Self-rated health (SRH) is a robust indicator of future health outcomes, consistently predicting mortality as well as the onset of illnesses across a wide range of studies. The predictive value of SRH is independent of various established medical, behavioral, and psychosocial factors. Studies in this area include seminal work from Idler & Angel showing that a single global health rating independently predicted mortality in a large US sample (Idler & Angel, 1990). Over recent decades, the strong association between SRH, morbidity, and mortality has been consistently replicated across numerous studies and diverse populations (Andreasson et al., 2024; Benyamini, 2011; DeSalvo et al., 2006; Dramé et al., 2023; Idler & Benyamini, 1997; Jylha, 2009), including in a sample nearly 500,000 adults (Ganna & Ingelsson, 2015), confirming robustness and generalizability.

When assessing their subjective health, people use a range of information including general symptoms, physical functioning, mental well-being, and knowledge of their own health behaviors (e.g., diet, exercise, medication adherence, obesity status). Self-assessments may reflect underlying physiological functioning, including conditions that are sub-clinical and/or not yet diagnosed in a clinical setting. Of importance from a mechanistic perspective, low grade systemic inflammation may contribute to intuitive feelings of poor health (via effects on mood, energy, vague aches/pains) even before clinical symptoms manifest. In this manner, bodily sensations for which information is only available to the individuals themselves, can provide a unique source of information (Jylha, 2009).

These types of effects are well-documented in “cytokine-induced sickness behavior,” which is characterized by fatigue, low mood, and reduced motivation and can be triggered not only by infections but also by immune-activating treatments such as interferon-alpha therapy and chemotherapy (Dantzer & Kelley, 2007). These effects are mediated by proinflammatory cytokines including IL-6 which influence brain function via pathways including the vagus nerve and hypothalamic-pituitary-adrenal (HPA) axis (Dantzer, 2001; Konsman et al., 2002; Lasselin, 2021; Raison et al., 2006). Correspondingly, even in health individuals, subtle immune activity may influence self-ratings of health through neuroimmune signaling, contributing to mild but noticeable changes in mood, energy, and cognition.

Indeed, a growing body of empirical evidence supports an association between self-rated health and inflammation (Christian et al., 2011; Christian et al., 2013; Lekander et al., 2004; Majeno et al., 2024; Murdock et al., 2016; Shanahan et al., 2014; Tamura et al., 2018; Uchino et al., 2019; Unden et al., 2007; Warnoff et al., 2016). Data from 265 primary health care patients found that, among women, poorer self-rated health was associated with elevations in circulating proinflammatory cytokines including IL-6 and TNF-α, independent of age, education, physical health, and diagnoses (Lekander et al., 2004). Subsequently, in a study of 250 generally health older adults, we found that poorer self-rated health was associated with significantly higher serum levels of C-reactive protein (CRP), and interleukin (IL)-6 (Christian et al., 2011). These associations remained after controlling for age, body mass index, sex, objective health conditions, depressive symptoms, neuroticism, and health behaviors including smoking and physical activity, indicating that inflammatory status provides unique predictive information. These effects have further been replicated in adolescents (Warnoff et al., 2016), young adults (Shanahan et al., 2014), as well as pregnant women (Christian et al., 2013), further supporting the hypothesis that individuals have an interoceptive sense of their inflammatory status based on factors such as general energy level, aches/pains, and other vague sensations that inflammation may ultimately affect.

Of health importance, adults who identify as lesbian, gay, bisexual, queer, or other non-heterosexual identities (LGBQ+) experience marked health disparities as compared to heterosexual adults, including heightened risk of developing cardiovascular diseases, depressive disorders, anxiety disorders, substance-use disorders, and suicidal ideation (Branstrom et al., 2016; Jackson et al., 2016; Malik et al., 2023; Rice et al., 2019). Further, in relation to self-rated health, population-level data demonstrate poorer self-rated health among LGBQ+ adults as compared to heterosexual individuals (Denney et al., 2013; Gonzales & Ehrenfeld, 2018; Institute of Medicine, 2011; Liu et al., 2013; Nelson et al., 2023; Reczek et al., 2017; Spiker, 2020). Mediating and moderating effects include structural and social factors, including socioeconomic status and state-level policies. In addition, Minority stress, stigma, and discrimination may contribute to poorer self-rated health by affecting psychological well-being, access to healthcare, and physiological stress responses (Christian et al., 2025; Flentje et al., 2022; Meyer, 2003). Indeed, our data show differences in inflammation in the context of anxiety and depressive symptoms based on sexual minority identity (Christian et al., in press), as well as associations between identify valence (i.e., positivity/negativity) and inflammation (Morgan et al., 2025). However, data are lacking on underlying biological correlates of self-rated health, which may also play a causal role.

