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. Author manuscript; available in PMC: 2025 Oct 24.
Published in final edited form as: Am J Orthopsychiatry. 2024 Oct 24;95(5):512–520. doi: 10.1037/ort0000806

Sexual Identity Differences in the Association Between Psychological Distress and Cardiometabolic Health Among Women: 2013–2018 National Health Interview Survey

Colleen D Beatriz 1, Elizabeth R Bertone-Johnson 1,2, Billy A Caceres 3, Nicole A VanKim 1
PMCID: PMC12018591  NIHMSID: NIHMS2043300  PMID: 39446635

Abstract

Poor psychological health has been consistently documented for sexually minoritized women. However, little is known about the association between poor psychological health and physical health. This study examined associations between psychological distress and cardiometabolic health, including cardiovascular disease risk conditions (hypertension, high cholesterol, and diabetes) and diagnoses (stroke, coronary heart disease, myocardial infarction, and angina), by sexual identity among women. Data are from the 2013–2018 National Health Interview Survey and included 102,279 women, who were straight (n = 97,909), lesbian/gay (n = 1,424), bisexual (n = 1,235), something else (n = 360), did not know (n = 712), and refused to disclose (n = 639). Multivariable multinomial logistic regression models were fit to estimate associations between psychological distress (measured with Kessler-6) and cardiometabolic health (self-reported diagnosis) and to examine sexual-identity differences in these associations. Covariates included sociodemographic characteristics. Overall, severe psychological distress was associated with significantly higher odds of having a cardiometabolic health condition (OR = 2.66). These associations generally did not statistically significantly differ based on sexual identity. However, potential substantive differences in the magnitude of the association existed among lesbian/gay (OR = 4.00) compared to straight women (OR = 2.73). Moreover, women who identified as gay/lesbian, bisexual, “something else,” or “I don’t know” all reported significantly higher prevalence of severe psychological distress than straight women. Given the overall positive association between psychological distress and cardiometabolic health as well as the higher prevalence of severe psychological distress among sexual minority women, more work is needed to longitudinally examine the effects of psychological distress on health among sexually minoritized women.

Keywords: sexual identity, health disparities, psychological distress, cardiometabolic health

Sexual minority women, including individuals who identify as lesbian, gay, or bisexual (LGB) may be at greater risk than straight women for cardiovascular disease (CVD; Alshehri, 2010; Caceres et al., 2020; Lick et al., 2013; National Heart Lung and Blood Institute, 2022). This risk, in part, is likely due to high prevalence of factors such as poor mental health, tobacco use, and excessive alcohol consumption (Caceres et al., 2017).

Despite the elevated risk for poor cardiometabolic health among sexual minority women, a 2017 review by Caceres et al. found very few differences in cardiometabolic health conditions, such as hypertension, diabetes, and high cholesterol. Recent evidence corroborates findings of this review, indicating no significant differences in CVD risk but higher glycosylated hemoglobin (HbA1c) levels among sexual minority women compared to straight women (Caceres et al., 2018a, 2018b; Diamant & Wold, 2003; Mays et al., 2018).

It is hypothesized that sexual-identity-based health disparities are likely due to experiencing additional stressors stemming from sexual-identity-based stigma and discrimination, as posited in the minority stress model (Meyer, 2003). These additional stressors likely contribute to a greater burden of poor mental and physical health among sexual minority populations (Lick et al., 2013). Indeed, evidence has consistently found worse mental health among sexual minority populations than straight populations (Cochran et al., 2003; Hatzenbuehler et al., 2008; Wu et al., 2018), which has implications for their physical health. General population studies have found that poor mental health in the form of psychological distress (which refers to symptoms of distress such as anxiety, depression, and other symptoms) is associated with significantly elevated risk of major CVD diagnoses and mortality (Mommersteeg et al., 2017; Smaardijk et al., 2020; Stewart et al., 2017). Collectively, this evidence suggests that poor mental health among sexual minority populations may have similar negative impacts on cardiometabolic health and mortality. However, little empirical research examining the association between psychological distress and cardiometabolic health among sexual minority populations exists.

A notable limitation of existing research on sexual-identity-based disparities is the exclusion of individuals with sexual identities other than straight or LGB. These individuals may include those who respond “other,” “don’t know,” or refuse to disclose their sexual identity (West & McCabe, 2021). The heterogeneity of these excluded individuals poses challenges with the conceptualization of sexual identity and understanding of sexual-identity-based health disparities. Importantly, research has found that people who self-identify as something other than straight or LGB on surveys may view their sexuality and gender as fluid and/or dynamic and may not be comfortable labeling their identities (Eliason et al., 2016). Previous work that included individuals who were unsure of their sexual identity found unique demographic and health distributions that suggest these may be important subgroups that require further attention (Eliason et al., 2016; Jackson et al., 2016; Price-Feeney et al., 2021). For example, one study found that women who reported “something else” or “don’t know” for their sexual identity also reported more heavy drinking than straight women (Jackson et al., 2016). Another study found that women who identify as “something else” were younger, more likely to report a disability, and had poorer mental health than lesbian and bisexual women (Eliason et al., 2016). Moreover, recent research found important changes to subgroup estimates when including “something else” as a response option (West et al., 2024), further highlighting the importance of including sexual-identity options beyond straight and LGB.

Understanding the mental health and its potential impact on cardiometabolic health among this overlooked group may highlight important unique health needs that should be integrated into existing prevention and intervention efforts. For example, existing research has identified the positive impact on health outcomes, including better mental health, among lesbian and bisexual patients who disclose their sexual orientation to health care providers (Ruben & Fullerton, 2018). However, those who self-identify as something other than lesbian or bisexual may likely need different or additional services to provide adequate care. With increasing efforts to collect sexual orientation data through electronic health records to improve the quality of patient-centered care, a better understanding of the health needs of this subgroup of patients is critical.

