Abstract
Introduction.
Chronic pain has been highlighted as an important public health and clinical health issue. The prevalence of chronic pain has been increasing, with notable disparities for many minoritized populations. However, evidence regarding sexual minoritized populations and chronic pain is lacking. Therefore, the purpose of this study is to compare the prevalence of chronic pain among men and women by sexual identity.
Methods.
Data from the 2019–2021 National Health Interview Survey (n=78,686), a population-based public health surveillance system were analyzed in 2023–2024. This included 592 lesbian/gay and 952 bisexual women as well as 868 gay and 317 bisexual men. Chronic pain measures included frequency, amount of pain, pain limiting activities, and pain affecting family and others. Covariates included age, race/ethnicity, relationship status, education attainment, income, and employment status.
Results.
After adjusting for covariates, significantly (p<0.05) more gay/lesbian (26.7%) and bisexual (31.6%) women reported experiencing chronic pain “most days or everyday” than straight women (21.7%). More bisexual women reported chronic pain as well as negative impacts in their life due to chronic pain than straight women. More bisexual men also reported experiencing chronic pain “most days or everyday” compared to straight men (26.1% vs. 19.6%), although no differences were found for other aspects of pain.
Conclusions.
Sexual minoritized populations have a greater burden of chronic pain that should be considered in moving forward in pain work. Future work in this area is needed to understand why these disparities exist and how best to provide care and treatment to those affected.
Introduction
Chronic pain, defined as on-going and recurrent pain lasting more than 6 months, is a common and complex experience that impacts an estimated 50 million (20%) adults in the United States.1 Important differences exist in prevalence of chronic pain, including significantly higher prevalence among middle- and older adults, females, non-Hispanic whites, veterans, and those at lower socioeconomic positions.1 Other estimates using differing definitions of chronic pain suggests the higher prevalence among Native American and multiracial adults.2 National public health efforts have prioritized chronic pain, including in Healthy People 2030 with the Federal Pain Research Strategy further prioritizing epidemiologic examination of pain disparities.3
Minority stress suggests that people exposed to socialized discrimination, stigma, and bias have worse mental and physical health than those not exposed to these stressors.4 Indeed, research has shown a link between exposure to discrimination and chronic pain.5 However, the burden of chronic pain among sexual minoritized adults, including those who identify as lesbian, gay, or bisexual, has not been well-documented, which impedes public health decision-making and prioritization.
Despite the growing public health focus on chronic pain disparities, few studies have examined disparities based on sexual orientation. Chronic pain has been conceptualized and measured differently, however, findings have consistently shown that more sexual minoritized people report chronic pain than their heterosexual counterparts.6–10 For example, a population-based study have found greater neck/back pain among male and female sexual minoritized older adults,6 while longitudinal cohort studies found greater migraine headaches among sexual minoritized males and females,11 and chronic pain,7 functional pain,10 or bodily pain8 among sexual minoritized females only. Collectively, this emerging area of research suggests that sexual minoritized adults may be an important group to include in understanding existing chronic pain disparities. Therefore, this study aims to examine disparities in the burden and impact of chronic pain among males and females by sexual identity.
Methods
The data used in this study is from the redesigned12 2019–2021 National Health Interview Survey (NHIS), a nationally representative survey of the civilian noninstitutionalized population in the United States.13–15 NHIS sampling and interviewing occurs continuously throughout the year and follows a multistage area probability design to allow for representative sampling. Additional NHIS details are publicly available (https://www.cdc.gov/nchs/nhis/data-questionnaires-documentation.htm). NHIS data are publicly available and does not require IRB review.
Participants are asked to identify themselves as “male” or “female”. Participants 18 years and older were included in these analyses (n=78,686), which included 42,555 females (41,011 straight; 592 lesbian/gay; 952 bisexual) and 36,131 males (34,966 straight; 848 gay; 317 bisexual). NHIS uses a cognitively tested question assessing participant sexual identity.16 Participants who did not identify as straight, lesbian/gay, or bisexual were not included in analyses.