Addressing gaps in knowledge, the current study examined LGBQ+ identity and self-rated health in a population-representative sample, the National Couples’ Health and Time Study (Kamp Dush et al., 2023). In addition, associations with inflammation were examined in a subsample who participated in the Stress Biology Study (NCHAT-BIO) (Christian et al., 2026). Self-rated health data were available from 3,477 (42.6% LGBQ+), while inflammatory marker data (IL-6 and CRP) were available for a subset of 654 (42.8% LGBQ+). We hypothesized that LGBQ+ individuals would report poorer self-rated health than their heterosexual counterparts. Further, we hypothesized that poorer self-rated health would be associated with greater inflammation, as indicated by levels of IL-6 and CRP. Finally, as described above, factors contributing to self-rated health are multi-factorial and can vary based on demographic characteristics. Thus, we examined the extent to which associations between LGBQ+ identity, self-rated health, and inflammation were influenced by physical health conditions, mental health (anxiety, depressive symptoms), and health behaviors/indicators (obesity, smoking, and alcohol use).

To address existing gaps in the literature, this study explored the association between LGBQ+ identity and self-rated health using a population-representative sample, and examined associations with inflammation in a subsample. Consistent with our hypotheses, in the overall NCHAT sample, LGBQ+ individuals reported poorer self-rated health compared to their heterosexual peers. Further, in the subset of participants who participated in NCHAT-BIO, poorer self-rated health was associated with inflammation as indicated by elevations in both IL-6 and CRP. The magnitude of the association between inflammation and self-rated health was similar among LGBQ+ and heterosexual adults.

First, this study demonstrates that LGBQ+ adults report significantly poorer self-rated health than heterosexual respondents. Notably, NCHAT is a population-representative sample of partnered adults in the US who come from all 50 states, replicating prior findings in a more robust sample. Many prior studies demonstrating poorer self-rated health among sexual minority adults (e.g.,Denney et al., 2013; Liu et al., 2013; Reczek et al., 2017; Spiker, 2020) have used the National Health Interview Survey (NHIS) which uses the gender identity of partners as a proxy for sexual orientation, thus bisexual respondents who are partnered with someone of a different gender were not identified as LGBQ+. Other studies use the Behavioral Risk Factor Surveillance System (Conron et al., 2010; Gonzales & Ehrenfeld, 2018; Liu et al., 2013; Nelson et al., 2023) which only allows for the examination of sexual orientation in states that opt in to asking sexual orientation questions – in 2023, 35 states included the module (Division of Population Health, 2025) but those that did not were some of the least protective states for LGBQ+ adults such as Arkansas and Mississippi (Movement Advancement Project, 2022). Other studies have used small, less statistically powered subsamples within larger studies such as the Health and Retirement Study (Liu et al., 2021). This study does replicate a Swedish population representative sample that had full coverage of the country between 2008 and 2013 (Bränström et al., 2016). Swedish lesbian, gay, and bisexual individuals reported poorer self-rated health than heterosexual individuals. Of note, the difference in self-rated health found in NCHAT was not observed in the NCHAT-BIO subsample which is smaller, highlighting the importance of a robust sample size. Thus, the current study provides an important replication and extension of prior findings.