Purpose

While research indicates that sexual minority stress is associated with increased psychological distress (Platt & Scheitle, 2018; Swim et al., 2009; Szymanski, 2009), it is unclear whether psychological distress contributes to sexual-identity-based disparities in cardiometabolic health. The present study aimed to (a) describe sexual-identity differences in the prevalence of psychological distress and cardiometabolic health and (b) explore sexual-identity-specific estimates of the association between psychological distress and cardiometabolic health.

Method

Design

Data are from the 2013–2018 National Health Interview Survey, before the design change that occurred in 2019, which resulted in recommendations against merging data sets of these two different designs. The National Health Interview Survey continues to be a nationally representative survey of the civilian noninstitutionalized population in the United States that is conducted continuously throughout the year by the National Center for Health Statistics and utilizes a multistage area probability design. Additional details on the National Health Interview Survey study design are publicly available (Parsons et al., 2014). The household response rates from 2013 to 2017 ranged from 64.2% (2018) to 75.7% (2013), and the conditional response rates for the adult sample component ranged from 79.7% (2015) to 83.9% (2018).

Sample

Female participants 18 years and older who participated in the adult sample were included in these analyses (n = 102,279), which included women who identified as straight (n = 97,909), lesbian/gay (n = 1,424), bisexual (n = 1,235), or something else (n = 360), and those who did not know (n = 712) or refused to disclose their sexual identity (n = 639). Additional demographic information is provided in Table 1.

Table 1.

Sociodemographic Characteristics by Sexual Identity, National Health Interview Survey 2013–2018 (N = 102,279)

Straight
n = 97,909
 Gay or Lesbian
n = 1,424
 Bisexual
n = 1,235
 Something else
n = 360
 I don’t know
n = 712
 Refused
n = 639
Sociodemographic M SE M SE p M SE p M SE p M SE p M SE p
Age 48.2 0.1 42.2 0.6 .00 32.4 0.5 .00 37.7 1.3 .00 47.0 1.0 .25 51.7 1.1 <.001
Sociodemographic n Wtd. % n Wtd. % p n Wtd. % p n Wtd. % p n Wtd. % p n Wtd. % p
Race/Ethnicity .510 .594 .174 <.001 .734
 Non-Hispanic White 62,488 64.5% 917 63.5% 831 67.2% 232 62.9% 354 45.6% 404 64.6%
 Non-Hispanic Black 13,211 12.3% 214 14.2% 150 11.3% 46 10.0% 84 14.2% 94 13.3%
 Hispanic 14,575 15.2% 193 14.7% 164 14.1% 43 14.7% 178 26.6% 85 13.3%
 Non-Hispanic other 7,438 8.0% 99 7.6% 88 7.4% 39 12.5% 95 13.6% 56 8.8%
Family income level relative to FPGa .026 <.001 <.001 <.001 .891
 <100% 13.9% 14.4% 26.0% 21.9% 20.4% 14.3%
 100%–199% 19.0% 17.6% 22.5% 22.3% 28.1% 20.0%
 200%–399% 29.2% 25.1% 26.1% 32.5% 27.8% 29.9%
 >=400% 37.9% 42.9% 25.4% 23.4% 23.7% 35.8%
Education level <.001 .041 .184 <.001 .437
 <High school 13,003 12.1% 116 8.3% 132 11.6% 45 12.0% 207 26.3% 80 11.9%
 High school 23,881 24.2% 270 18.6% 258 23.1% 76 20.4% 188 26.1% 133 20.8%
 Some college 31,233 31.8% 460 33.0% 461 37.1% 126 39.2% 173 28.5% 200 34.5%
 >=Bachelor’s degree 29,435 31.8% 577 40.0% 383 28.1% 113 28.4% 130 19.1% 198 32.8%
Employment status <.001 <.001 <.001 .017 .244
 Full time 32,264 35.3% 653 47.9% 444 35.6% 104 31.0% 179 32.3% 224 37.8%
 Part time 19,275 21.5% 299 21.9% 349 30.4% 96 26.2% 118 16.2% 109 16.9%
 Unemployed 3,655 3.9% 81 5.4% 109 9.8% 23 11.4% 38 5.3% 21 3.5%
 Not in work force 41,236 39.4% 368 24.8% 303 24.1% 126 31.4% 357 46.2% 256 41.8%
Region .245 .045 .060 .363 <.001
 Northeast 16,116 18.0% 264 18.7% 201 15.2% 70 21.5% 121 18.9% 163 27.0%
 Midwest 21,126 22.1% 253 19.1% 268 23.8% 71 20.3% 142 18.9% 125 21.0%
 South 35,925 37.2% 507 37.6% 407 34.4% 94 28.5% 241 36.0% 200 31.0%
 West 24,742 22.7% 400 24.6% 359 26.6% 125 29.7% 208 26.2% 151 21.0%
Relationship status <.001 <.001 <.001 <.001 <.001
 Married or living with partner 46,621 58.6% 617 53.3% 410 39.5% 77 26.4% 192 35.5% 175 37.5%
 Separated, divorced, widowed 31,721 21.9% 196 8.9% 254 13.2% 99 17.9% 264 22.1% 223 29.1%
 Never married 19,365 19.5% 605 37.7% 568 47.3% 184 55.7% 253 42.4% 211 33.4%
Insurance status <.001 <.001 .009 <.001 .007
 Private 45,141 52.7% 786 57.7% 607 54.0% 148 44.7% 229 40.1% 293 50.9%
 Public 42,749 37.5% 468 30.1% 451 31.3% 168 38.1% 389 46.6% 290 43.3%
 Uninsured 9,607 9.8% 163 12.1% 170 14.7% 41 17.2% 88 13.3% 46 5.8%
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Note. p values are generated from t test (age) and Pearson chi-square test (race/ethnicity, education level, employment status, region, relationship status, and insurance status) or f test (family income relative to FPG) with straight as referent group. SE = standard error; Wtd. = weighted.

a

Federal poverty guidelines.

