What Do You Mean By Gay? Measuring Sexual Orientation and Gender Identity in Public Health Studies

Sexual orientation and gender identity (SOGI) are increasingly recognized as social determinants of health. Public health studies, the majority from the US and Europe, show disparities in mental and physical health that are attributed to queer people’s marginalization, discrimination, and poorer access to healthcare. While such evidence is important for improving healthcare delivery and queer health advocacy and activism, most current studies do not explain how they define or operationalize their participants' sexual and gender identities. However, what we understand as lesbian, gay, bisexual and transgender (LGBT) identity emerged from a particular historical and geographical context, and queer identities are specific and contested from place to place. What does this mean then for studies about SOGI-related health disparities? What do we measure when we measure SOGI, and who do we include and exclude as participants?

Using empirical evidence from a comparative quantitative study on SOGI-related mental health disparities in Kenya, South Africa and Swaziland, we present challenges and contradictions in trying to make queer identities identifiable in a public health study. We present our strategies to determine participants’ sexual orientation and gender identity, and show how the contradictions in our results raise crucial questions about how to measure health inequalities related to contested social identities, even more so in postcolonial contexts where concepts of sexual and gender identity differ from Western understandings of lesbian, gay, bisexual and transgender. We argue that the process of operationalizing sexual or gender identity into survey questions and variables - by choice of language, terms, and concepts - invariably delimits who is identified as LGBT and thus counted, and that this represents a crucial limitation in studies that take such categories for granted. We end our paper by discussing the implications for the globally emerging field of LGBT Health.