Nonresponse to a question on self-identified sexual orientation in a public health survey and its relationship to race and ethnicity

Trends in Sexual Orientation and Gender Identity Data Collection

OBJECTIVE

The aim of this study was to determine response patterns to sexual orientation and gender identity (SOGI) questions in the Behavioral Risk Factor Surveillance System (BRFSS) over time and to assess nonresponse and indeterminate responses by demographic characteristics.

METHODS

This is a secondary data analysis of the SOGI module of the BRFSS. We used data from 46 states and Guam that implemented SOGI questions between 2014 and 2022. We used weighted analyses that accounted for the sampling design, determined SOGI response patterns by year, and assessed nonresponse and indeterminate responses by demographic characteristics.

RESULTS

Over time, increasing numbers self-reported as sexual and gender minority respondents, while heterosexual identity declined. Sexual orientation nonresponse and indeterminate responses increased with time, while respondents' reports of not knowing gender identity declined. Hispanic, older, respondents, those with lower education, and those who completed the questionnaire in Spanish had higher SOGI nonresponse and indeterminate responses.

CONCLUSIONS

The low amount of SOGI nonresponse and indeterminate responses in the BRFSS can be instructive for the implementation of SOGI questions in medical settings. SOGI data collection in all settings requires improving procedures for the groups that have been shown to have elevated nonresponse and indeterminate response.

Inequities in colorectal and breast cancer screening: At the intersection of race/ethnicity, sexuality, and gender

Objective

To investigate the joint impact of sexual orientation, gender identity, and race/ethnicity on colorectal and breast cancer screening disparities in the United States.

Methods

Utilizing sampling weighted data from the 2016 and 2018 Behavioral Risk Factor Surveillance System, we assessed differences in two metrics via chi-square statistics: 1) lifetime uptake, and 2) up-to-date colorectal and breast cancer screening by sexual orientation and gender identity, within and across racial/ethnic classifications.

Results

Within specific races/ethnicities, lifetime CRC screening was higher among gay/lesbian (within NH-White, Hispanic, and Asian/Pacific Islander) and bisexual individuals (Hispanic) compared to straight individuals, and lowest overall among transgender women and transgender nonconforming populations (p < 0.05). Asian transgender women had the lowest lifetime CRC screening (13.0%; w.n. = 1,428). Lifetime breast cancer screening was lowest among the Hispanic bisexual population (86.6%; w.n. = 26,940) and Hispanic transgender nonconforming population (71.8%; w.n. = 739); within all races, SGM individuals (except NH-White, Hispanic, and Black bisexual populations, and NH-White transgender men) had greater breast cancer screening adherence compared to straight individuals.

Conclusions

Due to small, unweighted sample sizes, results should be interpreted with caution. Heterogeneity in screening participation by SGM status within and across racial/ethnic groups were observed, revealing the need to disaggregate data to account for intersecting identities and for studies with larger sample sizes to increase estimate reliability.

Adults' willingness to report sexual orientation and gender identity when registering for a digital health application: A cross-sectional quantitative study

The collection of patient sexual orientation and gender identity information is crucial in identifying and addressing disparities in healthcare access, quality, and outcomes for sexual and gender minority individuals. While some studies have explored patients' willingness to disclose this information in specific settings, little is known about response rates in digital health applications. In light of the growing use of digital health, including virtual care, we sought to determine whether adults would respond to optional sexual orientation and gender identity fields during registration for a digital health application offered through their employer-provided benefits. We analyzed response rates for sexual orientation and gender identity by age, race and ethnicity, and region among individuals over age 17 between September 9th and December 31, 2022. Our study, which included over 41,000 commercially-insured adults from all 50 states, found that nearly 80% were willing to report their sexual orientation and gender identity. However, we observed higher nonresponse rates among older adults and individuals living in central and southern regions, with no consistent pattern by race and ethnicity. Our findings indicate that digital health applications could be a valuable resource for collecting this data from a diverse group of adults. Nevertheless, digital health companies must ensure that they use the data responsibly, identifying quality improvement initiatives and contributing to research that can inform health policies for sexual and gender minority individuals.

Long-term survey of sexual well-being after breast reconstruction using the BREAST-Q in the Japanese population

BACKGROUND

The objective of this study was to identify response patterns related to sexual well-being following breast operations in the Japanese population.

METHODS

Patient-reported outcomes were analyzed at 1 year and 5 years after breast operations, including breast reconstruction, for Japanese women at a single center, with a focus on "Sexual well-being" in BREAST-Q. Response analysis and multiple regression analysis were performed. The scores at years 1 and 5 were also compared across three types of operation: mastectomy only, TE/Imp, and DIEP.

RESULTS

The response rate for Sexual well-being on BREAST-Q in the prospective cohort of patients with breast cancer dropped from 60.0% in postoperative year 1-34.3% in year 5. The mean score for Sexual well-being increased from 32 (year 1) to 38 (year 5). There were significant differences between respondents and non-respondents in age at year 1 (P = 0.007) and for mastectomy only (P = 0.01) and TE/Imp (P = 0.03) at year 5. In regression analysis, only DIEP was positively associated with Sexual well-being at year 1 (p < 0.001) and there were no significant factors at year 5. Among the operative procedures, scores after DIEP were significantly better than those after mastectomy only at year 1 (p < 0.001), but there was no difference at year 5. There were no significant changes from year 1 to year 5 for each operation.

CONCLUSIONS

A low response rate for Sexual well-being on BREAST-Q was found in Japanese women at 5 years postoperatively. This suggests the need for development of a modified evaluative scale that avoids nonresponse bias and considers ethnic differences.

