Measuring and Addressing Health
Disparities Based on Gender
Identity and Sexual Orientation
LINDA DRACH
CHRISTOPHER GRAY
ANGIE TISSI
…AND FRIENDS!
LINDA.DRACH@STATE.OR.US
Gender, Sexual Orientation, and Public Health
 Gender and sexuality are explicitly or subtly present
in much of our public health work.
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Anybody here deal with issues of gender or sexuality in their
professional lives?
But…
 Public health data systems and other
evaluation/assessment tools generally are limited in
their ability to capture the full range of gender and
sexual expression.
Checking Boxes: The Binary Bind
 Gender and sexual orientation are different.

Compressing them into one category is generally a mess.
 Gender or ‘sex’ is a standard demographic variable,
collected by virtually all.

Almost universally conceptualized as binary (Male or Female)
 Sexual orientation is now included in some large
datasets; usually limited to 3 categories (hetero-, homo-,
and bisexual) :
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Oregon and Washington BRFSS (since ‘03)
Oregon Healthy Teens (since ‘06)
National Health Interview Study, Nurses’ Health Study II
How is this a Measurement Problem?
 Gender and sexuality are flexible social constructs that vary
across location, culture, and time.
 Solarz et al say sexuality can be expressed in 3 ways: identity,
behavior/activity, and orientation/desire. Mann added a 4th
dimension of participation in community and social groups.
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Sexual identity and behavior don’t always play nice with 2x2 tables.
So, is your 3-category orientation variable measuring what you think it’s
measuring?
 Gender is similarly complex.
 A ‘Male’ or ‘Female’ category may include people with a different gender
assigned at birth and/or who do not identify with the given category.
Queer the Census Example
 No sexual orientation or
expanded gender ID items on
2010 Census, but measures
same sex partnership and
same-sex legal marriages.
 QtC instructed respondents to
“tell your truth as you know
it” because “there is no wrong
answer.”

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Politically legitimate: “We are
developing the new portrait of
America”
But increases potential for
measurement error
How is this a Public Health Problem?
 Existing data point to significant health disparities based
on gender identity and sexual orientation.

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Historically, these data were from convenience samples: suggestive,
but problematic
Now, growing evidence base from population-based datasets (mostly
for differences by sexual orientation)
 Without good data:

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Health and other social disparities among gender and sexual
minorities will remain unrecognized and unaddressed
Important differences within the diverse LGBTQ community cannot
be recognized and addressed
Funding for this health disparity work will be lacking
How Many People are We Talking About?
 Lack of good population estimates, but…
 3.3% Portland metro area residents identified as
LGB (based on ‘03-’05 OR/WA BRFSS)
 Nationally, 565,000 same sex couples (2008 ACS):


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1 in 6 live in rural areas
20% nonwhite
65,000 individuals who are in same-sex couples serve in the
military
 Same sex couples live in 99.3% of U.S. counties;
LGBT parents live in 97% of U.S. counties (2000
Census)
Queer: New Frontier?
 Queer: Claimed by some LGBT as term of self-
empowerment; re-appropriated to describe S.O. or
gender identity/expression that does not conform to
heteronormative society

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Still seen as offensive to some, particularly older LGB who may
have experienced the term as derogatory (as it was indeed used
through much of the 20th century)
Wikipedia says: some use as “inclusive, unifying, sociopolitical
umbrella term” (!)
Preferred by many because of its ambiguity and breadth
Genderqueer: New Frontier?
 Genderqueer: Umbrella term for all genders that are
not male or female

People who identify as genderqueer may identify as both male
and female, neither male nor female, or outside of the
currently-understood gender continuum altogether

Emergent term (since 1990s): some like it, some don’t. Some
may prefer “gender variant” or “gender nonconforming”

