Sexual Orientation Information Background

In 2011, the U.S. Department of Health and Human Services (DHHS) announced plans to begin collecting health data on lesbian, gay, and bisexual (LGB) populations on the 2013 National Health Interview Survey (NHIS). In part, this announcement was spurred by an Institute of Medicine report on the health of LGB and transgender persons released the same year. This report called for an ongoing collection of sexual orientation data in federally-funded surveys and more research on inequities in health care. To remain at the forefront of addressing public health research needs, in 2013 the NHIS added a question on sexual orientation. This question complements the wealth of other health topics already on the survey, and can be used to fill the gaps that exist in the state of knowledge about the general health behaviors, health status, and health care utilization of LGB persons, and to monitor changes over time.

The NHIS sexual orientation question was designed to capture the sexual identity component of self-reported sexual orientation, as opposed to sexual attraction or sexual behavior. This question is asked of all sample adults aged 18 and older, and reads:

‘‘Which of the following best represents how you think of yourself?’’

For men, the response options are:

• Gay
• Straight, that is, not gay
• Bisexual
• Something else
• I don’t know the answer

For women, the response options read:

• Lesbian or gay
• Straight, that is, not lesbian or gay
• Bisexual
• Something else
• I don’t know the answer

The NHIS sexual orientation question was the culmination of an extensive testing effort. Over an 11-year period, the National Center for Health Statistics Coordinating Center for Questionnaire Design and Evaluation Research (CQDER) conducted 377 in-depth cognitive interviews to better understand the interpretive and response process patterns people use to answer questions on sexual identity. One-hundred thirty-nine of those interviews were conducted specifically in the development of the NHIS sexual orientation question. The CQDER encountered several challenges, including fluid and changing sexual identities, differential saliency of the topic for lesbian, gay, bisexual, and transgender (LGBT) and non-LGBT respondents, and lack of consistent interpretation of the terms “heterosexual,” “homosexual,” and “bisexual.” A series of methodological publications have been published detailing this question testing, and can be found in the Reference section of this special topics website.

Once the cognitive testing was completed, the sexual orientation question was further evaluated in three field tests. For the first two tests, the sexual orientation question was embedded in an audio computer-assisted self-interviewing (ACASI) module of roughly 30 questions that appeared at the end of the NHIS computer-assisted personal interviewing (CAPI) questionnaire. ACASI is a private, self-administered mode of administration in which the respondent wears headphones, listens to audio recordings of the questions, and enters his/her answers directly into the laptop computer. The first test was small (approximately 50 interviews) and designed to assess the integration of an ACASI module with the CAPI interview. The second test – of roughly 500 interviews – focused on the Spanish translation of the sexual orientation question. In the third and final test, a split-ballot experiment was conducted in which 60% of sample adults were randomly assigned to receive the sexual orientation question by ACASI and 40% by CAPI. Using a nationally-representative sample, over 5,300 sample adults were asked the sexual orientation question. No significant differences were identified by mode for the percentage of adults identifying as gay/lesbian or bisexual (ACASI = 2.2% vs. CAPI = 2.4%). Subsequently, the decision was made to include the sexual orientation question as part of the NHIS CAPI interview, and not to administer it in its own ACASI module.

For more detailed information and examples of the use of the NHIS sexual orientation data, please refer to Reference section of the NHIS Sexual Orientation Information website.