15 Chapter 15: Epidemiology of Gender and Sexual Minority Health

Chapter 15: Epidemiology of Gender and Sexual Minority Health

Objectives

After completing this module, you should be able to:

Describe the sub-field of gender and sexual minority health.

Describe the methods of measurement in the epidemiology of gender and sexual minority health.

15.1 Introduction

Gender identities and sexual orientations are dynamic and diverse (Ferguson, 2019; Russo, 2014; Warwick Wellbeing and Student Support, 2022). The term “gender” refers to one’s internal sense of being male, female, a blend of both or neither, or otherwise non-conforming to one’s assigned sex at birth. Gender identity also can be dynamic and change over time. The term “sex” refers to “the combinations of physical characteristics typical of males or females”. At the time of writing, the sex attributed to an individual at their birth may be reassigned following medical procedures. Thus, the term “sex assigned at birth” is used to refer to the sex at the time of one’s birth and is used interchangeably with “sex” in this chapter. On the other hand, the term “sexual orientation” refers to a “pattern of emotional, romantic, and/or sexual attractions to men, women, or both” (American Psychological Association, 2024). At the time of writing, it is generally accepted in medical circles that gender identities and sexual orientation exist on a spectrum (Russo, 2014; WebMD Editorial Contributors, 2023). Thus, the above-mentioned terms and categorization are by no means exclusive or inflexible.

At the time of writing, the majority of the human population identify as the same gender as their sex (referred to as “cisgender”) and are sexually attracted to other cisgender people of a different gender (referred to as “heterosexual”). Individuals who do not identify as cisgender heterosexual persons are thus in the minority. The terms that members of this minority group use to refer to themselves have changed over time (National Institute of Health, 2016). At the time of writing, the acronym “LGBTQ” is widely used, which stands for “lesbian, gay, bisexual, transgender, queer,” as well as variations thereof. These variations include “LGBTQIA” (the “I” stands for “intersex” and the “A” stands for “asexual”) and “LGBTQIA+” (the plus (+) symbol refers to other groups not included in the acronym). However, there are other sub-groups within the minority who may be under-represented but are not included in the acronym, such as those who do not identify with being either male or female (“gender non-binary”) and those with multiple gender identities that shift (“gender fluid”). Thus, for inclusivity and consistency, organizations such as the U.S. National Institute of Health (NIH) opt to use the term “gender and sexual minority” (GSM) as a broader umbrella term (National Institute of Health, 2016). The author agrees with this approach and will use the term “gender and sexual minority” or “GSM” in this chapter to describe behavioral health epidemiology among members of these population sub-groups.

Gender and sexual minority health epidemiology is an emerging field with multiple research foci. These include but are not limited to:

Disparities in behavioral health (Gonzales et al., 2021; Wichaidit et al., 2021, 2023), particularly in understudied LGBTQIA+ sub-groups (Smalley et al., 2016)

Quality of life of gender and sexual minority persons (Preston, 2024)

Stigmatization and discrimination against gender and sexual minority persons (Casey et al., 2019; Hatzenbuehler et al., 2024)

Healthcare experiences of gender and sexual minority persons (Davy & Siriwardena, 2012)

Reproductive health priorities and healthcare experience among gender and sexual minority persons (Wingo et al., 2018)

The content of this chapter will focus on the author’s own research pertaining to disparities in behavioral health between gender and sexual minority persons, on the one hand, and cisgender-heterosexual persons, on the other hand. The presented findings here are based on two waves of nationally representative surveys of secondary school students in Thailand at the levels of Matthayom 1 (12–13 years old), Matthayom 3 (14–15 years old), and Matthayom 5 or Vocational Certificate Year 2 (16–17 years old in general education and vocational education systems, respectively). Gender and sexual minority identity and rights issues are still evolving, and studies in gender and sexual minority health epidemiology tend to adopt a multi-disciplinary approach. Thus, part of the content will include details about how the investigators presented and discussed the constructs of gender and sexual orientation.

