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Volume 15 No. 11
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Sexual Orientation and Sleep Behaviors in a National Sample of Adolescents Followed Into Young Adulthood

Jeremy W. Luk, PhD1,2; Kellienne R. Sita, BS1; Daniel Lewin, PhD3; Bruce G. Simons-Morton, EdD, MPH1; Denise L. Haynie, PhD, MPH1
1Social and Behavioral Sciences Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland; 2Department of Medical and Clinical Psychology, Suicide Care, Prevention, and Research Initiative, Uniformed Services University of the Health Sciences, Bethesda, Maryland; 3Children's National Health System, Washington, District of Columbia

ABSTRACT

Study Objectives:

Sexual minority adolescents experience mental and physical health disparities attributable to increased discrimination and minority stress. These same factors may also impair sleep health, although available literature on this topic is limited. This study examined longitudinal associations between adolescent sexual minority status and seven sleep behaviors in young adulthood and tested depressive symptoms and overweight as mediators.

Method:

Data were drawn from Waves 2 (11th grade) to 7 (4 years after high school) of the NEXT Generation Health Study, a national longitudinal cohort study of US adolescents (n = 1946; 6.3% sexual minorities).

Results:

There were no significant sexual orientation disparities in sleep duration, trouble falling asleep, trouble staying asleep, or trouble waking up during young adulthood. Relative to heterosexual females, sexual minority females had higher odds of snoring/stop breathing (36.6% versus 19.2%; adjusted odds ratio = 2.57; 95% confidence interval = 1.30, 5.09) and reported more frequent daytime sleepiness (b = 0.66, 95% confidence interval = 0.05, 1.27). Mediation analyses revealed that female sexual minority status was associated with increased risk of snoring/stop breathing though overweight status (mediated 43.6% of total effect) and was also associated with increased daytime sleepiness through higher depressive symptoms (mediated 70.8% of total effect).

Conclusions:

Among US youth, no sexual orientation disparities were found except for snoring/stop breathing and daytime sleepiness among females. Sexual orientation disparities in these aspects of sleep are partially due to worse mental and physical health among sexual minority females, highlighting depressive symptoms and overweight problems as potential intervention targets.

Clinical Trial Registration:

Registry: ClinicalTrials.gov; Title: Health Behavior in School-Aged Children: NEXT Longitudinal Study 2009-2016; Identifier: NCT01031160

Citation:

Luk JW, Sita KR, Lewin D, Simons-Morton BG, Haynie DL. Sexual orientation and sleep behaviors in a national sample of adolescents followed into young adulthood. J Clin Sleep Med. 2019;15(11):1635–1643.


BRIEF SUMMARY

Current Knowledge/Study Rationale: Few studies have examined sexual orientation disparities in sleep behaviors among adolescents and young adults. This study is the first nationally representative study of sleep behaviors among adolescents longitudinally followed into young adulthood.

Study Impact: Sexual orientation disparities in snoring/stop breathing and daytime sleepiness among female youth were mediated through underweight status and depressive symptoms, respectively. The epidemiologic evidence found in our study has important implications for the assessment and treatment of sleep problems among underserved minority populations.

INTRODUCTION

Insufficient sleep has been increasingly recognized as a public health issue.1 Inadequate sleep during adolescence has been associated with a wide range of physical and mental health problems, including obesity and depression.2 Prior research has documented demographic characteristics (eg, age and regional differences) as correlates of sleep patterns and problems during adolescence.3 However, the role of sexual minority status as a contributor to sleep patterns and problems during the transition from adolescence into young adulthood has largely been neglected. In theory, increased social challenges (eg, rejection from peers or parents),4,5 heightened stress level (eg, stress unique to sexual identity development),6,7 and poorer physical or psychological health (eg, overweight or depression)8,9 all may contribute to potential difficulties with sleep among sexual minority youth. The goal of this study is to examine whether sexual minority adolescents in the United States are more likely than heterosexual adolescents to experience sleep-related problems in emerging adulthood, and to evaluate overweight status and depressive symptoms as potential mediators of sexual orientation differences in sleep behaviors.

