Research: Homosexuality Social Stress stigmatization - not the full story
Sexuality, Mental Health Outcomes, and Social
Stress
Compared to the general population, non-heterosexual and
transgender subpopulations have higher rates of mental health problems such as
anxiety, depression, and suicide, as well as behavioral and social problems
such as substance abuse and intimate partner violence. The prevailing
explanation in the scientific literature is the social stress model, which
posits that social stressors — such as stigmatization and discrimination —
faced by members of these subpopulations account for the disparity in mental health
outcomes. Studies show that while social stressors do contribute to the
increased risk of poor mental health outcomes for these populations, they
likely do not account for the entire disparity.
Many of the issues surrounding sexual orientation and gender
identity remain controversial among researchers, but there is general agreement
on the observation at the heart of Part Two: lesbian, gay, bisexual, and
transgender (LGBT) subpopulations are at higher risk, compared to the general
population, of numerous mental health problems. Less certain are the causes of
that increased risk and thus the social and clinical approaches that may help
to ameliorate it. In this part we review some of the research documenting the
increased risk, focusing on papers that are data-based with sound methodology,
and that are widely cited in the scientific literature.
A robust and
growing body of research examines the relationships between sexuality or sexual
behaviors and mental health status. The first half of this part discusses the
associations of sexual identities or behaviors with psychiatric disorders (such
as mood disorders, anxiety disorders, and adjustment disorders), suicide, and
intimate partner violence.
The second half explores the reasons for the
elevated risks of these outcomes among non-heterosexual and transgender
populations, and considers what social science research can tell us about one
of the most prevalent ways of explaining these risks, the social stress model.
As we will see, social stressors such as harassment and stigma likely explain
some but not all of the elevated mental health risks for these populations.
More research is needed to understand the causes of and potential solutions for
these important clinical and public health issues.
We turn first to the evidence for the statistical links between
sexual identities or behaviors and mental health outcomes. Before summarizing
the relevant research, we should mention the criteria used in selecting the
studies reviewed. In an attempt to distill overall findings of a large body of
research, each section begins by summarizing the most extensive and reliable
meta-analyses — papers that compile and analyze the statistical data from the
published research literature. For some areas of research, no comprehensive
meta-analyses have been conducted, and in these areas we rely on review
articles that summarize the research literature without going into quantitative
analyses of published data. In addition to reporting these summaries, we also discuss
a few select studies that are of particular value because of their methodology,
sample size, controls for confounding factors, or ways in which concepts such
as heterosexuality or homosexuality are operationalized; and we discuss key
studies published after the meta-analyses or review articles were published.
As we showed in Part One, explaining the exact biological
and psychological origins of sexual desires and behaviors is a difficult
scientific task, one that has not yet been and may never be satisfactorily
completed. However, researchers can study the correlations between sexual
behavior, attraction, or identity and mental health outcomes, though there may
be — and often are found to be — differences between how sexual behavior,
attraction, and identity relate to particular mental health outcomes.
Understanding the scope of the health challenges faced by individuals who
engage in particular sexual behaviors or experience certain sexual attractions
is a necessary step in providing these individuals with the care they need.
In a 2008 meta-analysis of research on mental health outcomes for
non-heterosexuals, University College London professor of psychiatry Michael
King and colleagues concluded that gays, lesbians, and bisexuals face “higher
risk of suicidal behaviour, mental disorder and substance misuse and dependence
than heterosexual people.”[1] This survey of the literature examined
papers published between January 1966 and April 2005 with data from 214,344
heterosexual and 11,971 non-heterosexual individuals. The large sample size
allowed the authors to generate estimates that are highly reliable, as
indicated by the relatively small confidence intervals.[2]
Compiling the risk ratios found in these papers, the authors
estimated that lesbian, gay, and bisexual individuals had a 2.47 times higher
lifetime risk than heterosexuals for suicide attempts,[3] that they were about twice as likely to
experience depression over a twelve-month period,[4] and approximately 1.5 times as likely
to experience anxiety disorders.[5] Both non-heterosexual men and women
were found to be at an elevated risk for substance abuse problems (1.51 times
as likely),[6] with the risk for non-heterosexual
women especially high — 3.42 times higher than for heterosexual women.[7] Non-heterosexual men, on the other
hand, were at a particularly high risk for suicide attempts: while
non-heterosexual men and women together were at a 2.47 times greater risk of
suicide attempts over their lifetimes, non-heterosexual men were found to be at
a 4.28 times greater risk.[8]
These findings have been replicated in other studies, both in the
United States and internationally, confirming a consistent and alarming
pattern. However, there is considerable variation in the estimates of the
increased risks of various mental health problems, depending on how researchers
define terms such as “homosexual” or “non-heterosexual.” The findings from a
2010 study by Northern Illinois University professor of nursing and health
studies Wendy Bostwick and colleagues examined associations of sexual
orientation with mood and anxiety disorders among men and women who either
identified as gay, lesbian, or bisexual, or who reported engaging in same-sex
sexual behavior, or who reported feeling same-sex attractions.
The study
employed a large, U.S.-based random population sample, using data collected
from the 2004–2005 wave of the National Epidemiologic Survey on Alcohol and Related
Conditions, which was based on 34,653 interviews.[9] In its sample, 1.4% of respondents
identified as lesbian, gay, or bisexual; 3.4% reported some lifetime same-sex
sexual behavior; and 5.8% reported non-heterosexual attractions.[10]
Women who identified as lesbian, bisexual, or “not sure” reported
higher rates of lifetime mood disorders than women who identified as
heterosexual: the prevalence was 44.4% in lesbians, 58.7% in bisexuals, and
36.5% in women unsure of their sexual identity, as compared to 30.5% in
heterosexuals. A similar pattern was found for anxiety disorders, with bisexual
women experiencing the highest prevalence, followed by lesbians and those
unsure, and heterosexual women experiencing the lowest prevalence. Examining
the data for women with different sexual behavior or sexual attraction (rather than identity), those
reporting sexual behavior with or attractions to both men and women had a
higher rate of lifetime disorders than women who reported exclusively
heterosexual or homosexual behaviors or attractions, and women reporting
exclusive same-sex sexual behavior or exclusive same-sex attraction in fact had
the lowest rates of lifetime mood and anxiety
disorders.[11]
Men who identified
as gay had more than double the prevalence of lifetime mood disorders compared
to men who identified as heterosexual (42.3% vs. 19.8%), and more than double
the rate of any lifetime anxiety disorder (41.2% vs. 18.6%), while those who
identified as bisexual had a slightly lower prevalence of mood disorders
(36.9%) and anxiety disorders (38.7%) than gay men. When looking at sexual
attraction or behavior for men, those who reported sexual attraction to “mostly
males” or sexual behavior with “both females and males” had the highest
prevalence of lifetime mood disorders and anxiety disorders compared to other groups,
while those reporting exclusively heterosexual attraction or behavior had the
lowest prevalence of any group.
Other studies have found that non-heterosexual populations are at
a higher risk of physical health problems in addition to mental health problems.
A 2007 study by UCLA professor of epidemiology Susan Cochran and colleagues
examined data from the California Quality of Life Survey of 2,272 adults to
assess links between sexual orientation and self-reported physical health
status, health conditions, and disability, as well as psychological distress
among lesbians, gay men, bisexuals, and those they classified as “homosexually
experienced heterosexual individuals.”[12] While the study, like most, was
limited by the use of self-reporting of health conditions, it had several
strengths: it studied a population-based sample; it separately measured identity
and behavioral dimensions of sexual orientation; and it controlled for race
(ethnicity), education, relationship status, and family income, among other
factors.
While the authors
of this study found a number of health conditions that appeared to have elevated
prevalence among non-heterosexuals, after adjusting for demographic factors
that are potential confounders the only group with significantly greater
prevalence of non-HIV physical health conditions was bisexual women, who were
more likely to have health problems than heterosexual women. Consistent with
the 2010 study by Bostwick and colleagues, higher rates of psychological stress
were reported by lesbians, bisexual women, gay men, and homosexually
experienced heterosexual men, both before and after adjusting for demographic
confounding. Among men, self-identified gay and homosexually experienced
heterosexual respondents reported the highest rates of several health problems.
Using the same California Quality of Life Survey, a 2009 study by
UCLA professor of psychiatry and biobehavioral sciences Christine Grella and
colleagues (including Cochran) examined the relationship between sexual
orientation and receiving treatment for substance use or mental disorders.[13] They used a population-based sample,
with sexual minorities oversampled to provide more statistical power to detect
group differences. The usage of treatment was classified according to whether
or not respondents reported receiving treatment in the preceding twelve months
for “emotional, mental health, alcohol or other drug problems.” Sexual
orientation was operationalized by a combination of behavioral history and
self-identification. For example, they grouped together as “gay/bisexual” or
“lesbian/bisexual” both those who identified as gay, lesbian, or bisexual, and
those who had reported same-sex sexual behaviors. They found that women who were
lesbian or bisexual were most likely to have received treatment, followed by
men who were gay or bisexual, then heterosexual women, with heterosexual men
being the least likely group to have reported receiving treatment.
Overall,
more than twice as many LGB individuals, compared to heterosexuals, had
reported receiving treatment in the past twelve months (48.5% compared to
22.5%). The pattern was similar for men and women; 42.5% of homosexual men,
compared to 17.1% of heterosexual men, had reported receiving treatment, while
55.3% of lesbian and bisexual women and 27.1% of heterosexual women reported
receiving treatment. (Bostwick and colleagues had found that women with
exclusively same-sex attractions and behaviors had a lower prevalence of mood
and anxiety disorders compared to heterosexual women. The difference in results
could be due to the fact that Grella and colleagues grouped those who
identified as lesbians together with those who identified as bisexuals or who
reported same-sex sexual behavior.)
A 2006 study by Columbia University psychiatry professor Theodorus
Sandfort and colleagues examined a representative, population-based sample from
the second Dutch National Survey of General Practice, carried out in 2001, to
assess links between self-reported sexual orientation and health status among
9,511 participants, of whom 0.9% were classified as bisexual and 1.5% as gay or
lesbian.[14] To operationalize sexual orientation,
the researchers asked respondents about their sexual preference on a 5-point
scale: exclusively women, predominantly women, equally men and women,
predominantly men, and exclusively men. Only those who reported an equal
preference for men and women were classified as bisexual, while men reporting
predominant preferences for women, or women reporting a predominant preference
for men were classified as heterosexual.
They found that gay, lesbian, and
bisexual respondents reported experiencing higher numbers of acute mental
health problems and reported worse general mental health than heterosexuals.
The results for physical health were mixed, however: lesbian and gay
respondents reported experiencing more acute physical symptoms (such as
headaches, back pain, or sore throats) over the past fourteen days, though they
did not report experiencing two or more such symptoms any more than
heterosexuals.
