep and poor emotional support among Wisconsin adults, by sexual orientation, 2008-2010 Mental health Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Questions were not asked in 2011. 39

40. LGBT Overweight and obesity among Wisconsin adults, by sexual orientation and sex, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Nutrition 40

41. LGBT Rates of HIV testing and risk among Wisconsin men, by sexual orientation, 2008-2011 Reproductive and sexual health Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. 41

42. LGBT Rates of high cholesterol and high blood pressure among Wisconsin adults, by sexual orientation, 2009 and 2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Questions only asked 2009 and 2011. Chronic diseases 42

43. LGBT Rates of tooth removal and dental visits in the past year among Wisconsin adults, by sexual orientation, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Note: Tooth removal question asked in 2008, 2010, and 2011. Dentist visit question asked in 2008 and 2010. Oral health 43

44. LGBT References 1.University of Wisconsin Population Health Institute. County Health Rankings 2013. http://www.countyhealthrankings.org/our-approach http://www.countyhealthrankings.org/our-approach 2.Center for Urban Population Health. Milwaukee Health Report 2011. http://www.cuph.org/mhr/2011-milwaukee-health-report.pdf http://www.cuph.org/mhr/2011-milwaukee-health-report.pdf 3.LaVeist TA, Gaskin DA, Richard. P (2009). The Economic Burden of Health Inequalities in the United States. Joint Center for Political and Economic Studies. http://www.jointcenter.org/sites/default/files/upload/research/files/The%20Economic% 20Burden%20of%20Health%20Inequalities%20in%20the%20United%20States.pdf http://www.jointcenter.org/sites/default/files/upload/research/files/The%20Economic% 20Burden%20of%20Health%20Inequalities%20in%20the%20United%20States.pdf 4.Thomas JC, Sage M, Dillenberg J, Guillory VJ (2002). A Code of Ethics for Public Health. Am Journal of Public Health. 92(7):1057–1059. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447186/ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447186/ 5.Wisconsin Department of Health Services (DHS). Healthiest Wisconsin 2020. http://www.dhs.wisconsin.gov/publications/P0/P00187.pdf http://www.dhs.wisconsin.gov/publications/P0/P00187.pdf 6.Centers for Disease Control and Prevention (CDC). Adolescent and School Health, Sexual Risk Behaviors. http://www.cdc.gov/HealthyYouth/sexualbehaviors/http://www.cdc.gov/HealthyYouth/sexualbehaviors/ 7.Institute of Medicine (2011).The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. http://www.iom.edu/Reports/2011/The-Health-of-Lesbian-Gay-Bisexual-and- Transgender-People.aspx http://www.iom.edu/Reports/2011/The-Health-of-Lesbian-Gay-Bisexual-and- Transgender-People.aspx 44 References

45. LGBT 8.Gallup Politics, State of the States, February 15, 2013, http://www.gallup.com/poll/160517/lgbt-percentage-highest-lowest-north-dakota.aspx http://www.gallup.com/poll/160517/lgbt-percentage-highest-lowest-north-dakota.aspx 9.Lieb S. et al. Statewide estimation of populations of MSM in the United States. Public Health Reports 2011;126(1):60–72. 10.Birkett M, Espelage DL, Koenig B. LGB and questioning students in schools: The moderating effects of homophobic bullying and school climate on negative outcomes. J Youth Adolescence. http://link.springer.com/article/10.1007%2Fs10964-008-9389-1http://link.springer.com/article/10.1007%2Fs10964-008-9389-1 11.CDC. Regular Check-Ups Are Important. http://www.cdc.gov/family/checkup/http://www.cdc.gov/family/checkup/ 12.Lee JGL, Griffin GK, Melvin CL (2009). Tobacco use among sexual minorities in the USA, 1987 to May 2007: A systematic review. Tobacco Control, 18, 275-282. http://tobaccocontrol.bmj.com/content/18/4/275.full http://tobaccocontrol.bmj.com/content/18/4/275.full 13.Mayer KH, et al. (2008). Sexual and Gender Minority Health: What We Know and What Needs to Be Done. Am J Public Health. 2008 June; 98(6): 989–995. http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2007.127811 http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2007.127811 14.Boehmer U, Bowen DJ, Bauer GR. Overweight and obesity in sexual minority women: evidence from population-based data. American Journal of Public Health. 2007; 97: 1134–1140. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1874217/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1874217/ 15.National Eating Disorders Association. Eating Disorders in LGBT Populations. http://www.nationaleatingdisorders.org/sites/default/files/ResourceHandouts/LGBTQ. pdf http://www.nationaleatingdisorders.org/sites/default/files/ResourceHandouts/LGBTQ. pdf 45 References

46. LGBT Links to other resources Lesbian, Gay, Bisexual, Transgender Health in Wisconsin. http://www.dhs.wisconsin.gov/lgbthealth http://www.dhs.wisconsin.gov/lgbthealth Wisconsin YRBS and Sexual Minority Youth. http://www.dhs.wisconsin.gov/lgbthealth/HealthReports/index.htm Wisconsin AIDS/HIV Program, Statistics and Reports. http://www.dhs.wisconsin.gov/aids-hiv/ http://www.dhs.wisconsin.gov/aids-hiv/ CDC Lesbian, Gay, Bisexual and Transgender Health. http://www.cdc.gov/lgbthealth/ http://www.cdc.gov/lgbthealth/ 46 Links

47. LGBT Contacts AIDS/HIV Program Bureau of Communicable Diseases and Emergency Response Division of Public Health Wisconsin Department of Health Services Molly Herrmann, MS Contract Monitor, LGBT Health Coordinator Email: Molly.Herrmann@dhs.wisconsin.govMolly.Herrmann@dhs.wisconsin.gov Mari Gasiorowicz, MA HIV and Health Disparities Epidemiologist Email: Mari.Gasiorowicz@dhs.wisconsin.govMari.Gasiorowicz@dhs.wisconsin.gov 47 Contacts