Sexual Orientation and Sleep Behaviors

As inadequate sleep is increasingly recognized as a public health problem, there is sparse but growing literature on sexual minority status and sleep behaviors among adults. Data from the 2013–2014 National Health Interview Survey revealed that, relative to heterosexual adults, sexual minority adults experience more sleep disturbances, including difficulty falling asleep, waking up at night, and not feeling rested.10 A separate analysis of the 2013–2015 National Health Interview Survey revealed that although both homosexual and bisexual females were at increased risk for sleep problems relative to heterosexual females, homosexual men were at increased risk relative to both heterosexual and bisexual men.11 Data from the 2013–2014 New York City Health and Nutrition Examination Survey indicated that bisexual adults were at higher risk for sleep problems than heterosexual adults.12 Data from Wave IV of the National Longitudinal Study of Adolescent to Adult Life indicated that sexual minority adults have greater trouble falling and staying asleep than heterosexual adults.13

Despite the aforementioned studies, which point to the presence of sexual orientation disparities in sleep behaviors among adults, the literature on sexual orientation and sleep behaviors among adolescents is almost nonexistent. A thorough search of the literature revealed only one study of sleep among sexual minority adolescents. In a large cross-sectional survey conducted in China, sexual minority adolescents were less likely to sleep 8 or more hours per day and reported poorer sleep quality relative to heterosexual adolescents.14 The lack of corresponding data in the United States is a notable literature gap, particularly in light of research showing that sexual minority adolescents experience poorer mental and physical health, as well as increased discrimination and minority stress than heterosexual adolescents.15,16

Physical and Psychological Health as Mediators

An important endeavor in sexual orientation health disparities research is to identify mediators that explain why sexual minorities are at risk, so that prevention strategies can be built around modifiable mediators. To date, victimization from school bullying is the only factor that has been shown to be a mediator of sexual minority status and poor sleep quality.14 One possible explanation for the lack of mediation analyses is that most prior studies utilized cross-sectional data, limiting the potential to address questions related to mechanisms. The current study addresses this second research gap by testing overweight status and depressive symptoms as potential physical and psychological health pathways to worse sleep behaviors using a longitudinal cohort of adolescents in the United States.

Prior research has documented an overall positive link between insufficient sleep and overweight status among children and adolescents.17 Of particular clinical interest is the elevated prevalence of sleep apnea and related breathing issues (eg, snoring) among youth who are overweight.18 A clinical study has found that sleep-disordered breathing is very common among children and adolescents who are overweight or obese.19 Among youth in the United States, there is cross-sectional evidence linking sexual minority status to overweight/obese status.9,20,21 Moreover, overweight adolescents tend to have more sleep-disordered breathing symptoms, later sleep onset, and more disrupted sleep than healthy control patients.22 Given these prior findings, it is important to examine whether overweight status may attenuate or mediate possible longitudinal association between sexual minority status and snoring over time.

Sleep disturbances are common symptoms of major depression.23 A meta-analysis of sleep and depression during the adolescent period revealed that adolescents with depression had more wakefulness in bed, exhibited lighter sleep, and reported more sleep disturbances.24 Although the direction of effect between sleep and depression remains not entirely clear,25 sleep was found to predict depressive symptoms during the transition from high school into college.26 Given the robust associations between sexual minority status and depressive symptoms,8,27 one possible pathway from adolescent sexual minority status to sleep problems during emerging adulthood may be through increased depressive symptoms during late adolescence.

This study reports on the associations between sexual minority status and seven sleep variables (scheduled day sleep duration, unscheduled day sleep duration, trouble falling asleep, trouble staying asleep, trouble waking up, snoring/stop breathing, and daytime sleepiness) in a recent national cohort of US adolescents. We examined longitudinal associations between adolescent sexual minority status and young adulthood sleep behaviors 5 years later and evaluated overweight and depressive symptoms during the annual assessments in between as mediators of these prospective associations.

METHODS

Sample

The NEXT Generation Health Study (NEXT) is a 7-year longitudinal study of 2,785 10th graders who were followed annually from 2009/2010 to 2015/2016. A three-stage stratified design was used to recruit a nationally representative sample of US high school students. In the NEXT study, sexual orientation was assessed at Waves 2 to 4 with the use of a single item on sexual attraction. For the current analysis, we used sexual attraction assessed in Wave 2 during which participants were in 11th grade (n = 2,439; 87.6% of the full sample; mean age = 17.2, standard deviation = 0.51). The final analytic sample included 1,946 youth (79.8% of Wave 2 sample; mean age = 22.6, standard deviation = 0.52) who provided valid responses to race/ethnicity, family affluence, sexual orientation, and sleep behaviors at Wave 7. Parents provided written consent for adolescent participation; upon turning 18 years of age, participants provided consent. Participants’ responses to the survey were kept confidential. The study was approved by the Institutional Review Board of the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Measures

Sexual Orientation (Wave 2):

Sexual attraction is the most important dimension of sexual orientation during adolescence.28 Accordingly, participants were asked to choose which of the following best describe their sexual orientation: (1) “attraction to opposite gender,” (2) “attraction to same gender,” (3) “attraction to both genders,” and (4) “questioning.” Table 1 presents frequencies and percentages of responses. Due to low frequencies, those endorsing any same-sex or questioning attraction were combined for analyses.

