Health Care Utilization and Health Indicators Among a National Sample of U.S. Veterans in Same-Sex Partnerships

Abstract

Objectives

To examine health indicators of same-sex partnered veterans as compared with their opposite-sex partnered veteran and nonveteran peers.

Methods

Same-sex partner status was derived by self-reported same-sex partnerships in data from the 2004 Behavioral Risk Factor Surveillance System. Outcome variables included health risk disparities associated with sexual minority status (e.g., frequent mental distress) and veteran status (e.g., firearm ownership). Stratified multiple logistic regression models were used to examine the association of same-sex partnered veteran status with health indicators.

Results

Same-sex partnered veterans had higher odds of being overweight and keeping firearms in the house compared with same-sex partnered nonveterans. Same-sex partnered veterans were less likely than opposite-sex partnered veterans to be overweight, and they were more than twice as likely to be current smokers when compared with opposite-sex partnered nonveterans.

Conclusions

Findings suggest both that some health disparities patterns identified by same-sex partnership status among the general population also exist among veteran populations, and that some unique distinctions may exist, particularly related to BMI and firearm ownership. Collection of information about sexual minority status within Department of Veterans Affairs data sources is needed to more accurately assess the health of this minority population.

INTRODUCTION

The universe of approximately 22 million U.S. veterans of military service is not a homogenous population, and disparities exist among different subpopulations of veterans. For instance, American Indian/Alaska Native veterans have higher odds of being uninsured than their White veteran counterparts,¹ and McGinnis et al² found that Black and Hispanic veterans diagnosed with HIV had higher rates of mortality than their HIV-positive White peers. In addition to racial/ethnic differences, disparities among veterans may also exist by sexual orientation. Numerous health disparities identified among general samples of lesbian, gay, and bisexual (i.e., sexual minority) populations—such as smoking, poor mental health, and health care coverage³—may exist among sexual minority veterans. To date, there are little to no published reports about the health and risk behaviors of the nearly 1 million sexual minority persons estimated to be among the U.S. veteran population.⁴

Studies using general samples of sexual minority individuals document several differences in health and risk behaviors, such as significantly higher rates of smoking,⁵ alcohol use,⁶ and overweight/obesity (particularly among lesbians compared with heterosexual women).⁷ There are also significantly greater rates of poor mental health (e.g., depression, distress) and suicidal ideation and suicide attempt among sexual minority populations,⁸ as well as victimization, particularly adverse childhood experiences.^9,10 The literature is less clear about access and health insurance coverage. Some studies report significantly lower access and coverage among sexual minority persons compared with their heterosexual peers, whereas others report no differences, depending on gender and method of identifying sexual minority status.^11-14

Given the mounting evidence of health inequities identified among sexual minority populations,³ sexual minority veterans may be a group within the general veteran population that is likely to experience several health disparities, and recent preliminary evidence seems to support this. For instance, Blosnich et al¹⁵ reported that sexual minority veterans had higher prevalence of suicidal ideation than their heterosexual veteran peers. In a large sample of women veterans, Booth et al found that women who reported same-sex sexual partners had higher prevalence of lifetime substance use disorders and sexual assault. Even after adjusting for demographic characteristics and sexual assault, women veterans who had same-sex sexual partners were over three times more likely to report a lifetime substance use disorder.¹⁶

In addition to empirical evidence, there is also theoretical underpinning for disparities among sexual minority veterans. Generally, the minority stress framework has been used to explain elevated negative health outcomes among sexual minority persons. Minority stress maintains that members of a devalued minority status experience unique, elevated, and persistent stress derived from social persecution and bias.¹⁷ Building from this framework, sexual minority veterans may have experienced particularly pronounced stress, stigma, and harassment since they were part of an institution (i.e., the military) that overtly discriminated against lesbian, gay, and bisexual people under the policy that was commonly referred to as “Don’t Ask, Don’t Tell” (DADT).¹⁸

Although this information sheds some light on the sexual minority veteran population, basic demographic and health and risk behaviors of sexual minority veterans are not well documented in population-based data. Using a national probability-based sample of U.S. adults, the present analyses aimed to examine demographic characteristics (e.g., income, education), health and risk indicators (e.g., frequent mental distress, current smoking), and health care utilization among veterans with same-sex partners and compare them with their same-sex partnered nonveteran, opposite-sex partnered veteran, and opposite-sex partnered nonveteran peers.

