A Statistical Understanding of Disability in the LGBT Community

Abstract For the first time ever, the United States Census Bureau began collecting data on the LGBT community with Phase 3.2 of the Household Pulse Survey. The Household Pulse Survey assesses how residents of the United States are doing during the COVID-19 pandemic. The data provided by the Household Pulse Survey Week 34 through Week 39 provides information to understand the lives of LGBT residents of the United States and how the LGBT community as a whole is doing economically. This study merges six weeks of the Household Pulse Survey, for a total of 382,908 survey responses. The sample represents a population of 250,265,449 adult residents aged 18 and older in the United States. This study provides the first nationally representative sample of residents of the United States that identify as transgender. This study specifically focuses on LGBT people with disabilities but highlights disparities facing transgender disabled U.S. adult residents. Disability is defined in the Household Pulse Survey as a severe or total impairment of those with seeing, hearing, remembering, and mobility disability types. The data indicates significant disparities for LGBT people compared to non-LGBT people, specifically in terms of economic considerations like work loss, household finances, and mental health.


Introduction
For several years, the federal government has been trying to understand the lives of sexual and gender minorities (SGM) in the overall economy, along with the policy issues and disparities facing this population.SGM are referred to more specifically as lesbian, gay, bisexual, and transgender (LGBT) people for this study in terms of the U.S. Census Household Pulse Survey (HPS).All of the federal surveys up until the release of Phase 3.2 of the HPS have excluded questions about sexual orientation and gender identity.Additionally, there was an effort by the Trump Administration to essentially "erase" LGBT people from the decennial Census in 2020 (Human Rights Campaign 2017;National LGBTQ Task Force 2017;Carrazana and Rummler 2021).This erasure has sociological and policy considerations as many nonprofits and advocacy groups are trying to "close the gap" between LGBT and non-LGBT people.Much of the public dialogue on equity has been centered on racial equity, while discussions on "LGBT equity" have not been realized or actualized in the public sphere (Surfus 2021).

Vaccines
In terms of vaccines, McNaghten (2022, p. 1) states that "COVID-19 vaccine coverage and vaccine confidence were higher among gay or lesbian adults than among heterosexual adults and higher among gay men than gay or lesbian women." While vaccination coverage and confidence are higher among CONTACT Chris R. Surfus chris.surfus@wmich.edu233 Fulton St. E, Ste.210-F, Grand Rapids, MI 49503.
LGBT people, the LGBT community is at a higher overall risk of contracting a severe COVID-19 case, due to comorbidities and exposure.Garg et al. (2021, p. 877) states that "The Human Rights Campaign Foundation has reported that LGBTQ+ people are more likely to work in highly affected industries, often with more exposure, such as food service, hospitals, and K-12 education, colleges and universities, and retail." While LGBT people face higher overall exposure due to the workplace, those with disabilities may not have a similar level of exposure.Still, McNaghten (2022) findings on higher vaccine coverage in the LGBT community is not true for those with disabilities overall.Ryerson et al. (2021Ryerson et al. ( , p. 1366) ) states that "COVID-19 vaccination coverage was lower among U.S. adults with a disability than among those without a disability, even though adults with a disability reported less hesitancy to getting vaccinated." Vaccine hesitancy appears to be a common theme, even among LGBT people (Cirruzzo 2021;Emerson et al. 2021;Garg et al. 2021).Carbajal (2021) counters the points by Ryerson et al. (2021) and Cirruzzo (2021) with a focus on "barriers, " emphasizing that vaccine hesitancy among those with disabilities is actually lower.Thus, understanding the intersectionality of disability and LGBT identity is an important, emergent area for research.Dawson et al. (2021, p. 1) state that, "While LGBT people report wanting to get vaccinated at a similar pace as non- LGBT people, a greater share of LGBT adults see doing so as part of everyone's responsibility to protect the health of others (75% vs. 48%), while greater shares of non-LGBT people see vaccination as a personal choice (49% vs. 24%)." Understanding the prior research on reasons for receiving a COVID-19 vaccine is important because the HPS provides a national sample on the various reasons for getting or not getting a COVID-19 vaccine.Human Rights Campaign (2021b) shows that 42% of LGBTQ+ adults are very likely to get vaccinated, compared to 39% of all adults in the United States.These findings provide a basis for comparison with vaccination rates in the HPS.

