Sexual Orientation Disparities in Risk Factors for Adverse COVID-19–Related Outcomes, by Race/Ethnicity

Behavioral Risk Factor Surveillance System, United States, 2017-2019

Kevin C. Heslin, PhD; Jeffrey E. Hall, PhD

Morbidity and Mortality Weekly Report. 2021;70(5):149-154.

Abstract and Introduction

Introduction

Sexual minority persons experience health disparities associated with sexual stigma and discrimination and have a high prevalence of several health conditions that have been associated with severe coronavirus disease 2019 (COVID-19).^[1,2] Current COVID-19 surveillance systems do not capture information about sexual orientation. To begin bridging the gap in knowledge about COVID-19 risk among sexual minority adults, CDC examined disparities between sexual minority and heterosexual adults in the prevalence of underlying conditions with strong or mixed evidence of associations with severe COVID-19–related illness,^[3] by using data from the 2017–2019 Behavioral Risk Factor Surveillance System (BRFSS).* When age, sex, and survey year are adjusted, sexual minority persons have higher prevalences than do heterosexual persons of self-reported cancer, kidney disease, chronic obstructive pulmonary disease (COPD), heart disease (including myocardial infarction, angina, or coronary heart disease), obesity, smoking, diabetes, asthma, hypertension, and stroke. Sexual minority adults who are members of racial/ethnic minority groups disproportionately affected by the pandemic also have higher prevalences of several of these health conditions than do racial/ethnic minority adults who are heterosexual. Collecting data on sexual orientation in COVID-19 surveillance and other studies would improve knowledge about disparities in infection and adverse outcomes by sexual orientation, thereby informing more equitable responses to the pandemic.

Conducted by the 50 states, the District of Columbia, three U.S. territories, and two freely associated states, BRFSS is a collection of population health surveys that gather demographic and health-related information from noninstitutionalized U.S. residents aged ≥18 years. BRFSS includes standard core questions and optional modules. All participants are asked "Has a doctor, nurse, or other health practitioner ever told you that you have…" followed by a list of health conditions.^† The number of jurisdictions opting to include questions on sexual orientation in BRFSS has increased in recent years. Gender identity is addressed in a BRFSS survey question separately from sexual orientation questions. This analysis combined the 3 most recent years of BRFSS data for states that include a sexual orientation question: a total of 28 states in 2017, a total of 29 states in 2018, and a total of 31 states in 2019.^§ The percentage of BRFSS respondents who refused to answer the sexual orientation question was 1.8% (both male and female) in 2017, 1.5% (male) and 1.9% (female) in 2018, and 1.6% (male) and 2.0% (female) in 2019. Among states with a sexual orientation question, the median overall survey response rate was 42.3% in 2017, 48.5% in 2018, and 46.4% in 2019.

For this analysis, respondents were classified as sexual minority persons (versus heterosexual persons) if they selected any of the following responses from the 2017–2019 questions on sexual orientation: "gay," "lesbian or gay," or "bisexual^¶" (sexual minority: 24,582 [unweighted], 4.7% [weighted]; heterosexual: 619,374 [unweighted], 95.3% [weighted]). Race and ethnicity were categorized as Hispanic (any race), non-Hispanic Black, non-Hispanic White, and non-Hispanic other; the non-Hispanic other category includes non-Hispanic Asian, non-Hispanic American Indian/Alaskan Native, and non-Hispanic persons of other races/ethnicities. Adults with the following conditions are at increased risk for severe illness from COVID-19: cancer, chronic kidney disease, COPD, heart conditions, obesity, pregnancy, sickle cell disease, smoking, and type 2 diabetes mellitus.^[3] In addition, adults with the following conditions might be at increased risk for severe illness from COVID-19: asthma, cerebrovascular disease, cystic fibrosis, hypertension, immunocompromised state, neurologic conditions (e.g., dementia), liver disease, overweight, pulmonary fibrosis, thalassemia, and type 1 diabetes mellitus. Among these conditions with strong or mixed evidence of associations with adverse COVID-19–related outcomes,^[3,4] the following variables from the BRFSS core module were included: asthma (current and ever), cancer (except nonmelanoma skin cancer), COPD, heart disease (myocardial infarction, angina, or coronary heart disease),^[4] diabetes, hypertension, kidney disease, obesity (current), smoking (current), and stroke. Hypertension questions were asked only in 2017 and 2019.**

Adjusted percentages and adjusted prevalence ratios (aPRs) comparing sexual minority persons and heterosexual persons with each condition were calculated overall and stratified by race/ethnicity. Using Stata (version 16.0; StataCorp) software to account for the BRFSS survey design, all estimates were adjusted for age, sex (male or female), and survey year, using multivariate logistic regression with the margins and nonlinear combination of estimators (nlcom) postestimation commands. The nlcom procedure takes nonlinear transformations of a parameter estimate from a fitted model and applies the delta method to calculate the variance. All aPRs with 95% confidence intervals that exclude 1 are considered statistically significant.

