Response to: Goodyear et al. Re: Morgan et al., Disparities in Prescription Opioid Misuse Affecting Sexual Minority Adults Are Attenuated by Depression and Suicidal Ideation

Dear Editor:

We thank Goodyear et al.¹ for their thoughtful and insightful response to our recent article,² in which we demonstrated that sexual orientation-related disparities in prescription opioid misuse were attenuated by depression and suicidal ideation. In particular, we appreciated their acknowledgment of the importance of examining differences between subgroups of sexual minority individuals (e.g., gay and lesbian vs. bisexual individuals) rather than treating them as a monolithic group. In this response, we take the opportunity to acknowledge and address the concerns raised by Goodyear et al.¹

As the authors pointed out, a key limiting factor in our own and others' studies using national data sets is the conflation of sex and gender. As these national studies have been conducted over long periods of time, it can be difficult for them to quickly adjust to new norms and practices in research. Of particular relevance to our study, the National Survey on Drug Use and Health (NSDUH) questionnaire, which is administered by an interviewer, uses the terms sex and gender interchangeably.³ Interviewers are required to record respondents' “gender” as either “male” or “female” (words in quotes reflect the language used in the questionnaire). If responses to subsequent questions seem to contradict the “gender” recorded by the interviewer, then the interviewer is prompted to confirm the respondent's “sex.”

Although the terms “sex” and “gender” are used interchangeably, they are likely intended to reflect sex assigned at birth given that subsequent questions about pregnancy and cervical cancer are only asked of “females” and subsequent questions about prostate cancer are only asked of “males.” Therefore, in addition to conflating sex and gender, NSDUH relies on interviewers' perceptions rather than respondents' self-reports. Given that the response options were “male” and “female,” we elected to refer to this variable as sex in our article. However, as Goodyear et al. point out, we referred to men and women (terms commonly used to refer to gender rather than sex) throughout our results.¹ In hindsight, we agree that it would have been more consistent to use different terms (e.g., male sexual minority individuals, female sexual minority individuals).

As noted by Goodyear et al.,¹ there is a critical need for national studies such as NSDUH to update their language in line with best practices for assessing sex and gender.⁴ Furthermore, rather than relying on interviewers' perceptions, they should allow respondents to self-report their sex assigned at birth and current gender identity. Not only would these changes be more inclusive, they also would improve the accuracy of the data and they would facilitate much-needed research on the health of transgender and gender-diverse individuals. Finally, to truly advance research on health equity, there is also a need for national studies to include measures of discrimination and other stigma-related stressors. Doing so would allow researchers to go beyond simply documenting health inequities and instead to move toward examining their underlying mechanisms at the population level.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Drug Abuse or the National Institutes of Health. The sponsor had no involvement in the conduct of the research or the preparation of this letter.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

The study discussed in this letter was supported by grants from the National Institute on Drug Abuse at the National Institutes of Health (K08DA045575, principal investigator [PI]: B.A.F.; K01DA046716, PI: C.D.).