Journal of Homosexuality

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Coping Patterns During the COVID-19 Pandemic by

Sexual and Gender Identity

Laura M. Houghtaling, Wendy D. Manning & Claire M. Kamp Dush

To cite this article: Laura M. Houghtaling, Wendy D. Manning & Claire M. Kamp Dush (02 Oct
2023): Coping Patterns During the COVID-19 Pandemic by Sexual and Gender Identity, Journal
of Homosexuality, DOI: 10.1080/00918369.2023.2260920

To link to this article: https://doi.org/10.1080/00918369.2023.2260920

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JOURNAL OF HOMOSEXUALITY
https://doi.org/10.1080/00918369.2023.2260920

Coping Patterns During the COVID-19 Pandemic by Sexual

and Gender Identity
Laura M. Houghtaling, PhD a, Wendy D. Manning, PhD b
,
and Claire M. Kamp Dush, PhD c
a
Division of Epidemiology & Community Health, School of Public Health, University of Minnesota,
Minneapolis, Minnesota, USA; bDepartment of Sociology and Center for Family and Demographic
Research, Bowling Green State University, Bowling Green, Ohio, USA; cDepartment of Sociology,
University of Minnesota, Minneapolis, Minnesota, USA

ABSTRACT KEYWORDS
National polls have shown that COVID-19 has been highly COVID-19; pandemic; coping;
stressful, negatively affecting well-being and life satisfaction sexual orientation; gender
overall, but few studies have focused on individuals with sexual identity; disparities
and gender diverse identities. Pandemic-related stress may
increase engagement in adverse or negative health-related cop­
ing behaviors and decrease engagement in positive coping
strategies, potentially exacerbating existing LGBTQ+ health dis­
parities. Relying on a nationally representative population-
based sample, we examine disparities in rates of negative and
positive COVID-19 coping behaviors by sexual and gender iden­
tities. Using Poisson regression models adjusted for key socio­
demographic and pandemic related factors, we found higher
rates of negative and positive coping behaviors among certain
sexual and gender diverse groups compared to their heterosex­
ual and cisgender counterparts. Specifically, we find that lesbian
and gay respondents reported more positive and negative cop­
ing strategies compared to heterosexual persons. We also found
higher rates of negative coping behaviors among plurisexual
(bisexual, pansexual, omnisexual) and noncisgender adults
(transgender or other nonbinary gender identity) compared to
heterosexual and cisgender adults, respectively. We contribute
to prior studies by focusing on both negative and positive
pandemic related coping among sexually and gender diverse
populations. These responses to the pandemic may have long-
term implications for the health and well-being of sexual and
gender diverse individuals.

Introduction
The COVID-19 pandemic has had a profound impact on the U.S. population
with daily stress levels reaching unprecedented levels at the beginning of the
pandemic and remaining above pre-pandemic levels in 2021 (Gallup, Inc., 2021,
2022). Vulnerability and exposure to COVID-19 related stress, however, varies

CONTACT Laura M. Houghtaling andre480@umn.edu Division of Epidemiology & Community Health,

School of Public Health, University of Minnesota, 300 West Bank Office Building, 1300 S. 2nd St, Minneapolis, MN
55454, USA.
Supplemental data for this article can be accessed online at https://doi.org/10.1080/00918369.2023.2260920.
© 2023 Taylor & Francis Group, LLC
2 L. M. HOUGHTALING ET AL.

with sexual and gender minority populations at greater risk of mental health
issues and of experiencing high levels of stress (Gato et al., 2021; Goldbach et al.,
2021; Kamal et al., 2021; Manning & Kamp Dush, 2022; Quinn et al., 2021). The
social isolation brought on by the pandemic cut off or limited vital social
support networks for some LGBTQ+ populations (Davis, 2021; Gustafson
et al., 2023; Kamal et al., 2021). The weakened social connections along with
anxiety related to contracting the coronavirus potentially exacerbated preexist­
ing sexual and gender identity-based health disparities (Akré et al., 2021; Davis,
2021; Kamal et al., 2021; Lazaroiu, 2021). For example, an online nationally
representative survey (n = 1,676 adults) from December 2020 to January 2021
showed that twice as many LGBT people reported that coronavirus-related
stress or worry had a major negative impact on their mental health compared
to non-LGBT people (Kaiser Family Foundation, 2021); a secondary analysis of
an online convenience sample from April to May 2020 limited to US respon­
dents (n = 1,362) found twice the perceived stress among LGBTQ+ respondents
than non-LGBTQ+ respondents (Levandowski et al., 2022); and an online
nationwide convenience sample in April 2020 of adults (n = 1,105) revealed
increased risk of exposure to COVID-19 stressors among non-heterosexual
adults (Park et al., 2020). Similarly, using representative data from the
National Couples’ Health and Time Study (n = 3,642), partnered adults with
minoritized sexual identities reported higher levels of stress than their hetero­
sexual counterparts (Manning & Kamp Dush, 2022). Further, a population-
based sample of young adults (n = 2,298) in California from May to
October 2020 indicated higher levels of pandemic related stress (Krueger
et al., 2021).
Disparities in pandemic-related stress may in turn increase engagement in
adverse or negative health-related coping behaviors and decrease engagement
in positive coping strategies among minoritized populations, further exacer­
bating existing health disparities. In the previously cited study by Park et al.
(2020), based on a convenience sample of adults across the U.S., non-hetero­
sexual respondents reported less productive coping strategies during the pan­
demic such as substance use and behavioral disengagement (Park et al., 2020).
Further, research focused on young adults (n = 2,298) in California indicated
greater engagement in less productive coping behaviors (substance use,
adverse eating behaviors and self-harm) among participants who identified
as sexual or gender minorities (Krueger et al., 2021). A series of papers have
found differentials in drinking during the pandemic. For instance, analysis of
population representative panel data collected from adults across five major
metropolitan areas in the U.S. from May through July 2020 indicated that
LGBTQ+ respondents reported more problem drinking during the pandemic
compared to cisgender straight respondents (Akré et al., 2021). Another study
that examined alcohol use patterns before and during the pandemic by sexual
identity found that in a U.S. representative sample, all non-heterosexual adults
 JOURNAL OF HOMOSEXUALITY 3