METHODS

The data for this project are from the 2004 National Behavioral Risk Factor Surveillance System (BRFSS) dataset, which is deidentified and publically available from the CDC web site. The BRFSS is currently the world’s largest telephone-based national survey, which is conducted in all 50 U.S. states, the District of Columbia, and U.S. territories (i.e., surveying entities). Respondents are drawn using probability-based methods for each surveying entity’s sampling frame of noninstitutionalized adults aged 18 years or older. Each year the CDC compiles a required core questionnaire that must be asked by all surveying entities and reported back to the CDC. The 2004 BRFSS had a median response rate of 52.7%. Further information about the BRFSS methodology is available from the CDC web site.¹⁹

In 2004, the CDC added a Family Planning module to the core questionnaire, which asked respondents about behaviors related to birth control and having children. The module was asked to all male respondents ages 18 to 60 and to all female respondents ages 18 to 44 who never had a hysterectomy and who currently were not pregnant (n = 146,690). The first question of the Family Planning module asked, “Are you or your [partner] doing anything now to keep from getting pregnant?” Response options included “Yes; No; No partner/not sexually active; Same sex partner; Do not know/not sure; Refuse to answer.” For the present analysis, same-sex partnered persons were defined as those who indicated having a same-sex partner (n = 1,077). Persons who indicated yes or no to using birth control methods were defined as the opposite-sex partnered reference group (n = 119,610). Because the same-sex partnered sample was comprised of only those persons in same-sex couples (i.e., people who were partnered), we excluded from the analytic sample anyone who responded “no partner/not sexually active” (n = 22,572), those who indicated “don’t know/not sure” (n = 333), and refusals (n = 3,098), creating a sample of 120,687 partnered persons.

All persons who indicated that they had a history of active duty military service were asked “Which of the following best describes your service in the United States military?” Response options included (1) currently on active duty, (2) currently in a National Guard or Reserve unit, (3) retired from military service, (4) medically discharged from military service, and (5) discharged from military service. Respondents indicating current active duty (n = 1,934) were excluded from analysis, creating a final analytic sample of 118,753 respondents. Other demographic variables included education (college degree vs. less than a college degree), sex, and a continuous measure of age that was derived from a variable supplied by the CDC, in which mean imputation was used for respondents who did not report their ages. Approximately 0.7% of the sample had imputed ages. Income was recoded to those who earned less than $25,000/year vs. those who earned $25,000/year or more. Because of the small sample size of same-sex partnered veterans, race was recoded to non-Hispanic White vs. a combined group of non-White and Hispanic persons.

Health care utilization was operationalized by three different questions. Veterans were asked if they had received any care from a Veterans Health Administration (VHA) facility in the last 12 months (yes/no). Having health care coverage plan (yes/no) was gathered from the question, “Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?” Not seeking care because of medical cost (yes/no) was defined from responses to “Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?”

Risk behaviors included current smoking (i.e., smoking >100 cigarettes within one’s lifetime and currently smoking on some days or every day), being overweight (BMI ≥ 25 but <30) or obese (BMI ≥ 30), and risk for binge drinking (any adult having ≥5 alcoholic drinks in one sitting in the past 30 days). Of note, in 2004, the CDC did not use sex-specific definitions of binge drinking. Also, because sexual minority persons have high rates of suicidal behavior,⁸ and ownership of firearms has been associated with increased risk for suicide both in the general population²⁰ and specifically among veterans,²¹ we also examined whether respondents indicated having a firearm in their homes (yes/no). Health indicators included frequent mental distress, defined as reporting ≥6 days of poor mental health in the last 30 days,²² self-rated fair/poor general health status, and experiencing any limitation in activities as a result of physical, mental, or emotional problems.