Sample characteristics for the analytic sample and by sex.

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Table 1

Sample characteristics for the analytic sample and by sex.

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Weight Status (Waves 3–6):

Participants reported their weight without clothes in pounds and height without shoes in feet and inches, which were used to calculate body mass index (BMI). BMI z-scores were first computed based on the Centers for Disease Control and Prevention growth charts to adjust for age and sex differences.29 BMI groups were then created based on the American Academy of Pediatrics weight guidelines (underweight: BMI < 5th percentile; normal weight: 5th percentile ≤ BMI < 85th percentile; overweight: 85th percentile ≤ BMI < 95th percentile; and obese: ≥ 95th percentile).30 As participants aged out of pediatric weight guidelines, adult cutoffs were used for these weight categories (underweight: BMI < 18.5; normal weight: BMI 18.5–24.9; overweight: BMI 25.0–29.9; obese: BMI ≥ 30). Underweight status was coded as missing due to low frequencies (2.1% [n = 24] of female participants), whereas overweight status was coded as a three-category variable: 0 = “normal weight,” 1 = “overweight,” and 2 = “obese.”

Depressive Symptoms (Waves 3–6):

The Patient-Reported Outcomes Measurement Information System (PROMIS) scale31 was used to measure depressive symptoms, with the standardized T scores used as indicators of the latent factor. Each item was treated as a continuous indicator, with a higher latent mean score indicating higher depressive symptoms.

Sleep Duration (Wave 7):

Participants responded to four separate items inquiring wake up and sleep time on days when they had to go to school, work, or similar activities (scheduled days) and on days when they do not have to get up at a certain time (unscheduled days). Scheduled and unscheduled day sleep duration were calculated based on the time (in hours and minutes in either am or pm) when they usually wake up and go to sleep. Durations that are either too short (< 5 hours) or too long (> 15 hours) were considered improbable and these participants (n = 145; 5.9% of the Wave 2 sample) were excluded from analyses.32 Sleep durations for unscheduled and scheduled days were first coded as a three-category variable for analyses: short (less than 8 hours per night), optimal (8 to 9.5 hours; referent group), and long (more than 9.5 hours per night). In addition, we referenced the National Sleep Foundation’s (NSF) age-specific sleep duration recommendation and created a binary variable for further analyses. Specifically, young adults who slept for 7 to 9 hours were coded as meeting the NSF sleep recommendation, and those who did not were coded as not meeting the NSF sleep recommendation.33

Troubles With Sleep (Wave 7):

Participants responded to three separate items on the number of days over the past 4 weeks that they had (1) trouble falling asleep, (2) trouble staying asleep, and (3) trouble waking up. Response options were (1) “Never,” (2) “Less than once a week,” (3) “1-2 times a week,” (4) “3-4 times a week,” and (5) “5 or more times a week.” These items were dichotomized as 0 = “less than once a week” versus 1 = “once or more per week.”

Snoring/Stop Breathing (Wave 7):

Participants reported whether they (yes/no) snore or stop breathing when they were asleep.

Daytime Sleepiness (Wave 7):

The last sleep item assessed the number of days per week (ranging from 0 to 7; treated as a continuous variable) participants feel sleepy during the day.

