Prevalence of LGBTQ+ identity among people with disabilities and long-term services and supports needs in the United States

Abstract

Background

People with disabilities and sexual orientation and gender identity minority individuals are both considered health disparity populations, but there has been limited work assessing the prevalence of lesbian, gay, bisexual, transgender, and queer (LGBTQ+) identity among people with disabilities. This study examines the prevalence of LGBTQ+ identity among people with disabilities, with a particular focus on people with long-term services and supports (LTSS) needs.

Methods

We conducted secondary analysis of 2022 data from the Behavioral Risk Factor Surveillance System (BRFSS), a United States population-based, cross-sectional telephone survey administered annually to adults over age 18 residing in non-institutional settings. Our sample includes 272,124 respondents from 31 states. We used chi-square tests to compare participants with no disability and any disability, as well as people who reported a disability related to activities of daily living (ADLs) or instrumental activities of daily living (IADLs), who were considered to have LTSS needs.

Results

13% of individuals with a disability in the sample, including 16% of individuals who are disabled and have long-term service and support (LTSS) needs, identify as LGBTQ+, compared to 7% of non-disabled respondents. Disabled people who report LTSS needs have the highest rate of LGBTQ+ identification, and there is a significant association between LTSS need and LGBTQ+ identity.

Conclusions

Respondents to BRFSS with disabilities report LGBTQ+ identity at higher rates than non-disabled individuals. Disabled people with LTSS needs report the highest rate of LGBTQ+ identity. Improved prevalence estimates for this intersectional population can support efforts to make healthcare, services, and programs more accessible and inclusive.

Background

As of 2023, the National Institutes of Health has designated both people with disabilities1 and sexual orientation and gender identity minorities as health disparity populations [1–3]. NIH designation of a community as a health disparity population is important because it guides funding and resource allocation for research and intervention. However, there has been less consideration of individuals who belong to multiple marginalized groups, and consequently, are part of more than one health disparity population. Improvements to population health depend on a thorough understanding of that population, including precise estimates of population size and demographic composition [4]. Previous research suggests that disabled adults are more likely to identify as lesbian, gay, bisexual, transgender, and queer (LGBTQ+) than their non-disabled peers [5, 6]. Given recent increases in the number of people identifying as either disabled or LGBTQ+ [7–9], it is important to more carefully consider these populations’ intersection. Our study re-examines the prevalence of LGBTQ+ identity among people with disabilities using updated, nationally representative data, with specific consideration of LGBTQ+ identity among people who need long-term services and supports (LTSS).

Disability and LGBTQ+ identity

Previous studies have been limited in their ability to estimate prevalence of LGBTQ+ identity among people with disabilities due to reliance on single-state data [5, 10] and non-random samples [11]. One multi-state, representative estimate appeared as part of a brief report on disability prevalence using 2019 data, but this report does not explore overlap between disability and LGBTQ+ identity in detail [6]. While a number of recent studies have examined rates of LGBTQ+ identification, and in particular transgender identity, among autistic adults [12–16], there has not been a comparable body of work regarding LGBTQ+ prevalence among the wider disability community. Additionally, previous studies focusing on LGBTQ+ individuals with disabilities have not differentiated disabled people who have LTSS needs, as indicated by difficulty with activities of daily living (ADLs) or instrumental activities of daily living (IADLs), and who represent an important subpopulation of disabled individuals.

LTSS in the United States

LTSS are a range of health and social services for people with disabilities that encompass ongoing assistance with ADLs, like eating, bathing, and dressing, and IADLs, like shopping and meal preparation, housecleaning, and medication management [17]. Need for LTSS, in both research and policy, is typically measured by limitations in ability to perform ADLs or IADLs [17, 18]. Policy related to LTSS in the United States is highly complex. The primary funder of paid, formal LTSS is Medicaid, which is a means-tested public health program for low-income and disabled individuals [17, 19, 20]. As a joint program between the federal government and individual states that administer it, Medicaid is governed by federal regulations but subject to state authority leading to significant variation in coverage, eligibility requirements, and reimbursement rates [17, 20]. Eligibility for Medicaid LTSS varies by state, but generally requires individuals to meet financial criteria that limit income and assets and often specifies state-defined level-of-care criteria that determine need for LTSS [17, 20]. While historically, LTSS funding prioritized institutional care, advocacy efforts by the disability community and policy shifts over recent decades have led to a shift towards greater use of and funding for home and community-based services (HCBS), which enable disabled people to receive care and supports in their own home or community [17, 19].

