Hiding Gay

The question of whether homosexuality should be considered a mental disorder is a question about classification. It can be answered by debating which behaviors, cognitions, or emotions should be considered indicators of a mental disorder American Psychiatric Association, To use postmodernist understanding of scientific knowledge, such a debate on classification concerns the social construction of mental disorder—what we as a society and as scientists agree are abnormal behaviors, cognitions, and emotions.

The answer, therefore, depends on scientific and social consensus that evolves and is subject to the vicissitudes of social change Gergen, , This distinction between prevalences of mental disorders and classification in the DSM was apparent to Marmor , who in an early discussion of the debate said,.

The basic issue … is not whether some or many homosexuals can be found to be neurotically disturbed. In a society like ours where homosexuals are uniformly treated with disparagement or contempt—to say nothing about outright hostility—it would be surprising indeed if substantial numbers of them did not suffer from an impaired self-image and some degree of unhappiness with their stigmatized status.

If LGB people are indeed at risk for excess mental distress and disorders due to social stress, it is important to understand this risk, as well as factors that ameliorate stress and contribute to mental health. Only with such understanding can psychologists, public health professionals, and public policymakers work toward designing effective prevention and intervention programs. The relative silence of psychiatric epidemiological literature regarding the mental health of LGB populations may have aimed to remove stigma, but it has been misguided, leading to the neglect of this important issue.

Recently, researchers have returned to the study of mental health of LGB populations. Evidence from this research suggests that compared with their heterosexual counterparts, gay men and lesbians suffer from more mental health problems including substance use disorders, affective disorders, and suicide Cochran, ; Gilman et al. This hypothesis can be described in terms of minority stress Brooks, ; Meyer, In this article I review research evidence on prevalences of mental disorders and show, using meta-analyses, that LGB people have higher prevalences of mental disorders than heterosexual people.

I offer a conceptual framework for understanding this excess in prevalence of disorder in terms of minority stress. This conceptual framework is the basis for a review of research evidence, suggestions for future research directions, and exploration of public policy implications. In its most general form, recent stress discourse has been concerned with external events or conditions that are taxing to individuals and exceed their capacity to endure, therefore having potential to induce mental or somatic illness Dohrenwend, Some have used an engineering analogy, explaining that stress can be assessed as a load relative to a supportive surface Wheaton, Stress researchers have identified both individual and social stressors.

In psychological literature, stressors are defined as events and conditions e. Stress researchers have studied traumatic events, eventful life stressors, chronic stress, and role strains, as well as daily hassles and even nonevents as varied components of stress Dohrenwend, a. The concept of social stress extends stress theory by suggesting that conditions in the social environment, not only personal events, are sources of stress that may lead to mental and physical ill effects.

The notion that stress is related to social structures and conditions is at once intuitively appealing and conceptually difficult. It is appealing because it recalls the commonplace experience that environmental and social conditions can be stressful.

Hundreds in hiding as Tanzania launches anti-gay crackdown

Also, it rests on rich foundations of psychological and sociological theory that suggest the person must be seen in his or her interactions with the social environment Allport, It is conceptually difficult because the notion of stress, in particular as conceived of by Lazarus and Folkman , has focused on personal rather than social elements Hobfoll, I return to the discussion of this tension between the social and the personal, or objective and subjective, conceptualizations of stress.

One elaboration of social stress theory may be referred to as minority stress to distinguish the excess stress to which individuals from stigmatized social categories are exposed as a result of their social, often a minority, position. The foundation for a model of minority stress is not found in one theory, nor is the term minority stress commonly used. Rather, a minority stress model is inferred from several sociological and social psychological theories. Relevant theories discuss the adverse effect of social conditions, such as prejudice and stigma, on the lives of affected individuals and groups e.

Social theorists have been concerned with the alienation from social structures, norms, and institutions. According to Durkheim, people need moral regulation from society to manage their own needs and aspirations. Anomie, a sense of normlessness, lack of social control, and alienation can lead to suicide because basic social needs are not met. The minority person is likely to be subject to such conflicts because dominant culture, social structures, and norms do not typically reflect those of the minority group. An example of such a conflict between dominant and minority groups is the lack of social institutions akin to heterosexual marriage offering sanction for family life and intimacy of LGB persons.

Social psychological theories provide a rich ground for understanding intergroup relations and the impact of minority position on health. Social identity and self-categorization theories extend psychological understanding of intergroup relations and their impact on the self. These theories posit that the process of categorization e. Interactions with others are therefore crucial for the development of a sense of self and well-being. Symbolic interaction theories thus suggest that negative regard from others leads to negative self-regard.

Similarly, the basic tenet of social evaluation theory is that human beings learn about themselves by comparing themselves with others Pettigrew, Both these theoretical perspectives suggest that negative evaluation by others—such as stereotypes and prejudice directed at minority persons in society—may lead to adverse psychological outcomes. Similarly, Allport described prejudice as a noxious environment for the minority person and suggested that it leads to adverse effects.

Beyond theoretical variations, a unifying concept may emerge from stress theory. Certainly, when the individual is a member of a stigmatized minority group, the disharmony between the individual and the dominant culture can be onerous and the resultant stress significant Allison, ; Clark et al. I discuss other theoretical orientations that help explain minority stress below in reviewing specific minority stress processes. American history is rife with narratives recounting the ill effects of prejudice toward members of minority groups and of their struggles to gain freedom and acceptance.