Prevalence estimates, stratified by both same-sex partnership status and veteran status, were compared through χ² tests of independence (except age, which was analyzed with independent samples t-tests). We employed a Holm’s sequential Bonferroni adjustment when examining the bivariate differences in order to prevent type I error.²³ However, given that Bonferroni adjustments inflate type II error,²⁴ we elected to report all crude p-values to demonstrate where significant findings would have occurred without an adjusted significance level (i.e., if the typical significance level of p < 0.05 had been used). However, only p-values less than or equal to the Bonferroni-adjusted significance level are indicated as statistically significant. Odds of health indicators among same-sex partnered veterans, adjusted for demographic characteristics, were tested with three different sets of multiple logistic regression models comparing same-sex partnered veterans with (1) same-sex partnered non-veterans, (2) opposite-sex partnered veterans, and (3) opposite-sex partnered non-veterans. Adjusted odds ratios are reported with 95% confidence intervals. Both because the analytic sample was a subset of the national BRFSS dataset and because the sample size of same-sex partnered veterans was small, estimates are unweighted. All analyses were conducted using Stata/SE ver. 12.²⁵ This study was approved by the Institutional Review Board at the Syracuse Veterans Affairs Medical Center.

RESULTS

Overall, both same-sex partnered veterans and opposite-sex partnered veterans were significantly older than their non-veteran counterparts, and same-sex partnered veterans were significantly younger than opposite-sex partnered veterans (Table I). A substantially greater proportion of same-sex partnered women reported veteran status than opposite-sex partnered women. Similar proportions of same-sex partnered veterans and opposite-sex partnered veterans used VHA services and had any health care coverage. However, significantly more same-sex partnered veterans than opposite-sex partnered veterans reported not seeking medical care because of cost (p = 0.01); although after adjustment for multiple testing, this was not statistically significant.

TABLE I.

Demographics, Health Care Utilization, and Risk and Health Indicators by Partnership and Veteran Statuses

	Same-Sex Partnered			Opposite-Sex Partnered
	Veteran (n = 100)	Nonveterana (n = 971)		Veteranb (n = 13,827)		Nonveteranc (n = 103,666)
	%	%	p	%	p	%	p
Demographics
Non-White	23.5	19.0	0.287	18.9	0.252	25.0	0.718
College Degree	43.0	52.3	0.078	32.3	0.023	36.8	0.197
Income <$25,000/Year	18.8	26.7	0.090	15.1	0.317	23.6	0.260
Sex (Female)	25.0	41.6	0.001*	6.4	0.001*	50.7	<0.001*
Age (Mean)	44.0	37.8	<0.001*	47.2	<0.001*	36.5	<0.001*
Health Care Utilization
VHA Care in Past 12 Months	15.0	—	—	14.7	0.938	—	—
Any Health Care Coverage Plan	86.0	80.9	0.216	87.1	0.754	82.5	0.357
Did Not Seek Care Because of Cost	19.0	19.9	0.830	11.1	0.013	15.1	0.278
Risk Indicators
Current Smoking	34.7	31.9	0.581	28.4	0.170	23.7	0.011
Binge Drinking	24.5	23.3	0.794	19.7	0.240	19.5	0.209
Firearms in Home	31.6	15.2	<0.001*	56.7	<0.001*	37.5	0.230
Overweight	44.8	30.6	0.004*	47.6	0.591	35.9	0.065
Obese	17.3	22.6	0.233	28.9	0.012	22.8	0.197
Health Indicators
Frequent Mental Distress	17.5	25.9	0.071	13.8	0.291	16.1	0.709
Fair/Poor Health Status	17.2	11.9	0.127	13.0	0.223	9.7	0.012
Activity Limitations	21.0	17.8	0.431	20.3	0.863	11.8	0.005

CI, confidence interval;

^*Statistically significant using the Bonferroni-adjusted significance level of p ≤ 0.004.

^aComparisons of same-sex partnered veteran vs. same-sex partnered nonveteran.

^bComparisons of same-sex partnered veteran vs. opposite-sex partnered veteran.

^cComparisons of same-sex partnered veteran vs. opposite-sex partnered nonveteran.

In multivariate models adjusted for demographic confounding variables, different constellations of higher/lower odds of outcomes surfaced in health risk behaviors among same-sex partnered veterans. When compared with their oppostite-sex partnered veteran counterparts, same-sex partnered veterans had lower odds of obesity and lower odds of keeping firearms in the home (Table II). Same-sex partnered veterans had elevated, but not significantly higher, estimates of binge drinking and smoking compared with their opposite-sex partnered veteran peers. The lack of statistical significance could be as a result of lower power because of small sample size as the lower bounds of both confidence intervals for these two outcomes were 0.93 and 0.92, respectively.

TABLE II.

