Health Equity| Volume 33, ISSUE 1, P87-96, January 2023

Different Categorizations of Women's Sexual Orientation Reveal Unique Health Outcomes in a Nationally Representative U.S. Sample

Published:August 18, 2022DOI:



      Sexual minority women (i.e., women minoritized for their sexualities) are identified as high risk for mental health and substance use problems; however, there is no consensus on the criteria by which women are categorized as sexual minority. Though there is some evidence suggesting that certain subgroups of women are at higher risk than others based on sexual orientation, different categorization schemes for sexual orientation have yet to be compared within the same sample.


      Using data from the National Epidemiologic Survey of Alcohol and Related Conditions–III (N = 19,528), we examined how multiple categorization schemes (i.e., identity, behavior, recency of sexual behavior) for categorizing women who have sex with women (WSW) yield different estimates of prevalence of mental health and substance use issues. We used chi-square and logistic regression to analyze the link between sexual orientation categorization schemes and health, categorizing by 1) self-identification only, 2) behavior only, and 3) the combination of self-identification and behavior (recent vs. past).


      We discovered high prevalence rates of health problems among heterosexual-identified WSW who reported no recent sexual activity with women (i.e., previously had sex with women but not within the past 12 months); this category of women comprised 35% of all WSW.


      Step by step, we found more detailed information about these women's experiences by moving to the complex categorization scheme (the combination of self-identification and behavior). Heterosexual-identified women who have had sex with women in their past (though not recently) presented as a large group with high prevalence rates of substance use and mental disorders. These women remain invisible to researchers who categorize sexual orientation only by sexual identity or by behavior and ignore the role of behavior change over time—imprecisely categorizing such women as heterosexual or as women who have sex with men. They thus are underserved by health research and represent a significant population for further study and intervention.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Women's Health Issues
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Abma J.C.
        • Martinez G.M.
        Sexual activity and contraceptive use among teenagers in the United States, 2011-2015.
        National Health Statistics Reports. 2017; 104: 1-23
        • American Psychiatric Association
        Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. Washington, D.C.: American Psychiatric Publishing, Inc. Available:, 2013
        • Bauer G.R.
        • Jairam J.A.
        • Baidoobonso S.M.
        Sexual health, risk behaviors, and substance use in heterosexual-identified women with female sex partners: 2002 US National Survey of Family Growth.
        Sexually Transmitted Diseases. 2010; 37: 531-537
        • Berghe W.V.
        • Dewaele A.
        • Cox N.
        • Vincke J.
        Minority-specific determinants of mental well-being among lesbian, gay, and bisexual youth.
        Journal of Applied Social Psychology. 2010; 40: 153-166
        • Blosnich J.
        • Lee J.G.
        • Horn K.
        A systematic review of the aetiology of tobacco disparities for sexual minorities.
        Tobacco Control. 2013; 22: 66-73
        • Bolton S.L.
        • Sareen J.
        Sexual orientation and its relation to mental disorders and suicide attempts: Findings from a nationally representative sample.
        Canadian Journal of Psychiatry. 2011; 56: 35-43
        • Bostwick W.B.
        • Boyd C.J.
        • Hughes T.L.
        • McCabe S.E.
        Dimensions of sexual orientation and the prevalence of mood and anxiety disorders in the United States.
        American Journal of Public Health. 2010; 100: 468-475
        • Fenton W.S.
        • Stover E.S.
        Mood disorders: Cardiovascular and diabetes comorbidity.
        Current Opinion in Psychiatry. 2006; 19: 421-427
        • Fiedorowicz J.G.
