Download:
pdf |
pdfNSFG
OMB Attachment C
OMB No. 0920‐0314
Justifications for Sensitive Questions
in the National Survey of Family Growth (NSFG)
All references cited in this attachment are listed at the end of Supporting Statement Part B.
ALPHABETICAL LIST OF ACRONYMS
ACASI
Audio Computer‐Assisted Self Interviewing
CASI
Computer‐Assisted Self‐Interview
CAWI
Computer‐Assisted Web Interview
CDC
Centers for Disease Control and Prevention, DHHS
DHP
Division of HIV Prevention (of CDC/NCHHSTP)
DHHS
Department of Health and Human Services
DSTDP
Division of STD Prevention (of CDC/NCHHSTP)
NCHHSTP
National Center for HIV/AIDS, Viral Hepatitis, STD, and Tuberculosis
Prevention
NCHS
National Center for Health Statistics (of CDC)
NCIPC
National Center for Injury Prevention and Control
NICHD
Eunice Kennedy Shriver National Institute of Child Health and Human
Development (of National Institutes of Health, DHHS
OVERVIEW
This attachment provides justification for the sensitive topics included primarily in the
final section of the NSFG questionnaire (female section J and male section K) and explains
how the data are used. For those completing the NSFG survey online using computer‐assisted
web interview (CAWI), there will be no change in mode when they arrive at this final
questionnaire section, but for those interviewed in person by an NSFG field interviewer, this
final section will be self‐administered using computer‐assisted self‐interview (CASI). Most of
these topics have been covered in previous NSFG surveys, and this attachment gives particular
attention to the justification for questions that are new or refined in female section J and male
section K for data collection beginning in January 2022. For further information on the uses and
rationale for data collected in earlier sections of the NSFG, please see:
Section 2 in Supporting Statement A (“Purpose and Use of Information Collection”)
Authorizing legislation (Attachments A1‐A11)
Memoranda of support from other government offices (Attachments E1‐E13)
Bibliographies of publications using NSFG data
The questionnaires that are to be fielded beginning in January 2022 are similar in
content to those last fielded in 2017‐2019, however some topics have been streamlined or
restructured to reduce complexity and respondent burden. In addition, due to the use of both
face‐to‐face interviewing and online surveys in the NSFG data collection, the final section of
1
NSFG
OMB Attachment C
OMB No. 0920‐0314
interview will not involve a mode change for some respondents. Following some background
on the NSFG self‐administered component and brief outlines of the female and male surveys,
the remainder of this attachment discusses sensitive topics included primarily in the final
section (female J; male K) of the questionnaires, emphasizing their program and policy uses.
BACKGROUND OF THE NSFG AND THE ACASI (SELF‐ADMINISTERED) COMPONENT
Since its inception in 1973, the mission of the NSFG has been to collect information on
pregnancy, childbearing, and maternal and reproductive health. In 1973‐1995 (Cycles 1‐5), the
survey interviewed only females, and its focus was primarily on factors related to the proximate
determinant of fertility, including sexual activity, contraception, marriage, cohabitation, and
infertility. Beginning with the 2002 NSFG (Cycle 6), data were also collected from males to help
provide more complete information related to fertility and family formation in the United
States, as well as public health concerns related to sexually transmitted diseases (STDs),
including HIV. Below are brief outlines of the female and male NSFG questionnaires, in order to
describe the context in which respondents arrive at the final section of the questionnaire with
more sensitive content (female J and male K).