The second key finding from this study is that self-rated health is associated with inflammation in terms of both CRP and IL-6, with similar magnitude of effects regardless of sexual orientation. Self-rated health has previously been associated with inflammation in a number of studies, including investigations of older adults, young adults, adolescents, and pregnant women (Andreasson et al., 2012; Arnberg et al., 2016; Christian et al., 2011; Christian et al., 2013; Kananen et al., 2021; Shanahan et al., 2014; Tanno et al., 2012; Warnoff et al., 2016). Via replication in LGBQ+ adults, this study provides novel support for the generalizability of the association between self-rated health and inflammation, further bolstering the robust nature of a single-item measure of self-rated health. As only a subsample of NCHAT participated in the NCHAT-BIO, and those with versus without biological markers of interest differed in age, BMI, and SRH, future replication in a larger sample would bolster these findings.

When models linking self-rated health and inflammation were adjusted for BMI, age, health conditions, and sex, associations for both IL-6 and CRP were modestly attenuated whereby effects were no longer present at a p value < 0.05. Similarly, models were modestly attenuated by inclusion of depressive symptoms, smoking, alcohol, and sleep. These factors likely contribute to the link between SRH and inflammation via at least two pathways. First, individual’s knowledge of the presence of an unhealthy behavior (e.g., smoking) may lead them to rate their health more poorly. In addition, and concurrently, the unhealthy behavior may promote inflammation and therefore enhance interoceptive cues of unwellness. Thus, these factors may serve as mediating factors rather than simply “confounds”. Because these factors tend to be inter-correlated (e.g., depressive symptoms and obesity), disentangling the unique effects of a given factor is not possible given the cross-sectional design.

One limitation of the current study is that all participants were married or cohabiting, limiting generalizability. The average levels of mental health, physical health and self-rated health may be higher than observed in the general population because there are numerous studies showing that single individuals often fare worse than their partnered counterparts across a wide array of outcomes (Frech & Williams, 2007; Liu & Umberson, 2008; Musick & Bumpass, 2012; Wang et al., 2020). There are some complexities in this body of work that include whether individuals are in a first marriage or remarriage (Hsu & Barrett, 2020), cohabiting versus married (Musick & Bumpass, 2012) and differentiating the effect of divorce or widowhood rather than never being married (Kalmijn, 2017; Marks & Lambert, 1998). An overarching issue in this body of work is whether selection is operating, such that healthy individuals are more likely to form relationships and, as a result, the partnered population appears healthier (Brown et al., 2012). Thus, there is some debate about whether marriage or union formation itself causes better health.

A review of studies that found that marriage was associated with health benefits for the LGBTQ+ population; this review relied on data largely preceding the passage of the Obergefell v. Hodges in 2015 (Karney et al., 2024). However, marriage is not always associated with improved health benefits, as shown in analysis of self-rated health in the National Health Interview Study (2013–2014) data comparing married, cohabiting, never married and previously married gay and lesbian respondents (Reczek et al., 2017). Further, a study based on the National Health Interview Survey 2013–2017 indicated that marriage was protective of physical health (self-reported health and functional limitations) for individuals who identified as heterosexual, gay or lesbian, but married bisexual men and women reported poorer health than their unmarried counterparts (Hsieh & Liu, 2019). Recent research focusing on LGB populations since marriage to same-sex couples has been legal across the United States is limited and finds that married or partnered individuals experience better mental health and physical health (self -rated health or physical health limitations)(Akré et al., 2025; Goldsen et al., 2017; Kamp Dush & Manning, 2022; Song, 2025). Analysis of lesbian, gay and bisexual men and women’s psychological distress shows that partnered lesbian women fared better than their unpartnered counterparts, but partnership status was not associated with psychological distress for bisexual women, gay or bisexual men (Wilson et al., 2022). Future studies inclusive of unpartnered individuals would help to elucidate unique effects of being partnered within our models.

