MEASURING SEXUAL IDENTITY IN
NCHS SURVEYS
Jennifer Madans, Ph.D.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
National Center for Health Statistics
NCHS Staff
 NSFG
Anjani Chandra
 Casey Copen
 Bill Mosher
 Catlainn Sionean

 NHIS
Marcie Cynamon
 Jim Dahlhamer
 Beth Taylor

 QDRL
Heather Ridolfo
 Kristen Miller
 Aaron Maitland
 Mike Ryan

Background
 Need to better understand health of sexual
minority groups
 Some evidence of health disparities
Challenges to Researching
Sexual Minority Health
 Conceptual Complexity  Survey design
 Sexual
identity
 Sexual attraction
 Sexual behavior
 Fluidity of identity
 Comprehension of
terms
 Commonality of terms
 Population subgroup
differences
 Context
of questions
 Incorporation into
ongoing survey
 Consideration of future
survey changes
Definition of Construct
 Sexual Orientation:

Generic term, catch-all
 Sexual Behavior:



Same-sex vs. opposite-sex behavior
Not necessarily consistent with self-conception or presentation of self
Design problem: what counts as “sex” varies across sub-groups
 Sexual Attraction:




Same vs. opposite sex/gender desire
Not necessarily consistent with self-conception or presentation of self
Latent and elusive phenomena, not tangible, not observable
Design problem: Variation in conceptualization, particularly in what respondents consider
and actually report
 Sexual Identity




Conscious understanding and identification of self
Similar to racial identity
Represents individuals’ relationship to social world
Design problem: complex and fluctuating
Patterns of Interpretation/Construct Equivalence
Non-Minority Patterns
Lack of salient sexual
identity
No concept of sexual identity but
rather dis-identification
“not me,”
“I’m normal,” “soy mujer,”
“I don’t know”
Provided response categories:
Interpretation of ‘heterosexual’ as gay;
‘bisexual’ as heterosexual
LGBT Patterns
Highly salient
Identity rooted in complex
process of negotiating and forming a
sexual identity
Shifting sexual identity
For transgender respondents,
intersection of gender
and sexuality
Provided response categories:
Use of non-traditional
identity categories
Results Thus Far
 National Survey of Family Growth (NSFG)
 National Health and Nutrition Examination
Survey (NHANES)
 Questionnaire Design Research Laboratory
(QDRL)
NSFG Cycle 6 (2002)
Do you think of yourself as…
Heterosexual
Homosexual
Bisexual
or Something else
NSFG Cycle 6 (2002)
Table 1. Sexual identity by gender.
Sexual Identity
Men
Women
All
Heterosexual
90.2%
90.3%
90.3%
Homosexual
2.3
1.3
1.8
Bisexual
1.8
2.8
2.3
Missing
5.7
5.6
5.6
100
100
100
55,399
55,742
111,141
Weighted N in
thousands
Note. Missing data= something else, refused, and don’t know responses
NHANES 2002-2008
Do you think of yourself as…
Heterosexual or straight (attracted to men/women)
Homosexual or lesbian/gay (attracted to women/men)
Bisexual (attracted to men and women)
Something else
Not sure
NHANES 2002-2008
Table 2. Sexual identity by gender.
Sexual Identity
Men
Women
All
95.4%
93.2%
94.3%
Homosexual or gay/lesbian
2.3
1.5
1.9
Bisexual
1.3
3.3
2.3
Missing
1.1
2.0
1.6
100
100
100
(3697)
(4201)
(7898)
Heterosexual or straight
n
Note: Missing data = something else, not sure, don’t know, refused and
don’t know responses
NHANES 2002-2008
Table 3. Distribution of missing data by education
Men
Women
Missing data
<HS
HS
>HS
<HS
HS
>HS
Yes
3.4%
0.8%
0.4%
5.7%
2.1%
1.1%
No
96.7
99.2
99.6
94.3
98.0
99.0
100
100
100
100
100
100
(976)
(995)
(1724)
(976)
(918)
(2306)
n
Chi-square = 42.34, p<.0001
Chi-square = 50.29, p<.0001
NHANES 2002-2008
Table 4. Distribution of missing data by gender and ethnicity.
Men
Missing data
Women
Hispanic
Non-Hispanic
Hispanic
Non-Hispanic
Yes
3.4%
0.6%
5.8%
1.3%
No
96.6
99.4
94.2
98.7
100
100
100
100
(1103)
(2594)
(1247)
(2954)
n
Chi-square = 42.10, p<.0001
Chi-square = 46.06, p<.0001
Note. Missing data = something else, not sure, refused, and don’t know
responses
NHANES 2004-2008
Table 5. Distribution of missing data by language and ethnicity (for
women only).
Missing data
Hispanic
Hispanic
Non-Hispanic
English interview
Spanish interview
English interview
Yes
3.3%
9.9%
1.4%
No
96.7
90.1
98.6
100
100
100
(496)
(426)
(2169)
n
Note. Chi-square = 43.85, p<.0001
Results
 High
rates of missing data in
comparison to the target group
(something else, not sure, don’t know,
and refused responses)
 Unevenly distributed across
population
 Higher
among low education
 Higher among minority population
NSFG 2006-2008
Do you think of yourself as…
Heterosexual or straight
Homosexual or gay/lesbian
Bisexual
or Something else
When you say “something else” what do you
mean? Please type in your answer
NSFG 2006-2008
Table 6. Sexual identity by gender. United States, aged 1844, 2006-2008
Sexual Identity
Men
Women
All
Heterosexual
95.7%
93.7%
94.7%
Homosexual
1.7
1.1
1.4
Bisexual
1.1
3.5
2.3
Missing
1.5
1.7
1.6
100
100
100
55,556
56,032
111,588
Weighted N in
thousands
Note. Missing data= something else, refused, and don’t know
responses
NSFG 2002 and 2006-2008
Table 7. Percent missing data for sexual identity by selected
characteristics: United States, aged 18-44, 2002 and 2006-2008
Men
Women
2002
2006-08
2002
2006-08
Hispanic
10.8
4.5
10.2
4.8
NH White
3.0
0.5
3.5
0.9
NH Black
10.7
0.4
8.5
2.2
ACASI -English
5.4
0.9
5.1
1.2
ACASI-Spanish
12.0
8.5
12.6
9.2
Ethnicity
Language
Note. Missing data= something else, refused and don’t know responses
NSFG 2002 and 2006-2008
Table 7 Continued. Percent missing data for sexual identity by selected
characteristics: United States, aged 18-44, 2002 and 2006-2008
Men
Women
2002
2006-08
2002
2006-08
Less than HS
12.7
3.9
15.1
4.2
HS
8.7
1.5
8.4
1.1
Some college
1.7
0.8
2.5
1.1
Bachelor’s degree
or higher
1.3
0.7
1.5
1.0
Education
Note. Missing data= something else, refused, and don’t know responses
NSFG Results
 2006-2008 NSFG
 Significantly
improved question wording
 Lower rates of missing data
 Still high rates of missing in some populations
Lowest educational level
Spanish speaking, especially women
Women: BMI by ‘Sexual Orientation’
2002 NSFG
Normal
Overweight
HETEROSEXUAL
49.7
25.6
HOMOSEXUAL
30.5
35.3
BISEXUAL
48.5
29.6
Obese
24.7
34.2
22.0
2006 NSFG
Normal
Overweight
Obese
STRAIGHT OR
HETEROSEXUAL
40.7
26.5
32.8
GAY OR LESBIAN
OR HOMOSEXUAL
38.2
33.0
28.8
BISEXUAL
36.5
19.5
44.0
Preparing to Add Questions to the NHIS
 What’s different about the NHIS?
 Multipurpose
General Population Survey
 Interviewer Conducted Interview
 Areas Needing Development
 Audio
Computer Assisted Self Interview
(ACASI)Development
 Question Development
Sources Informing NHIS Question
Development
 Quantitative Studies
 2001-2008 National Health and Nutrition Examination Survey
(NHANES)
 2002 -2003 National Survey of Family Growth (NSFG)
 2006-2008 NSFG
 Qualitative Studies
 7 cognitive testing study results
 This project 139 interview
 Total 377 cognitive interviews
139 Cognitive Interviews conducted
139 Cognitive Interviews conducted
Design for New Question
Goals for New Question:
1. Reduce misclassification, especially for non-minorities
2. Reduce “something else” and “don’t knows”
3. Sort non-minority from minority cases
Revision Based on Principles:
1. Use labels that respondents use to refer to themselves
2. Do not use labels that respondents do not understandespecially if not required by any respondents
3. Use follow-up questions to meaningfully categorize
‘something else’ and ‘don’t know’
Revised sexual identity question
Do you think of yourself as…