Lesbian and gay
respondents were more likely to report chronic health problems, though bisexual
men (that is, men who reported an equal sexual preference for men and women)
were less likely to report chronic health problems and bisexual women were no
more likely than heterosexual women to do so. The researchers did not find a
statistically significant relationship between sexual orientation and overall
physical health. After controlling for the possible confounding effects of
mental health problems on the reporting of physical health problems, the researchers
also found that the statistical effect of reporting a gay or lesbian sexual
preference on chronic and acute physical conditions disappeared, though the
effect of bisexual preference remained.
The Sandfort study
defined sexual orientation in terms of preference or attraction without
reference to behavior or self-identification, which makes it a challenge to
compare its results to the results of studies that operationalize sexual
orientation differently. For example, it is difficult to compare the findings
of this study regarding bisexuals (defined as men or women who report an equal
sexual preference for men and women) with the findings of other studies
regarding “homosexually experienced heterosexual individuals” or those who are
“unsure” of their sexual identity. As in most of these types of studies, the
health assessments were self-reported, which may make the results somewhat
unreliable. But this study also has several strengths: it used a large and
representative sample of a country’s population, as opposed to the convenience
samples that are sometimes used for these kinds of studies, and this sample
included a sufficient number of gays and lesbians for their data to be treated
in separate groups in the study’s statistical analyses. Only three people in
the sample reported HIV infection, so this did not appear to be a potential
confounding factor, though HIV could have been underreported.
In an effort to summarize findings in this area, we can cite the
2011 report from the Institute of Medicine (IOM), The Health of Lesbian, Gay,
Bisexual, and Transgender People.[15] This report is an extensive review of
scientific literature citing hundreds of studies that examine the health status
of LGBT populations. The authors are scientists who are well versed in these
issues (although we wish there had been more involvement of experts in
psychiatry). The report reviews findings on physical and mental health in
childhood, adolescence, early and middle adulthood, and late adulthood.
Consistent with the studies cited above, this report reviews evidence showing
that, compared with heterosexual youth, LGB youth are at a higher risk of
depression, as well as suicide attempts and suicidal ideation. They are also
more likely to experience violence and harassment and to be homeless. LGB
individuals in early or middle adulthood are more prone to mood and anxiety
disorders, depression, suicidal ideation, and suicide attempts.
The IOM report shows that, like LGB youth, LGB adults — and women
in particular — appear to be likelier than heterosexuals to smoke, use or abuse
alcohol, and abuse other drugs. The report cites a study[16] that found that self-identified
non-heterosexuals used mental health services more often than heterosexuals,
and another[17] that found that lesbians used mental
health services at higher rates than heterosexuals.
The IOM report notes that “more research has focused on gay men
and lesbians than on bisexual and transgender people.”[18] The relatively few studies focusing on
transgender populations show high rates of mental disorders, but the use of
nonprobability samples and the lack of non-transgender controls call into
question the validity of the studies.[19] Although some studies have suggested
that the use of hormone treatments may be associated with negative physical
health outcomes among transgender populations, the report notes that the
relevant research has been “limited” and that “no clinical trials on the
subject have been conducted.”[20] (Health outcomes for transgender
individuals will be further discussed below in this part and also in Part Three.)
The IOM report claims that the evidence that LGBT populations have
worse mental and physical health outcomes is not fully conclusive. To support
this claim, the IOM report cites a 2001 study[21] of mental health in 184 sister pairs
in which one sister was lesbian and the other heterosexual. The study found no
significant differences in rates of mental health problems, and found
significantly higher self-esteem in the lesbian sisters. The IOM report also
cites a 2003 study[22] that found no significant differences
between heterosexual and gay or bisexual men in general happiness, perceived
health, and job satisfaction. Acknowledging these caveats and the studies that
do not support the general trend, the vast majority of studies cited in the
report point to a generally higher risk of poor mental health status in LGBT
populations compared to heterosexual populations.
The association between sexual orientation and suicide has strong
scientific support. This association merits particular attention, since among
all the mental health risks, the increased risk of suicide is the most
concerning, owing in part to the fact that the evidence is robust and
consistent, and in part to the fact that suicide is so devastating and tragic
for the person, family, and community. A better understanding of the risk
factors for suicide could allow us, quite literally, to save lives.[23]
Sociologist and suicide researcher Ann Haas and colleagues
published an extensive review article in 2011 based on the results of a 2007
conference sponsored by the Gay and Lesbian Medical Association, the American
Foundation for Suicide Prevention, and the Suicide Prevention Resource Center.[24] They also examined studies reported
since the 2007 conference. For the purposes of their report, the authors
defined sexual orientation as “sexual self-identification, sexual behavior, and
sexual attraction or fantasy.”[25]
Haas and colleagues
found the association between homosexual or bisexual orientation and suicide
attempts to be well supported by data. They noted that population-based surveys
of U.S. adolescents since the 1990s indicate that suicide attempts are two to
seven times more likely in high school students who identify as LGB, with
sexual orientation being a stronger predictor in males than females. They
reviewed data from New Zealand that suggested that LGB individuals were six
times more likely to have attempted suicide. They cited health-related surveys
of U.S. men and Dutch men and women showing same-sex behavior linked to higher
risk of suicide attempts. Studies cited in the report show that lesbian or
bisexual women are likelier, on average, to experience suicidal ideation, that
gay or bisexual men are more likely, on average, to attempt suicide, and that
lifetime suicide attempts among non-heterosexuals are greater in men than in
women.
Examining studies that looked at rates of mental disorders in
relation to suicidal behavior, Haas and colleagues discussed a New Zealand
study[26] showing that gay people reporting
suicide attempts had higher rates of depression, anxiety, and conduct disorder.
Large-scale health surveys suggested that rates of substance abuse are up to
one third higher for the LGB subpopulation. Combined worldwide studies showed
up to 50% higher rates of mental disorders and substance abuse among persons
self-identifying in surveys as lesbian, gay, or bisexual. Lesbian or bisexual
women showed higher levels of substance abuse, while gay or bisexual men had
higher rates of depression and panic disorder.
Haas and colleagues also examined transgender populations, noting
that scant information is available about transgender suicides but that the
existing studies indicate a dramatic increased risk of completed suicide.
(These findings are noted here but examined in more detail in Part Three.) A
1997 clinical study[27] estimated elevated risks of suicide
for Dutch male-to-female transsexual individuals on hormone therapy, but found
no significant differences in overall mortality. A 1998 international review of
2,000 persons receiving sex-reassignment surgery identified 16 possible
suicides, an “alarmingly high rate of 800 suicides for every 100,000
post-surgery transsexuals.”[28] In a 1984 study, a clinical sample of
transgender individuals requesting sex-reassignment surgery showed suicide
attempt rates between 19% and 25%.[29] And a large sample of 40,000 mostly
U.S. volunteers completing an Internet survey in 2000 found transgender persons
to report higher rates of suicide attempts than any group except lesbians.[30]
Finally, the review by Haas and colleagues suggests that it is not
clear which aspects of sexuality (identity, attraction, behavior) are most
closely linked with the risk of suicidal behavior. The authors cite a 2010
study[31] showing that adolescents identifying
as heterosexual while reporting same-sex attraction or behavior did not have
significantly higher suicide rates than other self-identified heterosexuals.
They also cite the large national survey of U.S. adults conducted by Wendy
Bostwick and colleagues (discussed earlier),[32] which showed mood and anxiety
disorders — key risk factors for suicidal behavior — more closely related to
sexual self-identity than to behavior or attraction, especially for women.
A more recent critical review of existing studies of suicide risk
and sexual orientation was presented by Austrian clinical psychologist Martin
Plöderl and colleagues.[33] This review rejects several hypotheses
developed to account for the increased suicide risk among non-heterosexuals,
including biases in self-reporting and failures to measure suicide attempts
accurately. The review argues that methodological improvements in studies since
1997 have provided control groups, better representativeness of study samples,
and more clarity in defining both suicide attempts and sexual orientation.
The review mentions a 2001 study[34] by Ritch Savin-Williams, a Cornell
University professor of developmental psychology, that reported no
statistically significant difference between heterosexual and LGB youths after
eliminating false-positive reports of suicide attempts and blaming a
“‘suffering suicidal’ script” for leading to an over-reporting of suicidal
behavior among gay youths. Plöderl and colleagues argue, however, that the
Savin-Williams study’s finding that there was no statistically significant
difference between the suicide rates of LGB and heterosexual youths might be
attributable to the small sample size, which yielded low statistical power.[35] The later work has not replicated this
finding. Subsequent questionnaire or interview-based studies with stricter
definitions of suicide attempts have found significantly increased rates of
suicide attempts among non-heterosexuals. Several large-scale surveys of young
people have found that the elevated risk of reported suicidal behavior
increased with the severity of the attempts.[36] Finally, according to Plöderl and
colleagues, comparing results of questionnaires with clinical interviews
indicates that homosexual youth are less likely to over-report suicide attempts
in surveys than heterosexual youth.
Plöderl and
colleagues concluded that among psychiatric patients, homosexual or bisexual
populations are over-represented in “serious suicide attempts,” and that sexual
orientation is one of the strongest predictors of suicide. Similarly, in
nonclinical population-based studies, non-heterosexual status is found to be
one of the strongest predictors of suicide attempts. The authors note:
The most exhaustive collation of published and unpublished
international studies on the association of suicide attempts and sexual
orientation with different methodologies has produced a very consistent
picture: nearly all studies found increased incidences of self-reported suicide
attempts among sexual minorities.[37]
In acknowledging the challenges of all such research, the authors
suggest that “the major problem remains as to where one draws the line between
a heterosexual or non-heterosexual orientation.”[38]
A 1999 study by Richard Herrell and colleagues analyzed 103 middle-aged
male twin pairs from the Vietnam Era Twin Registry in Hines, Illinois, in which
one twin, but not the other, reported having a male sex partner after the age
of 18.[39] The study adopted several measures of
suicidality and controlled for potential confounding factors such as substance
abuse or depression. It found a “substantially increased lifetime prevalence of
suicidal symptoms” in male twins who had sex with men compared with co-twins
who did not, independent of the potential confounding effects of drug and
alcohol abuse.[40] Though it is a relatively small study
and relied on self-reporting for both same-sex behaviors and suicidal thoughts
or behaviors, it is notable for using a probability sample (which eliminates
selection bias), and for using the co-twin control method (which reduces the
effects of genetics, age, race, and the like). The study looked at middle-aged
men; what the implications might be for adolescents is not clear.
