Adding Sexual Orientation and 

Gender Identity Measures to the 

Medicare Current Beneficiary 

Survey (MCBS)

Andrea Mayfield, Melissa Heim Viox, Marisa 

Wishart, Hannah Murrow

NORC at the University of Chicago

Marina Vornovitsky

Centers for Medicare and Medicaid Services

October 25, 2023 1

This research was conducted under the Medicare Current Beneficiary Contract 

sponsored by the Centers for Medicare and Medicaid Services (Contract: 

75FCMC19D0092; Task order: 75FCMC21F0001). The opinions and views expressed 

in this work are those of the authors. No official endorsement by the Department of 

Health and Human Services or the Centers for Medicare & Medicaid Services is 

intended or should be inferred.
Medicare Current Beneficiary Survey

• Serves as the leading source of information on 

the Medicare program and its impact on beneficiaries.

• Conducted by the Centers for Medicare & Medicaid Services 

(CMS) through a contract with NORC at the University of Chicago.

• Nationally representative, continuous, longitudinal, multipurpose 

survey of the Medicare population.

• Primary topics include health care utilization and cost, access 

and barriers to care, and physical, emotional, and financial well- being.

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MCBS Sociodemographic Items

• Prior to 2023, the MCBS did not capture beneficiary sexual 

orientation or gender identity (SOGI).

• Prior to 2022, sex was preloaded from administrative data and 

confirmed by the interviewer.

• In 2022, beneficiaries were asked if they are male or female in the 

Introductory Questionnaire section at the beginning of the interview.

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Closing Data Gaps on the MCBS

• CMS and NORC have conducted research spanning 2015-2023 to 

inform the implementation of SOGI items on the MCBS. 

• Early version of items was fielded in Winter 2023 to MCBS beneficiaries as 

part of an international research collaboration. 

• SOGI items will be added to the main MCBS starting in Fall 2023. 

• This addition will improve measures of health equity on the MCBS: 

• Will provide nationally representative data on topics such as the 

accessibility and utilization of services by LGBTQ+ populations and 

resulting health disparities that impact this community.

• Will help inform CMS’ strategy to address Executive Order 13988 on 

Preventing and Combating Discrimination on the Basis of Gender Identity 

and Sexual Orientation.

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5 Executive Order 13988 on Preventing and Combating Discrimination on the 

Basis of Gender Identity and Sexual Orientation
Adopting SOGI on the MCBS

• Careful consideration has been given for implementing SOGI 

items from existing surveys in the context of the MCBS 

questionnaire. 

• During this presentation, we will discuss: 

• Results from initial feasibility research/cognitive testing efforts.

• Current item selection and design.

• Operationalization of SOGI items in the context of a longitudinal health 

survey.

• Interviewer training and preliminary results from fielding.

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Initial Feasibility Research and 

Cognitive Testing

2015-2016

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SOGI Item Cognitive Testing

• Timing: 2015-2016

• Interview languages: 

English and Spanish

• Interview mode: 

In-person

• Tested abbreviated 

questionnaire with SOGI 

items at end in 

demographic section.

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Focus of probing Examples of probes

Comprehension of questions 

and terms; identification of 

sources of confusion or 

ambiguity

• Were there any words that 

you were uncertain about? 

Which ones? 

• What does 

[bisexual/transgender] mean 

to you?

Uncover decision-making 

processes and assumptions that 

respondents make when 

answering identity questions

• How did you decide on that 

answer?

• What did you think about 

when I asked that question? 

Ease in answering questions 

about one’s sexual orientation 

and gender identity

• Did you have any trouble 

deciding on that answer?
SOGI Items Initially Tested

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Which of the following best represents 

how you think about yourself?

• Lesbian or gay

• Straight, that is, not lesbian or gay

• Bisexual

• Something else

• I don’t know how to answer

What sex were you assigned at birth, on 

your original birth certificate?

• Male

• Female

How do you describe yourself?

• Male

• Female

• Transgender

• Do not identify as female, male, or 

transgender

Sexual Orientation Question Gender Identity Questions
Major Findings from Testing

• English-speaking respondents:

• Answered SOGI questions without issue.

• Provided responses consistent with screener responses. 

• Spanish-speaking respondents:

• Able to answer the two-step sex and gender questions even though 

they were often uncertain about the meaning of transgender. 

• Had problems answering the sexual orientation question:

• Women and those with high school or less education did not understand 

meaning of response categories and were uncertain about the term 

“heterosexual”.

• Heterosexual participants identified their sexual orientation as “normal.” 