LTSS and accessible healthcare as key components of public health

Despite their role in enabling people to live and participate in their communities, LTSS are not distributed equitably across subpopulations by race, ethnicity, geographic locale, and LGBTQ+ identity [21, 22]. These disparities are not limited to paid supports provided through formally funded home and community-based services (HCBS), but persist in receipt of informal supports as well. Upwards of 75% of all LTSS is provided through unpaid and informal caregiving, often by family members [23]. However, people with disabilities tend to have smaller natural support networks than their non-disabled peers [24], which may limit their access to needed supports. These support limitations may be compounded for disabled people who also identify as LGBTQ+, who are less likely to have children and more likely to experience family rejection [25–27]. While scholars have recently called for work to address the unique needs of LGBTQ+ individuals who receive in-home care and services [28, 29], outside of research focusing on older LGBTQ+ adults there has been little work that specifically considers the intersection of LTSS need and LGBTQ+ identity, even in work that explores LGBTQ+ identity and disability more broadly.

People who are both disabled and LGBTQ+ experience disparities in access to healthcare and LTSS, and in the quality of care they receive. Recent studies have found that the majority of LGBTQ+ disabled adults report experiencing identity-based discrimination, and they are more likely to have unmet healthcare needs than their nondisabled, straight, and cisgender peers [30, 31]. Similarly, studies on the experiences of LGBTQ+ autistic people have found that they have more unmet healthcare needs and report higher rates of service refusal by medical providers [32, 33]. The intersection between disability and LGBTQ+ identity may also be important to understand health disparities among aging adults, who may experience new or greater LTSS need and service use. Results of a survey of lesbian, gay, and bisexual adults aged 50 and older found that lifetime victimization and internalized stigma were both associated with greater likelihood of poor health among this population [34]. A separate analysis of data from the same survey revealed that transgender older adults report fear of accessing healthcare outside the LGBTQ+ community at significantly higher rates than cisgender lesbian, gay, and bisexual older adults, and experience more lifetime victimization and internalized stigma [35]. Updated estimates of the prevalence of LGBTQ+ identity among disabled people, especially those with LTSS need, are important for informing appropriate investment in services and supports.

Study aim and research questions

This study aims to contribute to our understanding of people who are both disabled and LGBTQ+ by estimating the prevalence of LGBTQ+ identity among disabled people, with a specific focus on people who have disabilities that confer LTSS need. Specifically, we address the following research questions:

• RQ1a: What is the prevalence of LGBTQ+ identity among people with disabilities?

• RQ1b: What is the prevalence of LGBTQ+ identity among people with disabilities that confer LTSS need?

• RQ2a: Are people with disabilities more likely to identify as LGBTQ+ than people without disabilities?

• RQ2b: Are people with LTSS need more likely to identify as LGBTQ+ than disabled people without LTSS need?

Methods

Dataset

We use data from the 2022 Behavioral Risk Factor Surveillance System (BRFSS). Overseen by the Centers for Disease Control and Prevention (CDC), BRFSS is a United States population-based, cross-sectional telephone survey administered annually to adults over age 18 residing in non-institutional settings across all 50 states and 4 territories [36]. Since its creation in 1984, BRFSS has been used to assess the prevalence of health behaviors and risk factors [37]. All U.S. states use BRFSS data to track health objectives and plan health programs, and most use the data for health-related legislative initiatives [38]. BRFSS uses random digit dial sampling and adjusted this procedure to incorporate both landline and cellphone phone numbers in 2011 [39].