Employment
The pandemic has changed how people with disabilities work, with a great migration over to teleworking (Schur, Ameri, and Kruse 2020;Marso 2021).LGBT people experience higher unemployment due to the COVID-19 pandemic, which could be used as a basis for understanding employment and the LGBT community during the pandemic when examining the HPS data (Edelstein 2022).Movement Advancement Project (2020, pp.2-3) identifies that LGBTQ+ people face "higher rates of job losses, economic uncertainty, and greater economic insecurity and upheaval." The unemployment disparities that LGBT people faced are during the pandemic as a result of how the pandemic changed people's lives.

Mental Health
Data collected on LGBTQ+ mental health before and during the pandemic held to be relatively consistent in terms of mental health findings on anxiety, worry, loss of interest, depression, and other measures of mental health.The data collected during the pandemic found that COVID-19 worsened mental health as a whole by exploiting socioeconomic differences and vulnerabilities (Dawson et al. 2021;Okoro et al. 2021;Phillips 2021;Shakespeare, Ndagire, andSeketi 2021, p. 1332).The effect of the pandemic on mental health has been studied in various countries as it relates to "psychosocial effects" among youth (Barrientos et al. 2021;Gato et al. 2021;Ormiston and Williams 2022), thus, supporting the other mental health literature.Akré et al. (2021) found that, Cisgender straight participants had the lowest levels of depression, anxiety, and problem drinking compared with all other sexual orientation, sexual behavior, and gender identity groups, and, in general, LGBTQ+ participants were more likely to report that these health problems were "more than usual" during the COVID-19 pandemic. (p. 1610) Thus, an understanding of mental health comparatively between LGBT and non-LGBT people that is provided in HPS data is essential to understand mental health in the LGBT community.

Methods
For the purposes of this study, the lesbian, gay, bisexual, and transgender (LGBT) community is used as LGBT (rather than LGBTQ+ or LGBTQIA+) while excluding queer, questioning, and intersex because United States Census Bureau (2021) only specifically measures sexual orientation and gender identity in the survey questions.Thus, the population of the LGBTQ+ or LGBTQIA+ community is larger than the population used for this study of just the LGBT community.United States Census Bureau (2021) was analyzed after combining six weeks of data, weeks 34 through 39, of HPS responses to create a sample of 382,908 responses.The data was weighted using replicated weights to represent 250,265,449 adult residents in the United States.All analyses were conducted in Stata.All data tables were created in Microsoft Excel.
Disability identification was through seeing, hearing, remembering, and mobility variables in the HPS.LGB identification (excluding transgender) was through the sexual orientation variable in the HPS.Transgender identification was used through respondent identification as transgender and through gender identity at birth compared to current gender identity to ensure the most accurate identification of the transgender population, as some identify as gender binary (male or female) even though they are transgender.Vaccination, employment, and mental health were used through corresponding variables (i.e., received vaccine, any work performed, etc.) in the HPS.

Disability Types by Sexual Orientation and Gender Identity
Overall, 14.0% of residents of the United States have one or more disability types, which is consistent with Paul, Rafal, and Houtenville (2020).Disability types (i.e., seeing, hearing, remembering, and mobility) were assessed using United States Census Bureau (2021) to understand sexual orientation, gender identity, and disability comparatively.Overall, 2.1% of U.S. adults have a hearing-type disability (2.4% for LGBT and 6.5% for transgender alone).Hearing-type disability is significant for those that are transgender when compared to those that are not transgender.3.1% of U.S. adults have a seeing-type disability (4.2% for LGBT and 8.1% for transgender alone).Seeingtype disability is significant for both LGBT collectively and transgender exclusively when compared to those that are not LGBT and not transgender, respectively.4.9% of U.S. adults have a remembering-type disability (11.9% for LGBT and 19.5% for transgender alone).Remembering-type disability is significant for both LGBT collectively and transgender exclusively when compared to those that are not LGBT and not transgender, respectively.4.6% of U.S. adults have a mobility-type disability (4.5% for LGBT and 11.0% for transgender alone).Mobilitytype disability is significant for those that are transgender when compared to those that are not transgender.The mobility-type disability is slightly lower for LGBT than overall, which is the only disability type category to have this trend.It is important to note that in every disability type category, transgender respondents had a significant disparity.The most alarming disability-type trend is in the remembering-type disability category (Table 1).These may include ADHD, dementia, bipolar disorder, and various mental health conditions that affect memory and cognition (United States Census Bureau 2021).Disability as a whole in the LGBT community was 156% more prevalent than non-LGBT people, and this rises to 281% more prevalent for transgender people when compared to non-LGBT people.For the entire LGBT community, seeing and remembering disability types were statistically significant (p < 0.001) when compared to non-LGBT people.Every disability type was statistically significant (p < 0.001) for the transgender community.