Covariates:

Participants reported race/ethnicity, which was categorized into four groups: white, African American, Hispanic, and other. The Health Behavior School-Aged Family Affluence Scale was used to measure perceived family affluence with items such as family car and computer ownership and frequency of family holidays.34

Statistical Analyses

Sexual orientation disparities in seven sleep behaviors were examined using adjusted multinomial logistic regression (for the three-category sleep duration variables), binary logistic regression (for sleep duration variables based on the NSF sleep duration recommendation, troubles with sleep, and snoring/stop breathing), and linear regression model (for daytime sleepiness), conducted separately for males and females. Based on literature review and analyses as described previously, we conceptualized overweight status and depressive symptoms as potential mediators that might explain observed sexual orientation disparities among female adolescents. We modeled overweight/obese status and depressive symptoms as latent variables using self-reported BMI and the PROMIS T scores across Waves 3 to 6 within a structural equation modeling (SEM) framework. Specifically, self-reported BMI (specified as ordinal variables) and PROMIS T scores (specified as continuous variables) from each wave were treated as indicators of the latent constructs. Mediated effects were evaluated using the product of coefficients with bootstrapped confidence intervals. Missing data were allowed in the mediation analyses. For overweight status, almost all female participants had at least one wave of BMI data (n = 1,121, 97.4% of female participants) and most had at least three waves of BMI data (n = 923, 80.2%). For depressive symptoms, all except 2 participants had at least a single wave of PROMIS data (n = 1,149, 99.8%) and most had at least three waves of PROMIS data (n = 1,073, 93.2%). The Robust Weighted Least Squares estimator was used to handle missing data in overweight status and was used to model snoring/stop breathing as a binary outcome. The Robust Maximum Likelihood estimator was used to handle missing data in depressive symptoms and to model frequency of daytime sleepiness as a continuous outcome. Logistic and linear regression analyses were conducted in STATA 14 (StataCorp LP, College Station, Texas, United States), and mediation analyses were conducted in Mplus 8 (Muthén & Muthén, Los Angeles, California, United States). All analyses accounted for the complex survey design of the NEXT study.

RESULTS

Demographic characteristics for the analytic sample are presented in Table 1. The sample was 59.1% female and racially and ethnically diverse, with 59.0% white, 18.7% African American, 18.6% Hispanic, and 3.7% other. About half of the participants (49.8%) reported a medium level of family affluence. Sexual minority status was reported among 3.5% of male and 8.2% of female participants.

Sleep behaviors in emerging adulthood by sexual orientation are presented in Table 2 and Table 3 (for males and females, respectively), along with adjusted relative risk ratios from multinomial logistic regression models (for categorical outcomes), adjusted odds ratios from logistic regression models (for binary outcomes), and regression coefficients from linear regression models (for continuous outcomes). No sexual orientation disparities were found for sleep duration (regardless of whether it was coded into three categories or using the NSF recommended cutoff) or any of the three types of sleep troubles. Relative to heterosexual females, sexual minority females were more likely to report snoring/stop breathing (36.6% versus 19.2%; adjusted odds ratio = 2.57, 95% confidence interval [CI] = 1.30, 5.09) and more days feeling sleepy (b = 0.66, 95% CI = 0.05, 1.27).

Adolescent sexual minority status (Wave 2) as a predictor of sleep behaviors in emerging adulthood (Wave 7) among males (n = 795).

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Table 2

Adolescent sexual minority status (Wave 2) as a predictor of sleep behaviors in emerging adulthood (Wave 7) among males (n = 795).

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Adolescent sexual minority status (Wave 2) as a predictor of sleep behaviors in emerging adulthood (Wave 7) among females (n = 1,151).

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Table 3

Adolescent sexual minority status (Wave 2) as a predictor of sleep behaviors in emerging adulthood (Wave 7) among females (n = 1,151).

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To test underlying mediators of the observed sleep disparities among sexual minority females, we constructed two SEM models. The first model examined overweight status as a mediator of sexual minority status and snoring/stop breathing. This SEM model fitted the data well: χ2 = 28.739, degrees of freedom = 20, P = .09; root mean square error of approximation = 0.019 (90% CI = 0.000, 0.034); comparative fit index = 0.999; Tucker-Lewis Index = 0.999. Factor loadings and regression coefficients are reported in Figure 1. Sexual minority females were more likely to be overweight than heterosexual females (b = 0.650, standard error [SE] = 0.179, 95% CI = 0.287, 0.984), which in turn led to increased likelihood of snoring/stop breathing (b = 0.375, SE = 0.046, 95% CI = 0.286, 0.461). The percentage of the association mediated by overweight status was 43.6%. Table 4 presents the cross-tabulation of overweight status and sexual minority status among female participants.

Structural equation model testing overweight as a mediator of sexual orientation disparities in snoring/stop breathing among female youth (n = 1,151).

