健康、法律和LGBT群体：一个未完成的故事.

On Monday, the US Supreme Court 决定 the case of 杰作蛋糕店诉科罗拉多州民权委员会. 该案的起因是一位面包师基于宗教原因反对为同性伴侣购买婚礼蛋糕。 最高法院的判决对这位面包师有利，基于程序上的理由，裁定他没有得到科罗拉多州民权委员会（Colorado Civil Rights Commission）的公平听证。肯尼迪大法官在撰写最高法院多数意见时表示，该委员会成员使用的语言构成了“对宗教怀有敌意”的证据。 从这个意义上说，这项裁决相当狭隘，没有解决一个更大的问题，即企业拒绝向LGBT（女同性恋、男同性恋、双性恋和变性人）美国人提供服务是否符合宪法。 I refer the reader 观点 in SPH This Week by Professors Raifman and 乌尔里希, who discuss the legal basis of the court case in more detail.

尽管存在这种悬而未决的问题，但该案件仍然表明了公共卫生面临的核心挑战，特别是歧视性法律造成的不平等可能导致的卫生差距。 数据显示，歧视性政策与健康状况不佳之间存在联系。 In a recent JAMA精神病学 新濠影汇线上赌场研究 led by Professor 茱莉亚Raifman, 我们发现 that state laws permitting denial of services to same-sex couples are associated with a 46 percent increase in the proportion of sexual minority adults who experience mental distress. Writing last week in 行家, Professors Raifman and 乌尔里希 说明 this statistic among the broader health challenges faced by sexual minority populations—which include higher rates of 自杀 and mental distress than their heterosexual peers—as well as the discriminatory practices faced by these populations in many states.

Since the Supreme Court issued its momentous decision, in 奥贝格费尔诉霍奇斯案, ruling that the 14th Amendment requires states to issue marriage licenses to same-sex couples, it has become clear that there is still work to be done before LGBT Americans can enjoy the full measure of equality that is necessary for a healthy life. Despite his campaign promises to the contrary, Donald Trump’s administration has been 一直敌对 to sexual minorities. At the same time, many states have either passed laws 推进 LGBT rights or laws that 限制 these rights, reflecting a debate that is still very much in flux. Here in Massachusetts, 例如, we will  vote in November on whether or not to sunset the state’s current law safeguarding the rights of transgender individuals to use spaces of public accommodation. Our school community will continue to engage with this conversation as it unfolds, through our scholarship, our 与媒体接触, and 我们的公共活动. Consistent with this, we today rerun a modified version of 院长笔记 on LGBT health, with an eye toward building a world where no one is made to bear a disproportionate burden of poor health as a consequence of legal, social, or political marginalization.

越来越多的新濠影汇线上赌场研究表明，LGBT人群的健康状况在多个层面上都比可比的大多数人群更糟糕。This work reflects, much as I have discussed in a previous 迪安的注意, the ineluctable role of context in shaping the health of populations.

LGBT人群比异性恋人群更差的两个哨兵健康指标可能是艾滋病毒和自杀风险。 在美国，艾滋病毒对男同性恋、双性恋和变性女性的影响尤为严重。 Men who have sex with men make up about two percent of the US population but account for 占所有流行病例的一半以上，占所有突发病例的三分之二 of 艾滋病毒. 黑人男性的自杀率最高，在2008年至2010年间增加了20%。 Among men who have sex with men diagnosed with 艾滋病毒 by 2010, only 51%的人接受了整整一年的治疗. One 荟萃分析 found 超过四分之一的美国变性女性 have tested positive for 艾滋病毒, and 55 percentof 艾滋病毒 testing events among transgender people take place outside of healthcare facilities (e.g. community centers). In addition to 艾滋病毒, LGBT people are also at higher risk for 梅毒, 人乳头状瘤病毒, and 病毒性肝炎.

Population-based studies in the US have found 报道 自杀 attempt rates among adolescents who identify as LGBT to be 高出两到七倍 compared to those who identify as heterosexual. Sexual orientation may be a particularly strong predictor of 自杀 attempts among 男性青少年.

A 荟萃分析 found a two-fold excess in 自杀 attempts among LGB individuals, a 1.5 times higher risk of anxiety and depression, and a 1.5 times higher risk of alcohol or substance dependence, which was even higher among lesbian and bisexual women. In the Nurses Health Study II, lesbian women were 更有可能报告抑郁和使用抗抑郁药. A 中年人的新濠影汇线上赌场研究 revealed that gay and bisexual men experienced more panic attacks and depression than heterosexual men, and that lesbian/bisexual women had a higher prevalence of generalized anxiety disorder than heterosexual women.

变性人 in particular, though less studied, have many health indicators that are even worse than lesbian, gay, and bisexual individuals, including 艾滋病毒 (and many 不知道自己的艾滋病毒状况), 自杀, and 滥用.

Other studies have shown that LBG populations are more likely to report 哮喘, 超重, 高血压，糖尿病，身体残疾, and self-报道 poor health compared to heterosexual individuals. The Nurses Health Study II found that lesbian women had a higher prevalence of risk factors for cardiovascular disease, including 更高的身体质量指数，吸烟和更多的酒精消费. A 新濠影汇线上赌场研究 using the 全国成人烟草调查 found that LGBT respondents had comparable exposure to tobacco cessation advertising and awareness and use of cessation methods compared to heterosexual adults, despite higher rates of smoking among LGBT populations.

