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. Author manuscript; available in PMC: 2023 Feb 1.
Published in final edited form as: Stigma Health. 2021 Sep 2;7(1):70–79. doi: 10.1037/sah0000338

When Sexual Identity and Sexual Behaviors Do Not Align: The Prevalence of Discordance and its Physical and Psychological Health Correlates

David M Mendelsohn 1, Allen M Omoto 1, Karen Tannenbaum 1, Christopher S Lamb 1
PMCID: PMC8974320  NIHMSID: NIHMS1732488  PMID: 35369673

Abstract

Although scholarly work on the complexity of human sexuality has increasingly been a focus of scholarship, comparatively little research has focused on the phenomenon of mismatch, or discordance, between different aspects of sexuality. This study used secondary data of sexually active adults (N=116,950) from a statewide representative survey which included both a measure of sexual identity (i.e., identifying as “heterosexual”, “bisexual”, etc.) and a measure of sexual behaviors (i.e., indicating the sex of your sexual partners). Using these data, we examined the prevalence and correlates of sexual identity-behavior discordance (IBD), and also included data from bisexual-identified individuals. In support of our hypotheses, we found that sexual IBD was particularly prevalent among young-adult women. However, we did not find sex differences in the prevalence of IBD overall. Furthermore, individuals who were categorized as IBD also tended to report poorer physical health and psychological functioning than both heterosexual- and gay/lesbian-identified concordant individuals, as well as more negative behaviors typically associated with poor psychological functioning (i.e., binge drinking and suicidal ideation.) Our findings highlight the need for more sensitive instruments and measures assessing sexual orientation in both research and practice, as well as the need for continued study into the area of discordance, and particularly across other dimensions of sexuality (e.g., attraction).

Keywords: sexuality, discordance, sexual orientation, physical health, psychological health

Sexuality is commonly regarded as a central aspect of the human experience and has continually received much focus as a subject of scholarship and empirical research. It has also been increasingly noted that human sexuality is complex and multi-faceted (e.g., Diamond, 2008; Savin-Williams, 2006). As such, we can conceptualize human sexuality in a number of different ways, and typically we focus on three. Namely, these lenses through which we can conceptualize sexuality are those based on attraction, identity, and behavior. Attraction-based sexuality relates to individuals’ patterns of attraction, both in terms of sexual and romantic attraction. Identity-based sexuality relates to how an individual defines or categorizes themselves in terms of their sexuality (e.g., “gay”, “bisexual”, or “heterosexual”). Finally, conceptualizing sexuality based on behaviors focuses on the sex of an individual’s sexual partners (e.g., same-sex or different-sex sex partners). Literature in the field is consistent with these dimensions, often defining and measuring sexuality in one of these manners (see Gates, 2011; Vrangalova & Savin-Williams, 2012). However, a large portion of research in this area incorporates only one definition of sexuality at a time, and the need for research utilizing more than one definition and/or measure of sexuality has increasingly been noted (Institute of Medicine [IOM], 2011).

In research, the incorporation of multiple dimensions in measuring sexual orientation can provide unique means of understanding the individuals in a study (Priebe & Svedin, 2013). The inclusion of multiple measures of sexuality may also be particularly important in light of evidence that the three dimensions of sexual orientation are imperfectly correlated and are inconsistently predictive of each other, especially when estimating prevalence of same-sex sexuality in a population (Savin-Williams, 2006). There may even be potential negative consequences in utilizing only one dimension of sexuality in research without inclusion or consideration of others. Said research may, at best, only be able to tell part of the story, or may miss an entire population of people that should be targeted for intervention. For example, behavior-based measures of sexual orientation excluding sexual identity may lead to misinformed conclusions about sexually transmitted infection (STI) disparities (Everett, 2013). Specifically, STI risks were noted to be elevated among heterosexual and bisexual women engaging in sex with women but were lower among lesbian women with histories of same-sex sexual behaviors. Nevertheless, targeting only behavior may be appropriate or even preferred in certain circumstances, such as when designing HIV risk interventions or clinical screenings (e.g., Young & Meyer, 2005).

The incorporation of multiple measures of sexual orientation becomes essential when exploring the potential mismatch across different dimensions of sexuality, termed discordance (Ross, et al., 2003). An individual is considered discordant when their reports along two (or more) dimensions of sexuality are not in alignment. For example, a man who identifies as heterosexual but engages in same-sex sexual behaviors or a woman who identifies as a lesbian but has same-sex and different-sex attractions. Discordance, and particularly sexual identity-behavior discordance (IBD), has been the target of increased interest in sexuality research in recent years. Some have speculated that sexual IBD may exist in individuals due to internalized homophobia or heterosexism (Szymanski, et al., 2008). Discordance may also occur because individuals may simply not perceive themselves as being gay or lesbian although they engage in same-sex sexual behaviors (or vice versa.) As such, there are multiple forms of discordance, and classifying individuals as discordant does not imply that they are similar. This literature base is still somewhat nascent, however, and psychological research along this line of inquiry has been primarily qualitative in nature. In addition, there is a general dearth of research focusing on the prevalence of discordance, as well as its relationship with physical health and psychological functioning.

