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

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.

Charlton BM1,2,3,4, Gordon AR1,2, Reisner SL2,4,5,6, Sarda V1, Samnaliev M1,2, Austin SB1,2,3,7.

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Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.
Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.
Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA.
Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.
The Fenway Institute, Fenway Health, Boston, Massachusetts, USA.
Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA.



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


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.


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


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.


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.


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.


epidemiology; health economics; public health; sexual medicine

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