Measures

Sexual Identity.

Sexual identity was measured consistently across the 5 years using the cognitively tested question (Miller & Ryan, 2011) “How do you think of yourself?” Response options were “Lesbian or gay,” “Straight, that is, not lesbian or gay,” “Bisexual,” “Something else,” “I don’t know the answer” and “Refused.”

Psychological Distress.

The Kessler six-item Psychological Distress Scale was utilized to indicate nonspecific psychological distress (Kessler et al., 2010). Participants were asked how often they felt (a) so sad that nothing could cheer them up, (b) nervous, (c) restless or fidgety, (d) hopeless, (e) that everything was an effort, and (f) worthless. Responses were ranked on a 0- to 4-point scale ranging from none of the time (0 points) to all of the time (4 points) and added for a total score of up 24 points. Following widely accepted guidelines, scores below 5 points were considered to be “no/limited psychological distress,” 5–12 points were considered “moderate psychological distress,” and 13 or more points were considered “severe psychological distress” (Kessler et al., 2010).

Cardiometabolic Health.

Participants were asked whether they had ever been told that they had hypertension, high cholesterol, diabetes, coronary heart disease, a heart attack, stroke, or angina pectoris. Due to small sample sizes for some sexual-identity subgroups, participants who answered “yes” to any of these conditions were considered to have any cardiometabolic health condition.

Covariates.

Covariates in these analyses include sociodemographic factors that have been previously linked with CVD and psychological distress, including age, race/ethnicity (Hispanic, non-Hispanic White, non-Hispanic Black, and non-Hispanic other), relationship status (married or living with a partner; separated, divorced, or widowed; never married), region of residence (Northeast, Midwest, South, West), educational attainment (less than high school, high school graduate/general education development, some college/associate’s, and bachelor’s or greater), employment status (full time, part time, unemployed, and not in labor force), and insurance status (private, public, and uninsured). Family income relative to the federal poverty guidelines was categorized into four groups: <100%, 100%–199%, 200%–399%, and ≥400%.

Analysis

Prevalence of cardiometabolic health conditions and psychological distress were estimated for each sexual-identity group. Pearson chi-square tests and t tests were used to test for independence between sexual identity and covariates, as well as health outcomes. Logistic regression models were fit to assess the relationship between psychological distress and any cardiometabolic health condition. Additionally, multivariable logistic regression models were fit adjusting for age, race/ethnicity, relationship status, region, family income level, education, employment, and insurance status. Straight women were the reference group for all analyses. We tested for effect modification by sexual identity on the relationship between psychological distress and any cardiometabolic health condition as well as examined sexual-identity-specific estimates of the association using multivariable logistic regression models.

All data management and analyses were performed using Stata/SE Version 17.0. Consistent with recommendations from the National Center for Health Statistics (Division of Health Interview Statistics & N. C. for H. S, 2018), all analyses were weighted using the provided sampling weights. In addition, multiple imputations (mi commands) in Stata were used to account for missing responses to family income.

Results

Table 1 describes sociodemographic characteristics by sexual identity. Approximately 4.3% of participants reported a sexual identity other than straight. On average, women who identified as lesbian/gay, bisexual, or something else were significantly younger than straight women, while women who “refused” were significantly older than straight women. Women who did not identify as straight (i.e., LGB, something else, “I don’t know,” and “refused”) were more likely to have never married than straight women. Additionally, compared to straight women, women who identified as bisexual, “something else,” or “I don’t know” were more likely to have a family income <200% of the Federal Poverty Guidelines. Compared to straight women, a greater proportion of lesbian/gay women had a family income at least 400% greater than the Federal Poverty Guidelines, had a college degree, were employed full time, and had private health insurance. In contrast, more bisexual women were employed part time or unemployed and were uninsured; more women who identified as “something else” were unemployed and uninsured; more women who reported “I don’t know” were Hispanic, had less than a high school education, were not in the workforce, and had public health insurance; and more women who “refused” were residing in the Northeast and had public health insurance.

Distributions of cardiometabolic health conditions and psychological distress by sexual identity are presented in Table 2. Compared to straight women, lesbian/gay women had lower prevalence of hypertension, diabetes, and any cardiometabolic health condition, while bisexual women had lower prevalence of hypertension, high cholesterol, diabetes, coronary heart disease, stroke, angina, and any cardiometabolic health condition. Women who identified as something else had lower prevalence of hypertension, high cholesterol, and any cardiometabolic health condition than straight women. There were no statistically significant differences in any of the cardiometabolic health conditions between straight women and women who “did not know” or “refused.” Additionally, compared to straight women, a greater proportion of women who identified as lesbian/gay, bisexual, “something else,” or “did not know” reported moderate psychological distress; and a greater proportion of women who identified as lesbian/gay, bisexual, “something else,” or “did not know” reported severe psychological distress. However, a smaller proportion of women who refused to report their sexual identity reported moderate psychological distress as compared to straight women.

Table 2.