Prevalence of Discordance and Demographic Differences

While there has been much work focusing on demographic differences (e.g., sex, age) in sexuality, less research has focused on whether there are these types of demographic differences among discordant individuals. Although a common contention is that the relationship between sexual attraction and sexual identity tends to be stable, discordance has been reported and described in depth, and longitudinally (Diamond, 2000). Additionally, it has been noted that sexual identity development for women is different than sexual identity development for men (Diamond, 2012). For example, attraction to same-sex others tends to materialize before beginning puberty for sexual minority men, while often not until adulthood for sexual minority women (Cass, 1990). Literature on sexual fluidity further suggests that women are more likely than men to be discordant, possibly as a result of increased susceptibility for heterosexual women to experiment or otherwise participate in same-sex sexual behavior, or that sexuality among women may simply be fundamentally fluid (Diamond, 2008).

There may also be reason to suspect that discordance may vary across different age groups. Considering the cultural shift in current society towards a more accepting view of same-sex romantic behavior as manifested both through the lens of the media (GLAAD, 2014) and legislature (Witeck, 2014), younger people in the 21st century may be more open to engaging in discordant sexual behavior relative to their identity. Young adults and adolescents may be more likely to venture outside the realm of their sexual identity simply because their generational cohort may value sexual experimentation and sexual fluidity as socially acceptable. While these individuals may self-reflect on the possibility of being same-sex oriented, they may engage in same-sex sexual behavior without disclosing such behavior to others or changing their outward heterosexual identity. In this stage, IBD is entirely plausible, as one may explore same-sex behavior without committing to a gay or lesbian identity, thereby enabling engagement in discordant behavior.

Research corroborates the tendency for IBD among women in adolescence and young adulthood (Garnets & Peplau, 2001). Similarly, gay and lesbian American youth may report sexual behavior with different-sex youth as a way of confirming a lack of desire for different-sex partners (Mustanski et al., 2014). Importantly, the authors noted a need to explore similar issues in an adult population. As such, although sexual IBD has theoretically been expected to decrease over time in individuals (such that their reported sexual identity and sexual behaviors fall more in line as they age), there is very little empirical research examining this assumption.

Correlates of Discordance: Physical Health and Psychological Functioning

Health care concerns for sexual minority populations provide incentive to discuss correlates between behavior-identity discordance and issues regarding physical health and psychological functioning. Cognitive dissonance theory (Festinger, 1957) offers at least some insight, as the dissonance experienced as a consequence of IBD can manifest through mental and physical health outcomes for both men and women (Young & Meyer, 2005). Such potential correlates can also be considered through the lens of minority stress theory (Meyer, 2003), in terms of experienced stigma associated with an individual’s status as a sexual minority. Specifically, individuals who conceal their sexual identity, or who expect that they will experience rejection if they disclose their sexual identity, may be less likely to disclose this identity, regardless of their sexual behavior (Meidlinger & Hope, 2014; Pachankis et al., 2008). This stigma is associated with poorer mental health outcomes among sexual minorities.

Although not a central focus in sexual IBD literature, past research suggests a relationship between discordance in individuals and poor physical health. For example, heterosexual-identified men who engage in sexual behavior with other men are less likely than their concordant counterparts to get tested for HIV, and more likely to engage in riskier sex behaviors, including less condom use (Pathela et. al, 2006). Sexually transmitted infection diagnoses have been reported to be higher for discordant than concordant heterosexual-identified men (Everett, 2013). Similarly, same-sex behavior in heterosexual-identified women is an indicator for substance abuse and risky sexual behavior unseen in exclusively heterosexual women, bisexual women, or lesbians (Bauer, et al., 2010). Discordant lesbian women may be less likely to both pursue PAP smears or mammograms (Kerker, et al., 2006), report more instances of STIs (Everett, 2013), and have more days where they report feeling physically unhealthy (Schick, et al., 2012) than lesbian women who are concordant.

Research has also demonstrated increased risk of suicidal ideation (Jiang, et al., 2010), binge drinking (Cogger, et al., 2012), depression (D’Augelli, 2002), and anxiety (Bostwick, et al., 2010) in sexual minority individuals. These mental health outcomes may be similarly correlated, if not more strongly correlated, with IBD. For example, Gattis, et al. (2012) found that IBD in women was correlated with greater risk of substance-use, and an increased risk of alcohol and inhalant use in discordant men. Similarly, lesbian-identified women who are discordant report more drinking behavior and drinking-related problems than their concordant counterparts (Talley, et al., 2015). It may be that, while gay and lesbian individuals typically report poorer physical health and psychological functioning, discordant individuals exhibit different patterns of correlation with similar outcomes.

The Current Study: Hypotheses and Additional Considerations

The current study seeks to explore the prevalence of sexual IBD using secondary data from a statewide representative survey of health. Additionally, we seek to understand whether differences in sex or age exist among reports of this type of discordance. Finally, we seek to determine whether discordance is associated with poorer reports of physical and mental health, as well as behaviors associated with poor psychological functioning. In guiding our hypotheses dealing with correlates of discordance, we predict that heterosexual concordant individuals will report the most favorable physical health and psychological functioning, followed by gay/lesbian concordant individuals, with discordant individuals reporting the poorest outcomes.