15.2 Examples of Research in Gender and Sexual Minority Health

15.2.1 Example 1: Disparities in behavioral health outcomes and experience of violence between transgender students and cisgender students

Introduction: The term “transgender” is an adjective that means that the person or group’s gender identity differs from their sex assigned at birth. Transgender people often face discrimination and violence (Manalastas et al., 2017) and have a higher level of health risk behaviors. Although many perceive Thailand as a safe haven for transgender persons (Shrestha et al., 2020), transgender Thai women (those who are assigned male at birth and identify as female) have reported experiencing discrimination and violence (de Lind van Wijngaarden & Fongkaew, 2020). Studies on the health outcomes and quality of life of Thai transgender youth either include only qualitative methods (Nikratok & Nilvarangkul, 2013) or are mostly based on small-scale surveys, which are not representative of the broader population. The National School Survey on Alcohol Consumption, Substance Use and Other Health-Risk Behaviors is a nationally representative large-scale cross-sectional study among Thai school-going adolescents that included questions on gender identity and behavioral health, presenting an opportunity to assess disparities by gender (Paileeklee et al., 2016). The third round of the survey was conducted in 2016 and included questions regarding both sex and gender identity, which enabled the identification of both transgender and cisgender students as well as a nationally representative description of disparities in behavioral health and experience of violence among school-attending secondary students. The findings from such analyses can provide empirical evidence for stakeholders in education and adolescent health. The objective of the study is “to assess the extent that behavioral health outcomes and exposure to violence varied by gender among respondents of the National School Survey on Alcohol Consumption, Substance Use, and other Health-Risk Behaviors” (Wichaidit et al., 2021).

Methods: The full detail of the survey’s methodology has been described elsewhere (Wichaidit et al., 2021). In short, the study included data from self-administered questionnaires completed by secondary school students at over 100 schools throughout Thailand. The demographic characteristics section at the beginning of the questionnaire contained two questions: one for the measurement of sex assigned at birth and the other for the measurement of gender identity. Investigators identified participants according to their responses to these two questions and presented a weighted prevalence of self-reported health risk behaviors and experience of violence.

Results: The results tables are very extensive and will not be presented in this sub-section. The authors made the following statements in the Results section:

“Transgender girls and transgender boys accounted for approximately 2.5% of all respondents (Table 1).”

“Transgender boys had higher prevalence of depressive experience and suicidality compared to cisgender boys and girls, particularly with regard to suicidal ideation in past 12 months (APR = 2.97; 95% CI = 1.89, 4.67 when compared to cisgender boys, and APR = 2.29; 95% CI = 1.55, 3.40 when compared to cisgender girls) (Table 3). Similarly, transgender girls had higher prevalence of suicidality compared to cisgender boys. Transgender respondents (both boys and girls) also had higher prevalence of foregoing contraceptive use at last sexual encounter compared to cisgender respondents (both boys and girls). Transgender girls were less likely than cisgender boys and girls to be ever drinkers, while transgender boys were more likely than cisgender boys and girls to be ever drinkers. Similar differences were also observed in prevalence of being ever smokers. Transgender boys had significantly higher prevalence of lifetime history of using illicit drugs compared to cisgender girls, particularly in the use of yaba (methamphetamine pills) (APR = 2.99; 95% CI = 1.33, 6.73).”

Source: Wichaidit et al., 2021, Results section

Discussion: The authors made the following remarks regarding the categorization of participants, with suggestions for questionnaire design in future studies:

“…approximately one-sixth of the respondents did not answer the gender identity question. The Thai word in the questionnaire was ‘phet withi’, which was not part of vernacular Thai. It is possible that respondents who did not answer the gender identity question either did not understand it or perceived it to be a duplicate of the question pertaining to sex assigned at birth and decided to skip it. Future studies should consider changing the sex assigned at birth question may be changed from “Sex…” to “What sex were you assigned at birth?”. Future studies should consider modification of the gender identity measurement question to help reduce this non-response, e.g., changing from “You think you are…” (“Khun kid waa khun ben phet…”) to “What gender do you identify as?” (“Tuaton tii tae jing khun ben phet dai”) to reflect the notion that gender identity is firmly felt and integral to one’s being. With regard to the answer choices, both the birth gender and gender identity questions contained only binary responses of ‘male’ and ‘female’. The responses to the gender identity question may include additional answers of ‘Not sure / Questioning’, ‘Genderfluid’, ‘Non-binary’, and ‘Do not identify as male, female, or transgender’ in order to allow respondents to identify themselves as questioning, genderfluid and gender non-binary.”