        • He J.
        • Merikangas K.R.
        The association between mood and anxiety disorders with vascular diseases and risk factors in a nationally representative sample.
        Journal of Psychosomatic Research. 2011; 70: 145-154
        • Fredriksen-Goldsen K.I.
        • Kim H.J.
        • Barkan S.E.
        • Balsam K.F.
        • Mincer S.L.
        Disparities in health-related quality of life: A comparison of lesbians and bisexual women.
        American Journal of Public Health. 2010; 100: 2255-2261
        • Frost D.M.
        • Meyer I.H.
        Measuring community connectedness among diverse sexual minority populations.
        Journal of Sex Research. 2012; 49: 36-49
        • Galupo M.P.
        • Mitchell R.C.
        • Davis K.S.
        Sexual minority self-identification: Multiple identities and complexity.
        Psychology of Sexual Orientation and Gender Diversity. 2015; 2: 355-364
        • Gates G.J.
        LGBT data collection amid social and demographic shifts of the US LGBT community.
        American Journal of Public Health. 2017; 107: 1220-1222
        • Gattis M.N.
        • Sacco P.
        • Cunningham-Williams R.M.
        Substance use and mental health disorders among heterosexual identified men and women who have same-sex partners or same-sex attraction: Results from the national epidemiological survey on alcohol and related conditions.
        Archives of Sexual Behavior. 2012; 41: 1185-1197
        • Grant B.F.
        • Chu A.
        • Sigman R.
        • Amsbary M.
        • Kali J.
        • Sugawara Y.
        • Goldstein R.
        Source and accuracy statement: National epidemiologic survey on alcohol and related conditions-III (NESARC-III).
        National Institute on Alcohol Abuse and Alcoholism, Rockville, MD2014
        • Grant B.F.
        • Goldstein R.B.
        • Smith S.M.
        • Jung J.
        • Zhang H.
        • Chou S.P.
        • Hasin D.S.
        The Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 (AUDADIS-5): Reliability of substance use and psychiatric disorder modules in a general population sample.
        Drug and Alcohol Dependence. 2015; 148: 27-33
        • Green K.E.
        • Feinstein B.A.
        Substance use in lesbian, gay, and bisexual populations: An update on empirical research and implications for treatment.
        Psychology of Addictive Behaviors. 2012; 26: 265-278
        • Hasin D.S.
        • Shmulewitz D.
        • Stohl M.
        • Greenstein E.
        • Aivadyan C.
        • Morita K.
        • Grant B.F.
        Procedural validity of the AUDADIS-5 depression, anxiety and post-traumatic stress disorder modules: Substance abusers and others in the general population.
        Drug and Alcohol Dependence. 2015; 152: 246-256
        • Herek G.M.
        Sexual orientation differences as deficits: Science and stigma in the history of American psychology.
        Perspectives on Psychological Science. 2010; 5: 693-699
        • Horn K.
        • Swartz J.A.
        A comparative analysis of lifetime medical conditions and infectious diseases by sexual identity, attraction, and concordance among women: Results from a National US Survey.
        International Journal of Environmental Research and Public Health. 2019; 16: 1399
        • Horne S.G.
        • Puckett J.A.
        • Apter R.
        • Levitt H.M.
        Positive psychology and LGBTQ populations.
        in: Pedrotti J.T. Edwards L.M. Perspectives on the intersection of multiculturalism and positive psychology. Springer, Dordrecht: Springer, 2014: 189-202
        • Hughes T.L.
        • Wilsnack S.C.
        • Kristjanson A.F.
        Substance use and related problems among US women who identify as mostly heterosexual.
        BMC Public Health. 2015; 15: 1-8
        • Katz-Wise S.L.
        Sexual fluidity in young adult women and men: Associations with sexual orientation and sexual identity development.
        Psychology & Sexuality. 2015; 6: 189-208
        • Klesse C.
        Shady characters, untrustworthy partners, and promiscuous sluts: Creating bisexual intimacies in the face of heteronormativity and biphobia.
        Journal of Bisexuality. 2011; 11: 227-244
        • Korchmaros J.D.
        • Powell C.
