Abstract
This survey study discusses changes in the proportion of youths who selected “not sure” among other response options to questions about their sexual identity in the National Youth Risk Behavior Survey between 2019 and 2021 and recommends measures to inclusively reflect sexual identities.
The Youth Risk Behavior Survey (YRBS) has tracked population-level health behavior among US high school students since 1991. In 2015, the National YRBS first included the question about sexual identity (SI), with 3.2% of the respondents selecting “not sure” as a response option.1 Although this response could mean questioning one’s SI, multiple interpretations are possible. Respondents could be not sure what the question is asking or how to respond if they do not associate their identity with any response option. The National YRBS changed response options in 2021 (Table 1).2 This update reduces interpretation confusion but requires work to unify results from previous surveys.
Table 1. National Youth Risk Behavior Survey Questions and Responses, 2015-2021.
| Question topic, year | Question | Response options |
|---|---|---|
| Sexual identity, 2015-2019 | Which of the following best describes you? |
|
| Sexual identity, 2021 | Which of the following best describes you? |
|
Methods
The YRBS is a biennial, national survey conducted by the Centers for Disease Control and Prevention. Participation in the YRBS requires parental approval but is voluntary and anonymous.3 This survey study followed AAPOR.
We explored whether the proportion responding “not sure” about their SI changed significantly between 2019 and 2021. We further examined differences by sex (Table 2), reported as either female or male in response to “What is your sex?” We tested differences in the weighted percentage of youths who selected each intersection between 2019 and 2021. We were unable to statistically test differences for those who selected “I describe my sexual identity some other way” and “I do not know what this question is asking.” Race and ethnicity data were not included owing to the study’s focus on changes in SI. Data were weighted to account for complex survey sampling methods and analyzed from June 4 to 9, 2023, using SAS, version 9.4 (SAS Institute Inc). Two-tailed P < .05 indicated statistical significance.
Table 2. Sexual Identity by Sex Among High School–Aged Youth in the US, 2019 and 2021.
| Sexual identity | No. (weighted %)a | ||
|---|---|---|---|
| Total | Male | Female | |
| 2019 | |||
| Heterosexual | 10 776 (84.5)b | 5728 (91.2)b | 5048 (77.6)b |
| Gay or lesbian | 368 (2.5)c | 157 (2.1) | 211 (2.9)c |
| Bisexual | 1130 (8.6)b | 201 (3.4)d | 929 (13.9)b |
| Not sure | 573 (4.4)c | 223 (3.3)b | 350 (5.6)b |
| 2021 | |||
| Heterosexual | 12 350 (74.7)b | 7358 (87.3)b | 4992 (61.6)b |
| Gay or lesbian | 493 (3.0)c | 195 (2.4) | 298 (3.7)c |
| Bisexual | 1805 (12.0)b | 356 (4.1)d | 1449 (20.0)b |
| I am not sure about my sexual identity (questioning) | 802 (5.1)c | 198 (2.3)c | 604 (8.0)b |
| I describe my sexual identity some other waye | 586 (3.5) | 135 (1.4) | 451 (5.7) |
| I do not know what this question is askinge | 321 (1.8) | 224 (2.5) | 97 (1.0) |
P values were produced by comparing SI categories in 2019 with their corresponding categories in 2021.
P ≤ .001.
P ≤ .01.
P ≤ .05.
No comparison for these 2 categories was conducted.
Results
This survey study included 12 847 respondents (6538 females [50.9%], 6309 males [49.1%]) in 2019 and 16 357 (7891 females [48.2%], 8466 males [51.8%]) in 2021 (overall response rates, 60% in 2019 and 57.5% in 2021, a decrease attributed to COVID-19 school lockdowns). From 2019 to 2021, there was a significant decrease in the proportion of heterosexual youths (84.5% vs 74.7%; P < .001; Table 2), a slight increase in gay or lesbian youths (2.5% vs 3.0%; P = .004), and a significant increase in bisexual youths (8.6% vs 12.0%; P < .001).4 Slightly more youths in 2021 than 2019 selected “not sure” (5.1% vs 4.4%; P = .007). In 2021, 3.5% reported “some other way” in response to the SI question, while 1.8% were unsure what the question was asking. In 2019, 5.6% of females and 3.3% of males selected “not sure” in response to the SI question. In 2021, the proportions shifted to 8.0% and 2.3%, respectively. In 2021, more females than males reported identifying some other way (5.7% vs 1.4%); twice as many males as females did not understand the question (2.5% vs 1.0%).
Discussion
Although limited by YRBS’s binary construct of sex, it is important to present potential explanations for findings. Among females, this change in proportion for “not sure” may be associated with their comfort with disclosing sexual uncertainty.5 While changes in “not sure” identity among males were minor, they may indicate heteronormative ideologies that problematize sexual uncertainty.6
New wording options mean researchers will no longer be unsure of the “not sure” option’s meaning. However, challenges remain. For researchers wishing to harmonize YRBS data across the 2019 to 2021 SI response option change to facilitate trend analyses, we recommend: (1) create a subset of participants from 2021 onward who responded, “I do not know what this question is asking” or “I describe my sexual identity some other way”; (2) harmonize pre-2021 “not sure” respondents with “I am not sure about my sexual identity (questioning)” respondents in 2021 and beyond; and (3) focus analyses on unchanged categories (eg, bisexual youth).
As response options change, appropriate approaches must be revisited. Ultimately, we should strive toward using measures that inclusively capture youths’ SI.
Data Sharing Statement
References
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Associated Data
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Supplementary Materials
Data Sharing Statement