Indoor Tanning, Sunless Tanning, and Sun-Protection Behaviors Among Sexual Minority Men

Sexual minority men (SMM), including gay and bisexual men, report increased rates of skin cancer and indoor tanning, whereas sexual minority women report decreased rates of skin cancer and indoor tanning.¹ Indoor tanning has been associated with other risky behaviors, including decreased use of protective clothing and shade when outdoors.^2,3 However, no data exist on these other skin cancer risk behaviors among SMM. This study assesses the impact of sexual orientation on indoor tanning, sunless tanning, and sun-protection behaviors among men.

This cross-sectional study including 13 698 adult men used data from the 2015 National Health Interview Surveys. We calculated the age-adjusted prevalence rates and multivariable-adjusted odds ratios (aOR) by sexual orientation for indoor tanning, sunless tanning, sunburn, and sun avoidance. In a subpopulation analysis of sun-exposed individuals, we calculated mean behavioral scores and multivariable-adjusted regression coefficients (using linear regression) by sexual orientation for sun-protection behaviors, including a composite measure. As a secondary outcome, we assessed frequent indoor tanning (≥10 sessions annually) by sexual orientation among current indoor tanners. Multivariable analyses controlled for age, race/ethnicity, region, education level, body mass index (calculated as weight in kilograms divided by height in meters squared), sun sensitivity, and personal and family history of skin cancer. Analyses were weighted and performed using STATA version 13.1 (Stata Corp). This study was exempt from institutional board review at the University of Minnesota.

Our study included 370 SMM and 13 328 heterosexual men; SMM, compared with heterosexual men, had increased odds of reporting indoor tanning (both ever and in the last year), sunless tanning, and sun avoidance. There were no differences in sunburn rates (Table 1). Among current indoor tanners, frequent indoor tanning did not differ between SMM and heterosexual men (mean [SE] 37.0% [5.9%] vs 33.9% [6.6%], respectively; aOR, 0.66; 95% CI, 0.19-2.31). Among sun-exposed individuals, SMM were more likely to use sunscreen and seek shade but less likely to use protective clothing when outdoors, and their composite sun protection scores were lower (Table 2).

This study demonstrates that indoor tanning, sunless tanning, and sun-protection behaviors differ by sexual orientation among men in the United States. Sexual minority men report increased indoor and sunless tanning and decreased use of sun-protective clothing when outdoors, but are more likely to avoid sun exposure and, if sun-exposed, to use sunscreen and seek shade when outdoors.

These findings have important implications for skin cancer prevention in SMM. Higher rates of indoor and sunless tanning suggest an increased desire for tanned skin in SMM. This likely relates to increased emphasis on body image and appearance concerns,¹ which has been associated with indoor tanning use among SMM.⁴ While SMM are more likely to avoid sun exposure, seek shade, and use sunscreen when outdoors, their composite sun protection scores were lower, and it is possible that lower rates of protective clothing may lead to increased chronic sun exposure among SMM. Furthermore, frequent use of sunscreen⁵ and indoor tanning⁶ have both been correlated with increased outdoor sun exposure, which may also be elevated in SMM. Study strengths include the use of a nationally representative data set. Limitations include self-reported data, the relatively small number of SMM, and the lack of data on outdoor sun exposure. Gay and bisexual men were analyzed together to increase statistical power. This may limit the generalizability of our results when applied individually across these heterogeneous populations.

Dermatologists should be aware that indoor tanning, sunless tanning, and sun-protection behaviors are different in SMM and should consider routine assessment of sexual orientation in clinical settings to help guide behavioral screening and counseling. Future studies should investigate the motivations contributing to these differences and outdoor sun exposure behaviors in SMM. Targeted interventions designed to change behaviors could help reduce the risk of skin cancer among SMM.

Corresponding Authors: Matthew D. Mansh, MD, Department of Dermatology, University of Minnesota, 516 Delaware St S E, Phillips-Wangensteen Bldg, Ste 4-240, Minneapolis, MN 55455 (mansh@umn.edu).

Accepted for Publication: January 2, 2018.

Published Online: February 28, 2018. doi:10.1001/jamadermatol.2018.0003

Author Contributions: Dr Mansh had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Gao, Mansh.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Gao, Mansh.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Gao, Mansh.

Administrative, technical, or material support: Gao, Polcari, Mansh.

Study supervision: Arron, Linos, Polcari, Mansh.

Conflict of Interest Disclosures: Dr Linos is supported by the National Institutes of Health (grants K76AG054631, R21CA212201, DP2OD024079), as well as the University of California, San Francisco Helen Diller Impact Grant Award.

Meeting Presentation: These data were presented at the 2018 American Academy of Dermatology Association Annual Meeting: Residents & Fellows Symposium; February 17, 2018; San Diego, California.