Challenges and Solutions to Collecting Sexual Orientation and Gender Identity Data

Limitations of Sexual Orientation and Gender Identity Information as Reported in the National Violent Death Reporting System

The National Violent Death Reporting System (NVDRS) is a Centers for Disease Control and Prevention (CDC) restricted-access database detailing precipitating circumstances to U.S. violent deaths. In 2013 and 2015, the CDC added codes denoting sexual orientation and gender identity (SOGI) and sex of partner. In the past decade, researchers have leveraged NVDRS data to document SOGI-related patterns and characteristics of violent death including suicide. Yet, there are substantial limitations to NVDRS SOGI information that should be considered in responsible reporting by researchers and informed assessment by reviewers. In this perspective, we summarize some of these challenges and offer recommendations for using NVDRS SOGI data responsibly.

Sexual orientation in transgender adults in the United States

BACKGROUND

Sexual orientation refers to a person's enduring emotional, romantic, or sexual attractions to other people. Sexual orientation measures do not typically consider desires for, or sexual behavior with, transgender people. We describe measures inclusive of transgender people and characterize sexual orientation identity, behavior, and attraction in a representative sample of the U.S. transgender population.

METHODS

Between April 2016-December 2018, a U.S. national probability sample of transgender (n = 274) and cisgender (n = 1,162) adults were invited to complete a self-administered web or mailed paper survey. We assessed sexual identity with updated response options inclusive of recent identity terms (e.g., queer), and revised sexual behavior and attraction measures that included transgender people. Multiple response options were allowed for sexual behavior and attraction. Weighted descriptive statistics and sexual orientation differences by gender identity groups were estimated using age-adjusted comparisons.

RESULTS

Compared to the cisgender population, the transgender population was more likely to identify as a sexual minority and have heterogeneity in sexual orientation, behavior, and attraction. In the transgender population, the most frequently endorsed sexual orientation identities were "bisexual" (18.9%), "queer" (18.1%), and "straight" (17.6%). Sexually active transgender respondents reported diverse partners in the prior 5 years: 52.6% cisgender women (CW), 42.7% cisgender men (CM), 16.9% transgender women (TW), and 19.5% transgender men (TM); 27.7% did not have sex in the past 5 years. Overall, 73.6% were "somewhat"/ "very" attracted to CW, 58.3% CM, 56.8% TW, 52.4% TM, 59.9% genderqueer/nonbinary-females-at-birth, 51.9% genderqueer/nonbinary-males-at-birth. Sexual orientation identity, behavior, and attraction significantly differed by gender identity for TW, TM, and nonbinary participants (all p < 0.05).

CONCLUSIONS

Inclusive measures of sexual orientation captured diverse sexual identities, partner genders, and desires. Future research is needed to cognitively test and validate these measures, especially with cisgender respondents, and to assess the relation of sexual orientation and health for transgender people.

How to Ensure Inclusivity in Large-Scale General Population Cohort Studies? Lessons Learned with Regard to Including and Assessing Sex, Gender, and Sexual Orientation

Despite recent advances in the measurement of sex, gender, and sexual orientation in large-scale cohort studies, the three concepts are still gaining relatively little attention, may be mistakenly equated, or non-informatively operationalized. The resulting imprecise or lacking information hereon in studies is problematic, as sex, gender, and sexual orientation are important health-related factors. Omission of these concepts from general population cohort studies might dismiss participants' identity and experiences and pushes research on sexual or gender minority populations toward purposive sampling, potentially introducing selection bias. It also reinforces the unintentional notion of irrelevance of these concepts to health research, ultimately disadvantaging sexual and gender minority populations. Similarly, a lack of uniform measures on sex, gender, and sexual orientation hampers multi-cohort studies in which data from multiple studies are combined, facilitating increased statistical power. This paper discusses the encountered pitfalls and lessons learned on including and assessing sex, gender, and sexual orientation in large-scale general population cohort studies, exemplified by the Dutch Lifelines Cohort Study. Additionally, we propose hands-on strategies on how to operationalize these concepts in an inclusive manner that is useful for large-scale general population cohort studies.

Association of receiving opioid medication-assisted treatment with sexual identity and mental health/substance use disorder symptoms in a nationally representative sample of adults

Background

Although the literature suggests that medication-assisted treatment (MAT) is an effective treatment for opioid use disorder, limited studies have assessed the prevalence or the association between MAT use and sexual identity, mental health, or substance use disorder among a nationally representative sample. We assessed the prevalence and association of opioid MAT use between sexual identity, depressive disorder symptoms, alcohol use dependence, and marijuana use dependence in the United States.