Brief Outline of the Female Questionnaire
Section A: Background and demographic information, foster care experience
Section B:
Pregnancy history; care of nonbiological children, including adoption
Section C:
Marital and relationship history, including information on current same‐
sex spouse or cohabiting partner; first sexual intercourse with a male;
recent male sexual partners (up to 3 in last 12 months)
Section D: Sterilization and impaired fecundity
Section E:
Contraceptive history and intendedness of pregnancies
Section F:
Family planning and related medical services
Section G: Desires and intentions for future children
Section H: Infertility services and reproductive health; disability; cancer experience;
HIV testing, HPV vaccine
Section I:
More background including access to health care, demographic
information and attitude questions
Section J:
General health status measures; substance use; STD/HIV risk behaviors;
nonvoluntary intercourse; same‐sex sexual experience; sexual identity;
adverse childhood events; income
Brief Outline of the Male Questionnaire
Section A: Background and demographic information, foster care experience
(largely same as female A)
Section B:
Sex education, vasectomy & infertility, sexual intercourse, enumeration
and relationship with up to 3 recent (or last) sexual partners
Section C:
Current spouse or cohabiting partner: key dates and characteristics for
2
NSFG
OMB Attachment C
Section D:
Section E:
Section F:
Section G:
Section H:
Section I:
Section J:
Section K:
OMB No. 0920‐0314
this spouse; if a wife of female cohabiting partner, further information on
sexual intercourse, contraceptive use, and current pregnancy
Up to 3 female sexual partners in last 12 months (or last female partner
ever): similar information collected as in Section C
First former wife and first female cohabiting partner: similar information
collected as in Section C, except for contraception; series on first female
sexual partner ever
Biological children he has fathered; nonbiological children he currently
parents; any other pregnancies that did not end in live birth
Fathering activities – using 1 focal child he lives with and 1 focal child he
doesn’t live with
Desires and intentions for future children
Access to health care; receipt of health services; disability; cancer
experience; HPV vaccine; infertility services; HIV testing
More background, more demographic information and attitude questions
General health status measures; substance use; STD/HIV risk behaviors;
nonvoluntary intercourse; same‐sex sexual experience; sexual identity;
adverse childhood events; income
While other NSFG survey content may be seen as sensitive by some respondents, the
final section of the survey contains questions that would likely be seen as the most sensitive in
the survey. For the respondents who are interviewed in person and for all online mode
respondents, this final section is self‐administered, which affords respondents greater privacy
when answering the questions. The self‐administered survey mode, with or without an audio
component, has been found to improve the reporting of sensitive, private, or potentially
stigmatizing behaviors such as abortions, substance use, HIV/STD risk behaviors, and same‐sex
sexual activity (Fu et al., 1998; Hamilton et al., 2010; Mullany et al., 2013; Turner et al. 1998).
NCHS staff have authored a number of descriptive reports based on the NSFG ACASI
data collected from 2002 through 2015‐2017 (e.g., Anderson et al., 2005, 2006; Chandra et al.,
2011; 2012a, 2012b, 2012c; Mosher et al., 2005). (Given recency of release of the 2017‐2019
NSFG data, no ACASI‐based reports have been published yet.) These reports, along with the
wide range of analyses by NCHS and other researchers thus far with the NSFG ACASI data,
provide a strong demonstration of the value and usefulness of these data. For example, ACASI
data have been used to study confidentiality concerns of sexual and reproductive health
services among 15‐25 year olds (Copen et al, 2016; Leichliter et al, 2017); substance use and
reproductive service utilization (Hall et al., 2013), the link between sexual coercion and STD
experience or other health outcomes (Hawks et al., 2019; Williams et al., 2013), HIV risk
behaviors, such as number of sexual partners (Haderxhanaj et al., 2014a), and associations
between sexual identity and indicators such as poverty, health care use and military service
(Agénor et al., 2017; Badgett et al, 2013; Hoover et al., 2017; Wheldon et al., 2013).
3
NSFG
OMB Attachment C
OMB No. 0920‐0314
JUSTIFICATION OF SENSITIVE TOPICS, PRIMARILY IN FEMALE J AND MALE K
Unless otherwise indicated, all topics below are covered in the final section of the
survey for both male and female respondents, and the same questions are asked for males and
females.
Height and Weight
All respondents are asked for their height and weight, which can be used to define body
mass index (BMI) or other summary measures. The public‐use files released through 2017‐2019
NSFG include BMI constructed only for men aged 20‐44 and non‐pregnant women aged 20‐44,
however researchers are able to construct different measures if they choose, by accessing the
original, restricted‐use variables in the NCHS Research Data Center (RDC) . Several studies
have been published with NSFG height and weight data to document the prevalence of
overweight and obesity among women of childbearing age (Vahratian, 2009), as well as the
association of BMI with oral contraceptive failure, unintended pregnancy, sexual behavior, and
family planning practices (Boehmer et al., 2007; Brunner & Hogue, 2005; Brunner‐Huber &
Toth, 2007; Callegaria et al., 2014; Kaneshiro et al., 2008a,b; 2012; Vahratian, 2009; Eisenberg,
2010). Respondents are also asked follow‐up questions about health care provider interactions
related to their weight.
