Health Disparities Among Lesbian, Gay, and Bisexual Service Members and Veterans – American Journal of Preventive Medicine
Introduction
This study investigated whether health disparities exist among lesbian, gay, and bisexual individuals serving in the U.S. military by examining the associations of sexual orientation with mental, physical, and behavioral health among a population-based sample of service members and veterans.
Methods
Sexual orientation and health outcomes were self-reported on the 2016 Millennium Cohort Study follow-up questionnaire (N=96,930). Health outcomes were assessed across 3 domains: mental health (post-traumatic stress disorder, depression, anxiety, binge eating, problematic anger), physical health (multiple somatic symptoms, physical functioning, BMI), and behavioral health (smoking, problem and risky drinking, insomnia). Adjusted logistic regression models conducted between 2019 and 2022 estimated the associations between sexual orientation and each health outcome.
Results
Lesbian, gay, and bisexual individuals (3.6% of the sample) were more likely to screen positive for post-traumatic stress disorder, depression, anxiety, binge eating, problematic anger, multiple somatic symptoms, and insomnia than heterosexual individuals. Gay/lesbian and bisexual women reported more adverse health outcomes (overweight and obesity, smoking, problem/risky drinking) than heterosexual women. Gay and bisexual men reported some adverse health outcomes (e.g., smoking and problem drinking) but better physical health (e.g., less overweight/obesity) than heterosexual men.
Conclusions
Lesbian, gay, and bisexual service members reported poorer mental, physical, and behavioral health than heterosexual peers, most notably among gay/lesbian women and bisexual individuals. Findings suggest that lesbian, gay, and bisexual service members experience health disparities, despite many having equal eligibility for health care, highlighting the need for improved equity initiatives that promote cultural responsiveness, acceptance, and approaches to support the healthcare needs of lesbian, gay, and bisexual military members.
INTRODUCTION
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Health disparities among LGB individuals can be attributed in part to the effects of minority stress, defined as stressors including discrimination and stigma that minority groups face in excess of general stressors, which then compound to cause mental and somatic illness.
In the military context, the legacy of Don’t ask, don’t tell (DADT) and related stigma toward LGB individuals may further contribute to experiences of minority stress and impact the health and readiness of LGB service members.
Burrelli DF. Don’t ask, don’t tell: the law and military policy on same-sex behavior. Washington, DC: Congressional Research Service. https://fas.org/sgp/crs/misc/R40782.pdf. Published October 14, 2010. Accessed June 24, 2022.
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However, the majority of this research used small convenience samples or regional surveys, limiting generalizability. Moreover, research examining health outcomes among currently serving LGB military personnel is scarce. One survey of active duty service members found that LGB personnel were more likely to report binge drinking, smoking, risky sexual behavior, depression, and suicidal behaviors than heterosexual personnel but was limited by low response rates.
The limited research among actively serving populations prevents any clear assessment of how the health and readiness of active duty, Reserve, and National Guard (NG) service members differ by sexual orientation. The objective of this study was to examine whether differences in mental, physical, and behavioral health exist by sexual orientation among a large sample of active duty and Reserve/NG U.S. service members and veterans.
METHODS
Study Sample
Invited participants were randomly selected from U.S. military rosters, representing all service branches and components. Over 200,000 individuals enrolled across 4 separate study panels in 2001–2003 (Panel 1), 2004–2006 (Panel 2), 2007–2008 (Panel 3), and 2011–2013 (Panel 4) (see Ryan et al. and Smith et al. for detailed methodology).
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For this cross-sectional study, eligible participants completed the full version of the 2014–2016 survey (referred to as the 2016 survey), which first assessed sexual orientation identity. Participants who provided a response other than prefer not to answer were included. This study was approved by the Naval Health Research Center IRB. Written or electronic informed consent was obtained for all participants.
Measures
Sexual orientation identity was assessed by a single question asking participants whether they considered themselves to be heterosexual or straight, gay or lesbian, or bisexual.
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A positive screen for depression was assessed using the Patent Health Questionnaire (PHQ) 8 depression scale on the basis of DSM-IV criteria.
