COVID-19 Vaccination Coverage and Vaccine Confidence by Sexual Orientation and Gender Identity

United States, August 29-October 30, 2021

A.D. McNaghten, PhD; Noel T. Brewer, PhD; Mei-Chuan Hung, PhD; Peng-Jun Lu, MD; Demetre Daskalakis, MD; Neetu Abad, PhD; Jennifer Kriss, PhD; Carla Black, PhD; Elisabeth Wilhelm, MA; James T. Lee, MD; Adi Gundlapalli, MD, PhD; Janet Cleveland, MS; Laurie Elam-Evans, PhD; Kimberly Bonner, PhD; James Singleton, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2022;71(5):171-176.

Abstract and Introduction

Introduction

Lesbian, gay, bisexual, and transgender (LGBT) populations have higher prevalences of health conditions associated with severe COVID-19 illness compared with non-LGBT populations.^[1] The potential for low vaccine confidence and coverage among LGBT populations is of concern because these persons historically experience challenges accessing, trusting, and receiving health care services.^[2]Data on COVID-19 vaccination among LGBT persons are limited, in part because of the lack of routine data collection on sexual orientation and gender identity at the national and state levels. During August 29–October 30, 2021, data from the National Immunization Survey Adult COVID Module (NIS-ACM) were analyzed to assess COVID-19 vaccination coverage and confidence in COVID-19 vaccines among LGBT adults aged ≥18 years. By sexual orientation, gay or lesbian adults reported higher vaccination coverage overall (85.4%) than did heterosexual adults (76.3%). By race/ethnicity, adult gay or lesbian non-Hispanic White men (94.1%) and women (88.5%), and Hispanic men (82.5%) reported higher vaccination coverage than that reported by non-Hispanic White heterosexual men (74.2%) and women (78. 6%). Among non-Hispanic Black adults, vaccination coverage was lower among gay or lesbian women (57.9%) and bisexual women (62.1%) than among heterosexual women (75.6%). Vaccination coverage was lowest among non-Hispanic Black LGBT persons across all categories of sexual orientation and gender identity. Among gay or lesbian adults and bisexual adults, vaccination coverage was lower among women (80.5% and 74.2%, respectively) than among men (88.9% and 81.7%, respectively). By gender identity, similar percentages of adults who identified as transgender or nonbinary and those who did not identify as transgender or nonbinary were vaccinated. Gay or lesbian adults and bisexual adults were more confident than were heterosexual adults in COVID-19 vaccine safety and protection; transgender or nonbinary adults were more confident in COVID-19 vaccine protection, but not safety, than were adults who did not identify as transgender or nonbinary. To prevent serious illness and death, it is important that all persons in the United States, including those in the LGBT community, stay up to date with recommended COVID-19 vaccinations.

Abstract and Introduction
Discussion
References
Sidebar

*Vaccination was defined as receipt of ≥1 dose of BNT162b2 (Pfizer-BioNTech), mRNA-1273 (Moderna), or other COVID-19 vaccine, or 1 dose of Ad.26.COV2.S (Janssen [Johnson & Johnson]) COVID-19 vaccine.
^†Survey weights were calibrated to match the number of persons reported in each jurisdiction by sex and age group as of mid-month, as reported by jurisdictions to CDC.
^§Response rate was calculated according to the American Association for Public Opinion Research type 3 response rate. https://www.aapor.org/AAPOR_Main/media/publications/Standard-Definitions20169theditionfinal.pdf
^¶Survey respondents were asked a series of questions on perceived COVID-19 risk, current COVID-19 vaccination status, and attitudes and perceived barriers to getting vaccinated (https://www.cdc.gov/vaccines/imz-managers/nis/downloads/NIS-ACM-Questionnaire-Q2-2021_508.pdf). These questions are based on the Behavioral and Social Drivers framework for increasing vaccine confidence. https://www.cdc.gov/vaccines/covid-19/downloads/vaccination-strategies.pdf.
**45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.
^††Urbanicity status was derived based on the centroid of the zip code of residence, categorized as MSA principal city, MSA nonprincipal city, or non-MSA. An MSA is defined by the U.S. Office of Management and Budget (OMB) as consisting of "at least one urbanized area of 50,000 or more population, plus adjacent territory that has a high degree of social and economic integration with the core as measured by commuting ties." MSAs are geographically delineated by groupings of neighboring counties and can cross state boundaries; names are assigned by OMB based on the names of one to three principal cities or places within each MSA. https://www.census.gov/topics/housing/housing-patterns/about/core-based-statistical-areas.html

