Sunday, June 19, 2011

Homosexual Health Disparities




What is this page about?

Each section below presents extensive scientific evidence for the link between heterosexism/minority stress and a key LGBT health disparity which it impacts. These same disparities are frequently cited by heterosexists to demonstrate that the "homosexual lifestyle" is risky, unhealthy or dangerous. Ironically, given that heterosexism itself causes these disparities, rather than homosexuality, such criticisms are not only flawed but additionally, hypocritical and counter-productive.

What is heterosexism?

Heterosexism refers to an ideology centred around the concept that heterosexuality is the default or normal sexual orientation and that any other variants are therefore inferior. It is similar to homophobia, though homophobia is a stigmatized term, the use of which may therefore inhibit discussion. Heterosexism can arise in many sources, including parents, peers and social/legal institutions and may be particularly prolifically directed towards people with atypical gender-expression. This can lead to a pervasive climate of prejudicially motivated discrimination for LGBT individuals and minority stress results from these factors, as elaborated upon below.

What is minority stress?

I.H. Meyer, 1995, Journal of Health and Social Behavior, 36(1), 38-56:
"The concept of minority stress is based on the premise that gay people in a heterosexist society are subjected to chronic stress related to their stigmatization. Minority stressors were conceptualized as: internalized homophobia, which relates to gay men's direction of societal negative attitudes toward the self; stigma, which relates to expectations of rejection and discrimination; and actual experiences of discrimination and violence."

Other facets of sexual minority stress include failure to live up to parental expectations, the strain of concealing one's minority status and romantic relationship formation in an environment that demands inconspicuousness or invisibility. The image below contains further examples. The various impacts of minority stress, as described in the proceeding sections, interact synergistically, as will be elucidated in the conclusion.

- Studies appear in reverse chronological order.
- Please click any of the contents sections to be taken to that section.
- Links and DOIs for each study are provided at the end, in the same numerical order as the studies.
- Some studies have (DUTCH) in their citations because heterosexists occasionally use LGBT mental health disparities in the "gay-friendly" Netherlands to insinuate that minority stress can't be the cause.
- All studies cited below include LGBT sample populations unless stated otherwise.

Numerous studies actually link increased mental health issues, among sexual minorities, with internalized heterosexism/ minority stress etc:

01) Gevonden et al. 2014, Psychological Medicine, 44(2), 421-33 (DUTCH):
"The finding that LGB orientation is associated with psychotic symptoms adds to the growing body of literature linking minority status with psychosis and other mental health problems, and suggests that exposure to minority stress represents an important mechanism."

02) Bockting et al. 2013, American Journal of Public Health, 103, 5, 943-951:
"Respondents had a high prevalence of clinical depression (44.1%), anxiety (33.2%), and somatization (27.5%). Social stigma was positively associated with psychological distress. Our findings support the minority stress model."

03) Kuyper & Fokkema, 2011, Journal of Counseling Psychology, 58(2), 222-233 (DUTCH):
"Participants with a higher level of internalized homonegativity and those who more often encountered negative reactions from other people on their same-sex sexual attraction reported more mental health problems".

04) Chakraborty et al. 2011, The British Journal of Psychiatry, 198(2), 143-148:
"This study corroborates international findings that people of non-heterosexual orientation report elevated levels of mental health problems and service usage, and it lends further support to the suggestion that perceived discrimination may act as a social stressor in the genesis of mental health problems in this population".

05) Nemoto et al. 2011, American Journal of Public Health, 101(10), 1980-1988:
"Transphobia, suicidal ideation, and levels of income and education were significantly and independently correlated with depression."

06) Vanden Berghe et al. 2010, Journal of Applied Social Psychology, 40(1), 153–166:
"Hierarchical regression shows that LGB-specific unsupportive social interactions have the greatest direct effect on mental well-being of LGB youth, followed respectively by stigma consciousness, internalized homonegativity, and confidant support".

07) Ryan et al. 2010, Journal of Child and Adolescent Psychiatric Nursing, 23(4), 205-213:
"Family acceptance predicts greater self-esteem, social support, and general health status; it also protects against depression, substance abuse, and suicidal ideation and behaviors".

08) Chae et al. 2010, International Journal of Health Services, 40(4), 589-608:
"Linear regression analyses revealed that reports of racial/ethnic discrimination and sexuality discrimination were associated with higher levels of psychological distress among sexual minority participants".

09) McLaughlin et al. 2010, American Journal Of Public Health, 100(8), 1477–1484:
"Psychiatric disorders are more prevalent among individuals reporting past-year discrimination experiences".

10) Toomey et al. 2010, Developmental Psychology, 46(6), 1580-1589:
"We found that victimization due to perceived or actual LGBT status fully mediates the association between adolescent gender nonconformity and young adult psychosocial adjustment (i.e., life satisfaction and depression)."

