Sexual Minority Health and Health Risk Factors: Intersection Effects of Gender, Race, and Sexual Identity

doi:10.1016/j.amepre.2015.11.016

American Journal of Preventive Medicine

Volume 50, Issue 6, June 2016, Pages 746-755

https://doi.org/10.1016/j.amepre.2015.11.016 Get rights and content

Introduction

Although population studies have documented the poorer health outcomes of sexual minorities, few have taken an intersectionality approach to examine how sexual orientation, gender, and race jointly affect these outcomes. Moreover, little is known about how behavioral risks and healthcare access contribute to health disparities by sexual, gender, and racial identities.

Methods

Using ordered and binary logistic regression models in 2015, data from the 2013 and 2014 National Health Interview Surveys (n=62,302) were analyzed to study disparities in self-rated health and functional limitation. This study examined how gender and race interact with sexual identity to create health disparities, and how these disparities are attributable to differential exposure to behavioral risks and access to care.

Results

Conditional on sociodemographic factors, all sexual, gender, and racial minority groups, except straight white women, gay white men, and bisexual non-white men, reported worse self-rated health than straight white men (p<0.05). Some of these gaps were attributable to differences in behaviors and healthcare access. All female groups, as well as gay non-white men, were more likely to report a functional limitation than straight white men (p<0.05), and these gaps largely remained when behavioral risks and access to care were accounted for. The study also discusses health disparities within sexual, gender, and racial minority groups.

Conclusions

Sexual, gender, and racial identities interact with one another in a complex way to affect health experiences. Efforts to improve sexual minority health should consider heterogeneity in health risks and health outcomes among sexual minorities.

Introduction

Many studies indicate that sexual minorities have poorer health outcomes, including self-rated health (SRH), cardiovascular conditions, diabetes, functional limitations, and lifetime mood and anxiety disorders, relative to heterosexuals.1, 2, 3, 4, 5 Sexual minorities are also more likely to exhibit health risks, such as smoking, heavy drinking, obesity (particularly among sexual minority women), and limited access to healthcare services.1, 6, 7, 8, 9, 10, 11, 12 However, few studies have examined how gender and race/ethnicity may jointly interact with sexual orientation to affect health and exposure to health risks. Although recent population-level surveys have shown that some disparities in health risks by sexual identity, including obesity, drinking, and insurance coverage, are more pronounced among women than men,1, 10, 13 research on the intersection effects of race/ethnicity and sexual orientation on health is still limited in quantity and scope. Some research hypothesizes that sexual minorities of color may be exposed to greater stress and health risks than their white counterparts due to higher levels of heterosexism in their communities, but empirical evidence, based mostly on small samples, remains inconsistent.14, 15, 16 Other work suggests that sexual minorities of color are more resilient in the face of heterosexism because they have developed skills and strategies to cope with racism.16, 17, 18 However, whether their health outcomes also reflect such resilience remains an open question.

The present study aims to fill this gap by comparing health status, behavioral risks, and access to health care across 12 sexual, gender, and racial identity groups (including white and non-white straight/gay/bisexual men and women). Recognizing that few studies have investigated the link between health outcomes and risk factors across these groups,¹⁹ the study also examines how behavioral risks and healthcare access contribute to observed health disparities. Building on the approach of intersectionality,20, 21, 22, 23, 24, 25, 26, 27 this study tests whether individuals with multiple disadvantages in their social position (in terms of sexual orientation, gender, and race) experience much poorer health than their privileged or singly disadvantaged counterparts. Notably, intersectionality is not an additive approach and does not privilege any single dimension of inequality. Instead, it emphasizes the configurations of social identities that produce unique advantages and disadvantages for health and well-being.20, 24, 26 Therefore, sexual minority women of color, for example, may not exhibit the poorest health outcomes, as might be expected. Rather, as the resilience perspective posits, strengths and strategies developed to cope with sexism, racism, or heterosexism may buffer the harmful consequences of one another. Using a nationally representative sample, this paper is one of the few studies incorporating intersectionality into population health research.21, 24

