Sexual Orientation Identity and Its Implication in the Disparities in Psychological Health-Related Quality of Life

Abstract

Purpose:

To examine disparities in psychological health-related quality of life (HRQoL) among sexual minority women within racial/ethnic subgroups.

Design:

A secondary analysis of the 2018 Behavioral Risk Factor Surveillance Survey (BRFSS).

Setting:

United States.

Subjects:

Noninstitutionalized, cisgender, adult women in the U.S (unweighted n = 81,947).

Measures:

Socioeconomics, health behaviors, and healthcare access as risk factors, whereas 1 item measures psychological HRQoL as an outcome.

Analysis:

Weighted multivariable logistic regressions to estimate the odds of having adversely psychological HRQoL in relation to sexual orientation and other correlates within a racial/ethnic subgroup independently.

Results:

The prevalence of adverse psychological HRQoL was greater in bisexual and “other” sexual orientation women. Both bisexual (adjusted odds ratio [aOR] = 1.58; 95% confidence interval [CI] = 1.26-2.00) and “other” sexual orientation (Aor = 1.93; 95%CI = 1.26-2.96) had greater adjusted odds of adversely psychological HRQoLcompared to their heterosexual peers in non-Hispanic White women. Bisexual women (aOR = 3.42; 95%CI = 1.98-5.88) had greater adjusted odds of adversely psychological HRQoLcompared to their heterosexual peers in Latinas. No similar pattern was observed in non-Hispanic Black women.

Conclusion:

Disparities in psychological HRQoL varied by sexual orientation identities within different racial/ethnic subgroups. The magnitude of the association for Latina bisexual women was strong. Implications for bisexual health among people with intersecting identities are discussed.

Keywords

psychological HRQOL bisexuality cisgender women sexual orientation race/ethnicity

Purpose

A growing body of evidence indicates that sexual minority women (SMW, refers to women who are not straight/heterosexual identified) disproportionately suffer mental health morbidities, and this is significantly worse for racial/ethnic minorities.¹ However, some mixed findings appeared that mental health in sexual minorities of color had similar to or lower morbidities than the lesbian, gay, and bisexual adults in general, which was influenced by some protective factors, such as religious practices, family cohesion, and community connectedness.^2,3 The research emphasized the need for identifying mental health disparities among women of color. Our study sought to examine disparities in psychological health-related quality of life (HRQoL) among sexual minority women belonging to different racial/ethnic subgroups.

Methods

Design

The secondary data were extracted from the Behavioral Risk Factor Surveillance Survey (BRFSS) 2018, a state-based system of a health survey, collecting information on physical, mental, and medical health, nutrition, health behaviors, and healthcare access in a noninstitutionalized population aged 18 or above in the United States.⁴This study was an analysis of a publicly available, de-identified dataset from Centers for Disease Control and Prevention (CDC); thus, Institutional Review Board approval was not required.

Sample

The eligibility for the present study was as follows: 1) assigned female at birth; 2) self-reported as cisgender, and 3) self-reported sexual orientation. We omitted responses of “I don’t know the answer,” “Refused,” or “Not asked or missing” across the 3 criteria in our data.

Measures

The domains selected for analysis included Socioeconomics, Health Behaviors, Healthcare Access, and Health-Related Quality of Life (HRQoL).

Socioeconomicsincluded: race/ethnicity [non-Hispanic White (NH-White), non-Hispanic Black (NH-Black), and Latina], sexual orientation, age, education attainment, annual household income, marital status, self-reported general health, and numbers of children in the household. Health Behaviorsincluded: smoking status, heavy drinker, physical activity/exercises in the past 30 days, and overweight/obese. Healthcare Accessvariables included: health insurance coverage, medical cost burden in the past 12 months, and the duration of time since most recent routine checkup. The outcome variable was psychological HRQoL. We used one question of psychological HRQoL with 2-level computed responses of whether or not an individual had 14 or more days where their mental health was poorin the past 30 days.

Analysis

Unadjusted Wald tests were used to assess differences in the prevalence of psychological HRQoL by sexual orientation overall and stratified by race/ethnicity (Table 1). We then tested for statistical interaction between sexual orientation and race/ethnicity in psychological HRQoL via 3 multivariable logistic regression models with different hypothesized combinations confounding factors (Table 2). We adjusted the overall and race-/ethnicity-stratified models for Socioeconomics in Model 1, followed by Model 2, which adjusted for Socioeconomics and Health Behaviors. Finally, we added Socioeconomics, Health behavior, and Healthcare access in Model 3. Analyzes were performed using Stata 16 (College Station, TX) and adjusted for the complex survey design.⁵ Odds ratio (OR) and 95% confidence intervals (CI) were calculated.