11) Roberts et al. 2010, American Journal of Public Health, 100(12), 2433-2441:
"Profound sexual orientation disparities exist in risk of PTSD (posttraumatic stress disorder) and in violence exposure, beginning in childhood. Our findings suggest there is an urgent need for public health interventions aimed at preventing violence against individuals with minority sexual orientations and providing follow-up care to cope with the sequelae of violent victimization."

12) Rosser et al. 2008, Journal of Homosexuality, 55(2), 185-203:
"Negative attitudes towards homosexuality, not homosexuality itself, are associated with both poorer mental and sexual health outcomes seen in sexual minorities".

13) Hatzenbuehler et al. 2008, Health Psychology,  27(4), 455-462:
"The results provide evidence for the predictive validity of minority stress".

14) Poteat & Espelage, 2007, The Journal of Early Adolescence, 27(2), 175-191:
"Homophobic victimization significantly predicted increased anxiety and depression, personal distress, and lower sense of school belonging in males and higher levels of withdrawal in females".

15) Mays & Cochran, 2001, American Journal of Public Health, 91(11), 1869-1876:
"Perceived discrimination was positively associated with both harmful effects on quality of life and indicators of psychiatric morbidity in the total sample".

16) D'Augelli & Grossman, 2001, Journal of Interpersonal Violence, 16(10), 1008-1027:
"Participants who had been physically attacked reported lower self-esteem, more loneliness, and poorer mental health than others. More suicide attempts were reported among those older adults who were physically attacked."

17) Safren & Heimberg, 1999, Journal of Consulting and Clinical Psychology, 67(6), 859-866:
"These results suggest that environmental factors associated with sexual orientation... play a major role in predicting distress in this population".

18) Otis & Skinner, 1996, Journal of Homosexuality, 30(3), 93-121:
"Results indicate that victimization has a significant positive effect on depression for both lesbians and gay men when controlling for other variables".

19) Ilan H. Meyer, 1995, Journal of Health and Social Behaviour, Vol. 36(1), 38-56:
"Men who had high levels of minority stress were twice to three times as likely to suffer also from high levels of distress".

20) Ritch C. Savin-Williams, 1994, Journal of Consulting and Clinical Psychology, 62(2), 261-269:
"A common theme identified in empirical studies and clinical reports of lesbian, gay male, and bisexual youths is the chronic stress that is created by the verbal and physical abuse they receive from peers and adults".

21) Michael W. Ross, 1990, Journal of Clinical Psychology, 46(4), 402-411:
"Data suggest that the impact of life events may be amplified by stigmatization and that the degree of life change is associated closely with psychological dysfunction".

Other, non-LGBT studies attest to the impact of minority stress upon other minorities and to the importance of family relationships in mitigating risky of psychopathy, a factor which could be particularly critical for LGBT youth:

22) Chou et al. 2011, Cultural Diversity & Ethnic Minority Psychology, 18(1), 74-81:
"The results suggest that the perception of racial discrimination is associated with psychopathology in the three most common U.S. minority groups."

23) Grant et al. 2006, Clinical Psychology Review, 26(3), 257-283:
"There is substantial evidence for the mediating role of family relationship in the relation between stressors and child and adolescent psychological symptoms"

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Multiple Studies indicate that increased discrimination suffered also correlates with increased substance abuse:

01) Peacock et al. 2015, Journal of Urban Health, DOI: 10.1007/s11524-014-9930-3:
"Among MSM, high self-stigma was associated with binge drinking at least weekly. These findings support multiple pathways linking stigma-related stress to alcohol use. Specifically, those with high self-stigma and identity concealment may be using alcohol as a maladaptive coping and emotion regulation strategy".

02) Rowe et al. 2015, Drug and Alcohol Dependence, 147, 160–166:
"We conducted a secondary data analysis of a study on HIV risk and resilience among trans female youth. Those who experienced gender-related discrimination had increased odds of drug use.., drug use concurrent with sex... and use of multiple drugs. Those with psychological distress had increased odds of using multiple heavy drugs."

03) O’Cleirigh et al. 2015, Journal of Psychosomatic Research:
"Adjusted logistic regression analysis revealed a significant dose effect of number of sexual minority stressors/traumas with odds of ever smoking."

04) Reisner et al. 2015, Journal of Sex Research, 52(3), 243-256:
"Gender minority youth disproportionately experienced bullying and harassment in the past 12 months, and this victimization was associated with increased odds of all substance use indicators. Bullying mediated the elevated odds of substance use for gender minority youth compared to cisgender adolescents."

05) Goldbach et al. 2014, Prevention Science, 15(3), 350-363:
"Results from 12 unique studies of LGB youth indicated that the strongest risk factors for substance use were victimization, lack of supportive environments, psychological stress, internalizing/externalizing problem behavior, negative disclosure reactions, and housing status."

