Abstract
This cross-sectional study evaluated data from a large US survey (2013-2018) to determine how health status and access have changed among lesbian, gay, and bisexual adults compared with heterosexual counterparts.
A previous analysis identified health disparities among US adults who are lesbian, gay, or bisexual (LGB)1 using data from the 2013 to 2014 National Health Interview Survey (NHIS). Since then, there have been substantial policy, legislative (eg, Obergefell vs Hodges2), and sociocultural shifts that may have differentially affected sexual minority subgroups by recognizing the constitutional right to marriage equality, expanding state-level protections for LGB populations, and increasing public support for LGB-related issues.3
Understanding whether the US has made progress in reducing health inequities among sexual minority groups is critical for informing future public health and policy efforts. Therefore, this study sought to evaluate whether and how health status and health care access have changed from 2013 through 2018 among US adults who identify as LGB, and how these changes compare with those experienced by their heterosexual counterparts during the same time period.
Methods
This serial cross-sectional study used 2013 through 2018 NHIS data. Adult participants were classified as lesbian or gay, bisexual, or heterosexual based on responses to a sexual orientation question. This study focused on 3 health status outcomes (self-reported health status, functional limitation, and severe psychological distress) and 3 health care access outcomes (usual source of care, health care utilization, and health care affordability).
Multivariable logistic regression models were used to compute annual outcome rates adjusted for age and region among heterosexual and gay male survey participants and heterosexual female and lesbian participants, and to compare changes within and between sexual orientation subgroups during the study period. Given the small sample size of bisexual adults, another set of models with pooled 2016 to 2018 data was constructed to compare outcomes between heterosexual, gay, and bisexual male participants and between heterosexual, lesbian, and bisexual female participants. The first set of models adjusted for demographic characteristics, and fully adjusted models included comorbidities and substance use. Additional details are provided in eMethods 1 and the eTable in Supplement 1.
This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines and did not require approval from an institutional review board because it used only deidentified publicly available data. Details on study limitations are provided in eMethods 2 in Supplement 1.
Results
The study sample consisted of 183 020 adult participants, of whom 177 100 (93.8%) were classified as heterosexual, 3176 (1.6%) as lesbian or gay, and 1744 (0.9%) as bisexual. Between 2013 and 2018, significant annual reductions in poor or fair health status were observed among heterosexual male participants (−0.21%, 95% CI, −0.40 to −0.03), but not among gay male participants (Table 1). Significant annual reductions in forgoing or delaying medical care due to cost were observed among heterosexual female participants (−0.48%; 95% CI, −0.69 to −0.28), but not among lesbian female participants. Gaps in all measures of health status and health care access between heterosexual and gay male participants and between heterosexual and lesbian female participants did not change significantly during the study period.
Table 1. Changes in Health Status and Health Care Access From 2013 to 2018, by Sex and Sexual Orientationa,b.