Housing insecurity
All respondents are asked two questions on housing insecurity: whether in the past 12
months they did not have a permanent place to stay and had to stay at least overnight in a
shelter, car or someplace outdoors; or similarly, with a friend or relative. Housing insecurity is
important in the context of the NSFG because these experiences may be associated with
behaviors that place individuals at risk of unintended pregnancy and sexually transmitted
infection, as well as reducing their access to preventive health services .
School Suspension and Expulsion
All respondents aged 15‐24 are asked two questions on school suspension and
expulsion. Suspension or expulsion from school is an adverse experience that may indicate
academic and social problems. Unlike some measures of educational attainment, it is a
measure appropriate for young people who have not finished high school. It is well‐
documented that school performance and educational attainment have important associations
with a host of outcomes measured by the NSFG: age at first sexual intercourse, the likelihood of
using contraception (particularly at first intercourse), age at first birth, the occurrence of
unwanted pregnancies, the use of reproductive health services, and risk of contracting STIs
(Brown et al., 2003; Ford et al., 2005; Gibson‐Davis et al., 2014; Magnusson et al., 2011;
Martinez, et al., 2018; Santelli et al., 2000). Suspension or expulsion may be accompanied by
other risk‐taking behaviors including substance use.
4
NSFG
OMB Attachment C
OMB No. 0920‐0314
Jail or Prison Experience
In addition to housing insecurity and school suspension questions asked of both male
and female respondents, male respondents are asked about time spent in jail, prison, or
detention center (in last 12 months and in lifetime). If he has spent any time in a jail, prison or
detention center, he is asked the frequency of incarceration (1 time or more than 1 time) and
the length of time in a jail, prison or detention center (the last time). This information on
prison/jail experience is asked of men as a key life event that may greatly change a person's
social network or environment or may constitute a stressful life event that affects attitudes or
behaviors.
Cigarette Smoking
Tobacco use has been the leading preventable cause of premature death in the United
States, accounting for over 480,000 deaths each year (U.S DHHS, 2014). For women, smoking is
a risk factor for infertility, PID, cervical cancer, and other health problems (ACOG, 2011),
particularly when combined with use of hormonal birth control (Hatcher et al., 2018). Smoking
in pregnancy significantly increases the likelihood of low birthweight, miscarriage, and
pregnancy complications. In the context of adolescence, tobacco is also considered a
“gateway” drug to use of potentially more dangerous, more addictive, and illegal substances
(Kandel et al., 2015).
For females (since 2002) and males (since 2015), questions on cigarette smoking have
been asked in the context of a series on substance use, including a question on age at first
cigarette smoking. Respondents are asked if they have ever smoked at least 100 cigarettes in
their lifetime, and if so, they are asked their age when they first began smoking fairly regularly,
and the number of cigarettes they currently smoke per day on average. Questions about
cigarette smoking during pregnancy have been in the NSFG’s pregnancy history (female B) for
women in some form since 1982, and they will continue to be asked for all recent pregnancies
(i.e., those within the last 5 years). Data on smoking during pregnancy and smoking among
reproductive‐aged women using data from prior surveys have been published in several articles
and reports (Chandra, 1995; Chandra et al., 2005; Gillum & Sullins, 2008; Melbostad et al 2017;
Page et al., 2009).
Alcohol and Other Substance Use
The focus of the series on alcohol and other substance use is frequency of use within the
last 12 months, as this has been shown to be most closely correlated with other risk behaviors
and adverse outcomes. Respondents are asked about alcohol, including questions on binge
drinking.
5
NSFG
OMB Attachment C
OMB No. 0920‐0314
All respondents are then asked about use of marijuana, cocaine, crack, crystal meth
(methamphetamines), and illegal injected drugs, with a focus on use during the past 12 months.
Beginning in 2022, the series will include a question on the use of opioids without a
prescription. Studies with the NSFG as well as other data sources have illustrated associations
between use of alcohol and other substances and behavioral risk for STDs including HIV
(Adimora et al., 2011; Anderson et al., 2005, 2006; Bryant‐Genevier et al., 2014; Fryer et al.,
2007; Lansky et al., 2014; Paschen et al., 2019; vanGelder et al., 2011; Van Handel et al., 2015).