Sexual minority women (women who have sex with females only or both males and females) have been shown to have a 终生患乳腺癌的风险更高 (although there 结果好坏参半). A 国家级的新濠影汇线上赌场研究 (which does not necessarily tell us about individual risk) found that among men, higher bisexual population density was associated with lower incidence of lung cancer and with higher incidence of colorectal cancer. 在女性中，女同性恋人口密度与肺癌和结直肠癌发病率较低以及乳腺癌发病率较高相关； 然而，双性恋人口密度与较高的肺癌和结直肠癌发病率以及较低的乳腺癌发病率相关。 A book by our faculty member Professor Ulrike》, 癌症和LGBT群体, presents the data about cancer disparities clearly and eloquently.

LGBT youth in particular are more likely to be 无家可归，从事性工作， and be 受虐者.

然而，这些数据要求我们仔细关注解释LGBT和异性恋人群之间健康差异的机制。 也就是说，为什么LGBT人群的健康状况与大多数人群不同？

从本质上讲，对LGBT群体的歧视和边缘化几乎肯定是解释这些差异的核心机制。 A 新濠影汇线上赌场研究 using the 2004–2005 National Epidemiologic Survey on Alcohol and Related Conditions found that lesbian, gay, and bisexual individuals had high levels of past-year perceived discrimination, which was associated with past-year mood, anxiety, and substance use disorders. Similarly, the 全国中年发展调查数据 showed that LGB individuals 报道 more lifetime and daily experiences of discrimination, and that almost half attributed the discrimination to their sexual orientation. 这种感知到的歧视与患有精神疾病和干扰完整而富有成效的生活有关，即使按种族分层也是如此。

The 少数应力模型 posits that chronic stress may result from stigmatization, prejudice, and discrimination, creating a hostile social environment for minorities. 2011年医学新濠影汇线上赌场研究所的一份报告强调了对LGBT健康的复杂影响，包括少数族裔压力模型，以及生命历程视角、交叉性视角（考虑个人多重身份的不同方面）和社会生态学视角（考虑包括家庭、社区和整个社会在内的外部影响领域）。 An example of the social ecology perspective considers individual experienced discrimination and societal discrimination in terms of 获得医疗保险、住房、婚姻、就业和退休福利. Mark Hatzenbuehler和他的同事 比较了美国有针对基于性取向的仇恨犯罪和就业歧视的保护措施的州和没有的州，发现生活在缺乏这些政策的州的LGB成年人与生活在同一州的异性恋成年人和生活在有保护法律的州的LGB成年人相比，精神疾病的患病率要高得多。

LGBT人群获得医疗服务的机会也可能较少，部分原因是受到污名化和对当局的不信任的影响。 The National Health Interview Survey 报道 that women in same-sex relationships were less likely than women in heterosexual relationships to have health insurance or to have seen a medical provider in the past year, and more likely to have unmet medical needs. 即使LGBT人群确实有机会获得医疗服务，他们也经常报告说缺乏文化上有能力的医疗服务提供者。 Transgender people in particular may be 对医疗保健的不信任 due to 病耻感和负担能力.

In perhaps a singularly good illustration of the pervasive influence of stigma and marginalization, it has been shown that while LGBT populations do not differ from their heterosexual counterparts in their 渴望戒烟 or their awareness of quitting programs, minority stress or discrimination may be contributing to 吸烟率上升 in LGBT populations.

同性恋、双性恋和变性青年的家庭不接受他们可能会导致他们与家庭隔绝，这两者都会导致他们无家可归和吸毒。 At the other end of the lifecourse, 老年LGBT人群 are less likely to have adult children help them with care and more likely to live alone. One 新濠影汇线上赌场研究 of transgender adults and their non-transgender siblings found that the transgender siblings 报道 less perceived social support from the same families.

总之，LGBT人群通常比异性恋人群承受更大的疾病负担。 这种差异在很大程度上是由于耻辱和歧视导致这一群体被边缘化。 婚姻平等带来了法律、经济和结构上的好处，这些好处来自于成为一个完全认可的家庭单位的一部分。 医院探视权、从医生那里获取信息的权利、将伴侣加入雇主医疗保险计划的权利——这些都是许多LGBT伴侣长期以来没有享受到的权利，现在他们享受到了。 因此，婚姻平等是朝着正确方向迈出的一步，它将使LGBT群体融合在一起，消除加剧耻辱和支持边缘化的结构性差异，并使我们更接近一种促进所有人群健康的群体平等文化。 当然，下一步是确保性少数群体的基本公民权利得到保护，这样他们的健康不仅会得到改善，而且会蓬勃发展。

我希望每个人都有一个美好的一周。 下周见。

温暖的问候,

桑德罗

桑德罗 Galea, MD, DrPH
Dean and Professor, 波士顿大学 公共卫生学院
@sandrogalea

Acknowledgement: I am grateful to Laura Sampson and 凯瑟琳Ettman for their contributions to this 迪安的注意.

以前的院长笔记存档于： /sph/category/news/deans-notes/