reported more alcohol use pre-pandemic but increases in alcohol use were
greater for bisexual men and women and other sexual identity women com­
pared to heterosexual men and women during the pandemic (Fish et al., 2021).
Similarly, research relying on the population representative NCHAT found
a greater odds of drinking alcohol to cope during the pandemic among gay,
lesbian, bisexual, pansexual, omnisexual and queer respondents compared to
heterosexual respondents, as well as greater odds of drinking to cope among
cisgender men compared to cisgender women (Stewart et al., 2023). While
these studies provide much needed data on LGBTQ+ populations during the
pandemic, they were limited to only one negative coping behavior, did not
examine positive coping behaviors, and/or restricted to one geographic area or
age group.
More LGBTQ+ specific research on coping is needed, especially by more
nuanced categories of sexual and gender identities (Goldbach et al., 2021;
Krueger et al., 2021; Park et al., 2020), reflecting the state of the literature on
distinct risks and behaviors among plurisexual populations (defined as bisex­
ual, pansexual, omnisexual, queer, and/or fluid sexual identities) (Galupo
et al., 2015); and among transgender and nonbinary populations (gender
identity does not conform to societal expectations of binary gender, i.e.
“man” or “woman”) (Bowleg & Landers, 2021; Feinstein & Dyar, 2017;
Hughes et al., 2020; Plöderl & Tremblay, 2015; Tan et al., 2020; White
Hughto et al., 2015). Further, the coping literature is most often limited to
negative coping strategies and research on positive coping strategies is less well
developed. One study of sexual and gender minority men who lived through
the HIV/AIDS epidemic found that the experiences of having lived through
a former public health crisis, having faced significant stigma around HIV/
AIDS and having experienced community organizing and collective action
during that time helped them adaptively cope (taking action to make the
situation better) during the COVID-19 pandemic (Quinn et al., 2021). Given
the focus on risks associated with public health crises, most research appears to
target negative coping behaviors and ignores potentially positive behaviors,
such as exercise or connection.
Outside of responses to the pandemic, there are well-established differences
in maladaptive or negative health-related behaviors by sexual and gender
identities in both adult and young adult populations. These include elevated
rates of alcohol misuse, smoking, and substance use disorders among plur­
isexual individuals relative to monosexual (heterosexual, gay or lesbian) peers;
among transgender and nonbinary individuals relative to cisgender peers; and
among subgroups embodying multiple minoritized identities, such as bisexual
women and Black and Hispanic lesbian and bisexual women (Corliss et al.,
2010; Dyar et al., 2020; Felner et al., 2020; Lewis et al., 2021; McCabe et al.,
2009; Schuler et al., 2020). There is much less research on differences in
positive health-related behaviors or coping strategies by sexual and gender
4 L. M. HOUGHTALING ET AL.