Each iteration of the survey includes core questions and rotating core questions that are included in the surveys administered across all states and territories. These core questions include the American Community Survey (ACS) 6 disability questions, which were originally developed as a standardized way of identifying most people with disabilities in national surveys based on functional limitations in core domains [40–42]. The ACS 6 are now included in a variety of surveys conducted or sponsored by the U.S. federal government and are recommended by the U.S. Department of Health and Human Services as the standard for defining the U.S. disabled population [43]. In addition to the core questions, the CDC offered 28 optional modules in 2022 which states could choose to incorporate, including a Sexual Orientation and Gender Identity (SOGI) module which 33 states administered [44]. Figure 1 shows the different components of the BRFSS survey, including the sources of specific variables related to disability and LGBTQ+ identity which we used in our analyses.

Fig. 1.

Components of the BRFSS Survey

Sample

Our sample includes 272,124 respondents who have non-missing data for the disability questions included in the core BRFSS survey, and who took the survey in one of the 31 states that administered Version 1 of the SOGI module. While some states administer their own questions about LGBTQ+ identity, responses to state-added questions are not included in the public BRFSS dataset, and are not standardized; we therefore limited our sample to states that used the BRFSS-provided module. Additionally, two states reported administering alternate versions of the optional SOGI module but did not make responses available in the public dataset. A list of states included in our sample appears in Table 1.

Table 1.

State selection for sample

State/Territory Name1	Reported administering any SOGI module?	Responses from SOGI module in public dataset?	Included in sample?
Alabama	No	No	No
Alaska	Yes	Yes	Yes
Arizona	No	No	No
Arkansas	No	No	No
California	No	No	No
Colorado	Yes	Yes	Yes
Connecticut	Yes	Yes	Yes
Delaware	Yes	Yes	Yes
Florida	No	No	No
Georgia	Yes	Yes	Yes
Hawaii	Yes	Yes	Yes
Idaho	No	No	No
Illinois	Yes	Yes	Yes
Indiana	Yes	Yes	Yes
Iowa	Yes	Yes	Yes
Kansas	Yes	Yes	Yes
Kentucky	No	No	No
Louisiana	Yes	Yes	Yes
Maine	No	No	No
Maryland	Yes	Yes	Yes
Massachusetts	Yes	Yes	Yes
Michigan	Yes	Yes	Yes
Minnesota	Yes	Yes	Yes
Mississippi	No	No	No
Missouri	Yes	Yes	Yes
Montana	Yes	Yes	Yes
Nebraska	No	No	No
Nevada	Yes	Yes	Yes
New Hampshire	No	No	No
New Jersey2	Yes	No	No
New Mexico	Yes	Yes	Yes
New York	No	No	No
North Carolina	Yes	Yes	Yes
North Dakota	Yes	Yes	Yes
Ohio	Yes	Yes	Yes
Oklahoma2	Yes	No	No
Oregon	No	No	No
Pennsylvania	Yes	Yes	Yes
Rhode Island	Yes	Yes	Yes
South Carolina	No	No	No
South Dakota	No	No	No
Tennessee	No	No	No
Texas	Yes	Yes	Yes
Utah	Yes	Yes	Yes
Vermont	Yes	Yes	Yes
Virginia	Yes	Yes	Yes
Washington	Yes	Yes	Yes
West Virginia	Yes	Yes	Yes
Wisconsin	Yes	Yes	Yes
Wyoming	No	No	No
District of Columbia	No	No	No
Guam	Yes	Yes	No
Puerto Rico	No	No	No
Virgin Islands	No	No	No

¹ Italicized text indicates states that were included in the sample

² Oklahoma and New Jersey administered versions 2 and 3 of the SOGI module respectively, but responses to these versions were not available in the public BRFSS dataset

Prior to beginning the full analyses, we compared demographic descriptives for individuals living in states that did and did not administer Version 1 of the SOGI module. We found significant differences between people who lived in states which administered the module and those who did not. People who lived in states which provided SOGI module responses to the public dataset were more likely to be non-Hispanic white and less likely to be non-Hispanic Black (p < 0.001); less likely to report a disability (p < 0.001); and more likely to report incomes over $100,000 per year (p < 0.001).