06) Mereish et al. 2014, Psychology, Health & Medicine, 19(1), 1-13:
"Substance use problems were a significant partial mediator between LGBT-based victimization and suicidal ideation and between LGBT-based victimization and suicide attempts for sexual and gender minorities. Substances might be a temporary and deleterious coping resource in response to LGBT-based victimization, which have serious effects on suicidal ideation and behaviors."

07) Hatzenbuehler et al. 2011, Drug and Alcohol Dependence, 115(3), 213-220:
"Results indicated significant indirect effects from discrimination to alcohol-related problems through negative affect and coping motives".

08) Keyes et al. 2011, Psychopharmacology, 218(1), 1-17:
"Both perceptions of discrimination and objective indicators of discrimination are associated with alcohol use and alcohol use disorders among racial/ethnic and sexual minorities."

09) Blosnich & Horn, 2011, Nicotine & Tobacco Research, 13(12), 1284-1295:
"After adjusting for age and race, lesbians/gays who were in physical fights or were physically assaulted had higher proportional odds of being current smokers when compared with their lesbian/gay counterparts who did not experience those stressors."

10) Hatzenbuehler et al. 2011, Archives of Pediatrics and Adolescent Medicine. 165(6), 527-532:
"A more supportive social environment for LGB youth was significantly associated with reduced tobacco use".

11) Lehavot & Simoni, 2011, Journal of Consulting and Clinical Psychology, 79(2), 159-170:
"Direct links emerged between victimization and substance use and between internalized homophobia and substance use".

12) McCabe et al. 2010, American Journal of Public Health, 100(10), 1946-1952:
"The odds of past-year substance use disorders were nearly 4 times greater among LGB adults who reported all 3 types of discrimination prior to the past year than for LGB adults who did not report discrimination".

13) Hughes et al. 2010, Social Science & Medicine, 71(4), 824-831:
"Findings implicate stress as an important predictor of substance use and emphasize the need for research that more systematically examines the relationships between minority stress and substance use in sexual minority women".

14) Wilsnack et al. 2010, Addiction, 105(12), 2130–2140:
"Results showed strong associations between victimization and any past-year SUDs (Substance use disorders) and confirmed findings from several previous studies indicating that, compared with heterosexuals, sexual minority women and men are at heightened risk for life-time victimization".

15) Rosario et al. 2009, Psychology of Addictive Behaviors, 23(1), 175-184:
"The number of rejecting reactions to disclosure (of sexual identity) was associated with current and subsequent alcohol, cigarette, and marijuana use".

Non-LGBT specific studies demonstrate similar influences of minority stress upon other minorities as well as the interconnectedness of the resultant health disparities:

16) Otiniano et al. 2014, Cultural Diversity and Ethnic Minority Psychology, 20(1), 43-51:
"(Racial/Gender) Discrimination was significantly associated with increased risk of alcohol abuse for women and increased risk of drug abuse for men. These data indicate that discrimination is associated with different substance abuse outcomes between genders."

17) Sung et al. 2011, Nicotine & Tobacco Research, 13(12), 1183-1192:
"Adults with SPD (serious psychological distress) were more likely to be current smokers and to smoke heavily and less likely to quit than those without SPD".

18) Khoury et al. 2010, Depression and Anxiety, 27(12), 1077–1086:
"Exposure to traumatic experiences, especially those occurring in childhood, has been linked to substance use disorders (SUDs), including abuse and dependence... The level of substance use, particularly cocaine, strongly correlated with levels of childhood physical, sexual, and emotional abuse as well as current PTSD symptoms."

19) Bowden et al. 2010, Australian and New Zealand Journal of Psychiatry, 45(4), 325-331:
"People with a mental illness, particularly severe mental illness displayed higher measures of tobacco dependence."

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Substance abuse significantly mediates the link between heterosexism/ minority stress, sexual risk behaviour and STI prevalence, as demonstrated by a range of studies, with other consequences of minority stress likely also playing a role:

01) Hladik et al. 2012, PLoS One, 7(5), e38143:
"Those reporting ever having been exposed to homophobic abuse (verbal, moral, sexual, or physical abuse; AOR 5.38, 95% CI 1.95–14.79) were significantly more likely to be HIV infected."

02) Mizuno et al. 2012, AIDS and Behavior, 16(3), 724-735:
"Men exposed to both homophobia and racism were more likely than men exposed to neither form of discrimination to report unprotected receptive anal intercourse with a casual sex partner (AOR = 1.92, 95% CI, 1.18-3.24) and binge drinking (AOR = 1.42, 95% CI, 1.02-1.98)."

03) Parsons et al. 2012, American Journal of Public Health, 102(1), 156-162:
"We found strong positive interrelationships among syndemic factors including sexual compulsivity, depression, childhood sexual abuse, intimate partner violence, and polydrug use. In bivariate analyses, all syndemic health problems except for childhood sexual abuse were positively related to HIV seropositivity and high-risk sexual behavior."