Table 1.

Unadjusted, Weighted Distribution of Psychological HRQoL in Relationship to Sexual Orientation Identity and Race/Ethnicity Among U.S. Cisgender Women, 2018 BRFSS.

	14⁺ days when mental health was not good (unweighted N = 81,947)
Variable	%	95%CI	P value
Total	14.88	14.37-15.41	<0.01
Heterosexual (REF)	13.94	13.43-14.47
Lesbian	21.22	16.51-26.84
Bisexual	33.36	29.73-37.19
“Other” sexual minority	27.24	21.52-33.83
NH-White	14.97	14.43-15.53	<0.01
Heterosexual (REF)	14.14	13.59-14.69
Lesbian	22.27	16.85-28.83
Bisexual	32.55	28.65-36.71
“Other” sexual minority	27.07	20.01-35.52
NH-Black	14.99	13.59-16.52	<0.01
Heterosexual (REF)	14.04	12.64-15.57
Lesbian	20.45	9.98-37.35
Bisexual	31.04	21.65-42.32
“Other” sexual minority	37.90	20.55-59.00
Latina	14.20	12.19-16.47	<0.01
Heterosexual (REF)	12.50	10.47-14.85
Lesbian	15.76	7.73-29.47
Bisexual	38.91	28.11-50.93
“Other” sexual minority	23.66	14.29-36.54

Note:

The statistical interaction between sexual orientation and race/ethnicity in relationship to Psychological HRQoL is presented.

Prevalence estimates (%) and 95% CI account for the complex survey design.

Abbreviations: CI, confidence intervals; REF, reference group.

Table 2.

Survey-Weighted Logistic Regression of Psychological HRQoL by Sexual Orientation and Race/Ethnicity Among U.S. Cisgender Women, 2018 BRFSS.

Variable	Model 1		Model 2		Model 3
Variable	aOR	95% CI	aOR	95% CI	aOR	95% CI
NH-White
Heterosexual	REF	REF	REF	REF	REF	REF
Lesbian	1.47	1.05-2.06	1.23	0.87-1.73	1.27	0.91-1.77
Bisexual	1.93	1.57-2.37	1.66	1.32-2.07	1.58	1.26-2.00
“Other” sexual minority	1.82	1.19-2.78	1.97	1.30-2.98	1.93	1.26-2.96
NH-Black
Heterosexual	REF	REF	REF	REF	REF	REF
Lesbian	1.45	0.64-3.29	1.27	0.55-2.91	1.15	0.51-2.58
Bisexual	2.19	1.32-3.61	1.77	1.05-2.96	1.66	0.98-2.80
“Other” sexual minority	3.58	1.18-10.81	2.73	0.78-9.55	2.88	0.82-10.08
Latina
Heterosexual	REF	REF	REF	REF	REF	REF
Lesbian	1.14	0.46-2.86	0.97	0.45-2.10	1.04	0.46-2.36
Bisexual	4.20	2.45-7.22	3.36	1.95-5.81	3.42	1.98-5.88
“Other” sexual minority	1.95	0.99-3.82	1.87	0.94-3.73	1.88	0.93-3.80

Note:

Model 1 adjusts for socioeconomics.

Model 2 adjusts for socioeconomics and health behaviors.

Model 3 adjusts for socioeconomics, health behaviors, and healthcare access.

Less than 14 days when mental health was not good the reference category.

Bolded values refer to aORs with 95% CI that were significant at 0.05.

Results

Overall, about 73.37% were NH-White, followed by 15.13% were NH-Black, and 11.50% were Latina women. An estimated 93.81% were heterosexual, followed by 1.52% lesbian, 3.47% bisexual, and 1.21% “other” sexual orientation women. Table 1 showed unadjusted bivariate analyzes of psychological HRQoL by sexual orientation and stratified by race/ethnicity among U.S. cisgender women (unweighted N = 81,947). About 14.9% (95% CI = 14.4-15.4) of participants overall had adversely psychological HRQoL. All sexual minority women (SMW; lesbian, bisexual, and “other” sexual minority) appeared to have a higher prevalence of adversely psychological HRQoL than their heterosexual peers (p < 0.01). The highest prevalence of adversely psychological HRQoLoccurred among bisexual women (33.4%; 95%CI = 29.7-37.2), followed by “other” sexual minority women (27.2%; 95%CI = 21.5-33.8), and lesbians (21.2%; 95%CI = 16.5-26.8), compared to that in heterosexual women (13.9%; 95%CI = 13.4-14.5). For NH-Black and Latina women, both bisexuals and “other” sexual minorities had significantly poorer psychological HRQoL than their heterosexual peers. For NH-White, all SMW (lesbian, bisexual, and “other” sexual minorities) were significantly worse in psychological HRQoL than their heterosexual peers.