Methods

We used the 2019 National Survey on Drug Use and Health public-use data on adults aged 18-64 years (N = 38,841) to conduct a weighted multivariable logistic regression analysis.

Results

A total of 4.80% and 2.32% of the population identified as bisexual and lesbian/gay, respectively. About 0.31% (612,750 people) of the population reported receiving opioid MAT, 3.73% had alcohol use dependence, 1.42% had marijuana use dependence, and 9.13% had major depressive episode (MDE) symptoms. Of those who had received opioid MAT, 0.57% were bisexuals and 1.07% were lesbians/gays, 0.65% were people with alcohol use dependence, 2.32% with marijuana use dependence, and 1.59% with MDE symptoms. Lesbian/gay individuals were more likely to receive opioid MAT (AOR = 3.43, 95% CI = 1.42, 8.25) compared to heterosexual individuals. The odds were higher for people with marijuana use dependence (AOR = 3.44, 95% CI = 1.47, 8.06) and MDE symptoms (AOR = 5.22, 95% CI = 3.46, 7.89) than their counterparts.

Conclusions

In this study, sexual minorities, people with MDE symptoms, and those dependent on marijuana use were more likely to receive opioid MAT, suggesting the need to investigate further opioid use disorder symptoms and their risk factors among these populations.

Food insecurity and SNAP use among sexual minority people: analysis of a population-based sample from National Health Interview Survey, 2017

Background

Food insecurity is a pressing public health problem. Lesbian, gay, and bisexual (LGB) people are at increased risk for food insecurity, yet this issue remains grossly understudied among this population. The purpose of this study was to add to the existing literature surrounding food insecurity and the use of federal food assistance programs (SNAP) among LGB people.

Methods

This study used publicly available, de-identified data from the 2017 National Health Interview Survey (NHIS). Primary variables were sexual orientation, food security status, and receipt of SNAP. Food security was assessed using the 10-item USDA Family Food Security measure.

Results

In our sample, people who identified as bisexual had the highest rates of food insecurity (23.8%, n = 76). Female sexual minorities were 52% more likely to experience food insecurity (aOR = 1.518, 95% CI 1.105–2.087, p = .01) and 44% more likely to report household SNAP assistance than their heterosexual counterparts (aOR = 1.441, 95% CI 1.025–2.028, p = .03). SNAP partially mediated the association between sexual orientation and food insecurity for LGB females.

Conclusions

Our findings add to the growing empirical evidence documenting food insecurities among sexual minority adults. Our results reiterate the need for sexual orientation to be included in nationally representative federal food security measures.

Who We Are Today: a National Survey of Diversity Among Psychiatry Program Directors

OBJECTIVE

In March 2018, the American Association of Directors of Psychiatric Residency Training (AADPRT) formed the Diversity and Inclusion (D&I) Committee. One of the committee's goals was to understand the AADPRT membership's composition and their perceptions of D&I. This study's objective was to identify the demographic characteristics of the AADPRT membership.

METHODS

Program directors were invited by email to participate in an anonymous survey. The survey collected participants' demographic information including gender, race/ethnicity, training background, age, disability/differently abled status, job role, geographic region where their program is located, type of program, and their program's community setting.

RESULTS

Two hundred fifty six of 657 AADPRT members (39%) completed the survey. Respondents were mostly White (64.5%) followed by Asian/Southeast Asian (17.6%), Hispanic/Latinx (4.3%), and Black (1.6%). Only 13.3% of the participants were international medical graduates. Women were more prevalent (61.7%) than men (37.5%), and 9.4% self-identified as members of the LGBTQ+ Community.

CONCLUSIONS

This study represents the first systematic investigation into the diversity among psychiatry program directors throughout the USA and Canada. Future qualitative studies are needed to better understand the reasons behind this initial study's findings. Potential concerns requiring exploration include the possibility of the program director role serving as a "glass ceiling" for some women and a "leaky pipeline" in academia for groups underrepresented in medicine.

