LGBT Health: Sexual Orientation and Gender Identity Questions Are a Must

From 1995 to 2012, 27 states asked a sexual orientation question at least once in their Behavioral Risk Factor Surveillance System (BRFSS) survey. This is according to an analysis just published by The Fenway Institute in Boston, written by Fenway researchers Leigh Evans, Kelsey Lawler and Sammy Sass. Among these 27 states were North Carolina, Georgia and Florida, as well as Texas and several Great Plains and Rocky Mountain states. However, in any given year, only a small number of states ask the sexual orientation questions. For example, in 2009, only 13 states and the District of Columbia included a sexual orientation question on their BRFSS.

The BRFSS survey asks questions about health risk behaviors, such as smoking and substance use, as well as healthy behaviors, such as regular cardiovascular exercise and eating fresh fruits and vegetables. BRFSS allows states to document racial and ethnic disparities in health risk behaviors. It also allows them to ask sexual orientation and gender identity questions. Very few states, including Massachusetts, ask about both sexual orientation and gender identity. The Fenway Institute encourages all 50 states to ask sexual orientation and gender identity questions on their BRFSS surveys every year, to better understand LGBT health disparities.

BRFSS surveys 500,000 Americans in all 50 states annually. Asking about sexual orientation -- ideally both identity and behavior -- dramatically increases knowledge about health disparities affecting lesbian, gay and bisexual people (LGB).

States that have asked about sexual orientation have documented disparities and used the data to inform public health programming to address them. For example:

  • Arizona's public health department found through its BRFSS that 31 percent of Arizona lesbians smoked, about twice the rate of the state's general female population. As a result, Tobacco Free Arizona targets lesbians and other members of the lesbian, gay, bisexual and transgender (LGBT) community with prevention and cessation interventions.
  • New Mexico, Washington state and Massachusetts also documented tobacco use disparities affecting lesbian, gay and bisexual people through, and also target the LGBT community with tobacco prevention and cessation efforts.
  • BRFSS data from several states have shown that lesbians are less likely to get mammograms than other women, and have found higher rates of suicide among LGB veterans, findings that have important public health implications.

We know from community-based surveys that transgender and gender nonconforming people experience high rates of violence victimization -- as do LGB people -- as well as high rates of mental health and substance use burden. Having population-level data on transgender people would dramatically increase our knowledge of transgender health disparities and could inform more effective public health planning.

States in all regions of the country have tested sexual orientation questions on their Behavioral Risk surveys and gathered invaluable public health data. But right now most states are not asking these questions. We strongly urge state health departments to add sexual orientation and gender identity questions to their BRFSS surveys to help identify health disparities affecting LGBT people.

The Fenway Institute BRFSS analysis, available at, recommends language for sexual identity and sexual behavior questions, and recommends that data on lesbians, gay men and bisexual women and men be analyzed separately, as lumping the data together can mask important differences among these groups. For example, BRFSS data show that gay men are less overweight and obese, on average, than heterosexual men, while lesbians are more likely to be overweight or obese. The Massachusetts BRFSS found poorer health among bisexual respondents compared with gay, lesbian, and heterosexual respondents, as well as higher rates of mental health issues and smoking. The Youth Risk Behavior Survey in seven states and six large cities -- a survey of high school students -- also found higher rates of health risk behaviors among bisexual youth compared with gay and lesbian youth. Lesbian, gay and bisexual youth report much higher rates of health risk behaviors than heterosexual youth.

The Fenway Institute recommends inclusion of sexual orientation measures in the BRFSS core questionnaire. This would recognize the health disparities facing sexual minority populations and allow for a larger data set that can be analyzed. If all 50 states asked these questions every year, we would have a much larger data set and could look at the intersection of racial/ethnic health disparities with sexual minority disparities, and at issues affecting older adults who are lesbian, gay and bisexual.

Some state BRFSS surveys only ask sexual orientation questions of people under 65, leaving out LGB elders. The Fenway Institute brief recommends that all adult age cohorts be asked about sexual orientation, to increase our understanding of issues affecting LGB elders. These include living alone and social isolation. For example, we know from BRFSS that older gay men are more likely to live alone than heterosexual men. Living alone can lead to social isolation, which can correlate with depression and substance use. These issues can make it harder for older gay men living with HIV to adhere to their antiretroviral treatment regimens. So even issues that are not, at first glance, public health issues can have important public health implications.

The Fenway Institute also encourages states to ask about gender identity on their BRFSS surveys. A separate group of researchers, called GENIUSS, is promoting the inclusion of gender identity questions on health surveys. The Fenway Institute Research Scientist Kerith Conron, ScD, is an active member of that group.

Gathering data on sexual orientation and gender identity on state BRFSS surveys is consistent with the federal governments increased attention to LGBT health. For example, the U.S. Department of Health and Human Services just released its strategic plan for the next five years. A key goal is to increase scientific knowledge of LGBT health. One simple and inexpensive way to do that would be if all 50 states asked about sexual orientation and gender identity as standard demographic variables on their Behavioral Risk Factor Surveillance System surveys.


Sean Cahill, PhD, is Director of Health Policy Research at The Fenway Institute and teaches public policy at several universities. From 2001 to 2008 he was a member of the Sexual Minority Assessment Research Team, a group that promoted sexual orientation data collection on national and state health and demographic surveys.