Prevalence of Cardiometabolic Health Conditions and Psychological Distress by Sexual Identity, National Health Interview Survey 2013–2018

Straight
 Gay/Lesbian
 Bisexual
 Something else
 I don’t know
 Refused
Health measure N Wtd. % N Wtd. % p a N Wtd. % p a N Wtd. % p a N Wtd. % p a N Wtd. % p a
Cardiometabolic health condition
 Hypertension 33,733 30.2% 370 22.6% *** 255 18.8% *** 103 20.2% *** 256 29.2% 225 32.1%
 High cholesterol 23,786 26.9% 318 25.5% 191 16.1% *** 85 18.0% ** 183 25.4% 145 26.8%
 Diabetes 3,991 3.3% 42 2.0% ** 23 1.4% *** 15 2.6% 35 3.5% 33 3.7%
 Coronary heart disease 10,179 9.1% 132 8.5% 76 6.7% * 33 7.2% 94 11.6% 72 10.3%
 Stroke 3,438 2.9% 50 2.9% 25 1.4% ** 13 1.6% 25 3.0% 17 2.4%
 Myocardial infarction 2,670 2.2% 30 1.9% 23 1.3% 13 2.6% 16 2.2% 27 2.7%
 Angina 1,864 1.6% 24 1.2% 13 0.7% * 9 1.5% 12 1.8% 15 2.1%
 Any cardiometabolic health condition 45,739 47.7% 561 41.3% *** 381 31.9% *** 153 33.2% *** 358 45.4% 292 46.8%
Psychological distress
 None (0–4) 74,377 77.2% 971 70.4% 580 48.5% 174 43.1% 456 68.3% 412 82.6%
 Moderate (5–12) 18,476 18.8% 348 24.1% *** 463 39.0% *** 132 39.6% *** 164 21.9% * 65 12.1% **
 Severe (13–24) 4,155 4.0% 91 5.5% ** 190 12.5% *** 51 17.3% *** 60 9.9% *** 21 5.3%
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Note. Wtd. = weighted.

a

p values for comparing to straight participants.

*

p < .05.

**

p < .01.

***

p < .001.

Association Between Psychological Distress and Cardiometabolic Health

Odds ratios examining the association between psychological distress and cardiometabolic health are presented in Table 3. After adjusting for covariates, higher psychological distress was associated with significantly higher odds of having a cardiometabolic health condition, moderate psychological distress: OR = 1.66, 95% confidence interval (CI) [1.58, 1.75]; severe psychological distress: OR = 2.66, 95% CI [2.39, 2.96], among women overall. Similar associations were identified among straight women in sexual-identity-specific estimates as well as lesbian/gay women. There were also significant positive associations between moderate psychological distress and cardiometabolic health in adjusted models among women who reported “I don’t know” for their sexual identity (OR = 2.80, 95% CI [1.50, 5.23]). Tests for interaction found no statistically significant effect modification on the association between psychological distress and cardiometabolic health ( p = .27).

Table 3.

Association Between Psychological Distress and Cardiometabolic Health by Sexual Identity, National Health Interview Survey 2013– 2018

Psychological distress OR (95% CI)
Sexual identity Model None Moderate Severe
Overall unadj 1.00 1.30 (1.25–1.37)*** 2.24 (2.02–2.47)***
adja 1.00 1.66 (1.58–1.75)*** 2.66 (2.39–2.96)***
Straight unadj 1.00 1.34 (1.27–1.40)*** 2.40 (2.17–2.66)***
adja 1.00 1.66 (1.57–1.75)*** 2.72 (2.44–3.04)***
Gay/Lesbian unadj 1.00 1.56 (1.13–2.16)** 2.80 (1.63–4.78)***
adja 1.00 2.19 (1.50–3.19)*** 4.00 (2.26–7.07)***
Bisexual unadj 1.00 0.91 (0.66–1.26) 1.43 (0.90–2.27)
adja 1.00 1.20 (0.83–1.74) 1.79 (1.11–2.86)*
Something else unadj 1.00 0.54 (0.32–0.92)* 0.68 (0.30–1.56)
adja 1.00 1.21 (0.59–2.50) 1.86 (0.79–4.36)
I don’t know unadj 1.00 1.76 (1.12–2.77)* 1.78 (0.98–3.23)
adja 1.00 2.80 (1.50–5.23)** 1.85 (0.81–4.20)
Refused unadj 1.00 1.45 (0.84–2.49) 1.40 (0.45–4.36)
adja 1.00 1.22 (0.65–2.31) 1.39 (0.49–3.93)
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Note. Cardiometabolic health includes hypertension, high cholesterol, diabetes, coronary heart disease, a heart attack, stroke, or angina pectoris. CI = confidence interval; unadj = unadjusted; adj = adjusted.

a

Adjusted for age, race/ethnicity, relationship status, region, education level, employment, insurance, and income.

*

p < .05.

**

p < .01.

***

p < .001.

Discussion

This research contributes to existing literature in two ways. First, we estimated prevalence of psychological distress and cardiometabolic health among a frequently overlooked group of people who do not report a straight sexual identity (i.e., “something else,” “I don’t know,” and “refused”). Second, we examined sexual-orientation-specific associations between mental health and cardiometabolic health. Overall, we found that the majority of women who reported a sexual identity other than straight also reported higher prevalence of both moderate and severe psychological distress compared to straight women. However, there were some notable exceptions including no difference in moderate psychological distress between women who responded “I don’t know” and straight women, while fewer women who “refused” reported moderate psychological distress compared to straight women.

We found that the association between psychological distress and cardiometabolic health did not statistically significantly differ by sexual identity. Consistent with previous work (Mommersteeg et al., 2017; Smaardijk et al., 2020; Stewart et al., 2017), the overall association suggests that psychosocial distress is associated with poorer cardiometabolic health; however, when we further assessed this association by estimating sexual-identity-specific effects, we identified potentially substantive differences, which could have been masked due to smaller sample sizes of the sexual-identity subgroups (as reflected in the wide confidence intervals in these analyses). These substantive subgroup findings suggest that, for some women who report a sexual identity other than straight, the association between psychological distress and cardiometabolic health may be larger in magnitude than for their straight counterparts. For example, the associations between moderate psychological distress and cardiometabolic health were greater in magnitude among women who identified as lesbian/gay (OR = 2.19, 95% CI [1.50, 3.19]) and among women who did not know their sexual identity (OR = 2.80, 95% CI [1.50, 5.23]) as compared to straight women ([OR = 1.66, 95% CI [1.57, 1.75]). Additionally, the associations between severe psychological distress and cardiometabolic health were greater in magnitude among women who identified as lesbian/gay (OR = 4.00, 95% CI [2.26, 7.07]) than among straight women (OR = 2.73, 95% CI [2.44, 3.04]). Similar findings (i.e., no statistically significant effect modification but potentially important substantive subgroup differences) were identified when examining the association between the climate of support and obesity by sexual-identity groups (VanKim et al., 2020). Although both studies were cross-sectional, future work should continue to explore sexual-identity-specific estimates as a strategy to identify important subgroup differences that may impact intervention efforts.