Tobacco smoking in three “left behind” subgroups: indigenous, the rainbow community and people with mental health conditions

Purpose

This paper aims to investigate the extent to which three subgroups – people with mental health conditions, people belonging to sexual minority and gender groups and Indigenous peoples – have been “left behind” by countries implementing the World Health Organization’s Framework Convention on Tobacco Control.

Design/methodology/approach

A general review of electronic bibliographical databases to provide an overview of smoking prevalence among the three groups and interventions designed specifically to reduce their smoking rates.

Findings

Although explanations and specific rates differ, two trends are consistent across all three groups. First, information reported in the past two decades suggests that smoking prevalence is disproportionately high among people with mental health conditions, and in the rainbow and indigenous communities. Second, most cessation programmes are targeted at majority politically dominant groups, missing opportunities to reduce smoking rates in these minority communities.

Research limitations/implications

There is a general dearth of data preventing detailed analysis. Better data collection efforts are required. Trials to identify effective smoking reduction interventions for marginalised groups are needed.

Social implications

It is socially unjust that these groups are being systematically ignored by tobacco control initiatives. A failure to equitably reduce tobacco harms among all groups across society has contributed to the perceived concentration of smoking in some subgroups. The increasing stigmatisation of people who smoke then adds a marginality, compounding the negative effects associated with belonging to a marginalised group. Ongoing marginalisation of these groups is an important determinant of smoking.

Originality/value

Cross-case analysis of neglected subgroups with disproportionately high smoking rates suggests social marginalisation is a shared and important determinant of smoking prevalence.

HIV Risk and Prevention Outcomes in a Probability-Based Sample of Gay and Bisexual Men in the United States

BACKGROUND

Although gay and bisexual men (GBM) represent the largest group of HIV-infected individuals in the United States, nearly all evidence on their HIV risk and prevention outcomes derive from nonprobability samples.

SETTING

A probability-based cohort of GBM (N = 502) from 45 states and Washington, DC.

METHODS

Cross-sectional survey.

RESULTS

Among HIV-negative/unknown/untested GBM, only 6.7% reported using pre-exposure prophylaxis (PrEP) in the past 6 months. Two-thirds (63.3%) of PrEP users reported daily adherence in the past week. Over half (54.2%) of GBM reported not using a condom during anal sex with their most recent male partner; of these men, 93.8% were not on PrEP. Most GBM had been tested for HIV (80.7%) and other sexually transmitted infections (67.1%) in their lifetime, with 45.2% having tested for HIV during the past year. Among those ever tested, 14.1% reported being HIV infected, whereas an additional 8.9% reported testing positive for at least one other sexually transmitted infection after their most recent test. All HIV-positive GBM reported being currently on antiretroviral treatment, and 94.7% reported an undetectable viral load, but nearly one-third (30.4%) reported not taking their medication every day during the past month. A majority of HIV-negative/unknown/untested GBM (64.3%) reported that they had never discussed HIV prevention with their primary health care provider.

CONCLUSIONS

Our findings present a decidedly mixed picture regarding the success of the US National HIV/AIDS Strategy in meeting its stated goals of addressing HIV risk among the general population of GBM.

More Similarities Than Differences? An Exploratory Analysis Comparing the Sexual Complaints, Sexual Experiences, and Genitourinary Health of Older Sexual Minority and Sexual Majority Adults

BACKGROUND

Little is known about sexual problems and genitourinary health of older sexual minority adults, who comprise up to 4% of the adult population but may differ in experiences of genitourinary aging, given known health disparities and behavior differences.

AIM

To examine and compare genitourinary and sexual complaints among older sexual minority and sexual majority adults.

METHODS

We analyzed data from the 2010-2011 National Social Life, Health, and Aging Project (NSHAP), a nationally representative sample of older community-dwelling U.S. adults. Sexual minority men were defined as those who have sex with men or with both women and men. Sexual minority women were those who have sex with women or with both women and men. Descriptive statistics, weighted frequencies, and the chi-square test were used to compare outcomes by sexual orientation group and gender.

MAIN OUTCOME MEASURES

Structured questionnaires examined sexual activity, practices, and genitourinary problems such as erectile dysfunction, insufficient vaginal lubrication, and urinary incontinence (UI).