Neighborhood cohesion and psychological distress across race and sexual orientation

Introduction

Method

Result

Conclusion

•

Lesbian, gay, and bisexual (LGB) people are more likely to meet the criteria for psychological distress than non-LGB people.

•

Neighborhood cohesion (NC) has differing impact on psychological distress by race and sexual orientation.

•

NC provides greater protection against moderate distress for non-LGB groups and severe psychological distress for LGB groups.

Functional Limitations and Access to Long-Term Services and Supports Among Sexual Minority Older Adults

Objective: Little is known about sexual minority (SM) older adults' activities of daily living (ADL) and instrumental activities of daily living (IADL) limitations and their subsequent access to long-term services and supports (LTSS). Methods: We analyzed cross-sectional data from the 2016 Health and Retirement Study limited to individuals ≥50 years old. Bivariate analyses were performed to examine 1) sexual identity differences in the prevalence of ADL/IADL limitations and 2) associations of sexual identity with having ADL/IADL limitations and having access to help with ADL/IADL limitations. Results: Our sample consisted of 3833 older adults, 6% (n = 213) were SM. Compared to heterosexual participants, bisexual older adults had greater reports of ADL/IADL limitations (20.9% vs. 35.9%, p = 0.013). Among those who reported having ADL/IADL limitations (n = 803), there were no sexual identity differences in accessing help for ADL/IADL limitations (p = .901). Discussion: Our findings contribute to the limited research on LTSS access among SM older adults.

Hispanic/Latinx ethnic subgroup differences in sociodemographic, sociocultural, and smoking characteristics in a cessation trial: An exploratory study

INTRODUCTION

Hispanic/Latinx smokers in the United States are often treated as a homogeneous group. However, population-based studies suggest cigarette use differs among Hispanic/Latinx subgroups by sociodemographic or sociocultural characteristics. This secondary analysis aimed to advance the limited literature by examining differences in smoking-related variables.

METHODS

We used baseline data from a randomized controlled trial testing a self-help Spanish-language smoking cessation intervention. Puerto Rican (PR), Mexican, and Cuban, the three largest Hispanic/Latinx subgroups in the sample (N=1028), were first compared on sociodemographic and sociocultural variables (acculturation and familism). Primary analyses assessed subgroup differences in cigarette use variables [e.g., cigarettes per day (CPD), nicotine dependence (Fagerström Test for Nicotine Dependence), daily smoking] and smoking-related cognitive constructs (motivation to quit, smoking outcome expectancies and abstinence self-efficacy) controlling for sociodemographic and sociocultural variables. Additional analyses explored differences between men and women within subgroups.

RESULTS

Mexicans exhibited the lowest levels of daily smoking (90% vs. 95% Cubans and 96% PR; p=.001), CPD (M=13.5, SD=9.5 vs. M=20.1, SD=9.9 Cubans and M=16.7, SD=10.1 PR; p=.016), and nicotine dependence (M=4.2, SD=2.3 vs. M=6.0, SD=2.1 Cubans and M=5.7, SD=2.2 PR; p< .001), with no differences between PRs and Cubans. Within-subgroup comparisons between men and women showed the most differences among PRs [e.g., men were more nicotine dependent (M=6.0, SD=1.9) than women (M=5.4, SD=2.3; p=.041)] and Cubans [e.g., men smoked more CPD (M=22.2, SD=12.2) than women (M=19.3, SD=12.0; p=.042)], and the fewest among Mexicans.

CONCLUSIONS

Findings support heterogeneity within Hispanic/Latinx smokers and highlight the potential utility of examining sociodemographic, sociocultural, and smoking characteristics important for developing salient cessation interventions.

IMPLICATIONS

Findings demonstrate that treatment-seeking Hispanic/Latinx smokers in the US differ in sociodemographic, sociocultural, and smoking-related variables (cigarette use and smoking-related cognitive constructs) by subgroup (i.e., Puerto Rican, Mexican, Cuban) and within subgroups by sex. These differences suggest that heterogeneity among subgroups should be considered when developing cessation interventions for Hispanics/Latinxs. Future research should examine how differences in sociodemographic and smoking-related variables impact intervention outcomes and explore the role of sociocultural factors (e.g., acculturation and familism) as determinants of cessation.

Refusal Rates to Sexual Orientation and Gender Identity Items in the Behavioral Risk Factor Surveillance System, 2014-2019

Objectives. To explore trends in sexual orientation and gender identity (SOGI) item refusal in the Behavioral Risk Factor Surveillance System (BRFSS). Methods. We used annual data from 7 US states that implemented the SOGI module of the BRFSS from 2014 to 2019 to examine prevalence of sexual orientation (n = 373 332) and gender identity (n = 373 336) item refusal. Analyses included the weighted Wald χ2 test of association between refusal and year and logistic regressions predicting refusal by year. We weighted analyses to account for complex sampling design. Results. We found low SOGI item refusal rates, significant declines in these refusal rates over time, and differences in refusal rates by age, sex, race, education, and language. We also found that Hispanic group membership did not explain SOGI item refusal when accounting for interview language; interview language was strongly associated with both sexual orientation and gender identity item refusal. Conclusions. Our results indicate acceptance of SOGI measurement and empirically support continuation of SOGI in health surveillance surveys. Findings indicate a need to further investigate the association between survey translation and item refusal.