Variables

We considered two measures of disability: whether an individual reported any disability, and whether an individual reported long-term services and supports (LTSS) needs.

Disability

Overall disability status was based on responses to the American Community Survey (ACS) 6 disability questions. As noted above, the ACS 6 are included as part of BRFSS’s fixed core survey, are one of the most common ways of collecting disability data in the U.S., and are widely used in national survey data collection and for disability prevalence estimates [40–43, 45]. They ask respondents whether they experience “serious difficulty” in six areas, intended to capture the functional domains most commonly associated with disability: hearing; seeing; concentrating, remembering, or making decisions; walking or climbing stairs; dressing or bathing; or doing errands alone [41]. The full text for each question as it appears in BRFSS is included in Table 2. Individuals responding yes to any of these questions were considered to be disabled, consistent with both the intent of the developers of the ACS 6 and previous research on disability using BRFSS data [6, 40–43, 45, 46].

Table 2.

ACS 6 questions included in BRFSS

Some people who are deaf or have serious difficulty hearing use assistive devices to communicate by phone. Are you deaf or do you have serious difficulty hearing?

Are you blind or do you have serious difficulty seeing, even when wearing glasses?

Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

Do you have serious difficulty walking or climbing stairs?

Do you have difficulty dressing or bathing?

Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?

LTSS Need

We based the sub-group of people with LTSS needs on responses to the two ACS 6 questions that asked about difficulty with (1) dressing or bathing or (2) doing errands alone. These two questions correspond to needing assistance with ADLs and IADLs, respectively. Individuals who reported difficulty with either ADLs or IADLs were considered to have LTSS need, consistent with approaches used in previous disability-focused research using BRFSS data and with U.S. policies and programs that define LTSS need based on functional limitations in these domains [18, 20, 46, 47].

LGBTQ+ Identity

LGBTQ+ identity is based on questions from the optional SOGI module. The BRFSS core survey first asks if a respondent is male or female as part of screening and excludes individuals who indicate that they are neither (e.g., by responding that they are intersex or non-binary) in states that have not chosen to administer the optional sex at birth module or added their own sex at birth question. Only ten of the 33 states that reported administering the SOGI module in 2022 also included the sex at birth module (though others may have added a sex at birth question), thus we included all states that administered version 1 of the SOGI module regardless of whether they asked about sex at birth.

We considered LGBTQ+ identity overall and disaggregated by sexual orientation and gender identity individually. People who said they were either non-heterosexual or transgender were considered to be LGBTQ+. We retained people who responded that they didn’t know or were unsure of their identity as a separate group, rather than reclassifying them as having missing responses to retain sample size and to avoid conflating people who might be questioning their identity or still in a process of self-discovery with those who declined to answer the SOGI module questions.

Sexual orientation

Sexual orientation was based on response to the question, “Which of the following best represents how you think of yourself?” Response options included straight (not gay), gay, bisexual, something else (not straight), and don’t know/unsure. Individuals who selected gay, bisexual, or “something else” were considered to be non-heterosexual.

Gender identity

Gender identity was based on response to the question, “Do you consider yourself to be transgender?” Response options included yes, transgender male-to-female; yes, transgender female-to-male; yes, transgender, gender nonconforming; no (not transgender); and don’t know/unsure. All “yes” responses were considered indicative of transgender identity. We considered respondents who selected “transgender male-to-female” to be trans women; respondents who selected “transgender female-to-male” to be trans men; and respondents who selected “transgender, gender nonconforming” to be non-binary.

LGBTQ+ identity

We considered individuals to be LGBTQ+ if they indicated they were non-heterosexual and/or transgender.

Unsure of LGBTQ+ identity

Respondents who selected “I don’t know/unsure” for sexual orientation and/or gender identity questions were retained as a separate category for prevalence estimates.

Analyses

To examine the prevalence of LGBTQ+ identity among disabled people, we began by using descriptive statistics to assess the percentage of the sample that could be categorized into each of four groups: non-disabled non-LGBTQ+, disabled non-LGBTQ+, non-disabled LGBTQ+, and disabled LGBTQ+. We used analytic weights supplied in the BRFSS public dataset to complete these estimates. Next, we used bivariate tests to examine associations between disability and LTSS need and SOGI minority status, to determine whether there was a significant relationship between them. Analyses were performed using Stata version 18.0.