| Outcome | Annual, % (95% CI) | P value | Difference compared with heterosexual counterparts, % (95% CI) | P valuec | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Prevalence | Mean change, 2013-2018 | ||||||||||
| 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | 2013 | 2018 | ||||
| Poor or fair health status | |||||||||||
| Male | |||||||||||
| Heterosexual | 12.9 (12.4 to 13.5) | 12.7 (12.3 to 13.1) | 12.5 (12.2 to 12.8) | 12.3 (11.9 to 12.7) | 12.1 (11.6 to 12.5) | 11.9 (11.3 to 12.5) | −0.21 (−0.40 to −0.03) | .02 | NA | NA | .19 |
| Gay | 11.9 (8.2 to 15.6) | 12.3 (9.5 to 15.2) | 12.8 (10.5 to 15.0) | 13.2 (11.1 to 15.3) | 13.7 (11.1 to 16.3) | 14.2 (10.6 to 17.7) | 0.45 (−0.74 to 1.60) | .46 | 0.22 (−4.7 to 5.2) | 4.8 (−0.27 to 9.8) | |
| Female | |||||||||||
| Heterosexual | 13.3 (12.8 to 13.7) | 13.1 (12.8 to 13.5) | 13.0 (12.7 to 13.3) | 12.8 (12.5 to 13.2) | 12.7 (12.3 to 13.1) | 12.6 (12.0 to 13.1) | −0.14 (−0.31 to 0.03) | .11 | NA | NA | .95 |
| Lesbian | 16.7 (11.5 to 22.0) | 16.6 (12.7 to 20.5) | 16.4 (13.4 to 19.5) | 16.3 (13.2 to 19.3) | 16.1 (12.2 to 20.0) | 16.0 (10.8 to 21.2) | −0.15 (−1.90 to 1.60) | .86 | 5.8 (−1.5 to 13.1) | 5.8 (−1.4 to 13.0) | |
| Any functional limitation | |||||||||||
| Male | |||||||||||
| Heterosexual | 30.0 (29.3 to 30.8) | 30.8 (30.2 to 31.3) | 31.5 (31.1 to 32.0) | 32.3 (31.8 to 32.9) | 33.1 (32.4 to 33.8) | 33.9 (32.9 to 34.8) | 0.77 (0.50 to 1.00) | <.001 | NA | NA | .14 |
| Gay | 36.5 (31.5 to 41.6) | 35.8 (32.0 to 39.6) | 35.0 (32.1 to 38.0) | 34.3 (31.6 to 37.0) | 33.6 (30.3 to 36.8) | 32.8 (28.6 to 37.1) | −0.74 (−2.30 to 0.78) | .34 | 6.4 (−0.61 to 13.3) | −0.26 (−6.0 to 5.5) | |
| Female | |||||||||||
| Heterosexual | 38.8 (38.0 to 39.5) | 39.2 (38.7 to 39.8) | 39.7 (39.2 to 40.2) | 40.2 (39.6 to 40.7) | 40.6 (39.9 to 41.4) | 41.1 (40.1 to 42.1) | 0.47 (0.19 to 0.74) | .001 | NA | NA | .82 |
| Lesbian | 44.8 (39.2 to 50.5) | 45.9 (41.7 to 50.1) | 46.9 (43.6 to 50.2) | 47.9 (44.5 to 51.4) | 49.0 (44.4 to 53.6) | 50.0 (43.9 to 56.2) | 1.00 (−0.94 to 3.00) | .30 | 11.7 (3.8 to 19.5) | 13.1 (4.6 to 21.5) | |
| Severe psychological distress | |||||||||||
| Male | |||||||||||
| Heterosexual | 2.9 (2.6 to 3.2) | 2.8 (2.6 to 3.0) | 2.7 (2.6 to 2.9) | 2.7 (2.5 to 2.8) | 2.6 (2.4 to 2.8) | 2.5 (2.2 to 2.8) | −0.07 (−0.16 to 0.02) | .14 | NA | NA | .12 |
| Gay | 5.4 (2.6 to 8.3) | 5.5 (3.3 to 7.8) | 5.7 (3.9 to 7.4) | 5.8 (4.2 to 7.3) | 5.9 (4.1 to 7.7) | 6.0 (3.5 to 8.5) | 0.12 (−0.76 to 1.00) | .79 | 1.5 (−1.8 to 4.8) | 5.4 (1.4 to 9.4) | |