Among all racial/ethnic groups combined, sexual minority persons had higher adjusted prevalences of asthma (current and ever), cancer, heart disease, COPD, hypertension, kidney disease, obesity (current), smoking (current), and stroke than did heterosexual persons (Table). Among non-Hispanic Black persons, sexual minority persons had higher adjusted prevalences of asthma (current and ever), COPD, and smoking (current) than did heterosexual persons. Among non-Hispanic White persons, sexual minority persons had higher adjusted prevalences of asthma (current and ever), cancer, COPD, diabetes, hypertension, kidney disease, obesity (current), smoking (current), and stroke than did heterosexual persons. Among Hispanic persons, sexual minority persons had higher adjusted prevalences of asthma (current and ever), cancer, COPD, smoking (current), and stroke than did heterosexual persons. Among non-Hispanic other persons, sexual minority persons had higher adjusted prevalences of asthma (current and ever), cancer, heart disease, COPD, obesity (current), and smoking (current) than did heterosexual persons. Among the 11 conditions studied, the highest significant aPRs were observed among sexual minority persons overall, and for eight of these 11 conditions, the highest significant aPRs were among sexual minority persons within a racial/ethnic minority group. None of the 11 conditions studied was more prevalent among heterosexual persons than among members of sexual minority groups.

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Abstract and Introduction
Discussion
References
Sidebar

*BRFSS collects information on demographics and health, including underlying conditions, use of preventive services, health care access, and health-related behavioral risk factors for the 50 states, District of Columbia, three U.S. territories (American Samoa, Guam, and U.S. Virgin Islands), and two freely associated states (Federated States of Micronesia and Palau). https://www.cdc.gov/brfss/index.html
^†Health conditions were elicited by the question "Has a doctor, nurse, or other health practitioner ever told you that you have…" followed by a set of conditions, including those used in this analysis: a heart attack, also called a myocardial infarction; angina or coronary heart disease; stroke; asthma (with positive responses followed by "Do you still have asthma?"); any other type of cancer (other than skin cancer); chronic obstructive pulmonary disease, emphysema, or chronic bronchitis; kidney disease (not including kidney stones, bladder infection, or incontinence); or diabetes (followed by questions allowing separation of gestational diabetes, prediabetes, and borderline diabetes). Hypertension was assessed separately but with the same question format. Possible responses to these questions were "yes," "no," "don't know/not sure," or refused. Because coronary heart disease is the most common cause of heart attack/myocardial infarction, respondents answering affirmatively to questions about a heart attack/myocardial infarction, angina, or coronary heart disease were counted as having heart disease.
^§Jurisdictions with a sexual orientation question in 2017 were California, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Louisiana, Massachusetts, Minnesota, Mississippi, Montana, Nevada, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Texas, Vermont, Virginia, Washington, Wisconsin, and Guam. Jurisdictions with a sexual orientation question in 2018 were Connecticut, Delaware, Florida, Hawaii, Idaho, Illinois, Kansas, Louisiana, Maryland, Minnesota, Mississippi, Missouri, Montana, Nevada, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Vermont, Virginia, Washington, West Virginia, Wisconsin, and Guam. Jurisdictions with a sexual orientation question in 2019 were Alaska, Arizona, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Indiana, Kansas, Louisiana, Maryland, Minnesota, Mississippi, Montana, New York, North Carolina, Ohio, Oklahoma, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, and Guam.
^¶In 2017, the BRFSS question on sexual orientation was "Do you consider yourself to be: straight, lesbian or gay, or bisexual?" The interviewer recorded responses of "other," "don't know/not sure," and refusals. In 2018 and 2019, the BRFSS question on sexual orientation was "Which of the following best represents how you think of yourself?" Response options for men were "gay"; "straight, that is, not gay"; "bisexual"; and "something else." Response options for women were "lesbian or gay"; "straight, that is, not gay"; "bisexual"; and "something else." The interviewer recorded "don't know" responses and refusals. The analysis excludes 3.4% of respondents who responded "something else," "other," or "don't know" to the sexual orientation question or who refused to respond.
**The differences between the CDC list of conditions that place adults at increased risk for severe illness from COVID-19 and the BRFSS variables are the following, respectively: current cancer versus lifetime history of (ever) cancer; current chronic kidney disease versus ever kidney disease; current chronic obstructive pulmonary disease versus ever chronic obstructive pulmonary disease; current heart condition versus ever coronary heart disease, angina, or heart attack/myocardial infarction; obesity and severe obesity versus obesity; and current type 2 diabetes mellitus versus ever diabetes. BRFSS does not include a variable on sickle cell disease, which is one of the conditions on the CDC "at increased risk" list. The differences between the CDC list and BRFSS variables are the following, respectively: moderate to severe asthma versus asthma; current cerebrovascular disease versus ever stroke; current hypertension versus ever hypertension; and current type 1 diabetes mellitus versus ever diabetes.

