Food Insecurity in SMW
Our results extend the existing literature by documenting food insecurity disparities in diverse subgroups of SMW, using a comprehensive, USDA endorsed measure of food insecurity. Compared to exclusively heterosexual women, lesbian WSW, bisexual WSW, and heterosexual WSW were 37-53% more likely to report experiencing past 12-month food insecurity. Alarmingly, SMW were 51-72% more likely to experience at least one period during the past 12-months where eating patterns were disrupted and food intake was reduced due to lack of money or other resources (i.e., severe food insecurity). This study is among the first to document food insecurity disparities in heterosexual WSW—a hidden and understudied subgroup of SMW.
Our results differ from others where significant differences in food security were not indicated between sexual minority and heterosexual adults in bivariate analyses (12% vs. 11%, p = n.s.), nor multivariable models (aOR = 1.19, p = n.s.), nor by gender [9]. This may reflect a measurement issue; respondents in these studies were asked to report only on past 30-day experiences of food insecurity [9]. In the general US population, approximately 5.9% of households report past 30-day food insecurity; however, over 11.1% report experiencing food insecurity over the past 12 months [1]. On average, food insecure households experience food insecurity for 7 months out of the year [1]; as such, surveys using 30-day recall periods may underestimate food insecurity disparities. By using a comprehensive measure of food security with a 12-month recall period, our study depicts the extent of food insecurity and disparities experienced annually by SMW.
Food Assistance Resource Use in SMW
Existing studies indicate that SMW are 30-70% more likely to receive SNAP benefits than heterosexual adults [8, 9]; however, our study did not evidence differences in SNAP use by sexual orientation. In contrast, lesbian WSW were 96% more likely and heterosexual WSW were 47% more likely to report past 12-month use of emergency food assistance (e.g., food pantries and soup kitchens) than exclusively heterosexual women. Emergency food participation has not been explored in previous population-based studies of food insecurity in sexual minority populations; consequently, this finding represents a new addition to the food insecurity and sexual minority health disparities literatures.
It is concerning that SMW are more likely to use emergency food assistance resources, but not more likely to use SNAP, despite evidencing disparities in food insecurity. SNAP participation reduces food insecurity [30, 31]; as such, increasing SMW’s SNAP participation may alleviate disparities. One explanation for SMW’s underutilization of SNAP is that SMW women may earn too much to qualify for SNAP, but not enough to afford food. SNAP guidelines require that a recipient’s gross income fall below 130% FPL (approximately $15,800 annually). However, a meta-analysis of earnings and wages suggests that, on average, lesbians earn 9% more than heterosexual women [32]. For low income SMW, this “lesbian premium” (i.e., a 9% wage differential) could be great enough to exclude SMW from qualifying for SNAP while leaving a reduced amount of income to afford food without federal assistance. “Working poor” Americans are more likely to recurrently use community-based emergency food assistance [33], which may explain SMW’s prevalent emergency food assistance use.
Public Health Implications
Several multilevel community-based and policy solutions may be implemented to reduce food insecurity in SMW. At the local level, increasing access to local food assistance resources is necessary to support food insecure SMW who do not qualify for SNAP benefits. One solution is the rise of LGBT-specific food pantries sponsored by community-based organizations in major metropolitan areas. However, it is unclear how many food insecure SMW know about or access these pantries, nor how accessible they are for SMW living in rural and suburban areas. Mixed-methods studies investigating local factors that exacerbate and alleviate food insecurity for SMW (e.g., food pantries, community networks, and individual-level coping strategies) may inform the improvement of existing food pantries or development of newer methods. These may include locally organized food sharing communities via online social platforms that proactively engage vulnerable, food insecure SMW.
It is not enough, however, to increase access to emergency food resources. Decreasing food insecurity in SMW also requires increasing SMW’s participating in food insecurity-alleviating programs. Increasing SNAP participation in food insecure SMW may be challenging, as limits on SNAP benefits may disproportionately disadvantage SMW. In 2018, the USDA proposed a rule that would limit access to SNAP benefits to able-bodied adults without dependents (ABAWD) having trouble securing employment [34]. This is problematic for many SMW who are not protected from sexual orientation-based employment discrimination. One in ten LGBT workers have left a job due to employment discrimination and almost 1 in 7 fear termination due to their sexual orientation [35]. Evidence from the general population suggests that expansion of work requirements eliminates SNAP benefits for ABAWD by nearly one-third [36]. In light of workplace and hiring discrimination, the proposed changes to SNAP could disproportionately affect SMW. Without SNAP to supplement food supplies, it is possible that more SMW will experience food insecurity and negative sequelae.
Decreasing food insecurity in SMW also requires addressing determinants of economic instability. Employment discrimination results in destabilized employment histories and lowered wages for SMW, which increases risk for poverty and food insecurity. Preventing employment discrimination for SMW requires instituting federal and/or state nondiscrimination laws that protect sexual minorities. To date, most employment nondiscrimination policies are state-based, creating a patchwork of protections for SMW. More recently, a coalition of 180 businesses guided by the Human Rights Campaign pledged support for the federal Equality Act; legislation that would prohibit discrimination based on sex, sexual orientation, and gender identity across public accommodations, employment, housing, education, and federal funding [37]. While promising, the Equality Act has yet to pass both the House and Senate [37]. Decreasing food insecurity disparities and increasing health equity for SMW, requires public health researchers and practitioners to lead policy efforts that promote sexual minority-supportive workplaces.
Limitations
NHANES’ sexual identity measures are double-barreled; each identity response (e.g., “lesbian”) is paired with a statement about sexual attraction (e.g., “sexually attracted to females”). This may conflate responses as individuals must choose a single response that comprises multiple aspects of their sexual orientation in a single question. Also, a considerable number of respondents did not complete the NHANES’ sexual behavior questionnaire, which may influence food insecurity estimates in sexual minority populations. Individuals who responded to sexual identity questions as “something else”, “other”, “don’t know”, or “refused” were excluded in this study as best practices for studying sexual minority health disparities caution against including respondents who refuse to answer sexual orientation questions due to potential confounding [23]. Finally, NHANES asks sexual orientation questions only for women up to age 59; estimates of food insecurity may differ in older SMW.