In a 2011 study, Robin Mathy and colleagues analyzed the impact of
sexual orientation on suicide rates in Denmark during the first twelve years
after the legalization of same-sex registered domestic partnerships (RDPs) in
that country, using data from death certificates issued between 1990 and 2001
as well as Danish census population estimates.[41] The researchers found that the
age-adjusted suicide rate for same-sex RDP men was nearly eight times the rate
for men in heterosexual marriages, and nearly twice the rate for men who had
never married. For women, RDP status had a small, statistically insignificant
effect on suicide mortality risk, and the authors conjectured that the impact
of HIV status on the health of gay men might have contributed to this
difference between the results for men and women. The study is limited by the
fact that RDP status is an indirect measure of sexual orientation or behavior,
and does not include those gays and lesbians who are not in a registered
domestic partnership; the study also excluded individuals under the age of 18.
Finally, the absolute number of individuals with current or past RDP status was
relatively small, which may limit the study’s conclusions.
Professor of pediatrics Gary Remafedi and colleagues published a
1991 study that looked at 137 males age 14–21 who self-identified as gay (88%)
or bisexual (12%). Remafedi and colleagues attempted, with a case-controlled
approach, to examine which factors for this population were most predictive of
suicide.[42] Compared to those who did not attempt
suicide, those who did were significantly more likely to label themselves and
identify publicly as bisexual or homosexual at younger ages, report sexual
abuse, and report illicit drug use. The authors noted that the likelihood of a
suicide attempt “diminished with advancing age at the time of bisexual or
homosexual self-labeling.” Specifically, “with each year’s delay in
self-identification, the odds of a suicide attempt declined by more than 80%.”[43] This study is limited by using a
relatively small nonprobability sample, though the authors note that its result
comports with their previous finding[44] of an inverse relationship between
psychosocial problems and the age at which one identifies as homosexual.
In a 2010 study, Plöderl and colleagues solicited self-reported
suicide attempts among 1,382 Austrian adults to confirm existing evidence that
homosexual and bisexual individuals are at higher risk.[45] To sharpen the results, the authors
developed more rigorous definitions of “suicide attempts” and assessed multiple
dimensions of sexual orientation, distinguishing among sexual fantasies,
preferred partners, self-identification, recent sexual behavior, and lifetime
sexual behavior. This study found an increased risk for suicide attempts for
sexual minorities along all dimensions of sexual orientation. For women, the
risk increases were largest for those with homosexual behaviors; for men, they
were largest for homosexual or bisexual behavior in the previous twelve months
and self-identification as homosexual or bisexual. Those reporting being unsure
of their identity reported the highest percentage of suicide attempts (44%),
although this group was small, comprising less than 1% of participants.
A 2016 meta-analysis by University of Toronto graduate student
Travis Salway Hottes and colleagues aggregated data from thirty cross-sectional
studies on suicide attempts that together included 21,201 sexual minority
adults.[46] These studies used either
population-based sampling or community-based sampling. Since each sampling
method has its own strengths and potential biases,[47] the researchers wanted to examine any
differences in the rates of attempted suicide between the two sampling types.
Of the LGB respondents to population-based surveys, 11% reported having
attempted suicide at least once, compared to 4% of heterosexual respondents to
these surveys.[48] Of the LGB respondents to
community-based surveys, 20% reported having attempted suicide.[49] Statistical analysis showed that the
difference in the sampling methods accounted for 33% of the variation in the
suicide figures reported by the studies.
The research on
sexuality and the risk of suicide suggests that those who identify as gay,
lesbian, bisexual, or transgender, or those who experience same-sex attraction
or engage in same-sex sexual behavior are at substantially increased risk of
suicidal ideation, suicide attempts, and completed suicide. In the section
later in Part Two on the social stress model, we will examine — and raise
questions about — one set of arguments put forward to explain these findings.
Given the tragic consequences of inadequate or incomplete information in these
matters and its effect on public policy and clinical care, more research into
the reasons for elevated suicide risk among sexual minorities is desperately
needed.
Several studies have examined the differences between rates of
intimate partner violence (IPV) in same-sex couples and opposite-sex couples.
The research literature examines rates of IPVvictimization (being subjected to violence by a
partner) and rates of IPV perpetration (committing violence against a
partner). In addition to physical and sexual violence, some studies also
examine psychological violence, which comprises verbal attacks, threats, and
similar forms of abuse. The weight of evidence indicates that the rate of
intimate partner violence is significantly higher among same-sex couples.
In 2014, London School of Hygiene and Tropical Medicine researcher
Ana Buller and colleagues conducted a systematic review of 19 studies (with a
meta-analysis of 17 of these studies) examining associations between intimate
partner violence and health among men who have sex with men.[50]Combining
the available data, they found that the pooled lifetime prevalence of any IPV
was 48% (estimates from the studies were quite heterogeneous, ranging from 32%
to 82%). For IPV within the previous five years, pooled prevalence was 32%
(estimates ranging from 16% to 51%). IPV victimization was associated with
increased rates of substance use (pooled odds ratio of 1.9), positive HIV
status (pooled odds ratio of 1.5), and increased rates of depressive symptoms
(pooled odds ratio of 1.5). IPV perpetration was also associated with increased
rates of substance use (pooled odds ratio of 2.0). An important limitation of
this meta-analysis was that the number of studies it included was relatively
small. Also, the heterogeneity of the studies’ results may undermine the
precision of the meta-analysis. Further, most of the reviewed studies used
convenience samples rather than probabilistic samples, and they used the word
“partner” without distinguishing long-term relationships from casual
encounters.
English psychologists Sabrina Nowinski and Erica Bowen conducted a
2012 review of 54 studies on the prevalence and correlates of intimate partner
violence victimization among heterosexual and gay men.[51] The studies showed rates of IPV
victimization for gay men ranging from 15% to 51%. Compared to heterosexual
men, the review reports, “it appears that gay men experienced more total and
sexual IPV, slightly less physical IPV, and similar levels of psychological
IPV.”[52] The authors also report that according
to estimates of IPV prevalence over the most recent twelve months, gay men
“experienced less physical, psychological and sexual IPV” than heterosexual
men, though the relative lack of twelve-month estimates may make this result
unreliable. The authors note that “one of the most worrying findings is the
prevalence of severe sexual coercion and abuse in male same-gender
relationships,”[53]citing
a 2005 study[54] on IPV in HIV-positive gay men.
Nowinski and Bowen found positive HIV status to be associated with IPV in both
gay and heterosexual relationships. An important limitation of their review is
the fact that many of the same-sex IPV studies they examined were based on
small convenience samples.
Catherine Finneran and Rob Stephenson of Emory University in 2012
conducted a systematic review of 28 studies examining IPV among men who have
sex with men.[55] Every study in the review estimated
rates of IPV for gay men that were similar to or higher than those for all
women regardless of sexual orientation. The authors conclude that “the emergent
evidence reviewed here demonstrates that IPV — psychological, physical, and
sexual — occurs in male-male partnerships at alarming rates.”[56]Physical
IPV victimization was reported most frequently, with rates ranging from 12% to
45%.[57] The rate of sexual IPV victimization
ranged from 5% to 31%, with 9 out of 19 studies reporting rates over 20%.
Psychological IPV victimization was recorded in six studies, with rates ranging
from 5% to 73%.[58]Perpetration
of physical IPV was reported in eight studies, with rates ranging from 4% to
39%. Rates of perpetration of sexual IPV ranged from 0.7% to 28%; four of the
five studies reviewed reported rates of 9% or more. Only one study measured
perpetration of psychological violence, and the estimated prevalence was 78%.
Lack of consistent research design among the studies examined (for example,
some differences regarding the exact definition of IPV, the correlates of IPV
examined, and the recall periods used to measure violence) makes it impossible
to calculate a pooled prevalence estimate, which would be useful given the lack
of a national probability-based sample.
A 2013 study by UCLA’s Naomi Goldberg and Ilan Meyer used a large
probability sample of almost 32,000 individuals from the California Health
Interview Survey to assess differences in intimate partner violence between
various cohorts: heterosexual; self-identified gay, lesbian, and bisexual
individuals; and men who have sex with men but did not identify as gay or
bisexual, and women who have sex with women but did not identify as lesbian or
bisexual.[59] All three LGB groups had greater
lifetime and one-year prevalence of intimate partner violence than the
heterosexual group, but this difference was only statistically significant for
bisexual women and gay men. Bisexual women were more likely to have experienced
lifetime IPV (52% of bisexual women vs. 22% of heterosexual women and 32% of
lesbians) and to have experienced IPV in the preceding year (27% of bisexuals
vs. 5% of heterosexuals and 10% of lesbians). For men, all three
non-heterosexual groups had higher rates of lifetime and one-year IPV, but this
was only statistically significant for gay men, who were more likely to have
experienced IPV over a lifetime (27% of gay men vs. 11% of heterosexual men and
19.6% of bisexual men) and over the preceding year (12% of gay men vs. 5% of
heterosexual men and 9% of bisexual men). The authors also tested whether binge
drinking and psychological distress could explain the higher prevalence of IPV
victimization in gay men and bisexual women; controlling for these variables
revealed that they did not. This study is limited by the fact that other
potentially confounding psychological variables (besides drinking and distress)
were not controlled for, statistically or otherwise, and may have accounted for
the findings.
To estimate the prevalence of battering victimization among gay
partners, AIDS-prevention researcher Gregory Greenwood and colleagues published
a 2002 study based on telephone interviews with a probability-based sample of
2,881 men who have sex with men (MSM) in four cities from 1996 to 1998.[60] Of those interviewed, 34% reported
experiencing psychological or symbolic abuse, 22% reported physical abuse, and
5% reported sexual abuse. Overall, 39% reported some type of battering
victimization, and 18% reported more than one type of battering in the previous
five years. Men younger than 40 were significantly more likely than men over 60
to report battering violence. The authors conclude that “the prevalence of
battering within the context of intimate partner relationships was very high”
among their sample of men who have sex with men, and that since lifetime rates
are usually higher than those for a five-year recall, “it is likely that a
substantially greater number of MSM than of heterosexual men have experienced lifetime
victimization.”[61] The five-year prevalence of physical
battering among this sample of urban MSM was also “significantly higher” than
the annual rate of severe violence (3%) or total violence (12%) experienced in
a representative sample of heterosexual women living with men, suggesting that
the estimates of battering victimization for MSM in this study “are higher than
or comparable to those reported for heterosexual women.”[62] This study was limited by its use of a
sample from four cities, so it is not clear how well the results generalize to
non-urban settings.
The research literature for mental health outcomes in transgender
individuals is more limited than the research on mental health outcomes in LGB
populations. Because people identifying as transgender make up a very small
proportion of the population, large population-based surveys and studies of
such individuals are difficult if not impossible to conduct. Nevertheless, the
limited available research strongly suggests that transgender people have
increased risks of poor mental health outcomes. It appears that the rates of
co-occurring substance use disorders, anxiety disorders, depression, and
suicide tend to be higher for transgender people than for LGB individuals.