Four aspects of chronic pain were measured: frequency in the past three months; amount of pain (“A little”, “A lot”, and “Somewhere in between a little and a lot”); frequency of pain limiting life or work activities; and frequency of pain affecting family and significant others. Frequency response options included: “never”, “some days”, “most days”, and “every day”. To accommodate small sample sizes for sexual identity sub-groups and maintain consistency with previous NHIS data, “most days” and “every day” were collapsed into one category.
Sociodemographic characteristics associated with chronic pain and/or sexual identity were included as covariates:1,9 age, race/ethnicity (Hispanic; non-Hispanic white; non-Hispanic Black; non-Hispanic other), relationship status (married or living with a partner; separated, divorced, or widowed; never married), educational attainment (less than high school; high school graduate/GED; some college/associate’s; bachelor’s or greater), family income relative to the federal poverty guidelines (<100%; 100%−199%; 200%−399%; ≥400%), and employment status (full-time; part-time; unemployed; not in labor force).
Analyses were performed in 2023–2024. Weighted percents were calculated using the NHIS sampling weights. Adjusted prevalences were calculated from multinomial logistic regression models regressing chronic pain outcomes on sexual identity and including covariates. Statistical significance comparing lesbian/gay and bisexual to straight was determined from multinomial logistic regression models. All data management and analysis was performed using StataSE version 18.0.
Results
Compared to straight females, a significantly (p<0.001) higher proportion of bisexual females reported experiencing pain in the past three months “some days” (44.6% vs. 39.7%) or “most days or everyday” (27.7% vs 22.1%) as well as experiencing “between a little and a lot” (48.9% vs 39.7%) or “a lot” (22.4% vs 19.7%) of pain (Table 1). More bisexual females also report pain limiting their life or work (48.8% vs. 36.2%) or impacting family (32.2% vs. 22.1%) “some days” than straight females. After adjustment for covariates, these differences remained between bisexual and straight females. There were few differences between lesbian/gay and straight females, although, after adjusting for covariates, a higher proportion of lesbian/gay females reported experiencing pain “some days” (44.0% vs. 40.2%, p<0.05) or “most days or everyday” (26.7% vs. 21.7%, p<0.05) than straight females.
Table 1.
Sexual identity and chronic pain among females, National Health Interview Survey 2019–2021
| Straight | Lesbian/Gay | Bisexual | Straight | Lesbian/Gay | Bisexual | Straight | Lesbian/Gay | Bisexual | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Chronic Pain Measures | Sample Size (n) | Weighted %b | Adjusted Weighted %c | ||||||||||
| Chronic Pain in Past 3 Months | |||||||||||||
| Never | 14,608 | 191 | 259 | 38.2 % | 35.6 % | ref a | 27.8 % | ref a | 38.1% | 29.3% | ref a | 22.5% | ref a |
| Some days | 16,470 | 242 | 413 | 39.7 % | 39.8 % | 44.6 % | *** | 40.2% | 44.0% | * | 45.9% | *** | |
| Most days or Everyday | 9,888 | 159 | 281 | 22.1 % | 24.6 % | 27.7 % | *** | 21.7% | 26.7% | * | 31.6% | *** | |
| How much pain last time | |||||||||||||
| A little | 10,740 | 154 | 212 | 40.6 % | 39.4 % | ref a | 28.7 % | ref a | 41.4% | 38.8% | ref a | 28.6% | ref a |
| Between a little and a lot | 10,395 | 170 | 338 | 39.7 % | 42.5 % | 48.9 % | *** | 39.7% | 43.9% | 48.5% | *** | ||
| A lot | 5,195 | 77 | 144 | 19.7 % | 18.2 % | 22.4 % | *** | 18.9% | 17.3% | 22.9% | ** | ||
| How often pain limits life/work | |||||||||||||
| Never | 10,486 | 142 | 234 | 48.6 % | 40.7 % | ref a | 38.0 % | ref a | 48.2% | 41.6% | ref a | 38.4% | ref a |
| Some days | 7,737 | 140 | 289 | 36.2 % | 43.5 % | * | 48.8 % | *** | 37.9% | 42.6% | 48.6% | ** | |
| Most days or Everyday | 3,472 | 53 | 83 | 15.2 % | 15.8 % | 13.2 % | 13.9% | 15.8% | 13.0% | ||||
| How often pain impacts family | |||||||||||||