| Female | |||||||||||
| Heterosexual | 3.9 (3.6 to 4.1) | 3.9 (3.7 to 4.1) | 4.0 (3.8 to 4.2) | 4.0 (3.8 to 4.2) | 4.1 (3.8 to 4.4) | 4.2 (3.8 to 4.5) | 0.06 (−0.05 to 0.16) | .28 | NA | NA | .84 |
| Lesbian | 4.5 (2.5 to 6.5) | 4.8 (3.2 to 6.4) | 5.1 (3.8 to 6.4) | 5.4 (4.1 to 6.8) | 5.8 (3.9 to 7.6) | 6.1 (3.5 to 8.7) | 0.32 (−0.45 to 1.10) | .41 | 1.3 (−2.0 to 4.5) | 1.8 (−1.9 to 5.6) | |
| Lack of usual source of care at the time of interview | |||||||||||
| Male | |||||||||||
| Heterosexual | 19.6 (18.8 to 20.3) | 19.3 (18.7 to 19.8) | 18.9 (18.5 to 19.4) | 18.6 (18.1 to 19.1) | 18.3 (17.7 to 19.0) | 18.0 (17.2 to 18.9) | −0.31 (−0.57 to −0.05) | .02 | NA | NA | .84 |
| Gay | 15.5 (11.6 to 19.3) | 14.9 (12.1 to 17.7) | 14.3 (12.2 to 16.5) | 13.8 (11.6 to 15.9) | 13.2 (10.5 to 15.9) | 12.7 (9.2 to 16.2) | −0.55 (−1.80 to 0.66) | .37 | −6.0 (−10.6 to −1.5) | −6.5 (−11.2 to −1.7) | |
| Female | |||||||||||
| Heterosexual | 11.3 (10.8 to 11.8) | 11.1 (10.7 to 11.5) | 10.9 (10.6 to 11.2) | 10.8 (10.4 to 11.1) | 10.6 (10.1 to 11.1) | 10.4 (9.8 to 11.0) | −0.17 (−0.35 to 0.01) | .07 | NA | NA | .50 |
| Lesbian | 15.7 (11.9 to 19.4) | 15.0 (12.3 to 17.7) | 14.3 (12.1 to 16.6) | 13.7 (11.2 to 16.2) | 13.1 (9.9 to 16.3) | 12.5 (8.4 to 16.6) | −0.63 (−1.90 to 0.66) | .34 | 5.6 (0.26 to 11.0) | 2.3 (−4.1 to 8.7) | |
| No health care utilization in the past year | |||||||||||
| Male | |||||||||||
| Heterosexual | 23.2 (22.4 to 23.9) | 22.5 (22.0 to 23.1) | 21.9 (21.5 to 22.4) | 21.3 (20.9 to 21.8) | 20.7 (20.2 to 21.3) | 20.2 (19.4 to 20.9) | −0.60 (−0.85 to −0.35) | <.001 | NA | NA | .13 |
| Gay | 17.1 (13.0 to 21.1) | 15.1 (12.4 to 17.9) | 13.4 (11.3 to 15.4) | 11.8 (9.8 to 13.8) | 10.4 (8.0 to 12.7) | 9.1 (6.3 to 11.9) | −1.60 (−2.70 to −0.47) | .005 | −7.9 (−13.4 to −2.4) | −12.1 (−16.1 to −8.2) | |
| Female | |||||||||||
| Heterosexual | 11.7 (11.2 to 12.2) | 11.4 (11.0 to 11.7) | 11.0 (10.7 to 11.3) | 10.7 (10.3 to 11.0) | 10.3 (9.9 to 10.8) | 10.0 (9.4 to 10.6) | −0.35 (−0.53 to −0.17) | <.001 | NA | NA | .26 |
| Lesbian | 15.0 (10.8 to 19.2) | 14.5 (11.6 to 17.5) | 14.1 (11.8 to 16.4) | 13.6 (11.2 to 16.1) | 13.2 (9.9 to 16.4) | 12.8 (8.5 to 17.0) | −0.45 (−1.90 to 0.97) | .54 | 1.4 (−4.2 to 6.9) | 5.9 (−1.1 to 13.0) | |
| Forgone or delayed medical care due to cost in the past year | |||||||||||
| Male | |||||||||||
| Heterosexual | 12.1 (11.6 to 12.6) | 11.9 (11.5 to 12.3) | 11.8 (11.5 to 12.1) | 11.6 (11.3 to 11.9) | 11.5 (11.0 to 11.9) | 11.3 (10.7 to 11.9) | −0.15 (−0.33 to 0.03) | .10 | NA | NA | .66 |
