Health Related Behavior Study 2018 – General Sexual Health and Sexual Orientation of the Active Servicemembers

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The HRBS is the U.S. Department of Defense's (DoD) flagship study of the health, health-related behaviors and well-being of military personnel. The HRBS has been conducted regularly for more than 30 years and covers areas that may affect military readiness or the ability to meet the demands of military life.

The Department of Defense Office of Health and Human Services commissioned the RAND Corporation to review and conduct the 2018 HRBS survey among active and reserve military personnel. This summary discusses the results for the active component.

This summary presents results for sexual orientation and health. Some results are compared to the Healthy People 2020 (HP2020) goals set by the U.S. Department of Health and Human Services for the U.S. population. Because military personnel differ considerably from the general population (e.g., military personnel are more likely to be young and male than the general population), these comparisons are of interest only.

Sexual Orientation in the Military

The health issues and needs of lesbian, gay, and bisexual (LGB) individuals differ somewhat from those of their peers. In the U.S. population, LGB adults are more likely than their heterosexual peers to smoke, drink heavily, use marijuana and other illicit drugs, abuse opioids, and suffer from a range of chronic health problems.

Sexual minorities are more likely to suffer from mental health problems and to use mental health services, although they are less likely to use mainstream health care. The HRBS asked respondents about their sexual activity with same-sex partners in the past 12 months and their gender identity.

Overall, 3.4% (confidence interval [CI]: 2.8-4.0) of men and 9.9% of women (CI: 8.7-11.0) reported having had one or more same-sex partners in the past 12 months. In addition, 1.6% (CI: 1.2-1.9) of HRBS men and 6.0% (CI: 5.2-6.8) of HRBS women reported being gay or lesbian, and 2.5% (CI: 2.1-2.9) of HRBS men and 11.6% (CI: 10.2-13.0) of HRBS women reported being bisexual.

Across all services, 6.3% (CI: 5.8-6.9) of individuals described themselves as LGB. There are few significant differences in this percentage between services, but there are significant differences between men and women: 4.1% (CI: 3.5-4.5) of men and 17.6% (CI: 16.0-19.2) of women were LGB.

Health Promotion and Disease Prevention Among the LGB Group

Among LGB men, 67.5% (CI: 63.2-71.9) reported having had a routine check-up in the past 12 months. This figure was not significantly different from the 70.4% (CI: 69.2-71.7) of non-LGB service men who reported having had a routine check-up in the past 12 months. LGB service users were also similar to non-LGB service users in terms of moderate to vigorous physical activity in the past 30 days.

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

Substance Use of LGB People

LGB users are significantly more likely than non-LGB users to report heavy drinking (i.e., 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 binge drinking (i.e., heavy drinking at least once a week in the past 30 days).

LGB workers are significantly more likely to report use of e-cigarettes in the past 30 days and drugs in the past 12 months, but significantly less likely to report use of smokeless tobacco. There were no significant differences in cigarette and prescription drug use between LGB and non-LGB workers in the past 12 months.

Mental health and use of mental health services Among LGB People

The HRBS asked respondents about a range of mental health indicators and use of mental health services. All mental and emotional health problems studied were more common among LGB than non-LGB staff, although for most indicators only a small proportion of LGB staff reported problems.

LGB service users were also more likely to use all mental health services surveyed. However, significantly more LGB service users stated that they had not needed mental health services in the past 12 months and felt that mental health treatment would harm their military career.

General Physical Health of LGB People

The HRBS asked whether a doctor or health professional had told respondents in the past 12 months that they had high blood pressure, diabetes, high cholesterol, asthma, back pain, or musculoskeletal disability.

For all of these issues, there were no significant differences between LGB and non-LGB personnel (for more information on physical health indicators for all personnel, see the summary on physical health and disability in the active military).

Unwanted sexual activity and physical abuse of LGB Personnel

In the general US population, a higher proportion of LGB than non-LGB individuals reported experiencing past sexual and physical abuse. In the 2018 HRBS, significantly more LGB than non-LGB individuals reported experiencing unwanted sexual contact after joining the military and in the past 12 months. Significantly more reported experiencing physical violence since joining the military and in the past 12 months.

