Large-scale health surveys, such as the Australian Bureau of Statistics’ National Health Survey 2007–08, Disability, Ageing and Carers Survey 2009, and National Survey of Mental Health and Wellbeing 2007 (http://www.abs.gov.au), are designed to provide broadly representative data on the population's health and on health differentials for particular subgroups. One subgroup of increasing importance includes people who identify as gay, lesbian or non-heterosexual orientation.1 These communities may have specific health needs,2,3 and experience difficulties in accessing appropriate health care services.4 However, many surveys do not include questions to identify sexual orientation.
The 45 and Up Study is a longitudinal study being conducted within New South Wales, surveying around 267,000 men and women aged 45 and over every five years.5 This study has ethics approval from the University of NSW Human Research Ethics Committee, its primary ethics committee. The SEEF (Social, Economic and Environmental Factors) Project is one of the research projects being conducted through the 45 and Up Study, and it aims to identify how social, economic and environmental factors influence the health and wellbeing of our population in mid to later life (see http://www.saxinstitute.org.au/our-work/45-up-study/research-underway/#the-impact-of-social-economic-and-geographic-disadvantages-on-health).
The SEEF questionnaire has 78 questions, encompassing a broad range of topics, covering general behaviour (e.g. smoking, alcohol, physical activities), household-related issues (such as living arrangements), health, work and income, social support and neighbourhood. A sexual orientation question was included in the self-complete questionnaire, with the question stem of “Which of these most closely describes your sexual orientation? (Please cross one box only)”. Response options included: exclusively heterosexual; mainly heterosexual; bisexual; mainly homosexual (lesbian/gay); exclusively homosexual (lesbian/gay); I don't know; I don't want to answer. Previously, questions concerning sexual orientation have often not been included in health surveys because of a general reluctance to pry into an individual's ‘private life’, coupled with a concern that such a question might be offensive to many participants, generating a high proportion of missing responses. The data from the SEEF project demonstrated that this concern is unfounded.
Of the 60,404 participants, 90.2% identified as exclusively heterosexual, 1.9% identified as mainly heterosexual, 0.9% as exclusively homosexual, 0.3% as mostly homosexual, 0.3% identified as being bisexual and 1.0% answered that they did not know. There were 5.4% of participants who did not answer the question concerning sexual identity. This proportion of missing data contrasted favourably when compared with the proportion of missing data for questions concerning household income (15.2%) and personal income (15.7%), two questions that are often included in surveys. The level of missing data for sexual orientation was similar to that for the questions about ability to pay the mortgage/rent (5.1% missing), asking for financial assistance from friends and family (3.4%) and ability to pay utilities (3.0%). Participants were more likely to provide an answer when asked about their marital status (0.8% missing) or religious beliefs (1.3%). Participants aged 65 or older were more likely not to answer the question on sexual orientation (7.9%) compared to their younger counterparts (3.4%), and women had a higher rate of missing data for this question than men (6.1% versus 4.6% respectively) – see Table 1.
|SEEF Question||Overall(N=60,404)||Males(n=28,056)||Females(n=32,348)||≤65 years(n=33,543)||>65 years(n=26,861)|
|Relationship status (Q19)||0.8%||1.0%||0.7%||0.6%||1.1%|
|Household incomea (Q60)||15.2%||11.2%||18.8%||11.4%||20.1%|
|Unable to pay utilities (Q67)||3.0%||2.7%||3.2%||2.0%||4.3%|
|Unable to pay mortgage/rent (Q67)||5.1%||4.6%||5.6%||3.2%||7.5%|
|Asked for financial help (Q67)||3.4%||3.1%||3.6%||2.2%||4.8%|
|Sexual orientationa (Q18)||5.4%||4.6%||6.1%||3.4%||7.9%|
Gay and lesbian health advocacy organisations are keen to encourage the inclusion of questions on sexual orientation in population health surveys in order to provide essential information on the health needs of these communities, particularly as people get older and have increasing needs for health and aged care.6,7 The SEEF project has demonstrated the inclusion of a sexual orientation question is feasible and provides data broadly in line with other sexuality-specific investigations.1