Table 2 showed 3 multivariable logistic models of psychological HRQoL by sexual orientation and race/ethnicity. Among NH-White women, both bisexual and “other” sexual minority women had significantly greater odds of adversely psychological HRQoL than their heterosexual counterparts across all 3 models. NH-White lesbian women had adjusted greater odds of adversely psychological HRQoL than their NH-White, heterosexual peers in Model 1 (adjusted odds ratio [aOR] = 1.47; 95%CI = 1.05-2.06).

Among NH-Black women, sexual orientation identity disparities in adversely psychological HRQoL were attenuated after adjusting for socioeconomic, health behaviors, and health care access factors. In Model 1, bisexual (aOR = 2.19; 95%CI = 1.32-3.61) and “other” sexual minority (aOR = 3.58; 95%CI = 1.18-10.81) women who were NH-Black had significantly greater odds of adversely psychological HRQoL than their NH-Black, heterosexual counterparts. In Model 2, adjusted odds seemed lower for NH-Black bisexual (aOR = 1.77; 95%CI = 1.05-2.96)than their heterosexual peers, but not for “other” sexual minority women. No significant sexual identity disparities were found in Model 3 for NH-Black women (Table 2).

Among Latina women, bisexuals had significantly greater odds of adversely psychological HRQoL compared to their heterosexual counterparts across all 3 adjustment models [Model 1: aOR = 4.20, 95%CI = 2.45-7.22; Model 2: aOR = 3.36, 95%CI = 1.95-5.81; Model 3: aOR = 3.42, 95%CI = 1.98-5.88], but not in lesbian and “other” sexual minority women (Table 2).

Discussion

Summary

We found significant disparities of psychological HRQoL by sexual orientation within racial/ethnic subgroups independently. Among the U.S. cisgender women overall, bisexual and “other” sexual minority women had significantly greater odds of adverse psychological HRQoL compared to heterosexual women, along with significant socioeconomic disadvantages, risky health behaviors like heavy drinking and smoking, and healthcare access barriers.⁶ They are also notably underrepresented in LGBT health studies and community (health) organizations.⁷ For NH-White women, healthy behavior disparities played a major role in the psychological well-being of lesbians. NH-Black women appeared to share similar characteristics in health behaviors and medical access regardless of sexual orientation identities.⁸ Latina bisexual women had significantly worse psychological HRQOL than their heterosexual peers, even adjusting for any confounding factors.⁹ Our findings suggest it is imperative to develop tailored programs (e.g., career development & training, mental health counseling, etc.) and incorporate the mobilization of resources in mental health interventions for sexual minority women of color (SM WOC).

Limitations

This was a cross-sectional national survey that limited temporal or causal conclusions. Small numbers of NH-Black and Latina SMW in our study resulted in wide confidence intervals for these groups, which might have increased Type II error and thus prevented us from detecting related factors for HRQoL. Potential mediators, such as identity-related stigma and discrimination, were not available in the BRFSS. Also, the framework of HRQOL was still under development and improved for psychological results.¹⁰

Significance

Our results highlighted the differential burdens from socioeconomic and healthcare access among SM WOC. Such findings can inform future interventions designed to increase psychological HRQoL in SM WOC by improving interpersonal protective factors (e.g., job opportunity, medical care access) and creating safe and affirming spaces for them.

So What?

What is already known on this topic?

There are known disparities of psychological HRQoL in sexual orientations within different racial/ethnic subgroups.

What does this article add?

Given limited bisexual health research, findings reveal that bisexual and “other” sexual minority women had significantly greater risks of adverse psychological HRQoL, along with significant socioeconomic disadvantages, risky health behaviors like heavy drinking and smoking, and healthcare access barriers. Our results highlighted the differential burdens from socioeconomic and healthcare access among sexual minority women of color.

What are the implications for health promotion practice or research?

We need tailored programs to promote psychological HRQoL/mental health among sexual minority women of color.

Footnotes

Authors’ Note

The data is publicly available from the Centers for Disease Control and Prevention. HX analyzed and interpreted the analysis and was a major contributor in writing the manuscript. YL and CT wrote the manuscript and provided feedbacks. All authors read and approved the final manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Hui Xie, MPH

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