Table. Adjusted prevalence and adjusted prevalence ratios (aPRs)* of underlying health conditions ^† among sexual minority ^§ and heterosexual adults, by race and Hispanic origin — Behavioral Risk Factor Surveillance System, United States, 2017–2019
Characteristic	% (95% CI)
Characteristic	All	Black, non-Hispanic	White, non-Hispanic	Other, non-Hispanic	Hispanic
Respondents, no.	643,956	54,486	495,278	51,781	42,411
Sexual minority persons,^¶ no. (%)	24,582 (4.7)	2,004 (4.7)	17,656 (4.4)	2,616 (5.5)	2,306 (5.3)
Underlying condition
Asthma, current
Sexual minority	13.8 (13.0–14.6)	14.5 (12.2–16.8)	13.3 (12.4–14.3)	13.5 (11.1–16.0)	14.2 (11.5–16.9)
Heterosexual	8.9 (8.8–9.1)	10.7 (10.2–11.2)	9.2 (9.0–9.3)	8.1 (7.5–8.7)	6.8 (6.3–7.3)
aPR	1.55 (1.45–1.64)	1.35 (1.13–1.58)	1.46 (1.35–1.56)	1.67 (1.35–2.00)	2.09 (1.67–2.51)
Asthma, ever
Sexual minority	19.8 (18.8–20.8)	21.0 (18.2–23.8)	19.1 (18.0–20.1)	19.7 (16.7–22.8)	20.9 (17.7–24.0)
Heterosexual	14.1 (13.9–14.2)	15.9 (15.3–16.5)	14.3 (14.1–14.6)	13.3 (12.5–14.0)	11.8 (11.2–12.4)
aPR	1.41 (1.34–1.48)	1.32 (1.14–1.50)	1.33 (1.25–1.41)	1.49 (1.24–1.73)	1.78 (1.49–2.06)
Cancer**
Sexual minority	9.2 (8.4–10.0)	7.9 (5.6–10.2)	9.2 (8.4–9.9)	9.1 (6.5–11.6)	9.7 (6.2–13.3)
Heterosexual	7.3 (7.2–7.4)	6.1 (5.8–6.5)	7.8 (7.6–7.9)	5.8 (5.3–6.4)	5.9 (5.4–6.5)
aPR	1.26 (1.15–1.37)	1.29 (0.90–1.67)	1.18 (1.08–1.28)	1.56 (1.10–2.02)	1.64 (1.02–2.26)
Heart disease^††
Sexual minority	8.0 (7.3–8.9)	8.8 (6.2–11.4)	7.3 (6.6–8.0)	10.9 (7.8–14.1)	9.8 (6.6–13.0)
Heterosexual	6.8 (6.6–6.9)	7.0 (6.6–7.4)	6.7 (6.6–6.8)	7.0 (6.5–7.5)	6.7 (6.1–7.3)
aPR	1.19 (1.08–1.30)	1.26 (0.88–1.64)	1.09 (0.98–1.19)	1.56 (1.10–2.03)	1.46 (0.97–1.95)
COPD
Sexual minority	10.3 (9.5–11.1)	10.2 (7.8–12.7)	10.1 (9.4–11.1)	9.2 (7.1–11.3)	10.3 (7.3–13.3)
Heterosexual	6.9 (6.8–7.0)	7.1 (6.7–7.6)	7.3 (7.2–7.5)	5.9 (5.4–6.3)	4.8 (4.3–5.3)
aPR	1.49 (1.37–1.61)	1.44 (1.09–1.78)	1.40 (1.28–1.52)	1.45 (1.14–1.76)	2.15 (1.49–2.81)
Diabetes
Sexual minority	12.5 (11.6–13.4)	18.5 (15.3–21.7)	11.0 (10.1–11.9)	17.4 (13.1–21.6)	14.6 (11.4–17.7)
Heterosexual	11.6 (11.4–11.7)	17.1 (16.6–17.7)	9.8 (9.6–9.9)	13.7 (12.9–14.4)	16.1 (15.3–16.8)
aPR	1.08 (1.00–1.16)	1.08 (0.89–1.27)	1.12 (1.03–1.22)	1.27 (0.95–1.59)	0.91 (0.71–1.11)
Hypertension^§§
Sexual minority	35.7 (34.2–37.1)	45.4 (41.5–49.4)	34.9 (33.2–36.5)	35.9 (30.1–41.1)	32.3 (27.4–37.2)
Heterosexual	33.6 (33.3–33.9)	45.2 (44.3–46.1)	32.1 (31.8–32.4)	31.0 (29.7–32.2)	32.1 (31.1–33.1)