| Gay | 15.5 (11.8 to 19.2) | 15.4 (12.7 to 18.2) | 15.4 (13.3 to 17.6) | 15.4 (13.2 to 17.5) | 15.4 (12.6 to 18.1) | 15.3 (11.7 to 19.0) | −0.03 (−1.20 to 1.20) | .96 | 5.9 (0.70 to 11.1) | 4.1 (−0.90 to 9.1) | |
| Female | |||||||||||
| Heterosexual | 16.0 (15.4 to 16.7) | 15.5 (15.1 to 16.0) | 15.0 (14.6 to 15.4) | 14.5 (14.1 to 14.9) | 14.1 (13.6 to 14.5) | 13.6 (13.0 to 14.2) | −0.48 (−0.69 to −0.28) | <.001 | NA | NA | .47 |
| Lesbian | 22.8 (17.9 to 27.8) | 22.4 (18.7 to 26.1) | 21.9 (19.1 to 24.8) | 21.5 (18.7 to 24.3) | 21.1 (17.5 to 24.7) | 20.7 (15.9 to 25.4) | −0.44 (−2.00 to 1.20) | .60 | 7.8 (1.7 to 13.9) | 10.6 (2.6 to 18.6) | |
All rates are adjusted for age and US region using multivariable logistic regression.
Bisexual male and female participants were not included in single-year analyses due to small sample sizes and the resulting unreliability of single-year parameter estimates, defined as relative SEs exceeding 30%.
Interaction between sexual orientation (heterosexual male vs gay male or heterosexual female vs lesbian female participants) and year (2013 vs 2018).
During the 2016 to 2018 period, compared with heterosexual male participants, gay male participants had higher odds of poor or fair health status (odds ratio [OR], 1.39; 95% CI, 1.06-1.80), severe psychological distress (OR, 2.30; 95% CI, 1.55-3.40), and forgoing or delaying medical care due to cost (OR, 1.37; 95% CI, 1.07-1.74), and lower odds of lacking a usual source of care (OR, 0.66; 95% CI, 0.50-0.86) and not seeing a health care professional during the past year (OR, 0.44; 95% CI, 0.32-0.60) (Table 2). Similar patterns were observed among bisexual male participants, although there was no significant difference in lacking a usual source of care. Compared with heterosexual female participants, lesbian female participants had higher odds of any functional limitation (OR, 1.34; 95% CI, 1.06-1.70), lacking a usual source of care (OR, 1.51; 95% CI, 1.10-2.07), not seeing a health care professional during the past year (OR, 1.46; 95% CI, 1.07-1.98), and forgoing or delaying medical care due to cost (OR, 1.36; 95% CI, 1.05-1.75). Similar patterns in addition to higher odds of poor or fair health status (OR, 1.67; 95% CI, 1.18-2.34) and severe psychological distress (OR, 2.37; 95% CI, 1.71-3.27) were observed among bisexual female participants.
Table 2. Associations Between Sexual Orientation and Health Status and Health Care Access, Stratified by Sex, 2016 to 2018a .