identities. The existing research provides mixed evidence for sexual orienta­
tion-based disparities in sleep quality and length and in leisure-time physical
activity (Jackson et al., 2016; Patterson & Potter, 2019; Trinh et al., 2017).
There is also a body of literature on the development of adaptive or positive
health-related behaviors due to facing discrimination and stigma among
sexual and gender diverse populations, such that LGBTQ+ individuals may
have stronger preexisting social networks than heterosexual and cisgender
individuals in response to this excess stress (Meyer, 2003; Testa et al., 2014).
Prior research on sexual minority women found that negative and positive
coping strategies are not two sides of the same coin, and thus engaging in
positive coping strategies does not translate directly into not engaging in
negative coping strategies (Lehavot, 2012). Negative and positive coping
strategies are not complementary and focusing on reducing negative coping
strategies will not necessarily result in more positive coping strategies unless
additional interventions are designed to increase adaptive coping directly
(Lehavot, 2012).
Disparities in health-related behaviors by sexual and gender identity are
largely shaped by stigma and discrimination (Hatzenbuehler, 2017; McCabe
et al., 2010; White Hughto et al., 2015). The inequitable increased exposure to
stigma and discrimination experienced by sexually and gender diverse indivi­
duals forms the basis of the theory of minority stress (Brooks, 1981; Meyer,
2003), which guides this research. We know that the structural forces of
sexism, heterosexism and cisgenderism contribute to excess stress due to
stigma and discrimination experienced by people who identify with
a minoritized sexual and/or gender identity (Hatzenbuehler, 2017). This
excess stress, also referred to as minority stress, may indirectly affect health
through both behavioral and biological pathways, such as through increased
substance use or through elevated blood pressure and inflammation (Christian
et al., 2021; Flentje et al., 2020; Meyer, 2003).
Given these preexisting inequitable disparities in health behaviors by sexual
and gender identities and guided by the minority stress model, this paper
provides a timely contribution to existing analyses of LGBTQ+ related data
collected during the peak of COVID-19 (Akré et al., 2021; Davis, 2021; Fish
et al., 2021; Gato et al., 2021; Kamal et al., 2021; Krueger et al., 2021; Lazaroiu,
2021; Levandowski et al., 2022; Stewart et al., 2023) by examining disparities in
both positive and negative pandemic related coping behaviors according to
individual’s sexual and gender identities. A focus on both negative and positive
coping provides a more comprehensive understanding of coping. We use the
National Couples’ Health and Time Study (NCHAT) dataset, a rich and
unique opportunity to explore experiences of sexual and gender diverse
populations during the COVID-19 pandemic through a nationally represen­
tative probability-based sample of married or cohabiting adults aged 20–60
years with oversamples of racial, ethnic, and sexual minorities. These data
 JOURNAL OF HOMOSEXUALITY 5

provide important insights not only into the coping behaviors but discrimina­
tion and stress that may underlie distinctions according to gender and sexual
identity.
Based on the minority stress model, we expect to see more deleterious
coping behaviors among sexual and gender minority populations due to excess
stress attributable to stigma and discrimination (Brooks, 1981; Meyer, 2003).
We also expect to see worse health behaviors and outcomes among bisexual
and other plurisexual individuals based on the idea of double discrimination
or binegativity: bisexual people experience discrimination both from hetero­
sexual as well as from gay or lesbian individuals who hold negative attitudes
toward bisexuality (Dyar et al., 2020; Feinstein & Dyar, 2017). Such negative
attitudes are based on stereotypes that bisexuality is a fluid sexual orientation
and thus a questionable or transient identity, and on perceptions that bisexual
individuals are more promiscuous (Feinstein & Dyar, 2017). Based on the
small literature on positive coping behaviors in LGBTQ+ adult populations
(Jackson et al., 2016; Patterson & Potter, 2019; Trinh et al., 2017), we expect to
see fewer positive behaviors overall among respondents with minoritized
sexual and/or gender identities, even though the proportion of LGBTQ+
respondents engaging in certain positive coping behaviors might be greater
than heterosexual cisgender respondents.
Because social identities are interdependent, we expect that negative and
positive coping behaviors will vary according to sexual identity by gender
identity. The idea that minority stress may have differential effects on minor­
itized groups due to embodying multiple minoritized identities comes from
intersectionality theory (Bowleg et al., 2003). Intersectionality is a theoretical
research framework for understanding the interconnected nature of minor­
itized identities and the associated systems of power and oppression that
sustain the status quo (Bowleg, 2012; Crenshaw, 1991). We expect to find
greater negative coping behaviors and fewer positive coping behaviors among
specific intersections of the minoritized identities under study: specifically,
plurisexual respondents who identify as cisgender women, transgender or as
a nonbinary gender identity.

Methods
Sample
The National Couples’ Health and Time Study (NCHAT) dataset (N =
3,642) has representative samples of sexual, gender, racial and ethnic
diverse individuals aged 20–60 years. The survey was fielded from
September 2020 through April 2021 and includes information on health,
relationship functioning, COVID-19 pandemic, discrimination, racial
trauma and more. The sample was recruited from the Gallup Panel and
6 L. M. HOUGHTALING ET AL.

Gallup Recontact Sample and consists of 3,642 main respondents. The

overall response rate for main respondents was 28%. All analyses were
conducted in Stata 16.1 and are weighted to be representative of cohabiting
or married adults aged 20–60 in the general U.S. population. The data are
available for download at (https://doi.org/10.3886/ICPSR38417.v1) (Kamp
Dush & Manning, 2022).
The 2019 National Health Interview Survey and the 2019 American
Community Survey were used to construct the weights by sexual identity,
specifically correcting for the overrepresentation of bisexual individuals in
different-gender couples (Kamp Dush et al., 2022). For more information
about NCHAT methodology, please refer to (Kamp Dush et al., 2022).
Participants who reported their sexual identity or gender identity and com­
pleted the survey question about pandemic related coping behaviors were
included in the analytic sample (n = 3,638).