In 2015, Harvard pediatrics professor and epidemiologist Sari
Reisner and colleagues conducted a retrospective matched-pair cohort study of
mental health outcomes for 180 transgender subjects aged 12–29 years (106
female-to-male and 74 male-to-female), matched to non-transgender controls
based on gender identity.[63] Transgender youth had an elevated risk
of depression (50.6% vs. 20.6%)[64] and anxiety (26.7% vs. 10.0%).[65] Transgender youth also had higher risk
of suicidal ideation (31.1% vs. 11.1%),[66] suicide attempts (17.2% vs. 6.1%),[67] and self-harm without lethal intent
(16.7% vs. 4.4%)[68]relative
to the matched controls. A significantly greater proportion of transgender
youth accessed inpatient mental health care (22.8% vs. 11.1%)[69] and outpatient mental health care
(45.6% vs. 16.1%)[70] services. No statistically significant
differences in mental health status were observed when comparing female-to-male
transgender individuals to the male-to-female transgender individuals after
adjusting for age, race/ethnicity, and hormone use.
This study had the merit of including individuals who presented to
a community-based health clinic, and who thus were not identified solely as
meeting the diagnostic criteria for gender identity disorder in the fourth
edition of the American Psychiatric Association’s Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV),
and were not selected from a population of patients presenting to a clinic for
treatment of gender identity issues. However, Reisner and colleagues note that
their study has the limitations typically found in the retrospective chart
review study design, such as incomplete documentation and variation in the
quality of information recorded by medical professionals.
A report from the American Foundation for Suicide Prevention and
the Williams Institute, a think tank for LGBT issues at the UCLA School of Law,
summarized findings on suicide attempts among transgender and
gender-nonconforming adults from a large national sample of over 6,000
individuals.[71] This constitutes the largest study of
transgender and gender-nonconforming adults to date, though it used a convenience
sample rather than a population-based sample. (Large population-based samples
are nearly impossible given the low overall prevalence in the general
population of transgendered individuals.) Summarizing the major findings of
this study, the authors write:
The prevalence of suicide attempts among respondents to the
National Transgender Discrimination Survey (NTDS), conducted by the National
Gay and Lesbian Task Force and National Center for Transgender Equality, is 41
percent, which vastly exceeds the 4.6 percent of the overall U.S. population
who report a lifetime suicide attempt, and is also higher than the 10–20
percent of lesbian, gay and bisexual adults who report ever attempting suicide.[72]
The authors note that “respondents who said they had received
transition-related health care or wanted to have it someday were more likely to
report having attempted suicide than those who said they did not want it,”
however, “the survey did not provide information about the timing of reported
suicide attempts in relation to receiving transition-related health care, which
precluded investigation of transition-related explanations for these patterns.”[73] The survey data suggested associations
between suicide attempts, co-occurring mental health disorders, and experiences
of discrimination or mistreatment, although the authors note some limitations
of these outcomes: “The survey data did not allow us to determine a direct
causal relationship between experiencing rejection, discrimination,
victimization, or violence, and lifetime suicide attempts,” although they did
find evidence that stressors interacted with mental health factors “to produce
a marked vulnerability to suicidal behavior in transgender and gender non-conforming
individuals.”[74]
A 2001 study by Kristen Clements-Nolle and colleagues of 392
male-to-female and 123 female-to-male transgender persons found that 62% of the
male-to-female and 55% of the female-to-male transgender persons were depressed
at the time of the study, and 32% of each population had attempted suicide.[75] The authors note: “The prevalence of
suicide attempts among male-to-female and female-to-male transgender persons in
our study was much higher than that found in US household probability samples
and a population-based sample of adult men reporting same-sex partners.”[76]
The greater prevalence of mental health problems in LGBT
subpopulations is a cause for concern, and policymakers and clinicians should
strive to reduce these risks. But to know what kinds of measures will help
ameliorate them we must better understand their causes. At this time, the
medical and social strategies for helping non-heterosexual populations in the
United States are quite limited, and this may be due in part to the relatively
limited explanations for the poor mental health outcomes offered by social
scientists and psychologists.
Despite the limits of the scientific understanding of why
non-heterosexual subpopulations are more likely to have such poor mental health
outcomes, much of the public effort to ameliorate these problems is motivated
by a particular hypothesis called the social
stress model. This model posits that discrimination, stigmatization, and
other similar stresses contribute to poor mental health outcomes among sexual
minorities. An implication of the social stress model is that reducing these
stresses would ameliorate the mental health problems experienced by sexual
minorities.
Sexual minorities face distinct social challenges such as stigma,
overt discrimination and harassment, and, often, struggle with reconciling
their sexual behaviors and identities with the norms of their families and
communities. In addition, they tend to be subject to challenges similar to
those of some other minority populations, arising from marginalization by or
conflict with the larger part of society in ways that may adversely impact
their health.[77] Many researchers classify these
various challenges under the concept of social
stress and believe that
social stress contributes to the generally higher rates of mental health
problems among LGBT subpopulations.[78]
In attempting to account for the mental health disparities between
heterosexuals and non-heterosexuals, researchers occasionally refer to a social
or minority stress hypothesis.[79] However, it is more accurate to refer
to a social or minority stress model,
because the postulated connection between social stress and mental health is
more complex and less precise than anything that could be stated as a single
hypothesis.[80] The term stress can have a number of meanings, ranging
from a description of a physiological condition to a mental or emotional state
of anger or anxiety to a difficult social, economic, or interpersonal
situation. More questions arise when one thinks about various kinds of stressors that may disproportionately affect
mental health in minority populations. We will discuss some of these aspects of
the social stress model after a concise overview of the model as it has been
presented in recent literature on LGBT mental health.
The social stress model attempts to explain why non-heterosexual
people have, on average, higher incidences of poor mental health outcomes than
the rest of the population. It does not put forth a complete explanation for
the disparities between non-heterosexuals and heterosexuals, and it does not
explain the mental health problems of a particular patient. Rather, it describes
social factors that might directly or indirectly influence the health risks for
LGBT people, which may only become apparent at a population level. Some of
these factors may also influence heterosexuals, but LGBT people are probably
disproportionately exposed to them.
In an influential 2003 article on the social stress model,
psychiatric epidemiologist and sexual orientation law expert Ilan Meyer
distinguished between distal and proximate minority stressors. Distal stressors
do not depend on the individual’s “perceptions or appraisals,” and thus “can be
seen as independent of personal identification with the assigned minority
status.”[81] For instance, if a man who was
perceived to be gay by an employer was fired on that basis, this would be a
distal stressor, since the stressful event of discrimination would have had
nothing to do with whether the man actually identified as gay, but only with
someone else’s attitude and perception. Distal stressors tend to reflect social
circumstances rather than the individual’s reaction to those circumstances.
Proximate stressors, in contrast, are more subjective and are closely related
to the individual’s self-identity as lesbian, gay, bisexual, or transgender. An
example of a proximate stressor would be when a young woman personally
identifies as being a lesbian, and chooses to hide that identity from her
family members out of fear of disapproval, or because of an internal sense of
shame. The effects of proximate stressors such as this one are highly dependent
on the individual’s self-understanding and unique social circumstances. In this
section we describe the types of stressors postulated in the social stress
model, starting at the distal and proceeding to the most proximate stressors,
and examine some of the empirical evidence that has been offered on the links
between the stressors and mental health outcomes.
Discrimination and
prejudice events. Overt acts of mistreatment, ranging from violence to harassment
and discrimination, are categorized together by researchers as “prejudice
events.” These are thought to be significant stressors for non-heterosexual
populations.[82] Surveys of LGBT subpopulations have
found that they tend to experience these kinds of prejudice events more
frequently than the general population.[83]
The available evidence indicates that prejudice events likely
contribute to mental health problems. A 1999 study by UC Davis professor of
psychology Gregory Herek and colleagues using survey data from 2,259 LGB
individuals in Sacramento found that self-identified lesbians and gays who
experienced a bias crime in the preceding five years — a crime, such as
assault, theft, or vandalism, motivated by the actual or perceived sexual
identity of the victim — reported significantly higher levels of depressive
symptoms, traumatic stress symptoms, and anxiety than lesbians and gays who had
not experienced a bias crime over that same period.[84] Additionally, lesbians and gays who
reported being the victims of bias crimes in the last five years showed
significantly higher levels of depressive and traumatic stress symptoms than
individuals who experienced non-bias crimes in the same period (though the two
groups did not display significant differences in anxiety). Comparable
significant correlations were not found for self-identified bisexuals, who
constituted a much smaller portion of the survey respondents. The study also
found that lesbians and gays subject to bias crimes were significantly more
likely than other respondents to report feelings of vulnerability and a
decreased sense of personal mastery or agency. Corroborating these findings on
the harmful impact of bias crimes was a 2001 study by Northeastern University social
scientist Jack McDevitt and colleagues that examined aggravated assaults using
data from the Boston Police Department.[85] They found that bias crime victims
tended to experience the effects of victimization more intensely and for a
longer period of time than non-bias crime victims. (The study looked at
bias-motivated assaults in general, rather than restricting its analysis to
assaults motivated by LGBT bias, though a substantial portion of the subjects
did experience assaults motivated by their non-heterosexual status.)
Similar patterns also appear among non-heterosexual adolescents,
for whom maltreatment is particularly high.[86] In a 2011 study, University of Arizona
social and behavioral scientist Stephen T. Russell and colleagues analyzed a
survey of 245 young LGBT adults that retrospectively assessed school
victimization due to actual or perceived LGBT status between the ages of 13 and
19. They found strong correlations between school victimization and poor mental
health as young adults.[87] Victimization was assessed by asking
yes-or-no questions, such as, “During my middle or high school years, while at
school, I was pushed, shoved, slapped, hit, or kicked by someone who wasn’t
just kidding around,” followed by a question of how often these events were
related to the respondent’s sexual identity. Respondents who reported high
levels of school victimization due to their sexual identity were 2.6 times more
likely to report depression as young adults and 5.6 times more likely to report
that they had attempted suicide, compared to those who reported low levels of
victimization. These differences were highly statistically significant, though
the study is potentially limited by its use of retrospective surveys to measure
incidents of victimization. A study by professor of social work Joanna Almeida
and colleagues, which relied on the 2006 Boston Youth Survey (a biennial survey
of high school students in Boston public schools), found that perceptions of
having been victimized due to LGBT status accounted for increased symptoms of
depression among LGBT students. For male LGBT students, but not females, the
study also found a positive correlation between victimization and suicidal
thoughts and self-harm.[88]
Differences in compensation suggest discrimination in the
workplace, which can have both direct and indirect effects on mental health.