Hypothesis 1a. There will be a higher prevalence of IBD in women than men.

Hypothesis 1b. There will be a higher prevalence of IBD among younger individuals than older individuals, and this will be especially true for women.

Hypothesis 2a. Individuals who are IBD will report poorer physical health than those who are IBC, and particularly as compared to heterosexual-identified IBC individuals.

Hypothesis 2b. Individuals who are IBD will report poorer mental health, including higher depression and anxiety, higher incidence of binge drinking behavior, and higher incidence of suicidal ideation, than those who are IBC, and particularly as compared to heterosexual-identified IBC individuals.

We also examined a post-hoc research question focusing on whether the outcomes associated with IBD vary for individuals who are heterosexual-identified compared to those who are gay- or lesbian-identified. For example, heterosexual-identified individuals who are IBD may report poorer outcomes because engaging in same-sex behaviors may be a source of stigma (e.g., Stahlman et al., 2016).

Importantly, bisexual-identified individuals represent a unique group when operationalizing discordance for this study. Traditional definitions of discordance have simply included bisexual people with other concordant individuals, as sexual behavior with same-sex or other-sex partners is in line with their sexual identity (Schick et al. 2012). However, the reality may be more complex, and labeling bisexuality as a concordant status outright may not be doing justice to this population. Research has tended to note comparatively poor physical health and psychological functioning in bisexual individuals. For example, bisexual individuals reported more depression and suicidal ideation, and had higher risk for cardiovascular disease compared with heterosexual people (Conron, et al. 2010; also see Fredricksen-Goldsen, et al., 2013). Furthermore, bisexual individuals are subject to a unique form of stigma, namely that they are considered to be “actually straight” or “actually gay”, which is relevant to both their sexual identity and behaviors, and may also impact their health outcomes (Yost & Thomas, 2012). While the data gathered will not allow for bisexual-identified individuals to be classified as either concordant or discordant, we want to ensure that bisexual-identified individuals are represented in our analyses whenever possible. As such, we will also present data on prevalence, physical health and psychological functioning for bisexual-identified individuals, in addition to those data presented for concordance and discordance.

Method

This research employed pooled data from four separate (i.e., not longitudinal) implementations of the California Health Interview Survey (CHIS 2003, 2005, 2007, 2009). Conducted by telephone every 2 years using random-digit dialing (RDD), the CHIS is both the nation’s largest population-based state health survey and a leader in telephone survey methodology, and is representative of the state’s population. One randomly selected adult (aged 18 years or older) was interviewed in each household.

Sample

Data were analyzed for a total of 116,950 (52,345 men and 64,605 women) sexually active adults (i.e., those who responded that they had had sex in the past 12 months) aged 70 years and younger (M=43.45 years, SD=12.63 years). For prevalence analyses, we categorized age into younger adulthood (aged 18-39; N=40,070), middle adulthood (aged 40-59; N=57,794), and holder adulthood (aged 60 and older; N=19,086). As the sample was representative, the vast majority identified as heterosexual (96.8%). Two percent identified as sexual minorities (2.8% of men identified as gay while 1.4% of women identified as lesbian), while 1.2% identified as bisexual (0.9% of men and 1.5% of women). With regards to sexual behaviors, the majority of the sample (97.1%; 96.3% of men and 97.7% of women) reported only other-sex sexual partners in the past 12 months. Additionally, 2.5% (3.3% of men and 1.9% of women) reported only same-sex sexual partners, while 0.4% (0.4% of both men and women) reported sex partners of both sexes in the past 12 months.

Measures

Sexual Identity-Behavior Discordance

Sexual identity at present was assessed nominally with the question, “Do you think of yourself as straight or heterosexual, as gay/lesbian or homosexual, or bisexual?” As a measure of sexual behavior, respondents were asked, “In the past 12 months, have your sexual partners been male, female, or both male and female?”

Gender

Gender was assessed with the single, binary question “Are you male or female?”

The sexual identity and sex of sexual behavior variables were used to code individuals as either IBC or IBD. When present sexual identity (e.g., lesbian; heterosexual) matched up with the sex of the individual’s partners during the past year, (e.g., heterosexual man who had sex with women only; gay man who had sex with men only) the individual was coded as concordant. Conversely when an individual’s sexual identity did not match up with the sex of their partners during the previous year (e.g., lesbian women reporting sex with men only or men and women; heterosexual women reporting sex with women only or both men and women) the individual was coded as discordant. Bisexual-identified individuals were included in comparative analyses but were not assigned a label of discordant or concordant.

Physical Health

Physical health was assessed using a single item which asked, “Would you say that in general your health is excellent, very good, good, fair, or poor?” (M = 2.36, SD = 1.05). Responses followed a 5-point Likert scale, with higher scores indicating poorer physical health.

Depression & Anxiety

Respondent depression and anxiety were assessed using the 6-item Kessler distress scale. These six items were split and averaged to form two composites; one with two items related to anxiety (e.g., About how often in the past 30 days did you feel nervous?; α = .64; M = 4.20, SD = 0.79) and another with four items related to depression (e.g., During the past 30 days, about how often did you feel hopeless?; α = .77; M = 4.66, SD = 0.56). Responses followed a 5-point Likert-type scale ranging from 1 (All [of the time]) to 5 (None [of the time]), with higher scores indicating less psychological distress.