As a corollary, the positive association between psychological distress and cardiometabolic health suggests that the high prevalence of poor mental health among sexual minority populations (Bränström et al., 2023; Gonzales & Henning-Smith, 2017; Hsieh, 2019; Mongelli et al., 2019; Williams et al., 2022; Wittgens et al., 2022) may negatively affect their risk for developing a cardiometabolic health condition. We can speculate that some of these potential substantive differences that we identified in sexual-identity-specific estimates may reflect how the added stigma and discrimination experienced by sexual minority women contributes to the higher prevalence of psychological distress, which in turn, may increase their risk for poor cardiometabolic health, as posited in the minority stress model (Meyer, 2003). Indeed, research has identified stigma and discrimination as a chronic stressor that may yield physiologic differences that further disadvantage minoritized groups in terms of health risks, such as for cardiometabolic risk conditions and diagnoses (Caceres et al., 2020; Frost et al., 2015; Wardecker et al., 2021). However, consistent with existing limitations of this area of research, the cross-sectional study design and reliance on self-reported diagnostic data inhibit our ability to examine this association more robustly. Collectively, these findings indicate the need for longitudinal work examining changes in mental health, experiences of stigma and discrimination, and subsequent risk of poor cardiometabolic health using metabolic biomarkers to understand how these exposures affect disease risk.

A unique contribution of this study are the findings regarding individuals who reported “something else,” “I don’t know,” or “refused” to disclose their sexual identity. While these groups are seldom analyzed in sexual-identity research, prior studies have found that when individuals are able to select their sexual identity from a larger range of response options, the heterogeneity within each sexual-identity subgroup decreases (West & McCabe, 2021). Therefore, although fewer people endorsed these response options, including these subgroups likely allowed us to generate better estimates of associations between sexual-identity and health outcomes. In particular, we were able to establish that the prevalence of severe psychological distress was higher among those who identified as “something else” or “I don’t know,” suggesting that psychological distress, which can be part of the process of sexual self-identification and development, might contribute to poor mental health, particularly in a society where those who are minoritized experience more stigma and discrimination. In combination with findings from existing research on the impact on patient experiences related to their sexual identity (Rahman et al., 2023; Ruben & Fullerton, 2018), our findings suggest that efforts to be inclusive of patient experiences should also consider sexual identities other than straight and LGB. Moreover, growing evidence shows the importance of accounting for sexual fluidity (change in sexual orientation dimensions over time) in research and clinical practice. Clinically, inclusive assessment of sexual orientation should occur at multiple time points, not only to ensure that holistic care is provided in line with individual changes during one’s life course (Katz-Wise & Todd, 2022) but also to help provide important contextual information regarding patient experiences. For example, recent state-level policies such as “Don’t Say Gay,” which bans discussion of sexual orientation and gender identity in classrooms, have substantial negative impacts on individual mental health and on healthy equity more broadly (Kline et al., 2022). Additionally, existing evidence suggests a lack of standardized education and expected competency for providers in both mental and primary health care (Bunting et al., 2022; Nowaskie, 2020; Williams et al., 2024). Development and implementation of training programs have been shown to be associated with increased clinical preparedness and basic knowledge of sexually minoritized health (Moe et al., 2021; Patel & Nowaskie, 2024; Traister, 2020). Collectively, this evidence highlights the importance of implementing inclusive assessments of sexual orientation (including sexual identities other than straight and LGB) at multiple time points and training programs to providers so that patients receive more holistic mental and physical health care. Future research should examine how changes and developments associated with one’s sexual identity may affect mental health and, subsequently, cardiometabolic health and identify relevant health needs during these sexual-identity changes and developments.

The use of self-report data for cardiometabolic health measures was a major limitation of the present study. Differential access to health care based on sexual identity (sexual minority populations have been shown to be less likely to access health care compared to their straight counterparts; Fish et al., 2021; Tabaac et al., 2020) likely introduces bias toward the null. Although we adjusted for health insurance coverage, women who reported a sexual identity other than straight were more likely to be uninsured than straight women, thus, potentially underestimating the prevalence of cardiometabolic health conditions and subsequent association between psychological distress and cardiometabolic health. An additional limitation is the cross-sectional study design, which inhibits determination of temporality and causation. Importantly, these data were collected prior to COVID-19-related events. Given evidence of the differential impact of COVID-19 on minoritized populations, including sexual minorities (Fish et al., 2021), it is likely that psychological distress would be underestimated during COVID-19 and after COVID-19-related restrictions were lifted. In relation to this, measures of stigma and discrimination (including individual-level experience as well as state- or federal-level policies) along with biospecimen were not collected, which limits directly testing mechanisms proposed in the minority stress model. Consistent with the minority stress model, the link between psychological distress and poor cardiometabolic health spans over an extended period in one’s life course, and the accumulation of these negative experiences, including large-scale disruptions such as the COVID-19 pandemic, likely is more indicative of disease risk than a snapshot in time. Collectively, these findings and limitations indicate the need for larger longitudinal studies that includes biological measures to ascertain cardiometabolic health outcomes (Caceres et al., 2018a; Farmer et al., 2013; Juster et al., 2019; Peterson et al., 2016; Wardecker et al., 2021) as well as assessment of discrimination, stigma, and psychological distress to more accurately determine their risk for poor cardiometabolic health.

