For public health departments and providers to plan appropriate services for a population, especially a vulnerable one, it is essential to have reliable data on population demographics and health status. Until recently, many of the research studies conducted in the LGBT community were community-based studies using nonprobability sampling techniques.[2, 3] The studies, often using convenience sampling, were prone to selection bias. For example, studies conducted at bars and clubs were known to have overestimated certain health issues such as the prevalence of tobacco and substance use. In addition, the use of small nonprobability samples to examine the health of LGBT communities may not be representative of the population’s racial, ethnic, and socioeconomic composition.

To adequately describe the LGBT population and assess health indicators and risks, it is therefore necessary to conduct well-designed population-based studies. An additional issue with investigating the LGBT community is that no single question adequately captures the diversity and complexity of the lives of LGBT individuals. Self-disclosed sexual orientation has been shown to not predict sexual behavior. A person who identifies as lesbian or gay may still have sexual relations with members of the opposite sex, for example.

The first national survey on sexual behaviors among U.S. adults examined sexual orientation,  attraction,  and identity.  This study highlighted the difficulty with defining sexual identity in this population. Findings showed that 9.9 percent of men and 4.3 percent of women reported having same-sex partners; 7.7 percent of men and 7.5 percent of women have same-sex desire/attraction, however, only 2.8 percent of men and 1.4 percent of women reported self-identification as homosexuals. Homosexual identity was found to be less likely among African Americans, those living in rural areas, and those with less formal education.[4]

Another study of men in New York City found considerable discordance between sexual orientation and behavior with 9.4 percent of straight-identified men reporting sexual intercourse with at least one man in the previous year.[5] The 2002 National Survey of Family Growth (NSFG) also measured indicators of sexual behavior, orientation, and identity among males and females, 15-44 years of age, using face-to-face interviews.

While 4.1 percent of both men and women identified as homosexual or bisexual, a greater number reported same-sex activity: 6 percent of men reported having either oral or anal sexual contact with another man, while 11 percent of women answered yes when asked, “Have you ever had any sexual experience of any kind with another female?” Four percent of women and 2.9 percent of men reported same-sex partners in the last 12 months. The survey also asked about sexual attraction, with 3.2 percent of men and 3.4 percent women reporting same-sex attraction to males and females.[6] Studies conducted among adolescents have also shown a discordance of self-reported sexual orientation and the gender of sexual partners, with lesbian youth more likely than heterosexually identified women to report high-risk sexual activity with opposite-sex partners.[7, 8]

Sexual orientation and gender identity have not been included routinely as demographic markers in population-based research. One key source of demographic data, the U.S. Census, does not include a question on sexual orientation. In 1990, the category of “unmarried partner” appeared on the census form for the first time, allowing enumeration of unmarried,  same-sex partner households.  In the 2000 census, of 4.9 million unmarried-partner households, approximately one in nine (594,000) had partners of the same sex.[9] Census 2010 will again gather information on same-sex partner households, and in a reversal of a previous decision, will allow married same-sex couples to indicate their status as “husband or wife” instead of “unmarried partner.” Transgender individuals are not separately identified on the U.S. Census. Several LGBT organizations, most notably the National Coalition for LGBT Health, based in Washington, D.C., have been advocating for the addition of sexual orientation and gender identity questions in the National Health Interview Survey (NHIS), one of the major data collection programs of the National Center for Health Statistics (NCHS). The inclusion of these demographic markers in national random-sample population-based studies will greatly increase the knowledge of health conditions and risk factors affecting the LGBT community.

In addition to the paucity of population-based studies that address LGBT individuals, there remains the difficulty of increasing participation in studies by members of the community. Despite liberalization of societal norms, LGBT participants may be uncomfortable answering sensitive questions about their sexual orientation, gender identity, and sexual practices on surveys. There is currently no federal-level protection against housing or employment discrimination on the basis of sexual orientation or gender identity, which could affect participation of LGBT in research studies, especially if they fear public disclosure of confidential information. For certain individuals (for example, those in the military), disclosure of sexual orientation can have disastrous consequences such as loss of employment, dishonorable discharge, and loss of pensions and other benefits. For men who identify as gay or bisexual, there is an added concern of stigmatization for their perceived increased risk of HIV.

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Anita Radix, MD, MPhil, MPH, and Gal Mayer, MD, MS

Anita Radix, MD, MPhil, MPH, Director of Research and Education, Callen-Lorde Community Health Center
Dr. Gal Mayer MD practices internal medicine in New York, New York. Callen Lorde Community Health Center

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REFERENCES

1. The Gay and Lesbian Medical Association. Healthy People 2010 companion document for LGBT Health. 
2. Solarz AL,  Institute of Medicine,  eds.  Lesbian Health:  Current Assessment and Directions for the Future. 1st ed. Washington, DC: National Academies Press; 1999.
3. Dean L, Meyer I, Robinson K, Sell R, et al. Lesbian, gay, bisexual, and transgender health: findings and concerns. J Gay Lesbian Med Assoc. 2000;4(3):101-151.
4. Laumann E, Gagnon J, Michael R, Michaels S. The Social Organization of Sex: Sexual Practices in the United States. Chicago, IL: University of Chicago Press; 1994.
5. Pathela P, Hajat A, Schillinger J, Blank S, Sell R, Mostashari F. Discordance between sexual behavior and self-reported sexual identity: a population-based survey of New York City. Men Ann Intern Med. 2006;145:416-425.
6. Mosher W, Chandra A, Jones J. Sexual behavior and selected health measures: men and women 15-44 years of age,  United States,  2002.  Vital Health Stat. 2005;362:21-26.
7. Goodenow C, Szalacha L, Rubin L, Westheimer K. Dimensions of sexual orientation and HIV-related risk among adolescent females: evidence from a statewide survey. Am J Pub Health. 2008;98(6):1051-1058.

Full References  »