Section snippets

Study Sample

The study used pooled data from the 2013−2014 National Health Interview Survey (NHIS), collected by the National Center for Health Statistics. The NHIS is a household survey conducted annually since 1957, with questions on sexual orientation first asked in 2013. The NHIS covers a broad range of health topics, including health status and limitation of activity, health behaviors, and healthcare access and utilization. The survey generates representative samples of the civilian,

Results

Table 1 displays the characteristics of the NHIS sample, by racial, gender, and sexual identity. Bisexuals were generally younger than straights, gays, and lesbians of the same race and gender; this age difference was more pronounced among women. Sexual minorities tended to have higher (or at least comparable) levels of education than straights of the same race and gender, but non-white bisexual women exhibited lower educational attainment. Sexual minorities were also less likely to be married

Discussion

Population research on health disparities by sexual orientation has rarely examined how gender and race/ethnicity interact with sexual orientation to affect health experiences. Moreover, few studies have tested the relationship between health outcomes and health risk factors across sexual, gender, and racial identity groups. The current study shows that sexual, gender, and racial identities interact with one another in a complex way to affect health. For both SRH and functional limitation,

Limitations

A few limitations of the study should be noted. First, the data are cross-sectional, and the causal direction of the relationship between health risk factors and health outcomes cannot be determined. Although the relationship is most likely bidirectional, prior studies based on longitudinal data have validated the direction from exposure to risks to health. For example, sleep disturbance or deprivation may rouse inflammatory responses and increase the severity of physical disorders.34, 35 Also,

Conclusions

Despite the limitations, this study advances the understanding of the link between health behavior, healthcare access, and health outcomes among groups with different sexual, gender, and racial identities. It suggests that research focusing on one-dimensional status (e.g., gender, race/ethnicity, or sexual orientation) may miss the health risk or benefit related to a unique configuration of social identities. In particular, sexual minorities of different gender and race may be exposed to

Acknowledgments

The research is partially supported by funding from NIH, including the National Institute on Aging (T32AG000243, P30AG012857). The funders played no role in the study design, analysis and interpretation of the data, writing the manuscript, or the decision to submit the manuscript for publication.

No financial disclosures were reported by the authors of this paper.

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Research ArticleSexual Minority Health and Health Risk Factors: Intersection Effects of Gender, Race, and Sexual Identity

Introduction

Methods

Results

Conclusions

Introduction

Section snippets

Study Sample

Results

Discussion

Limitations

Conclusions

Acknowledgments

Am J Prev Med

Am J Prev Med

Prev Med

Soc Sci Med

Soc Sci Med

A population-based study of sexual orientation identity and gender differences in adult health

Am J Public Health

Dimensions of sexual orientation and the prevalence of mood and anxiety disorders in the United States

Am J Public Health

Health behaviors, health status, and access to and use of health care: a population-based study of lesbian, bisexual, and heterosexual women

Arch Fam Med

Disability among lesbian, gay, and bisexual adults: disparities in prevalence and risk

Am J Public Health

Eating disorder symptoms and obesity at the intersections of gender, ethnicity, and sexual orientation in U.S. high school students

Am J Public Health

Adult health behaviors over the life course by sexual orientation

Am J Public Health

Sexual orientation, substance use behaviors and substance dependence in the United States

Addiction

The effects of unequal access to health insurance for same-sex couples in California

Health Aff (Millwood)

Demonstrating the importance and feasibility of including sexual orientation in public health surveys: health disparities in the Pacific Northwest

Am J Public Health

Black-white differences in attitudes toward homosexuality and gay rights

Public Opin Q

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LGB of color and white individuals’ perceptions of heterosexist stigma, internalized homophobia, and outness: comparisons of levels and links

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Research Article
Sexual Minority Health and Health Risk Factors: Intersection Effects of Gender, Race, and Sexual Identity