| Outcome | Odds ratio (95% CI) | |||||||
|---|---|---|---|---|---|---|---|---|
| Male participants | Female participants | |||||||
| Gay vs heterosexual | Bisexual vs heterosexual | Lesbian vs heterosexual | Bisexual vs heterosexual | |||||
| Demographic-adjustedb | Fully adjustedc | Demographic-adjustedb | Fully adjustedc | Demographic-adjustedb | Fully adjustedc | Demographic-adjustedb | Fully adjustedc | |
| Poor/fair health status | 1.36 (1.05-1.75)d | 1.39 (1.06-1.80)d | 1.71 (1.08-2.72)d | 1.69 (1.03-2.78)d | 1.46 (1.06-2.00)d | 1.20 (0.86-1.69) | 1.91 (1.38-2.66)e | 1.67 (1.18-2.34)f |
| Any functional limitation | 1.10 (0.91-1.34) | 1.07 (0.87-1.30) | 1.22 (0.83-1.78) | 1.14 (0.77-1.70) | 1.62 (1.28-2.05)e | 1.34 (1.06-1.70)d | 1.97 (1.58-2.45)e | 1.72 (1.36-2.16)e |
| Severe psychological distress | 2.32 (1.58-3.42)e | 2.30 (1.55-3.40)e | 3.50 (1.83-6.70)e | 3.56 (1.80-7.00)e | 1.54 (1.03-2.31)d | 1.24 (0.81-1.89) | 2.76 (2.01-3.79)e | 2.37 (1.71-3.27)e |
| Lack of usual source care at interview | 0.70 (0.53-0.93)d | 0.66 (0.50-0.86) | 1.06 (0.74-1.52) | 1.10 (0.76-1.60) | 1.45 (1.06-1.99)d | 1.51 (1.10-2.07)d | 1.48 (1.12-1.96)f | 1.52 (1.14-2.03)f |
| No health care utilization in past year | 0.45 (0.33-0.60)e | 0.44 (0.32-0.60)e | 0.50 (0.34-0.74)e | 0.52 (0.35-0.77)e | 1.35 (1.00-1.82) | 1.46 (1.07-1.98)d | 1.34 (0.99-1.82) | 1.49 (1.08-2.04)d |
| Forgone/ delayed medical care due to cost in past year | 1.50 (1.18-1.91)e | 1.37 (1.07-1.74)d | 1.95 (1.28-2.98)f | 1.84 (1.17-2.89)f | 1.57 (1.21-2.02)e | 1.36 (1.05-1.75)d | 1.49 (1.18-1.90)e | 1.30 (1.02-1.65)d |
Data are pooled from the 2016, 2017, and 2018 National Health Interview surveys.
From multivariable logistic regression models adjusting for age group (18-39, 40-64, ≥65 years), race and ethnicity (Asian, Black, Hispanic, other, or White), relationship status (married/living with a partner or not), education level (<high school, high school diploma, some college, or ≥ bachelor degree), employment status (with a job/working, not in labor force/unemployed), family income (<200% of federal poverty thresholds or not), US citizenship, US region (Northeast, Midwest, South, or West), language of interview, health insurance status (uninsured or not), and survey year.
From multivariable logistic regression models adjusting for the above demographic characteristics plus number of comorbidities (0, 1, or ≥2), alcohol use status (never, former, infrequent, light, or moderate current use, or heavy current use), and cigarette use status (never, former, moderate current use, and heavy current use).
P < .05.
P ≤ .001.
P ≤ .01.
Discussion
The findings of this nationally representative study indicate that differences in health status and health care access between sexual minorities and their heterosexual counterparts did not change from 2013 through 2018. Nearly all subgroups of LGB adults continued to report higher levels of poor or fair health status, functional limitation, severe psychological distress, and difficulties with health care affordability than their heterosexual counterparts. Study limitations included survey response biases, limited sample size of bisexual adults, and lack of gender identity data.
Health inequities among LGB individuals are posited to be driven by minority group stress and multifaceted societal marginalization.4 The persistence of these inequities highlights the need for renewed action at the policy, legislative, sociocultural, and health system levels. In the midst of attacks on the fundamental rights of LGB individuals by state legislators, federal legislation through the Equality Act5 could ameliorate minority group stress by explicitly prohibiting discrimination on the basis of sexual orientation. The health sector could also promote health among sexual minority groups by ensuring that all clinicians receive adequate LGB-related training and by increasing access to practitioners with expertise in sexual minority health.6
eMethods 1. Data Source, Study Variables, and Statistical Analysis
eMethods 2. Study Limitations
eTable. Detailed Description of Study Outcomes
Data Sharing Statement
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eMethods 1. Data Source, Study Variables, and Statistical Analysis
eMethods 2. Study Limitations
eTable. Detailed Description of Study Outcomes
Data Sharing Statement