Inequalities in US Life Expectancy by Area Unemployment Level, 1990-2010

This study examined the association between unemployment and life expectancy in the United States during 1990-2010. 

Census-based unemployment rates were linked to US county-level mortality data. Life expectancies were calculated by age, sex, race, and unemployment level during 1990-2010. Differences in life expectancy were decomposed by age and cause of death. 

Life expectancy was consistently lower in areas with higher unemployment rates. In 2006-2010, those in areas with high unemployment rates (≥9%) had a life expectancy of 76.9 years, compared with 80.7 years for those in areas with low unemployment rates (<3%). The association between unemployment and life expectancy was stronger for men than for women. 

Life expectancy ranged from 69.9 years among black men in high unemployment areas to 90.0 years among Asian/Pacific Islander women in low unemployment areas. Disparities persisted over time. In 1990-1992, life expectancy was 4.7 years shorter in high unemployment than in low unemployment areas. In 2006-2010, the life expectancy difference between the lowest and highest unemployment areas decreased to 3.8 years. Heart disease, cancer, homicide, unintentional injuries, diabetes, HIV/AIDS, and liver cirrhosis contributed most to the lower life expectancy in high unemployment areas. High unemployment areas recorded larger gains in life expectancy than low unemployment areas, contributing to the narrowing gap during 1990-2010.

Below:  Life expectancy at birth by sex and area unemployment level, United States, 1990–2010

Below:  Survivorship by age, race, and unemployment level, United States, 1990–2010

Below:  Conditional probability of survival between ages of 25 and 64 years by unemployment level, United States, 1990–2010

Full article at:   http://goo.gl/FI27Gt

By:  Singh GK1, Siahpush M2.

• 1US Department of Health and Human Services, 5600 Fishers Lane, Rockville, MD 20857, USA.
• 2Department of Health Promotion, Social and Behavioral Health, University of Nebraska Medical Center, College of Public Health, Omaha, NE 68198-4365, USA.
• Scientifica (Cairo). 2016;2016:8290435. doi: 10.1155/2016/8290435. Epub 2016 Mar 17. 

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Breast Cancer in a Male to Female Transsexual Patient with a BRCA2 Mutation

Breast cancer is rare in male patients. Certain predisposing factors, be they genetic (e.g. BRCA2 gene mutations) or hormonal (imbalance between estrogen and androgen levels) have been implicated in male breast cancer pathophysiology. 

Male to female (MtF) transsexualism is a condition that generally involves cross-sex hormone therapy. Anti-androgens and estrogens are used to mimic the female hormonal environment and induce the cross-sex secondary characteristics. In certain situations, the change of the hormonal milieu can be disadvantageous and favor the development of hormone-dependent pathologies, such as cancer. 

We report a case of a MtF transgender (TG) patient who developed breast cancer after seven years of cross-sex hormonal therapy. The patient was found to be BRCA2 positive, and suffered recurrent disease. The patient was unaware of being a member of an established BRCA2 mutation positive kindred. 

This represents the first case of a BRCA2 mutation predisposing to breast cancer in a MtF transgender patient.

Purchase full article at:   http://goo.gl/4SsOEP

By:  Corman V1, Potorac I2, Manto F3, Dassy S4, Segers K5, Thiry A6, Bours V7, Daly AF8, Beckers A9.

• 1V Corman, Department of Endocrinology, CHU de Liege, Liege, Belgium.
• 2I Potorac, Department of Endocrinology, CHU de Liege, Liege, 4000, Belgium.
• 3F Manto, Faculty of Medicine, University of Liege, Liege, Belgium.
• 4S Dassy, Department of Oncology, St. Nikolaus-Hospital, Eupen, Belgium.
• 5K Segers, Department of Human Genetics, CHU de Liege, University of Liege, Liege, Belgium.
• 6A Thiry, Department of Anatomo-pathology, CHU de Liege, Liege, Belgium.
• 7V Bours, Department of Human Genetics, CHU de Liege, University of Liege, Liege, Belgium.
• 8A Daly, Department of Endocrinology, University of Liège, Liège, Belgium.
• 9A Beckers, Department of Endocrinology, Domaine Universitaire du Sart-Tilman, CHU de Liege, Liege, Belgium albert.beckers@chu.ulg.ac.be.
• Endocr Relat Cancer. 2016 Mar 21. pii: ERC-16-0057

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Incidence, Duration, Persistence & Factors Associated with High-Risk Anal HPV Persistence among HIV-Negative Men Having Sex with Men

BACKGROUND:

Given high rates of anal disease, we investigated the natural history of high-risk anal HPV among a multi-national group of men having sex with men (MSM) aged 18-64 years.