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Major Findings from Testing, Ctd

• Based on these findings, the CMS Office of Minority Health, National 

Center for Health Statistics (NCHS) Questionnaire Design Research 

Laboratory, and NORC drafted alternative versions of Spanish 

language sexual orientation question response categories and 

completed further cognitive testing with 39 Spanish speakers. 

• The revised question showed marked improvement in 

comprehension and consistency. 

• Other Federal agencies, including NCHS, tested and implemented a 

revised Spanish version of the item.

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Current Design and 

Implementation Research

2021-2023

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SOGI Implementation on MCBS

• CMS and NORC leveraged SOGI research efforts and 

advancements from across the federal statistical community:

• Previous cognitive testing conducted by CMS/NORC in 2015-2016.

• Review of current SOGI items on other large, federal surveys.

• Alignment with recommendations from the National Academies of 

Sciences, Engineering, and Medicine’s (NASEM) 2022 report, 

“Measuring Sex, Gender Identity, and Sexual Orientation”.

• Discussions with survey and SOGI experts at NORC and other 

organizations.

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SOGI Items from Other Surveys

• Items selected for 2023 MCBS were drawn from the most 

current national surveys fielding SOGI: 

• Two items about sexual orientation from the National Health Interview 

Survey (NHIS).

• Two items about gender identity from the U.S. Census Household 

Pulse Survey.

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Sexual Orientation Items

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Variable Question Text Code List

SEXORINT

Do you think of yourself 

as lesbian or gay; 

straight, that is, not 

lesbian or gay; bisexual; 

something else; or you 

don't know the answer?

(01) LESBIAN OR GAY

(02) STRAIGHT, THAT IS, NOT LESBIAN OR GAY

(03) BISEXUAL

(04) SOMETHING ELSE

(05) I DON'T KNOW THE ANSWER

(-8) Don't Know

(-9) Refused

SEXORIOS What do you mean by 

something else? (01) continuous answer
Gender Identity Items

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Variable Question Text Code List

GENIDENT

[(Do you)/(Does (SP))] currently 

describe [yourself/themselves] as 

male, female or transgender?

(01) MALE 

(02) FEMALE

(03) TRANSGENDER

(04) NONE OF THESE

(-8 ) Don't Know

(-9) Refused

SEXASGN

What sex [(were you)/(was (SP))] 

assigned at birth on [your/(SP)’s] 

original birth certificate?

(01) MALE 

(02) FEMALE

(-8 ) Don't Know

(-9) Refused
Issues of Operationalization

• Even though CMS and NORC used existing, tested SOGI items, 

there were still challenges in operationalizing these items within the 

complex structure of a longitudinal, general health survey with a 

rotating panel design: 

• Where to place these items in the survey vis-à-vis other questionnaire 

sections related to health care experiences, cost, and utilization?

• How often to administer these items to beneficiaries during their tenure in 

the study?

• How to navigate text fills for interviews conducted with proxy respondents?

• How to navigate routing for sex-specific health status and prevention 

items?

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SOGI Item Administration

• Placement

• Replaced previous sex item in 

Introduction with NHIS and 

Census Pulse SOGI items.

• Placed new items in 

Demographics and Income (DIQ) 

Section (per recommendations 

outlined in the NASEM report).

• Frequency of Administration

• Administered to all beneficiaries in 

Fall 2023 and then in subsequent 

years, only to Incoming panel 

beneficiaries. 

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Proxy Interview Administration

Proxy Interview Administration - English

• Refer to survey respondents by their first name, rather than pronouns

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[Has SP] ever had an exam 

for oral cancer in which the 

doctor or dentist pulls on 

[his/her] tongue, sometimes 

with gauze wrapped around 

it, and feels under the 

tongue and inside the 

cheeks?

[Has SP] ever had an exam 

for oral cancer in which the 

doctor or dentist pulls on 

[(SP)’s] tongue, sometimes 

with gauze wrapped around 

it, and feels under the 

tongue and inside the 

cheeks?
Proxy Interview Administration

Proxy Interview Administration - Spanish

• Spanish proxy interviews use respondent first name, but some 

gendered language structure had to be retained.

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English question text HOSMED Spanish question text HOSMED

After [your/(SP)'S] most recent 

hospital stay, [were you/was (SP)] 

prescribed any medicines?

Después de [su/la] estancia 

hospitalaria más reciente [de (SP)], 

¿fue [usted/(SP)] recetado/a algunas 

medicinas?
Sex-Specific Health Questions

Some health status and prevention items are dependent on the 

anatomy of the beneficiary:

• For example, items about hysterectomies and prostate surgery.

Sex assigned at birth (SAAB) is used to drive routing for questions 

related to a beneficiary’s anatomy. 