04) O’Cleirigh et al. 2011, Annals Of Behavioral Medicine, 42(2), 227-234:
"Experiencing HIV-related stigma may increase risk for sexual transmission risk behavior and mental health problems."

05) Martin & Alessi, 2010, American Journal of Orthopsychiatry, 80(3), 293–301:
"The findings provide evidence that American gay and bisexual men may experience a variety of stressful life events, including a surprising amount of victimization, and that at least some episodes of UAS (unprotected anal sex) may be associated with attempts to cope with distress associated with such events".

06) Mansergh et al. 2010, PLoS Medicine 7(8), e1000329:
"Substance use during sex is associated with sexual risk behavior among men who have sex with men (MSM)".

07) Yi Huso et al. 2010, Health Psychology, 29(2), 205–214:
"Gay men who reported UAI (unprotected anal intercourse), compared to the men without UAI, reported significantly higher levels of internalized homophobia."

08) Johnson et al. 2008, Journal of Consulting and Clinical Psychology, 76(5), 829-839:
"Results supported the hypothesized model in which IH (Internalized heterosexism) was associated with unprotected receptive (but not insertive) anal intercourse with HIV-negative or unknown HIV status partners, and with ART (HIV antiretroviral therapy) non-adherence indirectly via increased negative affect and more regular stimulant use."

09) Ross et al. 2008, AIDS and Education Prevention, 20(6), 547-557:
"For those with higher IH (internalized homonegativity), two significant paths led to unsafe sexual behavior: first, to serodiscordant unprotected anal intercourse (SDUAI) through being less “out”—thus disclosing serostatus to secondary partners less frequently, and second, to lower condom self-efficacy and SDUAI through lower sexual comfort".

10) Choi et al. 2008, AIDS and Behavior, 12(1), 71-77:
"We found significant positive direct associations of experiences of homophobia and financial hardship with having unprotected anal sex with men".

11) Neilands et al. 2008, Archives of Sexual Behavior, 37(5), 838-844:
"Enacted stigma measured direct personal experiences of stigmatizing behaviors. Enacted stigma... was associated with HIV sexual risk behavior."

12) Celentano et al. 2006, Sexually Transmitted Diseases, 33(4), 265-71:
"Report of unprotected receptive anal intercourse at least once in the prior 6 months was associated with being under the influence of alcohol, cocaine, amphetamines or marijuana during sex".

13) Shoptaw & Reback, 2006, Journal of Urban Health, 83(6), 1151-7:
"Methamphetamine use is associated with high rates of HIV prevalence and sexual risk behaviors".

14) Diaz et al. 2004, Cultural Diversity and Ethnic Minority Psychology, 10(3), 255-267:
"Men who reported more instances of social discrimination and financial hardship were more psychologically distressed and more likely to participate in "difficult" sexual situations, as predicted. Participation in difficult sexual situations mediates the effects of social oppression and psychological distress on sexual risk behavior".

15) O'Connell et al. 2004, AIDS and Behavior, 8(1), 17-23:
"MSM/IDU reported more casual sexual partners and in multivariate analyses were twice as likely to report unprotected receptive anal intercourse with casual partners (than non-injection-drug using MSM)."

16) Colfax et al. 2004, American Journal of Epidemiology, 159(10), 1002-1012:
"Heavy alcohol use and use of poppers, amphetamines, or sniffed cocaine in general, as well as specifically just before or during sex, were significantly associated with increased risk of having unprotected anal sex with an HIV-positive or unknown-serostatus partner".

17) Rusch et al. 2004, Sexually Transmitted Diseases, 31(8), 492-8:
"UAI was significantly associated with sexual situation-specific use of marijuana (OR, 1.43), crystal methamphetamine (OR, 1.75), ecstasy (OR, 1.88), and ketamine (OR, 2.17); global use associations were similar".

18) Stall et al. 2003, American Journal of Public Health, 93(6), 939–942:
"We measured the extent to which a set of psychosocial health problems have an additive effect on increasing HIV risk among men who have sex with men (MSM). Greater numbers of health problems are significantly and positively associated with high-risk sexual behavior and HIV infection."

19) Stueve et al. 2002, AIDS Education and Prevention, 14(6), 482-95:
"Being high was associated with unprotected receptive anal intercourse with nonmain partners (odds ratio = 1.66, p = .02)".

20) Mansergh et al. 2001, The American Journal of Public Health, 91(6), 953-958:
"Consistent with other studies, 17, 21 we found drug use to be associated with sexual risk behavior".