Source: Wichaidit et al., 2021, Discussion section

The authors also note the absence of a question to measure sexual orientation; thus, the authors deemed the identification of sexual and gender minority participants to be incomplete:

“…we only asked the respondents about their sex and gender identity, and not their sexual orientation. In that regard, cisgender respondents who were homosexuals and bisexuals were identified in the same group as cisgender respondents who were heterosexual. Likewise, transgender participants were also presumably grouped together without regard for their sexual identity. Future surveys should include a separate question to identify sexual orientation.”

Source: Wichaidit et al., 2021, Discussion section

The authors then incorporated these remarks by revising the survey questionnaire for the fifth round of the survey, which is summarized in Example 2.

15.2.2 Example 2: Behavioral health and experience of violence among cisgender heterosexual and gender and sexual minority adolescents in Thailand

Introduction: As a follow-up to the previous study on disparities in behavioral health and experience of violence among cisgender and transgender adolescents in Thailand, the investigators decided to modify the questionnaire for the fifth round of the survey, conducted in 2020 and 2021, to allow for a more inclusive identification of sexual and gender minority adolescents based on the construct of “lesbian, gay, bisexual, transgender, queer and questioning, and asexual” (LGBTQA+) identities in the Western context. The findings from such analyses can provide additional basic information that may be of interest to stakeholders in adolescent health and LGBTQA+ rights. The objective of the study was “to assess the extent that behavioral health outcomes and exposure to violence varied between cisgender-heterosexual and LGBTQA+ youths in Thailand’s 5th National School Survey on Alcohol Consumption, Substance Use and Other Health-Risk Behaviors” (Wichaidit et al., 2023).

Methods: The methods used in the fifth round of the survey were similar to those in the third round (Wichaidit et al., 2021), albeit gender and sexual minority identities were measured with two questions on sex assigned at birth and gender identity and one question on sexual orientation that allowed for multiple answers.

Results: Approximately 23% of the participants provided answers that identified them as LGBTQA+. The authors then provided the following remarks regarding health disparities:

“Among participants included in our analyses…23 percent identified as LGBTQA+ with the most common identities being bisexual/polysexual girls (7 percent) and otherwise queer and questioning, assigned female at birth (AFAB) persons (6 percent)…

…depressive symptoms at time of study and within past year was higher among bisexual, transgender, asexual, and otherwise queer and questioning youths compared to those who identified as cisgender-heterosexual or cisgender-homosexual, and such prevalence was generally higher among assigned female at birth participants than among their assigned male at birth counterparts (Table 3A and 3B). Similar general patterns were found with regard to past-year suicidality. Lifetime history of sexual activity was highest among assigned male at birth transgender persons and cisgender-homosexual boys, and lowest among those who identified as asexual. Participants who identified as LGBTQA+ generally had higher prevalence of lifetime alcohol use than cisgender-heterosexual participants, whereas those who identified as asexual had the lowest prevalence of alcohol use. Participants who were assigned male at birth generally had higher prevalence of alcohol use than their assigned female at birth counterparts. Similar patterns were also observed for lifetime history of illicit drug use.”

Source: Wichaidit et al., 2023, Results section

Discussion: The authors made the following remarks regarding the measurement of gender identity and sexual orientation, particularly with regard to the ambiguity of the sexual orientation measurement question and the need to separate romantic and sexual attraction:

“We attempted to improve our gender identity question in this round of the survey by changing the question wording to more closely reflect the notion of identity [16]. We also included the answer choices of “gender diverse” and “not sure”. However, the term “gender diverse” (Thai: Phet thang luek) was also used as an umbrella term to refer to the LGBTQ community [27,28]. Similarly, our sexual orientation measurement question (“H1b. To which gender are you attracted?”) did not distinguish between romantic attraction and sexual attraction. Thus, the labels of “heterosexual”, “homosexual”, “bisexual/polysexual”, and “asexual” in our study could refer to either romantic or sexual orientation, depending on the perception of the individual participant [2]. In that regard, participants with “mixed orientation” or “cross-orientation” could be misclassified with regard to either their romantic or sexual orientation [3]. These issues should be considered when interpreting the findings of this study.”

Source: Wichaidit et al., 2023, the Discussion section

The authors plan to incorporate the suggestions noted in the Discussion section in the design of the sixth round’s questionnaire.

