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Chapter Seven Sexual Orientation and Mental Health

Introduction

This chapter is concerned with the risk and resilience factors as they impact differentially on lesbian, gay, bisexual and transgender people ( LGBT).

There is consistent evidence of higher/different rates of depression, anxiety, suicidal thoughts, self-harming behaviour, eating disorders and substance misuse among LGBT people. But, being lesbian, gay, bisexual or transgender is not per se a cause of mental distress, nor is it a mental health problem. Homosexuality was declassified as a mental illness by the American Psychiatric Association in 1973 and the World Health Organization in 1992. The significant factors are the social and economic disadvantages LGBT people experience as a result of homophobia, transphobia and heterosexism. ³ This can result in discrimination, bullying at school or in the workplace, harassment, violence (including domestic violence) and exclusion.

Some people may experience multiple disadvantages based on different aspects of their social identity, for example, LGBT people who have a disability, or come from a black or minority ethnic community or who are older. In these contexts the discrimination and exclusion may be both from the wider social communities of which people are a part, but also from within LGBT communities. For women, in particular, double disadvantages may accrue based both on gender and sexual orientation.

These disadvantages may impact on access to, and experience of, services. People may be reluctant to 'come out' to service providers, or experience negative responses to disclosure of their sexual orientation due to:

• Lack of awareness/sensitivity among providers.
• Perceived homophobia/prejudice among professionals.
• Inappropriate treatment regimes. Although beyond the scope of the current paper, there are therapeutic controversies, between officially condemned 'conversion therapies' aimed at 'curing' homosexuality and 'affirmative therapies' targeted at addressing internalized homophobia. ⁴

Given that approximately half a million of Scotland's population are lesbian, gay, bisexual or transgender (Inclusion Project, 2003), this raises significant issues for mental health improvement and mental health service delivery.

Sexual Orientation and Mental Health: Some Indicators

Data from the US, Australia, New Zealand, Europe, Northern Ireland, England and Wales, as well as Scotland-specific studies all point to higher levels of depression and anxiety, self-harming and suicidal thoughts, eating disorders and substance misuse among LGBT people. Younger people and bisexual and transgender people may be particularly vulnerable groups.

Depression and anxiety

International studies have found gay men to have a rate of depression as much as eight times higher than the general population, and as high as two-thirds of lesbians have been found to have suffered depression (McNair et al, 2001). In one English study one-quarter of men, and over one-third of women in a sample of LGBT people had been diagnosed with clinical depression or other kinds of depression (Healthy Gay Life, Birmingham, nd). In Glasgow two-thirds of a sample of lesbians and gay men stated that they had experienced depression (John and Patrick, 1999). Reviews of studies have indicated
a greater lifetime risk for major depression among LGBT people (Cochran, 2001).

Young LGBT people may be particularly vulnerable to depression and anxiety. A health needs assessment of young lesbian, gay and bisexual people in Glasgow, for example, found that 41% of the women and 31% of the men had symptoms of depression. Comparison with data from a study of 'mainstream' young people of a similar age, indicates a rate of almost seven times higher for lesbian or bisexual young women,
and eight times higher for gay or bisexual young men (Coia et al, 2002).

People who are bisexual or transgender may also be at particular risk of depression. One Australian study found that people who were bisexual had the highest rates of anxiety and depression compared with homosexual and heterosexual groups (Jorm
et al, 2002), while a study in England and Wales found that bisexual men reported more psychological distress than their gay counterparts (King and McKeown in Pointon, 2003). One American study of transgender people found 62% of male-to-female, and 55% of female-to-male transgender people were depressed. Data from a study of young LGBT people in Northern Ireland also indicates the vulnerability of this group of people: around one-half of the young transgender people in the sample had been medicated for depression, compared with around one-quarter of young lesbian and gay young people (Carolan and Redmond, 2003).

Suicide and Self-harm

Studies also consistently indicate the high proportions of LGBT people who have attempted or seriously considered suicide, or who have engaged in self-harming behaviour (the number of successful suicides among this group of people is less easily quantifiable).