The Use of Multiple Imputation to Handle Missing Data in Secondary Datasets: Suggested Approaches when Missing Data Results from the Survey Structure

Secondary datasets are used in healthcare research because of its cost advantages, its convenience, and the size of the datasets. However, missing data can cause problems that are difficult to resolve. This manuscript reviews possible causes for missing data, and how to address them. Many researchers use multiple imputation as a solution, which consists of three phases: (a) the imputation phase, (b) the analysis phase, and (c) the pooling phase. When missing data is caused by a refusal to answer or by insufficient knowledge, multiple imputation works well. However, difficulties arise when there are problems with screening questions. If respondents do not answer a screening question, possible answers could be either “yes” or “no.” This paper suggests identifying “yes” responses on the screening question, and setting them aside for use in the analysis. The reasons for this approach are the impossibility of conducting multiple imputation twice, the problem of imputation based on the population after sample weight, and the difficulty of producing logical errors on the estimation in imputation phase. This manuscript uses as an example the techniques used to address missing data from screening questions in a national US dataset. These techniques of multiple imputation using examples from the dataset could be used by researchers in future healthcare research that relies on secondary datasets.

Service Provider Perspectives of Minority Stress among Black, Asian and Minority Ethnic Lesbian, Gay and Bisexual People in the UK

Mental health inequalities among Black, Asian and Minority Ethnic (BAME) people from lesbian, gay and bisexual (LGB) communities persist and remain under-researched. This study is the first in the UK to explore, from the perspective of service providers, minority stress experienced by BAME LGB people. Twenty-three participants were interviewed and data were analyzed using qualitative thematic analysis. Minority stress theory was utilized to inform the analysis, yielding the following themes: (1) Stress induced by conflicting sociocultural norms, (2) interpersonal inhibitors of coming out, (3) and problematic coping. BAME LGB individuals are exposed to stressors due to their intersecting sexual, gender, religious, and cultural identities. Major psychological stressors include stigmatized identity, expectations of a heterosexual marriage, and maladaptive coping strategies. This study sheds light on the potential steps that can be taken to ensure effective coping responses among BAME LGB people.

Sources of Missing Sexual Orientation and Gender Identity Data in the Behavioral Risk Factor Surveillance System

INTRODUCTION

This paper describes the sources, magnitude, and correlates of missing data in the Behavioral Risk Factor Surveillance System Sexual Orientation and Gender Identity module.

METHODS

Missing data from the Behavioral Risk Factor Surveillance System Sexual Orientation and Gender Identity module fielded from 2014 to 2019 were ascribed to 4 sources: the optional nature of the Sexual Orientation and Gender Identity module, out-of-state cell phone respondents, interview termination, and item nonresponse. The prevalence of missingness from these 4 sources was examined in relation to sociodemographic factors and survey process factors. Data were analyzed in 2018-2020.

RESULTS

From 2014 to 2019, of 2,698,738 Behavioral Risk Factor Surveillance System respondents, 1,330,025 (44.8%, weighted) were in states that did not administer the Sexual Orientation and Gender Identity module. Among 723,301 cell phone interviews in states administering the module, 12.5% (weighted) were out of state. Among 1,316,174 otherwise potential respondents, 9.4% (weighted) terminated the interview before Sexual Orientation and Gender Identity module administration. Among 1,205,177 administered the module, item-level missingness was 3.4% for sexual orientation and 1.3% for gender identity. Correlates of missingness varied considerably at each stage.

CONCLUSIONS

Missing the Behavioral Risk Factor Surveillance System Sexual Orientation and Gender Identity data is much more prevalent than item nonresponse alone would suggest. Analytic techniques that consider only item nonresponse, such as complete case analysis, risk producing biased findings. Including the Sexual Orientation and Gender Identity module in the required core demographics section is the only feasible method to reduce the amount and complexity of missing data.

Factors associated with non-adherence to social distancing rules during the COVID-19 pandemic: a logistic regression analysis

BACKGROUND

On March 23, 2020, the government of the United Kingdom told the British people to stay home, an unprecedented request designed to limit the spread of the COVID-19 virus and stop the National Health Service from being overwhelmed.

METHODS

This study undertook a cross-sectional design to survey a convenience sample of 681 residents of North London on their social distancing (SD) behaviours, demographics, housing situation, politics, psychology and social support using an online questionnaire. Logistic regression was used to measure the associations between these explanatory factors and non-adherence to all SD rules and intentional non-adherence to SD rules.

RESULTS

The vast majority (92.8%) of participants did not adhere to all SD rules and nearly half (48.6%) engaged in intentional non-adherence of rules. The odds of not adhering to all SD rules increased if a participant was not identified as highly vulnerable to COVID-19 [OR = 4.5], had lower control over others' distancing [OR = .724], had lower control over responsibilities for which coming into contact with others was unavoidable [OR = .642], and if SD behaviours were reported after lockdown was first relaxed [OR = .261]. The odds of intentionally not adhering to SD rules increased if a participant had a lower intention to socially distance [OR = .468], had lower control over others' distancing [OR = .829], had a doctoral degree compared to a master's degree [OR = .332], a professional qualification [OR = .307], a bachelor's degree [OR = .361] or work-related qualification [OR = .174], voted for the UK Government compared to not voting for the Government [OR = .461], perceived higher normative pressure from neighbours [OR = 1.121] and had greater support from friends [OR = 1.465].

CONCLUSIONS

Non-adherence to all SD rules had a stronger association with vulnerability to COVID-19 and control over SD, whereas intentional non-adherence had a stronger association with intention and anti-social psychological factors. It is recommended that people living in high-risk environments, such as those living in houses of multiple occupancy, should be specially supported when asked to stay at home, and public health messaging should emphasise shared responsibility and public consciousness.