Odds of Health Care Utilization and Risk and Health Indicators for Same-Sex Partnered Veterans

	Same-Sex Partnered Veteran vs. Opposite-Sex Partnered Veteran		Same-Sex Partnered Veteran vs. Same-Sex Partnered Nonveterans		Same-Sex Partnered Veteran vs. Opposite-Sex Partnered Nonveterans
	AOR	95% CI	AOR	95% CI	AOR	95% CI
Health Care Utilization
Any Health Care Coverage Plan	1.09	0.56–2.11	1.33	0.68–2.63	1.17	0.61–2.23
Did Not Seek Care Because of Cost	1.42	0.78–2.58	1.03	0.56–1.92	1.39	0.78–2.47
Risk Indicators
Current Smoking	1.44	0.92–2.26	1.18	0.73–1.92	2.01	1.28–3.15*
Binge Drinking	1.52	0.93–2.46	1.31	0.78–2.21	1.41	0.87–2.29
Firearms in Home	0.38	0.24–0.61*	2.18	1.30–3.67*	0.54	0.34–0.87*
Overweight	1.03	0.68–1.57	1.61	1.02–2.53*	1.12	0.74–1.70
Obese	0.57	0.33–0.97*	0.73	0.41–1.32	0.60	0.35–1.03
Health Indicators
Frequent Mental Distress	1.25	0.71–2.19	0.74	0.41–1.33	1.50	0.86–2.60
Fair/Poor Health Status	1.68	0.95–3.00	1.24	0.65–2.37	1.76	0.99–3.15
Activity Limitations	1.12	0.67–1.88	1.10	0.63–1.93	1.59	0.95–2.67

AOR, adjusted odds ratio; analyses adjusted for race/ethnicity, gender, income, education, and age;

^*p < 0.05.

Several differences were also found in comparisons between same-sex partnered nonveterans and same-sex partnered veterans. First, among same-sex partnered respondents, veterans more than twice as likely to keep firearms in their homes, and veterans were 61% more likely to be classified as overweight than their nonveteran counterparts. When same-sex partnered veterans were compared with opposite-sex partnered nonveterans, same-sex partnered veterans were less likely to have firearms in their home and were more than twice as likely to be current smokers. Some health indicators were also elevated, but not significant, in comparisons between same-sex partnered veterans and opposite-sex partnered nonveterans, particularly fair/poor health status and experiencing activity limitations. Again, with lower confidence interval bounds relatively close to 1.00, the inability to detect significance may have been as a result of small sample size.

DISCUSSION

To our knowledge, this article uses data from the first year in which the BRFSS collected a measure of sexual minority status (i.e., same-sex partnership) in the core questionnaire, and it is the first report about demographic and health information about same-sex partnered veterans from a national probability-based sample. Some health-related differences surfaced that corroborate previous findings among general samples of sexual minority persons, namely higher prevalence of smoking⁵ and lower prevalence of obesity (at least among men).^13,26 This alignment with general population trends in differences noted by sexual orientation suggests that similar patterns of disparities may exist among the general veteran population. However, findings suggest that same-sex partnered veterans have some unique distinctions that may be related to having a history of military service.

First, when compared with their same-sex partnered non-veterans peers, a higher proportion of same-sex partnered veterans were overweight. Since physical exercise and fitness are components of military training, this finding seems contradictory in that one may hypothesize that veterans would be in better shape given both the military requirement of physical fitness and the initial health screening to get into the military. One explanation may be BMI misclassifying physically fit persons—particularly muscular persons—as overweight.²⁷ This bias stems from the inability of BMI as a height–weight calculation to account for muscle mass.²⁸ Thus, if same-sex partnered veterans tend to exercise more or be more physically fit than their same-sex partnered nonveteran peers, excess muscularity may be misclassified in BMI as being overweight. However, given documented weight-related disparities among sexual minority and heterosexual populations,^7,26,29 future research is needed to further explore veteran status as a potential modifier of weight status among sexual minority persons.