Table 1. COVID–19 vaccination status and intent, by sex, gender identity, sexual orientation, and race/ethnicity — National Immunization Survey Adult COVID Module, United States, August 29–October 30, 2021
Characteristic	Unweighted no.	% (95% CI)*
		Vaccinated (n= 131,215)		Unvaccinated (n = 21,176)
		≥1 dose	Fully vaccinated^†	Definitely plan to get vaccinated	Probably will get vaccinated or unsure	Probably or definitely will not get vaccinated
Sex
Male (Ref.)	74,387	74.5 (73.8–75.2)	71.5 (70.7–72.2)	2.3 (2.1–2.6)	8.0 (7.5–8.4)	15.2 (14.6–15.8)
Female	77,372	78.8 (78.2–79.4)^§	76.1 (75.5–76.7)^§	2.0 (1.8–2.3)	7.0 (6.6–7.4)^§	12.2 (11.7–12.7)^§
Transgender or nonbinary
No (Ref.)	136,929	76.7 (76.2–77.2)	73.9 (73.4–74.4)^§	2.1 (2.0–2.3)	7.4 (7.1–7.7)	13.8 (13.4–14.2)
Yes	5,594	75.7 (73.3–78.0)	71.4 (68.8–73.8)	2.8 (2.0–3.8)	8.0 (6.7–9.6)	13.5 (11.7–15.5)
Sexual orientation
Heterosexual/Straight (Ref.)	132,608	76.3 (75.8–76.8)	73.5 (73.0–74.0)	2.1 (1.9–2.3)	7.4 (7.1–7.7)	14.2 (13.8–14.6)
Gay or lesbian	3,941	85.4 (82.5–87.8)^§	83.1 (80.2–85.6)^§	1.5 (0.9–2.5)	4.9 (3.5–7.0)^§	8.2 (6.3–10.5)^§
Bisexual	4,395	76.3 (73.6–78.9)	72.6 (69.8–75.2)	4.1 (3.0–5.6)^§	9.4 (7.6–11.7)	10.2 (8.6–12.1)^§
Something else	2,532	75.3 (71.7–78.7)	71.9 (68.2–75.4)	4.2 (2.7–6.5)^§	8.6 (6.6–11.0)	11.9 (9.5–15.0)
Race/Ethnicity
White, non-Hispanic (Ref.)	96,923	76.9 (76.3–77.5)	74.5 (73.9–75.1)	1.8 (1.6–2.0)	6.4 (6.1–6.8)	14.9 (14.4–15.4)
Black, non-Hispanic	17,159	74.1 (72.7–75.5)^§	69.7 (68.3–71.1)^§	3.2 (2.7–3.8)^§	10.9 (10.0–11.9)^§	11.8 (10.7–12.9)^§
Hispanic	19,344	76.4 (75.1–77.6)	72.5 (71.2–73.8)^§	3.1 (2.6–3.7)^§	9.1 (8.3–10.0)^§	11.4 (10.5–12.4)^§
Other, non-Hispanic	15,037	80.1 (78.6–81.6)^§	78.0 (76.5–79.5)^§	1.8 (1.3–2.3)	6.5 (5.6–7.5)	11.6 (10.4–12.9)^§

Abbreviation: Ref. = referent group.
*Weighted estimate.
^†Respondents self-reported receipt of ≥2 doses of BNT162b2 (Pfizer-BioNTech), mRNA-1273 (Moderna), or other COVID-19 vaccine, or 1 dose of Ad.26.COV2.S (Janssen [Johnson & Johnson]) COVID-19 vaccine.
^§Compared with ref, p<0.05.