Where Sexual Orientation Has No Name: Sexual Orientation Missing Data in the Canadian Community Health Survey (2005-2014)

This study used data from the Canadian Community Health Survey (CCHS) (2005-2014) to analyze the relationships between sexual orientation item nonresponse and interview language, conversation language, migration status (migrant-non-migrant), cultural background, sex, age, education level, and marital status in a cross-sectional sample over 18 (n = 351,713 participants). Item nonresponse rates oscillated between 0.87% in 2007 and 1.4% in 2014. Individuals who self-declared as belonging to cultural groups such as Chinese, South Asian, South East Asian, Arab, Indigenous and Other had higher nonresponse odds compared to people who self-identified as Whites. The results showed significant higher nonresponse odds among immigrants. Women had higher nonresponse rates. The likelihood of non-answer increased with age and decreased with education. French interviews, interviews in other languages and speaking both English and French produced less nonresponse. Contrary to common beliefs, sexual orientation questions are not too controversial. Sexual orientation nonresponse is low and stable over time suggesting that research participants are willing to answer sexual orientation questions. These findings highlight that immigrants and people who self-declare as belonging to different cultural groups may interpret the sexual orientation questions differently.

Sexual Minority Women in Longitudinal Survey Research: Is Attrition a Problem?

As more longitudinal surveys collect information on sexual orientation, evaluating the quality of these data and understanding how sexual minorities engage with the survey process are increasingly important endeavors. This study constitutes the first systematic analysis of sexual orientation as a predictor of attrition from longitudinal surveys. Drawing upon the minority stress model, we developed testable hypotheses about how sexual identity and sexual identity change relate to panel attrition. These hypotheses were subsequently tested using data from two national cohorts of Australian women from the Australian Longitudinal Study on Women's Health (one born 1973-1978, n = 11,262, and one born 1989-1995, n = 16,689). In the older cohort, sexual minority women were more likely to attrit from the survey than exclusively heterosexual women-largely due to noncontact rather than noncooperation. The associations faded once sociodemographic and health-related covariates were included in the models. Further, higher rates of noncontact were observed among women who changed their sexual identity in a more same-sex-oriented direction, compared to women with a stable sexual identity. None of these associations were apparent in the younger cohort. Taken together, our results suggest that sexual minority status may be a risk factor for panel attrition among older but not younger cohorts of women and that improved efforts to locate and contact participants who are generally vulnerable could increase the retention of sexual minorities in longitudinal studies. Effect sizes were nevertheless small, suggesting that existing research on sexual orientation using longitudinal surveys is unlikely to be biased by non-random attrition of non-heterosexual individuals.

Exposure to the Deepwater Horizon Oil Spill, Associated Resource Loss, and Long-Term Mental and Behavioral Outcomes

OBJECTIVE

The aim of this study was to (1) assess the long-term mental and behavioral health outcomes of the Deepwater Horizon Oil Spill of residents in the Gulf Coast and to (2) identify populations that may be particularly vulnerable to future disasters.

METHODS

The Survey of Trauma, Resilience, and Opportunity in Neighborhoods in the Gulf (STRONG) is a population-representative sample of 2520 coastal residents surveyed in Texas, Louisiana, Alabama, Mississippi, and Florida in 2016. We present prevalence estimates for positive screens of depression, anxiety, and alcohol misuse, as well as receipt of health care services. We examine differences in these outcomes across states, affected occupational groups, and demographic groups.

RESULTS

Resource loss attributed to the spill was associated with positive screens for depression and anxiety. Almost 50% of adults screened positive for depression, anxiety, or alcohol misuse, but less than 20% of these currently access mental health care. Black residents were less likely to have health insurance and a usual source of care but were more likely to have visited the emergency room in the past 12 months.

CONCLUSIONS

Surveillance data from STRONG can help policy-makers and other stakeholders develop targeted approaches to foster resilience, particularly among vulnerable populations, and thereby mitigate the effects of future disasters.

Using Ancillary Sociodemographic Data to Identify Sexual Minority Adults Among Those Responding "Something Else" or "Don't Know" to Sexual Orientation Questions

BACKGROUND

General population surveys are increasingly offering broader response options for questions on sexual orientation-for example, not only gay or lesbian, but also "something else" (SE) and "don't know" (DK). However, these additional response options are potentially confusing for those who may not know what the terms mean. Researchers studying sexual orientation-based disparities face difficult methodological trade-offs regarding how best to classify respondents identifying with the SE and DK categories.

OBJECTIVES

Develop respondent-level probabilities of sexual minority orientation without excluding or misclassifying the potentially ambiguous SE and DK responses. Compare 3 increasingly inclusive analytic approaches for estimating health disparities using a single item: (a) omitting SE and DK respondents; (b) classifying SE as sexual minority and omitting DK; and (c) a new approach classifying only SE and DK respondents with >50% predicted probabilities of being sexual minorities as sexual minority.

MATERIALS AND METHODS

We used the sociodemographic information and follow-up questions for SE and DK respondents in the 2013-2014 National Health Interview Survey to generate predicted probabilities of identifying as a sexual minority adult.

RESULTS

About 94% of the 144 SE respondents and 20% of the 310 DK respondents were predicted to identify as a sexual minority adult, with higher probabilities for younger, wealthier, non-Hispanic white, and urban-dwelling respondents. Using a more specific definition of sexual minority orientation improved the precision of health and health care disparity estimates.

CONCLUSIONS

Predicted probabilities of sexual minority orientation may be used in this and other surveys to improve representation and categorization of those who identify as a sexual minority adult.

