Results of this study provide compelling evidence that the prevalence of mental health disorders does differ across dimensions of sexual orientation and that patterns of risk are different for women and men, as well as for specific sexual minority groups. Among men, any sexual minority status—whether defined by identity, attraction, or behavior—was generally associated with a higher prevalence of lifetime disorders. Among women, however, although any sexual minority identity was associated with higher rates of lifetime and past-year disorders, this was not the case in comparisons based on sexual attraction or sexual behavior. Exclusive same-sex attraction, as well as exclusive lifetime same-sex behavior, was associated with lower rates of almost all lifetime and past-year mood and anxiety disorders among women. For example, 44.4% of women with a lesbian identity reported any lifetime mood disorder, compared with 23.8% of women reporting only same-sex attraction and 19.4% reporting only same-sex behavior.
That “nonheterosexuality” by any definition was more consistently associated with increased mental health disorders among men indicates that the role of sexual orientation in health outcomes probably functions differently for men and women. Although there are many ways to understand this gender disparity (e.g., genetically, biologically, or culturally), the difference probably emerges in large part from the more extreme stigma that is associated with male homosexuality in the United States. For example, surveys of attitudes toward gays and lesbians demonstrate more negative attitudes toward gay men than lesbian women.26,27
Furthermore, transgressions of heteronormative behavioral scripts or violations of “traditional” sex norms are more severely sanctioned among and by men,28
leading to more serious types of victimization, such as physical violence.29
Experiences of physical harm, as well as threats of harm, are strongly associated with poor mental health outcomes.10,30
The finding that same-sex attraction or behavior may confer protective mental health benefits for women highlights the need to broaden discussions of the health status of sexual minority populations, and to move beyond what some have deemed a “minoritizing” or “repathologizing” view.31,32
Rather than assume that sexual minority status is always associated with poorer health outcomes, we must acknowledge that there are positive aspects of being a member of a sexual minority and, conversely, that heterosexuality may also carry health risks. Results demonstrating better overall mental health for some sexual minority women compared with heterosexual women point to the need for further exploration of the health benefits of sexual minority status33
and more considered inquiry into areas such as resilience and functional well-being among lesbian, gay, and bisexual groups (K.M. Kertzner et al., unpublished data).
Our study is unique in that it included groups that were unsure about their sexual identity. Some investigators have suggested that not claiming a sexual identity may exacerbate mental health problems,8,10
but others contend that a “nonidentity” is becoming the norm and that such groups may be healthier.34
Our findings suggest that neither of these contentions is universally true and that, to the extent that claiming a sexual identity may be protective, it differs by sex. Although male participants who were unsure about their sexual identity had significantly higher odds of mood and anxiety disorders (similar to males who identified as gay or bisexual), this was not the case for female participants.
We found that bisexual identity and behavior were strongly and persistently associated with heightened risk of mood and anxiety disorders for both men and women over both lifetime and past-year time frames. This finding is generally consistent with a growing body of work showing poorer health outcomes among bisexual groups than among lesbians and gay men, as well as among heterosexual women and men.35–38
Those who identify as bisexual face a unique stigma, which is qualitatively different than the stigma experienced by lesbian and gay persons. Pervasive stereotypes and negative attitudes about bisexuality are present not only among the “dominant” heterosexual population but among lesbian and gay populations as well, resulting in a “double stigma” for bisexuals.39–41
This stigma manifests itself through narratives of indeterminacy, confusion, and deceit, wherein bisexual persons are cast as being unable to choose their identity or, worse, lying about their “true” identity.42
This perpetual contestation of a salient and meaningful aspect of one’s self—which is to say, one’s sexual identity—likely takes a psychic toll.43
Although explanations for health disparities among populations identifying as bisexual are typically linked to the stigma associated specifically with bisexuality and the lack of an identifiable community, it is unclear whether these reasons explain the association between bisexual behavior and higher odds of mental health disorders seen here. Investigations into the context in which bisexual behavior occurs may shed some light on these findings. For instance, some of the sexual behavior reported in the NESARC may reflect unwanted or coerced experiences such as childhood or adult sexual abuse, or situational factors such exchanging sex for money, drugs, or other resources. More research is needed to determine why bisexual behavior is associated with a disproportionately higher risk for mental health disorders.
Studies of sexual orientation and mental health that use sexual behavior measures have typically combined all respondents who report any same-sex sexual behavior, rather than analyzing data separately for those reporting exclusive same-sex behavior and those reporting bisexual behavior.7,44,45
Results of the current study suggest that this practice may inflate risk among some groups, mask risk among others, and obscure the presence of possible protective benefits conferred by exclusive same-sex behavior.
This study has a number of noteworthy strengths. It is based on data from the largest national sample of sexual minority populations to date. It includes multiple measures of sexual orientation, allowing comparisons across dimensions. Mental health disorders are based on DSM-IV diagnostic criteria and the measures are well validated, an improvement over earlier studies. The study also controlled for a variety of demographic factors, such as age, relationship status, and educational level, that may otherwise confound the association between sexual orientation and mental health disorders.
Limitations of the study include its reliance on cross-sectional data. Only wave 2 of the NESARC included questions about sexual orientation; therefore, we were unable to establish temporal order and do not know if the development of a minority sexual orientation preceded mental health disorders or vice versa. The use of face-to-face interviews may have led to underreporting of sensitive information such as sexual behavior, identity, or attraction, although the estimates are similar to those in other national studies.14,46
Of potentially greater importance is that the analysis relied on a lifetime measure of sexual behavior, in contrast to other national studies that have used past-year or past-5-year measures.7,44,45
This difference makes direct comparisons with other studies more difficult and emphasizes the importance of standardizing sexual orientation measures, particularly question wording, for use in future studies.17
Finally, the current investigation did not take into account variables such as level of disclosure of sexual orientation,47
experiences of discrimination associated with sexual minority status,48
or victimization experiences such as childhood sexual abuse and adult sexual assault,49
all factors that are associated with mental health status among sexual minority groups.
The connection between sexual minority identity and health disparities has gained increasing scholarly and theoretical attention. Meyer’s minority stress model, for example, provides a multidisciplinary framework for understanding how discrimination and stigma based on sexual identity operate as stressors and, in turn, contribute to the increased prevalence of mental health disorders among lesbian, gay, and bisexual populations.8
However, the relationships between sexual attraction and sexual behavior and mental health are much less understood. More work needs to be done to establish the theoretical underpinnings of the associations between all dimensions of sexual orientation and mental health.
In conclusion, this study provides strong evidence of increased risk for mood and anxiety disorders among some sexual minority groups and demonstrates that different dimensions of sexual orientation are associated with varying prevalence estimates of DSM-IV mental health disorders. These findings caution against considering dimensions of sexual orientation as equivalent or assuming that health risks or benefits associated with one dimension of sexual orientation can be extrapolated to another dimension. Results reinforce the importance of including multiple measures of sexual orientation in future studies.