Results

We obtained prevalence estimates using a weighted, population-representative sample of individuals in 31 states. The overall prevalence of disability we estimate from our sample is consistent with other recent estimates using BRFSS data, which find that more than 1 in 4 U.S. adults report a disability [6]. As shown in Fig. 2, based on this sample, approximately 4% of people have a disability and also identify as LGBTQ+. 25% have a disability and are not LGBTQ+, 5% are nondisabled and LGBTQ+, and 66% do not have a disability and are not LGBTQ+. Among individuals with any disability, 5% reported both LTSS needs and LGBTQ + identity.

Fig. 2.

Disability Status and LGBTQ + Identity

Prevalence of LGBTQ+ identity among people with disabilities

Overall, 13% of disabled people identify as LGBTQ+, compared to 7% of nondisabled people. To better understand the overlap between disability and LGBTQ+ identity, we calculated the prevalence of each sub-category of sexual orientation and gender identity (e.g., lesbian/gay, bisexual, transgender non-binary, etc.) by disability (any disability or no disability). These full prevalence rates for LGBTQ+ identity by disability are shown in Table 3.

Table 3.

Weighted prevalence of LGBTQ+ Identity by disability status

		Disability Status
		No disability	Any disability
		n = 193,480	n = 78,644
LGBTQ + Identity	Sexual Orientation
	Total participants with responses	n = 174,541	n = 71,735
	Straight/heterosexual	161,363 (93.97%)	67,607 (90.68%)
	Any non-heterosexual orientation	12,409 (7.11%)	9,023 (12.58%)
	Gay/lesbian	3,589 (2.06%)	1,741 (2.43%)
	Bisexual	5,850 (3.50%)	4,707 (6.56%)
	Other non-heterosexual	2,970 (1.70%)	2,574 (3.59%)
	Don’t know/unsure	1,906 (1.09%)	1,474 (2.05%)
	Gender Identity
	Total participants with responses	n = 176,439	n = 72,664
	Cisgender	174,954 (99.16%)	71,148 (97.91%)
	Any transgender identity	871 (0.49%)	1119 (1.54%)
	Transgender woman	289 (0.16%)	324 (0.45%)
	Transgender man	283 (0.16%)	327 (0.45%)
	Non-binary	298 (0.17%)	469 (0.64%)
	Don’t know/unsure	615 (0.35%)	397 (0.55%)
	Sexual Orientation + Gender Identity
	Total participants with responses	n = 174,246	n = 71,635
	Any LGBTQ + identity (non-heterosexual OR transgender)	12,775 (7.33%)	9,239 (12.90%)
	Both non-heterosexual AND transgender	507 (0.29%)	904 (1.24%)
	Unsure of both sexual orientation and gender identity	171 (0.09%)	123 (0.16%)

LGBTQ+ identity is more prevalent among people with disabilities than among the non-disabled population. Compared to 7% of non-disabled respondents, 13% of individuals with a disability indicated that they were gay/lesbian, bisexual, or other non-heterosexual. The largest differences in prevalence of sexual orientation subcategories were observed among individuals identifying as bisexual (7% of disabled people compared to 4% of non-disabled people) or some other non-heterosexual orientation (4% of disabled people compared to 2% of non-disabled people). About 2% of individuals with a disability indicated that they identify as transgender, compared to less than 1% of non-disabled individuals.

We further explored prevalence of LGBTQ+ identity among disabled individuals by LTSS need (any or none). Disabled people with LTSS need reported LGBTQ+ identity at higher rates than disabled people who did not indicate LTSS need. Nearly 16% of individuals with LTSS needs are gay, lesbian, bisexual, or some other non-heterosexual orientation, compared to 11% of disabled individuals not reporting LTSS need. As with differences in prevalence of sexual orientation subgroups between disabled and non-disabled individuals, the greatest differences in prevalence rates are in those of individuals identifying as bisexual (8% of people with LTSS need compared to 6% of disabled individuals without LTSS need) or some other non-heterosexual orientation (5% of people with LTSS need compared to 3% of disabled people without LTSS need). Individuals with LTSS need also have greater prevalence of transgender identity: over 2% of people with LTSS need compared to 1% of people with disabilities who do not have LTSS need. Full prevalence estimates for LGBTQ+ identity among disabled people by LTSS need are shown in Table 4.