METHODS:

Anal specimens from HIV-negative men from Brazil, Mexico, and the USA were genotyped. Over 2 years, 406 MSM provided evaluable specimens every six months for ≥2 visits. These men were stratified into men having sex only with men (MSOM, n=70) and men having sex with women and men (MSWM, n=336). Persistence was defined as ≥12-months type-specific duration and could begin with either a prevalent or incident infection. Prevalence ratios and 95% confidence intervals were calculated by Poisson regression.

RESULTS:

Median follow-up time was 2.1 years. Retention was 82%. Annual cumulative incidence of 9-valent vaccine types was 19% and 8% among MSOM and MSWM, respectively (log rank p-value 0.02). Duration of anal HPV did not differ for MSOM and MSWM and was a median of 6.9 months for HPV-16 after combining men from the two groups. Among men with prevalent high-risk infection (n=106), a total of 36.8%, retained the infection for at least 24 months. For those with prevalent HPV-16 (n=27), 29.6% were persistent for at least 24 months. Persistence of high-risk HPV was associated with number of male anal sex partners and inversely associated with number of female sex partners.

CONCLUSIONS:

MSM with prevalent high-risk HPV infection should be considered at increased risk for non-transient infection.

Purchase full article at:   http://goo.gl/B9jEDS

By: Nyitray AG1, Carvalho da Silva RJ2, Chang M3, Baggio ML4, Ingles DJ5, Abrahamsen M6, Papenfuss M6, Lin HY7, Salmerón J8, Quiterio M9, Lazcano-Ponce E9, Villa LL10, Giuliano AR11.

• 1Center for Infectious Diseases, University of Texas School of Public Health at Houston, Houston, TX, USA.
• 2Centro de Referência e Treinamento em DST/AIDS São Paulo, Brazil.
• 3Division of Biostatistics, University of Texas School of Public Health at Houston, Houston, TX, USA.
• 4Center of Translational Oncology, Instituto do Câncer do Estado de São Paulo - ICESP, São Paulo, Brazil.
• 5Vanderbilt Institute for Global Health, Nashville, TN, USA.
• 6Center for Infection Research in Cancer, Moffitt Cancer Center, MRC-CANCONT, Tampa, FL, USA.
• 7Biostatistics, School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA, USA.
• 8Instituto Nacional de Salud Pública, Cuernavaca, Mexico and Instituto Mexicano del Seguro Social, Cuernavaca, Mexico.
• 9Instituto Nacional de Salud Pública, Cuernavaca, México.
• 10Faculdade de Medicina, Universidade de São Paulo Department of Radiology and Oncology, Centro de Investigação Translacional em Oncologia - ICESP, São Paulo, SP, Brazil.
• 11Center for Infection Research in Cancer, Moffitt Cancer Center, Tampa, FL, USA.
• Clin Infect Dis. 2016 Mar 8. pii: ciw140.  

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Prostate Cancer in Gay, Bisexual, and Other Men Who Have Sex with Men: A Review

Purpose:

Prostate cancer in gay, bisexual, and other men who have sex with men (GBM) is an emerging medical and public health concern. The purpose of this review is to summarize the literature on prostate cancer in GBM, including its epidemiology, clinical studies, and anecdotal reports.

Methods:

In 2015, we undertook a structured literature review of all studies from 2000 to 2015.

Results:

Despite prostate cancer being the most common cancer in GBM, the main finding of this review is that prostate cancer in GBM is very under-researched. With only 30 published articles in English (a rate of 1.9 articles per year), most of the literature is limited to case studies or anecdotal reports. There is some evidence of a link between human immunodeficiency virus (HIV)-positive status and prostate cancer, with early studies showing HIV infection as a risk factor and more recent studies as it being protective. Antiretroviral treatment appears protective. Globally, only four quantitative studies have been published. Based on this admittedly limited literature, GBM appear to be screened for prostate cancer less than other men and are diagnosed with prostate cancer at about the same rate, but have poorer sexual function and quality-of-life outcomes.