RESULTS

Of 2,813 participants (median age 69.6 years), 4.2% were sexual minorities (5.3% of men, 3.5% of women). Among men, sexual minorities were more likely to report UI (35.6% vs 21.8%; P = .029), but otherwise the 2 groups had similar prevalences of other urinary symptoms, importance of sexual activity, sexual practices, sexual activity within the last 3 months, and erectile difficulty (P > .10 for all). Among women, sexual minorities were more likely to report receiving oral sex (42.5% vs. 21.2%; P = .004), but otherwise the 2 groups had similar prevalences of UI, other urinary symptoms, importance of sexual activity, sexual activity within the last 3 months, and difficulty with lubrication (P > .10 for all).

CLINICAL IMPLICATIONS

Sexual activity and sexual problems may be as common among older sexual minority adults as in their sexual majority counterparts, whereas UI may be more common in sexual minority men compared with sexual majority men. Therefore, clinicians should employ culturally-relevant health screening, diagnosis, and treatment to ensure reaching all adults regardless of sexual orientation.

STRENGTHS & LIMITATIONS

Strengths include a national population-based sample of older adults that describes sexual and genitourinary health. Statistical power was limited by the small numbers of sexual minority individuals.

CONCLUSION

Here we provide new evidence that older sexual minority men may experience UI more often than sexual majority men, and that sexual practices may differ between sexual minority and majority women, but frequency of sexual problems is similar. Given the challenges faced by sexual minority individuals in accessing equitable health care, clinicians must ensure that diagnosis and treatment are relevant to people of all sexual orientations. Obedin-Maliver J, Lisha N, Breyer BN. More Similarities Than Differences? An Exploratory Analysis Comparing the Sexual Complaints, Sexual Experiences, and Genitourinary Health of Older Sexual Minority and Sexual Majority Adults. J Sex Med 2019;16:347-350.

Tobacco use among lesbian, gay, bisexual and transgender young adults varies by sexual and gender identity

BACKGROUND

Research shows that tobacco products are disproportionately used by sexual and gender minorities, known collectively as those who are lesbian, gay, bisexual, and transgender (LGBT). While usage varies within this population by identity, differences in tobacco use patterns are not well understood. The present study uses evaluation data for This Free Life, a tobacco public education campaign from the FDA, to examine differences in tobacco use among LGBT young adults by subgroups based on sex at birth, gender and sexual identity.

METHODS

Data are from 4,057 18-24 LGBT young adults who completed the baseline This Free Life evaluation survey in 2016. Multivariable logistic regression models examined differences in tobacco use (cigarettes, cigars, hookah and electronic nicotine products) and poly use (2+ of any product, 2+ combustibles, at least one combustible and one noncombustible) between LGBT subgroups (cisgender gay males, cisgender bisexual males, cisgender lesbian/gay females, cisgender bisexual females and gender minorities).

RESULTS

Sexual minority females were more likely than gay males to use any tobacco product, electronic nicotine products and hookah. Cisgender bisexuals were more likely than gay males and gender minorities to use electronic nicotine products. Cisgender bisexual males were less likely than all other groups to use cigarettes. Cisgender sexual minority females were more likely than gender minorities to engage in poly use.

CONCLUSIONS

Findings suggest that sexual minority females are more likely to use tobacco than other subgroups. More research can help campaign developers better understand reasons for intragroup differences in tobacco use among LGBT subgroups.

Differences in Caregiving Outcomes and Experiences by Sexual Orientation and Gender Identity

PURPOSE

The purpose of this study was to determine whether caregiving experiences and their health-related outcomes differ by sexual orientation and gender identity in a representative U.S. caregiver sample.

METHODS

A secondary data analysis was performed of the cross-sectional, nationally representative National Alliance for Caregiving online survey that was conducted in 2014. To account for the study design, we used sampling weights and then added propensity score weighting to account for imbalances between LGBT respondents and their heterosexual and cisgender counterparts, that is, non-LGBT caregivers. Outcomes consisted of caregivers' self-reported health, financial strain, physical strain, and emotional stress.

RESULTS

LGBT caregivers were significantly younger, more racially and ethnically diverse, less likely to be married, and more likely to be of low socioeconomic status than their non-LGBT counterparts. Caregiving experiences and intensity were similar, but after controlling for demographic and caregiving characteristics, LGBT caregivers were significantly more likely to report financial strain and showed trends toward elevated levels of poor health and emotional stress. Physical strain was similar by LGBT status.

CONCLUSION

Caregiving itself is universal, yet LGBT caregivers differed demographically and were more likely to report financial strain compared with non-LGBT caregivers.