Sun protection use and habits in the LGBTQI+ community in Lebanon: A cross sectional study

Sun exposure is an extrinsic risk factor for skin aging, wrinkle formation, and the development of skin cancer, namely melanoma, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC). Sun protection measures have emerged as an important means of preventing these harmful effects. Studies have shown that sexual minority men have a greater prevalence of skin cancer than heterosexual men.


| INTRODUC TI ON
Our skin is exposed to sunlight on a daily basis.Sun exposure is an extrinsic risk factor for skin aging, wrinkle formation, and the development of skin cancer, namely melanoma, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC).Sun protection measures have emerged as an important means of preventing these harmful effects.They have been shown to decrease the risk of skin cancer, photo-aging, and disorders of hyperpigmentation, as well as play an important role in the management of photosensitive skin disorders. 1xual and gender minority (SGM) populations, according to the National Institutes of Health, "include, but are not limited to, individuals who identify as lesbian, gay, bisexual, asexual, transgender, two-spirit, queer, and/or intersex".Studies have shown that sexual minority men have a greater prevalence of skin cancer than heterosexual men.A recently published analysis of a nation-wide questionnaire in the United States (US) showed that gay and bisexual men, of which 7516 and 5088 were included respectively, had significantly elevated odds of developing skin cancer than heterosexual men, with an odds ratio of 1.26 for gay men and 1.48 for bisexual men. 2 In a previous cross-sectional study that included 3083 homosexual, gay, or bisexual men, it was also found that this group of men was more likely to report having tanned indoors. 3ere is limited research investigating the reasons behind this risk of skin cancer development.This is especially important because identifying preventable risk factors, like those pertaining to sun exposure behaviors, can be targeted in the fight against skin cancer and help establish screening tools and preventive interventions for the SGM community.To our knowledge, studies have not previously investigated the sun protection behaviors/awareness practiced by SGM individuals and the prevalence of skin cancer in Lebanon.
In this study, we examined the habits of sun protection use, sun protection measures, and tanning habits among adults in the Lebanese SGM community, and aimed to explore the possible association between having a history of skin cancer or other photo-related skin conditions and sun protection awareness.

| Study design
This study is an Institutional Review Board (IRB)-approved, crosssectional study conducted to assess the use and habits of sun protection among adults in the SGM community in Lebanon.It was conducted as a survey that patients filled anonymously.The survey included questions about our patients' demographics, sun protection habits, sun protection measures, medical knowledge, and health resources (Supplementary document).

| Sampling strategy
The study population consisted of adults presenting to the dermatology clinics at the American University of Beirut Medical Center  Adults aged 18-80 years of age were recruited.Those who are not proficient in spoken English or Arabic and those who are mentally or visually impaired were excluded.To note, illiterate patients displayed notably higher SPF use (72.2%), compared to those obtaining information from media (18.2%) or family and friends (5.3%).
Discussion: Surveying the perception of the Lebanese SGM community towards sun damage and their adaptive practices to prevent it can help implement and gear a nation-wide campaign to spread proper awareness about this subject.Studying their behavioral tendencies for not using sunscreen can help overcome this contributing risk factor for skin cancers.

Conclusion:
Future investigations have yet to identify confounding variables contributing to higher levels of skin cancers in this population.

K E Y W O R D S
LGBTQI+, skin cancer, sunscreen were not excluded from the study, as they were assisted in filling the survey.
The prevalence of LGBTQI+ people in the United States is estimated at 4.5%. 4Since there is no data on the percentage of SGM in Lebanon, we assumed that a similar proportion of the Lebanese population is LGBTQI+, and we expected 4.5% of a sample from the general population to belong to this group.Hence, we aimed to have a sample of around 100 SGM participants, targeted at the nongovernmental organizations SIDC and Helem, where many SGM individuals are expected to be present, fill our questionnaire.Patients were recruited throughout the entire year, documenting responses during each of the four seasons to have a more representative sample.

| Statistical analysis
Data analysis was performed using SPSS (IBM SPSS 25.0).Categorical variables were presented using frequencies and percentages, while continuous variables were presented using mean and standard deviation (mean ± SD).Pearson's Chi-square and Fisher's exact tests were used to evaluate the associations between the different categorical variables.Significance was interpreted at α ≤0.05.

| RE SULTS
A total of 129 participants agreed to participate and answered our questionnaire (Table 1).The ages of the participants ranged between 18 and 51 years, with a mean of 28.98 years and a standard deviation (SD) of 7.1 years.Out of the 129 participants, 66 (50.8%) identified as gay, 21 (16.2%) as lesbian, 18 (13.8%)as bisexual, 5 (3.8%) as asexual and 19 (14.6%) identified their sexual orientation as other than the mentioned above.The majority of our participants had an undergraduate degree (43.1%), almost a quarter (23.1%) had a graduate degree, a quarter (25.4%) had a school degree and only a minority (6.9%) had a technical degree (Table 1).