Conclusion:

Methodological challenges to advancing research include challenges in subject identification, recruitment, heterocentric definitions of dysfunction based on vaginal intercourse and penetrative sex, and inappropriate measures. Six future directions, to advance the study of the effects of prostate cancer in GBM and to improve treatment, are detailed...

[H]eterocentric definitions of functioning limited to penetrative sex are problematic. While DSM-5¹¹⁵ defines “sexual dysfunction” as “a clinically significant disturbance in a person's ability to respond sexually,” erectile functioning in prostate cancer treatment is typically operationalized as “sufficient for vaginal penetration.”^5,116,117 This gold standard is irrelevant for sex between men. Physiologically, anal penetration requires a greater degree of penile rigidity than vaginal penetration,^28,30 which potentially explains the poorer outcomes of prostate cancer treatment for GBM. Population-appropriate measures and definitions need to be developed before the effects of prostate cancer treatment in GBM can be enumerated.

Six directions for future research are identified. First, methodological research is needed to identify ways to locate, recruit, and retain GBM with prostate cancer in studies and to develop population-appropriate definitions and measures. Second, more formative research is needed. In particular, in-depth examination of the effects of treatment on sexual functioning behavior and identities will advance a comprehensive sexological understanding of the experience of prostate cancer in GBM. Third, empirical studies to quantify the prevalence and incidence of sexual problems and effects of treatment by treatment type will be critical to informing clinical care. Fourth, comparative studies of treatment preferences for GBM and heterosexual men should confirm whether GBM are more, as, or less likely than heterosexuals to choose surgical intervention. Fifth, intervention studies to address the rehabilitation needs of GBM with prostate cancer are needed to develop evidence-based interventions tailored for this population. Finally, the training needs of urologists, surgeons, oncologists, and other specialists providing services to GBM with prostate cancer need to be identified and curricula developed to ensure culturally competent providers capable of addressing the sexual health needs and care of this population...

Full article at:   http://goo.gl/Y7ItUl

By:  B.R. Simon Rosser, PhD, MPH, ¹ Enyinnaya Merengwa, MD, MPH, CPH,² Benjamin D. Capistrant, ScD,¹ Alex Iantaffi, PhD,¹ Gunna Kilian,¹ Nidhi Kohli, PhD,³ Badrinath R. Konety, MD, MBA,⁴ Darryl Mitteldorf, MSW, MPA,⁵ and William West, PhD⁶

¹Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota.

²Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, Minnesota.

³Department of Educational Psychology, University of Minnesota, Minneapolis, Minnesota.

⁴Department of Urology, University of Minnesota, Minneapolis, Minnesota.

⁵Malecare Cancer Support, New York, New York.

⁶Department of Writing Studies, University of Minnesota, Minneapolis, Minnesota.

Corresponding author.

Address correspondence to:, B.R. Simon Rosser, PhD, MPH, Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, 1300 South 2nd Street, Suite 300, Minneapolis, MN 55454

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The National LGBT Cancer Action Plan: A White Paper of the 2014 National Summit on Cancer in the LGBT Communities

Despite growing social acceptance of lesbians, gay men, bisexuals, and transgender (LGBT) persons and the extension of marriage rights for same-sex couples, LGBT persons experience stigma and discrimination, including within the healthcare system. 

Each population within the LGBT umbrella term is likely at elevated risk for cancer due to prevalent, significant cancer risk factors, such as tobacco use and human immunodeficiency virus infection; however, cancer incidence and mortality data among LGBT persons are lacking. This absence of cancer incidence data impedes research and policy development, LGBT communities' awareness and activation, and interventions to address cancer disparities. 

In this context, in 2014, a 2-day National Summit on Cancer in the LGBT Communities was convened by a planning committee for the purpose of accelerating progress in identifying and addressing the LGBT communities' concerns and needs in the spheres of cancer research, clinical cancer care, healthcare policy, and advocacy for cancer survivorship and LGBT health equity. 

