Elsevier

Health & Place

Volume 15, Issue 4, December 2009, Pages 1029-1045
Health & Place

Mental health in sexual minorities: Recent indicators, trends, and their relationships to place in North America and Europe

https://doi.org/10.1016/j.healthplace.2009.05.003Get rights and content

Abstract

This meta-analysis featuring 12 national adult studies and 16 state/regional youth studies of sexuality and mental health finds that sexual minorities—as a likely consequence of place-contingent minority stress—experience mental health outcomes such as depression, anxiety, and suicide ideation much more frequently than their heterosexual counterparts. By interrogating the geographic variations in the findings, such as high rates of poor mental health outcomes in the United Kingdom, large gay-heterosexual disparities in the Netherlands, and lower and improving rates of both outcomes and risk factors in Vermont and British Columbia, this study asserts that policy regimes, health programming, and the ways in which sexual minorities are constructed in places all contribute to their mental health.

Introduction

During the past decade, researchers in psychology, psychiatry, public health, and other fields have increasingly linked poor mental health outcomes to sexual orientation. Although theoretical frameworks that emphasize stigma and discrimination as causes of poor mental health among gay, lesbian, bisexual, and other queer-identified individuals (see “minority stress” theory in Meyer, 2003, Meyer, 1995; Paul et al., 2002) are relatively well developed, the empirical evidence supporting such models—while strong—is disparate and rarely synthesized. Few government health agencies have sponsored national-level studies to measure mental health in sexual minority populations. In national studies where sexual orientation data are collected, sexual minorities tend to be under-sampled, resulting in low statistical power and limited publicly available data. In general, there is a lack of research on mental health and place (McKenzie and Whitley, 2002) and even less on gay, lesbian and other queer-identified individuals (Cochran, 2001). This gap may be attributable to the fraught past relationship between the psychiatry community and sexual minorities, characterized by the pathologizing and subsequent depathologizing of homosexuality, studies in mostly medicalized settings, and the (mis)application of various “reparative” therapies (Bayer, 1987; Friedman and Downey, 1994; King and Bartlett, 1999).

In the absence of national research agendas in this area, mental health researchers tend to conduct volunteer-based studies of sexual minority populations in a geographic area of interest to them, usually urban (see Klitzman et al., 2002; Botnick et al., 2002). Although these convenience-sample studies, such as the four-city Urban Men's Health Study (Mills et al., 2004; Paul et al., 2002), are successful in drawing large samples and data on a wide variety of specific mental health indicators, they typically lack a (heterosexual) referent group and may include skewed data due to volunteer bias. In addition, their findings cannot be generalized to gay men living outside particular zip codes or cities (Klitzman et al., 2002, p. 123). While common, these types of studies are difficult to synthesize and compare due to the variations in their choices of indicators and methods of data collection.

As an alternative, many researchers have recently employed pre-existing national health surveys to explore mental health outcomes among sexual minorities. Collectively, these studies suggest several factors that might be considered place-based determinants of gay men's mental health—including stigma, structural prejudice, coping structures, and treatment (see Fig. 1)—but rarely discuss them in detail. Qualitative research in public health and health geography also suggests that place-based factors, such as national or local policy regimes, cultural norms, and access to gay-specific mental health services, significantly influence mental health outcomes in gay men (see Knopp and Brown, 2003; Brown, 2006; Herdt and Kertzner, 2006). Qualitative and location-specific analyses, however, can be difficult to compare with each other or with the existing quantitative studies. The resultant lack of systematic assessments of geographic variation in the mental health outcomes of sexual minorities reflects the need for a new generation of mixed-methods research on mental health, place, and sexuality.