Developmental Trends in Sexual Attraction Among Puerto Rican Early Adolescents in Two Contexts

Sexual attraction (SA), the earliest stage of sexual orientation, is scarcely studied. This prospective study examined, over 3 years, prevalence, changes in SA, and the role of context, among 946 Puerto Rican youth, aged 11-13 years at initial assessment in the South Bronx (SBx), New York City, and Puerto Rico (PR). Overall, 98.1% of boys and 95.3% of girls reported opposite-sex only SA at some point, whereas 13.8% of girls and 12.0% of boys reported any-same SA. Opposite-sex only SA increased over time, whereas other SAs decreased except for any same-sex SA among SBx girls. Girls in the SBx and younger youth in PR reported more any same-sex SA. Context and culture may play a role in the developmental trajectories of adolescents' SA.

A Research Note on Canada's LGBT Data Landscape: Where We Are and What the Future Holds

There is a growing international literature on the lives of lesbian, gay, bisexual, and transgender (LGBT) individuals. One of the biggest limitations for researchers in this field continues to be the dearth of population-based surveys that include questions on sexual orientation, gender identity, and high-quality demographic, health, social, political, or economic variables. This research note provides an overview of the current LGBT data landscape in Canada. We start with some of the challenges for researchers studying the LGBT community, including issues of sample size, measurement, response bias, and concealment. Next, we provide an overview of Canadian surveys that include questions on sexual orientation and/or gender identity, including the strengths and weaknesses of each. We end with a brief discussion on newly available administrative data and provide recommendations for researchers and policymakers moving forward.

Health and Access to Care among Reproductive-Age Women by Sexual Orientation and Pregnancy Status

BACKGROUND

A large body of research has documented disparities in health and access to care among sexual minority populations, but very little population-based research has focused on the health care needs among pregnant sexual minority women.

METHODS

Data for this study came from 3,901 reproductive-age (18-44 years) women who identified as lesbian or bisexual and 63,827 reproductive-age women who identified as heterosexual in the 2014-2016 Behavioral Risk Factor Surveillance System. Logistic regression models were used to compare health care access, health outcomes, and health behaviors by sexual orientation and pregnancy status while controlling for demographic characteristics and socioeconomic status.

RESULTS

Approximately 3% of reproductive-age sexual minority women were pregnant. Pregnant sexual minority women were more likely to have unmet medical care needs owing to cost, frequent mental distress, depression, poor/fair health, activity limitations, chronic conditions, and risky health behaviors compared with pregnant heterosexual women. Nonpregnant sexual minority women were more likely to report barriers to care, activity limitations, chronic conditions, smoking, and binge drinking compared with nonpregnant heterosexual women. Health outcomes were similar between pregnant and nonpregnant sexual minority women, but pregnant sexual minority women were more likely to smoke cigarettes every day compared with other women.

CONCLUSIONS

This study adds new population-based research to the limited body of evidence on health and access to care for pregnant sexual minority women who may face stressors, discrimination, and stigma before and during pregnancy. More research and programs should focus on perinatal care that is inclusive of diverse families and sexual orientations.

The Association between State Policy Environments and Self-Rated Health Disparities for Sexual Minorities in the United States

A large body of research has documented disparities in health and access to care for lesbian, gay, and bisexual (LGB) people in the United States. Less research has examined how the level of legal protection afforded to LGB people (the state policy environment) affects health disparities for sexual minorities. This study used data on 14,687 sexual minority adults and 490,071 heterosexual adults from the 2014⁻2016 Behavioral Risk Factor Surveillance System to document differences in health. Unadjusted state-specific prevalence estimates and multivariable logistic regression models were used to compare poor/fair self-rated health by gender, sexual minority status, and state policy environments (comprehensive versus limited protections for LGB people). We found disparities in self-rated health between sexual minority adults and heterosexual adults in most states. On average, sexual minority men in states with limited protections and sexual minority women in states with either comprehensive or limited protections were more likely to report poor/fair self-rated health compared to their heterosexual counterparts. This study adds new findings on the association between state policy environments and self-rated health for sexual minorities and suggests differences in this relationship by gender. The associations and impacts of state-specific policies affecting LGB populations may vary by gender, as well as other intersectional identities.

Prevalence of Obesity, Prediabetes, and Diabetes in Sexual Minority Women of Diverse Races/Ethnicities: Findings From the 2014-2015 BRFSS Surveys

Purpose

The purpose of this study is to assess the weighted prevalence and odds ratios of obesity, prediabetes, and diabetes by (1) female sexual orientation (lesbian, bisexual, and straight) with racial/ethnic (Hispanic, non-Hispanic black, and non-Hispanic white) groups combined and (2) across and within racial/ethnic groups by sexual orientation.

Methods

A secondary analysis of pooled 2014-2015 Behavioral Risk Factor Surveillance System data from 28 states (N = 136 878) was conducted. Rao-Scott chi-square test statistics were computed and logistic regression models were developed to assess weighted prevalence and odds ratios of obesity, prediabetes, and diabetes with adjustments for demographics (age, income, and education), depression, and health care access factors.

Results

With racial/ethnic groups combined, lesbian and bisexual women, relative to straight women, had a significantly increased likelihood for obesity when controlling for demographics. Bisexual women were found to have significantly reduced odds for diabetes, compared with straight women, with adjustments for demographics, depression, and health care access factors. Compared with their non-Hispanic white counterparts, Hispanic lesbian women had significantly increased odds for obesity and diabetes, while non-Hispanic black bisexual women had a significantly greater likelihood for obesity, holding demographics, depression, and health care access factors constant. Non-Hispanic white lesbian women had an increased likelihood for obesity relative to their straight, ethnic/racial counterparts. Prediabetes subsample analysis revealed the prevalence was low across all female sexual orientation groups.