Summit participants were 56 invited persons from the United States, United Kingdom, and Canada, representatives of diverse identities, experiences, and knowledge about LGBT communities and cancer. Participants shared lessons learned and identified gaps and remedies regarding LGBT cancer concerns across the cancer care continuum from prevention to survivorship. 

This white paper presents background on each of the Summit themes and 16 recommendations covering the following: sexual orientation and gender identity data collection in national and state health surveys and research on LGBT communities and cancer, the clinical care of LGBT persons, and the education and training of healthcare providers...

Recommendations

1. Add SOGI questions to all national health surveys and promote SOGI data collection in diverse healthcare settings so as to better understand psychosocial, behavioral, and medical risk factors that can increase LGBT persons' cancer risk and to examine health outcomes and disparities in each LGBT community.
2. Organize stakeholders and promote education within the NIH and its institutes, centers, and offices, and in particular the NCI, about the health and cancer needs of LGBT communities to arm with facts and sensitize decision-makers who help set scientific and funding priorities.
3. Overcome the gap in financial support of research to develop and test cancer prevention and control interventions targeted and tailored to LGBT communities by issuing research funding opportunities specific to the population.
4. Increase the amount of federal funding dedicated to LGBT cancer research. Furthermore, assure that career development and training grants for under-represented populations in the workforce include those identifying as LGBT and with potential for conducting high-quality cancer research with LGBT communities.ⁱ
5. Address the absence of SEER cancer registry data on SOGI. SEER should consider partnering with cancer researchers to pilot test such an effort, perhaps within a region or state, to identify and overcome barriers to standard collection of SOGI data.
6. Recognize intersectionality within the LGBT communities when conducting cancer research by assessing and examining the impact of SOGI, race, ethnicity, class, disability/ability, and other sociodemographic factors on cancer outcomes across the cancer care continuum.

Recommendations

1. Increase research to document elevated cancer risks and cancer screening disparities in LGBT communities.
2. Develop psychosocial and educational support groups specifically for LGBT survivors and caregivers, and when this is not feasible, assure the cultural competence of professional support service providers to better meet the needs of LGBT communities.
3. Improve care coordination for LGBT patients, survivors, and caregivers through the integration of LGBT community resources. These resources include culturally competent oncologists, primary care and specialty physicians, mental health providers, and other professional providers.
4. Educate healthcare providers about the unique cooccurring conditions that LGBT cancer patients may present in their care settings.
5. Ensure that palliative and end-of-life care addresses the specific legal and psychosocial needs of LGBT communities.
6. Support efforts to increase insurance coverage for LGBT communities, with a focus on the transition and cancer care needs of transgender communities.

Recommendations

1. Develop accreditation agency standards for the provision of culturally competent care to LGBT people and to assure professional training in LGBT cultural competence and health for providers of primary care, cancer screening and treatment, and cancer survivorship healthcare both during their academic training and for those already working in the field. This can be best accomplished by working with LGBT-focused organizations and other content experts in these areas.
2. Educate LGBT communities about their increased cancer risks and the importance of appropriate cancer screening and early detection through outreach by cancer experts through tailored lectures, print materials, internet content, mass media messaging, and other means that will effectively engage the community.
3. Increase representation of LGBT persons in leadership positions and throughout the workforce. The workforce pipeline draws from many streams, but for there to be greater LGBT representation at all levels of the cancer healthcare continuum and in health policy and research, efforts are needed to welcome, include, and develop the potential of LGBT persons within the under-represented populations in the workforce. This will entail collecting SOGI data to track the effectiveness of such efforts, as well as targeting for recruitment of LGBT-identified persons in academic and training programs and assuring that they will experience LGBT-affirmative environments and mentoring opportunities in their new settings.
4. Initiate a comprehensive effort to identify and modify healthcare organization policies that are not inclusive or pose barriers to patient-centered cancer care for LGBT persons. These policies may range from how to manage the comfort and confidentiality of transgender patients presenting for cancer screening based on gender-specific anatomy to providing culturally sensitive psychosocial support for LGBT cancer survivors. Systemic changes promoting equity in LGBT cancer care are more likely to be implemented when an independent prestigious organization advocates such changes and more so when mandated by an accrediting or certifying organization. Furthermore, by instituting collaborations with LGBT advocacy and professional groups, healthcare organizations can establish a lifeline when addressing internal LGBT-related policies, procedures, and patient concerns.