Measures

COVID-19 coping behaviors dependent variables

NCHAT asked the following question about pandemic related coping beha­
viors: “What are you doing to cope with the coronavirus pandemic?”
Individuals were asked to report yes or no based on fourteen listed behaviors
in the following order: taking a break from the news or social media; exercising
or walking; praying or meditating; getting plenty of sleep; connecting with
friends or family; connecting with your religious community; connecting with
a mental or physical healthcare provider; watching or streaming TV or gam­
ing; smoking cigarettes or vaping; drinking alcohol; using drugs (like valium,
marijuana, or opioids); eating more food than usual; eating less food than
usual; cutting or self-injury. We divided the fourteen behaviors into clearly
positive or negative categories. Two behaviors (watching or streaming TV or
gaming; connecting with your religious community) were not included
because they did not consistently fit into a positive or negative category across
all sexual and gender identities (Schuck & Liddle, 2001).
Negative coping behaviors include smoking cigarettes or vaping; drinking
alcohol; using drugs (like valium, marijuana, or opioids); eating more food
than usual; eating less food than usual; cutting or self-injury. The final
dependent variable is a summated scale ranging from zero to six self-reported
negative coping behaviors with a mean value of 0.99 (see Supplemental
Figure S1).
Positive coping behaviors include taking a break from the news or social
media; exercising or walking; praying or meditating; getting plenty of sleep;
connecting with friends or family; connecting with a mental or physical
healthcare provider. The final dependent variable is a summated scale ranging
 JOURNAL OF HOMOSEXUALITY 7

from zero to six self-reported positive coping behaviors with a mean value of
2.99 (see Supplemental Figure S2).

Sexual and gender identity

Sexual Identity was assessed with one question: “Which of the following
do you consider yourself to be (select all that apply)? Heterosexual or
straight; Gay or Lesbian; Bisexual; Same-gender loving; Queer; Pansexual;
Omnisexual; Asexual; Don’t know; Questioning; Something else,” with an
option to specify. For regression analyses, we modeled sexual identity as
4-level categorical variable: exclusively heterosexual (referent), exclu­
sively gay or lesbian, plurisexual (includes respondents who identify as
bisexual, pansexual, queer and/or omnisexual), and other sexual identity
(includes respondents who selected any combination of the following
response options: asexual, same-gender loving, don’t know, questioning,
something else, or who selected multiple identities not including bisex­
ual, pansexual, queer or omnisexual). Respondents who selected hetero­
sexual and gay/lesbian; heterosexual and bisexual; or gay/lesbian and
bisexual were coded as “plurisexual.” Respondents who selected ONLY
heterosexual or straight were labeled as “exclusively heterosexual” and
respondents who selected ONLY gay or lesbian were labeled as “exclu­
sively gay or lesbian.”
Gender Identity was assessed by asking respondents about sex assigned
at birth followed by a two-part question about their gender identity. Sex
assigned at birth was asked as follows: “What sex appears on your original
birth certificate? Male, Female or Don’t know/does not apply.” Respondents
who selected “Don’t know/does not apply” were coded as missing.
Respondents then answered the following two-part question about their
gender identity: Part 1. “Which of the following best describes your gender
(select one)? Man; Woman; Trans man; Trans woman; Do not identify as
any of the above.” If respondents selected “Do not identify as any of the
above,” they were asked Part 2. “Do any of the following terms describe
your gender (select all that apply)? Nonbinary; Two-spirit; Agender;
Gender fluid; Gender neutral; Genderqueer; Other (with option to spe­
cify).” For main effects regression models, we modeled gender identity as
a 4-level categorical variable: cisgender man (referent), cisgender woman,
transgender man or woman, and other nonbinary identity. For interaction
models, we modeled gender identity as a 3-level categorical variable by
combining transgender and nonbinary gender identity respondents into
one category, “noncisgender.” The cisgender category includes those who
selected a gender identity (man or woman) that matched their sex assigned
at birth selection. The transgender category includes those who selected
trans man or trans woman OR whose selected gender identity did not
match sex assigned at birth. The nonbinary gender identity category
8 L. M. HOUGHTALING ET AL.

includes respondents who identified with one or more of the following

identities (Nonbinary; Two-spirit; Agender; Gender fluid; Gender neutral;
Genderqueer; Other.)

Demographic covariates

Age was calculated by self-reported birthdate and the date the survey was
completed and was modeled as a nominal variable. Race and ethnicity was
coded as non-Latina/x/o white (referent), non-Latina/x/o Black, non-Latina/x/
o Asian, Latina/x/o, non-Latina/x/o multiracial or non-Latina/x/o other race.
Foreign born was coded as “born in the U.S.” (referent) and “born outside the
U.S.” Marital status was coded as a dichotomous variable: “legal marriage”
(referent) and “partnered, commitment ceremony, registered domestic part­
nership, or civil union.” Children in Household was self-reported by partici­
pants and coded as “no children” (referent) and “any children in household.”
Socioeconomic status was assessed using the following two variables:
Educational attainment was coded as “high school degree/GED or less”
(referent), “some college or associate’s degree,” and “bachelor’s degree or
higher.” Employment status was coded as “full or part time” (referent), and
“unemployed or furloughed.” General health status was self-reported and
coded as a dichotomous variable: “good, fair, or poor” (referent) and “excellent
or very good.” COVID-19 related variables include Covid Symptoms, which
was coded as “never had or suspected had coronavirus” (referent) and “ever
had, currently have or suspected had/have coronavirus;” Covid Life Disruption
coded as “not at all or not much” (referent), “a fair amount” and “a great deal;”
and Covid Stress measured on a nominal scale from 1 (not at all stressed about
getting coronavirus) to 5 (very stressed about getting coronavirus). Survey
month was an eight-level categorical variable including months September
through April.