Table 2. COVID-19 vaccination (≥1 dose) coverage, by demographic characteristics stratified by sexual orientation, gender identity, and sex — National Immunization Survey Adult COVID Module, United States, August 29–October 30, 2021
Characteristic	% (95% CI)*
	Sexual orientation										Gender identity
	Heterosexual/Straight			Gay or lesbian			Bisexual			Something else	Not transgender or nonbinary	Transgender or nonbinary
	Overall	Men	Women	Overall	Men	Women	Overall	Men	Women	Total	Not transgender or nonbinary	Transgender or nonbinary
Total	76.3 (75.8–76.8)	73.8 (73.0–74.5)	78.9 (78.2–79.6)	85.4 (82.5–87.8)	88.9 (85.2–91.8)	80.5 (75.6–84.5)	76.3 (73.6–78.9)	81.7 (76.6–85.9)	74.2 (70.8–77.3)	75.3 (71.7–78.7)	76.7 (76.2–77.2)	75.7 (73.3–78.0)
Race/Ethnicity
White, non-Hispanic	76.5 (75.8–77.1)	74.2 (73.3–75.1)	78.6 (77.7–79.5)	91.7 (89.1–93.8)	94.1 (90.9–96.2)	88.5 (83.4–92.1)	76.4 (73.0–79.5)	81.4 (74.3–86.9)	74.6 (70.6–78.2)	78.8 (73.7–83.1)	76.9 (76.3–77.5)	77.5 (74.1–80.6)
Black, non-Hispanic	74.2 (72.7–75.6)	72.5 (70.3–74.6)	75.6 (73.6–77.4)	66.8 (54.9–76.9)	76.6 (58.3–88.5)	57.9 (41.9–72.3)	68.6 (59.6–76.3)	79.8 (62.9–90.3)	62.1 (51.2–71.9)	77.9 (68.2–85.3)	74.0 (72.5–75.4)	69.3 (63.2–74.7)
Hispanic	76.1 (74.6–77.4)	72.0 (69.9–74.0)	80.5 (78.6–82.3)	79.6 (71.7–85.8)	82.9 (71.1–90.6)	72.6 (60.3–82.3)	80.4 (74.1–85.4)	82.4 (70.8–90.0)	79.5 (71.7–85.6)	71.2 (61.9–79.0)	76.3 (74.8–77.6)	78.1 (72.5–82.8)
Other, non-Hispanic	80.3 (78.6–81.9)	76.9 (74.4–79.3)	84.4 (82.3–86.2)	80.7 (70.1–88.1)	80.1 (64.5–90.0)	81.2 (65.0–91.0)	75.6 (63.2–84.7)	83.3 (62.5–93.7)	73.0 (57.2–84.6)	74.5 (64.7–82.3)	80.6 (79.0–82.1)	74.7 (66.4–81.5)
Household income
Below poverty^†	64.6 (62.7–66.3)	64.6 (61.9–67.3)	64.4 (62.0–66.8)	74.3 (62.4–83.5)	77.7 (61.1–88.6)	70.2 (51.7–83.9)	60.1 (52.6–67.1)	63.4 (48.6–76.1)	58.7 (49.9–67.0)	68.0 (59.6–75.4)	63.9 (62.1–65.7)	65.3 (58.7–71.4)
Above poverty, <$75,000	74.7 (73.8–75.6)	72.0 (70.7–73.3)	77.2 (76.0–78.4)	82.9 (77.8–87.0)	87.7 (80.5–92.5)	76.0 (68.0–82.5)	77.7 (73.4–81.5)	83.9 (76.2–89.5)	75.3 (69.9–80.0)	74.5 (68.0–80.0)	74.9 (74.0–75.8)	78.2 (74.4–81.5)
Above poverty, ≥$75,000	82.7 (82.0–83.4)	79.1 (78.0–80.2)	86.8 (85.9–87.8)	94.3 (91.8–96.0)	96.3 (94.2–97.6)	91.3 (85.4–95.0)	90.3 (86.6–93.1)	94.5 (89.3–97.3)	88.8 (83.8–92.3)	85.2 (77.1–90.8)	83.5 (82.8–84.2)	80.0 (74.7–84.4)