Binge Drinking Behaviors

Binge drinking was assessed with a single item asking respondents how often in the past year they had engaged in binge drinking behavior (defined as 5+ drinks for men, and 4+ drinks for women.) Responses were provided on a 1 (No binge drinking in past year) to 6 (Daily or weekly) Likert-type scale (M = 2.07, SD = 1.57).

Suicidal Ideation

Suicidal ideation was assessed with a single binary (yes/no) item, using only the 2009 wave of CHIS data available (as this was not included on prior waves of the CHIS.) Respondents were asked whether they had ever seriously thought of committing suicide. Those who refused to answer or were unsure were not included in the analyses.

Results

Prevalence of Sexual IBD

Our preliminary research question was focused on the prevalence of sexual IBD, and all results related to sexual identity, sexual behavior, and the prevalence of discordance (based on both sex and age of participants) are summarized in Tables 1 and 2. In general, we found some support for these hypotheses. About 0.6% of men, as well as 0.5% of women, were classified as discordant; however, this sex difference was only marginally significant, χ2(1) = 3.63, p = .06. Discordance was next examined across chronological age groupings, using 2 (concordant vs. discordant) X 3 (younger adults vs. middle adults vs. older adults) cross-tabulations. Results of this analysis revealed that prevalence of discordance did not appear to differ across age groups for men, χ2(2) = 0.40, p = .82. However, among women, discordance was more common among younger adults than middle and older adults, χ2(2) = 17.77, p < .001. Furthermore, when sex was included as a factor in the analysis, the pattern of discordance across age groups was found to significantly differ for men and women, χ 2(4) = 17.60, p = .002, thus providing general support for Hypothesis 1b.

Table 1.

Sexual identity and sexual behavior over the past year for men (N = 52,345) and women (N = 64,605).

MEN
Sex w/ Men Only Sex w/ Women Only Sex w/ Men & Women
N % N % N % TOTAL %
Heterosexual 212 0.4 50,139 99.5 55 0.1 50,406 96.3
Gay 1,398 96.7 26 1.8 22 1.5 1,446 2.8
Bisexual 115 23.3 235 47.7 143 29.0 493 0.9
TOTAL 1,725 3.3 50,400 96.3 220 0.4 52,345 100.0
WOMEN
Sex w/ Men Only Sex w/ Women Only Sex w/ Men & Women
N % N % N % TOTAL %
Heterosexual 62,459 99.6 192 0.3 86 0.1 62,737 97.1
Lesbian 46 5.1 844 93.7 11 1.2 901 1.4
Bisexual 664 68.7 159 16.4 144 14.9 967 1.5
TOTAL 63,169 97.8 1,195 1.8 241 0.4 64,605 100.0
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Note: Cells with italicized values represent IBD individuals (e.g., heterosexual-identified men who report having sex with men).

Table 2.

Prevalence of sexual IBD for men (N = 52,345) and women (N = 64,605) by sexual identity and age.

Overall Heterosexual Gay/Lesbian Bisexual
Concordant
N (%)		 Discordant
N (%)		 Concordant
N (%)		 Discordant
N (%)		 Concordant
N (%)		 Discordant
N (%)		 N (%)
Men 51,537 (99.4) 315 (0.6) 50,139 (99.5) 267 (0.5) 1,398 (96.7) 48 (3.3) 493 (0.9)
 18-39 16,575 (99.4) 106 (0.6) 16,148 (99.5) 86 (0.5) 427 (95.5) 20 (4.5) 204 (1.2)
 40-59 25,369 (99.4) 154 (0.6) 24,577 (99.5) 131 (0.5) 792 (97.2) 23 (2.8) 205 (0.8)
 60+ 9,593 (99.4) 55 (0.6) 9,414 (99.5) 50 (0.5) 179 (97.3) 5 (2.7) 84 (0.9)
Women 63,303 (99.5) 335 (0.5) 62,459 (99.6) 278 (0.4) 844 (93.7) 57 (6.3) 967 (1.5)
 18-39 22,467 (99.3) 157 (0.7) 22,239 (99.4) 128 (0.6) 228 (88.7) 29 (11.3) 561 (2.4)
 40-59 31,572 (99.6) 140 (0.4) 31,032 (99.6) 116 (0.4) 540 (95.7) 24 (4.3) 354 (1.1)
 60+ 9,264 (99.6) 38 (0.4) 9,188 (99.6) 34 (0.4) 76 (95.0) 4 (5.0) 52 (0.6)
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Note: Bisexual individuals are not included in the Overall column totals, as they did not meet the requirements for the definition of IBC/IBD as used in the analytic plan. They are, however, included in the total sample sizes, located in the Title.