Ages of Sexual Partners for Teen Respondents 15‐17 Years of Age (Minors)
Sexual intercourse between minors and non‐minors is of concern because of well‐
documented associations with negative outcomes for the younger participant (Ryan et al, 2008;
Manlove et al., 2006; Masho et al., 2017; Volpe et al., 2013). In addition, the Department of
Justice and others engage in child protection and public health are concerned with the
prevalence of, and circumstances surrounding statutory rape (with the exact ages and age
differences varying from state to state). In order to reliably collect this sensitive information
while addressing concerns about the potential reportability of such age differences for
respondents who were interviewed in person, the ages of the first sexual partner for female
respondents, as well as the ages of any current sexual partners for female and male
respondents 15‐17 years of age, are asked only in the self‐administered section for respondents
interviewed in person.
Nonvoluntary Sexual Intercourse
In addition to knowing at what ages sexual intercourse is initiated, it is important to
understand the circumstances surrounding the initiation of sexual intercourse. Starting in 1995,
the NSFG has included questions to assess whether first intercourse was nonvoluntary and/or
unwanted at the time it occurred. An analogous series was included in the male questionnaire
when males began to be interviewed in 2002. Thus, this time series has allowed monitoring of
the prevalence of nonvoluntary or unwanted first intercourse for females and males. These
series have shown that a nontrivial proportion of first sexual intercourse is non‐voluntary or
unwanted. For example, 5% of females and 5% of males aged 18‐24 reported their first
intercourse was unwanted, according to data from the 2015‐2017 NSFG (Key Statistics NSFG,
2018) For females, it remains strongly related to young age at first sexual intercourse (Martinez
et al, 2011; Abma et al., 1998, 2004), and older age of the male partner (Manlove et al., 2006;
Moore et al. 1989). Nonvoluntary sexual intercourse increases the risk of adolescent pregnancy
and the acquisition of STIs, including HIV (Kirby, 2005; Boyer & Fine, 1992; Stockman et al.,
2010; Williams et al., 2014, Hawks, et al., 2019). Women who have experienced nonvoluntary
intercourse are also at greater risk of marital dissolution (Bramlett & Mosher, 2002) and
unintended first birth (Williams et al., 2009).
A related measure, which augments the information on first intercourse, is whether the
respondent has ever been forced to have sexual intercourse by a member of the opposite sex
6
NSFG
OMB Attachment C
OMB No. 0920‐0314
(females and males) or a member of the same sex (males). According to NSFG data from 2015‐
2017, 19% of women aged 18‐49 had ever been forced by a male to have sexual intercourse at
some time; 4.3% of males had ever been forced by a female; and 2.3% had ever been forced by
a male to have sex at some time (Key Statistics NSFG, 2018) A study that included this measure
found that 25% of U.S. women had experienced forced intercourse at some point by age 40‐44
(Axinn et al., 2018). Given its relatively high prevalence, it remains important to monitor this
basic history of forced intercourse, and to document its associations with subsequent adverse
outcomes.
Sexually Transmitted Disease (STDs)
Due to the more common usage in the general population, NSFG questions refer to
STDs, but this justification will refer more precisely to sexually transmitted infections (STIs).
There are about 20 million new STI cases in the United States each year. Prevalence estimates
suggest that young people aged 15–24 years acquire half of all new STDs and that 1 in 4
sexually active adolescent females have an STI, such as chlamydia or human papillomavirus
(HPV) (Satterwhite et al., 2013; Centers for Disease Control and Prevention, 2016). In addition
to increasing the risk of HIV infection and AIDS, the most serious complications of STIs are PID,
sterility or impaired fecundity, ectopic pregnancy, blindness, and cancer associated with human
papilloma virus (e.g., cervical cancer). STIs are also related to fetal and infant death, birth
defects, blindness, and mental retardation in babies born to infected mothers. For new cases
of STIs occurring among 15‐24 year olds alone in 2000, the total estimated burden was $6.5
billion (Chesson et al., 2004); the total for all age groups was nearly $16 billion (CDC, 2016). The
health and economic consequences of STDs continue to be a major concern (Eng & Butler,
1997).