Full article at:   http://goo.gl/2Gl9sl

By:  Jack E. Burkhalter, PhD,1,* Liz Margolies, LCSW,2,* Hrafn Oli Sigurdsson, PhD, NP, PMHNP-BC,3 Jonathan Walland, LLB,4 Asa Radix, MD, MPH,5 David Rice, RN, PhD,6 Francisco O. Buchting, PhD,7 Nelson F. Sanchez, MD,8 Michael G. Bare, MPH,9 Ulrike Boehmer, PhD,10 Sean Cahill, PhD,11 Tomas L. Griebling, MD, MPH,12 Diane Bruessow, PA-C, DFAAPA,13 and Shail Maingi, MD14

¹Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York.

²National LGBT Cancer Network, New York, New York.

³Nursing Professional Development, Memorial Sloan Kettering Cancer Center, New York, New York.

⁴The Office of General Counsel, Memorial Sloan Kettering Cancer Center, New York, New York.

⁵Callen-Lorde Community Health Center, New York, New York.

⁶City of Hope, Duarte, California.

⁷Buchting Consulting, Oakland, California; Horizons Foundation, San Francisco, California.

⁸Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.

⁹Grassroots Change, Oakland, California.

¹⁰Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts.

¹¹The Fenway Institute, Boston, Massachusetts.

¹²Department of Urology, School of Medicine, University of Kansas, Kansas City, Kansas.

¹³Healthy Transitions, LLC, Stirling, New Jersey.

¹⁴St. Peter's Health Partners Cancer Care, Troy, New York.

Corresponding author.

^*Cofirst authors.

Address correspondence to:, Jack E. Burkhalter, PhD, Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 641 Lexington Avenue, 7th Floor, New York, NY 10022,

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Disparities by Sexual Orientation in Frequent Engagement in Cancer-Related Risk Behaviors: A 12-Year Follow-Up

OBJECTIVES:

We examined sexual-orientation disparities in frequent engagement in cancer-related risk indicators of tobacco, alcohol, diet and physical activity, ultraviolet radiation, and sexually transmitted infections (STIs).

METHODS:

We used longitudinal data from the national Growing Up Today Study (1999-2010). Of the analytic sample (n = 9958), 1.8% were lesbian or gay (LG), 1.6% bisexual (BI), 12.1% mostly heterosexual (MH), and 84.5% completely heterosexual (CH).

RESULTS:

More sexual minorities (LGs, BIs, and MHs) than CHs frequently engaged in multiple cancer-related risk behaviors (33%, 29%, 28%, and 19%, respectively). Sexual-minority young women, especially BI and MH, more frequently engaged over time in substance use and diet and physical activity risk than CH women. More young gay than CH men frequently engaged over time in vomiting for weight control (odds ratio [OR] = 3.2; 95% confidence interval [CI] = 1.1, 9.4), being physically inactive (OR = 1.7; 95% CI = 1.2, 2.4), and using tanning booths (OR = 4.7; 95% CI = 3.0, 7.4), and had a higher prevalence of ever having an STI (OR = 3.5; 95% CI = 2.0, 6.4). Individual analyses were generally comparable to the group-level analyses.

CONCLUSIONS:

Young sexual minorities are at risk for cancer through frequent exposure to cancer-related risk behaviors over time. Long-term, longitudinal studies and surveillance data are essential and warranted to track frequent engagement in the risk behaviors and cancer-related morbidity and mortality.

Purchase full article at:   http://goo.gl/IqDFE7

By:  Rosario M1, Li F1, Wypij D1, Roberts AL1, Corliss HL1, Charlton BM1, Frazier AL1, Austin SB1.

• 1Margaret Rosario is with Department of Psychology, City University of New York-City College and Graduate Center, New York, NY. Fei Li and David Wypij are with Department of Biostatistics, Harvard T. H. Chan School of Public Health (HSPH), Boston, MA. David Wypij, Brittany M. Charlton, A. Lindsay Frazier, and S. Bryn Austin are with Department of Pediatrics, Harvard Medical School (HMS), Boston. David Wypij is also with Department of Cardiology, Boston's Children's Hospital, Boston. Andrea L. Roberts is with Department of Social and Behavioral Sciences, HSPH. Heather L. Corliss is with Division of Health Promotion and Behavioral Science at San Diego State University, San Diego, CA. Brittany M. Charlton and S. Bryn Austin are also with Division of Adolescent and Young Adult Medicine, Boston Children's Hospital. A. Lindsay Frazier is also with Dana-Farber Cancer Institute, Boston, and Department of Epidemiology, HSPH. A. Lindsay Frazier and S. Bryn Austin are also with Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, HMS. 
• Am J Public Health. 2016 Jan 21:e1-e9. 