Statistical analyses

We present sociodemographic characteristics of the sample by the weighted

means of negative and positive coping behaviors and compare coping beha­
viors by select population characteristics using an adjusted Wald test for
categorical variables in Table 1. We present weighted proportions of indivi­
dual COVID-19 positive and negative coping behaviors by sexual and gender
identity in Figures 1 and 2, respectively. Less than 1% of data was missing on
all study variables.
We estimated Poisson regression models for each of the two dependent
variables indicating the rate of positive or negative coping behaviors in Tables 2
and 3. We assumed a Poisson distribution after ruling out overdispersion of the
data, overall and by subgroups of gender and sexual identity. We used the Stata
 JOURNAL OF HOMOSEXUALITY 9

Table 1. Description of the study population by mean number of positive and negative COVID-19
coping behaviors (n = 3,638), unadjusted.
Positive Coping Behaviors Negative Coping Behaviors Total
Weighted Weighted Unweighted
mean SE p† mean SE p† sample size (n)
Sexual identity .5 <.001
Exclusively Heterosexual 2.99 0.043 0.96 0.026 2,019
Exclusively Gay or Lesbian 3.11 0.074 1.25 0.049 789
Plurisexual 3.04 0.12 1.82 0.094 611
Other Sexual Identity 3.11 0.18 1.48 0.17 170
Gender identity <.001 .004
Cisgender Men 2.70 0.056 0.93 0.038 1,756
Cisgender Women 3.27 0.061 1.03 0.034 1,717
Transgender 3.58 0.24 1.53 0.63 46
Other Nonbinary Identity 2.77 0.16 1.87 0.31 98
Race/ethnicity .002 .02
Non- Hispanic White 2.93 0.056 0.99 0.033 2,245
Non-Hispanic Black 3.27 0.097 1.05 0.066 335
Non-Hispanic Asian 2.82 0.010 0.74 0.073 209
Latina/o/x 3.13 0.069 1.01 0.048 584
Non-Hispanic Multiracial 3.01 0.14 1.02 0.10 206
Non-Hispanic Other race 2.56 0.32 1.08 0.22 57
Foreign Born .3 <.001
Born in the US 3.00 0.043 1.02 0.026 3,274
Born outside the US 2.89 0.11 0.72 0.055 342
Marital status .5 <.001
Legal marriage 3.01 0.048 0.91 0.025 2,678
Partnered/Civil union or similar 2.94 0.084 1.33 0.062 956
Children in Household .07 .9
No children 3.04 0.050 0.99 0.032 2,365
One or more children 2.93 0.053 0.98 0.037 1,273
Educational attainment .006 .009
Less than HS, HS degree or GED 2.79 0.090 0.94 0.046 640
Some college or associate’s degree 2.98 0.075 1.10 0.050 948
Bachelor’s degree 3.13 0.069 0.99 0.051 1,014
Master’s degree or higher 3.18 0.084 0.88 0.044 1,035
Employment status .1 .007
Full or part time 2.96 0.046 0.95 0.028 2,840
Unemployed or furloughed 3.08 0.071 1.10 0.050 794
Health status <.001 <.001
Good, fair or poor 2.74 0.054 1.16 0.037 2,000
Very good or excellent 3.29 0.057 0.78 0.034 1,629
COVID Symptoms .02 .6
Never had or suspected 2.94 0.047 0.99 0.028 2,885
Ever had, have or suspected 3.17 0.086 0.96 0.057 745
COVID Life Disruption .06 <.001
Not at all or not much 2.87 0.078 0.75 0.044 834
A fair amount 3.07 0.055 0.99 0.040 1,576
A great deal 2.99 0.065 1.22 0.048 1,225
Survey month .04 .02
September 3.00 0.076 0.89 0.040 1,233
October 3.59 0.18 0.87 0.097 180
November 2.97 0.10 0.94 0.068 366
December 2.84 0.12 1.13 0.087 352
January 2.95 0.066 1.08 0.050 766
February 2.94 0.22 1.11 0.16 178
march 3.04 0.079 0.93 0.054 451
April 2.87 0.19 0.93 0.12 112
TOTAL sample 2.99 0.041 0.99 0.025 3,638
†
Statistically significant difference by population characteristic determined using adjusted Wald F-test for categorical
variables.
10 L. M. HOUGHTALING ET AL.

100.0

90.0

80.0

70.0

60.0

50.0

40.0

30.0

20.0

10.0

0.0
Cutting or Eating less Using drugs Smoking Connecting Drinking Eating more Praying or Taking a Getting Exercising Connecting
self-injury food than (like valium, cigarettes with a alcohol food than meditating break from plenty of or walking with friends
usual cannabis, or vaping mental or usual news/social sleep or family
marijuana, physical media
or opioids) healthcare
provider

Overall Exclusively Heterosexual Exclusively Gay/lesbian Plurisexual Other sexual identity

Figure 1. Weighted proportions of individual COVID-19 coping behaviors overall and by sexual
identity.