M.V. Lee Badgett, a professor of economics at the University of Massachusetts,
Amherst, analyzed data collected between 1989 and 1991 in the General Social
Survey and found that non-heterosexual male employees received significantly
lower compensation (11% to 27%) than heterosexuals, even after controlling for
experience, education, occupation, and other factors.[89] According to a 2009 review by Badgett,[90] nine studies from the 1990s and early
2000s “consistently show that gay and bisexual men earned 10% to 32% less than
heterosexual men,” and that differences in occupation cannot account for much
of the wage disparity. Researchers have also found that non-heterosexual women
earn more than heterosexual women,[91] which may suggest either that patterns
of discrimination differ for men and women, or that there are other factors
associated with non-heterosexual behavior and self-identification in men and
women influencing their respective earnings, such as a lower rate of
child-rearing or being the family primary wage earner.
There is evidence that suggests that wage disparities can help
explain some population-level disparities in mental health outcomes,[92] though it is difficult to tell if
differences in mental health help explain the differences in wages. A 1999
study[93] by Craig Waldo on the relationship
between workplace heterosexism — defined as negative social attitudes toward
non-heterosexuals — and stress-related outcomes in 287 LGB individuals found
that LGB individuals who experienced heterosexism in the workplace “exhibited
higher levels of psychological distress and health-related problems, as well as
decreased satisfaction with several aspects of their jobs.” The cross-sectional
data used by many of these studies make it impossible to infer causality,
though both prospective studies and qualitative analyses of the impact of unemployment
on mental health suggest that at least some of the correlations are likely
accounted for by the psychological and material effects of unemployment.[94]
Stigma. Sociologists have for many years documented a range of adverse
effects of stigma on individuals, ranging from issues with self-esteem to
academic achievement.[95] Stigma is typically regarded as an
attribute attaching to a person that reduces that person’s worth to others in a
particular social context.[96] These negative evaluations are in many
cases widely shared among a cultural group and become the basis for excluding
or differentially treating stigmatized individuals. For example, mental illness
can become stigmatized when it is regarded as a character flaw in mentally ill
people. One reason why stigma serves an important role in the social stress
model is that it can be invoked as an explanation even in the absence of
particular events of discrimination or maltreatment. For example,
stigmatization of depression may take place when a depressed person conceals
the depression on the expectation that friends and family members will regard
it as a character flaw. Even when this concealment is successful, and there is
therefore no actual discrimination or mistreatment by the individual’s friends
or family, anxiety over the attitudes others may have can affect the depressed
person’s emotional and mental well-being.
Researchers have found associations between the risk of poor
mental health and stigma toward certain populations, though there has been
little empirical research on the mental health effects of stigma on LGBT people
in particular. Stigma is not easy to define or operationalize, making it a
difficult and vague concept for empirical social scientists to study.
Nevertheless, researchers have attempted to work with the concept using surveys
of self-perceived devaluation by others and have found correlations between
experiences of stigma and the risk of poor mental health status. One highly
cited 1997 study by sociologist and epidemiologist Bruce Link and colleagues on
the connection between stigma and mental health found a “strong and enduring”
negative effect of stigma on the mental well-being of men who were suffering
from a mental disorder and substance abuse.[97] In this study, the effects of stigma
appeared to persist even after the men had received largely successful
treatment for their original mental and substance abuse problems. The study found
significant correlations between certain stigma variables — self-reported
experiences of devaluation and rejection — and depressive symptoms before and
after treatment, suggesting that the effects of stigma are relatively
long-lasting. This might simply indicate that people with depressive symptoms
tend to report more stigma, but if that were the case, one would have expected
reports of stigma to decline over the course of the treatment program, as
depression did. However, since stigma reports stayed constant, the authors
concluded that stigma must have had a causal role in shaping depressive
symptoms. It is worth noting that this study found stigma variables to account
uniquely for around 10% or slightly more of the variance in depressive symptoms
— in other words, stigma had a minor effect on depressive symptoms, though such
an effect might manifest itself in significant ways on a population level. Some
other researchers have suggested that the effects of stigma are usually minor
and transitory; for example, Vanderbilt sociologist Walter Gove argued that for
the “vast majority of cases the stigma [experienced by mental patients] appears
to be transitory and does not appear to pose a severe problem.”[98]
Researchers have relatively recently begun pursuing both empirical
and theoretical work[99] on how stigma affects the mental
health of LGBT people, though there has been some controversy over the
magnitude and duration of effects due to stigma. Some of the controversy may
stem from the difficulty of defining and quantifying stigma as well as the
variations in stigma across different social contexts. A 2013 study by Columbia
University medical psychologist Walter Bockting and colleagues on mental health
in 1,093 transgender people found a positive correlation between psychological
distress and both enacted and felt stigma, which were measured using survey
questions.[100] A 2003 study[101]by
clinical psychologist Robin Lewis and colleagues of predictors of depressive
symptoms in 201 LGB individuals found that stigma consciousness was
significantly associated with depressive symptoms, where stigma consciousness
was assessed using a ten-item questionnaire that assessed “the degree to which
one expects to be judged on the basis of a stereotype.”[102] However, depressive symptoms are often
associated with negative cognition about the self, the world, and the future,
and this may contribute to the subjective perception of stigmatization among
individuals suffering from depression.[103] A 2011 study[104] by Bostwick that also used measures of
stigma consciousness and depressive symptoms found a modest positive
correlation between stigma scores and depressive symptoms in bisexual women,
although the study was limited by having a relatively small sample size.
However, a 2003 longitudinal study[105] of Norwegian adolescents by
psychologist Lars Wichstrøm and colleague found that sexual orientation was
associated with poor mental health status after accounting for a variety of
psychological risk factors, including self-worth. While this study did not
directly consider stigma as a risk factor, it suggests that psychological
factors such as stigma consciousness alone likely cannot fully account for the
disparities in mental health between heterosexuals and non-heterosexuals.
Additionally, it is important to note that due to the cross-sectional design of
these studies, causal inferences cannot be supported by the data — different
kinds of data and more evidence would be needed to support conclusions about
causal relationships. In particular, it is impossible to prove through these studies
that stigma leads to poor mental health, as opposed to, for example, poor
mental health leading people to report higher levels of stigma, or a third
factor being responsible for both poor mental health and higher levels of
stigma.
Concealment. Stigma may affect non-heterosexual individuals’ decisions about
whether to disclose or conceal their sexual orientation. LGBT people may decide
to conceal their sexual orientation to protect themselves against possible bias
or discrimination, to avoid a sense of shame, or to avoid a potential conflict
between their social role and sexual desires or behaviors.[106] Particular contexts in which LGBT
people may be more likely to conceal their sexual orientation include school,
work, and other places in which they feel that disclosure could negatively
affect the way that people regard them.
There is a large amount of evidence from psychological research
indicating that concealment of an important aspect of one’s identity may have
adverse mental health consequences. In general, expressing one’s emotions and
sharing important aspects of one’s life with others play large roles in
maintaining mental health.[107] Recent decades have seen a growing
body of research on the relationships between concealment and disclosure and
mental health in LGBT subpopulations.[108] For example, a 2007 study[109] by Belle Rose Ragins and colleagues of
workplace concealment and disclosure in 534 LGB individuals found that fear of
disclosing was associated with psychological strain and other outcomes such as
job satisfaction. However, the study also challenged the notion that disclosure
leads to positive psychological and social outcomes, since employees’
disclosure was not significantly associated with most of the outcome variables.
The authors interpret this result by saying that “this study suggests that
concealment may be a necessary and adaptive decision in an unsupportive or
hostile environment, thus underscoring the importance of social context.”[110] Due to the relatively rapid changes in
social acceptance of same-sex marriage and of same-sex relationships more
broadly in recent decades,[111] it is possible that some of the
research on the psychological effects of concealment and disclosure is
outdated, because in general there may now be less pressure for those
identifying as LGB to conceal their identities.
Testing the model. One of the implications of the social stress model is that
reducing the amount of discrimination, prejudice, and stigmatization of sexual
minorities would help reduce the rates of mental health problems for these
populations. Some jurisdictions have sought to reduce these social stressors by
passing anti-discrimination and hate-crime laws. If such policies are in fact
successful at reducing these stressors then they could be expected to reduce
the rates of mental health problems in LGB populations to the extent that the social
stress model accurately accounts for the causes of these problems. So far,
studies have not been designed in such a way that could allow them to test
conclusively the hypothesis that social stress accounts for the high rates of
poor mental health outcomes in non-heterosexual populations, but there is
research that provides some data on a testable implication of the social stress
model.
A 2009 study by sociomedical scientist Mark Hatzenbuehler and
colleagues investigated the association between psychiatric morbidity in LGB
populations and two state-level policies that pertained to these populations:
hate-crime laws that did not include sexual orientation as a protected
category, and laws prohibiting employment discrimination based on sexual
orientation.[112] The study used data on mental health
outcomes from Wave 2 of the National Epidemiologic Survey on Alcohol and
Related Conditions (NESARC), a nationally representative sample of 34,653
civilian, non-institutionalized adults, and measuring psychiatric disorders
according to DSM-IV criteria.[113] Wave 2 of NESARC took place in
2004–2005. Of the sample, 577 respondents identified as lesbian, gay, or
bisexual. The analysis of the data showed that LGB individuals living in states
with no hate-crime laws and no non-discrimination laws tended to have higher
odds of psychiatric morbidity (compared to LGB individuals in states with one
or two protective laws), but the analysis found statistically significant correlations
only for dysthymia (a less severe but more persistent form of depression),
generalized anxiety disorder, and post-traumatic stress disorder, while the
correlations between seven other psychiatric conditions investigated were not
found to be statistically significant. No epidemiological inferences can be
made due to the nature of the data, suggesting the need for more studies on
this and similar topics.
Hatzenbuehler and colleagues attempted to improve on this
cross-sectional study by doing a prospective study, published in 2010, this
time examining changes in psychiatric morbidity over the period in which
certain states passed constitutional amendments defining marriage as a union
between one man and one woman — amendments that were described by the study’s
authors as “bans on gay marriage.”[114] The authors examined differences in
psychiatric morbidity between Wave 1 of NESARC, which took place in 2001–2002,
and Wave 2, which coincided with the 2004 and 2005 state-constitutional
amendments. They observed that the prevalence in mood disorders in LGB
respondents living in states that passed marriage amendments increased by 36.6%
between Waves 1 and 2. Mood disorders for LGB respondents living in states that
did not pass marriage amendments decreased by 23.6%, though this change was not
statistically significant. The prevalence of certain disorders increased both
in states that passed such amendments and in states that did not. Generalized
anxiety disorder, for example, increased in both, but by a much larger and
statistically significant magnitude in states that passed marriage amendments.
Hatzenbuehler and colleagues found that drug-use disorders increased more in
states that did not pass marriage amendments, and the
increase was statistically significant only for those states. (Total substance
abuse disorders increased in both cases, by a roughly similar amount.) As with
the earlier cross-sectional study, for the majority of the psychiatric
conditions investigated there were no significant correlations between the
conditions and the social policies that were hypothesized to have an influence
on mental health outcomes.