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Because PTSD and depression are often comorbid and were strongly correlated in this population (r=0.86), these items were combined as neither, depression only, PTSD only, or comorbid PTSD and depression.
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Additional PHQ subscales were used to screen for panic syndrome (15 items)/other anxiety syndromes (7 items) using standardized scoring algorithms,
and the first 3 items from the PHQ eating subscale were used to screen for binge eating.
Problematic anger was assessed using the 5-item Dimensions of Anger Reactions scale.
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Physical functioning was assessed using the physical component summary score from the Short Form 36-Item Health Survey for Veterans.
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BMI was assessed using self-reported height and weight.
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Problem drinking was assessed using the PHQ alcohol scale.
Risky drinking was assessed on the basis of the number of alcoholic drinks consumed per day in the past week and instances of binge drinking in the past year,
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scored using sex-specific limits.
Insomnia symptoms were assessed using the Insomnia Severity Index.
Statistical Analysis
Interactions between sex and sexual orientation identity were examined for each model to determine whether effect estimates differed by sex. Sex-stratified models are presented where interaction terms were statistically significant (pp-values were 2 sided, and values
RESULTS
Of the eligible study population (N=103,245), participants were excluded owing to missing data (n=3,644) or a response of prefer not to answer (n=2,671) on the sexual orientation identity question, yielding an analytic sample of 96,930 participants.
Table 1Demographic and Military Characteristics by Sexual Orientation, Millennium Cohort Study 2014–2016 (N=96,930)
Note: Asterisks indicate statistical significance of the chi-square test for each variable versus sexual orientation (*p<0.05; **p<0.01; ***p<0.001).
Table 2Mental, Physical, and Behavioral Health by Sex and Sexual Orientation, Millennium Cohort Study 2014–2016 (N=96,930)
Note: Asterisks indicate the statistical significance of the chi-square test for each variable versus sexual orientation within each category of sex (*p<0.05; **p<0.01; ***p<0.001).
Owing to nonresponse, the number of missing responses on each outcome variable varies. Sample sizes range from 94,534 to 96,884.
PTSD, post-traumatic stress disorder.
Table 3AORs of Mental, Physical, and Behavioral Health Outcomes by Sex and Sexual Orientation
Note: Boldface indicates statistical significance (p<0.05).
Significant effect modification by sex was observed for these models (interaction p<0.05). All models are adjusted for birth year, race and ethnicity, marital status, education level, service status, service branch, pay grade, military occupation, deployment experience, and study enrollment panel.
Table 4AORs of Mental, Physical, and Behavioral Health Outcomes by Sexual Orientation
Note: Boldface indicates statistical significance (p<0.05).
No significant effect modification by sex was observed for these models (interaction p>0.05). All models are adjusted for sex, birth year, race and ethnicity, marital status, education level, service status, service branch, pay grade, military occupation, deployment experience, and study enrollment panel.
PTSD, post-traumatic stress disorder.
With the exception of problem drinking (interaction p-value=0.022), service status did not significantly moderate any of the associations (results not shown). LGB individuals were significantly more likely to report problem drinking than heterosexual peers of the same service status; these associations were stronger among active duty (gay/lesbian, AOR=2.31, 95% CI=1.64, 3.25; bisexual, AOR=1.91, 95% CI=1.32, 2.76) and Reserve/NG (gay/lesbian, AOR=2.33, 95% CI=1.69, 3.21; bisexual, AOR=2.78, 95% CI=1.97, 3.91) personnel than among veterans (gay/lesbian, AOR=1.63, 95% CI=1.39, 1.91; bisexual, AOR=1.76, 95% CI=1.50, 2.06).
DISCUSSION
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this study observed that LGB individuals reported more adverse health outcomes than heterosexual individuals and that there were notable differences by sex and within LGB groups.
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Previous studies have found that LGB and transgender service members and veterans reported high levels of minority stress, microaggressions, victimization, and institutional discrimination during military service.
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Evidence-based treatment of mental disorders may need to account for these additional stressors and traumatic events experienced by LGB individuals.
The presence of worse outcomes among bisexual individuals is consistent with literature in civilian populations
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as well as with previous findings from this cohort.