Second, same-sex partnered veterans had twice the odds of their same-sex partnered nonveteran counterparts of keeping firearms in the home. Again, history of military service likely explains this difference since part of military instruction includes familiarity with firearms through weapons training. The elevated likelihood of keeping firearms in the home may be of particular concern for sexual minority veterans for three key reasons. First, sexual minority populations in general may have higher prevalence of suicidal ideation, suicide attempt, and poor mental health associated with suicide risk.⁸ Second, veterans in general have higher rates of firearm-related suicide.²¹ Third, having firearms in the home is an independent risk factor for gun-related suicide.³⁰ At the intersection of these three factors are sexual minority veterans, but data are unavailable to examine if they have higher risk for suicide. Future studies are needed to explore, for example, if among a high-risk group (i.e., sexual minority persons), a subpopulation that has greater access to firearms (i.e., sexual minority veterans) may have greater risk of suicide. Unfortunately, there are currently no data to facilitate such analyses, but inclusion of sexual minority measures on large national sur-veillance projects would help in addressing this paucity of data.

In terms of health care coverage, same-sex partnered persons were no different than opposite-sex partnered persons, which aligns with some findings from other studies that show no difference in health insurance coverage,^12,13,31 but contrasts with other research that suggests inequity in health care access.^11,12 For example, Conron et al¹³ did not find a difference in health care coverage among persons who self-identified as sexual minority persons, nor did Cochran et al³¹ who measured sexual minority status using self-report sexual behavior. Conversely, Heck et al¹² and Buchmueller and Carpenter¹¹ both identified health insurance disparities among sexual minorities defined by being in a same-sex couple. The present findings seem to stand somewhere in between these studies in that these results used a measure of same-sex couples, but had findings more similar to studies that used self-reported and behavioral measures of sexual minority status. The discordant findings among these studies and the present results may result from differences in operationalization of sexual minority status. Further research is needed to clarify these findings.

There was no difference detected in VHA utilization among same-sex partnered veterans and opposite-sex partnered veterans. These results suggest that, despite the potential impacts of “Don’t Ask, Don’t Tell” or the potential harassment experienced during military service,¹⁸ same-sex partnered veterans may utilize VHA services at the same prevalence as their opposite-sex partnered veteran peers. Assuring competent and sensitive health care for sexual minority patients is a developing area in health services, and numerous studies have documented bias, discrimination, and lack of knowledge about health issues unique to sexual minority populations within clinical systems.^32-34 Furthermore, The Joint Commission has recently issued a field guide explaining accreditation standards that have been amended to gauge sexual minority issues in health care facilities.³⁵ Given both the clear presence of same-sex partnered veteran patients in the VHA and changing accreditation standards, the VHA may benefit from several activities, such as self-assessment of health professionals’ needs and experiences with providing care for sexual minority veterans and amending data collection systems to enable examination of outcomes and unique needs of sexual minority patients.

The use of same-sex partnership status as a measure of sexual minority status presents potential issues of misclassification since both bisexual persons and unpartnered gay or lesbian person may not be identified through such a measure. Additionally, some of the risk measures examined may be modified by having a partner. For example, smoking behaviors have been shown to be modified by being in an intimate partnered relationship.²⁴ Future research is needed to examine whether significant differences arise in health indicators using different definitions of sexual minority status (e.g., self-identity vs. same-sex partnership) among veteran populations.

Several other limitations must be noted. First, as cross-sectional data, no causal statements are possible between the outcomes and explanatory variables. Second, generalizability of results are limited by several factors, including the response rate to the 2004 BRFSS, the analytic sample being a subset of only partnered adults, and the survey question having specific exclusion criteria. Additionally, given both the limits of the sample and the small numbers of same-sex partnered minority veterans, the estimates are unweighted, thus not accounting for complex survey design or nonresponse coverage. Lastly, the measure of veteran status did not permit ascertainment of either objectively confirming actual military service or gathering information pertinent to veteran health, such as tour of duty, number of deployments, and combat exposure.

CONCLUSIONS

With the recent repeal of DADT, military servicepersons can now serve openly, but clearly sexual minorities have served well before—and during—the era of DADT. Thus, there is a need to monitor and address health issues of sexual minority veterans. Our results indicate that, among this sample, similar percentages of sexual minority and heterosexual veterans received care through the VHA in the previous year, yet nothing is known about whether the potential disparities that affect sexual minority populations—such as HIV, asthma, different forms of cancer, and suicidal behavior—also occur in VHA veterans or among veterans in general. Unfortunately, these issues will remain invisibly embedded amidst the population until data sources include measures of sexual minority status.