21) Stone et al. 1999, Journal Of AIDS and Human Retrovirology, 20(5),495-501:
"Multivariate analysis of reported failures found more frequent condom use to be associated with a decreased per condom failure rate, and amphetamine and heavy alcohol use with increased rates in both models".  (Amphetamine and heavy alcohol use resulted in increased condom failure rate).

Non-LGBT-specific studies likewise identify the interrelatedness of substance abuse, psychopathy, high risk sexual behavior and STI contraction:

22) National Institute on Drug Abuse:
"Drug and alcohol intoxication affect judgment and can lead to risky sexual behaviors that put people in danger of contracting or transmitting HIV".
"NIDA has established that drug abuse treatment is HIV prevention".

23) Semple et al. 2010, Journal of Sex Research, 47(4), 355-363:
"Negative life events were positively associated with total number of unprotected sex acts, whereas positive life events were not associated with sexual risk-taking."

24) Fisher et al. 2007, Sexually Transmitted Diseases, 34(11), 856-863:
"Alcohol use was associated with HIV infection in Africa and alcohol-related interventions might help reduce further expansion of the epidemic".

25) Colfax er al. 2006, Clinical Infectious Diseases 42(10), 1463-1469:
"Most epidemiological data support the role of club drugs in increasing sexual risk behavior, with some studies demonstrating an independent association between use of certain club drugs and HIV infection".

26) Lehrer et al. 2006, Pediatrics, 118(1), 189-200:
"Depressive symptoms predicted sexual risk behavior in a national sample of male and female middle and high school students over a 1-year period".

27) Cook & Clark, 2005, Sexually Transmitted Diseases, 32(3), 156-64:
"The literature supports an overall association between problematic alcohol consumption and STDs".

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Mental health disorders, especially depression, are a major predictor of suicidality. This provides an obvious route via which heterosexism may induce increased suicidality in LGBT people. Heterosexism itself may also directly elevate suicidality:

01) Van Bergen et al. 2013, American Journal of Public Health, 103(1), 70-72 (DUTCH):
"The data showed that victimization at school was associated with suicidal ideation and actual suicide attempts. Homophobic rejection by parents was also associated with actual suicide attempts."

02) Burton et al. 2013, Journal of Youth and Adolescence, 42(3), 394-402:
"Sexual minority-specific victimization significantly mediated the effect of sexual minority status on depressive symptoms and suicidality."

03) Schneider et al. 2012, American Journal of Public Health, 102(1), 171-177:
"Victimization was higher among nonheterosexually identified youths."  "Distress was highest among victims of both cyberbullying and school bullying (adjusted odds ratios [AORs] were from 4.38 for depressive symptoms to 5.35 for suicide attempts requiring medical treatment)."

04) Hightow-Weidman et al. 2011, AIDS Patient Care and STDs, 25(S1), S39-S45:
"There was a significant association between experiencing a high level of sexuality-related bullying and depressive symptomatology (p=0.03), having attempted suicide (p=0.03), and reporting parental abuse (p=0.05)."

05) Hong et al. 2011, Journal of Adolescence, 34(5), 885–894:
"Sexual minority youth frequently struggle with rejection from their parents, peers, and teachers, as well as homophobia in society, which put them at risk for depression that can lead to self-destructive behavior such as suicide. It is imperative that bullying prevention programs are expanded to include a discussion about sexual orientation and how homophobic language creates unsafe environments".

06) Needham & Austin, 2010, Journal of Youth and Adolescence, 39(10), 1189-1198:
"Compared to heterosexual women, lesbian and bisexual women have higher odds of suicidal thoughts and recent drug use; bisexual women also have higher odds of elevated depressive symptomatology and heavy drinking. Gay men have higher odds of suicidal thoughts than heterosexual men. With the exception of heavy drinking, parental support either partially or fully mediates each of the observed associations."

07) Birkett et al. 2009, Journal of Youth and Adolescence, 38(7), 989-100:
"LGB and sexually questioning youth were more likely to report high levels of bullying, homophobic victimization, and various negative outcomes than heterosexual youth. Students who were questioning their sexual orientation reported the most bullying, the most homophobic victimization, the most drug use, the most feelings of depression and suicidality, and more truancy than either heterosexual or LGB students. A positive school climate and a lack of homophobic victimization moderated the differences among sexual orientation status and outcomes."

08) Almeida et al. 2009, Journal of Youth and Adolescence, 38(7), 1001-1014:
"Perceived discrimination accounted for increased depressive symptomatology among LGBT males and females, and accounted for an elevated risk of self-harm and suicidal ideation among LGBT males."

09) Walls et al. 2008, Social Work, 53(1), 21-29:
"The findings suggest that risk factors related to suicidality include hopelessness, methamphetamine use, homelessness, and in-school victimization."

10) Friedman et al. 2006, Journal of Adolescent Health, 38(5), 621-623:
"This study hypothesized that gender-role nonconformity is associated with suicidality, and bullying mediates this relationship."  "Support for the hypotheses was found."