Table 4.

Weighted prevalence of LGBTQ+ Identity by LTSS need (Disabled respondents Only)

		LTSS Need
		No LTSS need	Any LTSS need
		n = 55,948	n = 25,717
LGBTQ + Identity	Sexual Orientation
	Total participants with responses	n = 50,939	n = 23,352
	Straight/heterosexual	44,255 (86.88%)	19,164 (82.07%)
	Any non-heterosexual orientation	5,699 (11.19%)	3,650 (15.63%)
	Gay/lesbian	1,188 (2.33%)	619 (2.65%)
	Bisexual	2,995 (5.88%)	1,878 (8.04%)
	Other non-heterosexual	1,516 (2.98%)	1154 (4.94%)
	Don’t know/unsure	984 (1.93%)	538 (2.30%)
	Gender Identity
	Total participants with responses	n = 51,584	n = 23,685
	Cisgender	50,738 (98.36%)	22,965 (96.96%)
	Any transgender identity	586 (1.14%)	575 (2.43%)
	Transgender woman	172 (0.33%)	164 (0.69%)
	Transgender man	152 (0.29%)	188 (0.79%)
	Non-binary	262 (0.51%)	215 (0.94%)
	Don’t know/unsure	260 (0.50%)	145 (0.61%)
	Sexual Orientation + Gender Identity
	Total participants with responses	n = 50,843	n = 23,298
	Any LGBTQ + identity (non-heterosexual OR transgender)	5831 (11.47%)	3737 (16.04%)
	Both non-heterosexual AND transgender	452 (0.87%)	487 (2.05%)
	Unsure of both sexual orientation and gender identity	78 (0.14%)	46 (0.18%)

Associations between disability, LTSS need, and LGBTQ+ identity

To better understand the intersection of disability and LGBTQ+ identification, we used chi-square tests to explore associations between disability, LTSS need, and LGBTQ+ identity. People with disabilities in general, and people with LTSS need specifically, report LGBTQ+ identity at a significantly higher rate than nondisabled people. People with disabilities are both more likely to report a sexual orientation other than heterosexual (p < 0.001) and more likely to identify as transgender (p < 0.001). LTSS need was also significantly associated with LGBTQ + identity (p < 0.001). Having LTSS need was significantly associated with both identifying as non-heterosexual (p < 0.001) and with transgender identity (p < 0.001).

We further examined the association between LTSS need and LGBTQ+ identity by restricting the sample to only those individuals who reported any disability, and comparing those who indicated LTSS need with those who did not. Even when comparing only individuals with disabilities, LTSS need is significantly associated with LGBTQ+ identity (p < 0.001). Among disabled people specifically, LTSS need is significantly associated with both non-heterosexual orientation (p < 0.001) and transgender identity (p < 0.001).

Discussion

This study represents the first comprehensive examination of the prevalence of LGBTQ+ identity among people with disabilities, including individuals with LTSS need specifically, using a population-representative sample. We find that disabled individuals report LGBTQ+ identity at higher rates than non-disabled individuals, and that there is a significant association between disability status and LGBTQ+ identity. While previous research has reported similar findings regarding greater rates of LGBTQ+ identification among the disability community [5, 6], our study is unique in its focus on the subgroup of disabled people who report LTSS need. This consideration of LTSS need is particularly important given that individuals reporting LTSS needs were the most likely to report LGBTQ+ identity, and the association between LTSS need and LGBTQ+ identity remained significant even when considering only disabled individuals. This finding underscores the need for greater consideration of LGBTQ+ individuals within HCBS and related policy and program areas.

