Research Brief

The Health Related Behaviors Survey (HRBS) is the U.S. Department of Defense's (DoD's) flagship survey for understanding the health, health-related behaviors, and well-being of service members. Fielded periodically for more than 30 years, the HRBS includes content areas that might affect military readiness or the ability to meet the demands of military life. The Defense Health Agency asked the RAND Corporation to revise and field the 2018 HRBS among members of both the active component and the reserve component. This brief discusses findings for the active component.

In this brief, results for sexual orientation and health are reviewed. Some results are compared with Healthy People 2020 (HP2020) objectives established by the U.S. Department of Health and Human Services for the general U.S. population. Because the military differs notably from the general population (for example, service members are more likely to be young and male than is the general population), these comparisons are offered only as a benchmark of interest.

Sexual Orientation

The health issues and needs of lesbian, gay, or bisexual (LGB) individuals differ somewhat from those of their peers. In the general U.S. population, LGB adults are more likely than their heterosexual peers to smoke cigarettes, binge drink and drink heavily, use marijuana and other illicit drugs, misuse opioids, and suffer from a variety of chronic health conditions.[1] Sexual minorities are also more likely to have mental health issues[2] and more likely to access mental health services,[3] though they are less likely to access routine health care.[4] Such disparities among LGB individuals may affect military readiness.

The HRBS asked respondents about their sexual activity with same-sex partners in the past 12 months, as well as their sexual identity. Overall, 3.4 percent (confidence interval [CI]: 2.8–4.0) of men and 9.9 percent of women (CI: 8.7–11.0) reported having one or more same-sex partners in the past 12 months. Furthermore, 1.6 percent (CI: 1.2–1.9) of men and 6.0 percent (CI: 5.2–6.8) of women in the HRBS identified as gay or lesbian, and 2.5 percent (CI: 2.1–2.9) of men and 11.6 percent (CI: 10.2–13.0) of women in the HRBS identified as bisexual.

Across all the services, 6.3 percent (CI: 5.8–6.9) of individuals described themselves as LGB. There were few significant differences between the services in this percentage, but the difference between men and women was substantial: 4.1 percent (CI: 3.5–4.5) of men and 17.6 percent (CI: 16.0–19.2) of women were LGB.

LGB Health Promotion and Disease Prevention

Among LGB service members, 67.5 percent (CI: 63.2–71.9) reported having a routine checkup in the past 12 months. This did not differ significantly from the 70.4 percent (CI: 69.2–71.7) of non-LGB service members who reported having a routine checkup in the past 12 months. LGB service members were also similar to non-LGB service members in their levels of moderate or vigorous physical activity in the past 30 days.

Significantly fewer LGB service members were classified as overweight or obese (53.9 percent, CI: 49.6–58.3) compared with non-LGB service members (64.1 percent, CI: 62.8–65.3). Significantly fewer LGB service members (55.9 percent, CI: 51.6–60.3) reported good or fairly good sleep quality in the past 30 days than did non-LGB service members (64.8 percent, CI: 63.5–66.0).

Substance Use

Significantly more LGB personnel reported binge drinking (that is, consumption of at least five drinks for men or at least four drinks for women on the same occasion at least once in the past 30 days) and heavy drinking (that is, binge drinking at least once each week during the past 30 days) than non-LGB personnel. Table 1 presents details for these and other substance use questions in the HRBS.

Table 1. Substance Use, by LGB Identity

LGB Non-LGB
Binge drinking, past 30 days 39.1% (CI: 34.9–43.3) 32.7% (CI: 32.4–34.9)
Heavy drinking, past 30 days 13.9% (CI: 10.9–16.9) 9.5% (CI: 8.7–10.4)
E-cigarette use, past 30 days 24.5% (CI: 20.6–28.3) 15.7% (CI: 14.6–16.8)
Smokeless tobacco use, past 30 days 5.8% (CI: 3.8–7.7) 13.9% (CI: 12.8–14.9)
Any drug use, past 12 months 3.1% (CI: 1.5–4.7) 1.2% (CI: 0.8–1.6)

Significantly more LGB personnel reported e-cigarette use in the past 30 days and any drug use in the past 12 months, but significantly fewer reported smokeless tobacco use. The difference between LGB and non-LGB personnel in cigarette smoking and in use of prescription pain relievers in the past 12 months was not significant.