| Never | 15,639 | 228 | 370 | 70.4 % | 66.7 % | ref a | 59.0 % | ref a | 70.5% | 64.6% | ref a | 61.0% | ref a |
| Some days | 4,450 | 83 | 182 | 22.1 % | 25.6 % | 32.2 % | *** | 23.0% | 27.4% | 33.1% | ** | ||
| Most days or Everyday | 1,571 | 24 | 52 | 7.5 % | 7.7 % | 8.8 % | 6.4% | 8.0% | 5.9% | ||||
reference group comparing sexual orientation and pain outcomes (i.e., gay or lesbian vs. straight; bisexual vs. straight & some days vs. never; a lot vs. a little)
calculated using survey sampling weights
estimated from marginal means using multinomial logistic regression models adjusting for age, race/ethnicity (Hispanic; non-Hispanic white; non-Hispanic Black; non-Hispanic other), relationship status (married or living with a partner; separated, divorced, or widowed; never married), educational attainment (less than high school; high school graduate/GED; some college/associate’s; bachelor’s or greater), family income relative to the federal poverty guidelines (<100%; 100%−199%; 200%−399%; ≥400%), and employment status (full-time; part-time; unemployed; not in labor force) Boldface indicates statistically significantly different values (p<0.05)
p<0.05,
p<0.01,
p<0.001; boldface indicates statistical significant difference from straight and the chronic pain reference group
In contrast to findings among females, there were no differences in chronic pain between gay and straight males (Table 2). A significantly higher proportion of bisexual males reported experiencing pain “some days” (49.5% vs. 38.4%, p<0.001) or “most days or everyday” (22.1% vs. 19.7%, p<0.01) compared to straight males, and while these differences were slightly attenuated after adjustment for covariates, findings remained statistically significant. There were no other differences between bisexual and straight males.
Table 2.
Sexual identity and chronic pain among males, National Health Interview Survey 2019–2021
| Straight | Lesbian/Gay | Bisexual | Straight | Lesbian/Gay | Bisexual | Straight | Lesbian/Gay | Bisexual | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Chronic Pain Measures | Sample Size (n) | Weighted %b | Adjusted Weighted %c | ||||||||||
| Chronic Pain in Past 3 Months | |||||||||||||
| Never | 13,756 | 380 | 91 | 41.9 % | 44.8 % | ref a | 28.4 % | ref a | 40.3% | 41.3% | ref a | 29.1% | ref a |
| Some days | 13,531 | 313 | 147 | 38.4 % | 36.6 % | 49.5 % | *** | 40.1% | 38.7% | 44.8% | * | ||
| Most days or Everyday | 7,646 | 155 | 79 | 19.7 % | 18.6 % | 22.1 % | ** | 19.6% | 20.0% | 26.1% | * | ||
| How much pain last time | |||||||||||||
| A little | 10,346 | 229 | 105 | 48.8 % | 50.8 % | ref a | 47.9 % | ref a | 50.3% | 46.1% | ref a | 43.5% | ref a |
| Between a little and a lot | 7,622 | 179 | 85 | 36.8 % | 38.0 % | 35.0 % | 36.3% | 39.8% | 37.7% | ||||
| A lot | 3,194 | 60 | 36 | 14.4 % | 11.2 % | 17.1 % | 13.4% | 14.0% | 18.7% | ||||
| How often pain limits life/work | |||||||||||||
| Never | 9,919 | 207 | 105 | 57.7 % | 56.4 % | ref a | 53.5 % | ref a | 57.8% | 56.3% | ref a | 49.5% | ref a |
| Some days | 5,282 | 118 | 66 | 30.1 % | 32.6 % | * | 35.4 % | 30.5% | 29.3% | 36.2% | |||
| Most days or Everyday | 2,320 | 51 | 25 | 12.2 % | 11.0 % | 11.0 % | 11.6% | 14.4% | 14.2% | ||||
| How often pain impacts family | |||||||||||||
| Never | 13,655 | 308 | 152 | 77.6 % | 79.7 % | ref a | 78.6 % | ref a | 77.4% | 79.4% | ref a | 73.9% | ref a |
| Some days | 2,816 | 53 | 33 | 16.5 % | 15.5 % | 16.0 % | 16.9% | 16.2% | 21.9% | ||||
| Most days or Everyday | 1,035 | 14 | 11 | 5.9 % | 4.8 % | 5.4 % | 5.8% | 4.4% | 4.2% | ||||
reference group comparing sexual orientation and pain outcomes (i.e., gay or lesbian vs. straight; bisexual vs. straight & some days vs. never; a lot vs. a little)
calculated using survey sampling weights