        • Stevens S.
        Chasing sexual orientation: A comparison of commonly used single-indicator measures of sexual orientation.
        Journal of Homosexuality. 2013; 60: 596-614
        • Kruk M.
        • Matsick J.L.
        • Wardecker B.M.
        Femininity concerns and feelings about menstruation cessation among lesbian, bisexual, and heterosexual women: Implications for menopause.
        Journal of Women's Health. Online ahead of print. 2021;
        • Kuperberg A.
        • Walker A.M.
        Heterosexual college students who hookup with same-sex partners.
        Archives of Sex Behavior. 2018; 47: 1387-1403
        • Lee J.H.
        • Gamarel K.E.
        • Bryant K.J.
        • Zaller N.D.
        • Operario D.
        Discrimination, mental health, and substance use disorders among sexual minority populations.
        LGBT Health. 2016; 3: 258-265
        • Lehavot K.
        • Simoni J.M.
        The impact of minority stress on mental health and substance use among sexual minority women.
        Journal of Consulting and Clinical Psychology. 2011; 79: 159-170
        • Lourie M.A.
        • Needham B.L.
        Sexual orientation discordance and young adult mental health.
        Journal of Youth and Adolescence. 2017; 46: 943-954
        • Lytle M.C.
        • De Luca S.M.
        • Blosnich J.R.
        The influence of intersecting identities on self-harm, suicidal behaviors, and depression among lesbian, gay, and bisexual individuals.
        Suicide and Life-Threatening Behavior. 2014; 44: 384-391
        • Matsick J.L.
        • Wardecker B.M.
        • Oswald F.
        Treat sexual stigma to heal health disparities: Improving sexual minorities’ health outcomes.
        Policy Insights from the Behavioral and Brain Sciences. 2020; 7: 205-213
        • McCabe S.E.
        • Matthews A.K.
        • Lee J.G.
        • Veliz P.
        • Hughes T.L.
        • Boyd C.J.
        Tobacco use and sexual orientation in a national cross-sectional study: Age, race/ethnicity, and sexual identity–attraction differences.
        American Journal of Preventative Medicine. 2018; 54: 736-745
        • Mercer C.H.
        • Bailey J.V.
        • Johnson A.M.
        • Erens B.
        • Wellings K.
        • Fenton K.A.
        • Copas A.J.
        Women who report having sex with women: British national probability data on prevalence, sexual behaviors, and health outcomes.
        American Journal of Public Health. 2007; 97: 1126-1133
        • Meyer I.H.
        Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence.
        Psychological Bulletin. 2003; 129: 674-697
        • Mizzi R.C.
        • Walton G.
        Catchalls and conundrums: Theorizing “sexual minority” in social, cultural, and political contexts.
        Paideusis. 2014; 22: 81-90
        • Mohapatra S.
        • Patra J.
        • Popova S.
        • Duhig A.
        • Rehm J.
        Social cost of heavy drinking and alcohol dependence in high-income countries.
        International Journal of Public Health. 2010; 55: 149-157
        • National Institute of Minority Health and Health Disparities
        Sexual and gender minorities formally designated as a health disparity population for research purposes. National Institutes of Health.
        • Petchesky R.P.
        The language of “sexual minorities” and the politics of identity: A position paper.
        Reproductive Health Matters. 2009; 17: 105-110
        • Plöderl M.
        • Tremblay P.
        Mental health of sexual minorities. A systematic review.
        International Review of Psychiatry. 2015; 27: 367-385
        • Przedworski J.M.
        • McAlpine D.D.
        • Karaca-Mandic P.
        • VanKim N.A.
        Health and health risks among sexual minority women: An examination of 3 subgroups.
        American Journal of Public Health. 2014; 104: 1045-1047
        • Puckett J.A.
        • Levitt H.M.
        • Horne S.G.
        • Hayes-Skelton S.A.
        Internalized heterosexism and psychological distress: The mediating roles of self-criticism and community connectedness.
        Psychology of Sexual Orientation and Gender Diversity. 2015; 2: 426-435
        • R Core Team
        R: A language and environment for statistical computing.