Younger people

In addition to international studies ( e.g. Vincke and van Herrigen, 1998, in Lumsdaine, 2002) studies in Glasgow, Edinburgh and Northern Ireland, all point to high rates of suicidal thoughts and attempted suicide among young LGBT people. The Glasgow study of young lesbian, gay and bisexual people, for example, found that 50% of the men and 80% of the women thought about suicide at one time: 32% of the women and 19% of the men had actually made an attempt. Comparison with a 'mainstream' group of young people of similar age suggested that young lesbian, gay and bisexual people were between 6-11 times more likely to attempt suicide (Coia et al, 2002). Focusing specifically on young gay and bisexual men in Edinburgh research by Gay Men's Health similarly found that young gay and bisexual men were 6.7 times more likely to have attempted suicide than the general population (Hutchison et al, 2003). This study found that young men aged 14-17 years were especially vulnerable.

In Northern Ireland a study of young LGBT people found that while across the sample 29% had attempted suicide this included almost one-half of those who identified as transgender (Carolan and Redmond, 2003).

The prevalence of self-harm among young LGBT people is also high, especially among young women. The Glasgow needs assessment found that just under 40% of the sample of young lesbian, gay and bisexual people had self-harmed: this included just under two-thirds of the sample of women, and 29% of the young men (Coia et al, 2002). The authors suggest that LGB young people are between 5-11 times more at risk of self-harming than other groups of young people. The Edinburgh study of gay and bisexual men also found that rates of self harming without suicidal intent were 5.6 higher than among young men in the general population (Hutchison et al, 2003).

The Northern Ireland study of young LGBT people again found that while 26% of the sample indicated they had self-harmed (33% of the women and 22% of the men), of those who identified as transgender, 50% admitted to self-harming (Carolan and Redmond, 2003).

Adults

Although the risk declines with age (Cochran, 2001), a Glasgow study of adult lesbians and gay men nonetheless found that nearly one-quarter had attempted suicide (41% of whom were women, 59% men) (John and Patrick, 1999).

Among people who are transgender one study found that 32% of the sample studied had attempted suicide (Clements-Nolle et al, 2001).

Self-harming behaviour is also prevalent among adults. The Glasgow study of adult lesbians and gay men found that just over one-quarter of the sample had self-harmed (John and Patrick, 1999). In both this and a study in Birmingham of adult LGBT people, between 32-36% of women had indicated that they had self-harmed, compared with 21-23% of men (Healthy Gay Life, Birmingham, nd; John and Patrick, 1999).

Eating disorders and substance misuse

Eating disorders

The Inclusion Project Report (2003), draws attention to the significance of eating disorders among LGBT people. Summarising the findings of a study comparing food-related attitudes and behaviours of heterosexual men and women with those of lesbians and gay men, the report highlights that gay men and heterosexual women were similar in disordered eating patterns, compared with lesbians and heterosexual men. Differences have also been found between gay and heterosexual male recurrent binge eating and purging. Gay men also report higher levels of body image disturbance compared to heterosexual men.

Over one-third of the young lesbian, gay and bisexual people included in the Glasgow needs assessment believed they had a problem with eating (Coia et al, 2002). A similar study in Northern Ireland, found 21% of young LGBT in the sample had experienced an eating disorder (Carolan and Redmond, 2003). In both samples the proportion of women reporting a problem with eating was higher than that for men. Nonetheless, the Northern Ireland study comments that the incidence of eating disorders among the men was higher than among the general population. This study also found that 57% of the sample of transgender people had experienced an eating disorder.

Substance misuse

Although the research is ambiguous (Inclusion Project, 2003), some evidence suggests that lesbian and gay people may have higher levels of substance abuse disorders and are more likely to have used recreational drugs (King and McKeown, in Pointon, 2003). Lesbians may also be more at risk of developing alcohol dependency than other women (Cochran, 2001).

In the Northern Ireland study of young LGBT people, 34% reported alcohol misuse and 23% drug misuse, with little difference between men and women. People who identified as transgender reported higher levels of drugs and alcohol misuse than their lesbian, gay and bisexual peers (Carolan and Redmond, 2003).

