PROJECT SUMMARY Researchers and health practitioners use data from federal health surveys, electronic health records (EHRs), and research studies to monitor the health of sexual and gender minority (SGM) populations. Compared to non-SGM populations, SGM populations are disproportionately affected by poor health, including disparities in alcohol use, substance use, and mental illness. Substantial prior work has supported the minority stress framework to contextualize SGM health disparities; stressors related to discrimination and victimization tied to SGM status are strongly associated with disparities. The ability to accurately identify such disparities and potential causal pathways is vital to ensure that public health and health care research, policy, and practice are appropriately equipped to address the health needs of marginalized populations such as SGM individuals. This is particularly true in the case of alcohol, which remains one of the most commonly used and abused drugs nationwide, particularly among both adolescent and adult SGM. However, measurement of demographic characteristics associated with SGM identity and stigmatization – e.g., sex, sexual orientation, and gender identity (SSOGI) – remains poorly defined and inconsistently used across health research and practice settings. For example, despite evident limitations, most studies, providers, and national surveys continue to use a binary framework (male vs. female) to assess sex assigned at birth. This approach fails to capture a substantial population of intersex individuals (estimated prevalence of 1-2 per 1,000 live births). Further, most surveys continue to use the non-recommended practice of conflating sex and gender identity by asking about only one of these constructs, thereby failing to appropriately identify or characterize transgender, non-binary, and gender nonconforming individuals. While a growing number of surveys ask about sexual orientation, they frequently do not account for its multidimensional nature: many items conflate identity (e.g., gay, bisexual), with behavior (e.g., sex with only same-sex partners) and attraction (e.g., only attracted to male-presenting individuals). This is especially concerning as research has shown that a substantial number of individuals would only be classified as a sexual minority based on one category, but not another (e.g., a person who identifies as heterosexual but has sex with same-sex partners). Furthermore, current measures often are not comprehensive, exclude understudied or emerging orientations (e.g., asexual, pansexual, queer), lack the ability to select multiple options, and fail to account for changes in identity over time. Without comprehensive, validated measures to assess SSOGI, the ability to understand the magnitude of SGM disparities or how best to intervene to promote SGM health equity is limited. Therefore, it is vital to develop standardized, flexible measures for use across diverse demographics and regions. This project will address these gaps through iterative, community-engaged development of new SSOGI measures, and will assess the effectiveness of new vs. prior measures to characterize disparities in alcohol use, substance use, and mental health among SGM.

PROJECT NARRATIVE The National Institutes of Health (NIH) designated the sexual and gender minority (SGM) communities a health disparity population in late 2016, acknowledging the disproportionate health burdens experienced by individuals who are socially marginalized on the basis of sex, sexual orientation, and gender identity (SSOGI). However, best-practice approaches to collecting demographic data on SSOGI characteristics remain poorly defined and inconsistently used across health care, research, and practice settings, limiting the ability to accurately measure SGM health disparities and presenting a significant barrier to appropriately addressing SGM health needs. As such, the Project Recognize team proposes to use a community-engaged, mixed methods approach to: assess the current state of SSOGI measurement; iteratively develop new SSOGI assessments; test the acceptability of new versus prior measures and investigate their ability to detect the magnitude of SGM health disparities in alcohol use, substance use, and mental health within a large, diverse sample; and leverage existing connections in research, clinical, and federal surveillance settings to support systemic, multi-level advancement in SSOGI data capture.