Individuals with LTSS need are more likely to receive home and community-based services (HCBS), and may be at greater risk of negative health outcomes and institutionalization if the care and services they receive are insufficient or inappropriate [48, 49]. A recent study examining the impact of forgone care due to COVID-19 related disruptions found that disabled respondents who were non-binary, transgender, or otherwise gender diverse were significantly more likely to have delayed or forgone care compared to cisgender disabled people, and more likely to report adverse impacts on their health and well-being as a result of delaying or forgoing care [50]. Such findings emphasize the importance of understanding the prevalence of LGBTQ+ identity among disabled people, so that we can improve planning and preparation for how people with LTSS need who are also LGBTQ+ may be impacted during public health emergencies.

Systems that are meant to serve the disability or LGBTQ+ communities independent of one another may not be meeting the unique needs of disabled people who are also LGBTQ+. Specifically, programs that serve the LGBTQ + community may not be accessible to disabled people, and disability services may not be inclusive of those who identify as LGBTQ+. For example, support groups and community programs targeting LGBTQ+ adults may be inaccessible due to physical location or the overall environment, or may lack services such as sign language interpretation that are necessary to ensure that disabled people can fully participate. Similarly, social skills programs for young adults with intellectual and developmental disabilities (IDD) typically assume that participants are straight and cisgender, and their guidance on and approach to discussing dating and romantic relationships tend to be premised on these assumptions. People who are both disabled and LGBTQ+ may also have different or additional needs that are not adequately addressed by programs for either group. Considering the experiences of people who are both disabled and LGBTQ+ and thinking about how to better understand and meet the needs of this population are critical steps towards equity. The updated prevalence estimates we present in this paper are an important first stage of this work.

Finally, policy and legislation that restrict the rights of LGBTQ+ people are increasingly being proposed and passed across the United States. As our findings show, LGBTQ+ identity is significantly more prevalent among disabled people, particularly those with LTSS need. Policy and legislation that protect the rights of the LGBTQ+ community therefore must specifically consider disability. One example is the recent wave of legislation restricting access to gender affirming care, which in some states has now expanded to limit Medicaid coverage of such services, creating potential for disproportionate impact on transgender people with disabilities [51–53]. Such laws may shape LGBTQ+ people’s decisions about where they live, and a recent survey found that more than a quarter of transgender adults surveyed reported that they had ever moved to a new neighborhood, city, or state because they thought it would be an accepting place for someone who is transgender to live [54]. Disabled people, particularly those who are receiving services, may face additional constraints on their ability to relocate, such as lack of accessible housing or risk of losing access to necessary services and supports. The significantly greater prevalence of LGBTQ + identity among disabled people found in our analyses, as well as the current political climate and dramatic increase in restrictive policies targeting LGBTQ+ individuals, demonstrate an urgent need for greater integration of disability into discussions of LGBTQ+ policy.

Limited data collection often renders both disabled and LGBTQ+ individuals invisible [55]. BRFSS is one of the first nationally representative surveys to include questions about both disability and LGBTQ + identity. However, the approach BRFSS takes to measurement of these categories creates some limitations for our findings regarding the prevalence of LGBTQ+ identity among disabled people. First, while the ACS 6 questions included in the BRFSS core survey are a common approach to disability data collection, they remain an imperfect measure of disability. The ACS 6 are known to undercount certain types of disabilities, particularly mental health conditions and certain developmental disabilities, and their reliance on the concept of “serious difficulty” with specific activities and functions means that they are influenced by differences in people’s subjective understanding of what may or may not constitute a “serious” limitation [42, 43, 45]. Additionally, while the ACS 6 asks about different functional limitations, these domains do not allow researchers to reliably identify specific disabilities; other researchers have noted that the question or questions to which a disabled person gives a “yes” response may not match the category to which their primary disability most clearly belongs [45]. This limited our ability to explore possible patterns in LGBTQ+ identity among individuals with different disabilities. The ACS 6 may also capture some people who have temporary disabilities and may fail to identify individuals who have disabilities that fluctuate or have varying impact on the functional domains included in the questions, which could impact our prevalence estimates [45, 56].