Conclusions

Overall, the results of this study support previous research suggesting that psychological distress is associated with poorer cardiometabolic health and that women who identify other than straight require a unique understanding of their disparate risks and outcomes. It also indicates that further research is needed to better disentangle the factors that may contribute to the relationship of psychological distress and cardiometabolic health, such as the impact of stigma and discrimination. Studying mechanisms that create health disparities in cardiometabolic health allows for potential interventions to better mitigate these disparities and, more effectively and comprehensively, improve the health of women who identify other than straight. Relatedly, providing inclusive patient-centered care needs to include acknowledgement of sexual identities other than straight and LGB. While the needs of patients who identify as something other than these identities is not yet well understood, research that includes these populations will begin to highlight how health care workers may provide appropriate support. Moreover, although the association between psychological distress and cardiometabolic health were similar across sexual-identity groups, given the high prevalence of psychological distress among women who identify other than straight, longitudinal research is needed to better understand the long-term health impacts this may cause.

Public Policy Relevance Statement.

Psychological distress negatively affects cardiometabolic health among all women. However, for some women, psychological distress may have a greater affect on cardiometabolic health than others. This study found that women who do not identify as straight generally report more psychological distress; furthermore, lesbian or gay women who experience psychological distress may also experience poorer cardiometabolic health. Moreover, findings highlight the importance of including more expansive sexual-identity categories in research in order to better understand the health needs of those who do not identify as straight, lesbian, gay, or bisexual and provide appropriate care.

Acknowledgments

Nicole A. VanKim is supported by Grant K01DK123193 from the Division of Diabetes, Endocrinology, and Metabolic Diseases, National Institute of Diabetes, Digestive, and Kidney Diseases, National Institutes of Health.

Footnotes

The authors have no conflicts of interest to disclose.

