Lesbian, gay and bisexual (LGB) people experience both disparities and resiliencies in health, according to data released July 15th by the Centers for Disease Control and Prevention (CDC). The data os from the 2013 National Health Interview Survey (NHIS), the first NHIS in 57 years to ask a sexual orientation identity question.
NHIS is the nation's largest survey of health status, risk behaviors, health services utilization and health care access. Key findings included:
- Higher rates of cigarette smoking among bisexuals (30%) and gays and lesbians (27%) compared with straight people (20%).
- Higher rates of binge drinking, especially among bisexuals.
- Higher rates of serious psychological stress among bisexuals.
- Lower rates of obesity among gay and bisexual men compared to straight men, and higher rates of obesity among bisexual women and lesbians compared to straight women.
Of a nationally representative sample of nearly 35,000 adults age 18 and older interviewed, NHIS found that:
- 1.6% of adults identified as gay or lesbian.
- 0.7% of adults identified as bisexual.
- A higher percentage of women than men identified as bisexual (0.9% compared with 0.4%).
- Among adults 65 and older, only 0.7% said they were gay or lesbian, and only 0.2% said they were bisexual.
Some LGBT health advocates have suggested that NHIS's finding that 2.3% of adults identify as LGB represents an undercount. It's possible. The CDC's methodology -- face to face interviews -- may lead to lower responses regarding LGB identity than a different approach, such as handing someone a tablet or iPad on which they can complete an anonymous survey. But 2.3% also falls within the range of five U.S. health and demographic surveys that asked about sexual orientation identity analyzed by demographer Gary Gates of the Williams Institute in 2011. Those surveys found that the percentage that identified as LGB ranged from 1.7% (in the National Epidemiological Survey on Alcohol and Related Conditions, 2004-2005) to 5.6% (in the National Survey of Sexual Health and Behavior, 2009). Surveys in Canada, Europe and Australia conducted between 2005 and 2010 found that only between 1.2% and 2.1% of respondents identified as LGB.
It is important to keep the NHIS findings in context, and to understand how significant an accomplishment it is that LGB people are now being counted on this national health survey. The NHIS data confirm important findings regarding health risk behaviors and disparities that we have seen in other studies. LGBT researchers and advocates have been promoting SO/GI questions on surveys since the 1990s. LGBT advocates worked closely with the Obama Administration and prioritized adding both sexual orientation and gender identity (SO/GI) questions to NHIS. A sexual orientation question was pilot tested in 2012 and added to NHIS in 2013. A gender identity question is still being developed. The Institute of Medicine's landmark 2011 report on LGBT health recommended adding SO/GI questions to NHIS and other health and demographic surveys.
Sexual orientation identity questions consistently get the lowest percentage of people saying that they are LGB -- on average about 3.5%. When people are asked if they engage in same-sex behavior, a higher percentage -- around 8% -- indicate that they do. Same-sex attraction gets the highest response rate -- around 11%.
The 2013 NHIS datum on bisexual identity is lower than on other U.S. surveys, which have found about the same percentage of self-identified bisexual men and women as gay men and lesbians. But the higher prevalence of bisexuality among women compared to men found on the 2013 NHIS is consistent with other surveys, as are the lower rates of LGB identity among older adults.
NHIS documented LGB disparities in accessing health care and in insurance coverage:
- Lesbian and bisexual respondents were less likely to have a usual place to go for medical care.
- Lesbians and bisexuals were less likely to obtain medical care in the past year due to cost.
- Bisexuals and lesbians were less likely to have health insurance than others. Gay men were more likely to have health insurance than straight men.
We look forward to future analyses of 2013 NHIS data, and of pooled longitudinal data from several years. We encourage the CDC to look at regional, racial/ethnic and age differences among the LGB sample. We commend the Obama Administration and former Health and Human Services Secretary Sebelius for adding a sexual orientation question to NHIS as part of enhanced LGBT data collection efforts under the Affordable Care Act, and encourage new HHS Secretary Burwell to build on these efforts and expand gender identity data collection as well.
Having data from a large, population-based, national survey which is conducted annually provides important additional knowledge about LGB health disparities, and could enhance our ability to reduce them. Asking about SO/GI in clinical settings and in Electronic Health Records (EHR) -- another step recommended by the 2011 Institute of Medicine report on LGBT health, as well as by a 2010 Joint Commission report on LGBT health -- is also essential to documenting, understanding and reducing LGBT health disparities affecting patients. Combining insights from population-level health surveys and EHR data will improve our ability to provide culturally competent and affirming care to LGBT people.
Sean Cahill, Ph.D. is Director of Health Policy Research at The Fenway Institute. Judy Bradford, Ph.D. is Co-Chair of The Fenway Institute and Director of the Center for Population Research in LGBT Health. Harvey Makadon, M.D. is Director of the National LGBT Health Education Center at The Fenway Institute and Clinical Professor at Harvard Medical School. Bradford and Makadon served on the IOM committee that oversaw the writing of the 2011 report on LGBT health.