At the request of CDC’s DSTDP and NICHD, questions were included in the 1988 and
1995 NSFG on whether the woman had ever been told by a doctor that she had gonorrhea,
chlamydia, genital herpes, or syphilis. These items have been further refined since then and
included for males and females. Despite the probable under‐reporting of STDs in self‐reported
surveys, reporting of these infections has been found to be significantly associated with a
number of important variables measured in the NSFG, including:
–
Pelvic inflammatory disease (PID) and infertility (Andersen et al., 2005; Aral et al., 1991;
Cates et al., 1990, 1994; Hillis et al., 1997 ; Leichliter et al, 2013; Petersen et al., 1991);
–
Health screening (Hewitt et al., 2002; Wilcox & Mosher, 1993);
–
Testing for HIV and STI (Anderson et al., 2005; Chandra et al, 2012a; Haderxhanaj et al,
2014; Mosher et al., 2005; Jeffries, 2010; Nearns et al, 2009; Tao et al, 2007); and,
–
HIV/STI risk behaviors (Anderson et al., 2006; Brookmeyer et al., 2019; CDC, 2011;
Chandra et al, 2011; Chandra et al., 2012b; 2012c; Leichliter et al, 2013; Miller et al.,
1999; Mosher et al., 2005)
In keeping with the focus on behaviors within a recent period, these questions on STDs
are generally limited to the last 12 months. For female respondents, a question on testing for
7
NSFG
OMB Attachment C
OMB No. 0920‐0314
chlamydia in the past year is asked in order to track progress towards a national health
objective that all sexually active women be tested annually. Chlamydia is often asymptomatic,
but linked to reproductive health problems, including PID and infertility (Tao et al., 2007). All
respondents, male and female, are asked whether they were treated or received medication for
an STD such as gonorrhea, chlamydia, herpes, or syphilis in the past 12 months. Then they are
asked separate questions about diagnosis in the last 12 months of gonorrhea or chlamydia.
Due to the chronic nature of genital herpes, genital warts, and syphilis, all respondents are
asked separate questions about ever being diagnosed with these STIs.
STD/HIV Risk‐Related Behavior
DHHS programs, including the co‐sponsors of the NSFG, need timely information on the
number and characteristics of people who are potentially exposed to the risk of HIV infection
through their sexual behavior or drug use (Anderson et al., 2006; Chandra et al., 2011, 2012a;
2012b; 2012c; Leichliter et al., 2019; Mosher et al., 2005; White House Office of National AIDS
Policy, 2010; 2015). In 2015, the diagnosed infections attributed to male‐male sexual contact
(70%) and those attributed to male‐female sexual contact (24%) accounted for approximately
94% of diagnosed HIV infections in the United States (CDC, 2015).
HIV Testing and Risk‐Related Behavior: Since the 1988 NSFG, questions on specific
sexual and drug‐related behaviors that affect the risk of HIV infection were asked at the request
of the NICHD and the CDC’s Divisions of STD and HIV Prevention. Questions on HIV testing
were included for the first time in the 1990 Telephone Re‐interview and retained in the main
(interviewer‐administered) portion of the survey since 1995. These data on HIV testing in
relation to HIV risk behavior have been published in several reports (Abma et al., 1997;
Anderson et al., 1996, 2000, 2005, 2006; Chandra et al., 2005; Chandra et al., 2011; Chandra et
al, 2012a; 2012b; 2012c; Copen et al, 2015; Leichliter & Aral, 2009; Mosher et al., 2005; Mosher
& Pratt, 1993; Wilson, 1993). The NSFG also includes questions about whether the respondent
reported having a non‐monogamous, opposite‐sex sexual partner in the last 12 months. Men
who have had sex with men are also asked about nonmonogamous male partners in the last 12
months. These data strengthen the NSFG’s ability to obtain a more current measure of HIV and
STI risk in the general population, as well as the risk of acquisition and spread of STI due to
one’s partners’ sexual behaviors (Adimora et al., 2007, 2011; 2014; Aholou et al, 2017; Aral &
Leichliter, 2010; Copen et al., 2019; Darroch et al., 1999; Finer et al., 1999; Leichliter et al.,
2010; 2013).
At the request of CDC/DSTDP, a question was added in 2017 to ask female and male
respondents about whether they had sex with anyone (male or female) they first met using a
dating or “hookup” website or mobile app. The addition of this question was added to replace
the question that only asked men if they had sex with other male partners they met online. The
purpose of this question is to obtain the overall prevalence of dating via the web in the general
population, which may be associated with other HIV and STI‐related behaviors measured in the
NSFG.