Some of the
limitations of the study’s findings noted by the authors include the following:
healthier LGB respondents may have moved out of the states that would
eventually pass marriage amendments into the states that would not; sexual orientation
was only assessed during Wave 2 of NESARC, and there is some fluidity to sexual
identity that may have led to misclassification of some LGB respondents; and
the sample size of LGB respondents living in states that passed marriage
amendments was relatively small, limiting the statistical power of the study.
One hypothesized causal mechanism for the change in mental health
variables associated with the marriage amendments is that the public debate
surrounding the amendments may have elevated the stress experienced by
non-heterosexuals — a hypothesis that was put forward by psychologist Sharon
Scales Rostosky and colleagues in a study of the attitudes of LGB adults in
states that passed marriage amendments in 2006.[115] The survey data collected during this
study showed that LGB respondents living in states that passed marriage
amendments in 2006 had higher levels of various kinds of psychological
distress, including stress and depressive symptoms. The study also found that
participation in LGBT activism during the election season was associated with
increased psychological distress. It may be that part of the psychological
distress recorded by this survey, which included perceived stress, depressive
symptoms (but not diagnoses of depressive disorders), and what the researchers
called “amendment-related affect,” may have simply reflected the typical feelings
of advocates when they experience political defeat on an issue that they care
passionately about. Other key limitations of the study were its cross-sectional
design and its reliance on volunteers for the survey (in contrast to the
previous study by Hatzenbuehler and colleagues). The survey methodology may
also have biased the results — the researchers advertised on websites and
through listserv e-mail announcements that they were looking for survey
respondents for a study on “attitudes and experiences of LGB ... individuals
regarding the debate” over gay marriage. As with many forms of convenience
sampling, individuals with strong attitudes regarding the issues under
investigation in the survey may have been more likely to respond.
As for the effects
of particular policies, the evidence is equivocal at best. The 2009 study by
Hatzenbuehler and colleagues demonstrated significant correlations between the
risk of some (though not all) mental health problems in the LGB subpopulation
and state policies on hate crime and employment protections. Even for the
aspects of mental health that this study found to be correlated with hate-crime
or employment-protection policies, the study was unable to show an
epidemiological relationship between policies and health outcomes.
Conclusion
The social stress model probably accounts for some of the poor
mental health outcomes experienced by sexual minorities, though the evidence
supporting the model is limited, inconsistent and incomplete. Some of the
central concepts of the model, such as stigmatization, are not easily
operationalized. There is evidence linking some forms of mistreatment,
stigmatization, and discrimination to some of the poor mental health outcomes
experienced by non-heterosexuals, but it is far from clear that these factors
account for all of the disparities between the heterosexual and
non-heterosexual populations. Those poor mental health outcomes may be
mitigated to some extent by reducing social stressors, but this strategy is
unlikely to eliminate all of the disparities in mental health status between
sexual minorities and the wider population. Other factors, such as the elevated
rates of sexual abuse victimization among the LGBT population discussed in Part
One, may also account for some of these mental health disparities, as research
has consistently shown that “survivors of childhood sexual abuse are
significantly at risk of a wide range of medical, psychological, behavioral,
and sexual disorders.”[116]
Just as it does a
disservice to non-heterosexual subpopulations to ignore or downplay the
statistically higher risks of negative mental health outcomes they face, so it
does them a disservice to misattribute the causes of these elevated risks, or
to ignore other potential factors that may be at work. Assuming that a single
model can explain all of the mental health risks faced by non-heterosexuals can
mislead clinicians and therapists charged with helping this vulnerable
subpopulation. The social stress model deserves further research, but should
not be assumed to offer a complete explanation of the causes of mental health
disparities if clinicians and policymakers want to adequately address the
mental health challenges faced by the LGBT community. More research is needed
to explore the causes of, and solutions to, these important public health
challenges.
Notes
[1] Michael King et al., “A systematic review of
mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual
people,” BMC Psychiatry 8 (2008): 70, http://dx.doi.org/10.1186/1471-244X-8-70.
[2] The researchers who performed this
meta-analysis initially found 13,706 papers by searching academic and medical
research databases, but after excluding duplicates and other spurious search
results examined 476 papers. After further excluding uncontrolled studies,
qualitative papers, reviews, and commentaries, the authors found 111 data-based
papers, of which they excluded 87 that were not population-based studies, or
that failed to employ psychiatric diagnoses, or that used poor sampling. The 28
remaining papers relied on 25 studies (some of the papers examined data from
the same studies), which King and colleagues evaluated using four quality
criteria: (1) whether or not random sampling was used; (2) the
representativeness of the study (measured by survey response rates); (3) whether
the sample was drawn from the general population or from some more limited
subset, such as university students; and (4) sample size. However, only one
study met all four criteria. Acknowledging the inherent limitations and
inconsistencies of sexual orientation concepts, the authors included
information on how those concepts were operationalized in the studies analyzed
— whether in terms of same-sex attraction (four studies), same-sex behavior
(thirteen studies), self-identification (fifteen studies), score above zero on
the Kinsey scale (three studies), two different definitions of sexual
orientation (nine studies), three different definitions (one study). Eighteen
of the studies used a specific time frame for defining the sexuality of their
subjects. The studies were also grouped into whether or not they focused on
lifetime or twelve-month prevalence, and whether the authors analyzed outcomes
for LGB populations separately or collectively.
[3] 95% confidence interval: 1.87–3.28.
[4] 95% confidence interval: 1.69–2.48.
[5] 95% confidence interval: 1.23–1.92.
[6] 95% confidence interval: 1.23–1.86.
[7] 95% confidence interval: 1.97–5.92.
[8] 95% confidence interval: 2.32–7.88.
[9] Wendy B. Bostwick et al., “Dimensions of Sexual
Orientation and the Prevalence of Mood and Anxiety Disorders in the United
States,” American Journal of
Public Health 100, no. 3
(2010): 468–475,http://dx.doi.org/10.2105/AJPH.2008.152942.
[10] Ibid., 470.
[11] The difference in health outcomes
between women who identify as lesbians and women who report exclusive same-sex
sexual behaviors or attractions is a good illustration of how the differences
between sexual identity, behavior, and attraction matter.
[12] Susan D. Cochran and Vickie M. Mays,
“Physical Health Complaints Among Lesbians, Gay Men, and Bisexual and
Homosexually Experienced Heterosexual Individuals: Results From the California
Quality of Life Survey,” American
Journal of Public Health 97,
no. 11 (2007): 2048–2055, http://dx.doi.org/10.2105/AJPH.2006.087254.
[13] Christine E. Grella et al., “Influence of gender,
sexual orientation, and need on treatment utilization for substance use and
mental disorders: Findings from the California Quality of Life Survey,” BMC Psychiatry 9, no. 1 (2009): 52, http://dx.doi.org/10.1186/1471-244X-9-52.
[14] Theo G.M. Sandfort et al., “Sexual Orientation and
Mental and Physical Health Status: Findings from a Dutch Population Survey,” American Journal of Public Health 96, (2006): 1119–1125,http://dx.doi.org/10.2105/AJPH.2004.058891.
[15] Robert Graham et al., Committee on Lesbian,
Gay, Bisexual, and Transgender Health Issues and Research Gaps and
Opportunities, Institute of Medicine, The
Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation
for Better Understanding (Washington,
D.C.: The National Academies Press, 2011),http://dx.doi.org/10.17226/13128.
[16] Susan D. Cochran, J. Greer Sullivan,
and Vickie M. Mays, “Prevalence of Mental Disorders, Psychological Distress,
and Mental Health Services Use Among Lesbian, Gay, and Bisexual Adults in the
United States,” Journal of
Consulting and Clinical Psychology 71,
no. 1 (2007): 53–61, http://dx.doi.org/10.1037/0022-006X.71.1.53.
[17] Lisa A. Razzano, Alicia Matthews, and
Tonda L. Hughes, “Utilization of Mental Health Services: A Comparison of
Lesbian and Heterosexual Women,” Journal
of Gay & Lesbian Social Services 14,
no. 1 (2002): 51–66,http://dx.doi.org/10.1300/J041v14n01_03.
[18] Robert Graham et al., The Health of Lesbian, Gay,
Bisexual, and Transgender People, 4.
[19] Ibid., 190, see also 258–259.
[20] Ibid., 211.
[21] Esther D. Rothblum and Rhonda Factor,
“Lesbians and Their Sisters as a Control Group: Demographic and Mental Health
Factors,” Psychological
Science 12, no. 1 (2001):
63–69, http://dx.doi.org/10.1111/1467-9280.00311.
[22] Stephen M. Horowitz, David L. Weis,
and Molly T. Laflin, “Bisexuality, Quality of Life, Lifestyle, and Health
Indicators,” Journal of
Bisexuality 3, no. 2 (2003):
5–28, http://dx.doi.org/10.1300/J159v03n02_02.
[23] By way of context, it may be worth
noting that in the United States, the overall suicide rate has risen in recent
years: “From 1999 through 2014, the age-adjusted suicide rate in the United
States increased 24%, from 10.5 to 13.0 per 100,000 population, with the pace
of increase greater after 2006.” Sally C. Curtin, Margaret Warner, and Holly
Hedegaard, “Increase in suicide in the United States, 1999–2014,” National
Center for Health Statistics, NCHS data brief no. 241 (April 22, 2016), http://www.cdc.gov/nchs/products/databriefs/db241.htm.
[24] Ann P. Haas et al., “Suicide and Suicide
Risk in Lesbian, Gay, Bisexual, and Transgender Populations: Review and
Recommendations,” Journal of
Homosexuality 58, no. 1
(2010): 10–51, http://dx.doi.org/10.1080/00918369.2011.534038.
[25] Ibid., 13.
[26] David M. Fergusson, L. John Horwood,
and Annette L. Beautrais, “Is Sexual Orientation Related to Mental Health
Problems and Suicidality in Young People?,” Archives
of General Psychiatry 56, no.
10 (1999): 876–880,http://dx.doi.org/10.1001/archpsyc.56.10.876.
[27] Paul J.M. Van Kesteren et al., “Mortality and
morbidity in transsexual subjects treated with cross-sex hormones,”Clinical
Endocrinology 47, no. 3
(1997): 337–343, http://dx.doi.org/10.1046/j.1365-2265.1997.2601068.x.
[28] Friedemann Pfäfflin and Astrid Junge, Sex Reassignment: Thirty Years of
International Follow-Up Studies After Sex Reassignment Surgery: A Comprehensive
Review, 1961–1991, Roberta B. Jacobson and Alf B. Meier, trans.
(Düsseldorf: Symposion Publishing, 1998),https://web.archive.org/web/20070503090247/http://www.symposion.com/ijt/pfaefflin/1000.htm.