Choices in how the SOGI module questions are framed may also have impacted our findings. Language describing sexual orientation and gender identity is both varied and evolving, and best practices for collecting this information via survey are still being developed and refined [57]. The response options within the SOGI module are limited and do not include some terms commonly used by members of the LGBTQ+ community, such as “queer” or “non-binary.” This may have impacted how, or whether, individuals chose to respond to the SOGI module.

Our findings are also limited by how the BRFSS survey was designed and administered. The SOGI module was an optional part of the 2022 data collection, and while states may choose to include their own questions about sexual orientation and gender identity, these are not standardized and are not part of the publicly available BRFSS dataset. Additionally, because BRFSS excludes participants who are not male or female unless states have chosen to include the optional sex at birth module or a state-added question, ending the survey and asking no further questions of participants who say that their gender is anything other than male or female unless an option for collecting sex at birth information exists in that state’s version of BRFSS, even states that did administer the SOGI module may still undercount sexual and gender minority individuals, particularly nonbinary and gender nonconforming people [58]. Our prevalence estimates are also limited by the BRFSS sampling frame, which excludes many people with certain types of disabilities. For example, adults with psychiatric, cognitive, and/or intellectual and developmental disabilities who live in congregate settings or who are institutionalized are not included within the sampling frame. In addition, since BRFSS is not household-based, adults with disabilities who live in the community in family homes are not guaranteed to be represented [59]. Finally, the 2022 BRFSS was administered during a period of significant political attacks on the rights of transgender people and other members of the LGBTQ+ community, which may have influenced participants’ willingness to disclose LGBTQ+ identity.

Conclusions

Up-to-date estimates of the prevalence of LGBTQ+ identification among disabled individuals are needed to ensure that healthcare, HCBS, and other services and support programs can adequately serve this population. This is particularly important in light of our finding that individuals with LTSS need are more likely to identify as LGBTQ+ than either non-disabled individuals or disabled people who do not have LTSS need. Individuals who are both disabled and LGBTQ+ may have unique needs that are not fully addressed by services aimed at either group. Ongoing work to improve and standardize data collection on disability, sexual orientation, and gender identity is a necessary first step in making programs for LGBTQ+ people more accessible and making services and supports for disabled people more inclusive of LGBTQ + individuals. Given that disabled people, including those with LTSS needs, identify as LGBTQ+ at greater rates than non-disabled people, researchers focusing on disability need to consider the impact of sexual orientation and gender identity as part of work to address inequities experienced by disabled people.

Abbreviations

ADL

Activity of Daily Living

BRFSS

Behavioral Risk Factor Surveillance System

CDC

Centers for Disease Control and Prevention

HCBS

Home and Community–Based Services

IADL

Instrumental Activity of Daily Living

IDD

Intellectual and Developmental Disabilities

LGBTQ+

Lesbian, Gay, Bisexual, Transgender, and Queer

LTSS

Long–Term Services and Supports

NIH

National Institutes of Health

SOGI

Sexual Orientation and Gender Identity

Authors’ contributions

IM conceptualized the project and methodology used, conducted formal analyses, and wrote and edited the original draft; KS conceptualized the project and methodology, conducted formal analyses, and wrote and edited the original draft; JC conceptualized the project, edited and contributed to revising the manuscript, and acquired funding; TN conceptualized the project, edited and contributed to revising the manuscript, and acquired funding. All authors read and approved the final manuscript.

Funding

The contents of this manuscript were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90RTCP0006). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The content is solely the responsibility of the authors and does not necessarily represent the official views of NIDILRR, ACL, or HHS.

Data availability

The dataset analyzed during the current study is available from the Centers for Disease Control and Prevention, https://www.cdc.gov/brfss/annual_data/annual_2022.html.

Declarations

Ethics approval and consent to participate

Because this study used publicly available de-identified data, IRB approval was not required. The Brandeis University IRB confirmed that the study did not meet the definition of human subjects research under the U.S. Code of Federal Regulations at 45 CFR Part 46, which constitute the Federal Policy for the Protection of Human Subjects, also known as the Common Rule.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.