All coefficients are unstandardized, with 95% confidence intervals presented. Bias-corrected indirect effects were obtained through bootstrapping. The arrow from sexual minority status to overweight represents the coefficient for the association between sexual minority status and overweight. The arrow from overweight to snoring/stop breathing represents the coefficient for the association between overweight and snoring/stop breathing, controlling for sexual minority status and covariates. The coefficient from sexual minority status to snoring/stop breathing quantifies the direct associations between sexual minority status and snoring/stop breathing not through the mediator. W2 = Wave 2; W3 = Wave 3; W4 = Wave 4; W5 = Wave 5; W6 = Wave 6; W7 = Wave 7.

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Figure 1

Structural equation model testing overweight as a mediator of sexual orientation disparities in snoring/stop breathing among female youth (n = 1,151).

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Cross-tabulation of overweight status and sexual minority status among female participants (n = 1,121).

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Table 4

Cross-tabulation of overweight status and sexual minority status among female participants (n = 1,121).

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The second model examined depressive symptoms as a mediator of sexual minority status and daytime sleepiness. This SEM model also fit the data well: χ2 = 33.176, degrees of freedom = 20, P = 0.03; root mean square error of approximation = 0.024 (90% CI = 0.007, 0.038); comparative fit index = 0.965; Tucker-Lewis Index = 0.939. Factor loadings and regression coefficients are reported in Figure 2. Sexual minority females reported higher depressive symptoms than heterosexual females (b = 3.729, SE = 0.981, P < .001, 95% CI = 2.073, 5.924), which in turn predicted increased frequency of daytime sleepiness (b = 0.125, SE = 0.026, P < .001, 95% CI = 0.078, 0.180). The percentage of the association mediated by depressive symptoms was 70.8%.

Structural equation model testing depressive symptoms as a mediator of sexual orientation disparities in daytime sleepiness among female youth (n = 1,151).

All coefficients are unstandardized, with 95% confidence intervals presented. Bias-corrected indirect effects were obtained through bootstrapping. The arrow from sexual minority status to depressive symptoms represents the coefficient for the association between sexual minority status and depressive symptoms. The arrow from depressive symptoms to days feeling sleepy represents the coefficient for the association between depressive symptoms and daytime sleepiness, controlling for sexual minority status and covariates. The coefficient from sexual minority status to days feeling sleepy quantifies the direct associations between sexual minority status and daytime sleepiness not through the mediator. W2 = Wave 2; W3 = Wave 3; W4 = Wave 4; W5 = Wave 5; W6 = Wave 6; W7 = Wave 7; PROMIS = Patient-Reported Outcomes Measurement Information System Depressive Symptoms Scale.

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Figure 2

Structural equation model testing depressive symptoms as a mediator of sexual orientation disparities in daytime sleepiness among female youth (n = 1,151).

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DISCUSSION

In this recent national cohort of youth in the United States, no sexual orientation disparities were found except for snoring/stop breathing and daytime sleepiness among females. On unscheduled days, the percentages of youth whose sleep duration met the NSF recommendation of 7 to 9 hours ranged from 54.5% to 69.7%. Among males, the percentages of heterosexual and sexual minority youth whose sleep duration met the NSF recommendation on scheduled days were 64.0% and 64.6%, respectively, numbers that were very similar to the percentage reported among US male adults (63.9%).11 Among females, the percentages of heterosexual and sexual minority youth whose sleep duration met the NSF recommendation on scheduled days were 67.3% and 45.9%, respectively, whereas the corresponding percentage among US female adults was 63.0%.11 Though the sexual orientation difference was not statistically significant in this sample, the overall pattern of findings may indicate sexual minority females as more vulnerable to suboptimal sleep health.

The absence of sexual orientation disparities in sleep problems, including trouble falling and staying asleep, was contrary to previous studies conducted among adults,10,12,13 and may be due to differences in measurement (ie, attraction versus identity or behavior) or reflect developmental differences. One possibility is that sleep insufficiency may generally be prevalent among youth regardless of sexual orientation,2 whereas sexual minority adults may exhibit more sleep problems than heterosexual adults due to persistent stress and worse physical and psychological health over time. Taken together, the current findings suggest that sleep problems experienced by sexual minorities in early adulthood only pertains to two specific aspects of sleep and only among females.

