The Health Behavior and Behavior Survey (HRBS) is the US Department of Defense's (DoD) primary survey of the health, health behaviors and well-being of military personnel. The HRBS, which has been conducted regularly for more than 30 years, covers areas that may affect military readiness or the ability to meet the demands of military life.
The Department of Defense commissioned the RAND Corporation to review and conduct the 2018 HRBS survey for active and reserve military personnel. This report examines the results of the Reserve portion of the survey.
This report examines results for sexual orientation and health. Some results are also compared to the U.S. Department of Health and Human Services' Health Promotion 2020 (HP2020) goals for the U.S. population. Because the armed forces are significantly different from the population (for example, members of the armed forces are more likely to be young and male than the population), these comparisons are presented for comparative purposes only.
Sexual Orientation Within the Reserve
The health problems and needs of lesbian, gay and bisexual (LGB) people differ somewhat from those of their peers. In the US population in general, LGB adults are more likely than their heterosexual peers to smoke cigarettes, drink heavily and excessively, use marijuana and other illicit drugs, abuse opioids, and suffer from a range of chronic diseases.
Sexual minorities are also more likely to suffer from mental health problems and to use mental health services, although they are less likely to use mainstream healthcare. HRBS asked respondents about their sexual activity with same-sex partners in the past 12 months and their sexual identity.
Overall, 2.8% (confidence interval [CI]: 2.3-3.3) of men and 9.8% (CI: 8.6-11.0) of women reported having had one or more same-sex partners in the past 12 months. In addition, 1.7% (CI: 1.4-2.1) of men and 7.2% (CI: 6.2-8.2) of women interviewed in the HRBS considered themselves to be homosexual or lesbian, and 2% (CI: 1.6-2.5) of men and 8.2% (CI: 7.0-9.4) of women considered themselves to be bisexual.
Across all services, 6.1% (CI: 5.6-6.7) of people described themselves as lesbian, gay or bisexual. There is little significant variation in the percentage between services, but there is a significant difference between men and women: 3.8% (CI 3.2-4.4) of men and 15.4% (CI 13.9-16.9) of women are homosexual.
Health Promotion and Disease Prevention Among LGB People
Among LGB military personnel, 67.0 percent (CI 62.3-71.8) reported having a routine health check-up in the past 12 months. This differs significantly from the 71.9% (CI: 70.7-73.1) of non-LGB service members who reported having a routine check-up in the past 12 months. LGB members were similar to non-LGB members in that they engaged in moderate to high levels of physical activity in the past 30 days.
The proportion of LGB staff classified as overweight or obese (54.6%, CI 49.8-59.4) was significantly lower than non-LGB staff (66.1%, CI 64.9-67.3). A significantly lower proportion of LGB staff (68.8% CI 64.4-73.2) than non-LGB staff (75.2% CI 74.1-76.2) reported having had satisfactory or somewhat satisfactory sleep in the last 30 days.
Substance Use Among the LGB People
Significantly higher proportions of LGB than non-LGB staff reported recent heavy drinking (i.e. at least five drinks in the past 30 days for men or at least four drinks in the past 30 days for women) and binge drinking (i.e. at least once a week in the past 30 days).
In addition, a significantly higher proportion of LGB workers reported having recently or currently used cigarettes or e-cigarettes, but a significantly lower proportion reported using smokeless tobacco. The proportion of LGB workers who use illegal drugs and prescription medicines is significantly higher.
Mental Health and Use of Mental Health Services of LGB People
As part of the HRBS, respondents were asked about several indicators of mental health and mental health service use. All of the mental health and emotional health problems surveyed were more common among LGB people than others, although for most indicators only a small proportion of LGB staff reported having problems.
LGB staff were also more likely to use all the mental health services tested. However, significantly more LGB personnel reported that they did not think they had needed mental health services in the past 12 months and that they believed mental health treatment would harm their military career.
The HRBS asked respondents if they had been told by a doctor or health professional in the past 12 months that they had high blood pressure, diabetes, high cholesterol, asthma, back pain, or musculoskeletal injuries.
With the exception of asthma, there were no significant differences between LGB and non-LGB workers for any of these indicators (for more information on physical health indicators for the total component, see the Physical health and disability data sheet for the total component).
Unwanted Sexual Intercourse and Physical Abuse of LGB People
In the US population, a higher proportion of homosexuals than non-homosexuals report experiencing sexual and physical abuse, which is also true in the US military.
Among reservists, a higher proportion of homosexual service members than non-homosexual service members report experiencing unwanted sexual contact since joining the armed forces and in the past 12 months. A higher proportion also report having been physically assaulted since joining the armed forces and in the last 12 months.