11) de Graaf et al. 2006, Archives of Sexual Behavior, 35(3), 253-262:
"Among homosexual men, perceived discrimination was associated with suicidality."

12) Hidaka & Operario, 2006, Journal of Epidemiology and Community Health, 60(11), 962-967: 
"Independent correlates of attempted suicide were psychological distress, history of being verbally harassed, history of sex with a woman...and not having a university degree."

13) Goodenow et al. 2006, Psychology In The Schools, 43(5), 573-589:
"Sexual minority adolescents in schools with LGB support groups reported lower rates of victimization and suicide attempts than those in other schools. Victimization and perceived staff support predicted suicidality."

14) D'Augelli et al. 2005, Suicide & Life Threatening Behavior, 35(6), 646-60:
"Early openness about sexual orientation, being considered gender atypical in childhood by parents, and parental efforts to discourage gender atypical behavior were associated with gay-related suicide attempts, especially for males."

15) Warner et al. 2004, The British Journal of Psychiatry, 185(6), 479-485:
"Out of the whole sample, 361 (31%) had attempted suicide. This was associated with markers of discrimination such as recent physical attack (OR=1.7, 95% CI 1.3-2.3) and school bullying."

16) Bontempo & D'Augelli, 2002, Journal of Adolescent Health, 30(5), 364-374:
"LGB youths reporting low levels of at-school victimization reported levels of substance use, suicidality, and sexual-risk behaviors that were similar to heterosexual peers who reported low at-school victimization."

17) Russell & Joyner, 2001, American Journal of Public Health, 91(8), 1276–1281:
"The strong effect of sexual orientation on suicidal thoughts is mediated by critical youth suicide risk factors, including depression, hopelessness, alcohol abuse, recent suicide attempts by a peer or a family member, and experiences of victimization."

18) Bagley & Tremblay, 2000, Crisis, 21(3), 111-7:
"Reasons for these elevated rates of suicidal behavior include a climate of homophobic persecution in schools, and sometimes in family and community--values and actions that stigmatize homosexuality and that the youth who has not yet "come out" has to endure in silence."

19) Garofalo et al. 1999, Archives of Pediatrics and Adolescent Medicine, 153(5), 487-493:
"Female gender (odds ratio [OR], 4.43), GLBN orientation (OR, 2.28), Hispanic ethnicity (OR, 2.21), higher levels of violence/victimization (OR, 2.06), and more drug use (OR, 1.31) were independent predictors of suicide attempt (P<.001)."

20) Hershberger et al. 1997, Journal of Adolescent Research, 12(4), 477-497:
"In comparison to youth who made no suicide attempts, attempters reported that they had disclosed more completely their sexual orientation to others, had lost more friends because of their disclosures, and had experienced more victimization due to their sexual orientation."

21) Rotheram-Borus et al. 1994, Journal of Adolescent Research, 9(4), 498-508:
"Gay-related stressors were significantly more common among suicide attempters as compared to nonattempters".

Non-LGBT-specific studies highlight similar risk factors for suicide, including other minority stress sequelae:

22) Turecki et al. 2012, Trends in Neurosciences, 35(1), 14-23:
"Recent animal and human data have suggested that early-life adversity leads to epigenetic regulation of genes involved in stress-response systems. We review this evidence and suggest that early-life adversity increases risk of suicide in susceptible individuals by influencing the development of stable emotional, behavioral and cognitive phenotypes... involved in responses to stress."

23) Windfuhr & Kapur, 2011, British Medical Bulletin, 100(1), 101-121:
"Suicide risk is most commonly associated with mental illness."

24) Bruffaerts et al. 2010, The British Journal of Psychiatry, 197(1), 20-27:
"Childhood adversities (especially intrusive or aggressive adversities) are powerful predictors of the onset and persistence of suicidal behaviours."

25) Gradus et al. 2010, International Journal of Epidemiology, 39(6), 1478-1484:
"Those diagnosed with acute stress reaction had 10 times the rate of completed suicide compared with those without this diagnosis. Persons with acute stress reaction and depression, or acute stress reaction and substance abuse, had a greater rate of suicide than expected based on their independent effects."

26) Masocco et al. 2010, Psychiatric Quarterly, 81(1), 57-71:
"These findings support the notion that marital status may play a central role in influencing suicide."

27) Qin et al. 2003, The American Journal of Psychiatry, 160(4), 765-772:
"Suicide risk is strongly associated with mental illness, unemployment, low income, marital status, and family history of suicide."

28) Aharonovich et al. 2002, The American Journal of Psychiatry, 159(9), 1600-1602:
"All three types of depression increased the risk for making a suicide attempt."

