Lack of Sexual Orientation and Gender Identity Data Masks Important Health Disparities in Department of Defense Surveys

Lesbian, gay, bisexual, and transgender (LGBT) people face a plethora of health disparities in the United States. Previous studies have demonstrated that LGBT populations face disparities in food security, health insurance coverage, sexual assault, and mental health outcomes. Although LGBT health and economic disparities are well documented in the US general population, there is very little information about the experience of LGBT individuals serving in the US military, the disparities they face, and whether such disparities affect their health, readiness to serve, or retention in the military.

The Department of Defense (DOD) has only recently allowed LGBT individuals to serve openly without the threat of disciplinary action or discharge. In 1994, the Don’t Ask, Don’t Tell policy permitted lesbian, gay, and bisexual (LGB) persons to serve in the military but prohibited them from disclosing their sexuality. The DOD rescinded this policy in favor of unrestricted service of LGB persons beginning in 2011.¹ Before 2016, the DOD prohibited accession and retention of transgender individuals based on medical conditions, psychiatric diagnoses, and administrative judgments regarding fitness for duty. The DOD lifted the ban on transgender individuals serving openly in 2016, partially reimposed it in 2017, and then lifted it again in 2021.²

Although LGBT individuals may now serve openly in the military, DOD policy and practice have prohibited the collection of military personnel’s sexual orientation and gender identity (SOGI) demographic data unless a waiver is granted. The 2011 DOD memorandum controlling sexual orientation data, which has not been publicly retracted, states:

DOD components, including the Services, are not authorized to request, collect, or maintain information about the sexual orientation of Service members except when it is an essential part of an otherwise appropriate investigation or other official action.¹

A similar restriction exists for the collection of gender identity data.³

In the absence of SOGI demographic data for military personnel, it is impossible to determine whether LGBT military personnel experience disparities that interfere with their health or mission effectiveness. Findings from the recent Secretary of Defense Independent Review Commission on Sexual Assault in the Military acknowledged this deficiency. The commission concluded that the current policy is an obstacle for prevention experts and other researchers who wish to study the unique risks and experiences of LGBT military personnel and that prevention research on these important populations must not be restricted.⁴

Only a few recent DOD-led surveys have collected SOGI data, including the Workplace and Gender Relations Surveys of Active Duty Members (WGRA) and the Health-Related Behaviors Surveys (HRBS). The 2018 WGRA reported that 3.7% of LGB men were victims of sexual assaults in the past year compared with only 0.4% of non-LGB men.⁵ This disparity was similar for women, with 9.0% of LGB women reporting sexual assault victimization in the past year compared with 4.8% of non-LGB women.⁵ RAND delved further into these data and found that the 12% of respondents who identified as LGB or did not identify as heterosexual, accounted for 43% of service members reporting sexual assault in the 2018 survey.⁶ Demographic data were collected for transgender respondents in the 2016 WGRA (only), but outcomes were not reported. In an analysis of the 2015 HRBS, LGB respondents were more likely to report unwanted sexual contact, lifetime suicide attempt, sexually transmitted infections, smoking, and marijuana use than were non-LGB respondents.⁷ Similar to the WGRA survey, the HRBS did not report outcomes for transgender respondents. Given the stark disparities revealed in the few DOD-led surveys in which SOGI data were collected, it is imperative that military surveys be permitted to collect SOGI data in the same manner that demographics are collected for birth sex, age, race, and ethnicity.

US medical and public health authorities have long endorsed the routine collection of SOGI data as a best practice. The Institute of Medicine validated the importance of this practice in 2011, the same year that Don’t Ask, Don’t Tell was repealed, when it recommended that data on sexual and gender minorities be included in demographic information collected in federally funded surveys and electronic health records. Similarly, Healthy People 2020 and 2030 have endorsed expanded collection of LGBT demographics in health surveys and population-based data systems. In October 2020, the US Government Accountability Office recommended that the Veterans Health Administration (VHA) routinely collect SOGI data, stating:

Until VHA can more consistently collect and analyze sexual orientation and self-identified gender identity data for the veteran population served, it will have a limited understanding of the health care needs of LGBT veterans, including any disparities they may face.⁸

Most recently, the Biden administration issued Executive Order 14035 directing the secretary of defense to promote equitable health care for LGBT military personnel, their beneficiaries, and their dependents. It is not clear how the DOD can comply with this mandate if enumeration of LGBT service members is subject to an approval process that effectively puts data collection beyond the reach of military health organizations and practitioners.

The current DOD policy barriers to collecting SOGI data should be removed. Military surveys should be permitted to collect SOGI data in a manner consistent with other demographic information that is relevant to service member health and well-being, with an option for respondents to decline if they choose to do so. This approach would enable more detailed population surveillance, remove a policy that compels disparate treatment, and shift control of privacy to those most able to discern its necessity: LGBT individuals.

Repeal of restrictions should be accompanied by additional strategies to increase service member confidence about disclosing their SOGI data. First, the military should engage with experts on LGBT populations to formulate standardized, culturally competent language for SOGI questions. Second, demographic intake on military surveys should include a statement on the intent of the data and a reminder that no individual responses will be reported. Third, marketing materials and resource pages should be updated to show LGBT positive imagery, including partners and children, to demonstrate affirmation and visibility of LGBT personnel and their families. Fourth, a DOD-wide resource page should be established to inform service members, their dependents, and DOD civilians about LGBT culturally competent resources.

The control of LGBT demographics may have been a well-intentioned measure to protect military personnel from undue scrutiny and discrimination; however, it has had the unintended consequence of obscuring the health disparities experienced by military personnel who identify as LGBT and potentially interfering with the optimization of their military readiness. Furthermore, the disparate treatment is itself a form of discrimination that has the potential to negatively affect the health and well-being of those who are treated differently. As long as the demographics of LGBT military personnel are treated differently from their non-LGBT counterparts, the vestiges of Don’t Ask, Don’t Tell will persist.