Conclusion

Sexual minority women, particularly those of color, may be at increased risk for obesity and diabetes. Research is needed to confirm the findings.

Sexual and Behavioral Health Disparities Among Sexual Minority Hispanics/Latinos: Findings From the National Health and Nutrition Examination Survey, 2001-2014

INTRODUCTION

Hispanics/Latinos (henceforth, Latinos) are the largest minority group in the U.S. With growing health disparities among this group, the highest burden remains among sexual and gender minority Latinos. Differences regarding sexual orientation have not been fully explored within this group using national representative samples. This study analyzed sexual and behavioral health disparities associated with sexual minority status among Latinos in the U.S.

METHODS

The study included data from 5,598 Latino adults who participated in the 2001-2014 waves of the National Health and Nutrition Examination Survey. Data analysis was conducted in 2016. Bivariate and multivariable logistic regression analyses examined the prevalence of HIV, sexually transmitted infections, mental health problems, cigarette smoking, and alcohol/illicit drug use among sexual minorities and heterosexual Latino adults. Sexual minorities were defined as "gay, lesbian, and bisexual" (GLB) and "other" non-heterosexual groups.

RESULTS

GLB Latinos reported higher prevalence of mental health problems and cigarette smoking compared with heterosexuals. After adjusting for covariates, GLB Latinos had greater odds of testing positive for HIV, lifetime diagnosis of sexually transmitted infections, poor mental health outcomes, cigarette smoking (including lifetime and current smoking status), and illicit drug use than heterosexuals.

CONCLUSIONS

The disproportionate impact of health disparities among Latinos varies significantly by sexual orientation, with GLB individuals facing elevated prevalence. In particular, elevated odds for HIV/sexually transmitted infections, mental health problems, smoking, and illicit substance use were found. Further research, including longitudinal studies to understand the trajectories of risks, is needed to identify intervention opportunities in this population.

Chronic Health Conditions and Key Health Indicators Among Lesbian, Gay, and Bisexual Older US Adults, 2013-2014

OBJECTIVES

To examine disparities in chronic conditions and health indicators among lesbian, gay, and bisexual (LGB) adults aged 50 years or older in the United States.

METHODS

We used data from the 2013 and 2014 National Health Interview Survey to compare disparities in chronic conditions, health outcomes and behaviors, health care access, and preventive health care by sexual orientation and gender.

RESULTS

LGB older adults were significantly more likely than heterosexual older adults to have a weakened immune system and low back or neck pain. In addition, sexual minority older women were more likely than their heterosexual counterparts to report having arthritis, asthma, a heart attack, a stroke, a higher number of chronic conditions, and poor general health. Sexual minority older men were more likely to report having angina pectoris or cancer. Rates of disability and mental distress were higher among LGB older adults.

CONCLUSIONS

At substantial cost to society, many disparities in chronic conditions, disability, and mental distress observed in younger LGB adults persist, whereas others, such as cardiovascular disease risks, present in later life. Interventions are needed to maximize LGB health.

Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity : The EQUALITY Study

Importance

The Institute of Medicine and The Joint Commission recommend routine documentation of patients' sexual orientation in health care settings. Currently, very few health care systems collect these data since patient preferences and health care professionals' support regarding collection of data about patient sexual orientation are unknown.

Objective

To identify the optimal patient-centered approach to collect sexual orientation data in the emergency department (ED) in the Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity study.

Design, Setting, and Participants

An exploratory, sequential, mixed-methods design was used first to evaluate qualitative interviews conducted in the Baltimore, Maryland, and Washington, DC, areas. Fifty-three patients and 26 health care professionals participated in the qualitative interviews. Interviews were followed by a national online survey, in which 1516 (potential) patients (244 lesbian, 289 gay, 179 bisexual, and 804 straight) and 429 ED health care professionals (209 physicians and 220 nurses) participated. Survey participants were recruited using random digit dialing and address-based sampling techniques.

Main Outcomes and Measures

Qualitative interviews were used to obtain the perspectives of patients and health care professionals on sexual orientation data collection, and a quantitative survey was used to gauge patients' and health care professionals' willingness to provide or obtain sexual orientation information.

Results

Mean (SD) age of patient and clinician participants was 49 (16.4) and 51 (9.4) years, respectively. Qualitative interviews suggested that patients were less likely to refuse to provide sexual orientation than providers expected. Nationally, 154 patients (10.3%) reported that they would refuse to provide sexual orientation; however, 333 (77.8%) of all clinicians thought patients would refuse to provide sexual orientation. After adjustment for demographic characteristics, only bisexual patients had increased odds of refusing to provide sexual orientation compared with heterosexual patients (odds ratio, 2.40; 95% CI, 1.26-4.56).

Conclusions and Relevance

Patients and health care professionals have discordant views on routine collection of data on sexual orientation. A minority of patients would refuse to provide sexual orientation. Implementation of a standardized, patient-centered approach for routine collection of sexual orientation data is required on a national scale to help to identify and address health disparities among lesbian, gay, and bisexual populations.

Sexual orientation and treatment-seeking for depression in a multilingual worldwide sample

BACKGROUND

Prior research has found higher rates of mental health problems among sexual minority individuals. We examine treatment-seeking for depression, as well as its relationship with sexual orientation, in a large, multilingual, international sample.

METHOD

Participants in an automated, quintilingual internet-based depression screening tool were screened for depression, and completed several background measures, including sexual orientation (with an option to decline to state) and past and current depression treatment seeking.

