Characterizing state-level structural cisheterosexism trajectories using sequence and cluster analysis, 1996-2016, 50 U.S. states and Washington, D.C., and associations with health status and healthcare outcomes

Structural cisheterosexism is a root cause of LGBTQ health inequities. Amidst ongoing legal attacks on LGBTQ populations' rights, research is needed to examine changes in policy contexts over time and associated implications for population health and inequities. To address this gap, we constructed state-level structural cisheterosexism trajectories for each U.S. state/D.C. from 1996-2016. We used sequence analysis to quantify differences between trajectories and cluster analysis to group similar trajectories. We evaluated associations between trajectory clusters and individual-level health(care) outcomes (self-rated health, frequent mental distress, lacking insurance, lacking a doctor, avoiding care due to cost) from the 2017 Behavioral Risk Factor Surveillance System, in the overall sample and by LGBTQ status (LGBTQ vs. cisheterosexual), using multilevel logistic models. From 38 unique trajectories, we identified five trajectory clusters: "consistently-predominantly-discriminatory", "consistently-fairly-discriminatory", "moderate-with-increasing-protection", "discriminatory-change-to-fairly-protective", and "fairly-discriminatory-change-to-predominantly-protective." Overall, health(care) was worse in states characterized by consistently discriminatory laws compared to states with increasingly protective laws and disproportionately so for LGBTQ people. Findings underscore the need to abolish harmful, cisheterosexist state laws and enact protective laws to advance LGBTQ health equity. More broadly, this study demonstrates the utility of sequence and cluster analysis for assessing long-term population health impacts of structural-level determinants.