Gays still depressed even in open tolerant Netherlands

Image via WikipediaThis study found a higher prevalence of various psychiatric disorders in homosexual people compared with heterosexual people, both regarding the preceding 12 months as well as on a lifetime basis. These differences seem to be gender specific with a higher prevalence of substance use disorders in homosexual women and a higher prevalence of mood and anxiety disorders in homosexual men, both compared with their heterosexual counterparts.
The interpretation of these findings requires consideration of some potential limitations, which could have cumulatively either inflated or deflated actual differences in prevalence rates.²⁵ Among those people contacted, there could have been a nonresponse related to homosexual behavior. Although nonresponseto specific questions was negligible owing to the computer-assisted interviewing, subjects might have differed in their reporting behavior. Compared with heterosexual men, homosexual men might have been less reluctant to admit specific complaints. Although some demographics were statistically controlled for, the possibility remains that at least part of the observed differences are accounted for by some other uncontrolled confounding variables. Finally, the study might underestimate the differences between homosexual and heterosexual people owing to the limited num
ber of homosexual subjects and the consequently broad CIs of the ORs.
When compared with other studies of sexual orientation and mental health, ours has several strengths. We used a large representative sample rather than a convenience sample and selected without reference to sexual orientation. The sample size allowed for separate analyses for men and women. The importance of this is shown by our findings. Furthermore, the outcome variables studied were assessed with a reliable and standardized diagnostic instrument, and sexual behavior was assessed only after questions regarding psychiatric disorders were answered. This study not only looked at lifetime prevalence of psychiatric disorders but prevalence in the preceding year as well, testing the relationship with homosexuality more critically. In doing this, the findings suggest that homosexuality is not only associated with mental health problems during adolescence and early adulthood, as has been suggested,²⁰but also in later life. Finally, this study did not group people together based on lifetime experiences, a common practice to make up for small numbers, bu
Image by Fellowship of Reconciliation via Flickrt looked at subjects' recent sexual behavior. Although various studies have demonstrated discrepancies between homosexual behavior and homosexual orientation or homosexual self-labeling,^23, 32, 33 we think that recent homosexual behavior is a better indicator of homosexual self-labeling than any lifetime homosexual involvement.
It is unclear to what extent findings from this Dutch study can be generalized to other cultures or nations. Compared with other Western countries, the Dutch social climate toward homosexuality has long been and remains considerably more tolerant.^34, 35, 36 To the extent that the level of social acceptance of homosexuality induces differences in mental health status in relation to homosexuality, the observed differences might be greater in other Western countries than in the Netherlands.
The strategy to control for demographic variables in assessing differences between heterosexual and homosexual people could be debated. Some of these demographic differences, which were found in other representative studies as well and seem to be structural,^23, 33, 37 could be considered a consequence of and not an antecedent to people's homosexuality. The larger proportion of homosexual men in urban regions compared with rural areas is usually understood as a consequence of a tendency to migrate from places with high levels of social control to more congenial social environments.^23, 38 The finding that homosexual people are less often involved in steady relationships than heterosexual people is seen as resulting from the limited opportunities homosexual people have to find an intimate partner, lesser legal and social support for developing and maintaining homosexual relationshipscompared with that for heterosexual relationships, and differing norms and values regarding sexuality and personal relationships.^{39, 40, 41, 42} It could be argued that not controlling for these demographic variables, which results in more significant differences in prevalence rates of specific disorders and in higher ORs, provides a more accurate estimate of the actual differences in prevalence rates between homosexual and heterosexual people.
Because of the study's cross-sectional design, it is not possible to adequately address the question of the causes of the observed differences. Differences observed in the preceding year might be a consequence of earlier differences, since ever having had a specific disorder might predispose people to subsequent disorders.⁴³
Because the acquired immunodeficiency syndrome can have an important effect on homosexual men and their mental health status,⁴⁴ we asked all respondents about their human immunodeficiency virus (HIV) serostatus. Only one person, a heterosexual woman, reported a positive HIV status. This result reflects the very low prevalence of HIV infection and acquired immunodeficiency syndrome in the general population as well as among homosexual men in the Netherlands.⁴⁵ Given that no homosexual man reported being infected with HIV,we do not believe that HIV infection can account for the observed mental health differences in this study.
The observed differences may result both from biological and social factors and an interaction between them. Biological and genetic factors in the causes and development of homosexuality^{46, 47, 48, 49, 50} might also predispose homosexual people to developing psychiatric disorders. This is in line with the higher prevalence of bipolar disorder we found in homosexual men compared with heterosexual men, which is generally considered to be largely congenital.⁵¹ The effects of social factors on the mental health status of homosexual men and women have been well documented in studies, which found a relationship between experiences of stigma, prejudice, and discrimination and mental health status.^{52, 53, 54, 55, 56, 57,58, 59, 60, 61} Furthermore, controlling for psychological predictors of present distress seems to eliminate differences in mental health status between heterosexual and homosexual adolescents.⁶² The mediating role of relationship status suggests that higher prevalence rates of some disorders in homosexual people compared with heterosexual people could also be caused by loneliness.
The differential pattern of differences for men and women can also be interpreted in various ways. First, an effect of sexual orientation in women might be more difficult to demonstratesince women already show higher levels of mood and anxiety disorders than men regardless of sexual preference.²⁴ Homosexual women could also be less exposed to social stressors than homosexual men, given that attitudes toward homosexual men are generally more negative than attitudes toward homosexual women.⁶³ The fact that homosexual men showed higher prevalence rates of disorders that are characteristic for women in general, whereas homosexual women showed higher prevalence rates of disorders that are characteristic formen in general, is in line with the theory that sex-atypical levels of prenatal androgens play a major role in the causes and development of homosexuality.¹⁴
In conclusion, this study offers evidence that homosexuality is associated with a higher prevalence of psychiatric disorders. The outcomes are in line with findings from earlier studies in which less rigorous designs have been employed. The processes underlying the established differences need further study. Research into these processes should be able to disentangle the potential interplay of various factors—social, attitudinal, behavioral, and biological—instead of testing one specific factor. The most promising design for such a study requires a large sample of both men and women, and is longitudinal and cross-cultural.

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