estimated from marginal means using multinomial logistic regression models adjusting for age, race/ethnicity (Hispanic; non-Hispanic white; non-Hispanic Black; non-Hispanic other), relationship status (married or living with a partner; separated, divorced, or widowed; never married), educational attainment (less than high school; high school graduate/GED; some college/associate’s; bachelor’s or greater), family income relative to the federal poverty guidelines (<100%; 100%−199%; 200%−399%; ≥400%), and employment status (full-time; part-time; unemployed; not in labor force) Boldface indicates statistically significantly different values (p<0.05)
p<0.05,
p<0.01,
p<0.001; boldface indicates statistical significant difference from straight and the chronic pain reference group
Discussion
A higher proportion of lesbian/gay and bisexual females as well as bisexual males report experiencing chronic pain compared to their straight counterparts. Moreover, a higher proportion of bisexual females report high-impact chronic pain. These findings corroborate those from Zajacova and colleagues who found higher prevalence of chronic pain among lesbian/gay and bisexual adults9 and further expands on their findings by examining males and females separately. As such, our findings, in combination with existing studies,6–11,17 suggest that sexual minoritized females, and bisexual females in particular, may be important to include in tailored chronic pain management and treatment efforts.
Our findings that greater proportions of bisexual males and females reported experiencing chronic pain than their straight counterparts is consistent with existing work documenting a wide range of health disparities between bisexual and straight people,18,19 including back pain.17 These differences may be due to experiences of antibisexual discrimination from straight people as well as from lesbian and gay people.20 Consistent with existing research linking discrimination with chronic pain,5 the addition of antibisexual discrimination to sexual minority stress likely contributes to documented health disparities,21,22 as well as socioeconomic disadvantages which further exacerbate disparities.19
Limitations
These estimates are population-based, therefore our findings are generalizable to the US adult population. However, the descriptive nature of these data does not allow examination of specific pathways that may contribute to these disparities. Moreover, despite controlling for important covariates, residual confounding may still exist. These findings demonstrate the high burden of chronic pain among sexual minoritized females and highlights the need to better understand why these disparities exist as well as how best to provide resources.
Conclusions
Chronic pain continues to be an important emerging public health issue that impacts large swaths of the US population. This study demonstrates that sexual minoritized populations, a public health priority population, likely experience a greater burden of chronic pain than their straight counterparts. Importantly, bisexual females and males, a group that experiences many other negative health outcomes, seem to be particularly impacted by chronic pain.
Supplementary Material
Acknowledgements
Study Funding
Dr. VanKim was supported by an award from the National Institute of Diabetes, Digestive, and Kidney Diseases (K01DK123193). The research presented in this paper is that of the authors and does not reflect the official policy of the NIH.
Footnotes
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Conflicts of Interest and Financial Disclosures
No conflicts of interest or financial disclosures were reported by the authors of this paper.
Credit Author Statement
VanKim: Conceptualization, methodology, formal analysis, writing – original draft Flanders: Conceptualization, writing – Reviewing and editing Bertone-Johnson: Conceptualization, writing – reviewing and edits
Contributor Information
Nicole A. VanKim, Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA.
Corey E. Flanders, Department of Psychology and Education, Mount Holyoke College, South Hadley, MA.
Elizabeth R. Bertone-Johnson, Department of Biostatistics and Epidemiology & Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA.
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