**Disclaimer**

**4.1 Limitations**

*Psycho-Social Aspects of Human Sexuality and Ethics*

First, as CHIS is a continuous cross-sectional study, our findings suggest a trend in the populace rather than a change in a discrete set of Californians. Second is that legal partnerships and legal marriage did not convey identical rights and privileges between 2005 and 2008, a period that included concurrent, limited periods of cityand county-based same-sex marriages in California. Moreover, litigation precluded issuance of marriage licenses to same-sex couples between November 2008 and June 2013. Disparate results among legally-partnered, married, and other gay male and lesbian Californians perhaps reflect that uncertainty. Third, we were unable to report results separately by legal same-sex marriage and partnership between 2013 and 2015 though our results nonetheless appear to correspond with the historical events related to this issue during the period. Fourth is the need to exclude bisexually-identified Californians because the survey's order and skip pattern complicate notions of selfidentification and self-report of sexual behavior. For example, a bisexually-identified respondent who reported no sex with a same-sex partner in the last 12 months would not have been asked the question of same-sex legal partnership/marriage. Addition-

ally, the partner's sex/gender and sexual orientation were not reported.

opposite-sex marriage on the health of bisexual or transgender people.

the same or opposite sex as the respondent.

become increasingly fluid and nuanced.

**Acknowledgements**

**86**

Researchers adapting CHIS to account more precisely for same-sex marriage influences could follow the current question on "now married, living with a partner in a marriage-like relationship, widowed, divorced, separated, or never married" [43] by asking whether the spouse/partner referenced in the previous question is

There are thorough conversations across and outside the academy that will lead to comprehensive revisions of survey methodologies to measure the identity and behavior of respondents and their respective spouses. In the interim, the California Health Interview Survey (CHIS) provides a best practice on how to design and adapt questions to collect data that can explain the influence of legal marriage and partnerships on health and well-being, including sex/gender and sexual orientation identities [1]. Research and surveillance methodologies occasionally must respond quickly to provide data-driven public health recommendations. This study demonstrates CHIS's ability to explore the health impact of marriage for same-sex couples, and a need for survey questions to elicit information about marital status and the sex/gender of a respondent's spouse inclusive of sexual identities. Such collection is critical for data-driven health recommendations as sexual and gender identities

The UCLA Center for Health Policy Research conducts the California Health Interview Survey (CHIS). The National Institutes of Health (NIH) Office of

This fourth limitation demonstrates that a respondent's reported sexual identity

is not necessarily equivalent to that respondent's sexual behavior or to the sex/ gender of that individual's spouse—particularly in our era of increasingly fluid sexual and gender identities [37–39] and growing researcher attention to the intersectionality framework to integrate the complexity of individual lived experiences within efforts to improve care and research in health and well-being [40–42]. For a more comprehensive understanding of the influences of sexual identity, gender identity, and marital status on human health and well-being, survey questions may elicit not only the sex/gender identity of a respondent but also of the respondent's spouse, for example, to help determine the influence of same- or

This article represents only the authors' views and perspectives, not the positions of the National Institutes of Health or the U.S. Government.