In the absence of publicly available datasets that feature multiple geographies, the most reasonable alternative is to conduct a meta-analysis of available, comparable studies of sexual orientation and mental health at the national and state/regional scales. Although brief meta-analyses have occasionally been used as addenda to qualitative discussions of sexuality and mental health (see Bagley and Tremblay, 2000; Cochran, 2001; Meyer, 2003), they are often presented in a perfunctory way—usually in the form of a simple table with little explanation. This deeper two-part discussion incorporates (1) national-level between-group studies (i.e., homosexual vs. heterosexual) in the United States, the Netherlands, the United Kingdom, and Austria and (2) state or regional between-group studies of adolescents. The latter stream includes both the Youth Risk Behavior Survey, used in Massachusetts, Vermont, Boulder County (Colorado), and Seattle (Washington), and similarly structured adolescent health surveys used in Minnesota and British Columbia. Since these two streams of studies “generalize” prevalence data in a percentage-based format (Paul et al., 2002, p. 1339), they allow for comparisons between gay and heterosexual cohorts, between adolescent and adult cohorts of gay men, and among multiple geographic jurisdictions.

Despite their usefulness, these studies have methodological drawbacks that need to be assessed critically. The studies are dependent on pre-determined categories of sexual orientation, placing them at odds with “queer theory” that rejects given categories of orientation and informs a good deal of current qualitative geographic research (see Giffney, 2004; Knopp, 2007). Although the work of psychoanalytic theorists such as Freud and Lacan has been used to inform aspects of queer theory, such as the role of public fantasy (e.g., mass media portrayals) in constructing sexual others and the use of gender “performance” to conceal or suppress socially unacceptable versions of gender expression (see Sullivan, 2003), it has also narrowed the parameters for research on sexual minorities. Early 20th-century psychoanalytic research ultimately replaced the concept of multiple non-normative sexuality “inversions” with the totalizing concept of “homosexuality”—a trend that has persisted in modern-day psychiatric research (Sullivan, 2003, p. 103). Consequently, most of the studies featured here use categories of gay, lesbian, and bisexual and—while sometimes allowing respondents to self-identify their sexual orientation—often impute orientation through questions about past sexual experiences.

The studies used here are also hampered by the fixed, pre-determined socio-political “scales” or “segments” for which data on mental health and sexual orientation are collected—what Dixon and Jones (1998, p. 258) call the “epistemology of the grid.” To date, most surveys that feature mental health data are fixed at the level of the country or state in which individual participants reside, leaving researchers somewhat trapped by the tools that they have developed to locate, segment, and capture social life. Political bodies, too, contribute to the issue of spatial fixity in mental health research. The spatially reified design of tools like health surveys is attributable to their intent (to inform health policy that is largely regulated by national or state bodies) and to the mechanisms that fund them (national and state health agencies and organizations). The result is a “governmentalized” vision (see Legg, 2005; Brown and Knopp, 2006) of mental health indicators, patterns, and trends that “prioritizes policy and programmatic decisions” and dictates the “social stakes” of research (Faulkner and Cranston, 1998, p. 262; Dixon and Jones, 1998, p. 254). Certain “treatable” issues (depression, anxiety) are highlighted while others (fear, isolation) are obscured, and the nation or state—rather than the city, neighborhood, or region—is posited as the primary container of mental health experiences and the factors mitigating them. This highly reified vision is at odds with both more fluid conceptions of geographic scale (see Delaney and Leitner, 1997) and with an increasing emphasis in health geography on lived experience. The turn toward individualized conceptions of health, rather than fixed indicators of illness, treatment, access, and care, has grown both in general health research (see Philo, 1996; Kearns and Moon, 2002) and with regard to sexual minorities (see Brown, 1997; Wilton, 1999). As such, the surveys used here—and the governmental influences that inform their design—may also foreclose from view the particular variables (local policies, “safe” space availability, access to counseling) or places (streets, workplaces, homes) that the otherwise-faceless participants in these surveys might see as important to their mental health.

