Sexual orientation-related disparities in employment, health insurance, healthcare access and health-related quality of life: a cohort study of US male and female adolescents and young adults

BMJ Open. 2018 Jul 26;8(6):e020418. doi: 10.1136/bmjopen-2017-020418.


Objective: To investigate sexual orientation-related disparities in employment and healthcare, including potential contributions to health-related quality of life (HRQL).

Setting: Growing Up Today Study, a USA-based longitudinal cohort that began in 1996; predominantly composed of participants who are white and of middle-to-high socioeconomic positions.

Participants: 9914 participants 18-32 years old at the most recent follow-up questionnaire.

Primary outcome measure: In 2013, participants reported if, in the last year, they had been unemployed, uninsured or lacked healthcare access (routine physical exam). Participants completed the EQ-5D-5L, a validated, preference-weighted measurement of HRQL. After adjusting for potential confounders, we used sex-stratified, log-binomial models to calculate the association of sexual orientation with employment, health insurance and healthcare access, while examining if these variables attenuated the sexual orientation-related HRQL disparities.

Results: Sexual minority women and men were about twice as likely as their respective heterosexual counterparts to have been unemployed and uninsured. For example, the risk ratio (95% CI) of uninsured bisexual women was 3.76 (2.42 to 5.85) and of unemployed mostly heterosexual men was 1.82 (1.30 to 2.54). Routine physical examination was not different across sexual orientation groups (p>0.05). All sexual minority subgroups had worse HRQL than heterosexuals (p<0.05) across the five EQ-5D-5L dimensions (mobility, self-care, usual activities, pain/discomfort and anxiety/depression). Controlling for employment and health insurance did not substantially attenuate the existing sexual orientation-related HRQL disparities.

Conclusions: Research on sexual orientation-related disparities in employment and healthcare has often been limited to comparisons between cohabitating different-sex and same-sex adult couples, overlooking sexual minority subgroups (eg, bisexuals vs lesbians), non-cohabitating populations and young people. Less is known about sexual orientation-related disparities in HRQL including potential contributions from employment and healthcare. The current study documents that disparities in employment, health insurance and various HRQL dimensions are pervasive across sexual minority subgroups, non-cohabitating couples and youth in families of middle-to-high socioeconomic positions.

Keywords: epidemiology; health economics; public health; sexual medicine.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Employment / statistics & numerical data*
  • Female
  • Health Services Accessibility / statistics & numerical data*
  • Health Status Disparities*
  • Health Surveys
  • Humans
  • Insurance, Health / statistics & numerical data*
  • Linear Models
  • Longitudinal Studies
  • Male
  • Multivariate Analysis
  • Quality of Life*
  • Sexual Behavior / psychology
  • Sexual Behavior / statistics & numerical data*
  • United States
  • Young Adult