Although bisexual-identified individuals did not fit into the analytic plan for the prevalence of discordance above, we did examine additional cross-tabulations of sexual identity and sexual behaviors which included bisexuals. Results of this 2 (sex) X 5 (group: heterosexual concordant; gay/lesbian concordant; heterosexual discordant; gay/lesbian discordant; bisexual) analysis did not show evidence of significant differences in sexuality for men and women, χ2(4) = 0.66, p = .96. Thus, men and women did not appear to differ significantly across identity-behavior categories. However, it should be noted that there was a higher prevalence of bisexual identification in women (1.5%) than men (0.9%). In addition, when bisexual individuals were included in the analyses comparing age groups, an interesting pattern emerged. Specifically, young adult women were more likely to identify as bisexual than women in middle or older adulthood, χ2(8) = 313.89, p < .001, while this pattern was less pronounced for men, χ2(8) = 65.77, p < .001. These data are also included in Tables 1 and 2.

Correlates of Sexual IBD

In order to assess Hypotheses 2a and 2b, we compared mean self-reports of general physical health and psychological distress (both depression and anxiety), as well as reports of binge drinking behaviors and suicidal ideation. We first compared IBC to IBD individuals overall, not including bisexual-identified individuals. Overall, IBD individuals reported greater anxiety, depression, and suicidal ideation, thus providing support for Hypothesis 2b, although not Hypothesis 2a (see Table 3). All remaining analyses were run separately for men and women.

Table 3.

Comparisons of IBC and IBD individuals across physical health and psychological functioning dimensions.

Overall Men Women
IBC
(N=114,840)		 IBD
(N=650)		 t (χ2) IBC
(N=51,537)		 IBD
(N=315)		 t (χ2) IBC
(N=63,303)		 IBD
(N=335) 		t (χ2)
Physical Health 2.36 (1.05) 2.29 (1.09) 1.69 2.36 (1.05) 2.29 (1.09) 1.18 2.34 (1.06) 2.48 (1.05) 2.41*
Anxiety 4.20 (0.79) 4.00 (1.00) 6.43*** 4.21 (0.79) 4.00 (1.00) 4.70*** 4.13 (0.82) 3.91 (0.91) 4.89***
Depression 4.66 (0.56) 4.51 (0.70) 6.80*** 4.66 (0.56) 4.51 (0.70) 4.73*** 4.59 (0.63) 4.38 (0.80) 6.08***
Binge Drinking 2.07 (1.57) 2.07 (1.64) <0.00 2.07 (1.57) 2.07 (1.64) <0.01 1.59 (1.18) 1.90 (1.47) 4.79***
Suicidal Ideation 9.30% 14.60% (4.05*) 7.80% 12.10% (1.47) 10.60% 16.90% (2.71)
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Note:

*

indicates that the difference is statistically significant at p<.05.

***

indicates that the difference is statistically significant at p<.001.

Means (standard deviations) and t tests are reported for all variables except for suicidal ideation, for which data is presented in terms of percentages reporting having suicidal thoughts and as a chi-square analysis. For t tests, the degrees of freedom were 115,488 for overall analyses, 51,850 for men analyses, and 63,636 for women analyses. All chi-square analyses had 1 degree of freedom. For anxiety and depression, lower mean values are associated with less desirable outcomes (i.e., poorer psychological functioning.) For physical health, binge drinking, and suicidal ideation, higher mean values are associated with less desirable outcomes (i.e., poorer health, more binge drinking behavior, and higher rate of suicidal thoughts.)

Correlates of Sexual IBD for Men

We first compared men who were IBC to those who were IBD. Men who were IBD reported higher depression and anxiety than their IBC counterparts (see Table 3). We next compared five groups: heterosexual men who were concordant (HM-C), gay men who were concordant (GM-C), heterosexual men who were discordant (HM-D), gay men who were discordant (GM-D), and bisexual men (see Table 4 for complete results, including post-hoc pairwise comparisons.) Our hypotheses were supported, although the results for men were somewhat mixed. Significant mean differences in reports of general physical health, F(4, 52340) = 7.06, p < .001, and psychological functioning in terms of depression, F(4, 39350) = 36.54, p < .001, and anxiety, F(4, 39350) = 26.48, p < .001, were revealed for men. While no significant differences in mean reports of binge drinking were found, F(4, 26659) = 1.03, p = .39, we did find that reports of suicidal ideation in men did significantly differ across the groups, χ2(4) = 159.76, p < .001.

Table 4.

Comparisons of IBC and IBD individuals, as well as bisexual-identified individuals, across physical health and psychological functioning dimensions.

