Dutch study shows Gay depressed even in an open and tolerant community

Image via WikipediaFOR A LARGE part of the past century, homosexuality itself was seen as a mental disorder. In 1973, the American Psychiatric Association removed homosexuality from its list of mental disorders. This removal came about because of support from research findings^{1, 2, 3, 4} and as a result of a persistent plea by both professionals and activists.⁵

In response to the former psychiatric stigmatization of homosexuality and ideologically inspired by a social movement aiming to achieve greater acceptance of homosexual people, some authors subsequently stressed the equality in mental health status of homosexual and heterosexual people.^6, 7 Others suggested that the mental health status of homosexual people might be impaired owing to various stresses, either temporary or in specific subgroups.⁸ Some authors expected an upsurge in suicidal behaviors, especially in adolescence and young adulthood, as a consequence of the stresses experienced during the coming-out process.^1, 9, 10 Levels of substance abuse were also expected to be higher in gay men and lesbians as compared with heterosexual people.^11, 12 Furthermore, negative health consequences such as body image dissatisfaction and eating disorders also came to be seen as related to the specific lifestyle and subculture of openly gay and lesbian people.^8, 13

Although many studies have assessed the mental health status of homosexual men and women, the results are still inconclusive. This is predominantly due to a variety of methodological problems, characteristic of most studies done since the 1960s, such as the use of convenience samples, small sample sizes, lack of adequate comparison groups, failure to control for potentially confounding factors, application of nonstandardized research instruments, and questionable external validity.^{14, 15, 16, 17}

Recent studies applying a more rigorous methodology showed that there is substantial support for the existence of orientation-related differences in mental health status. In a population-based study among adolescents, suicidal intent and actual suicide attempts were related to homosexuality in males but not females.¹⁸ Young people with a homosexual or bisexual orientation were found to be at increased risk of major depression, generalized anxiety disorder, conduct disorder, substance abuse/dependence, and suicidal behaviors.¹⁹Middle-aged men who reported ever having had male sex partners were at a higher lifetime risk for various suicidal symptoms compared with their heterosexual counterparts, even after controlling for substance abuse and depressive symptoms.²⁰ A small increased risk among homosexually active populations in 1-year psychiatric morbidity was found in a sample of the US population, with homosexually active men more likely than other men to experience major depression and panic attack syndromes and homosexually active women more likely than other women to be classified as having alcohol or other drug dependence.²¹ However, these studies still have various limitations.^10, 14, 22

Our study aims to explore differences in the prevalence of DSM-III-R psychiatric disorders in relation to homosexuality and to overcome some of the limitations of the earlier studies. It does so by using a large, representative sample of the Dutch population selected without reference to sexual orientation and allowing for separate analyses for men and women. The study categorizes people as homosexual or heterosexual based on recent rather than lifetime behavior, the latter being a more diffuse categorization than the former.²³ The study uses a validated and standardized instrument to assess psychiatric disorders, applied in face-to-face interviews. By looking at both lifetime and 12-month prevalence, we were able to assess the relationship between homosexuality and mental health more precisely than most other studies.

MEN
Compared with heterosexual men, homosexual men had significantly higher 12-month and lifetime rates of mood and anxiety disorders (Table 2 and Table 3). Inspection of the specific mood disorders revealed that compared with heterosexual men, homosexual men had a much larger chance of having had 12-month and lifetime bipolar disorders and a higher chance of having had lifetime major depression but no significant differences were seen regarding dysthymia. Regarding the specific anxiety disorders, the lifetime prevalence was significantly higher in homosexual men than in heterosexual men for all but generalized anxiety disorder. The biggest differences were found in obsessive-compulsive disorder and agoraphobia. The 12-month prevalences of agoraphobia, simple phobia, and obsessive-compulsive disorder were higher in homosexual men than in heterosexual men. Regarding substance use disorders, the only significant difference was found in lifetime alcohol abuse. This is the only disorder more frequently observed in heterosexual men than in homosexual men. Homosexual men were not more likely than heterosexual men to report 1 or more 12-month and lifetime disorders. More homosexual men than heterosexual men had 2 or more disorders, both lifetime and in the preceding year.



WOMEN
There were no significant differences between homosexual and heterosexual women in the 12-month prevalence of mood and anxiety disorders. On a lifetime basis, homosexual women had a significantly higher prevalence of general mood disorders and major depression than did heterosexual women. The lifetime prevalence of anxiety disorders did not differ between homosexual and heterosexual women. Regarding the preceding year, homosexual women reported a substantially higher rate of substance use disorders than did heterosexual women, although differences in the specific substance use disorders were not significant. Lifetime prevalence of both alcohol and other drug dependence was also significantly higher in homosexual women than in heterosexual women. Although more homosexual women than heterosexual women reported 1 or more DSM-III-R diagnoses, lifetime and in the preceding year,only the former difference was significant. Homosexual women were more likely than heterosexual women to have had 2 or more disorders during their lifetime but not in the preceding year.
If relationship status was not controlled for, ORs increased and the differences in 12-month alcohol dependence and lifetime social phobia were also significant. Both 12-month and lifetime prevalences of 1 or more disorders were higher in homosexual women than in heterosexual women (OR = 2.09, 95% CI = 1.08-4.05 and OR = 3.16, 95% CI = 1.61-6.18, respectively).

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