aPR	1.06 (1.02–1.11)	1.01 (0.92–1.09)	1.09 (1.05–1.14)	1.16 (0.98–1.33)	1.01 (0.85–1.16)
Kidney disease
Sexual minority	4.7 (4.0–5.4)	7.2 (4.2–10.2)	4.2 (3.6–4.8)	4.5 (3.0–5.9)	5.8 (2.7–8.8)
Heterosexual	3.2 (3.1–3.3)	4.2 (3.8–4.5)	2.9 (2.8–3.0)	3.6 (3.0–4.1)	3.7 (3.3–4.1)
aPR	1.47 (1.25–1.69)	1.73 (0.99–2.46)	1.42 (1.22–1.63)	1.25 (0.80–1.70)	1.55 (0.71–2.39)
Obesity (BMI≥30 kg/m²)
Sexual minority	34.1 (32.9–35.3)	41.4 (37.6–45.1)	33.6 (32.3–35.0)	26.2 (22.8–29.7)	35.4 (31.5–39.3)
Heterosexual	31.9 (31.6–32.1)	41.0 (40.2–41.8)	30.5 (30.2–30.7)	22.1 (21.1–23.0)	35.4 (34.4–36.5)
aPR	1.07 (1.03–1.11)	1.01 (0.92–1.10)	1.10 (1.06–1.15)	1.19 (1.03–1.35)	1.00 (0.89–1.11)
Smoking, current
Sexual minority	22.1 (21.1–23.1)	22.4 (19.4–25.4)	22.9 (21.7–24.0)	19.1 (16.2–22.0)	19.1 (16.0–22.2)
Heterosexual	15.5 (15.3–15.7)	16.9 (16.3–17.5)	16.5 (16.3–16.7)	12.8 (12.2–13.5)	11.5 (10.8–12.1)
aPR	1.43 (1.36–1.50)	1.32 (1.14–1.51)	1.39 (1.31–1.46)	1.49 (1.25–1.73)	1.67 (1.38–1.95)
Stroke
Sexual minority	4.7 (4.1–5.4)	7.5 (5.1–9.9)	4.0 (3.4–4.5)	5.7 (3.2–8.2)	6.2 (3.5–8.9)
Heterosexual	3.4 (3.4–3.5)	5.5 (5.2–5.9)	3.2 (3.1–3.3)	3.6 (3.2–4.0)	3.0 (2.6–3.4)
aPR	1.37 (1.19–1.56)	1.36 (0.91–1.81)	1.24 (1.05–1.43)	1.59 (0.88–2.30)	2.08 (1.13–3.00)

Abbreviations: BMI = body mass index; CI = confidence interval; COPD = chronic obstructive pulmonary disease.
*Adjusted for age, sex (female or male), and Behavioral Risk Factor Surveillance System survey year. Adjusted prevalence ratios with 95% CIs that exclude 1 are statistically significant.
^†Includes conditions with strong or mixed evidence of associations with COVID-19–associated adverse outcomes.
^§Includes persons who identified as gay, lesbian or gay, or bisexual. The analysis excludes those who responded to the sexual orientation question with "something else," "other," or "don't know" or who refused (3.4% of respondents).
^¶Unweighted number of respondents.
**Lifetime history of cancer, except nonmelanoma skin cancer.
^††Includes heart attack/myocardial infarction, coronary heart disease, or angina.
^§§2017 and 2019 Behavioral Risk Factor Surveillance Systems only.

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Sexual Orientation Disparities in Risk Factors for Adverse COVID-19–Related Outcomes, by Race/Ethnicity

Behavioral Risk Factor Surveillance System, United States, 2017-2019

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Introduction

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