15.3 Measuring the extent to which participants identify as gender and sexual minorities

In this sub-section, the author aims to provide details regarding the evolution of the questions to measure self-identification of gender and sexual orientation. The questions used in the third, fifth, and ongoing sixth rounds of the National School Survey on Alcohol Consumption, Substance Use and Other Health-Risk Behaviors are listed in Box 15.3.1.

Box 15.3.1 Measurement questions regarding gender identity and sexual orientation among school-going adolescents in Thailand

Third Round (2016) In the third round of the Survey in 2016, there was no question regarding sexual orientation. The measurement of gender identity was based on two questions: A1.1 Sex at birth [ ] 1) Male [ ] 2) Female A1.2 Gender Identity (You think that your gender is…) [ ] 1) Male [ ] 2) Female Fifth Round (2020–2021) In the fifth round of the survey (2020–2021), the questionnaire was modified to include the following questions: Section A. General Characteristics of the Student 1. Sex at Birth [ ] 1) Male (Dek Chai / Nai) [ ] 2) Female (Dek Ying / Nang Sao / Nang) 1b. Gender Identity (With what gender do you actually identify?) [ ] 1) Male [ ] 2) Female [ ] 3) Gender diverse [ ] 4) Not sure [ ] 9) Refuse to answer Section H. Sexual Activity 1b. To which gender are you attracted? (multiple answers allowed) [ ] 1) Male [ ] 2) Female [ ] 3) Transgender female / kathoey [ ] 4) Transgender male / tom [ ] 5) Neither male nor female [ ] 6) I’m not sure to whom I am attracted [ ] 7) I’m not attracted to any gender [ ] 9) Refuse to answer Sixth Round (2024) In the ongoing sixth round of the survey (2024), the questionnaire included additional answer choices to identify under-represented population sub-groups, e.g., intersex, non-binary, gender fluid, and questioning adolescents. The question on orientation is also split into two questions. Section A. General Characteristics of the Student 1. Sex at Birth (What sex were you born as?) [ ] 1) Male [ ] 2) Female [ ] 3) Others / Intersex 1b. Gender Identity (With what gender do you identify?) [ ] 1) Male [ ] 2) Female [ ] 3) Neither male nor female / gender diverse / non-binary [ ] 4) Gender fluid, no fixed gender [ ] 5) Not sure [ ] 9) Refuse to answer Section H. Sexual Activity H1b. Romantic attraction: In your opinion, you would want to date people within which of the following groups? (more than 1 answer allowed) [ ] 1) Cisgender male persons [ ] 2) Cisgender female persons [ ] 3) Transgender female / kathoey persons [ ] 4) Transgender male / tom persons [ ] 5) Neither male nor female / gender diverse / non-binary persons [ ] 6) Gender fluid, no fixed gender persons [ ] 7) Other [ ] 8) I don’t want to date anyone [ ] 88) Not sure [ ] 99) Refuse to answer H1c. Sexual attraction: Which of the following groups do you find sexually attractive? (more than 1 answer is allowed) [ ] 1) Cisgender male persons [ ] 2) Cisgender female persons [ ] 3) Transgender female / kathoey persons [ ] 4) Transgender male / tom persons [ ] 5) Neither male nor female / gender diverse / non-binary persons [ ] 6) Gender fluid, no fixed gender persons [ ] 7) Other [ ] 8) I don’t find anyone to be sexually attractive [ ] 88) Not sure [ ] 99) Refuse to answer

A number of other instruments currently exist for analyzing gender identity and sexual orientation (IPSOS, 2021). Persons interested in gender and sexual minority issues should consult additional sources and study instruments accordingly.

15.4 Conclusion

Gender identities and sexual orientations are dynamic and diverse. Those whose gender identities and sexual orientations are in the minority in a given population are referred to as “gender and sexual minorities,” an umbrella term that includes members of the lesbian, gay, bisexual, transgender, and queer (LGBTQ) group as well as other identities not represented in the acronym (sometimes represented using a +, i.e., LGBTQ+). The term “gender and sexual minority (GSM)” is the preferred choice in this chapter to improve consistency and inclusivity. The author presented previous research regarding disparities in behavioral health and violence experienced by cisgender heterosexual persons and gender and sexual minority persons, as well as changes in the questions used for measurement and identification of self-administered questionnaire participants as gender and sexual minority persons. However, other instruments for measurement exist, and persons interested in gender and sexual minority issues should consult additional sources and study instruments accordingly.

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