8
NSFG
OMB Attachment C
OMB No. 0920‐0314
Oral and Anal Sex: Previous research, with the NSFG and other data sources (Abdallah
et al., 2020; Anderson et al., 2006; Baggaley et al., 2013; Baggaley et al., 2008; Benson et al,
2015; D’Souza et al, 2014; Kumar et al., 2020; Leichliter et al. 2007; Lindberg et al, 2008),
indicates that sexual activity other than vaginal intercourse is an important component of risk
for STI, including HIV, among individuals identifying as heterosexual. Since the 2002 NSFG, the
survey has included questions to monitor the prevalence of oral and anal sex with opposite‐sex
partners. The relatively high prevalence of these behaviors and their association with STI
acquisition suggest that it is important to know not just lifetime prevalence but recent
experience.
Sexually transmitted infections, including gonorrhea, chlamydia, chancroid, human
papillomavirus (HPV), syphilis, and herpes, can be transmitted through noncoital sexual activity
such as oral and anal sex (ACOG, 2013; Baggaley et al, 2013; Cherpes, 2005; Edwards & Carne,
1998; Hawkins, 2001). Some groups may also be at elevated risk of HIV transmission, including
men who have sex with men and intravenous drug users (Brewer et al., 2007; Brookmeyer et
al., 2019; Freeman et al., 2011; German et al, 2015; Rothenberg et al., 1998; Xu et al., 2010).
Given the variability of STI risk and STI‐preventive behaviors (such as condom use) in
connection with different sexual behaviors and with different sexual partners, the NSFG
includes, upon request from CDC’s DHP and DSTDP, separate questions to ask the number of
opposite‐sex partners in the last 12 months, by type of sexual contact – specifically, the
numbers with whom the respondent has engaged in vaginal, oral, or anal sex in the last 12
months.
In response to educational campaigns that encourage teenagers to delay sexual activity,
some young people engage in oral or anal sex, which they may view as a means of retaining
their virginity or preventing pregnancy. NSFG data have been used to examine these issues
(Brewster & Tillman, 2008; Child Trends, 2005; Halpern‐Felsher et al., 2005; Mosher et al.,
2005; Remez, 2000; Reese et al., 2013; Sanders & Reinisch, 1999; Schuster et al., 1996). In
particular, an NSFG question on the timing of first oral sex relative to first vaginal intercourse
for 15‐24 year olds helps gauge potential exposure to STIs prior to their exposure to the risk of
pregnancy through vaginal intercourse (Copen et al., 2012).
Sexual Risk Assessment and Other Aspects of Health Care
At CDC/DSTDP request, two questions were added in 2013 to assess confidentiality
concerns for teenagers and young adults aged 15‐25 years. One question asked all 15‐17 year
olds and 18‐25 on their parents’ insurance whether they would ever not go for sexual or
reproductive health care because their parents might find out. The second asked 15‐17 year
olds whether they had time alone with a doctor or other health care provider without a parent
or guardian in the room in the past year. Also, four questions were added (in 2011 for males
9
NSFG
OMB Attachment C
OMB No. 0920‐0314
and in 2013 for females) about specific topics that a doctor or other medical care provider may
have asked the respondent about during a visit in the past 12 months:
sexual orientation or sex of his/her partners
number of sexual partners
condom use
types of sex they have (whether vaginal, oral, or anal).
These questions may provide useful information about the provider‐patient relationship in
terms of information shared regarding risk for unintended pregnancy and HIV/STD.
Sexual Attraction and Sexual Orientation/Identity
Questions on sexual attraction and sexual orientation or identity are placed after all
other female J/male K questions about specific sexual behaviors. Previous research by
Laumann, Michael, and others (1994; see also Bauer & Jairam, 2008; Bauer et al., 2010;
Chandra et al., 2011; Chandra et al., 2012c; Gates, 2010; Jeffries, 2011; Lindberg & Jerman,
2016; Mosher et al, 2005; Porsch et al., 2019; Turner et al., 2005) suggests that sexual
orientation, attraction, and behavior are correlated but not perfectly correlated dimensions,
and that it is valuable in surveys to collect all three to get accurate measures of sexual identity
and behavior in the general population.
Thus, these questions on sexual attraction and identity are asked, in conjunction with
sexual behavior, for several reasons: First, to provide national estimates of populations
15‐49 years of age (15‐44 years of age, in prior NSFG years) that are at increased risk of
STI (including HIV) (Anderson et al., 2006; Chandra, 2011; Chandra et al., 2012c; Copen
et al, 2016, Paschen‐Wolff et al., 2019).