100.0

90.0

80.0

70.0

60.0

50.0

40.0

30.0

20.0

10.0

0.0
Cutting or Eating less Using drugs Smoking Connecting Drinking Eating more Praying or Taking a Getting Exercising Connecting
self-injury food than (like valium, cigarettes or with a alcohol food than meditating break from plenty of or walking with friends
usual cannabis, vaping mental or usual news/social sleep or family
marijuana, physical media
or opioids) healthcare
provider

Overall Cisgender man Cisgender woman Transgender Other nonbinary identity

Figure 2. Weighted proportions of individual COVID-19 coping behaviors overall and by gender
identity.
 JOURNAL OF HOMOSEXUALITY 11

Table 2. Adjusted IRRs and 95% CIs of negative COVID-19 coping behaviors, from adjusted
Poisson regression models.
Negative Behaviors
IRR 95% CI
Sexual Identity (ref = Exclusively Heterosexual)
Exclusively Gay or Lesbiana 1.16 1.05, 1.29
Plurisexuala,b 1.41 1.24, 1.61
Other sexual identitya 1.22 1.01, 1.48
Gender Identity (ref = Cisgender Men)
Cisgender Women 1.04 0.95, 1.15
Transgender 1.43 0.67, 3.05
Other nonbinary identity 0.95 0.71, 1.27
a
Difference compared to reference group is statistically significant at an alpha level of 0.05.
b
Difference compared to gay or lesbian respondents OR cisgender women respondents as reference group is
statistically significant at an alpha level of 0.05.
Notes. Final model adjusted for age, race/ethnicity, nativity, marital status, children in household, education,
employment, health status, COVID symptoms, COVID life disruption, COVID stress, and survey month. IRR =
incidence rate ratio. CI = confidence interval.

Table 3. Adjusted IRRs and 95% CIs of positive COVID-19 coping behaviors, from adjusted
Poisson regression models.
Positive Behaviors
IRR 95% CI
Sexual Identity (ref = Exclusively Heterosexual)
Exclusively Gay or Lesbiana 1.07 1.01, 1.15
Plurisexual 1.01 0.93, 1.10
Other sexual Identity 1.06 0.94, 1.20
Gender Identity (ref = Cisgender Men)
Cisgender Womena 1.23 1.16, 1.29
Transgendera 1.39 1.22, 1.59
Other nonbinary identityb 1.08 0.94, 1.23
a
Difference compared to reference group is statistically significant at an alpha level of 0.05.
b
Difference compared to gay or lesbian respondents OR cisgender women respondents as reference group is
statistically significant at an alpha level of 0.05.
Notes. Final model adjusted for age, race/ethnicity, nativity, marital status, children in household, education,
employment, health status, COVID symptoms, COVID life disruption, COVID stress, and survey month. IRR =
incidence rate ratio. CI = confidence interval.

command glm to specify a Poisson distribution and log link, as well as robust
standard errors via the svy prefix. In the final Poisson models, we adjust for a full
set of demographic covariates that are known predictors of coping behaviors, as
well as novel COVID-19 specific predictors. We did not have a measure of health
behaviors prior to the pandemic in this sample and we adjusted for general health
status to control for differences in health at baseline between groups. We also
controlled for the survey month as this influenced respondent reported coping
behaviors. We did not include a variable for couple type in our models because it
was highly collinear with the sexual identity variable. We tested for an interaction
between sexual and gender identity using a Wald postestimation test. For the
interaction test, we grouped transgender and nonbinary gender identity respon­
dents together to obtain a minimum cell size of 10 for each subgroup. For our
final models, we present incidence rate ratios of negative COVID-19 coping
12 L. M. HOUGHTALING ET AL.

behaviors by sexual and gender identity in Table 2, and incidence rate ratios of
positive COVID-19 coping behaviors by sexual and gender identity in Table 3.
Both final models were adjusted for the same set of covariates.

Results
The weighted sample characteristics are presented in Table 1. During the
pandemic, it was more common to respond with positive than negative
coping behaviors. The most common coping strategies were connecting
with friends or family, exercising or walking, getting plenty of sleep and
taking a break from news or social media with more than half of the sample
reporting these behaviors (gray bars in Figures 1 and 2). However, our data
revealed stark disparities in the prevalence of certain coping behaviors by
sexual and gender identity. Over 40% of plurisexual respondents reported
using drugs compared to 11% of heterosexual and 16% of gay or lesbian
respondents, and 29% of other sexual identity respondents. Alarmingly,
a greater proportion of another sexual identity (5%) and other nonbinary
identity (14%) respondents reported cutting or self-injury compared to all
other respective sexual and gender identities. Transgender respondents more
commonly reported connecting with friends or family, praying or meditating
and smoking cigarettes or vaping compared to other gender and sexual
identities. Over 43% of other nonbinary identity respondents reported
using drugs compared to 12% of cisgender men, 11% of cisgender women,
and 38% of transgender respondents. Drinking alcohol was most common
among cisgender men, other nonbinary identity, and plurisexual
respondents.
Tables 2 and 3 show the main effects Poisson regression models adjusted for
covariates identified a priori as potential confounders. These results were
consistent with results from bivariate models including sexual identity as the
predictor and separately gender identity as the predictor, although the effect
estimates were attenuated in the fully adjusted models. The full models
including sociodemographic controls, survey month, and COVID-19 factors
are included as Supplemental Tables S1 and S2. We found that gay or lesbian
respondents reported 16% more, other sexual identity respondents 22% more,
and plurisexual respondents 41% more negative coping behaviors than hetero­
sexual respondents (p = .004, p = .04 and p < .001; Table 2). When compared to
cisgender male respondents, cisgender women (p = .4), transgender (p = .4)
and nonbinary respondents (p = .7) reported similar levels of negative coping
behaviors (Table 2). Compared to gay or lesbian respondents, plurisexual
respondents reported a higher rate of negative coping behaviors (1.22; 95%
CI: 1.05, 1.41; p = .01) (not pictured).
Gay or lesbian respondents reported 8% more positive coping behaviors
than heterosexual respondents (p = .02; Table 3). By gender identity, cisgender
 JOURNAL OF HOMOSEXUALITY 13