[29] Jean M. Dixen et al., “Psychosocial characteristics of
applicants evaluated for surgical gender reassignment,”Archives of Sexual
Behavior 13, no. 3 (1984):
269–276, http://dx.doi.org/10.1007/BF01541653.
[30] Robin M. Mathy, “Transgender Identity
and Suicidality in a Nonclinical Sample: Sexual Orientation, Psychiatric
History, and Compulsive Behaviors,” Journal
of Psychology & Human Sexuality 14,
no. 4 (2003): 47–65,http://dx.doi.org/10.1300/J056v14n04_03.
[31] Yue Zhao et al., “Suicidal Ideation and
Attempt Among Adolescents Reporting ‘Unsure’ Sexual Identity or Heterosexual
Identity Plus Same-Sex Attraction or Behavior: Forgotten Groups?,” Journal of the American Academy of
Child & Adolescent Psychiatry 49,
no. 2 (2010): 104–113, http://dx.doi.org/10.1016/j.jaac.2009.11.003.
[32] Wendy B. Bostwick et al., “Dimensions of Sexual
Orientation and the Prevalence of Mood and Anxiety Disorders in the United
States.”
[33] Martin Plöderl et al., “Suicide Risk and
Sexual Orientation: A Critical Review,” Archives
of Sexual Behavior 42, no. 5
(2013): 715–727, http://dx.doi.org/10.1007/s10508-012-0056-y.
[34] Ritch C. Savin-Williams, “Suicide
Attempts Among Sexual-Minority Youths: Population and Measurement Issues,”Journal
of Consulting and Clinical Psychology 69,
no. 6 (2001): 983–991, http://dx.doi.org/10.1037/0022-006X.69.6.983.
[35] For females in this study, eliminating
false positive attempts substantially decreased the difference between
orientations. For males, the “true suicide attempts” difference approached
statistical significance: 2% of heterosexual males (1 of 61) and 9% of
homosexual males (5 of 53) attempted suicide, resulting in an odds ratio of
6.2.
[36] Martin Plöderl et al., “Suicide Risk and
Sexual Orientation,” 716–717.
[37] Ibid., 723.
[38] Ibid.
[39] Richard Herrell et al., “Sexual Orientation and
Suicidality: A Co-twin Control Study in Adult Men,” Archives of General Psychiatry 56, no. 10 (1999): 867–874, http://dx.doi.org/10.1001/archpsyc.56.10.867.
[40] Ibid., 872.
[41] Robin M. Mathy et al., “The association
between relationship markers of sexual orientation and suicide: Denmark,
1990–2001,” Social Psychiatry
and Psychiatric Epidemiology 46,
no. 2 (2011): 111–117, http://dx.doi.org/10.1007/s00127-009-0177-3.
[42] Gary Remafedi, James A. Farrow, and
Robert W. Deisher, “Risk Factors for Attempted Suicide in Gay and Bisexual
Youth,” Pediatrics 87, no. 6 (1991): 869–875, http://pediatrics.aappublications.org/content/87/6/869.
[43] Ibid., 873.
[44] Gary Remafedi, “Adolescent
Homosexuality: Psychosocial and Medical Implications,” Pediatrics 79, no. 3 (1987): 331–337, http://pediatrics.aappublications.org/content/79/3/331.
[45] Martin Plöderl, Karl Kralovec, and
Reinhold Fartacek, “The Relation Between Sexual Orientation and Suicide
Attempts in Austria,” Archives
of Sexual Behavior 39, no. 6
(2010): 1403–1414, http://dx.doi.org/10.1007/s10508-009-9597-0.
[46] Travis Salway Hottes et al., “Lifetime Prevalence of
Suicide Attempts Among Sexual Minority Adults by Study Sampling Strategies: A
Systematic Review and Meta-Analysis,” American
Journal of Public Health 106,
no. 5 (2016): e1–e12, http://dx.doi.org/10.2105/AJPH.2016.303088.
[47] For a brief explanation of the
strengths and limitations of population- and community-based sampling, see
Hotteset al., e2.
[48] 95% confidence intervals: 8–15% and
3–5%, respectively.
[49] 95% confidence interval: 18–22%.
[50] Ana Maria Buller et al., “Associations between
Intimate Partner Violence and Health among Men Who Have Sex with Men: A
Systematic Review and Meta-Analysis,” PLOS
Medicine 11, no. 3 (2014):
e1001609,http://dx.doi.org/10.1371/journal.pmed.1001609.
[51] Sabrina N. Nowinski and Erica Bowen,
“Partner violence against heterosexual and gay men: Prevalence and correlates,” Aggression and Violent Behavior 17, no. 1 (2012): 36–52, http://dx.doi.org/10.1016/j.avb.2011.09.005.
It is worth noting that the 54 studies that Nowinski and Bowen consider
operationalize heterosexuality and homosexuality in various ways.
[52] Ibid., 39.
[53] Ibid., 50.
[54] Shonda M. Craft and Julianne M.
Serovich, “Family-of-Origin Factors and Partner Violence in the Intimate
Relationships of Gay Men Who Are HIV Positive,” Journal of Interpersonal Violence 20, no. 7 (2005): 777–791,http://dx.doi.org/10.1177/0886260505277101.
[55] Catherine Finneran and Rob Stephenson,
“Intimate Partner Violence Among Men Who Have Sex With Men: A Systematic
Review,” Trauma, Violence,
& Abuse 14, no. 2 (2013):
168–185, http://dx.doi.org/10.1177/1524838012470034.
[56] Ibid., 180.
[57] Although one study reported just 12%,
the majority of studies (17 out of 24) showed that physical IPV was at least
22%, with nine studies recording rates of 31% or more.
[58] Although Finneran and Stephenson say
this measure was recorded in only six studies, the table they provide lists
eight studies as measuring psychological violence, with seven of these showing
rates 33% or higher, including five reporting rates of 45% or higher.
[59] Naomi G. Goldberg and Ilan H. Meyer,
“Sexual Orientation Disparities in History of Intimate Partner Violence:
Results From the California Health Interview Survey,” Journal of Interpersonal Violence 28, no. 5 (2013): 1109–1118,http://dx.doi.org/10.1177/0886260512459384.
[60] Gregory L. Greenwood et al., “Battering
Victimization Among a Probability-Based Sample of Men Who Have Sex With Men,” American Journal of Public Health 92, no. 12 (2002): 1964–1969, http://dx.doi.org/10.2105/AJPH.92.12.1964.
[61] Ibid., 1967.
[62] Ibid.
[63] Sari L. Reisner et al., “Mental Health of
Transgender Youth in Care at an Adolescent Urban Community Health Center: A
Matched Retrospective Cohort Study,” Journal
of Adolescent Health 56, no.
3 (2015): 274–279,http://dx.doi.org/10.1016/j.jadohealth.2014.10.264.
[64] Relative risk: 3.95.
[65] Relative risk: 3.27.
[66] Relative risk: 3.61.
[67] Relative risk: 3.20.
[68] Relative risk: 4.30.
[69] Relative risk: 2.36.
[70] Relative risk: 4.36.
[71] Anne P. Haas, Philip L. Rodgers, and
Jody Herman, “Suicide Attempts Among Transgender and Gender Non-Conforming
Adults: Findings of the National Transgender Discrimination Survey,” Williams
Institute, UCLA School of Law, January 2014, http://williamsinstitute.law.ucla.edu/wp-content/uploads/AFSP-Williams-Suicide-Report-Final.pdf.
[72] Ibid., 2.
[73] Ibid., 8.
[74] Ibid., 13.
[75] Kristen Clements-Nolle et al., “HIV Prevalence, Risk
Behaviors, Health Care Use, and Mental Health Status of Transgender Persons:
Implications for Public Health Intervention,” American
Journal of Public Health 91,
no. 6 (2001): 915–921, http://dx.doi.org/10.2105/AJPH.91.6.915.
[76] Ibid., 919.
[77] See, for example, Ilan H. Meyer,
“Minority Stress and Mental Health in Gay Men,” Journal of Health and Social
Behavior 36 (1995): 38–56, http://dx.doi.org/10.2307/2137286; Bruce
P. Dohrenwend, “Social Status and Psychological Disorder: An Issue of Substance
and an Issue of Method,” American
Sociological Review 31, no. 1
(1966): 14–34,http://www.jstor.org/stable/2091276.
[78] For overviews of the social stress
model and mental health patterns among LGBT populations, see Ilan H. Meyer,
“Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual
Populations: Conceptual Issues and Research Evidence,” Psychological Bulletin 129, no. 5 (2003): 674–697, http://dx.doi.org/10.1037/0033-2909.129.5.674;
Robert Graham et al., The Health of Lesbian, Gay,
Bisexual, and Transgender People, op.
cit; Gregory M. Herek and Linda D. Garnets, “Sexual Orientation and Mental
Health,” Annual Review of
Clinical Psychology 3 (2007):
353–375,http://dx.doi.org/10.1146/annurev.clinpsy.3.022806.091510;
Mark L. Hatzenbuehler, “How Does Sexual Minority Stigma ‘Get Under the Skin’? A
Psychological Mediation Framework,” Psychological
Bulletin 135, no. 5 (2009):
707–730,http://dx.doi.org/10.1037/a0016441.
[79] See, for instance, Ilan H. Meyer, “The
Right Comparisons in Testing the Minority Stress Hypothesis: Comment on
Savin-Williams, Cohen, Joyner, and Rieger (2010),” Archives of Sexual Behavior 39, no. 6 (2010): 1217–1219.
[80] This should not be taken to suggest
that social stress is too vague a concept for empirical social science; the
social stress model may certainly produce quantitative empirical hypotheses,
such as hypotheses about correlations between stressors and specific mental
health outcomes. In this context, the term “model” does not refer to a
statistical model of the kind often used in social science research — the
social stress model is a “model” in a metaphorical sense.
[81] Meyer, “Prejudice, Social Stress, and
Mental Health in Lesbian, Gay, and Bisexual Populations,” 676.
[82] Meyer, “Prejudice, Social Stress, and
Mental Health in Lesbian, Gay, and Bisexual Populations,” 680; Gregory M.
Herek, J. Roy Gillis, and Jeanine C. Cogan, “Psychological Sequelae of
Hate-Crime Victimization Among Lesbian, Gay, and Bisexual Adults,” Journal of Consulting and Clinical
Psychology 67, no. 6 (1999):
945–951,http://dx.doi.org/10.1037/0022-006X.67.6.945;
Allegra R. Gordon and Ilan H. Meyer, “Gender Nonconformity as a Target of
Prejudice, Discrimination, and Violence Against LGB Individuals,” Journal of LGBT Health Research 3, no. 3 (2008): 55–71, http://dx.doi.org/10.1080/15574090802093562;
David M. Huebner, Gregory M. Rebchook, and Susan M. Kegeles, “Experiences of
Harassment, Discrimination, and Physical Violence Among Young Gay and Bisexual
Men,” American Journal of
Public Health 94, no. 7
(2004): 1200–1203, http://dx.doi.org/10.2105/AJPH.94.7.1200;
Rebecca L Stotzer, “Violence against transgender people: A review of United
States data,” Aggression and
Violent Behavior 14, no. 3
(2009): 170–179, http://dx.doi.org/10.1016/j.avb.2009.01.006;
Rebecca L. Stotzer, “Gender identity and hate crimes: Violence against
transgender people in Los Angeles County,” Sexuality
Research and Social Policy 5,
no. 1 (2008): 43–52,http://dx.doi.org/10.1525/srsp.2008.5.1.43.