May include people who are transgender or intersex, but not
necessarily and not interchangeable
A Local Example of Going Beyond the Binary
 Speak Out 2009 was a survey conducted among
sexual and gender minorities in the Portland
metropolitan area (and Benton County):
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Conducted online June-July 2009
Used combination of outcropping and network sampling to
recruit participants (e.g., computers at Gay PRIDE, e-mails to
various lists, Facebook, craigslist)
Eligibility: 18 and older, identify as gender and/or sexual
minority, resident of Multnomah, Washington, Clackamas (or
Benton) Counties in OR; Clark Co in WA
Additional outreach efforts to elders, people of color, and
transgender individuals
Speak Out 2009, continued
 Survey instrument covered broad range of topics:
 Health outcomes (e.g., mental and physical health conditions)
 Health behaviors (e.g., use of alcohol, tobacco, and other
drugs; physical activity and nutrition)
 Social determinants (e.g., discrimination and harassment,
experiences growing up, community connection)
 Survey sample was 843 individuals in the Portland
metropolitan area (Benton County analyzed separately)
Gender and Sexual Orientation Categories
 Speak Out offered:
 7 categories for sexual orientation, including lesbian, gay,
bisexual, queer, heterosexual, asexual, and undecided
 7 categories for gender identity, including transgender (MTF,
FTM, and not M or F), intersex, genderqueer, male, and female
 For subgroup analysis, categories were pooled into:
 4 gender categories (male, female, transgender, and
genderqueer)
 3 orientation categories (gay/lesbian, bisexual, and queer)
If You Build It, They Will Come…
Gender
60%
Sexual Orientation
51%
40%
50%
33%
40% 35%
31%
30%
30%
22%
20%
20%
7% 7%
10%
ay
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G
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en
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de
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ue
In e r
te
rs
ex
M
al
e
0%
11%
an
1%
Le
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i
10%
Overall Speak Out Findings—Broad Brush I
 Reported many risk factors for poor health; some
similar to general population; elevated prevalence in
some areas:

For example, like most Americans, Speak Out respondents
reported eating fewer fruits and vegetables than recommended

On the other hand, mental health issues (depression, anxiety,
and PTSD) and experiences of violence were prevalent, and
rates appeared higher than general population rates
Overall Speak Out Findings—Broad Brush II
 Family support around sexual orientation and
community connection were related to reports of
better overall physical health.
 People with fewer experiences of social isolation
reported better overall physical health.
 People who received more social support growing up
reported less depression.
Differences by Gender and/or Sexual Orientation
 Many statistically significant differences noted
between groups, suggesting that there are different
health risks and experiences within the community
related to gender and sexual orientation.
 For example:
 Transgender-identified people reported less access to health
care and more days of mental and physical disability
 Bisexual and queer respondents reported higher rates of
mental health diagnoses
For More Info on Speak Out 2009
 Please check out our report for much greater detail
on survey items, methods, and findings.
 Full report available at:
www.co.multnomah.or.us/health/hra/reports/speak
out_2009.pdf
Fabulous Example of Population-Based Work, I
 Conron, Mimiaga & Landers. A population-based study
of sexual orientation identity and gender differences in
adult health. AJPH 2010 Oct; 100(10): 1953-60.
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Compared with heterosexuals, sexual minorities (i.e.,
gays/lesbians, 2% of sample; bisexuals, 1%) more likely to report
activity limitation, tension or worry, smoking, drug use, asthma,
lifetime sexual victimization, and HIV testing.
Did not differ on 3-year Pap tests, lifetime mammography,
diabetes or heart disease.
Sexual orientation disparities in chronic disease risk,
victimization, health care access, mental health, and smoking
merit increased attention.
More research on heterogeneity in health and health
determinants among sexual minorities is needed.
Fabulous Example of Population-Based Work, II
 Dilley, Simmons, Boysun, Pizacani & Stark. Demonstrating
the importance and feasibility of including sexual
orientation in public health surveys: Health disparities in
the Pacific NW. AJPH 2010 Mar; 100(3): 460-7.

Many health disparities noted for lesbians, gay men, and
bisexuals compared to heterosexuals. Bisexuals of both
genders reported greatest number and magnitude of health
disparities compared to heterosexuals.

Sexual orientation can be effectively included as a standard
demographic variable in public health surveillance systems:
justification to go beyond “don’t ask, don’t tell” surveillance.
Additional Overview Reading
 Gay & Lesbian Medical Association. Healthy People 2010
Companion Document for Lesbian, Gay, Bisexual and
Transgender Health. San Francisco, CA: GLMA, 2001.
 Johnson, Mimiaga, & Bradford. Healthcare issues among
lesbian, gay, bisexual, transgender, and intersex (LGBTI)
populations in the United States: introduction. J of
Homosexuality 2008; 54(3): 213-24.
 Mayer, Bradford, Makadon, et al. Sexual and gender
minority health: What we know and what needs to be
done. AJPH 2008; 98(6): 989-95.