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Mental health inequalities among gay and bisexual men

Depression, substance abuse, and suicide have long been associated with homosexuality. In the decades preceding the gay liberation movement, the most common explanation for this association was that homosexuality itself is a mental illness. Much of the work of gay liberation consisted of dismantling the pathological understanding of homosexuality among mental health professionals. It was partly the direct challenges by gay people to the psychiatric profession that led to the removal of homosexuality by itself from the Diagnostic and Statistical Manual of Mental Disorders in 1973. Some still hold the view that gay desire is a pathology. It’s no coincidence that the Catholic Church declared that “homosexual acts are intrinsically disordered” in 1975, at precisely the same time that the psychiatric establishment was reorienting itself to the problems gay people experience rather than being gay itself.

Research about the mental health of sexual minorities (that does not start from the assumption that non-heterosexuality is the problem) is in its relative infancy. However, by now a number of studies using representative samples have shown that a range of mental health problems are more common among sexual minorities than the sexual majority. But generally, comparing gay people with straight people is about as far as they can go. Sometimes lesbians, gay men, bisexual men and women, and other non-heterosexuals are grouped together and when they are separated they are still considered as homogenous groups. Majorities tend to think minorities are more alike than they actually are. Because a minority group shares one characteristic, they are assumed to share most other characteristics. This is one of the mechanisms of stereotyping. However, even casual observation reveals that gay men, for example, are extremely diverse. So how is that diversity reflected in their mental health?

Since there are very few quantitative answers to this question, we sought to determine measures of depression, anxiety, suicidal ideation, and self-harm among a large convenience sample of gay and bisexual men recruited through a wide range of settings. All four indicators were associated with younger age, lower education, and lower income. Depression was also associated with being a member of visible ethnic minorities and sexual attraction to women as well as men. Cohabiting with a male partner and living in London were protective of mental health.

Convenience samples come in for a lot of criticism. But while we should be wary of their known problems, we should not dismiss them when they are the only source of evidence we have. Convenience surveys of sexual minorities complement, rather than compete with, representative general population surveys that include a sexuality question. Even the largest representative samples of the general population recruit only small absolute numbers of sexual minorities and this greatly limits the detail such studies can describe.

It is far from the case that the poor mental health experienced more often by sexual minorities than the sexual majority is equally experienced across those minorities. Mental health inequalities observed in the general population are carried over, perhaps compounded, among sexual minorities.

So why would gay and bisexual men who are also members of other minority groups be more vulnerable to mental health challenges? Understanding the relationships will be key to responding to them. Three possible explanations present themselves.

Firstly, if experience of homophobia is the primary cause of poor mental health among gay and bisexual men, it may not be equally experienced. Here the levels of discrimination (minority stressors) that cause poor mental health are different. This is congruent with the observation that younger men bear the brunt of homophobic abuse and assault and also suffer the greatest impact.

A second explanation is that even when homophobia is equally experienced across different groups (ie. same level of sexual minority stressors) what differs is that some men are more able to resist its impact than others. Some men, perhaps those with higher education and more social support, are better able to mitigate the effect of homophobic oppression if they are relatively privileged in other areas of their lives. In this explanation, the effects of homophobia are not uniform across other axes of social justice.

A third explanation proposes that regardless of the levels and effects of sexual minority stress, some gay and bisexual men also experience discrimination or marginalisation through mechanisms other than those related to their sexuality such as racism and poverty.

All three explanations may be in operation and the contribution each makes to overall outcomes could be expected to differ by the social axis under consideration. But it is clear that mental health promotion for gay and bisexual men will increase its impact if it attends to age, income, and relationship status, preferably targeting younger, poorer, single men. We need to challenge a narrow conception of the gay movement as being about equality between straight and gay and remind ourselves that the mental health challenges of young, poor, single gay men will not be addressed by well-off middle-aged gay couples becoming equal with well-off middle-aged straight couples.

Image credit: Gay Liberation Monument by Raphael Isla, CC-BY-SA-4.0 via Wikimedia Commons

Recent Comments

  1. Milo

    One wonders whether anyone has conducted a survey of the incidence of gay or bisexual persons among patients with a Thyroid disease.

    Alas, Hypothyroidism is still misdiagnosed as depression and even psychosis. Most research is focused on women (understandably as patients are predominantly female). But it has often struck me that male patients not only are frequently gay/bisexual men but also in the past have been incorrectly diagnosed with psychological disorder!

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