Lesbian or gay

Straight, that is, not lesbian or gay

Bisexual

Something Else

Don’t Know
Revised sexual identity question
By something else, do you mean that…

You are not straight, but identify with another label such as queer, trisexual,
omnisexual or pan-sexual

You are transgender or transexual

You have not or are in the process of figuring out your sexuality

You do not think of yourself as having a sexuality

You personally reject all labels of yourself

You made a mistake and did not mean to pick this answer

You mean something else
What do you mean by something else?
Please type in your answer
_____________________________________
Revised sexual identity question
By Don’t Know, do you mean that…

You don’t understand the words

You understand the words, but you have not or are in the process of
figuring out your sexuality

You mean something else
What do you mean by something else?
Please type in your answer
_____________________________________
Additional work
 Limitations:
 Washington DC metro region
 Different vocabulary can vary (particularly true for Spanish)
 Question still being evaluated/may change with:
 Field interview debriefings
 Analysis of field test data
NHIS
THREE PHASE TEST
The National Health Interview Survey
 Since 1957
 General health survey
 Noninstitutionalized population
 In person interviews by Census interviewers
 n = 40,000 households, national sample
 Data on households, adults, and children
 Annual , one time, and periodic content
 One hour
 Advance letter/informed consent
Phase 1: Bridging Field and Lab Techniques
 n = 50
 Maryland, Virginia, and Pennsylvania
 6 interviewers
 Adapting QDRL procedures to Census field
requirements
 Context of NHIS
 Transition from standard CAPI to ACASI
Phase 2: Testing Technical Procedures
 n = 500
 Several regions
 Full NHIS with ACASI at the end
 Tests procedures for
 Using
headphones
 Delivering instructions
 Respondent concerns
 Input and output
Phase 3: The Pilot
 N = 5,000
 Split Ballot
 ACASI compared to CAPI
 Additional issues and experimentation
 Spanish
 Question
wording, order
 Voice qualities (human or text to speech; sex;
speed)
 Placement
Evaluation Criteria
 Break off rates
 Nonresponse
 Don’t know and refused responses
 Impact on other survey data
 Interviewer debriefing
 Observer debriefing
 Comparisons to other surveys
Timeline
Date
Activity
Nov-Dec 2011
Phase 1
Apr-May 2012
Phase 2
Aug-Sep 2012
Phase 3
Jan 2013
Full Implementation
NHIS Pretest
Stay tuned….