Reproductive Health and Sexual Health

Sexual and reproductive health is influenced by key behaviors such as number of sexual partners and use of other forms of contraception. RAND researchers examined how sexual and reproductive health indicators differ by LGB status, as well as outcomes such as diagnosis of sexually transmitted infections, regular human immunodeficiency virus (HIV) testing, and unintended pregnancies, which can affect a person's health and readiness.

Significantly more LGB users had multiple sexual partners in the past 12 months and had sex with a new partner without using a condom. Significantly more LGB people had also been tested for STIs in the past 12 months and for HIV in the past six months. No significant differences were found for HIV testing in the past 12 months, absence of contraception at last vaginal intercourse in the past 12 months, or unintended pregnancies in the past 12 months.

Summary and Suggestions for Policy

LGB workers represent about 6% of the workforce. Although LGB workers are similar to non-LGB workers in many health characteristics, they differ in others. Drug use and certain risk behaviors are more prevalent among LGB workers than non-LGB workers, as are unwanted sexual activity and physical violence.

The higher prevalence of some of these problems among the LGB population suggests that the MoD and Coast Guard should take LGB-specific considerations into account when developing more broadly targeted health promotion activities, bearing in mind that LGB personnel are part of the military. Addressing LGB health disparities is unlikely to require the development of programs or policies specifically targeting this group, with some exceptions.

In fact, focusing on the higher levels of mental and sexual health problems among LGB personnel may increase the stigma associated with LGB status, exacerbate these disparities, and marginalize affected individuals. The Ministry of Defense and the Coast Guard must also address the specific mental health needs of LGB personnel.

Current and future campaigns to reduce mental health stigma and service use should include messages and images relevant to LGB individuals (e.g., feelings of isolation, lack of acceptance) and test their acceptability and effectiveness among LGB individuals. Mental health service providers should also take into account the specific needs of LGB users.

In addition, training health care providers in the military health system could help reduce sexual health disparities between LGB and non-LGB personnel, including high rates of STIs and HIV risk behaviors. It is unclear whether MHS personnel are aware that nearly two-thirds of LGB service members are bisexual.

Erroneous assumptions that bisexual service members are heterosexual, gay, or lesbian, based on the gender of their current sexual partners, may result in inadequate or incorrect counseling about condom and other contraceptive use and STI testing.

Women's health professionals should be aware that one in six patients identifies as gay. Adaptation of screening and counseling protocols and clinical forms may also be appropriate to identify the presence of LGB personnel among MHS patients.

Methodology

RAND conducted the 2018 HRBS survey of active and reserve military personnel in the US Air Force, Army, Navy, Marine Corps, and Coast Guard between October 2018 and March 2019. The 2018 HRBS was a confidential online survey that allowed researchers to address reminders to non-respondents and reduce survey burden by linking responses to administrative data. The sample was selected using a random sampling strategy, stratified by grade, class, and gender.

The overall weighted response rate was 9.6%, resulting in a final analysis sample of 17,166 responses. Missing data were treated by imputation, a statistical procedure that uses available data to estimate missing values. To represent the working population, RAND researchers weighted responses to account for oversampling of service members in some strata. Point estimates and 95% CIs are presented in the report of this study.

The RAND investigators controlled for differences in each outcome between key factor levels or by subgroups-branch of service, grade, gender, race/ethnicity, and age group-using a two-step procedure based on the Rao-Scott chi-square test to find overall differences between single factor levels, and if the overall test was statistically significant, then a two-sample t-test to examine any possible pairwise comparisons between factor levels (e.g., male and female).

Readers interested in these differences should refer to the HRBS 2018 active component final report. This summary is one of eight active summaries; this summary and six of the other seven correspond to different chapters of the full report, and the eighth summary provides an overview of all findings and policy implications. A similar set of eight summaries also covers the reserve forces findings.

Restrictions

The response rate to the survey is considered low. Although the low response rate does not automatically imply that the survey data are biased, it does increase the possibility of bias. As with any self-report, socially desirable bias is possible, especially for sensitive issues and topics. For some groups, which represent a small percentage of the total military population, survey estimates may be inaccurate and should be interpreted with caution.

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