01) DOI: 10.2105/AJPH.2012.300797
02) DOI: 10.1007/s10964-012-9901-5
03) DOI: 10.2105/AJPH.2011.300308
04) DOI: 10.1089/apc.2011.9877
05) DOI: 10.1016/j.adolescence.2011.01.002
06) DOI: 10.1007/s10964-010-9533-6
07) DOI: 10.1007/s10964-008-9389-1
08) DOI: 10.1007/s10964-009-9397-9
09) DOI: 10.1093/sw/53.1.21
10) DOI: 10.1016/j.jadohealth.2005.04.014
11) DOI: 10.1007/s10508-006-9020-z
12) DOI:10.1136/jech.2005.045336
13) DOI: 10.1002/pits.20173
14) DOI: 10.1521/suli.2005.35.6.646
15) DOI: 10.1192/bjp.185.6.479
16) DOI: 10.1016/S1054-139X(01)00415-3
17) DOI:
18) DOI: 10.1027//0227-5910.21.3.111
19) DOI: 10.1001/archpedi.153.5.487
20) DOI: 10.1177/0743554897124004
21) DOI: 10.1177/074355489494007
22) DOI: 10.1016/j.tins.2011.11.008
23) DOI: 10.1093/bmb/ldr042
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25) DOI: 10.1093/ije/dyq112
26) DOI: 10.1007/s11126-009-9118-2
27) DOI: 10.1176/appi.ajp.160.4.765
28) DOI: 10.1176/appi.ajp.159.9.1600

LGBT people undoubtedly experience a greater degree of lifetime victimisation on average than heterosexuals. Unsurprisingly, this lowers quality of life (Kerr et al. 2011, DOI: 10.1007/s12187-010-9078-y):

01) Katz-Wise & Hyde, 2012, Journal of Sex Research, 49(2-3), 142-67, DOI: 10.1080/00224499.2011.637247
"LGB individuals experienced greater rates of victimization than heterosexual individuals."

02) Marieka Klawitter, 2011, Journal of Policy Analysis and Management, 30(2), 334–358, DOI: 10.1002/pam.20563
"The results suggest that gay men face an earnings penalty that varies significantly (though not sizably) across local areas, and that state antidiscrimination policies may decrease that penalty in private sector employment."

03) Berlan et al. 2010, Journal of Adolescent Health, 46(4), 366–371, DOI: 10.1016/j.jadohealth.2009.10.015
"Mostly heterosexual males... and gay males... were more likely to report being bullied. Similarly, mostly heterosexual females..., bisexual females..., and lesbians... were more likely to report being bullied than were heterosexual females."

04) Baral et al. 2009, PLoS ONE, 4(3), e4997, DOI: 10.1371/journal.pone.0004997
"Human rights abuses, including blackmail and denial of housing and health care was prevalent with 42.1% (222/527) reporting at least one abuse."

05) Nick Drydakis, 2009, Labour Economics, 16(4), 364–372, DOI: 10.1016/j.labeco.2008.12.003
"Mailing pairs of curriculum vitae, distinguished only by the sexual orientation of the applicants, led to the observation that gay men faced a significantly lower chance of receiving an invitation for an interview."

06) Anthony D’augelli, 2002, Clinical Child Psychology & Psychiatry, 7(3), 433-456, DOI: 10.1177/1359104502007003010
"More than three-quarters had been verbally abused because of their sexual orientation, and 15 percent reported physical attacks. More than one-third said they had lost friends because of their sexual orientation. Youths who had experienced more victimization and who had lost friends reported more mental health symptoms."

07) Rosario et al. 2001, American Journal of Public Health, 91(6), 903-906, DOI: 10.2105/AJPH.91.6.903
"Youths who report same-sex or both-sex romantic attraction are more likely to experience extreme forms of violence than youths who report other-sex attraction."


Stall et al. 2003, American Journal of Public Health, 93(6), 939–942:
"This analysis of these data supports the view that additive psychosocial health problems—otherwise known collectively as a syndemic—exist among urban MSM and that the interconnection of these problems functions to magnify the effects of the HIV/AIDS epidemic in this population."

The studies above are referenced below to evidence the health disparities' interconnectedness, using the format 2.14, where 2 corresponds to section 2 and 14 corresponds to study 14 in that section. Other studies, referenced for the first time, will appear below. The health disparities described above can interact synergistically to accentuate or cause one another. This can arise from a range of possible mechanisms, including;
  • Substance abuse (2.01, 2.07) and risky sexual behaviour (3.05) may both result directly from victimisation, as attempts to cope, or, in the latter case, discomfort with discussing serostatus or condom use (3.08),
  • Substance abuse is strongly associated with sexual risk behaviour via a range of mechanisms, such as reduced condom use, higher condom failure rate (slippage/breakage) and more sex with serodiscordant partners (3.06, 3.12-13, 3.16-17, 3.19-21, 3.22, 3.09),
  • Mental illness, such as depression, can be a route in to substance abuse, likely as an attempt to self-medicate, both among LGBT people (2.17-19) and the general population (3.03). These two factors can in turn lead to suicidality (2.06, 4.17, 4.19),
  • Homelessness may also represent a significant route for LGBT youth to these health disparities (Bruce2014, Clatts2005, 4.09).