Single Dose Vaccination
Vaccination data was assessed using data from the United States Census Bureau (2021) to understand the relationship between vaccination status, LGBT, and disability identity.Furthermore, data was assessed individually and intersectionally on the reasons LGBT people and those with disabilities may or may not get a COVID-19 vaccine.88.9% of LGBT people without a disability compared to 80.2% of LGBT people with a disability have received at least one COVID-19 vaccine dose.This figure is less but similar to the 92% found by Human Rights Campaign (2021a) Disability status was not significant in terms of receiving a COVID-19 vaccine.88.9% of LGBT people without a disability vaccinated compared to 84.8% of non-LGBT people without a disability.This was statistically significant (p < 0.001) when LGBT and non-LGBT people are compared, without a disability.Overall, it could be said that disability identity reduces the likelihood that someone will receive a COVID-19 vaccine, while LGBT identity increases the likelihood that someone will receive a COVID-19 vaccine (Table 2).However, LGBT people with disabilities vaccinated at 80.2% compared to non-LGBT people with disabilities at 81.8% (United States Census Bureau 2021).

Multi-Dose Vaccination
LGBT and disability identity compared to non-LGBT and disability identity received all doses of the COVID-19 vaccine (two doses; pre-booster) at about the same rates overall.When disability identity is not a factor, LGBT vaccinated at higher, statistically significant rates (p < 0.001) than those that identify as non-LGBT, 85.0% and 80.4%, respectively (Table 3).There is a 10.4% gap (85.0%-74.6%)between LGBT not disabled and LGBT people with a disability in terms of receiving all COVID-19 vaccines (United States Census Bureau 2021).

Reasons for Not Vaccinating
Reasons #1-3, Reason #5, Reasons #7-10, and Reason #13 in Table 4 were statistically significant for LGBT people without disabilities.Of these reasons, Reason #10 was statistically significant where p < 0.05, Reason #2 was statistically significant where p < 0.01, and the remaining reasons were statistically significant where p < 0.001.Reason #2 and Reason #10 are statistically significant among LGBT people with and without disabilities.Essentially, those with disabilities that identify as LGBT doubt the efficacy of the vaccine and have access issues to getting the vaccine (perhaps due to disability identity and mobility issues or patient-physician relationship issues).Those that identify as LGBT often face medical provider discrimination and providers sometimes lack competency on LGBT issues (Ayhan et al. 2020).It is important to note that people that are both LGBT and disabled selected most of the 13 reasons at a higher rate than people that are non-LGBT and disabled.This trend was not consistent when disability identity was removed from consideration of the 13 reasons.It is apparent that disability identity overall is more likely to lead to higher identification of the 13 reasons.
LGBT people reported slightly higher than non-LGBT people in the belief that "one dose is enough, " in experiencing side effects, and experiencing difficulty or having access issues in getting the vaccine.In every other area, non-LGBT people were more resistant to the vaccine when disability identity was removed from the analysis (United States Census Bureau 2021).

Employment Data by LGBT and Disability
Employment data was examined using United States Census Bureau (2021) to assess the relationship between disability and LGBT identity as it relates to work loss in the past four weeks, performing any work in the past seven days, working on-site, and teleworking.For those with disabilities, 29.8% of LGBT and 24.7% of non-LGBT individuals experienced work loss in the past four weeks.For those without disabilities, 18.3% of LGBT and 14.5% of non-LGBT individuals experienced work loss in the past four weeks.This is a disparity of 3.8% for those without disabilities and 5.2% for those with disabilities when comparing LGBT to non-LGBT people that have experienced work loss in the past four weeks.For those with disabilities, 51.4% of LGBT and 39.2% of non-LGBT people performed any work in the past seven days.For those without disabilities, 69.2% of LGBT and 60.5% of non-LGBT people performed any work in the past seven days.It is important to note that "work loss" and "any work" are inverse relationships, so as "work loss" increases then "any work" decreases.For both work loss and performing any work, LGBT people with disabilities and LGBT people without disabilities were statistically significant (p < 0.001) when compared to non-LGBT people with disabilities and non-LGBT people without disabilities, respectively.LGBT people were more likely to work on-site and to telework overall, despite facing higher overall work loss for those with and without disabilities.For LGBT people with a disability, 58.8% worked on-site and 31.5% teleworked.This compares to 47.2% and 21.0% for non-LGBT people, respectively.For LGBT people without a disability, 68.4% worked on-site and 42.0% teleworked.This compares to 60.5% and 33.6% for non-LGBT people, respectively.Both on- site and teleworked were statistically significant (p < 0.001) when comparing LGBT to non-LGBT people (United States Census Bureau 2021).Data from United States Census Bureau (2021) was used to specifically understand economic and employment issues for the transgender community comparatively with those with disabilities.Transgender experienced work loss at a rate of 21.0% compared to 14.5% non-LGBT people.35.4% of those that are both disabled and transgender experienced work loss compared to 24.7% of non-LGBT people.Those that are transgender appeared to perform any work in the past seven days at roughly the same rate overall though, 60.7% compared to 60.5% for non-LGBT people.Transgender residents of the United States were more likely to work on-site and telework than the general population overall.Findings on transgender with disabilities were not statistically significant, while findings on transgender people without disabilities were statistically significant for work loss (p < 0.01) and working on-site (p < 0.05).The trends for LGBT people overall in terms of working on-site and teleworking at a higher rate likely indicates that LGBT people work in service sector and nonprofit jobs at a higher rate while having higher educational attainment overall, thus, increasing both on-site and teleworking for two separate instances (Table 5).(United States Census Bureau 2021).