        R Foundation for Statistical Computing, Vienna2018 (Available:)
        • Rehm J.
        • Mathers C.
        • Popova S.
        • Thavorncharoensap M.
        • Teerawattananon Y.
        • Patra J.
        Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders.
        Lancet. 2009; 373: 2223-2233
        • Riggle E.D.B.
        • Whitman J.S.
        • Olson A.
        • Rostosky S.S.
        • Strong S.
        The positive aspects of being a lesbian or gay man.
        Professional Psychology: Research and Practice. 2008; 39: 210-217
        • Rihmer Z.
        Suicide risk in mood disorders.
        Current Opinion in Psychiatry. 2007; 20: 17-22
        • Savin-Williams R.C.
        • Vrangalova Z.
        Mostly heterosexual as a distinct sexual orientation group: A systematic review of the empirical evidence.
        Developmental Review. 2013; 33: 58-88
        • Salomaa A.C.
        • Matsick J.L.
        Carving sexuality at its joints: Defining sexual orientation in research and clinical practice.
        Psychological Assessment,. 2019; 31: 167-180
        • Salomaa A.C.
        • Matsick J.L.
        Mental health for men who have sex with men (MSM) and women who have sex with women (WSW). In E. Rothblum (Ed.).
        Oxford handbook of sexual and gender minority mental health. 2020; (Oxford University Press): 343-356
        • Sewell K.K.
        • McGarrity L.A.
        • Strassberg D.S.
        Sexual behavior, definitions of sex, and the role of self-partner context among lesbian, gay, and bisexual adults.
        The Journal of Sex Research. 2017; 54: 825-831
        • Taggart T.C.
        • Rodriguez-Seijas C.
        • Dyar C.
        • Elliott J.C.
        • Thompson Jr., R.G.
        • Hasin D.S.
        • Eaton N.R.
        Sexual orientation and sex-related substance use: The unexplored role of bisexuality.
        Behaviour Research and Therapy. 2019; 115: 55-63
        • Talley A.E.
        • Aranda F.
        • Hughes T.L.
        • Everett B.
        • Johnson T.P.
        Longitudinal associations among discordant sexual orientation dimensions and hazardous drinking in a cohort of sexual minority women.
        Journal of Health and Social Behavior. 2015; 56: 225-245
        • U.S. Department of Health and Human Services
        Office of disease prevention and health promotion.
        Date: 2015
        Date accessed: August 15, 2021
        • van Anders S.M.
        Beyond sexual orientation: Integrating gender/sex and diverse sexualities via sexual configurations theory.
        Archives of Sexual Behavior. 2015; 44: 1177-1213
        • Wang P.S.
        • Simon G.
        • Kessler R.C.
        The economic burden of depression and the cost-effectiveness of treatment.
        International Journal of Methods in Psychiatric Research. 2003; 12: 22-33
        • Ware Jr., J.E.
        • Kosinski M.
        • Keller S.D.
        A 12-item short-form health survey: Construction of scales and preliminary tests of reliability and validity.
        Medical Care. 1996; 34: 220-233


      Anna C. Salomaa, PhD, is a Clinical Fellow in Psychiatry at VA Boston Healthcare System. Her research interests include 1) addressing issues in measuring sexual orientation in clinical and research settings and 2) enhancing health outcomes among sexual minority populations.


      Jes L. Matsick, PhD, is Assistant Professor of Psychology and Women's, Gender, and Sexuality Studies at Penn State. Her research incorporates feminist perspectives into the psychological study of stigma and prejudice, with an emphasis on outcomes for stigmatized groups (e.g., LGBTQ+ people).


      Cara E. Exten, PhD, MPH, is Assistant Professor in Penn State's College of Nursing. As an infectious disease epidemiologist, her research is focused on health disparities in the context of sexual health (e.g., HIV, STIs) and substance use, particularly among LGBTQ+ populations.


      Mary Kruk, MS, is a PhD candidate in Psychology and Women's, Gender, and Sexuality Studies at Penn State. Her research focuses on 1) experiences of stigma (e.g., identity threat and safety) and health and 2) women's resistance of conventional gendered expectations.