Second, they are asked as a correlate or explanatory factor for the sexual behavior data
collected in the rest of the questionnaire (Institute of Medicine, 2011; Jeffries, 2007,
2009, 2011; Jeffries & Dodge, 2007; Tao, 2008).
Third, they are asked to provide data that will help to assess the adequacy of HIV
testing, STI testing and treatment, HPV vaccination, health insurance coverage,
reproductive health care counseling, and other factors (Agénor et al., 2019; Anderson et
al., 2005; Chandra et al., 2005; Chandra et al., 2012a; Copen et al, 2015; Everett et al.,
2019; Martinez et al., 2006; Mosher et al, 2005; Porsch et al., 2019; Reich et al., 2020).
For example, a number of Healthy People 2020 objectives have been specified for
groups based on sexual orientation, and these measures could also respond to some of
those data needs.
50‐50 split/study of sexual orientation question from NSFG and NHIS: As described in
prior NSFG clearance requests, from September 2015 through September 2019 the NSFG ACASI
section included a 50‐50 randomized study of the NSFG and NHIS questions on sexual
orientation. The goal of this study was to assess the distributions based on these two question
approaches, when placed in the identical location and survey context with NSFG ACASI. Results
of this study based on weighted data from 2015‐2019 are summarized in Attachment D4.
10
NSFG
OMB Attachment C
OMB No. 0920‐0314
Based on NCHS requirements, the questionnaires to be fielded starting in January 2022 will only
contain the sexual orientation item used in the NHIS and all other NCHS surveys.
Detailed reports on sexual behavior, sexual orientation/identity, and sexual attraction,
based on the 2002, 2006‐2010 and 2011‐2013 NSFG have been published (Mosher et al, 2005;
Chandra et al., 2011; Chandra et al., 2012c; Copen et al, 2016).
Same‐Sex Sexual Activity
For Male Respondents: All male respondents are asked about their sexual experience
with male partners. Because of the greater risk of STIs associated with male‐male sexual
behavior, men are asked about same‐sex sexual behavior in greater detail than are women.
Similar to the series asked of men in section K about sex with females, men are asked whether
they have engaged in oral or anal sex with another male, whether they have engaged in any
other sexual experience with a male partner (other than oral or anal sex) and whether they
used a condom the last time they had oral or anal sex with a male. These questions are asked
separately for insertive and receptive anal sex due to differences in the associated disease risk.
For men reporting ever having a male sexual partner, questions are asked about the most
recent partner’s age (relative to the respondent) and their race/ethnicity. Men are also asked
their age at first sex ever with a male partner, the partner’s age, and the type of relationship
they had with this partner at first sex.
Also similar to the series asked of men in section K about sex with females, adult men
(18‐49) are asked to what degree their first sex with a male partner was wanted, and whether
they had ever experienced forced sexual activity with a male. Those who reported ever being
forced by a male are asked whether various types of force were used, similar to the questions
asked if ever forced by a female.
For men reporting any male sexual partners within the last 12 months, several
additional questions are asked to better characterize the HIV/STD risk of this subgroup of the
population. Questions are asked about non‐monogamous recent sexual relationships; choosing
sexual partners based on HIV status; recent rectal douching; and pharyngeal or rectal STD
testing in the past year. Several reports have been published on male same‐sex sexual activity
and related behaviors and health experiences based on the NSFG data since 2002 (Adimora et
al., 2007; Chandra et al., 2011; Haderxhanaj et al., 2014a; 2014b; Jeffries, 2007, 2009, 2010,
2011; Jeffries & Dodge, 2007, Leichliter et al., 2019; McCabe et al., 2011).
For Female Respondents: While there is less direct risk of STI associated with same‐sex
sexual activity among women, the NSFG does include questions on sexual activity between
female partners. Analyses of 2002 and 2006‐2010 NSFG data show that same‐sex activity
among women is correlated with having multiple male partners (Chandra et al., 2012c; 2011;
Mosher et al., 2005). Questions on same‐sex activity are asked in order to better characterize
same‐sex relationship experience as well as experience with male partners, which may impact
11
NSFG
OMB Attachment C
OMB No. 0920‐0314
overall risk of disease and unintended pregnancy. Women are asked whether they have given
or received oral sex with a female partner or engaged in any other sexual activity with a female.
