Beyond the Binary-Importance of Assessing Sexual and Gender Minority Status in Population Health

Ashley B. Murray¹; Jessica Gorzelitz, PhD, MS²; Joanne G. Patterson, PhD, MSW, MPH³; Richard P. Moser ⁴; & the Population Health Sciences SIG

The Population Health Sciences SIG aims to support behavioral researchers engaged in research focused on multiple determinants of health among different populations, with an emphasis on social, environmental, and organizational influences on health and health-related behavior. A core determinant of health is one’s identity and relationship to social constructs, including Sexual Orientation and Gender Identity (SOGI). These characteristics not only influence how people perceive themselves, but how society and others view and treat them. People from minoritized SOGI groups experience multilevel stigma and discrimination, resulting in myriad health disparities. Accurately measuring these demographic characteristics is key to understanding and developing interventions to improve individual and population health.

Sexual and gender minorities (SGM) include, but are not limited to, those who identify as lesbian, gay, bisexual, transgender, and queer or questioning, and are often referred to with the acronym "LGBTQ+"¹. Importantly, the terms identifying sexual orientation and gender identity have changed over time, thus it is important for continued research on how to best measure these populations within all types of research, from basic to population-level.

Research conducted by the National Academies of Science, Engineering, and Medicine (NASEM) recommends using a single item to assess sexual orientation, "Which of the following best represents how you think of yourself?" (response options: lesbian/gay, straight, bisexual, two-spirit [if American Indian or Alaska Native], or free-text). The NASEM report recommends using two questions to measure gender identity, including sex assigned at birth, "What sex were you assigned at birth, on your original birth certificate?" (response options: female, male, don’t know, prefer not to answer) and gender identity, "What is your current gender identity?" (response options: female, male, transgender, two-spirit [if American Indian or Alaska Native], or free-text).

The NASEM recommendations were limited to published work, which may have resulted in outdated item response options. This is critical as SGM demography is rapidly changing, and a greater number of young people are self-identifying within SGM populations. Accordingly, the language used to describe SGM people is broadening beyond that traditionally used in population health surveys; for example, SGM individuals may self-identify as queer, pansexual, asexual, non-binary, genderqueer, agender, transgender, and more. Thus, it is important to continually explore the most valid and precise SOGI measures—working closely with SGM advocates to ensure accuracy.

Why is accurate SOGI measurement important? Population-level evidence indicates that our estimates of SGM health disparities vary depending on how SOGI is measured.² For example, Wheldon et al³ found that, when sexual orientation is measured by how people self-identify, adult lesbian women had 2.9 higher odds, and bisexual women 4.7 higher odds, of current cigarette smoking than heterosexual women. When sexual orientation was measured by attraction, women reporting only same sex attraction had 2.4 greater odds, and women reporting attraction to both sexes 3.8 greater odds, of current cigarette smoking than women reporting only opposite sex attraction. In contrast, women reporting asexual attraction had 0.29 lower odds of current cigarette smoking than women reporting only opposite sex attraction. These findings suggest that single item measurement limits our understanding of the distribution and magnitude of sexual orientation-based population health inequities.⁴   

It is important for researchers to measure SOGI so that health data accurately describes how social determinants of health, related health behaviors, and health outcomes are distributed among minoritized populations, including SGM people. Future research must continually improve assessment related to SOGI at a population level to ensure that data collection efforts are accurate and inclusive. 

More information about SOGI measurement can be found through the NIH Sexual & gender Minority research Office and within the NASEM report.

Affiliations:

1. Program for Research in Survey Methodology, RTI International, Research Triangle, NC
2. Department of Health and Human Physiology, University of Iowa, Iowa City IA
3. Division of Health Behavior & Health Promotion, The Ohio State University College of Public Health, Columbus OH
4. Division of Cancer Control and Population Sciences, National Cancer Institute

References:

1.         National Academies of Sciences E, Medicine. Measuring Sex, Gender Identity, and Sexual Orientation. The National Academies Press; 2022:200.

2.         Institute of Medicine Committee on Lesbian GB, Transgender Health I, Research G, Opportunities. The National Academies Collection: Reports funded by National Institutes of Health. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. National Academies Press (US)

Copyright © 2011, National Academy of Sciences.; 2011.

3.         Wheldon CW, Kaufman AR, Kasza KA, Moser RP. Tobacco Use Among Adults by Sexual Orientation: Findings from the Population Assessment of Tobacco and Health Study. LGBT Health. Jan 2018;5(1):33-44. doi:10.1089/lgbt.2017.0175

4.         Patterson JG, Jabson JM, Bowen DJ. Measuring Sexual and Gender Minority Populations in Health Surveillance. LGBT Health. Apr 2017;4(2):82-105. doi:10.1089/lgbt.2016.0026