Unknown income	73.9 (72.8–75.1)	70.8 (69.1–72.5)	76.9 (75.3–78.4)	77.4 (67.6–84.8)	78.5 (63.8–88.3)	75.1 (60.4–85.7)	71.0 (63.9–77.1)	79.3 (66.7–88.0)	67.8 (59.3–75.3)	75.7 (68.0–82.0)	74.1 (73.0–75.2)	74.8 (69.5–79.4)
U.S. Census region
Northeast	84.7 (83.9–85.5)	82.2 (80.9–83.5)	87.1 (85.9–88.2)	88.5 (82.1–92.9)	95.3 (87.6–98.3)	78.4 (66.3–87.0)	84.4 (79.0–88.5)	88.6 (79.2–94.1)	82.2 (75.3–87.5)	78.8 (71.4–84.6)	84.7 (83.8–85.5)	83.7 (79.3–87.3)
Midwest	70.7 (69.4–72.0)	68.0 (66.1–69.8)	73.4 (71.6–75.2)	83.0 (74.6–89.0)	83.5 (70.4–91.5)	82.1 (70.9–89.6)	74.1 (67.1–80.1)	92.5 (85.9–96.2)	68.2 (59.7–75.7)	68.9 (59.4–77.0)	71.0 (69.8–72.3)	73.5 (67.8–78.5)
South	72.6 (71.8–73.4)	69.8 (68.6–70.9)	75.4 (74.3–76.5)	80.2 (74.9–84.6)	85.7 (79.3–90.4)	72.1 (62.7–79.8)	69.8 (64.7–74.4)	71.9 (61.5–80.4)	69.0 (63.0–74.3)	76.4 (70.8–81.1)	72.9 (72.1–73.6)	71.2 (67.1–74.9)
West	80.7 (79.6–81.7)	78.5 (77.0–80.0)	83.0 (81.5–84.4)	92.0 (87.4–95.0)	92.5 (84.7–96.5)	91.6 (85.3–95.3)	82.0 (77.5–85.8)	84.0 (74.4–90.4)	81.2 (75.8–85.6)	74.9 (65.7–82.4)	81.2 (80.2–82.2)	79.3 (73.7–84.0)
Urbanicity ^§
MSA, principal city	78.3 (77.4–79.1)	76.6 (75.3–77.8)	79.9 (78.7–81.1)	86.8 (82.8–90.0)	92.2 (88.0–95.0)	77.2 (69.1–83.7)	80.1 (76.1–83.7)	88.3 (82.0–92.6)	76.6 (71.3–81.1)	80.7 (75.0–85.4)	79.0 (78.1–79.8)	73.9 (69.5–77.8)
MSA, nonprincipal city	77.8 (77.1–78.4)	74.9 (73.9–75.9)	80.6 (79.7–81.5)	85.3 (80.5–89.1)	87.9 (80.8–92.6)	82.4 (75.0–87.9)	76.6 (72.7–80.1)	77.7 (69.0–84.5)	76.2 (71.7–80.2)	73.6 (68.3–78.3)	77.9 (77.2–78.5)	79.0 (75.7–82.0)
Non-MSA	66.6 (65.2–67.9)	63.3 (61.3–65.3)	69.9 (68.0–71.7)	77.9 (67.2–85.9)	72.9 (55.3–85.4)	84.2 (74.9–90.6)	61.6 (51.9–70.4)	73.0 (56.7–84.8)	58.1 (46.8–68.7)	64.6 (53.3–74.5)	66.4 (65.1–67.8)	68.3 (62.0–73.9)
SVI ^¶
Low SVI	79.3 (78.4–80.2)	76.9 (75.6–78.2)	81.6 (80.4–82.8)	89.3 (84.4–92.8)	92.2 (85.7–95.9)	85.7 (77.0–91.4)	79.5 (74.0–84.2)	87.4 (78.3–93.0)	76.7 (69.6–82.5)	78.7 (70.9–84.8)	79.7 (78.9–80.6)	79.3 (74.4–83.5)
Moderate SVI	77.6 (76.7–78.4)	75.2 (73.9–76.4)	80.0 (78.8–81.1)	87.2 (83.1–90.4)	93.7 (89.6–96.2)	78.5 (70.7–84.6)	75.9 (71.3–79.9)	76.9 (67.1–84.5)	75.4 (70.1–80.0)	75.2 (68.5–80.8)	77.9 (77.0–78.7)	77.9 (73.8–81.5)
High SVI	74.3 (73.3–75.2)	71.9 (70.5–73.3)	76.5 (75.2–77.8)	83.7 (77.5–88.5)	86.3 (78.1–91.7)	79.2 (68.2–87.1)	75.8 (70.7–80.3)	85.6 (77.9–90.9)	72.3 (66.0–77.9)	73.9 (66.6–80.0)	74.7 (73.7–75.6)	74.2 (69.5–78.3)