IBC Heterosexual IBC Gay/Lesbian IBD Heterosexual IBD Gay/Lesbian Bisexual df F (χ2) η2
Men
 Physical Health 2.36a (1.05) 2.27a,b,c (1.08) 2.30b,d (1.11) 2.25d (0.97) 2.55 (1.09) 4, 52,340 7.06*** .001
 Anxiety 4.21 (0.79) 4.05a (0.81) 4.05a,b (0.99) 3.69b,c (1.05) 3.93c (0.90) 4, 39,350 26.48*** .003
 Depression 4.66 (0.56) 4.58a,b (0.62) 4.52a,c (0.72) 4.44b,c,d (0.62) 4.36d (0.79) 4, 39,350 36.54*** .004
 Binge Drinking 2.07 (1.57) 2.04 (1.52) 1.97 (1.62) 2.62 (1.75) 2.10 (1.63) 4, 26,659 1.03 .001
 Suicidal Ideation 7.40% 22.70% 14.90% 0.00% 27.50% 4 (159.76***)
Women
 Physical Health 2.34a (1.06) 2.29a (1.04) 2.42 (1.03) 2.80 (1.14) 2.53 (1.13) 4, 64,600 10.63*** .001
 Anxiety 4.13 (0.82) 3.97a,b (0.89) 3.94a,c (0.87) 3.77b,c,d (1.08) 3.69d (0.94) 4, 48,806 59.02*** .005
 Depression 4.59a (0.63) 4.54a (0.70) 4.41b (0.82) 4.23b,c (0.70) 4.24c (0.82) 4, 48,806 62.88*** .005
 Binge Drinking 1.59a,b (1.18) 1.90a,c,d (1.44) 1.97c,e,f (1.52) 1.56b,d,e (1.21) 2.15f (1.59) 4, 32,821 35.59*** .004
 Suicidal Ideation 10.50% 18.90% 17.40% 15.80% 37.70% 4 (184.95***)
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Note:

***

indicates that the difference is statistically significant at p<.001.

Means (standard deviations) and ANOVAs are reported for all variables except for suicidal ideation, for which data is presented in terms of percentages reporting having suicidal thoughts and as a chi-square analysis. For anxiety and depression, lower mean values are associated with less desirable outcomes (i.e., poorer psychological functioning.) For physical health, binge drinking, and suicidal ideation, higher mean values are associated with less desirable outcomes (i.e., poorer health, more binge drinking behavior, and higher rate of suicidal thoughts.) Post-hoc Tukey’s HSD pairwise comparisons are delineated for all continuous outcomes (i.e., all except suicidal ideation), such that groups with the same superscript do not significantly differ from one another.

Where significant differences were uncovered, the pattern of results was largely consistent. The most desirable outcomes were reported by HM-C, followed by GM-C, and finally discordant men. Our findings also revealed that bisexual-identified men tended to report physical health and psychological functioning similar to, and in some cases poorer than, discordant men. Of particular note, bisexual-identified men reported the highest rate (nearly 28%) of suicidal ideation. The next highest rate of suicidal thoughts was reported by GM-C (approximately 23%).

Correlates of Sexual IBD for Women

When examining physical health and psychological distress, we found similar, though more consistent, results for women. Overall, women who were IBD reported poorer physical health, as well as higher anxiety, depression, and binge drinking than their IBC counterparts (see Table 3). We then compared five groups: heterosexual women who were concordant (HW-C), lesbian women who were concordant (LW-C), heterosexual women who were discordant (HW-D), lesbian women who were discordant (LW-D), and bisexual women. Results of these analyses are presented in Table 4. Significant differences were uncovered in reports of general physical health, F (4, 61600) = 10.63, p < .001, depression, F (4, 48806) = 62.88, p < .001, and anxiety, F (4, 48806) = 59.02, p < .001. Additionally, there were significant mean differences in reports of women’s binge drinking behavior, F (4, 32821) = 35.59, p < .001, as well as suicidal ideation, χ2(4) = 184.95, p < .001. The general pattern of results followed our predictions and was similar to that for men, such that HW-C tended to report more desirable outcomes than LW-C, and discordant women tended to report the least favorable outcomes.

An interesting pattern of results was also found for bisexual women. Analyses revealed that bisexual-identified women tended to report outcomes similar to, and in some cases even less favorable than, discordant women. This was particularly noteworthy when examining suicidal ideation. Nearly 38% of bisexual-identified women reported having suicidal thoughts. This was twice the rate of suicidal thoughts reported by LW-C (approximately 19%), the group with the next highest rate of reported suicidal thoughts.

Differences in Discordance Based on Sexual Identity

In line with our post-hoc research question 2, we sought to examine whether the prevalence and correlates of discordance differed based on sexual identity. We first examined a more nuanced breakdown of identity-behavior groups in a 2 (heterosexual vs. gay/lesbian) X 2 (concordant vs. discordant) cross-tabulations for men and women separately. These analyses revealed a comparable pattern of results for both men, χ2(1) = 181.19, p < .001, and women, χ2(1) = 587.11, p < .001, such that there was a higher prevalence of discordance among those who identified as gay or lesbian than those who identified as heterosexual. In other words, a larger proportion of gay or lesbian individuals were discordant compared to heterosexual individuals. An additional cross-tabulation of identity-behavior was examined to compare discordance across age groups. This resulted in 4 (heterosexual concordant; heterosexual discordant; gay/lesbian concordant; gay/lesbian discordant) X 3 (younger adults vs. middle adults vs. older adults) cross-tabulations for men and women separately. The results of these analyses were analogous to those for the overall cross-tabulations. Specifically, for both men, χ2(6) = 46.44, p < .001, and women, χ2(6) = 90.15, p < .001, a larger proportion of gay/lesbian individuals were discordant, when compared to heterosexual individuals.