TA B L E 1
Demographics and tanning habits of the selected population.Reasons for tanning varied among our participants: tanning to get a color (13.1%), tanning to get vitamin D (4.6%), tanning socially (6.9%), and tanning for mood elevation (0.8%) (Table 1).Almost half of the participants (46.9%) reported tanning for more than one reason mentioned above.As for the products used while tanning, more than half of the participants, 53.1%, reported using a tanning oil or a sunscreen with SPF, compared to 24.6% who used tanning oil without SPF and 11.5% who reported using Vaseline petroleum jelly or baby oil.Around 8.5% reported using tanning products other than the mentioned above (Table 1).
Although there was no significant association between sex- A higher percentage of SPF use was noted among those who had an office job as compared to those with a field job and those who are unemployed (31.4% vs. 28.6% vs. 18.6% respectively).
Nevertheless, no significant association was noted between the type of job and SPF use (p = 0.601).Despite no significance between SPF use and the highest educational degree attained (p = 0.070), the tendency to use SPF increased with higher levels of education.Only 10% of school degree holders reported SPF use, compared to 22.2% in those with a technical degree, 28.6% in those who held an undergraduate degree, and 40% in those who held a graduate degree (Table 3).
There was no significant association noted between knowledge that the sun causes skin cancer and SPF use (p = 0.067).The majority of participants (64.6%) who showed knowledge that sun causes skin cancer reported not using SPF, and only 32.9% reported using SPF.Likewise, more than half of the participants (64.7%) who did not know that sun causes skin cancer did not use SPF.No statistically significant association was noted between the knowledge that the sun causes pigmentation and SPF use (p = 0.325); only 32.1% of participants who had knowledge about the risks of pigmentation used SPF as compared to 27.3% who actually used SPF without knowing this risk (Table 4).
A significant association was found between the source of information that was used for sun protection information and SPF use (p < 0.001), where participants who obtained information from their dermatologists had significantly higher proportions of SPF use (72.2%) as compared to participants who obtained their information from media (18.2%), family and friends (5.3%) and those that used more than one source (26.7%,Table 5).

| DISCUSS ION
Among SGM groups, it has been reported that sexual minority men in the US are more likely to tan indoors and less likely to use protective clothes when outdoors.However, they were also more likely to avoid sun exposure and, when exposed, to use sunscreen and seek shade while outdoors. 5Still, the male population in the SGM community has been shown to tan more and protect less from the sun when compared to the heterosexual counterpart.There was an opposite relationship between females in the SGM community compared to the heteronormative one. 5One can assume that increased sun exposure is a modifiable contributing factor for the high risk of

TA B L E 2
The association between sexual orientation, SPF use and tanning bed use.

Yes N(%) No N(%) Total
Sexual orientation  6 Further research demonstrated that the genus beta of HPV amplifies the process of UV-induced DNA damage leading to skin cancer. 7Due to the high prevalence of HPV among SGM, it could be considered another relevant modifiable risk factor for the higher skin cancer in this population.
In 2011, a review on the prevalence of sunburn, sun-protection behaviors, and indoor tanning among US adults, adolescents, and children, found that around 3 in 10 adults routinely follow sunprotection practices. 8Sun protection practices were also correlated

TA B L E 3
The association between occupation, the highest degree attained and SPF use.

TA B L E 5
The association between the source of sun protection information and the use of SPF.

