An Integrated Approach to Measuring Sexual Orientation Disparities in Women's Access to Health Services: A National Health Interview Survey Application.

Abstract

The extent to which disparities affect all sexual minority women (SMW) versus specific subgroups of lesbian, bisexual, or other women remains unclear, in part due to inconsistent analysis of available data. We propose an integrated approach that aggregates subgroups to maximize power to detect broadly applicable disparities, then tests for subgroup heterogeneity, exercising caution with disaggregation when there is no direct evidence of heterogeneity. Multivariate analyses of 2014-2015 National Health Interview Survey data examined six barriers to care. We compared heterosexual women (n = 36,474) with SMW (n = 1048) overall and tested for heterogeneous outcomes among subgroups of SMW compared with heterosexual women and with each other. Controlling for sociodemographics and health status, aggregated analyses showed that SMW were more likely than heterosexual peers to have trouble finding a provider (adjusted percentages 5.1% vs. 3.2%, p < 0.01) and no optimal usual place of care (14.5% vs. 11.2%, p < 0.01). There was no evidence of subgroup heterogeneity for either barrier, suggesting uniform disparities for SMW. In contrast, only lesbian/gay women were more likely than heterosexual women to be told their health insurance was not accepted (p = 0.03); this was the only outcome for which the adjusted difference between bisexual and lesbian/gay women was significant (2.8% vs. 6.3%, p = 0.02). Analyses that only disaggregated data would have understated overall sexual minority disparities and perhaps overstated subgroup differences; an integrated approach can more accurately characterize disparities experienced by all SMW versus those specific to certain subgroups. Large national surveys should include sexual orientation questions to support adequately powered comparisons.