Mental Health Concerns in the LGBT Community
Data was examined and analyzed from United States Census Bureau (2021) to understand LGBT and disability identity as it relates to various mental health factors.These factors include whether an individual is facing anxiety, worry, loss of interest, depression, has used prescriptions, used mental health services, and had issues accessing mental health services.LGBT respondents reported anxiety, worry, loss of interest, depression, prescription drug usage, mental health service usage, and not able to get mental health services at a higher rate than non-LGBT respondents.This trend was consistent for those with and without disabilities.When examining LGBT compared to non-LGBT people: 1.The anxiety disparity is 22.3% and 21.7% for those with disabilities and those without disabilities, respectively.2. The worry disparity is 21.6% and 16.8% for those with disabilities and those without disabilities, respectively.3. The loss of interest disparity is 22.0% and 16.1% for those with disabilities and those without disabilities, respectively.4. The depression disparity is 23.4% and 18.1% for those with disabilities and those without disabilities, respectively.5.The use of prescriptions disparity is 19.9% and 13.1% for those with disabilities and those without disabilities, respectively.6.The use of mental health services disparity is 14.2% and 13.2% for those with disabilities and those without disabilities, respectively.7.In terms of not being able to access mental health services, the disparity is 20.6% and 14.1% for those with disabilities and those without disabilities, respectively.
For transgender people alone, the disparity gap in most areas is larger with the exception of disabled transgender people reporting anxiety and using prescriptions.Every LGBT measure for mental health is statistically significant (p < 0.001), while most  8.5 [9.7, 13.7] [8.5, 9.9] [5.1, 6.5] [8.3, 8.8 mental health measures for transgender only are statistically significant (p < 0.001) with the exception of using prescriptions for both disabled and not disabled, when compared to non- LGBT people (Table 6).This mental health data emphasizes the historical societal abuse, social isolation, and marginalization that LGBT people have faced from being unequal in rights and dignity (United States Census Bureau 2021).

Concluding Discussion
This analysis of the data from United States Census Bureau (2021) provides a snapshot of the intersectionality of LGBT people with disabilities.Much is yet to be understood about the LGBT community, but the findings of the HPS align with past research while providing a basis for future research into the lives and struggles of LGBT people with disabilities.The usage of all six weeks of the HPS provided for a nationally representative transgender sample.Prior research on the lives of transgender people have relied on self-identification or through convenience sampling, without having the grounding in statistical power provided by a federal survey.It is my wish that this body of research will lead to a greater understanding and additional research on the lives of LGBT people with disabilities.Future iterations of the HPS and ACS could provide additional areas for research on the lives of LGBT people, including LGBT people with disabilities.This would enhance our overall understanding of the public policy concerns facing these groups.26.9, 32.8] [23.8, 25.7] [29.1, 42.4] [17.1, 19.5] [14.2, 14.8] [16.4, 26.3 28.4, 34.8] [20.3, 21.7] [.286,.4668] [40.6, 43.5] [33.3, 33.9] [31.4, 42.4] Note: 95% confidence intervals in brackets and standard errors in parentheses.Significance.* p <0.05.

Table 1 .
Disability type by sexual orientation and gender identity.

Table 5 .
Employment, work loss, and type.

Table 6 .
Mental health, treatment, and services.