RESULTS

3695 participants screened positive for current or past depression and responded to the sexual orientation question. Those who declined to state their sexual orientation were far less likely to seek any treatment than individuals endorsing any orientation; they were especially unlikely to seek psychotherapy. Individuals identifying as bisexual sought both psychotherapy and alternative treatments at a higher rate than other groups. An interaction was observed between sexual orientation and gender, such that lesbian women were especially likely to have used psychotherapy. Other variables that emerged as significant predictors of treatment-seeking for depression included age and participant's language.

LIMITATIONS

Limitations include possible misinterpretation of translated terms due to regional differences, and possible limits to generalizability due to this study being conducted on the internet.

CONCLUSIONS

Our results suggest that individuals who decline to state their sexual orientation may be more likely to forgo effective treatments for depression. Further studies of depression service utilization should focus on developing treatment modalities that could better engage sexual minority individuals, especially those who are reluctant to disclose their orientation.

Disparities in Mental Health Quality of Life Between Hispanic and Non-Hispanic White LGB Midlife and Older Adults and the Influence of Lifetime Discrimination, Social Connectedness, Socioeconomic Status, and Perceived Stress

We assessed factors contributing to ethnic and racial disparities in mental health quality of life (MHQOL) among lesbian, gay, and bisexual (LGB) midlife and older adults. We utilized cross-sectional survey data from a sample of non-Hispanic White and Hispanic LGB adults aged 50 and older. Structural equation modeling was used to test the indirect effect of ethnicity/race on MHQOL via explanatory factors including social connectedness, lifetime discrimination, socioeconomic status (SES), and perceived stress. Hispanics reported significantly lower levels of MHQOL, compared to non-Hispanic Whites. In the final model, the association between ethnicity/race and MHQOL was explained by higher levels of perceived stress related to lower SES, higher frequency of lifetime discrimination, and lack of social connectedness among Hispanic LGB adults. This study suggests that perceived stress related to social disadvantage and marginalization plays an important role in MHQOL disparities among Hispanic LGB midlife and older adults.

A systematic review of the literature on weight in sexual minority women

BACKGROUND

Over the past 20 years, a growing literature has demonstrated that sexual minority women have greater weight than heterosexual women, prompting concern that they may be at high risk for disparities in physical disorders. In 2008, Bowen et al. published a review of the existing research on sexual minority women and obesity, finding no methodologically strong studies with representative sampling procedures.

METHOD

We conducted a systematic review of the literature covering the period of July 2006 to February 2014 on the relationship between sexual orientation and weight. The review includes 20 population-based and 17 nonprobability sample studies.

CONCLUSIONS

The majority of these studies found that lesbian and bisexual women had significantly greater body mass index (BMI) or a higher percentage with a BMI over 30 than heterosexual women. The difference in BMI was fairly consistent across the lifespan, with the weight differences beginning in adolescence. The studies, however, did not show a higher prevalence of physical disorders thought to be associated with weight. This potentially paradoxical finding warrants further research to compare prevalence of chronic disease by BMI category and sexual orientation.

Differences by Sexual Orientation in Expectations About Future Long-Term Care Needs Among Adults 40 to 65 Years Old

OBJECTIVES

We examined whether and how lesbian, gay, and bisexual (LGB) adults between 40 and 65 years of age differ from heterosexual adults in long-term care (LTC) expectations.

METHODS

Our data were derived from the 2013 National Health Interview Survey. We used ordered logistic regression to compare the odds of expected future use of LTC among LGB (n = 297) and heterosexual (n = 13 120) adults. We also used logistic regression models to assess the odds of expecting to use specific sources of care. All models controlled for key socioeconomic characteristics.

RESULTS

Although LGB adults had greater expectations of needing LTC in the future than their heterosexual counterparts, that association was largely explained by sociodemographic and health differences. After control for these differentials, LGB adults were less likely to expect care from family and more likely to expect to use institutional care in old age.

CONCLUSIONS

LGB adults may rely more heavily than heterosexual adults on formal systems of care. As the older population continues to diversify, nursing homes and assisted living facilities should work to ensure safety and culturally sensitive best practices for older LGB groups.

Trends in sexual orientation missing data over a decade of the California Health Interview Survey

OBJECTIVES

We explored changes in sexual orientation question item completion in a large statewide health survey.

METHODS

We used 2003 to 2011 California Health Interview Survey data to investigate sexual orientation item nonresponse and sexual minority self-identification trends in a cross-sectional sample representing the noninstitutionalized California household population aged 18 to 70 years (n = 182 812 adults).

RESULTS

Asians, Hispanics, limited-English-proficient respondents, and those interviewed in non-English languages showed the greatest declines in sexual orientation item nonresponse. Asian women, regardless of English-proficiency status, had the highest odds of item nonresponse. Spanish interviews produced more nonresponse than English interviews and Asian-language interviews produced less nonresponse when we controlled for demographic factors and survey cycle. Sexual minority self-identification increased in concert with the item nonresponse decline.

CONCLUSIONS

Sexual orientation nonresponse declines and the increase in sexual minority identification suggest greater acceptability of sexual orientation assessment in surveys. Item nonresponse rate convergence among races/ethnicities, language proficiency groups, and interview languages shows that sexual orientation can be measured in surveys of diverse populations.