[83] Stotzer, “Gender identity and hate
crimes,” 43–52; Emilia L. Lombardi et
al., “Gender Violence: Transgender Experiences with Violence and
Discrimination,” Journal of
Homosexuality 42, no. 1
(2002): 89–101,http://dx.doi.org/10.1300/J082v42n01_05;
Herek, Gillis, and Cogan, “Psychological Sequelae of Hate-Crime Victimization
Among Lesbian, Gay, and Bisexual Adults,” 945–951; Huebner, Rebchook, and
Kegeles, “Experiences of Harassment, Discrimination, and Physical Violence
Among Young Gay and Bisexual Men,” 1200–1203; Anne H. Faulkner and Kevin
Cranston, “Correlates of same-sex sexual behavior in a random sample of
Massachusetts high school students,”American Journal of Public Health 88, no. 2 (1998): 262–266, http://dx.doi.org/10.2105/AJPH.88.2.262.
[84] Herek, Gillis, and Cogan,
“Psychological Sequelae of Hate-Crime Victimization Among Lesbian, Gay, and
Bisexual Adults,” 945–951.
[85] Jack McDevitt et al., “Consequences for
Victims: A Comparison of Bias- and Non-Bias-Motivated Assaults,” American Behavioral Scientist 45, no. 4 (2001): 697–713, http://dx.doi.org/10.1177/0002764201045004010.
[86] Caitlin Ryan and Ian Rivers, “Lesbian,
gay, bisexual and transgender youth: Victimization and its correlates in the
USA and UK,” Culture, Health
& Sexuality 5, no. 2
(2003): 103–119, http://dx.doi.org/10.1080/1369105011000012883;
Elise D. Berlan et al.,
“Sexual Orientation and Bullying Among Adolescents in the Growing Up Today
Study,” Journal of Adolescent
Health 46, no. 4 (2010):
366–371, http://dx.doi.org/10.1016/j.jadohealth.2009.10.015;
Ritch C. Savin-Williams, “Verbal and Physical Abuse as Stressors in the Lives
of Lesbian, Gay Male, and Bisexual Youths: Associations With School Problems,
Running Away, Substance Abuse, Prostitution, and Suicide,” Journal of Consulting and Clinical
Psychology62, no. 2 (1994): 261–269, http://dx.doi.org/10.1037/0022-006X.62.2.261.
[87] Stephen T. Russell et al., “Lesbian, Gay,
Bisexual, and Transgender Adolescent School Victimization: Implications for
Young Adult Health and Adjustment,” Journal
of School Health 81, no. 5 (2011):
223–230,http://dx.doi.org/10.1111/j.1746-1561.2011.00583.x.
[88] Joanna Almeida et al., “Emotional Distress
Among LGBT Youth: The Influence of Perceived Discrimination Based on Sexual
Orientation,” Journal of Youth
and Adolescence 38, no. 7
(2009): 1001–1014, http://dx.doi.org/10.1007/s10964-009-9397-9.
[89] M.V. Lee Badgett, “The Wage Effects of
Sexual Orientation Discrimination,” Industrial
and Labor Relations Review48, no. 4 (1995): 726–739, http://dx.doi.org/10.1177/001979399504800408.
[90] M.V. Lee Badgett, “Bias in the
Workplace: Consistent Evidence of Sexual Orientation and Gender Identity
Discrimination 1998–2008,” Chicago-Kent
Law Review 84, no. 2 (2009):
559–595,http://scholarship.kentlaw.iit.edu/cklawreview/vol84/iss2/7.
[91] Marieka Klawitter, “Meta-Analysis of
the Effects of Sexual Orientation on Earning,” Industrial Relations 54, no. 1 (2015): 4–32, http://dx.doi.org/10.1111/irel.12075.
[92] Jonathan Platt et al., “Unequal depression for
equal work? How the wage gap explains gendered disparities in mood disorders,” Social Science & Medicine 149 (2016): 1–8, http://dx.doi.org/10.1016/j.socscimed.2015.11.056.
[93] Craig R. Waldo, “Working in a majority
context: A structural model of heterosexism as minority stress in the
workplace,” Journal of
Counseling Psychology 46, no.
2 (1999): 218–232, http://dx.doi.org/10.1037/0022-0167.46.2.218.
[94] M.W. Linn, Richard Sandifer, and
Shayna Stein, “Effects of unemployment on mental and physical health,”American
Journal of Public Health 75,
no. 5 (1985): 502–506, http://dx.doi.org/10.2105/AJPH.75.5.502;
Jennie E. Brand, “The far-reaching impact of job loss and unemployment,” Annual Review of Sociology 41 (2015): 359–375,http://dx.doi.org/10.1146/annurev-soc-071913-043237;
Marie Conroy, “A Qualitative Study of the Psychological Impact of Unemployment
on individuals,” (master’s dissertation, Dublin Institute of Technology,
September 2010),http://arrow.dit.ie/aaschssldis/50/.
[95] Irving Goffman, Stigma: Notes on the Management of
Spoiled Identity (New York:
Simon & Schuster, 1963); Brenda Major and Laurie T. O’Brien, “The Social
Psychology of Stigma,” Annual
Review of Psychology, 56 (2005): 393–421,http://dx.doi.org/10.1146/annurev.psych.56.091103.070137.
[96] Major and O’Brien, “The Social
Psychology of Stigma,” 395.
[97] Bruce G. Link et al., “On Stigma and Its
Consequences: Evidence from a Longitudinal Study of Men with Dual Diagnoses of
Mental Illness and Substance Abuse,” Journal
of Health and Social Behavior 38,
no. (1997): 177–190,http://dx.doi.org/10.2307/2955424.
[98] Walter R. Gove, “The Current Status of
the Labeling Theory of Mental Illness,” in Deviance
and Mental Illness, ed. Walter R. Gove (Beverly Hills, Calif.: Sage, 1982),
290.
[99] A highly cited piece of theoretical
research on stigma processes is Hatzenbuehler, “How Does Sexual Minority Stigma
‘Get Under the Skin’?,” op.
cit., http://dx.doi.org/10.1037/a0016441.
[100] Walter O. Bockting et al., “Stigma, Mental Health,
and Resilience in an Online Sample of the US Transgender Population,” American Journal of Public Health 103, no. 5 (2013): 943–951, http://dx.doi.org/10.2105/AJPH.2013.301241.
[101] Robin J. Lewis et al., “Stressors for Gay Men
and Lesbians: Life Stress, Gay-Related Stress, Stigma Consciousness, and
Depressive Symptoms,” Journal
of Social and Clinical Psychology 22,
no. 6 (2003): 716–729,http://dx.doi.org/10.1521/jscp.22.6.716.22932.
[102] Ibid., 721.
[103] Aaron T. Beck et al., Cognitive Therapy of Depression (New York: Guilford Press, 1979).
[104] Wendy Bostwick, “Assessing Bisexual
Stigma and Mental Health Status: A Brief Report,” Journal of Bisexuality 12, no. 2 (2012): 214–222, http://dx.doi.org/10.1080/15299716.2012.674860.
[105] Lars Wichstrøm and Kristinn Hegna,
“Sexual Orientation and Suicide Attempt: A Longitudinal Study of the General
Norwegian Adolescent Population,” Journal
of Abnormal Psychology 112,
no. 1 (2003): 144–151,http://dx.doi.org/10.1037/0021-843X.112.1.144.
[106] Anthony R. D’Augelli and Arnold H.
Grossman, “Disclosure of Sexual Orientation, Victimization, and Mental Health
Among Lesbian, Gay, and Bisexual Older Adults,” Journal of Interpersonal Violence 16, no. 10 (2001): 1008–1027,http://dx.doi.org/10.1177/088626001016010003;
Eric R. Wright and Brea L. Perry, “Sexual Identity Distress, Social Support,
and the Health of Gay, Lesbian, and Bisexual Youth,” Journal of Homosexuality 51, no. 1 (2006): 81–110,http://dx.doi.org/10.1300/J082v51n01_05;
Judith A. Clair, Joy E. Beatty, and Tammy L. MacLean, “Out of Sight But Not Out
of Mind: Managing Invisible Social Identities in the Workplace,” Academy of Management Review 30, no. 1 (2005): 78–95, http://dx.doi.org/10.5465/AMR.2005.15281431.
[107] For example, see Emotion, Disclosure, and Health (Washington, D.C.: American
Psychological Association, 2002), ed. James W. Pennebaker; Joanne Frattaroli,
“Experimental Disclosure and Its Moderators: A Meta-Analysis,”Psychological
Bulletin 132, no. 6 (2006):
823–865, http://dx.doi.org/10.1037/0033-2909.132.6.823.
[108] See, for example, James M. Croteau,
“Research on the Work Experiences of Lesbian, Gay, and Bisexual People: An
Integrative Review of Methodology and Findings,” Journal of Vocational Behavior 48, no. 2 (1996): 195–209,http://dx.doi.org/10.1006/jvbe.1996.0018;
Anthony R. D’Augelli, Scott L. Hershberger, and Neil W. Pilkington, “Lesbian,
Gay, and Bisexual Youth and Their Families: Disclosure of Sexual Orientation
and Its Consequences,” American
Journal of Orthopsychiatry 68,
no. 3 (1998): 361–371, http://dx.doi.org/10.1037/h0080345;
Margaret Rosario, Eric W. Schrimshaw, and Joyce Hunter, “Disclosure of Sexual
Orientation and Subsequent Substance Use and Abuse Among Lesbian, Gay, and
Bisexual Youths: Critical Role of Disclosure Reactions,” Psychology of Addictive Behaviors 23, no. 1 (2009): 175–184,http://dx.doi.org/10.1037/a0014284;
D’Augelli and Grossman, “Disclosure of Sexual Orientation, Victimization, and
Mental Health Among Lesbian, Gay, and Bisexual Older Adults,” 1008–1027; Belle
Rose Ragins, “Disclosure Disconnects: Antecedents and Consequences of
Disclosing Invisible Stigmas across Life Domains,” Academy of Management Review 33, no. 1 (2008): 194–215, http://dx.doi.org/10.5465/AMR.2008.27752724;
Nicole Legate, Richard M. Ryan, and Netta Weinstein, “Is Coming Out Always a
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