Bruce et al. 2014, Journal of Urban Health, 91(3), 568-580, DOI: 10.1007/s11524-014-9876-5:
"Sexual minority youth are more likely to experience homelessness. Direct significant paths were found from experience of sexual orientation-related stigma to internalization of sexual orientation-related stigma, having been kicked out of one’s home, experiencing homelessness during the past year, and major depressive symptoms during the past week. Having been kicked out of one’s home had a direct significant effect on experiencing homelessness during the past 12 months and on daily marijuana use."

Clatts et al. 2005, Journal of Adolescence, 28(2), 201–214, DOI: 10.1016/j.adolescence.2005.02.003:
"A prior experience of homelessness and currently being homeless are both strongly associated with both higher levels of lifetime exposure to drug and sexual risk as well as higher levels of current drug and sexual risk."


These health disparities can be ameliorated by a more supportive/less hostile environment (2.10, 4.07, 4.13, 4.16). Additionally, far from being unique to sexual minorities, these patterns of response to stress/victimisation and their interrelatedness appear integral to human nature;
  • Negative life events correspond to more unprotected sex (3.23),
  • Substance abuse is associated with higher STI rates (3.24, 3.27),
  • Depression increases sexual risk behaviour (3.26),
  • Mental illnesses, especially those entailing stress/depression, drastically increase suicidality (4.23, 4.25, 4.27-8).


Other minorities, such as racial minorities also appear to be affected by minority stress too (Inzlicht2006, Jackson2004, 1.22, 2.08, 2.16), though one key distinction between these and LGBT people, aside from the considerably more antiquated nature of racism, is parental support or rejection (1.07, 1.23, 4.01, 4.04-6, 4.13, 4.18, Pachankis2008, Ryan2009). Racial minorities have daily shining examples of those who exhibit their stigmatised trait. They can look up to their parents and be open with and supported by them. In contrast, LGBT people have no such support and even fear rejection by their parents, ranging from disapproval to physical assault, homelessness and murder.

Inzlicht et al. 2006, Psychological Science, 17(3), 262-269, DOI: 10.1111/j.1467-9280.2006.01695.x:
"These results suggest that (a) stigma is ego depleting and (b) coping with it can weaken the ability to control and regulate one's behaviors in domains unrelated to the stigma."

Jackson et al. 2004, International Journal of Methods in Psychiatric Research, 13(4), 196-207:
"Several studies indicate that racial discrimination adversely affects the emotional wellbeing and physical health of African-Americans and other ethnic groups (Harrell, Merritt and Kalu, 1998; Clark, Anderson, Clark and Williams, 1999; Krieger, 1999; Williams and Williams-Morris, 2000; Williams, Neighbors and Jackson, 2003)."

Pachankis et al. 2008, Journal of Consulting and Clinical Psychology, 76(2), 306-317, DOI: 10.1037/0022-006X.76.2.306:
"After establishing a reliable and valid measure of the gay-related rejection sensitivity construct, the authors use this to test the mediating effect of internalized homophobia on the relationship between parental rejection of one's sexual orientation and sensitivity to future gay-related rejection. The present data support this mediational model and also establish rejection sensitivity's unique contribution to unassertive interpersonal behavior in the context of internalized homophobia and parental rejection."

Ryan et al. 2009, Pediatrics, 123(1), 346 -352, DOI: 10.1542/peds.2007-3524:
"Lesbian, gay, and bisexual young adults who reported higher levels of family rejection during adolescence were 8.4 times more likely to report having attempted suicide, 5.9 times more likely to report high levels of depression, 3.4 times more likely to use illegal drugs, and 3.4 times more likely to report having engaged in unprotected sexual intercourse compared with peers (other LGBT people) from families that reported no or low levels of family rejection."


Finally, it is important to keep in mind when referring to these disparities that we are still typically only referring to small minorities within minorities that are affected by them, rather than them being universal among LGBT people. HIV for example is far more prevalent among MSM in some countries, such as the U.S., than among the general population. It still only affects ~10% of MSM in the U.S., meaning that ~90% are uninfected, while lesbian's transmission risk is vastly below that of heterosexuals.

Fujie et al. 2010, Sexually Transmitted Diseases, 37(6), 399-405, DOI: 10.1097/OLQ.0b013e3181ce122b
"The prevalence of HIV was 0.2%... in non-MSM, 9.1% (95% CI, 4.8–16.4) in MSM-Ever, and 11.8% (95% CI, 6.0–21.9) in MSM-Past Year".

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