Lastly, we examined whether heterosexual-identified discordant individuals differed from gay/lesbian-identified discordant individuals on the outcomes of interest. Across all of these comparisons, the only significant difference uncovered was that lesbian discordant women reported poorer physical health than heterosexual discordant women, p < .01. Thus, while discordant individuals tended to report poorer physical health and psychological functioning overall, this did not appear to differ based on whether these individuals identified as heterosexual or gay/lesbian.

Discussion

Prevalence and Correlates of Discordance

The findings from these analyses lend evidence to the ever-growing body of literature chronicling the complex and multi-faceted nature of human sexuality. It is also the first study that we are aware of to use a large, statewide representative sample to address questions regarding sexual IBD. The results suggest that the way in which sexual orientation is operationalized in research (i.e., identity, behaviors, attraction, etc.) may impact the data that is captured. For example, research focusing only on an identity aspect of sexual orientation may fail to capture individuals who identify as heterosexual but engage in same-sex sexual behaviors. Such individuals are discordant, or mismatched, across the varying dimensions by which human sexuality is typically conceived. The prevalence of discordance, based on this statewide representative sample, appears to be about 0.5% of the population. This figure is most likely an underestimate, as the behavioral measure of sexuality was only for a one-year time period, and as such, fails to capture sexual behaviors over the course of a lifespan. For example, IBD may be more prevalent when utilizing even a 24-month (as compared to 12-month) time period (e.g., Cochran & Mays, 2007), further illustrating the necessity for more temporally comprehensive sexual behavior measures.

The results of this study provide an interesting picture about the prevalence of discordance, as well as its implications for one’s psychological and physical health. Although we did not uncover sex differences in the prevalence of discordance overall, it was found that discordance tends to be more common among younger adults, and particularly for young adult women. This finding was predicted, given the existing research on fluidity in female sexuality (e.g., Diamond 2008). However, our findings suggest that male sexuality might be as fluid as female sexuality; but while the prevalence of discordance appears to drop over the lifespan for women, it seems to remain somewhat more consistent for men. Recently, researchers have begun to take more interest in fluidity related to male sexuality (see Mock & Eibach, 2012), and our findings demonstrate the need for further research along this line of inquiry.

Another unique contribution of this study is that we were able to test whether there were potentially deleterious outcomes associated with sexual IBD. Although the analyses were only correlational, they are still suggestive given the large and representative sample. Specifically, we found that in general, discordance was associated with poorer physical and psychological health (in terms of expressed feelings of anxiety and depression, as well as behaviors which are typically associated with poorer functioning). Although the results were not entirely consistent across each analysis, the general pattern of results suggests heterosexual concordant individuals experience the most positive outcomes, followed by gay/lesbian concordant individuals, and discordant individuals experience the most negative outcomes. While a great deal of research has focused on the negative outcomes experienced by sexual minorities as compared to heterosexual individuals (Meyer, 2003), our results suggest that discordant individuals may experience an even stronger negative impact than GM-C or LW-C individuals.

Some of the most impactful findings from the current study were those pertaining to bisexual-identified individuals. Because bisexuality did not fit the operationalization of concordance/discordance in this study (i.e., any sexual partners in the previous year, male or female or both, would be concordant with a bisexual identity), we were presented with a particular challenge in including these individuals in the analyses whenever possible while still being able to discuss discordance as a potentially distinct phenomenon. In terms of prevalence, our results suggest higher rates of bisexual identity in women compared to men, and especially among young adult women, which is consistent with existing research (Jorm, et al., 2002). What was particularly alarming though was that, in many of the analyses, bisexual-identified individuals reported similar (and in some cases, poorer) health outcomes compared to the discordant individuals. Most notably, large proportions of bisexual individuals, and particularly bisexual women, reported suicidal thoughts (nearly 28% of men and 38% of women), highlighting the necessity of research on bisexual health issues and intervention efforts specifically for suicidal thoughts endured in this population. Future research should also seek to elucidate whether bisexual individuals report these types of outcomes for reasons similar to discordant individuals. In other words, whether the mechanisms by which these outcomes occur are similar for discordant and bisexual individuals. For example, both discordant and bisexual individuals may end up concealing aspects of their sexuality (identity, behavior, etc.) more than concordant individuals, which may result in the negative effects seen in these data.

Another possible explanation to consider regarding poor health outcomes for bisexual individuals is felt disconnectedness from both the heterosexual and LGBT communities (Frost & Meyer, 2012). These experiences of disconnectedness may be propelled by negative attitudes from heterosexual (Herek, 2002) and other sexual minority (Greene, 2003) individuals. Bisexual-identified people may experience greater distress as a result of feeling unwelcomed in either community. Thus, future research may further delve into experiences among bisexual individuals regarding felt disconnectedness and the mental and physical health outcomes of disconnectedness from the LGBT and heterosexual communities. Differences in outcomes among bisexual individuals who engage in sexual behaviors with same-sex partners, different-sex partners, or both, should also be explored. Gender identity could also be taken into account, as different standards about what is considered stigmatized behavior may apply (e.g., Anderson et al., 2018; Oswald & Matsick, 2020). Because of the unique types of stigma that bisexual individuals may face (Yost & Thomas, 2012), it may be that, for example, bisexual women who engage in sexual behaviors with women experience less stigma than bisexual women who engage in sexual behaviors with men.