Sexual Orientation and Mental Health: Risk Factors

Economic and social discrimination

The prevalence of homophobia within the wider community is evidenced by an analysis of the 2002 Scottish Attitudes Survey which found that discriminatory attitudes were more likely to be expressed in respect of gay men and lesbians and people from minority ethnic groups, than disabled people or [heterosexual] women (Bromley and Curtice, 2003). The Inclusion Project report, citing a Glasgow City survey of sectarianism, notes that the numbers of people who would be 'very concerned' about a lesbian or gay person moving in next door was amongst the highest expressed (Inclusion Project, 2003).

Given these attitudes it is perhaps not surprising that studies have shown that, in comparison with heterosexual men and women, lesbian, gay and bisexual people report more frequent experiences of discrimination, both as discrete events and everyday affronts (Cochran, 2001). Among a sample of lesbians and gay men in Glasgow, for example, 70% of respondents stated that they had experienced discrimination because of their sexuality (John and Patrick, 1999). From the perspective of mental health, it has been found that these experiences are positively associated with psychological distress (Cochran, 2001; McNair et al, 2001).

This experience of discrimination can occur at school, in the workplace, in access to services such as health (see below) and housing, and in the community at large.

Studies have revealed, for example, evidence of homophobic discrimination within schools, whether manifested through bullying or abuse (see below) and/or heterosexist sex and relationships education (McNair et al, 2001; Inclusion Project, 2003; Loudes, 2003). The immediate impact is perhaps reflected in the finding that, of the sample of young lesbian, gay and bisexual people interviewed by Coia et al (2002), 86% believed that their school had not or did not seem a welcoming a place for young lesbian, gay
or bisexual people, or were unsure. Given the links made between homophobic discrimination and academic underachievement and higher than average truancy and drop out rates (Coia et al, 2002; Lumsdaine, 2002), this may have longer term social and economic impacts on subsequent life chances. Among a sample of lesbian and gay men in Glasgow, for example, just under 30% felt that their levels of educational achievement were negatively affected by their own feelings or the attitudes of others towards their sexuality (John and Patrick, 1999).

Beyond school, studies suggest the level of discrimination based on sexual orientation experienced by LGBT people in the workplace. Studies of adults in Birmingham (Healthy Gay Life, nd) and Glasgow (John and Patrick, 1999), indicate the proportions of people who feel that their sexual orientation resulted in being refused a job, being treated differently, victimized or being sacked. Among the Glasgow sample, for example, 43% believed they had experienced sexual discrimination or harassment at work; 20% felt they had had to leave their employment or refuse work because of their own or others' attitudes towards their sexuality; and 42% of unemployed respondents related their unemployment to their sexual orientation. Among young people, one study in Northern Ireland found that 20% of the sample felt they had to leave their job because of their experience as a young person who identified as lesbian, gay, bisexual or transgender (Carolan and Redmond, 2003). Other studies report that young LGB people may feel they have to hide some aspect of their identity in the workplace because they feel their sexual orientation will be a factor in their isolation and alienation from colleagues (Coia, et al, 2002; Loudes, 2003).

Lumsdaine, (2002) draws attention to the comparatively high levels of homelessness particularly among young LGBT people. This has been linked to negative responses to the person's sexuality, including family reactions to a young person disclosing their sexual orientation. Among a sample of lesbian and gay men in Glasgow, 34% had been homeless: over one-third felt this was related to their own or others' reaction to their sexual orientation (Patrick and John, 1999). Homophobia was also a factor in the decision by 42% of the sample to move home.

Homelessness is a known risk factor for physical and mental health, and may also be implicated in people selling sex as a survival strategy (Noell and Ochs, 2001; Coia et al, 2002; Cochrane et al, 2002; Lumsdaine, 2002).