Another limitation of this study is that it is cross-sectional in design, rather than longitudinal. Although poorer SRH is reliably linked to higher inflammation in cross-sectional studies, this relationship is far less consistent in available longitudinal studies. For example, a study of 131 older adults (mean age = 75 years) assessed self-rated health and IL-6 every 6 months for up to 5 years. Multilevel models showed stable SRH (between-person differences), but not dynamic changes in SRH were associated with IL-6 (Arnberg et al., 2016). Similarly, in a study of 899 adults assessed at baseline, with 666 assessed 5 years later, worse SRH was significantly associated with higher hsCRP at baseline, independent of age, sex, BMI, and health behaviors. While higher baseline hsCRP was associated with poorer SRH at 5 year follow-up, this association did not remain after covariate adjustment (Tamura et al., 2018). Thus, SRH reflects current inflammation, but may not be a strong predictor of future inflammation which may indicate shared underlying correlates rather than a direct causal link. The current cross-sectional design did not permit for clarifying temporal precedence, and future longitudinal data from the NCHAT cohort as well as other populations would be highly informative.

Another limitation of this study is lack of longitudinal data ultimately linking self-rated health with disease, disability, or mortality. Self-rated health is remarkably predictive of all-cause mortality, above and beyond traditional risk factors (Dramé et al., 2023). Meta-analyses suggest that this effect is consistent regardless of gender, age, or country of origin (DeSalvo et al., 2006). However, demographic differences in the predictive value of self-rated health for mortality have been noted in some studies, including in relation to age, gender, and socioeconomic status (Benyamini et al., 2003; Helweg-Larsen et al., 2003; Mackenbach et al., 2008). In addition, cohort effects have been reported whereby self-rated health is becoming more predictive over time, with evidence suggesting that this effect is driven by greater exposure to high quality health information (Schnittker & Bacak, 2014). Thus, there are multiple factors that contribute to an individual’s self-rating of health including knowledge of one’s health behaviors (Nehme et al., 2024), mood (Mulsant et al., 1997), fatigue/energy level (Engberg et al., 2017), as well as interoceptive cues, e.g., inflammatory processes and the relative weighting of various factors may differ based on gender, age, and other factors (Gupta et al., 2020; Hamplová et al., 2022; Jerdén et al., 2011; Spuling et al., 2015). Data are unavailable on the relative predictive value of self-rated health for mortality among LGBQ+ compared to heterosexual adults. Future studies should include the assessment of sexual orientation to provide the opportunity to examine the effects of this important identity factor empirically.

The primary focus of this investigation was the link between inflammatory biology and self-rated health. While the overall finding of poorer SRH among sexual minority vs heterosexual adults was observed, we did not examine mediating and moderating effects related to differences in SRH by sexual orientation. As reviewed, prior studies suggest multifactorial pathways, and moderated mediation may also be present. Thus, adequately examining these questions was beyond the scope of the current analyses. However, the NCHAT parent study provides a wealth of information including but not limited to racial/ethnic identity, age, socioeconomic factors, mental health indicators, contextual level factors (e.g., state/local policy), internalized stigma, exposure to discrimination, health behaviors, and health conditions which could be leveraged to thoroughly interrogate this question.

The analysis plan in this investigation was not preregistered. As a result, the findings reported here should be considered exploratory and hypothesis-generating, warranting confirmation by future confirmatory studies. Further, the current analyses is a focus only on cisgender adults. Of note, in the full NCHAT parent study, approximately 4.5% of participants identify as nonbinary, transgender, or another non-cisgender identity. However, the number who provided biological samples for NCHAT-BIO was limited. Moreover, gender-affirming care affects inflammatory markers which are the focus herein, complicating inclusion (Schutte et al., 2022). Thus, future studies permitting for examination of biological correlates of self-rated health inclusive of non-cisgender individuals would strengthen the literature.

In sum, this study contributes novel and meaningful insights into self-rated health, inflammation, and LGBQ+ identity. Our study strengthens the existing literature by leveraging NCHAT, a large population representative sample of partnered adults across the US, providing robust replication of prior findings that LGBQ+ plus adults report poorer self-rated health than their heterosexual peers. Moreover, this study extends the literature by demonstrating that self-rated health is associated with inflammation, as indicated by both CRP and IL-6, with similar magnitude of effects regardless of gender and sexual orientation. Our findings underscore the value of including sexual orientation in health research. Given the powerful predictive validity of self-rated health for mortality and its demonstrated linked to inflammation, further investigation into how social and identity-related factors affect self-perceptions of health remains a priority for advancing health equity.