The health equity promotion model: Reconceptualization of lesbian, gay, bisexual, and transgender (LGBT) health disparities

National health initiatives emphasize the importance of eliminating health disparities among historically disadvantaged populations. Yet, few studies have examined the range of health outcomes among lesbian, gay, bisexual, and transgender (LGBT) people. To stimulate more inclusive research in the area, we present the Health Equity Promotion Model-a framework oriented toward LGBT people reaching their full mental and physical health potential that considers both positive and adverse health-related circumstances. The model highlights (a) heterogeneity and intersectionality within LGBT communities; (b) the influence of structural and environmental context; and (c) both health-promoting and adverse pathways that encompass behavioral, social, psychological, and biological processes. It also expands upon earlier conceptualizations of sexual minority health by integrating a life course development perspective within the health-promotion model. By explicating the important role of agency and resilience as well as the deleterious effect of social structures on health outcomes, it supports policy and social justice to advance health and well-being in these communities. Important directions for future research as well as implications for health-promotion interventions and policies are offered.

Chronic Physical Health Problems in Sexual Minority Women: Review of the Literature

Although there is substantial literature about sexual minority women's mental health and use of alcohol, tobacco, and other drugs (ATOD), only recently has attention been focused on chronic physical health disorders thought to stem from stress and exposure to ATOD use. The most extensively studied aspect of physical health has been weight, with the majority of studies reporting higher prevalence of overweight and obesity. In addition, many studies report higher levels of stressful experiences in both childhood and adulthood for sexual minority women. In this paper, the hypothesized relationship between stress, unhealthy behaviors, and five common chronic physical health disorders is explored via review of the literature. Only asthma appeared to be consistently more common in sexual minority women, and few or no differences in diabetes, hypertension, cardiovascular disease, and most cancers were found. The limitations of these studies are reviewed, and the need for studies that directly address the relationships among stress, health-damaging practices, and chronic disorder is emphasized. However, if these findings hold up, and sexual minority women are not more prone to these disorders, the field may need better theoretical frameworks from which to explore potential differences in the manifestation of mental versus chronic physical health disparities.

A profile of North Carolina lesbian, gay, and bisexual health disparities, 2011

OBJECTIVES

We investigated the health profile of lesbian, gay, and bisexual (LGB) adults in North Carolina, the first state in the South to include a measure of sexual orientation identity in a probability-based statewide health survey.

METHODS

Using data from 9876 respondents in the 2011 North Carolina Behavioral Risk Factor Surveillance Survey, we compared sexual minorities to heterosexuals on a variety of health indicators.

RESULTS

LGB respondents were younger and more likely to be reached by cell phone. Many examined indicators were not different by sexual orientation. Significant results, however, were consistent with findings from state population surveys in other regions of the country, including disparities in mental health and, among women, smoking.

CONCLUSIONS

Reporting LGB identity in North Carolina is associated with poorer health. The concentration of anti-LGB policies in the South warrants ongoing monitoring of LGB health disparities in North Carolina and in other Southeastern states for potential effects on the health and well-being of LGB populations.

Health inequalities among sexual minority adults: evidence from ten U.S. states, 2010

BACKGROUND

Improving the health of lesbian, gay, and bisexual (LGB) individuals is a Healthy People 2020 goal; however, the IOM highlighted the paucity of information currently available about LGB populations.

PURPOSE

To compare health indicators by gender and sexual orientation statuses.

METHODS

Data are from Behavioral Risk Factor Surveillance System surveys conducted January-December of 2010 with population-based samples of non-institutionalized U.S. adults aged over 18 years (N=93,414) in ten states that asked about respondents' sexual orientation (response rates=41.1%-65.6%). Analyses were stratified by gender and sexual orientation to compare indicators of mental health, physical health, risk behaviors, preventive health behaviors, screening tests, health care utilization, and medical diagnoses. Analyses were conducted in March 2013.

RESULTS

Overall, 2.4% (95% CI=2.2, 2.7) of the sample identified as LGB. All sexual minority groups were more likely to be current smokers than their heterosexual peers. Compared with heterosexual women, lesbian women had more than 30% decreased odds of having an annual routine physical exam, and bisexual women had more than 2.5 times the odds of not seeking medical care owing to cost. Compared with heterosexual men, gay men were less likely to be overweight or obese, and bisexual men were twice as likely to report a lifetime asthma diagnosis.

CONCLUSIONS

This study represents one of the largest samples of LGB adults and finds important health inequalities, including that bisexual women bear particularly high burdens of health disparities. Further work is needed to identify causes of and intervention for these disparities.

Time for Transformation: Public Policy Must Change to Achieve Health Equity for LGBT Older Adults

The marriage equality movement and the Affordable Care Act have enormous potential to reduce health disparities in LGBT elders, but more data and additional policy changes are sorely needed.

Physical health indicators among lesbian, gay, and bisexual U.S. veterans

PURPOSE

To provide information about lesbian, gay, and bisexual (LGB) veterans' health status, diagnoses, and health screening behaviors compared with heterosexual veterans.

METHODS

Data are from 10 states' 2010 Behavioral Risk Factor Surveillance System surveys that contained sexual orientation data for veterans (n = 11,665). χ(2) tests and multiple logistic regression were used to examine outcomes among LGB and heterosexual veterans.

RESULTS

More LGB than heterosexual veterans reported current smoking, not seeking medical care owing to cost, and activity limitations. Compared with heterosexual veterans, LGB veterans had greater odds of ever having an human immunodeficiency virus test (odds ratio [OR], 5.42; 95% confidence interval [CI], 3.28-8.96) but lower odds of diabetes diagnosis (OR, 0.55; 95% CI, 0.34-0.89).

CONCLUSIONS

Findings from this sample suggest patterns of health behaviors and outcomes among LGB veterans that are both unique from and similar to results from general samples of LGB persons. With the formal end of the "Don't Ask, Don't Tell" policy that discriminated against LGB people in the military, institutions such as the Department of Veterans Affairs are likely to see an increase in its current population of LGB veterans. The Department of Veterans Affairs stands in a unique place to meet the health equity needs of this minority population.