Abuse, bullying, harassment and violence

Among young and adult LGBT people studies suggest the pervasive experience of abuse, harassment, bullying and violence related to their sexual orientation. Studies among young LGB people in Northern Ireland and Glasgow reveal the high level of violence to which young people are exposed in school and in the street when they are perceived as being gay. In Coia et al's study of young lesbian, gay and bisexual people in Glasgow, for example, four-fifths of the sample had experienced some form of abuse, harassment or violence, ranging from name calling/verbal abuse, to threats of, or actual physical violence or sexual assault (Coia et al, 2002). Studies among adults across Scotland, and in Edinburgh and Glasgow also reveal the level of abuse to which LGBT people are at risk. The Scotland-wide Beyond Barriers survey of LGBT people found that 35% of respondents had been verbally abused or threatened in the past year by someone who assumed they were LGBT (Beyond Barriers, 2002). A study of of lesbian and gay men in Glasgow (John and Patrick, 1999) found that as a result of being known, or presumed to be lesbian or gay:

• 85% had experienced verbal insults.
• 60% had been threatened with physical violence.
• 37% had been sexually harassed.
• 16% had been raped.

Among gay men in Edinburgh, 57% of respondents had experienced some form of harassment over the previous year (Morrison and MacKay, 2000). People in both the Glasgow and Edinburgh studies felt that the threat or experience of violence or abuse negatively affected how they acted or behaved, as well as impacting on self-confidence.

Again these negative experiences can occur at school, in the workplace and in the wider community, but also within the home.

A number of studies have drawn attention to young people's experience of homophobic bullying within the school environment. Over one-third of young gay and bisexual men and one-fifth of young lesbian and bisexual women in Birmingham had been bullied at school due to their sexual orientation (Healthy Gay Life, nd). In one Northern Ireland study of young LGBT people the figure is higher: 44% indicating that they had been bullied at school (Carolan and Redmond 2003). In Glasgow too, 41% of young lesbian and bisexual women, and 57% of young gay and bisexual men had experienced harassment or violence at school (Coia et al, 2002). In the Northern Ireland studies both fellow pupils and teachers were identified as the source of bullying. Given the negative impact of bullying on self-esteem and self-harm and possibly suicidal thoughts, this has possible implications for anti-bullying strategies within schools, and the extent to which they specifically address homophobic bullying.

In addition to the experience of employment discrimination, described earlier, a study in Edinburgh argues that the workplace is a significant setting for much of the violence and harassment that gay men experience (Morrison and MacKay, 2000).

For both young and adult LGBT people, however, much of the abuse is experienced in the street or other public places. In the Glasgow study of young LGBT people, for example, 38% of women and 51% of men had experienced harassment or violence in the street. The Scotland-wide Beyond Barriers (2002) survey of LGBT people found that where people felt least safe was the street, in or near a non-gay pub or venue or on public transport. Potentially this has implications for social connectedness and participation.

For some people, however, the home too, may not be a place of refuge. This has two dimensions. First, as already noted in the context of homelessness, for some LGBT young people, coming out can result in family rejection (Carolan and Redmond, 2003; Lunsdaine, 2002). Second, both young and adult LGBT people in same-sex relationships can be subject to domestic violence, with similar psychological implications as for people in abusive heterosexual partnerships (Inclusion, Project, 2003). Out of a sample of young lesbian, gay and bisexual people Coia et al (2002) found that 12% (14% of the young men, and 8% of the young women) had experienced violence or assault from a partner in a same sex relationship In one Glasgow study of lesbians and gay men 35% indicated that they had experienced violence in a same-sex relationship, of whom 60% were women (John and Patrick, 1999). ⁵

Social isolation

For young people in particular, the experience of discrimination, abuse and violence has significant implications for coming out, ⁶ and with it, for identity, self-esteem and mental health and well-being. Summarised by one study of young lesbian, gay and bisexual people in Northern Ireland:

'Because of the violence, social disapproval, isolation and discrimination they experience, young LGB people are more subject to depression, anxiety and poor mental health than their heterosexual peers … both the process of coming out in a society which devalues LGB lifestyles or the need to hide one's sexual orientation are factors impacting negatively on the emotional and mental well-being of young LGB people.' (Loudes, 2003)

For both younger people and adults the impact may be felt in terms both of social isolation or lack of social connectedness, and social and economic exclusion and disadvantage. These sources of exclusion may be compounded for lesbian or bisexual women, and/or LGBT people who have a disability, and/or come from a black or ethnic community, and/or are older.

Multiple identities; Multiple disadvantage

The impact of stress, stigma and homphobia may be compounded for LGBT people who are disabled, come from black or minority ethnic communities, or who are older (Cochran, 2001; McNair et al, 2001).

