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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
  1. Brittany M Charlton1,2,3,4,
  2. Allegra R Gordon1,2,
  3. Sari L Reisner2,4,5,6,
  4. Vishnudas Sarda1,
  5. Mihail Samnaliev1,2,
  6. S Bryn Austin1,2,3,7
  1. 1 Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
  2. 2 Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
  3. 3 Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
  4. 4 Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
  5. 5 Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, USA
  6. 6 The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
  7. 7 Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
  1. Correspondence to Dr Brittany M Charlton; bcharlton{at}


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

Setting 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.

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

Primary outcome measure 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.

Results 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.

Conclusions 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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  • Contributors BMC conceptualised the project, supervised the analyses, and led the development and writing of the article. SBA supervised the data collection and, along with ARG, SLR and MS, aided in the interpretation of data and critically reviewed the manuscript for important intellectual content. VS conducted the analyses.

  • Funding BMC was supported by grant F32HD084000 and SBA by R01HD057368 and R01HD066963 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. Additional funds were provided to BMC by GLMA: Health Professionals Advancing LGBT Equality’s Lesbian Health Fund and by MRSG CPHPS 130006 from the American Cancer Society. SLR was partly supported by grant CER-1403-12625 from the Patient-Centered Outcomes Research Institute.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval This study was approved by the Brigham and Women’s Hospital Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data available.

  • Presented at An abstract of this work was presented at the Society for Adolescent Health and Medicine Annual Meeting and GLMA Annual Conference on LGBT Health.

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