LGB Mental Health and Mental Health Services Use

The HRBS asked respondents about a variety of mental health indicators, as well as indicators of mental health service use. All of the mental and emotional health problems examined were more common among LGB service members than among non-LGB personnel, although for most indicators only a small proportion of LGB personnel indicated a problem.

Use of all forms of mental health services tested was also more common among LGB personnel. Nonetheless, significantly more LGB personnel report perceived unmet need for mental health services in the past 12 months, as well as a belief that mental health treatment would damage one's military career. Table 2 presents more details on mental and emotional health indicators by LGB status.

Table 2. Mental and Emotional Health and Mental Health Services Use, by LGB Identity

LGB Non-LGB
Serious psychological distress, past 12 months 30.5% (CI: 26.3–34.7) 15.5% (CI: 14.5–16.5)
Probable posttraumatic stress disorder 14.4% (CI: 11.5–17.3) 10.1% (CI: 9.3–10.8)
Suicidal thoughts, past 12 months 15.8% (CI: 12.5–19.1) 7.7% (CI: 7.0–8.5)
Suicide attempt, past 12 months 3.2% (CI: 1.6–4.8) 1.1% (CI: 0.8–1.5)
Any angry or aggressive behavior, past 30 days 54.4% (CI: 50.1–58.7) 48.8% (CI: 47.5–50.0)
Any mental health service use, past 12 months 35.7% (CI: 31.7–39.7) 24.8% (CI: 23.7–25.9)
Saw mental health care specialist, past 12 months 30.5% (CI: 26.6–34.4) 17.3% (CI: 16.4–18.3)
Saw general medical provider for a mental health problem, past 12 months 19.6% (CI: 16.2–22.9) 13.0% (CI: 12.1–13.9)
Used medication for a mental health problem, past 12 months 13.0% (CI: 10.7–15.4) 8.1% (CI: 7.5–8.8)
Perceived unmet need for mental health services, past 12 months 13.8% (CI: 10.8–16.9) 6.3% (CI: 5.7–7.0)
Believe mental health treatment would damage military career 45.6% (CI: 41.3–50.0) 33.5% (CI: 32.3–34.7)

LGB Physical Health

The HRBS asked whether respondents had been told by a physician or health professional during the past 12 months that they had high blood pressure, diabetes, high cholesterol, asthma, back pain, or musculoskeletal injury. For all of these, there were no significant differences between LGB personnel and non-LGB personnel. (For more information on physical health characteristics of the overall force, see the brief on physical health and functional limitations for the active component.)

LGB Unwanted Sexual Contact and Physical Abuse

In the general U.S. population, a larger percentage of LGB individuals than non-LGB individuals reported past sexual and physical abuse.[5] This is also the case in the U.S. military.[6] In the 2018 HRBS, significantly more LGB members than non-LGB members indicated experiencing unwanted sexual contact since joining the military and in the past 12 months. Similarly, significantly more indicated being physically assaulted since joining the military and in the past 12 months (Figure 1).

Figure 1. Unwanted Sexual Contact and Physical Abuse, by LGB Identity

LGB Non-LGB
Unwanted sexual contact since joining the military 29.5% 8.2%
Unwanted sexual contact in past 12 months 10.9% 1.9%
Physically assaulted since joining the military 8.2% 5.1%
Physically assaulted in the past 12 months 2.8% 1.0%

NOTES: For unwanted sexual contact, the exact question wording in the 2018 HRBS is "The next question is about unwanted sexual contact, meaning times when someone has touched you in a sexual way, had sex with you, or attempted to have sex with you when you did not consent or could not consent. By sexual contact we mean any sexual touching as well as oral, anal or vaginal penetration. Since joining the military, have you ever experienced unwanted sexual contact?" and "Did this unwanted sexual contact occur in the past 12 months?" The HRBS items are not directly comparable with existing civilian or military surveys, including the Workplace and Gender Relations Survey of Active Duty Members.