References

  1. Alshehri AM (2010). Metabolic syndrome and cardiovascular risk. Journal of Family & Community Medicine, 17(2), 73–78. 10.4103/1319-1683.71987 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Bränström R, Fellman D, & Pachankis JE (2023). Age-varying sexual orientation disparities in mental health, treatment utilization, and social stress: A population-based study. Psychology of Sexual Orientation and Gender Diversity, 10(4), 686–698. 10.1037/sgd0000572 [DOI] [Google Scholar]
  3. Bunting SR, Goetz TG, Gabrani A, Blansky B, Marr M, & Sanchez NF (2022). Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) health education in primary care graduate medical education programs: A national survey of program directors. Annals of LGBTQ Public and Population Health, 3(4), 242–259. 10.1891/LGBTQ-2021-0027 [DOI] [Google Scholar]
  4. Caceres BA, Brody AA, Halkitis PN, Dorsen C, Yu G, & Chyun DA (2018a). Cardiovascular disease risk in sexual minority women (18–59 years old): Findings from the National Health and Nutritional Examination Survey (2001–2012). Women’s Health Issues, 28(4), 333–341. 10.1016/j.whi.2018.03.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Caceres BA, Brody AA, Halkitis PN, Dorsen C, Yu G, & Chyun DA (2018b). Sexual orientation differences in modifiable risk factors for cardiovascular disease and cardiovascular disease diagnoses in men. LGBT Health, 5(5), 284–294. 10.1089/lgbt.2017.0220 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Caceres BA, Brody A, Luscombe RE, Primiano JE, Marusca P, Sitts EM, & Chyun D (2017). A systematic review of cardiovascular disease in sexual minorities. American Journal of Public Health, 107(4), e13–e21. 10.2105/AJPH.2016.303630 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Caceres BA, Streed CG Jr., Corliss HL, Lloyd-Jones DM, Matthews PA, Mukherjee M, Poteat T, Rosendale N, Ross LM, & the American Heart Association Council on Cardiovascular and Stroke Nursing; Council on Hypertension; Council on Lifestyle and Cardiometabolic Health; Council on Peripheral Vascular Disease; and Stroke Council. (2020). Assessing and addressing cardiovascular health in LGBTQ Adults: A scientific statement From the American Heart Association. Circulation, 142(19), e321–e332. 10.1161/CIR.0000000000000914 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Cochran SD, Mays VM, & Sullivan JG (2003). Prevalence of mental disorders, psychological distress, and mental health services use among lesbian, gay, and bisexual adults in the United States. Journal of Consulting and Clinical Psychology, 71(1), 53–61. 10.1037/0022-006X.71.1.53 [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Diamant AL, & Wold C (2003). Sexual orientation and variation in physical and mental health status among women. Journal of Women’s Health, 12(1), 41–49. 10.1089/154099903321154130 [DOI] [PubMed] [Google Scholar]
  10. Division of Health Interview Statistics, National Center for Health Statistics. (2018). Multiple imputation of family income and personal earnings in the National Health Interview Survey: Methods and examples. https://www.cdc.gov/nchs/data/nhis/tecdoc.pdf
  11. Eliason MJ, Radix A, McElroy JA, Garbers S, & Haynes SG (2016). The “something else” of sexual orientation: Measuring sexual identities of older lesbian and bisexual women using National Health Interview Survey questions. Women’s Health Issues, 26(Suppl. 1), S71–S80. 10.1016/j.whi.2016.03.012 [DOI] [PubMed] [Google Scholar]
  12. Farmer GW, Jabson JM, Bucholz KK, & Bowen DJ (2013). A population-based study of cardiovascular disease risk in sexual-minority women. American Journal of Public Health, 103(10), 1845–1850. 10.2105/AJPH.2013.301258 [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Fish JN, Turpin RE, Williams ND, & Boekeloo BO (2021). Sexual identity differences in access to and satisfaction with health care: Findings from nationally representative data. American Journal of Epidemiology, 190(7), 1281–1293. 10.1093/aje/kwab012 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Frost DM, Lehavot K, & Meyer IH (2015). Minority stress and physical health among sexual minority individuals. Journal of Behavioral Medicine, 38(1), 1–8. 10.1007/s10865-013-9523-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Gonzales G, & Henning-Smith C (2017). Health disparities by sexual orientation: Results and implications from the behavioral risk factor surveillance system. Journal of Community Health, 42(6), 1163–1172. 10.1007/s10900-017-0366-z [DOI] [PubMed] [Google Scholar]
  16. Hatzenbuehler ML, Nolen-Hoeksema S, & Erickson SJ (2008). Minority stress predictors of HIV risk behavior, substance use, and depressive symptoms: Results from a prospective study of bereaved gay men. Health Psychology, 27(4), 455–462. 10.1037/0278-6133.27.4.455 [DOI] [PubMed] [Google Scholar]
  17. Hsieh N (2019). Mental health disparities by sexual orientation in the U.S.: Current patterns and recent trends. EurAmerica, 49(2), 201. https://link.gale.com/apps/doc/A593148654/AONE?u=anon~f4451913&sid=googleScholar&xid=2c15b68d [Google Scholar]
  18. Jackson CL, Agénor M, Johnson DA, Austin SB, & Kawachi I (2016). Sexual orientation identity disparities in health behaviors, outcomes, and services use among men and women in the United States: A cross-sectional study. BMC Public Health, 16(1), Article 807. 10.1186/s12889-016-3467-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Juster R-P, Doyle DM, Hatzenbuehler ML, Everett BG, DuBois LZ, & McGrath JJ (2019). Sexual orientation, disclosure, and cardiovascular stress reactivity. Stress, 22(3), 321–331. 10.1080/10253890.2019.1579793 [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Katz-Wise SL, & Todd KP (2022). The current state of sexual fluidity research. Current Opinion in Psychology, 48, Article 101497. 10.1016/j.copsyc.2022.101497 [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Kessler RC, Grief Green J, Gruber MJ, Sampson NA, Bromet E, Cuitan M, Furukawa TA, Gureje O, Hinkov H, Oakley-Browne M, Posada-Villa J, Sagar R, Viana MC, & Zaslavsky AM (2010). Screening for serious mental illness in the general population with the K6 screening scale: Results from the WHO world mental health (WMH) survey initiative. International Journal of Methods in Psychiatric Research, 19(S1), 4–22. 10.1002/mpr.310 [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Kline NS, Griner SB, Neelamegam M, Webb NJ, Morales JJ, & Rhodes SD (2022). Responding to “don’t say gay” laws in the US: Research priorities and considerations for health equity. Sexuality Research & Social Policy, 19(4), 1397–1402. 10.1007/s13178-022-00773-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Lick DJ, Durso LE, & Johnson KL (2013). Minority stress and physical health among sexual minorities. Perspectives on Psychological Science, 8(5), 521–548. 10.1177/1745691613497965 [DOI] [PubMed] [Google Scholar]
  24. Mays VM, Juster RP, Williamson TJ, Seeman TE, & Cochran SD (2018). Chronic physiologic effects of stress among lesbian, gay, and bisexual adults: Results from the National Health and Nutrition Examination Survey. Psychosomatic Medicine, 80(6), 551–563. 10.1097/PSY.0000000000000600 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Meyer IH (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. 10.1037/0033-2909.129.5.674 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Miller K, & Ryan JM (2011). Design, development and testing of the NHIS sexual identity question. Questionnaire Design Research Laboratory, Office of Research and Methodology, National Center for Health Statistics. [Google Scholar]