Despite these drawbacks, a meta-analysis of these studies—when combined with a minority stress framework and a brief assessment of social and political geographies of the study locations—provides a useful point of departure (rather than a medicalized, reified “truth”) for future health geography research on the mental health of sexual minorities (Dixon and Jones, 1998, p. 250). Although the largely nomothetic exercise of using meta-analysis to establish trends and trend variations diverges from the recent idiographic leaning toward singular case studies in health geography, it is important to the ongoing analysis of mental health and sexuality. First, given the relative newness of this research field, it is important to establish an informed “baseline” of mental health differentials between gay and heterosexual individuals—something not yet done in the relatively scant literature on sexuality at the “international” scale (Brown, 2007). Second, it provides a model of potential causal pathways and expected mental health outcomes in which both existing and future idiographic studies (and the ways in which their results mirror or diverge from baseline hypotheses) can be couched. Third, it can inform future research of both the nomothetic variety (e.g., a synthesis of city-based studies on sexuality and mental health) and the idiographic (e.g., assessing modes of self-care for sexual minorities in a small town or rural area). Finally, it repositions the mental health field as an “ally” of gay rights movements by offering an impetus for policymakers to further invest in both health infrastructure (e.g., training in “gay affirmative” therapies) and social infrastructure such as anti-bullying/anti-homophobia policies and gay-straight alliances in both schools and communities (Bayer, 1987; Saewyc et al., 2009, p. 5).

Section snippets

Methods

Studies were collected by an initial search of the terms “gay” and “mental health” in the PubMed and Medline databases. These two searches each yielded about 200 article entries, 400 entries in total. Many of the entries, however, were duplicated both within each search and across the two searches, resulting in a lower number of entries overall—about 250. Four main categories of studies were identified: (1) national-level studies comparing mental health outcomes between gay men/lesbians and

Mental health of gay/bisexual and heterosexual men in between-group national studies

The first part of this discussion (1) identifies quantifiable differences in mental health outcomes between gay men and heterosexual men and (2) identifies notable variations among the four countries assessed—the United States, Netherlands, the United Kingdom and Austria. With the exceptions of one US study and the United Kingdom and Austria studies, each uses representative population samples to measure prevalence of various mental health conditions in gay and heterosexual men (see Table 1).

Mental health of LGB and heterosexual youth in between-group sub-national studies

The second part of this discussion (1) identifies quantifiable differences in mental health outcomes between lesbian, gay and bisexual (LGB) youth and their heterosexual counterparts and (2) identifies notable variations among the six places assessed—Minnesota, Massachusetts, Vermont, Seattle, British Columbia, and Boulder County in Colorado. There are between one and seven studies available for each place, and most are samples of high school students that measure the prevalence of various

Discussion

Collectively, the findings of the national-level studies of gay men provide strong evidence that sexual minorities are at higher risk for poor mental health outcomes. With only a few exceptions, gay men were consistently more likely than heterosexual men—often as much as three or four times more likely—to experience depression, anxiety, suicide ideation, and other disorders. The repetition of this trend in each of the four study locations (United States, the United Kingdom, Netherlands, and

Limitations

Although the results of this meta-analysis consistently point to poorer mental health outcomes among sexual minorities, several limitations must be considered. The gay population is still inadequately captured in many of the studies. The youth surveys, for example, do not capture street youth, chronic truants, dropouts, out-of-school youth, or incarcerated youth who would likely have much higher risks (Paul et al., 2002, p. 1338; Faulkner and Cranston, 1998, p. 265; Saewyc et al., 2009, p. 5).

Conclusion: bringing place into mental health research on sexual minorities

Most of the studies used in this meta-analysis ignore the impact of place-based factors in their findings, instead focusing only on the statistical relationship between sexuality itself and mental health outcomes. Such an approach, which is common in psychology and psychiatry, divorces mental health outcomes from place-based risk factors and almost tacitly excuses governments and health authorities from improving the conditions under which obvious mental health disparities are created. This can

Acknowledgements

I would like to thank Mark Rosenberg, Leela Viswanathan, Drew Bednasek, and my two anonymous reviewers for their comments on earlier versions of this article.

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