LGB Sexual and Reproductive Health

Sexual and reproductive health are influenced by key behaviors, such as numbers of sexual partners and use of other contraception. RAND researchers looked at how differences on sexual and reproductive health indicators varied by LGB status, as well as such outcomes as diagnoses for sexually transmitted infection (STI), regular testing for human immunodeficiency virus (HIV) infection, and unintended pregnancies, which can affect individual health and readiness. Table 3 presents these findings. Significantly more LGB service members had multiple sex partners in the past 12 months, as well as had sex with a new partner without condom use. Similarly, significantly more LGB members had an STI in the past 12 months and had HIV testing in the past six months. There were no significant differences for having an HIV test in the past 12 months, no birth control at last vaginal sex in the past 12 months, and unintended pregnancy in the past 12 months.

Table 3. Sexual and Reproductive Health, by LGB Identity

LGB Non-LGB
New partner without condom use, past 12 months 43.5% (CI: 39.2–47.8) 34.3% (CI: 33.1–35.5)
Two or more sex partners, past 12 months 41.8% (CI: 37.4–46.2) 17.8% (CI: 16.8–18.9)
STI, past 12 months 10.2% (CI: 6.9–13.5) 2.9% (CI: 2.5–3.4)
HIV test, past 6 months 43.1% (CI: 38.8–47.4) 37.9% (CI: 36.7–39.2)

Conclusions and Policy Implications[7]

LGB personnel make up about 6 percent of service members. Though LGB personnel are similar to non-LGB personnel in several health characteristics, they differ on others. Substance use and some risky sexual behaviors are more common among LGB service members than among their non-LGB peers, as were unwanted sexual contact and being physically assaulted.

The greater incidence of some of these problems among the LGB population suggests that DoD and the Coast Guard should include LGB-specific considerations when developing more broadly targeted health promotion efforts, keeping in mind that LGB individuals are part of the military. Addressing LGB health disparities is unlikely to require the development of programs or policies targeted specifically to this group, with only a few exceptions. Indeed, overemphasis on the higher rates of mental and sexual health issues among LGB personnel could increase the stigma associated with LGB status, exacerbating these disparities and marginalizing those affected.

DoD and the Coast Guard should also address the unique mental health needs of LGB personnel. Current and future campaigns to reduce stigma surrounding mental health and service use should include messaging and images relevant to LGB personnel (e.g., feeling isolated, lack of acceptance) and should be tested for acceptability and perceived effectiveness among LGB service members. Mental health service providers should also be sensitive to the unique needs of LGB service members.

Finally, education of health care providers in the Military Health System (MHS) could help reduce sexual health disparities between LGB and non-LGB personnel, including high rates of STI and HIV-risk behavior. It is unclear whether MHS personnel are aware that nearly two-thirds of LGB service members are bisexual. Incorrect assumptions that bisexual service members are heterosexual, gay, or lesbian based on the sex of their current sexual partners could lead to incomplete or incorrect counseling regarding use of condoms and other contraceptives and for STI testing. Providers of women's health services should be aware that one in six of their servicewomen patients identify as LGB. Adaptation of patient screening and counseling protocols and clinic forms may also be appropriate to recognize the presence of LGB personnel among MHS patients.