women and transgender respondents reported 23% more and 39% more
positive behaviors, respectively, compared to cisgender men (p < .001;
Table 3). When compared to cisgender women, transgender respondents
reported slightly more positive behaviors (1.13; 95% CI: 0.996, 1.29; p = .06)
(not pictured). Nonbinary respondents reported fewer positive behaviors than
cisgender women (0.88; 95% CI: 0.774, 0.996; p = .04) (not pictured).
With regard to the sociodemographic and pandemic-related covariates,
adults who are cohabiting or who have some college education reported 1.2
times the rate of negative coping behaviors than married adults; and adults
with some college education, technical school or associate’s degree reported
1.1 times more negative coping behaviors compared to those with a high-
school education or less. Adults in very good/excellent health or adults who
were born outside the U.S. reported 0.7 times the rate of negative coping
behaviors than adults in poor/fair/good health or than adults born within the
U.S., respectively. Negative coping behaviors decreased with age. Not surpris­
ingly, adults who reported a higher level of COVID-19 related stress and
disruption to their lives also had higher rates of negative coping behaviors.
Rates of positive behaviors were lower among respondents who reported any
children under the age of 18 in the household; or who reported a higher level
of COVID-19 related stress. Rates of positive behaviors were higher among
respondents who identified as non-Hispanic Black; had some college or higher
level of education; or reported very good or excellent health. Surprisingly,
adults who reported greater disruption to their lives due to COVID-19 or
having ever suspected they had COVID-19 reported slightly more positive
behaviors compared to those who reported no disruption and not ever having
COVID-19.
Based on the literature, the minority stress model and binegativity, we
hypothesized that the relationship between coping behaviors and sexual iden­
tity would differ based on gender identity and tested this hypothesis in
sensitivity analyses through adding an interaction term to our main effects
models. The Wald postestimation test for the global interaction between
sexual identity and the three-level gender identity variable was p = .05 for
negative coping behaviors and p = .02 for positive coping behaviors (results
not shown). These results indicated that there was some variation in the
number of positive coping behaviors across sexual identities by gender iden­
tity, but the results were not reliable due to small sample sizes within certain
subgroups defined by sexual and gender identity.
In additional supplementary analyses, we estimated the odds of reporting
any negative coping behaviors compared to none and any positive coping
behaviors compared to none, adjusting for all the same covariates as the
Poisson models. Similar to our primary analyses, we found that both gay or
lesbian and plurisexual respondents had significantly greater odds of engaging
in any negative behaviors compared to heterosexual respondents; and we
14 L. M. HOUGHTALING ET AL.

found no differences in reporting any negative behaviors by gender identity.

We also found that cisgender women had two times greater odds of engaging
in any positive behaviors compared to cisgender men.

Discussion
Our study contributes to the growing literature describing COVID-19 pan­
demic-related coping behaviors by sexual and gender identities with
a nationally representative sample of sexually and gender diverse cohabiting
or married adults. We found that differences in the number of negative
coping behaviors during the pandemic differed by sexual identity, whereas
differences in the number of positive coping behaviors weighed more heavily
on gender identity. We found higher rates of negative coping behaviors
among gay or lesbian, plurisexual, and other sexual identity respondents
compared to heterosexual respondents; and the highest overall rate among
plurisexual respondents. These findings were consistent with our under­
standing of minority stress theory and binegativity, but less so for minority
stress theory as it applies to gender. We also found higher rates of positive
coping behaviors among gay, lesbian, transgender and cisgender women
participants compared to heterosexual and to cisgender men participants,
respectively. While we expected to find higher rates of positive coping
behaviors among women compared to men, we did not expect to find higher
rates among transgender participants based on the minority stress model.
We speculate that among the transgender sample, respondents may have
reported more behaviors overall, both positive and negative, or may have
other resilience-related characteristics that increase the likelihood of report­
ing positive behaviors, such as strong family and LGBTQ+ support networks
and identity pride (Testa et al., 2015). The literature on transgender stigma
shows that family support, identity pride and peer support can buffer the
negative effects of minority stress on mental and physical health among adult
transgender U.S. populations (Bockting et al., 2013; Valente et al., 2020,
2022). Because all respondents in NCHAT were married or cohabiting, this
partnered sample of transgender adults may have a stronger support network
by definition and thus differ slightly from transgender adults in the general
population. Further examination of risk and protective factors by sexual and
gender identity is needed to explore these hypotheses and to develop context
for this finding.
Gay or lesbian respondents reported both more negative and positive beha­
viors than heterosexual respondents, and fewer negative behaviors than bisexual
respondents. These findings were fairly consistent with the literature showing
that gay or lesbian adults engaged in more harmful health-related behaviors
than heterosexual adults (Gonzales & Henning-Smith, 2017; Gonzales et al.,
2016) and the literature on health deficits in bisexual and plurisexual
 JOURNAL OF HOMOSEXUALITY 15