Together, this suggests that the effects of dual discrimination from both heterosexual and gay/lesbian communities experienced by bisexual individuals may also be present within the military.
Bisexual individuals may also experience bisexual erasure, which occurs when bisexual individuals are marginalized by others who refuse to recognize their unique identity, instead assuming that they are confused or presuming that they are heterosexual or gay/lesbian on the basis of the gender of their partner(s).
Bisexual service members may also have worse health outcomes because of different patterns of outness because they are less likely to be out to LGBT friends, medical providers, and counselors than gay and lesbian individuals.
In previous literature, women veterans have reported higher rates of cumulative trauma experiences than women civilians.
Moreover, lesbian and bisexual veterans may experience more sexual trauma in the military than heterosexual women veterans.
These traumatic experiences may exceed typical occupational stressors, such as deployment and combat, experienced by service members. Thus, current military programs aimed at preventing and addressing these other traumatic experiences may need additional tailoring for specific subpopulations.
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; however, civilian studies have found comparable or poorer general and functional health among gay and bisexual men than among heterosexual men.
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It is possible that needing to maintain higher levels of physical fitness and functioning as part of military duties may potentially ameliorate some of these negative health outcomes among sexual minority service men. Moreover, these findings, among gay men in particular, may be related to socially imposed fitness and appearance standards among gay-identifying men.
Still, gay and bisexual men had increased odds for numerous adverse behavioral health outcomes compared with heterosexual men. For example, gay and bisexual men were more likely to be current smokers and report problem drinking than heterosexual men, which is consistent with findings from other populations.
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Discrimination due to sexual orientation may contribute to stress-related substance use. Future studies should examine the drivers of positive differences in physical health among gay and bisexual men to determine whether these attributes could be promoted military wide to improve the physical health and readiness of all service members.
Finally, although veterans made up the majority of this study population, the authors observed that the associations between sexual orientation identity and health outcomes were consistent among active duty, Reserve/NG, and veteran individuals. This suggests that the poor health outcomes observed may not be entirely related to the availability of health care and medical services; active duty service members, who have universal healthcare access, reported experiences similar to those of Reservists and veterans, who may not have consistent access to care. In addition to the contributing role of minority stress, trauma, stigma, and discrimination, health disparities may be related to barriers to care, such as limited availability of culturally competent and nondiscriminatory healthcare services and scarcity of medical staff trained in LGB health issues. Findings may also suggest that previous results from studies of LGB veterans may be relevant to LGB service members. Future research could identify the factors associated with these health disparities so that steps can be taken to alleviate them.
To the authors’ knowledge, this is the largest study assessing sexual orientation identity among U.S. service members and veterans that represents all components, service branches, and ranks, providing the ability to examine underrepresented subgroups, such as bisexual individuals, and differences among LGB individuals by sex. Whereas much of the previous research has been conducted among veterans exclusively, all Millennium Cohort Study participants were actively serving at the time of study enrollment, and over 40% of the analytic sample was actively serving at the time of the 2016 survey.
Limitations
Although the 2016 survey was collected after the repeal of DADT in 2011, responses may not reflect current experiences in a post-DADT world because all participants served under DADT. Moreover, some participants may have declined to respond or endorsed a sexual orientation identity that did not accurately reflect their true identity because of limited response options (e.g., response options for queer, pansexual, asexual, or questioning individuals were not available). In addition, the exclusion of participants who preferred not to report their sexual orientation identity owing to the nonhomogeneous nature of this group prevents any examination of health outcomes among these individuals. Many within this diverse subgroup may have unique health risk factors and outcomes that are important to explore. Future studies should examine the characteristics, experiences, and challenges of different types of respondents who choose not to answer sexual orientation questions. In addition, this study was not able to assess gender identity, prohibiting investigation of health outcomes experienced by transgender and gender diverse service members. Data on sex are likely reflective of sex assigned at birth, with only options of female or male provided. Although the authors posit that discrimination is likely related to worse health outcomes among LGB individuals, the study did not specifically assess experiences of discrimination. In addition, the authors did not adjust for traumatic experiences and social support because these events may mediate (i.e., be on the causal pathway) between sexual orientation identity and the health outcomes. Finally, BMI was the only available body composition measure and is self-reported, thus not representing medical diagnoses of obesity. Results should be interpreted with caution given that BMI does not account for muscular or athletic builds among those with shorter stature, and this may disproportionately affect certain subgroups (e.g., muscular men and women of color).