Notes

  • [1] D. T. Duncan, S. Zweig, H. R. Hambrick, and J. J. Palamar, "Sexual Orientation Disparities in Prescription Opioid Misuse Among U.S. Adults," American Journal of Preventive Medicine, Vol. 56, No. 1, January 2019, pp. 17–26; K. I. Fredriksen-Goldsen, C. Shin, A. E. Bryan, J. Goldsen, and H. J. Kim, "Health Equity and Aging of Bisexual Older Adults: Pathways of Risk and Resilience," The Journals of Gerontology Series B, Psychological Sciences and Social Sciences, Vol. 72, No. 3, May 1, 2017, pp. 468–478; G. Gonzales and C. Henning Smith, "Health Disparities by Sexual Orientation: Results and Implications from the Behavioral Risk Factor Surveillance System," Journal of Community Health, Vol. 42, No. 6, December 2017, pp. 1163–1172; G. Gonzales, J. Prezedworski, and C. Henning Smith, "Comparison of Health and Health Risk Factors Between Lesbian, Gay, and Bisexual Adults and Heterosexual Adults in the United States: Results from the National Health Interview Survey," JAMA Internal Medicine, Vol. 176, No. 9, September 1, 2016, pp. 1344–1351; M. S. Schuler, C. E. Rice, R. J. Evans-Polce, and R. L. Collins, "Disparities in Substance Use Behaviors and Disorders Among Adult Sexual Minorities by Age, Gender, and Sexual Identity," Drug and Alcohol Dependence, Vol. 189, August 1, 2018, pp. 139–146; and M. S. Schuler, B. D. Stein, and R. L. Collins, "Differences in Substance Use Disparities Across Age Groups in a National Cross-Sectional Survey of Lesbian, Gay, and Bisexual Adults," LGBT Health, Vol. 6, No. 2, 2019, pp. 68–76.
  • [2] Grace Medley, Rachel N. Lipari, Jonaki Bose, Devon S. Cribb, Larry A. Kroutil, and Gretchen McHenry, "Sexual Orientation and Estimates of Adult Substance Use and Mental Health: Results from the 2015 National Survey on Drug Use and Health," NSDUH Data Review, October 2016 (https://www.samhsa.gov/data/sites/default/files/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015.htm); Brian W. Ward, James M. Dahlhamer, Adena M. Galinsky, and Sarah S. Joestl, "Sexual Orientation and Health Among U.S. Adults: National Health Interview Survey, 2013," National Health Statistics Reports, No. 77, July 15, 2014 (https://www.cdc.gov/nchs/data/nhsr/nhsr077.pdf).
  • [3] Susan D. Cochran, Vickie M. Mays, and J. Greer Sullivan, "Prevalence of Mental Disorders, Psychological Distress, and Mental Health Services Use Among Lesbian, Gay, and Bisexual Adults in the United States," Journal of Consulting and Clinical Psychology, Vol. 71, No. 1, February 2003, pp. 53–61.
  • [4] Institute of Medicine, The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding, Washington, D.C.: The National Academies Press, 2011 (https://www.nap.edu/catalog/13128/the-health-of-lesbian-gay-bisexual-and-transgender-people-building).
  • [5] S. L. Katz-Wise and J. S. Hyde, "Victimization Experiences of Lesbians, Gay, and Bisexual Individuals: A Meta-Analysis," Journal of Sex Research, Vol. 49, No. 2–3, 2012, pp. 142–167; M. L. Walters, J. Chen, and M. J. Breiding, The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Findings on Victimization by Sexual Orientation, Atlanta, Ga.: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2013.
  • [6] Lisa Davis, Amanda Grifka, Kristin Williams, and Margaret Coffey, eds., 2016 Workplace and Gender Relations Survey of Active Duty Members: Overview Report, Office of People Analytics: Alexandria, Va., OPA Report 2016-050, May 2017; and Rachel A. Breslin, Lisa Davis, Kimberly Hylton, Ariel Hill, William Klauberg, Mark Petsuky, and Ashlea Klahr, 2018 Workplace and Gender Relations Survey of Active Duty Members: Overview Report, Office of People Analytics: Alexandria, Va., May 2019.
  • [7] Additional implications and recommendations can be found in the full report at www.rand.org/t/RR4222.
  • [8] CIs provide a range in which the true population value is expected to fall. They account for sampling variability when calculating point estimates but do not account for problems with question wording, response bias, or other methodological issues that, if present in the HRBS, might bias point estimates.

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