This study does also have some notable limitations. For example, and due to the nature of secondary data analysis, gender in this study was limited only to the binary categories of male and female. Future research in this area of inquiry should seek to be more inclusive of individuals across the spectrum of gender identity (e.g., non-binary, gender-queer, transgender people), as there may be interesting and unique patterns of discordance across these populations, with differing reports in terms of their physical and psychological health. We also did not examine either the prevalence of correlates of discordance across racial groups. Recent research demonstrates that the intersection of race and sexual orientation may also involve a complex interaction in terms of both group perceptions and lived experience (e.g., Preddie & Biernat, 2020). Similarly, it may be that the intersection of race and IBD provides further insight into discordance as a phenomenon of interest, and whether that phenomenon is experienced uniquely across different racial groups. Future work should explore this line of inquiry.

This study also focuses on the disclosure of sexual identity and behavior, but we were unable to capture other processes that are demonstrably important in the sexual minority literature, most notably concealment. Concealment is noted as a key proximal stress process in the minority stress model (Meyer, 2003), and has been consistently linked to health disparities experienced by gender and sexual minorities (e.g., Brennan et al., 2020; Cole et al., 1996). Such findings are especially interesting as gender and sexual minority individuals often report engaging in concealment as a protective tool (e.g., to avoid discrimination or “pass” as heterosexual or straight), however it is associated with poorer mental and physical health in these populations. Discordance may further complicate this issue in that an individual may conceal certain aspects of their sexuality but not others (e.g., an openly gay male conceals that he engages in sexual behaviors with both men and women). Future research should explore how patterns of concealment correlate with discordance across different dimensions of sexuality.

Implications for Research

This study highlights the need for careful attention to how we conceptualize, define, measure, and discuss sexuality in research. The fact that the CHIS data is unique in that it is both representative and contains two measures of sexual orientation (identity and behavior) should draw attention to the general dearth of availability of these types of data, as well as the fact that even with these two dimensions included, the CHIS is still not comprehensive. It is also important to note that this study has only demonstrated one possible form of discordance, namely sexual IBD. It would be potentially enlightening to be able to analyze discordance across other dimensions of sexuality (e.g., identity-attraction discordance, IAD), as previous work has demonstrated differences in substance use and mental health disorders for individuals with different patterns of discordance (i.e., IBD vs IAD; Gattis, et al., 2012). Such findings suggest that, at minimum, researchers should attend to the dimension(s) of sexuality that they measure, as they may tap into populations with different characteristics.

It should be noted that the focus on discordance across different dimensions of sexuality has been increasingly noted in the research literature (see Harawa et al., 2008). However, a focus on the psychological experience of discordance has received rather little attention. While this study has noted some of the potential negative implications associated with discordance, we are unable to discuss how discordant individuals experience sexuality, and the meaning that they may attribute to their own various aspects of sexuality. This particular line of inquiry would lend itself well to qualitative methodology, where such questions could be asked explicitly and discordant participants could share their thoughts and experiences directly as an invaluable data source. Indeed, research of this nature may allow for the development and explication of a “psychology of discordance”, which could aid both researchers studying sexuality and discordance, as well as practitioners working with sexual minority populations.

Implications for Intervention Development and Policy

Finally, there appears to be a higher prevalence of discordance among individuals who do not identify as heterosexual, thus research focusing on sexual minority populations should consider which aspect(s) of sexuality should be tapped in order to ensure that the data is captured appropriately. For example, research seeking to develop interventions related to sexual health or policy should ensure that interventions are targeting appropriate populations. Early interventions related to HIV/AIDS targeted gay men, and ended up missing men who identified as heterosexual, but engaged in same-sex sexual behavior (Reback & Larkins, 2013). This discordant population was later recognized a gateway to the heterosexual (concordant) population, and later health care intervention models targeted gay men as well as men who had sex with men.

An important shortcoming in the U.S. health care system involves provider bias (e.g., Cochran, 2001), which may prevent sexual and gender minority individuals from actively seeking health care. In addition, extant research documents examples of the tendency for non-hetero identified individuals to conceal sexual behavior as a self-protection strategy thereby avoiding preventative care (Brotman, et al., 2002), perhaps out of fear that revealing such information would reduce the quality of received health care (Eliason & Schope, 2001; Smith, et al., 1985). While elucidating reasons for poor health outcomes suffered by discordant individuals is beyond the scope of the present study, implications can be made for medical screenings and health care provider intake questions. For instance, rather than simply asking patients to disclose sexual orientation, health care providers should work towards implementing basic processes to capture sexual behavior of their patients as well (Pathela, et al., 2006). Asking such questions may even serve as a safety cue in this context, signaling inclusivity and safety to sexual minority patients (see Cipollina & Sanchez, 2019). The present research promotes awareness of the prevalence of various mental and physical health outcomes among both sexual identity-behavior concordant and discordant individuals, and both highlighted and emphasizes the necessity for supportive, inclusive, and tailored health promotion and health care.

Acknowledgments

Research reported in this publication was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health under award number 1R03HD067407. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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