They are also asked questions about their first female sexual partner, including age and the
type of relationship they had at time of first sex.
Same‐Sex Sexual Relationships
As noted in Section 2 of Supporting Statement A, we have revised the entire male and
female instrument for 2022 to be more inclusive of same‐sex spouses and cohabiting partners,
particularly those with whom the respondent currently lives and may be raising children.
Furthermore, for all respondents who have ever had same‐sex sexual experience, starting in
2022 the NSFG will obtain additional information in the last section of the survey (female J;
male K) beyond what is described above for same‐sex sexual activity. Men and women with
same‐sex sexual experience will be asked about marriage and cohabitation with same‐sex
partners, as well as their legal marital status with respect to same‐sex spouses. In addition to
providing analogous descriptors for same‐sex relationships as obtained for opposite‐sex
relationships that can be used for analyses of fertility and family formation, these questions
provide additional context for same‐sex sexual experience that may relate to potential
exposure to HIV/STD risk.
Adverse Childhood Events, Suicide Ideation, and Positive Childhood Experience
At the request of the Division of Violence Prevention within CDC’s NCIPC, all
respondents starting in 2022 will answer a series of questions on adverse childhood
experiences (ACEs), positive childhood experiences that may mitigate the effect of ACEs, and
one question on suicide ideation. It is a strategic priority for NCIPC to better understand late
adolescent and adult respondent’s experiences of adverse childhood experiences (ACEs) and
their connection to a host of important reproductive and physical, mental, and behavioral
health outcomes (including the newly added suicide ideation and prescription opioid misuse
questions). One of NCIPC’s strategic goals with respect to ACEs is to improve nationally
representative surveillance of ACEs, particularly among late adolescents and adults. Currently,
states that have implemented the ACEs module in the Behavioral Risk Factor Surveillance
Surveys (BRFSS) represent the only national‐level source of ACEs data among adults, and the
National Survey of Children’s Health provides parent reports of children’s experiences of some,
but not all, ACEs. Asking ACEs questions within the NSFG will improve surveillance among late
adolescents and adults of reproductive age, as well as permit examination of the association
between ACEs and a number of later‐life outcomes of interest, including those that are cross‐
cutting strategic priorities for NCIPC (i.e., suicide ideation, substance misuse).
Income
Income (expressed as a percentage of the poverty level) is one of the most important
socio‐economic characteristics collected in the NSFG. It is critical to all co‐sponsors of the
12
NSFG
OMB Attachment C
OMB No. 0920‐0314
NSFG, as well as from a policy and program point of view, to be able to classify respondents by
their household income level because it relates to a number of behaviors and outcomes
measured in the survey. For example, income has been used as a socio‐demographic indicator
to examine these topics: infertility and infertility service use (Chandra et al., 2013, 2014);
women and men’s use of reproductive health services (Chabot et al., 2011; Martinez et al.,
2013; Martinez, et al., 2019); contraceptive non‐use and contraceptive choice (Mosher and
Jones, 2010; Mosher et al., 2015; Daniels, et al 2015); HIV and other STI risk, testing, and
treatment (Anderson et al., 2005; Chandra et al., 2012a, 2012b; Ford, 2011; Haderxhanaj et al,
2015); patterns of marriage and cohabitation (Bramlett & Mosher, 2002; Goodwin et al., 2010;
Nugent and Daugherty 2018); and fertility and family formation (Chandra et al., 2005; Martinez
et al., 2012; Martinez et al., 2006, 2018) as well as others. Because of the sensitive nature of
the income questions, they have been in the self‐administered final section since the 2002
NSFG. Moving the income questions to ACASI in 2002 reduced the level of missing data among
female respondents by one‐third, indicating greater respondent comfort with this mode.
Questions on the respondent’s own earnings (to complement information on family
income) are included, as had been done in most previous cycles. These questions on earnings
and income were adapted from the Current Population Survey’s series of questions on income
and public assistance. Updates have been made in consultation with the National Health
Interview Survey to maintain comparability between the NSFG and the NHIS.
13
File Type | application/pdf |
File Title | Microsoft Word - ATT-C-NSFG-SensitiveQuestionJustification-2021 |
Author | ayc3 |
File Modified | 2021-04-11 |
File Created | 2021-04-11 |