The multiple impacts of sexuality and gender are flagged up by John and Patrick (2003) in Glasgow who found that of the 51% of the sample who had experienced sexism, the great majority were women. The same study reports the comparative lack of social and cultural provision for lesbian respondents. Reflecting this, a Northern Ireland study of young lesbian, gay and bisexual people, refers to the comparative 'invisibility' in research and policy terms of young lesbians and bisexual women. In practice this has resulted in an increased sense of isolation for young women who have few places to meet to discuss their experiences (Loudes, 2003). As the Inclusion Project report (2003) suggests, the social and economic disadvantages which accrue on the basis of gender may have a particular impact on male to female transgender people.

Two studies point to the potential double or triple jeopardy experienced by LGBT people with physical disabilities. What the studies also highlight is the potential for exclusion: from the disability movement due to their sexual orientation; from the LGBT community because of their physical disability; and from 'mainstream' society both due to their disability and because it was felt hard for society to accept the idea of lesbian and gay sexuality among disabled people (Brothers, 2003; Molloy et al, 2003), this has implications for identity and sources of social support and social connectedness.

The potential for compounded disadvantage for LGBT people from black and minority ethnic communities is flagged up in the Inclusion Project report (2003), which suggests that racism within the LGBT community and homophobia and transphobia in some black and ethnic minority communities may act as barriers to inclusion.

A number of studies allude to the experiences of older LGBT people. An Edinburgh study of gay men, found, for example that it was both the oldest and youngest age groups who were most worried about being victims of violence Morrison and MacKay (2000), while older LGBT people in a Glasgow study reported experiences of discrimination in relation to housing (John and Patrick, 1999). The Beyond Barriers (2002) survey found that 45% of respondents had concerns about ageing, including, being alone, being isolated, in poor health and a lack of LGBT friendly services. This has echoes in a study by Manthorpe and Price (2003), which suggests that the onset of dementia in older gay men and lesbians may make their sexual orientation public for the first time, with implications for social care services.

Sexual Orientation and Mental Health: Resilience Factors

Notwithstanding the risk factors, the point is made by Cochran (2001) in her review of a number of studies, that the majority of homosexual or bisexual respondents did not evidence any of the measured mental health disorders.

The importance of family, a sense of social connectedness and social support have been found to contribute to psychological well-being particularly among young LGBT people (Detrie, 2002; Hershberger and D'Augelli, 1995). Exemplifying the importance of support and acceptance, young people in one study described how being part of LGBT youth groups enhanced their self esteem and self-respect (Carolan and Redmond, 2003).

Cochran, however, makes the point that more research is needed to identify the protective and resilience factors upon which LGBT people can draw.

Sexual Orientation and Mental Health: Preventing and Responding to Risk

Mental health improvement

Lumsdaine (2002) argues that there is a need to integrate the health concerns of LGBT people across all areas of health promotion activity, not just in relation to sexual health. This clearly has implications for mental health improvement strategies.

The Inclusion report identifies a number of innovative health projects, including a project focusing on awareness of LGBT people who self-harm; the development in Edinburgh of the LGBT Centre for Health and Well Being and a pilot LGBT youth project focusing on mental health and esteem (Inclusion, 2003). In addition the National Programme has contributed funding towards a transgender needs assessment.

One London-based organisation, PACE, has drawn up a set of good practice guidelines for working with lesbian, gay and bisexual people in mental health services ( PACE website, www.pacehealth.org.uk/guidelines.html , accessed 18 January 04). The suggested guidelines for meeting Standard One (mental health promotion) of the National Service Framework for mental health in England and Wales include: referring to LGB people in relevant publicity and promoting positive images; liaison with relevant LGB groups; promoting services and resources specifically for LGB people, including services such counselling and advocacy provided by LGB organisations.

Responding to mental health problems

Two themes emerge from studies looking at access to health services, including mental health services:

• A reluctance by LGBT people to disclose their sexual orientation to health care professionals because of a fear of discrimination or negative response.
• The lived experience of discrimination and negative reaction following disclosure, including breaches of confidentiality.