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CONCLUSIONS
In this large cohort of service members and veterans, LGB individuals reported poorer mental, physical, and behavioral health outcomes than heterosexual individuals, most notably among gay/lesbian women and bisexual individuals. Findings suggest that disparities in health outcomes exist on the basis of sexual orientation identity, despite the availability of medical care and health resources among active-duty personnel. This highlights the need for improved resources and policies within the Department of Defense and Veterans Health Administration aimed at promoting health and resiliency among LGB populations. Current programs and policies to prevent and address discrimination, stigma, and other traumatic experiences within the military should be further evaluated and improved. Specifically, organizational and policy shifts that promote cultural responsiveness and acceptance of LGB individuals need to be bolstered. It is important that future research identify the specific underlying factors that may contribute to these adverse health disparities and outcomes among LGB individuals in the military. Potential mechanisms that may need to be explored include minority stress, traumatic events, discrimination, stigma, and systemic bias. In addition, it is essential that health care and medical treatment options for LGB service members and veterans are evaluated and enhanced, including access to culturally competent and nondiscriminatory healthcare services. Ultimately, identifying and addressing the social and structural mechanisms that impact health among these populations may lead to a reduction in health disparities for LGB individuals in the military.
ACKNOWLEDGMENTS
In addition to the authors, the Millennium Cohort Study team includes Jennifer N. Belding, PhD; Satbir Boparai, MBA; Sheila F. Castañeda, PhD; Toni Rose Geronimo-Hara, MPH; Anna Rivera, MPH; Neika Sharifian, PhD, MS; Beverly Sheppard; Daniel W. Trone, PhD; Javier Villalobos, MS; Jennifer Walstrom; and Katie Zhu, MPH. The authors also appreciate contributions from the Deployment Health Research Department, Millennium Cohort Family Study, Birth and Infant Health Research Team, and Henry M. Jackson Foundation. We greatly appreciate the contributions of the Millennium Cohort Study participants. KL, VAS, and RPR are military service members or employees of the U.S. Government and prepared this work as part of their official duties under Title 17, U.S.C. §105, which provides that copyright protection under this title is not available for any work of the U.S. government. Title 17, U.S.C. §101 defines a U.S. Government work as work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties.
The views expressed in this study are those of the authors and do not reflect the official policy or position of the U.S. Department of the Navy, U.S. Department of the Army, U.S. Army Medical Department, U.S. Department of Defense, U.S. Department of Veterans Affairs, and the U.S. government. The funder had no part in the design of the study, collection of the data, analysis of the data, or writing of the manuscript. Research data were derived from an approved Naval Health Research Center, IRB protocol number NHRC.2000.0007.
Report Number 21-39 was supported by Military Operational Medicine Research Program, Defense Health Program, and Veterans Affairs under work unit number 60002.
The study protocol was approved by the Naval Health Research Center IRB in compliance with all applicable Federal regulations governing the protection of human subjects.
No financial disclosures were reported by the authors of this paper.
CRediT AUTHOR STATEMENT
Felicia R. Carey: Conceptualization, Data curation, Formal analysis, Methodology, Software, Validation, Visualization, Writing – original draft, Writing – review and editing. Cynthia A. LeardMann: Conceptualization, Methodology, Validation, Visualization, Writing – original draft, Writing – review and editing, Keren Lehavot: Conceptualization, Methodology, Validation, Writing – original draft, Writing – review and editing. Isabel G. Jacobson: Conceptualization, Methodology, Validation, Visualization, Writing – original draft, Writing – review and editing. Claire A. Kolaja: Conceptualization, Methodology, Validation, Writing – original draft, Writing – review and editing. Valerie A. Stander: Conceptualization, Methodology, Validation, Writing – review and editing. Rudolph P. Rull: Conceptualization, Methodology, Supervision, Validation, Writing – review and editing.
Appendix. SUPPLEMENTAL MATERIAL
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