Our study is the first to identify greater likelihood of snoring/stop breathing among sexual minority females. Using longitudinal mediation analyses, we further identified overweight status as a pathway from adolescent sexual minority status to snoring/stop breathing during emerging adulthood. Accordingly, our analyses indicate that sexual minority females may represent an at-risk group for snoring/stop breathing, although addressing the issue of overweight or obesity may potentially mitigate such risks. Prior research has demonstrated positive associations between snoring and risk of cardiovascular disease.35 More research is needed to examine whether snoring among sexual minority females may be indicative of subsequent health risks during mid and late adulthood.

Increased frequency of daytime sleepiness in the absence of shorter sleep duration or troubles with sleeping may indicate that sexual minority females have poorer sleep quality. Prior research has documented inverse association between daytime sleepiness and academic, behavioral, and psychological functioning during adolescence.36 An epidemiologic study of young adults indicated that daytime sleepiness was more commonly found among those who were single and employed full time, and was linked to both frequent snoring and major depression.37 Therefore, it is possible that sexual minority females may encounter increased functional impairment in multiple domains of life that are commonly associated with daytime sleepiness, warranting further research. Our mediation analyses add to this literature by identifying adolescent depressive symptoms as a contributor to daytime sleepiness among sexual minority females during emerging adulthood. As daytime sleepiness can lead to cognitive impairment and accidents during driving and at work,3840 strategies to improve sleep quality and reduce depressive symptoms may be important to mitigate these risks among sexual minority females.

Despite the strengths of this study, including the nationally representative sample, the assessment of multiple sleep behaviors, and the use of a recent, longitudinal dataset, it is important to recognize its limitations and consider the current findings to be preliminary. First, sexual orientation was measured using a single item focused on sexual attraction and did not assess sexual behavior or identity. A multidimensional measure of sexual orientation could provide more nuanced findings regarding the association between sexual orientation and sleep behaviors. Second, although the current sample was fairly large, the examination of sexual minority subgroup differences was not feasible due to the small cell sizes. In particular, adolescents who reported “questioning” their sexual attraction may not endorse any same-sex or bisexual attraction, behavior, or identity later in development. Future research using larger samples could further examine pattern of sexual minority subgroup differences and potential transitions from one subgroup to another across time.41 Third, the measure of sexual orientation was not available in Wave 7 and so it was not possible to examine the concurrent associations between sexual minority status and sleep behaviors at Wave 7. In light of research that shows the importance of fluidity of sexual identity,7 it would be innovative to model changes in sexual identity and sleep behaviors over time in future research. Fourth, sleep behaviors did not include a specific measure on insomnia and were measured using self-report questionnaire items could introduce measurement bias (eg, self-report of snoring may be inaccurate). Using objective sleep measurement to examine sexual minority status and sleep behaviors across development would be an important future research direction. Fifth, statistical power may be limited due to the relatively few sexual minority males in this sample. Finally, despite the theoretical importance of interpersonal and minority stressors in understanding sleep behaviors among sexual minority youth, these variables were not measured in the NEXT study. Future studies that incorporate these variables in their investigation would further advance our understanding of additional underlying pathways leading to sleep disturbances among sexual minority youth.

Despite these limitations, the current study is novel and holds implications for screening and interventions. Preliminary findings based on a national sample indicated that sexual orientation disparities in sleep behaviors are specific to two aspects of sleep among sexual minority females: snoring/stop breathing and daytime sleepiness. Longitudinal evidence points to the need for effective screening of overweight status and depressive symptoms to prevent sleep-related issues among sexual minority females. Sexual minority females may benefit from intervention targeting depressive symptoms and weight-related issues and addressing ways to reduce snoring and improve sleep quality. Moving forward, it would be important to collect annual data on sleep behaviors across mid to late adolescence to rule out the possibility that sexual orientation disparities during emerging adulthood simply reflect long-standing sleep problems. Additional longitudinal research is needed to examine how various dimensions of sexual orientation may be associated with the emergence and development of sleep and health behaviors across time.

DISCLOSURE STATEMENT

This project (contract HHSN275201200001I) was supported in part by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development; the National Heart, Lung, and Blood Institute; the National Institute on Alcohol Abuse and Alcoholism; the National Institute on Drug Abuse; and the Maternal and Child Health Bureau of the Health Resources and Services Administration. The opinions and assertions expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Uniformed Services University or the Department of Defense. The authors report no conflicts of interest.

ABBREVIATIONS

BMI

body mass index

NEXT

NEXT Generation Health Study

PROMIS

Patient-Reported Outcomes Measurement Information System

SEM

structural equation modeling

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