  27. Moe J, Pope A, Dominguez V, & Kemer G (2021). Factors predicting instruction of LGBTQ counseling competence. Journal of LGBTQ Issues in Counseling, 15(4), 389–405. 10.1080/15538605.2021.1967252 [DOI] [Google Scholar]
  28. Mommersteeg PMC, Arts L, Zijlstra W, Widdershoven JW, Aarnoudse W, & Denollet J (2017). Impaired health status, psychological distress, and personality in women and men with nonobstructive coronary artery disease. Circulation: Cardiovascular Quality and Outcomes, 10(2), Article e003387. 10.1161/CIRCOUTCOMES.116.003387 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Mongelli F, Perrone D, Balducci J, Sacchetti A, Ferrari S, Mattei G, & Galeazzi GM (2019). Minority stress and mental health among LGBT populations: An update on the evidence. Minerva Psichiatrica, 60(1), 27–50. 10.23736/S0391-1772.18.01995-7 [DOI] [Google Scholar]
  30. National Heart Lung and Blood Institute. (2022). Metabolic syndrome. U.S. Department of Health and Human Services. https://www.nhlbi.nih.gov/health-topics/metabolic-syndrome [Google Scholar]
  31. Nowaskie D (2020). A national survey of U.S. psychiatry residents’ LGBT cultural competency: The importance of LGBT patient exposure and formal education. Journal of Gay & Lesbian Mental Health, 24(4), 375–391. 10.1080/19359705.2020.1774848 [DOI] [Google Scholar]
  32. Parsons V, Moriarty C, Jonas K, Moore T, Davis K, & Tompkins L (2014). Design and estimation for the National Health Interview Survey, 2006–2015 (Vital Health Statistics, Series 2, Issue 165). National Center for Health Statistics. [PubMed] [Google Scholar]
  33. Patel AU, & Nowaskie DZ (2024). Affirmation of LGBTQ+ healthcare providers: A dynamic process, requiring ongoing education and training. Journal of Gay & Lesbian Mental Health, 28(3), 415–423. 10.1080/19359705.2023.2197848 [DOI] [Google Scholar]
  34. Peterson KL, Jacobs JP, Allender S, Alston LV, & Nichols M (2016). Characterising the extent of misreporting of high blood pressure, high cholesterol, and diabetes using the Australian Health Survey. BMC Public Health, 16(1), Article 695. 10.1186/s12889-016-3389-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Platt LF, & Scheitle CP (2018). Sexual orientation and psychological distress: Differences by race and gender. Journal of Gay & Lesbian Mental Health, 22(3), 204–225. 10.1080/19359705.2018.1437583 [DOI] [Google Scholar]
  36. Price-Feeney M, Green AE, & Dorison SH (2021). Suicidality among youth who are questioning, unsure of, or exploring their sexual identity. Journal of Sex Research, 58(5), 581–588. 10.1080/00224499.2020.1832184 [DOI] [PubMed] [Google Scholar]
  37. Rahman M, Fikslin RA, Matthews E, Vazquez Sanchez MA, Ahn GO, Kobrak PH, Lovinger ES, & Golub SA (2023). Exploring factors affecting patient–provider interactions and healthcare engagement among a diverse sample of women who have sex with women in New York City. Archives of Sexual Behavior, 52(2), 833–849. 10.1007/s10508-022-02478-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Ruben MA, & Fullerton M (2018). Proportion of patients who disclose their sexual orientation to healthcare providers and its relationship to patient outcomes: A meta-analysis and review. Patient Education and Counseling, 101(9), 1549–1560. 10.1016/j.pec.2018.05.001 [DOI] [PubMed] [Google Scholar]
  39. Smaardijk VR, Maas AHEM, Lodder P, Kop WJ, & Mommersteeg PMC (2020). Sex and gender-stratified risks of psychological factors for adverse clinical outcomes in patients with ischemic heart disease: A systematic review and meta-analysis. International Journal of Cardiology, 302, 21–29. 10.1016/j.ijcard.2019.12.014 [DOI] [PubMed] [Google Scholar]
  40. Stewart RAH, Colquhoun DM, Marschner SL, Kirby AC, Simes J, Nestel PJ, Glozier N, O’Neil A, Oldenburg B, White HD, Tonkin AM, & the LIPID Study Investigators. (2017). Persistent psychological distress and mortality in patients with stable coronary artery disease. Heart, 103(23), 1860–1866. 10.1136/heartjnl-2016-311097 [DOI] [PubMed] [Google Scholar]
  41. Swim JK, Johnston K, & Pearson NB (2009). Daily experiences with heterosexism: Relations between heterosexist hassles and psychological well-being. Journal of Social and Clinical Psychology, 28(5), 597–629. 10.1521/jscp.2009.28.5.597 [DOI] [Google Scholar]
  42. Szymanski DM (2009). Examining potential moderators of the link between heterosexist events and gay and bisexual men’s psychological distress. Journal of Counseling Psychology, 56(1), 142–151. 10.1037/0022-0167.56.1.142 [DOI] [Google Scholar]
  43. Tabaac AR, Solazzo AL, Gordon AR, Austin SB, Guss C, & Charlton BM (2020). Sexual orientation-related disparities in healthcare access in three cohorts of U.S. adults. Preventive Medicine, 132, Article 105999. 10.1016/j.ypmed.2020.105999 [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Traister T (2020). Improving LGBTQ cultural competence of RNs through education. Journal of Continuing Education in Nursing, 51(8), 359–366. 10.3928/00220124-20200716-05 [DOI] [PubMed] [Google Scholar]
  45. VanKim NA, Eisenberg ME, Erickson DJ, Lust K, & Laska MN (2020). College climate and sexual orientation difference in weight status. Prevention Science, 21(3), 422–433. 10.1007/s11121-019-01061-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Wardecker BM, Graham-Engeland JE, & Almeida DM (2021). Perceived discrimination predicts elevated biological markers of inflammation among sexual minority adults. Journal of Behavioral Medicine, 44(1), 53–65. 10.1007/s10865-020-00180-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. West BT, Engstrom CW, Schepis TS, Tani IJ, & McCabe SE (2024). How a “something else” response option for sexual identity affects national survey estimates of associations between sexual identity, reproductive health, and substance use. Archives of Sexual Behavior, 53(1), 107–126. 10.1007/s10508-023-02710-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. West BT, & McCabe SE (2021). Choices matter: How response options for survey questions about sexual identity affect population estimates of its association with alcohol, tobacco, and other drug use. Field Methods, 33(4), 335–354. 10.1177/1525822X21998516 [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Williams ND, Turpin RE, Akré EL, Boekeloo BO, & Fish JN (2022). Disparities in mental health care access among persons differing in sexual identity: Nationally representative findings. Psychiatric Services, 73(4), 456–459. 10.1176/appi.ps.202100045 [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Williams ND, Winer B, Aparicio EM, Smith-Bynum MA, Boekeloo BO, & Fish JN (2024). Professional expectations of provider LGBTQ competence: Where we are and where we need to go. Journal of Gay & Lesbian Mental Health, 28(2), 286–311. 10.1080/19359705.2022.2146825 [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Wittgens C, Fischer MM, Buspavanich P, Theobald S, Schweizer K, & Trautmann S (2022). Mental health in people with minority sexual orientations: A meta-analysis of population-based studies. Acta Psychiatrica Scandinavica, 145(4), 357–372. 10.1111/acps.13405 [DOI] [PubMed] [Google Scholar]
  52. Wu L, Sell RL, Roth AM, & Welles SL (2018). Mental health disorders mediate association of sexual minority identity with cardiovascular disease. Preventive Medicine, 108(January), 123–128. 10.1016/j.ypmed.2018.01.003 [DOI] [PubMed] [Google Scholar]

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