LGB Sexual and Reproductive Health Care
Sexual and reproductive health is influenced by key behaviours such as the number of sexual partners and use of alternative contraceptives. RAND researchers examined how sexual and reproductive health indicators varied by LGB status, as well as outcomes such as sexually transmitted infection (STI) diagnosis, regular human immunodeficiency virus (HIV) testing, and unintended pregnancy, which can affect an individual's health and readiness.
Significantly more LGB people reported that they had had multiple sexual partners in the past 12 months and that they had had sex with a new partner without a condom. A significantly higher proportion of LGB men also reported having had an STI in the last 12 months and having been tested for HIV in the last six months.
No significant differences were found for HIV testing in the last 12 months, for lack of contraception in the last vaginal intercourse in the last 12 months, or for unintended pregnancy in the last 12 months.
Comparisons to Active Members
To compare the HRBS results, RAND researchers constructed regression models for the active and reserve populations, taking into account the demographic characteristics of the respondents. Significant differences between LGB reservists and LGB soldiers on active duty included the following.
- Lower likelihood of engaging in moderate to vigorous physical activity.
- Higher likelihood of sleeping at least seven hours a day and better sleep quality.
- More likely to have used illegal drugs in the past year.
- Less likely to have seen a mental health professional in the past 12 months.
- Less likely to have had unwanted sexual intercourse since joining the military service.
- Less likely to have had multiple sexual partners and STIs in the past 12 months.
Conclusions and Implications for Policy
LGB personnel account for around 6% of the reserve personnel. LGB reservists are more likely to report substance abuse, risky sexual behaviour, unwanted sexual contact and physical assault than non-LGB reservists. DOD, unit and Coast Guard health promotion efforts should incorporate LGB-specific considerations where appropriate and recognize that LGB people are part of the unit.
Addressing health disparities for LGB people is unlikely to require the development of LGB-specific programs or policies, with some exceptions. However, excessive attention to the higher prevalence of mental and sexual health problems among LGB people may increase the stigma associated with LGB status, exacerbating these disparities and marginalising those affected.
Training health care providers in the military health care system can help reduce sexual health disparities between LGB and non-LGB personnel. For example, it is unclear whether MHS staff are aware that most LGB reservists are bisexual. Incorrect assumptions about the sexual orientation of armed forces personnel based on the gender of their current sexual partners can lead to inadequate or inaccurate counselling on the use of condoms and other contraceptives, and STI testing.
Service providers should be aware that almost one in six women identify as homosexual. Adaptation of screening and counselling protocols and clinical forms may also be appropriate to identify LGB people among MHS patients.
RAND conducted the 2018 HRBS survey among active duty and reserve components of the U.S. Army from October 2018 to March 2019. The reserve component survey included five reserve components – Air Force, Army, Ground Force, Navy, and Coast Guard – and two National Guard components – Air National Guard and Army National Guard.
The 2018 HRBS was a confidential online survey that allowed researchers to target reminders to non-respondents and reduce survey burden by linking responses to administrative data. The sample was selected using a stratified random sampling method by grade level, grade and gender. The overall weighted response rate to the survey was 9.4%, resulting in a final analytical sample of 16,475 responses for the Reserve.
To deal with missing data, RAND researchers used imputation, a statistical procedure that uses available data to estimate missing values. To represent the reserve population, responses were weighted to account for over-selection of service members in certain sections. Point estimates and 95% CIs are presented in this survey report.
RAND researchers controlled for differences in each outcome between key factor levels or subgroups – service area, salary level, gender, race/ethnicity, and age group – using a two-step procedure based on the Rao-Scott chi-square test for overall differences between individual factor levels, and if the overall test was statistically significant, a two-sample t-test for all possible pairwise comparisons between factor levels (e.g. men and women).
Readers interested in these differences should consult the full final report of the HRBS 2018 reserve component. This memo is one of eight memos on the Reserve; this memo and six of the other seven memos are the various chapters of the full report, with the eighth memo providing an overview of potential conclusions and policy implications. Eight similar reports deal with the results of the active part.
The response rate to the survey is considered low. Although a low response rate does not automatically mean that the survey data are biased, it does increase the possibility of bias. As with any self-report survey, social desirability bias is possible, especially for sensitive questions and topics. For some groups, representing a small percentage of the total military population, survey estimates may be inaccurate and should be interpreted with caution.
David W. Newton is a board certified pharmacist and also has been a board member for boards of examiners for the National Association of Boards of Pharmacy since 1983. His areas of expertise are primarily pharmaceuticals as well as cannabinoids. You can read an article about his expertise in CBD on the National Library of Medicine.