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Cancer Incidences for Women, per 100,000 Population (2012/15)

Via:  https://atlas.qz.com/charts/Ekrf305tg

Mortality in Postmenopausal Women by Sexual Orientation and Veteran Status

PURPOSE OF THE STUDY:

To examine differences in all-cause and cause-specific mortality by sexual orientation and Veteran status among older women.

DESIGN AND METHODS:

Data were from the Women's Health Initiative, with demographic characteristics, psychosocial factors, and health behaviors assessed at baseline (1993-1998) and mortality status from all available data sources through 2014. Women with baseline information on lifetime sexual behavior and Veteran status were included in the analyses (N = 137,639; 1.4% sexual minority, 2.5% Veteran). The four comparison groups included sexual minority Veterans, sexual minority non-Veterans, heterosexual Veterans, and heterosexual non-Veterans. Cox proportional hazard models were used to estimate mortality risk adjusted for demographic, psychosocial, and health variables.

RESULTS:

Sexual minority women had greater all-cause mortality risk than heterosexual women regardless of Veteran status (hazard ratio [HR] = 1.20, 95% confidence interval [CI]: 1.07-1.36) and women Veterans had greater all-cause mortality risk than non-Veterans regardless of sexual orientation (HR = 1.14, 95% CI: 1.06-1.22), but the interaction between sexual orientation and Veteran status was not significant. Sexual minority women were also at greater risk than heterosexual women for cancer-specific mortality, with effects stronger among Veterans compared to non-Veterans (sexual minority × Veteran HR = 1.70, 95% CI: 1.01-2.85).

IMPLICATIONS:

Postmenopausal sexual minority women in the United States, regardless of Veteran status, may be at higher risk for earlier death compared to heterosexuals. Sexual minority women Veterans may have higher risk of cancer-specific mortality compared to their heterosexual counterparts. Examining social determinants of longevity may be an important step to understanding and reducing these disparities.

Full article at:   http://goo.gl/ij9Twq

By:  Lehavot K1, Rillamas-Sun E2, Weitlauf J3, Kimerling R4, Wallace RB5, Sadler AG6, Woods NF7, Shipherd JC8, Mattocks K9, Cirillo DJ10, Stefanick ML11,Simpson TL12.

• 1Health Services Research & Development, VA Puget Sound Health Care System and Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle. keren.lehavot@va.gov.
• 2Division of Public Health Sciences, Fred Hutchinson Cancer Research Center and Health Services Research & Development, VA Puget Sound Health Care System, Seattle, Washington.
• 3Sierra Pacific Mental Illness, Research, Education and Clinical Center and Center for Innovation to Implementation, VA Palo Alto Health Care System, California. Department of Psychiatry & Behavioral Sciences and Stanford Cancer Institute, California.
• 4VA Palo Alto Health Care System, Menlo Park, California.
• 5University of Iowa College of Public Health, Iowa City.
• 6Iowa City VA Medical Center.
• 7University of Washington School of Nursing, Seattle.
• 8VA Boston Healthcare System, National Center for PTSD Women's Health Sciences, Boston University School of Medicine, Massachusetts. LGBTProgram Patient Care Services, Washington DC.
• 9VA Central Western Massachusetts, Leeds. University of Massachusetts Medical School, Worcester.
• 10Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, the University of Iowa Department of Epidemiology, New York.
• 11Stanford Prevention Research Center, Stanford University School of Medicine, California.
• 12Center of Excellence in Substance Abuse Treatment and Education, VA Puget Sound Health Care System and Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle.
• Gerontologist. 2016 Feb;56 Suppl 1:S150-62. doi: 10.1093/geront/gnv125. 

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More about photo: http://www.connecticut.va.gov/services/LGBT.asp