populations compared to gay or lesbian populations (Dyar et al., 2020; Shokoohi

et al., 2022). Considering again that NCHAT respondents were married or
cohabitating and the age distribution skewed older, our sample of gay or lesbian
adults may have had greater income, employment and social support than other
gay or lesbian samples that are unpartnered, younger or older. These factors
may have influenced engagement in more positive health behaviors in the
NCHAT sample than unpartnered gay or lesbian samples (Fredriksen-
Goldsen et al., 2015, 2017; Goldsen et al., 2017; Kim et al., 2017).
While we did not find statistically significant differences across sexual
identities by gender identity through testing the interaction effects, future
studies could focus on differences in coping behaviors by gender identity
within certain sexual identity groups, such as non-heterosexual or plurisexual
only. Another approach could focus on the most prevalent positive and
negative coping behaviors within specific populations, such that meaningful
differences by gender identity could be statistically reliable.

Limitations and considerations

A limitation of our study is that our data are cross-sectional and thus we do
not know how much COVID-19 exacerbated existing disparities in the
measured coping behaviors within our sample. Many of the coping measures
are included in other data sources fielded in 2020 and 2021, such as the
NHANES, BRFSS, or NHIS and could be compared with the prevalence of
the coping behaviors in our sample. However, no other data set includes the
range of positive and negative coping behaviors and sufficient samples of the
LGBTQ+ population. Whether or not COVID-19 exacerbated disparities,
however, does not undermine the need to address and examine in more
detail the disparities in COVID-19 coping behaviors uncovered here.
Another limitation is our estimates for transgender and nonbinary adults
were more vulnerable to random error (less precise) due to smaller sample
sizes. More research is needed to substantiate our findings in noncisgender
samples. Additional limitations are that our study is U.S. based; the statistical
methods used in this paper are limited in examining intersectionality; and we
did not account for the intensity of individual coping behaviors, such as
number of alcoholic drinks per day.
A strength of our study is the large sample of sexually and gender diverse
adults in a population-based sample. An additional strength is the following of
best practices for asking about sexual orientation on surveys (Badgett et al.,
2009) and for asking questions to identify transgender and other gender
minority respondents on population-based surveys (Badgett et al., 2014). For
example, the NCHAT survey had the option to select multiple identities from
a diverse set of sexual identities; and gender identity was assessed in a two-part
16 L. M. HOUGHTALING ET AL.

question, as well as asking separately about sex assigned at birth (defined as the
sex appearing on the respondent’s original birth certificate).

Future directions
To build on this descriptive study, future researchers could examine asso­
ciations between individual coping behaviors and COVID-19 stressors, and
explore the effect of couple type and the coping behaviors of one’s partner­
(s) on pandemic related coping behaviors for the main respondents.
Additional research could adopt an analytic method more supportive of
an intersectional framework and examine intersections of social identities
that experience a higher burden of specific harmful coping behaviors or
a higher prevalence of protective coping behaviors. This type of analysis
could also explicate differences by racial/ethnic identity within the context
of racism and racial trauma occurring during the same time period. Future
research could also explore the bisexual population separately from pan­
sexual, omnisexual and queer populations given recent evidence of impor­
tant variation within plurisexual identities (Dyar et al., 2020; Feinstein
et al., 2021). Finally, another avenue for additional research is differences
in resilience processes according to sexual and gender identity, such as
social support and identity pride, which may moderate or mediate the
effects of minority stress on certain pandemic-related coping behaviors
(Goldbach et al., 2021), and may provide context for some of our unex­
pected findings.

Conclusion
Our work highlights a wide range of positive and negative coping strategies
and our findings are generally consistent with prior studies of COVID-19
pandemic coping behaviors in sexually and gender diverse populations with
some unique findings. Our estimates for transgender and nonbinary adults are
more vulnerable to random error (less precise) due to smaller sample sizes.
More research is needed to substantiate our findings in noncisgender samples.

Acknowledgments
Miranda Berrigan for contribution to NCHAT dataset management and coding.

Disclosure statement
No potential conflict of interest was reported by the authors.
 JOURNAL OF HOMOSEXUALITY 17

Funding
The authors gratefully acknowledge support from the Minnesota Population Center (P2C
HD041023) funded through a grant from the Eunice Kennedy Shriver National Institute for
Child Health and Human Development (NICHD); Eunice Kennedy Shriver National Institute
of Child Health & Human Development (NICHD) (1R01HD094081-01A1).

ORCID
Laura M. Houghtaling http://orcid.org/0000-0003-2509-7657
Wendy D. Manning http://orcid.org/0000-0002-8063-7380
Claire M. Kamp Dush http://orcid.org/0000-0003-4307-6825

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