• When SAAB is not available, administrative data is used. 

• Added response option for when beneficiaries feel a question does not apply.

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Variable Question Text Code List

HYSTEREC [Have you/Has (SP)] ever had a hysterectomy?

(01) YES

(02) NO 

(03) QUESTION DOES NOT APPLY TO SP

(-8 ) Don't Know

(-9) Refused
Additional Considerations 

• To reflect current best practice in SOGI administration and to 

promote data quality, additional adaptations were made in 

operationalizing SOGI items on the MCBS:

Proxy administration is permitted for gender identity but not sexual 

orientation items.

A soft edit check is included for differing responses at gender identity 

items for interviewer reference to reduce the potential for data entry 

errors.

“Don’t Know” and “Refused” response options are included at SOGI 

items to allow respondents to opt out.

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Early Implementation Findings

2023

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SOGI on MCBS PaRIS Survey

• As a result of an international collaboration with the 

Organization for Economic Cooperation and Development 

(OECD), CMS and NORC fielded an earlier version of SOGI 

items via phone to MCBS beneficiaries in Winter 2023 via the 

Patient-Reported Indicator Survey (PaRIS). 

• This effort informed our training and implementation plans and 

reinforced that administration of SOGI items to Medicare 

beneficiaries was feasible by telephone.

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Interviewer Listening Sessions

• NORC held two listening sessions with interviewers following the 

MCBS PaRIS Survey

• Themes

• Training was thorough for the SOGI questions.

• Interviewers are experienced at neutral administration of other sensitive 

questions (e.g., income).

• Some respondents prefer not to answer or give non-answers – training on 

these scenarios is helpful.

• Application to Fall 2023 training

• Interviewer attitude can project a sense of neutrality at these questions.

• Reinforce the importance of reading verbatim without additional prelude.

• Educate interviewers further on the importance and purpose of the items.

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MCBS Interviewer Training

Interviewers were trained on SOGI administration for the main MCBS via a 

training module, which covered: 

• Background and research importance of the SOGI questions.

• Introduction to the questions and response options.

• Skills for probing, gaining cooperation, and reading verbatim.

• Practice with potential scenarios.

• Respondent is unfamiliar with response options.

• Respondent feels the questions are too sensitive or doesn’t want to answer.

• Respondent provides alternative response options (e.g., “I’m normal”).

• Respondents wonder why these questions are being asked.

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Monitoring and Evaluation

• Fall 2023 data collection round runs from July-December 2023.

• Item performance is being monitored and evaluated: 

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In-Round Monitoring

Preliminary Frequency 

Review

Interviewer Monitoring and 

Feedback

Round-End Review

Record Review

Respondent Characteristics

Open-Ended Responses
In-Round Monitoring

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• NORC conducts weekly review of 

item-level frequencies to monitor 

item-level non-response and item 

performance.

• Preliminary findings from frequency 

review show item-level non-response 

of less then 3%, which is in line with 

results from other federal surveys. 

Preliminary 

Frequency 

Review

• Differential analysis to look for 

patterns of skipped/don’t 

know/refused among specific 

interviewers, regions, etc. 

• Computer-assisted recorded 

interviewing (CARI) for all SOGI 

variables.

• Interviewer feedback on item 

administration also assessed via 

discussions with managers.

Interviewer 

Monitoring
Round-End Review

• Record review

• Review agreement of self-and proxy-reported gender identity with 

administrative data and Fall 2022 reports.

• Respondent characteristics

• Tabulate patterns in reporting by respondent language, use of an 

assistant, and self-report or proxy report.

• Open-ended responses

• Review free text entries for training points and/or questionnaire 

improvements.

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Thank you! 

For any questions, please contact: 

Mayfield-Andrea@norc.org

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References

• Exec. Order No. 13,988 (2021). https://www.govinfo.gov/content/pkg/DCPD202100057/pdf/DCPD-202100057.pdf.

• National Academies of Sciences, Engineering, and Medicine 2022. Measuring 

Sex, Gender Identity, and Sexual Orientation. Washington, D.C: The National 

Academies Press. https://doi.org/10.17226/26424.

• https://www.census.gov/library/stories/2021/08/household-pulse-surveyupdates-sex-question-now-asks-sexual-orientation-and-gender-identity.html

• Michaels, S., Milesi, C., Stern, M., Heim Viox, M., Morrison, H., Guerino, P., 

Dragon, C.N., Haffer, S.C. (2017). Improving Measures of Sexual and Gender 

Identity in English and Spanish to Identify LGBT Older Adults in Surveys. 

LGBT Health 4(6):412-418. https://doi.org/10.1089/lgbt.2016.0168

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