Abbreviations: MSA = metropolitan statistical area; SVI = Social Vulnerability Index.
*Weighted estimate.
^†Poverty was derived based on the number of persons reported in the household, the reported household income, and the 2020 U.S. Census poverty thresholds.
^§Urbanicity status was derived based on the centroid of the zip code of residence, categorized as MSA principal city, MSA non-principal city, or non-MSA.
^¶SVI was categorized as low, moderate, or high based on county of residence using tertiles of SVI score as cut-points. https://www.atsdr.cdc.gov/placeandhealth/svi/index.html

Table 3. Behavioral and social drivers of COVID-19 vaccination, by sexual orientation and gender identity — National Immunization Survey Adult COVID Module, United States, August 29–October 30, 2021
Central attitudes and experiences	% (95% CI)*
	Overall	Sexual orientation				Gender identity
	Overall	Heterosexual/Straight	Gay or lesbian	Bisexual	Something else	Not transgender or nonbinary	Transgender or nonbinary
Total	153,062	132,608	3,941	4,395	2,532	136,929	5,594
Concerned about COVID–19 (very or moderately)	48.5 (48.0–49.0)	48.1 (47.6–48.7)	56.8 (53.5–60.0)^†	51.3 (48.5–54.1)^†	52.8 (48.9–56.6)^†	48.4 (47.9–49.0)	49.4 (46.8–52.0)
Male	42.6 (41.9–43.4)	42.2 (41.5–43.0)	55.0 (50.8–59.3)^†	42.0 (37.1–47.1)	45.3 (39.4–51.4)	NA	NA
Female	53.9 (53.2–54.6)	54.0 (53.2–54.7)	59.1 (53.9–64.2)^†	54.9 (51.6–58.3)	57.8 (52.8–62.6)	NA	NA
Confidence in vaccine safety (completely or very)	64.4 (63.8–64.9)	63.9 (63.3–64.4)	76.3 (73.1–79.3)^†	70.4 (67.6–73.1)^†	69.3 (65.5–72.8)^†	64.7 (64.2–65.2)	62.8 (60.2–65.4)
Male	64.1 (63.4–64.9)	63.2 (62.4–64.0)	82.4 (78.3–85.9)^†	76.3 (71.0–80.8)^†	72.7 (67.2–77.6)^†	NA	NA
Female	64.6 (63.9–65.3)	64.5 (63.7–65.3)	67.4 (62.2–72.3)	68.1 (64.7–71.4)^†	66.9 (61.8–71.7)	NA	NA
Vaccine important to protect self (very or somewhat)	80.9 (80.5–81.3)	80.4 (80.0–80.9)	90.8 (88.5–92.7)^†	86.8 (84.7–88.6)^†	83.5 (80.0–86.5)	80.7 (80.3–81.2)	83.2 (81.1–85.1)^§
Male	77.7 (77.0–78.3)	76.9 (76.2–77.6)	92.9 (89.9–95.1)^†	87.6 (82.7–91.2)^†	80.8 (75.4–85.3)	NA	NA
Female	83.9 (83.4–84.5)	83.9 (83.2–84.4)	87.8 (83.9–90.9)^†	86.4 (84.2–88.5)^†	85.4 (80.5–89.2)	NA	NA
Had friends/family who were vaccinated (almost all or many)	70.2 (69.7–70.6)	70.0 (69.5–70.5)	76.4 (73.4–79.2)^†	71.2 (68.4–73.8)	72.7 (69.1–76.0)	70.6 (70.1–71.1)	67.6 (65.1–70.1)^§
Male	68.3 (67.6–69.0)	67.8 (67.1–68.6)	79.3 (75.5–82.8)^†	71.5 (66.2–76.4)	71.4 (65.9–76.4)	NA	NA
Female	71.9 (71.3–72.6)	72.1 (71.4–72.8)	72.4 (67.4–76.9)	71.0 (67.7–74.1)	73.5 (68.7–77.8)	NA	NA
Difficulty getting vaccinated (very or somewhat)^¶	14.9 (14.6–15.3)	14.9 (14.6–15.3)	18.9 (16.3–21.8)^†	12.0 (10.4–13.8)^†	16.1 (13.4–19.2)	15.1 (14.7–15.5)	13.2 (11.6–15.0)^§
Health care provider recommended the vaccine	41.2 (40.7–41.7)	41.3 (40.8–41.9)	47.3 (44.1–50.6)^†	38.1 (35.4–40.8)^†	40.3 (36.7–44.1)	41.3 (40.8–41.8)	38.4 (35.9–40.9)^§
Male	37.5 (36.8–38.2)	37.3 (36.5–38.0)	49.0 (44.7–53.3)^†	34.2 (29.3–39.5)	37.2 (31.7–43.0)	NA	NA
Female	44.7 (44.0–45.4)	45.3 (44.6–46.1)	45.0 (40.0–50.1)	39.6 (36.4–42.8)^†	42.5 (37.8–47.3)	NA	NA
Work or school requires the vaccine	22.6 (22.1–23.0)	22.1 (21.7–22.6)	26.4 (23.8–29.2)^†	26.5 (24.2–29.0)^†	29.4 (25.8–33.3)^†	22.5 (22.1–23.0)	25.9 (23.6–28.2)^§

Abbreviation: NA = not applicable.
*Weighted estimate.
^†Compared with heterosexual persons, p<0.05.
^§Compared with persons who were not transgender or nonbinary, p<0.05.
^¶Vaccinated respondents were asked, "How difficult was it for you to get a COVID-19 vaccine?"; unvaccinated respondents were asked "How difficult would it be for you to get a COVID-19 vaccine?

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COVID-19 Vaccination Coverage and Vaccine Confidence by Sexual Orientation and Gender Identity

United States, August 29-October 30, 2021

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