Yes N(%) No N(%) I do not know N(%) Total N(%)
Source of sun protection information with demographic factors.For example, adults were less likely to use sunscreen if their income was much lower than the poverty level.
Concurrently, household income was directly correlated with sunscreen use, which may suggest that cost is a barrier to sunscreen use. 9In our study, we found similar associations where people with office jobs were more inclined to wear sunscreen than people with field jobs regardless of their sexual orientation.This could be explained by the more stable higher income that comes with office jobs in our country, despite sun exposure in field jobs.In addition, people who were unemployed were the least inclined to use sunscreen, which matches the aforementioned study regarding the cost barrier of SPF or, more so, the probable lower socio-economic status, and level of education.In support of the latter, education level appears to be an important factor in regulating sunscreen use.People with low educational level reported less frequent sunscreen use and lower SPF factor, compared with people with a higher educational level. 10Concurrently, our study found that those who had a graduate degree more frequently wore sunscreen than those with a lower degree of education.However, among each of the participant educational groups, a higher percentage of participants did not wear SPF than those who did.
In our study, the LGBTQI+ community seemed to seek exposure to the sun for various reasons including social tanning, getting a darker skin color, increasing vitamin D levels, and elevating the mood.
Similarly, a recently developed biopsychosocial model revealed that mood/affect regulation and appearance reasons played a significant role in the motivation towards indoor tanning in the SGM community. 11Studies found that gay and bisexual men had higher rates of indoor tanning and had a higher risk of developing melanoma. 12terestingly, unlike these mentioned studies, in Lebanon most of our studied population did not have a previous history of artificial tanning.Whether these habits translate to a lower incidence of skin cancer among the Lebanese SGM population compared to those reported in the US-based studies is an issue has yet to be explored.
Lebanon is a Mediterranean country situated between Greece and Saudi Arabia both geographically and in terms of cultural norms, so we have yet to discover what level of awareness is most adopted here.The only study that has looked into sun protection habits in Lebanon was conducted on teenagers from the general population, in 2004. 13Although most were aware that sunscreen is protective, the vast majority reported enjoying tanning in the summer.Similarly, among our SGM population, even though the majority knew that sun exposure causes skin cancer and dyspigmentation, they did not report adopting sun protective measures, namely using SPF.Further investigations in the adult Lebanese population would be crucial to understand their sun protective habits and practices, as well as potentially compare them to those practiced by the SGM population.
In the previously mentioned Lebanese study, the most common source of information regarding the risks of sun exposure were television and journals, rather than radio, school, or doctors.
A group in Peru interviewed outpatients treated at dermatology clinics to assess their knowledge, attitudes, and practices about sun exposure and photoprotection.This population showed an appropriate degree of awareness about sun-protective behaviors, which could be attributed to their contact with a dermatologist during their visits at their clinics. 14In our study, a statistically significant relationship was found between SGM participants who got their skin health and sun protection information from dermatologists and SPF use compared to other sources of information.
These outcomes indicate that dermatologists are at the forefront of this awareness campaign tackling sun protective measures, skin health and skin cancer prevention, especially in the SGM community.
Indeed, our population is relatively limited in size and only addressed people from the SGM community.In addition, some of the questions in the survey had a low response rate and could not be reported or analyzed, which could have contributed to the decrease in significance of our results.Nevertheless, there was no significant difference between SPF use and sexual orientation; all members of this community showed a tendency towards not using SPF.The nationwide awareness and educational campaigns abroad, which we lack, might have contributed to a higher proportion of patients abiding to sunscreen use.More acceptance and diversity in the Western countries probably led to a higher awareness and more support groups educating about better sun protective measures.The SGM community is still marginalized in our country, and people who identify as such might find it difficult to reach out for help or seek medical advice.This could have contributed to the discrepancy in awareness and appropriate sun protective behaviors.

| CON CLUS ION
This study focused on members of the SGM community and demonstrated their tendency not to use sun-protective measures, as well as their deficits in knowledge of skin cancer prevention.Surveying the perception of the Lebanese SGM community towards sun damage and their adaptive practices to prevent it, can help implement and gear a nation-wide campaign to spread proper awareness about this subject.Studying their behavioral tendencies for not using sunscreen can help overcome this contributing risk factor for skin cancers.Future investigations have yet to identify confounding variables contributing to higher levels of skin cancers in this population.

(
AUBMC) for any dermatological complaint, in addition to adults presenting to the organizations Helem and SIDC.Helem is the first lesbian, gay, bisexual, transgender, queer, intersex (LGBTQI+) rights organization in the Arab world, officially established in Beirut, Lebanon in 2004.It is a nongovernmental organization, with a mission to lead the nonviolent struggle for the liberation of LGBTQI+ and other persons with nonconforming sexualities and/or gender identities in Lebanon and the Middle East and North Africa (MENA) region against violations of their individual and collective civil, political, economic, social, and cultural rights.
SIDC's mission is to develop social solidarity by reinforcing healthy behavior in Lebanon through community empowerment, prevention, harm reduction policies, advocacy, and psychosocial services.They provide all the necessary information about protective behaviors to reduce the risk of HIV and Hepatitis B/C transmission as well as the harms resulting from drug use, especially among vulnerable populations like SGM individuals.
Some of these factors include alcohol and tobacco use, concomitant human immunodeficiency virus (HIV) and/or HPV infection, and the use of estrogen hormone therapy which are all prevalent in the SGM community.AUTH O R CO NTR I B UTI O N SAll authors have read and approved the final manuscript.Nohra Ghaoui, Divina Justina Hasbani, Sally Hassan, and Dana Saade wrote the paper and analyzed the data.Nohra Ghaoui, Divina Justina Hasbani, Sally Hassan, Tarek Bandali, and Serena Saade The association between SPF use and having knowledge that sun causes skin cancer and sun causes pigmentation.