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Rapoport E, Athanasian CE, Adesman A. Prevalence of Nonheterosexual Identity and Same-Sex Sexual Contact Among High School Students in the US From 2015 to 2019. JAMA Pediatr. Published online June 14, 2021. doi:10.1001/jamapediatrics.2021.1109
Since 2015, the national Youth Risk Behavior Survey (YRBS) has included questions assessing sexual identity and the sex of respondents’ sexual contacts,1 providing the opportunity to assess longitudinal trends that can be generalized to high school students in the US. Prior to 2015, only some regional versions of the YRBS assessed these measures; analysis of these data demonstrated increases in the prevalence of nonheterosexual identity (for boys and girls) and same-sex sexual contact (for girls) between 2005 and 2015.2 Using the newly introduced questions in the national YRBS, the present study aimed to assess, in a nationally representative cohort of high school students, whether the prevalence of nonheterosexual identity or same-sex sexual contact had changed for boys and/or girls between 2015 and 2019.
This study was a secondary analysis of the 2015, 2017, and 2019 cohorts of the national YRBS, a biennial survey of high school students conducted by the US Centers for Disease Control and Prevention to monitor health-associated behaviors.3 Since secondary analysis of public-use data does not constitute human subjects research, this study did not require institutional review board review or informed consent per Northwell Health institutional policy.
All 3 surveys asked participants for their sexual identity, as well as their sex and the sex(es) of sexual contacts (questions and response options are in the footnotes of Tables 1 and 2). Nonheterosexual identity was operationalized as those identifying as gay, lesbian, or bisexual. Students reporting sexual contact with someone of the same sex, either exclusively or in addition to sexual contact with someone of a different sex, were defined as having had same-sex sexual contact.
Multivariate logistic regressions were used to assess whether the prevalence of nonheterosexual sexual identities and same-sex sexual contact changed between survey years, which were coded as a continuous variable. Students who reported being unsure of their sexual identity and students who denied having sexual contact were excluded from analyses investigating sexual identity and sexual contact, respectively. Alternative models were also specified in which nonheterosexual identity also included those unsure of their sexual identity.
Regressions were adjusted for sex, grade, and race/ethnicity. Sex-stratified analyses were also conducted, controlling for grade and race/ethnicity. Two-sided hypothesis testing was conducted at an α of .05. All analyses were conducted during February 2021 using R version 4.0.3 (R Foundation for Statistical Computing) and package survey version 4.0 and accounted for the complex survey design of the YRBS.
In the study sample (n = 41 884; median [interquartile range] age, 16 [15-17] years), there were 20 440 boys (weighted prevalence, 50.4%), 21 106 girls (weighted prevalence, 48.9%), and 338 participants who did not respond to the question assessing sex (weighted prevalence, 0.7%). Between 2015 and 2019, the prevalence of nonheterosexual identity increased by 41.4%, from 8.3% to 11.7% (adjusted odds ratio [aOR], 1.10 [95% CI, 1.05-1.15]) (Table 1). There was a 27.8% increase in prevalence, from 4.5% to 5.7%, among boys (aOR, 1.07 [95% CI, 1.00-1.14]) and a 45.8% increase, from 12.2% to 17.8%, among girls (aOR, 1.12 [95% CI, 1.07-1.18]). The alternative models for sexual identity yielded similar results. No changes in same-sex sexual contact prevalence were found (Table 2).
In this study, which is to our knowledge the first to longitudinally examine sexual identity and sexual contact in a nationally representative sample of high school students, an increase was noted for nonheterosexual identity but not same-sex sexual contact. However, it is unclear to what extent this increase reflects a change in the true prevalence of nonheterosexual sexual identities or whether the observed increase was in part because of increased comfort with self-disclosure.
In terms of additional limitations, the YRBS questionnaire never explicitly defined the term sexual contact4 and failed to adequately distinguish between same-sex and same-gender sexual contact.5 Moreover, some participants may have responded to the question assessing sex with their gender identity, leading to the incorrect classification of same-sex sexual contact. Furthermore, some youths in sexual minority groups may have felt their identity was not represented by the available responses to the question regarding sexual identity. Additionally, adolescents may have underreported nonheterosexual sexual identities and same-sex sexual contact because of persistent stigma associated with sensitive topics such as sexual identity.6
Although the YRBS measures are imperfect, the apparent increase in nonheterosexual identity among youth in the US calls for greater vigilance among health care professionals regarding the heightened risks faced by these youths, such as bullying and mental health challenges.
Accepted for Publication: March 30, 2021.
Published Online: June 14, 2021. doi:10.1001/jamapediatrics.2021.1109
Corresponding Author: Andrew Adesman, MD, Division of Developmental & Behavioral Pediatrics, Department of Pediatrics, Steven & Alexandra Cohen Children’s Medical Center of New York, 1983 Marcus Ave, Ste 130, Lake Success, NY 11042 (email@example.com).
Author Contributions: Mr Rapoport had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: Rapoport.
Drafting of the manuscript: Rapoport, Athanasian.
Critical revision of the manuscript for important intellectual content: Rapoport, Adesman.
Statistical analysis: Rapoport.
Conflict of Interest Disclosures: None reported.
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