Reluctance to disclose

Studies have found that between one-third and one-half of LGBT people may not have disclosed their sexual orientation to their GP (John and Patrick, 1999; Healthy Gay Lives, nd; Beyond Barriers, 2002). Among LGBT with physical disabilities the figure may be even higher. Brothers (2003) found a reluctance to come out to health care providers among a sample of lesbian, gay and bisexual people with disabilities because of their fear of being excluded from services or being treated in a negative way.

One study of a sample of 55 lesbian and gay people with experience of using mental health services found that 42% (23 people) would not feel 'safe' disclosing their sexual orientation within a mainstream mental health setting, a further 20 expressed reservations about disclosure (Golding, 1997). The two main reasons for being reluctant to disclose their sexual orientation were the fear of prejudicial treatment or discrimination, and/or that staff would assume that all their mental health problems were related to their sexuality.

Experiences of homophobia and discrimination within health services

For some people concerns about negative reactions have become a reality. King and McKeown found in their survey in England and Wales that up to a third of gay men, a quarter of bisexual men and more than 40% of lesbians had experienced negative or mixed reactions on disclosing their sexual orientation to a mental health practitioner (King and McKeown, 2003, in Pointon, 2003). An earlier survey of mental health service users found that 73% of the sample had experienced some form of prejudice and/or discrimination in connection with their sexual orientation within a mainstream mental health service (Golding, 1997), while a New Zealand survey of lesbians found that 30% of the women who had used mental health services had experienced discriminatory treatment (in, McNair et al, 2001).

For LGBT people with disabilities, prejudice may arise because of their sexual orientation, their physical disability, or in response to both aspects (Brothers, 2003).

In terms of treatment or therapy, heterosexism, homophobia, or a lack of understanding have been implicated in people's sexual orientation being given too much emphasis or being pathologised, that is identified as the cause of their mental distress; alternatively, people may find it difficult to explore issues relating to their sexual orientation because of a lack of understanding or awkwardness on the part of practitioners.

As a result of actual or anticipated discrimination and homophobia, people may be reluctant to access services, or may delay seeking help. For people who do seek help discrimination, homophobia, or lack of awareness or sensitivity, may compound rather than ameliorate distress (Cochran, 2001; Carr, 2002; Carolan and Redmond, 2003).

Sexual Orientation and Mental Health: Implications

Although the shorthand term LGBT is used, as the evidence suggests, it is important to be aware that the factors that impact on mental health and well-being, the ways in which these are experienced and expressed may be distinct between the different groups of people the acronym encompasses.

Embedding considerations of mental health impact on lesbian, gay, bisexual and transgender people into other policy domains

There are clearly issues around the experience of discrimination, homophobia and heterosexism which have implications for the implementation of the broader anti-discrimination and equalities agenda. For example, strategies relating to discrimination in employment and education, including sex education, and housing. The scope of community safety initiatives and anti-bullying strategies in the workplace and school also have implications for LGBT people.

Embedding consideration of inequalities within the mental health service system

Mental health improvement

A number of studies reinforce the need for a public health approach to include and address the specific health inequalities that arise from the homophobia, heterosexism and social exclusion to which LGBT people are exposed (McNair et al, 2001; Lumsdaine, 2002). According to Lumsdaine, this requires health promotion initiatives to shift attention away from seeing LGBT people as at risk groups to recognising the risk conditions which generate health inequalities.

In addition to consideration of the structural inequalities which LGBT people may experience, addressing the mental health and well being of LGBT people may raise questions relating to:

• The nature of programmes to improve the mental health and well being of LGBT people, including for younger people and older people.
• Mechanisms for addressing self-harm and suicide among younger and older LGBT people.
• Mechanisms for addressing stigma and discrimination experienced by LGBT people with mental health problems, including among LGBT communities.
• The implications of 'coming out' for the mental health and wellbeing of LGBT people.

Mental health services

In relation to mental health service design and delivery, the evidence suggests the need to:

• Reflect upon the homophobia and heterosexism that LGBT people perceive or experience within mental health services.
• Enhance awareness of the experiences of LGBT people, and the forms of discrimination and social exclusion they may encounter.
• Consider the nature of a 'culturally competent' mental health service for LGBT people.

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