There has been increased interest in the minority stress model, for example, as it applies to the social environment of Blacks in the United States and their experience of stress related to racism Allison, ; Clark et al. There is no consensus about specific stress processes that affect LGB people, but psychological theory, stress literature, and research on the health of LGB populations provide some ideas for articulating a minority stress model. I suggest a distal—proximal distinction because it relies on stress conceptualizations that seem most relevant to minority stress and because of its concern with the impact of external social conditions and structures on individuals.

Distal social attitudes gain psychological importance through cognitive appraisal and become proximal concepts with psychological importance to the individual. I describe minority stress processes along a continuum from distal stressors, which are typically defined as objective events and conditions, to proximal personal processes, which are by definition subjective because they rely on individual perceptions and appraisals.

From the distal to the proximal they are a external, objective stressful events and conditions chronic and acute , b expectations of such events and the vigilance this expectation requires, and c the internalization of negative societal attitudes. Other work, in particular psychological research in the area of disclosure, has suggested that at least one more stress process is important: As objective stressors, distal stressors can be seen as independent of personal identification with the assigned minority status Diamond, Nevertheless, if she is perceived as a lesbian by others, she may suffer from stressors associated with prejudice toward LGB people e.

In contrast, the more proximal stress processes are more subjective and are therefore related to self-identity as lesbian, gay, or bisexual. Such identities vary in the social and personal meanings that are attached to them and in the subjective stress they entail. Minority identity is linked to a variety of stress processes; some LGB people, for example, may be vigilant in interactions with others expectations of rejection , hide their identity for fear of harm concealment , or internalize stigma internalized homophobia.

As early as , Allport suggested that minority members respond to prejudice with coping and resilience. Modern writers have agreed that positive coping is common and beneficial to members of minority groups Clark et al. Empirical evidence supports these contentions. For example, in a study of Black participants Branscombe, Schmitt, and Harvey found that attributions of prejudice were directly related to negative well-being and hostility toward Whites but also, through the mediating role of enhanced in-group identity, to positive well-being.

In a separate study, Postmes and Branscombe found that among Blacks, a racially segregated environment contributed to greater in-group acceptance and improved well-being and life satisfaction. The importance of coping with stigma has also been asserted in LGB populations. Thus, stress and resilience interact in predicting mental disorder. A distinction between personal and group resources is often not addressed in the coping literature. It is important to distinguish between resources that operate on the individual level e.

Like other individuals who cope with general stress, LGB people use a range of personal coping mechanisms, resilience, and hardiness to withstand stressful experiences Antonovsky, ; Masten, ; Ouellette, Social evaluation theory suggests another plausible mechanism for minority coping Pettigrew, Members of stigmatized groups who have a strong sense of community cohesiveness evaluate themselves in comparison with others who are like them rather than with members of the dominant culture. The in-group may provide a reappraisal of the stressful condition, yielding it less injurious to psychological well-being.

Through reappraisal, the in-group validates deviant experiences and feelings of minority persons Thoits, The distinction between personal and group-level coping may be somewhat complicated because even group-level resources e. Whether individuals can access and use group-level resources depends on many factors, including personality variables.

Nevertheless, it is important to distinguish between group-level and personal resources because when group-level resources are absent, even otherwise-resourceful individuals have deficient coping. Group-level resources may therefore define the boundaries of individual coping efforts. Using this distinction, it is conceivable that an individual may have efficient personal coping resources but lack minority-coping resources. For example, a lesbian or gay member of the U.

Group identities are essential for individual emotional functioning, as they address conflicting needs for individuation and affiliation Brewer, Characteristics of identity may be related to mental health both directly and in interaction with stressors. A direct effect suggests that identity characteristics can cause distress.

An interactive effect with stress suggests that characteristics of identity would modify the effect of stress on health outcomes. For example, Linville found that participants with more complex self-identities were less prone to depression in the face of stress. For example, Brooks noted that the stress process for lesbians is complex because it involves both sexual and gender identities.

Valence refers to the evaluative features of identity and is tied to self-validation. Identity valence is a central feature of coming out models, which commonly describe progress as improvement in self-acceptance and diminishment of internalized homophobia. Finally, more complex identity structures may be related to improved health outcomes.

For example, Cass saw the last stage of coming out as an identity synthesis , wherein the gay identity becomes merely one part of this integrated total identity. Using the distal—proximal distinction, I propose a minority stress model that incorporates the elements discussed above. Dohrenwend b , described the stress process within the context of strengths and vulnerabilities in the larger environment and within the individual. For the purpose of succinctness, I include in my discussion only those elements of the stress process unique to or necessary for the description of minority stress.

It is important to note, however, that these omitted elements—including advantages and disadvantages in the wider environment, personal predispositions, biological background, ongoing situations, and appraisal and coping—are integral parts of the stress model and are essential for a comprehensive understanding of the stress process Dohrenwend, b , The model Figure 1 depicts stress and coping and their impact on mental health outcomes box i. Minority stress is situated within general environmental circumstances box a , which may include advantages and disadvantages related to factors such as socioeconomic status.

For example, minority stressors for a gay man who is poor would undoubtedly be related to his poverty; together these characteristics would determine his exposure to stress and coping resources Diaz et al. Circumstances in the environment lead to exposure to stressors, including general stressors, such as a job loss or death of an intimate box c , and minority stressors unique to minority group members, such as discrimination in employment box d. Similar to their source circumstances, the stressors are depicted as overlapping as well, representing their interdependency Pearlin, b.

For example, an experience of antigay violence box d is likely to increase vigilance and expectations of rejection box f. Because they involve self-perceptions and appraisals, these minority stress processes are more proximal to the individual, including, as described above for LGB individuals, expectations of rejection, concealment, and internalized homophobia box f. Of course, minority identity is not only a source of stress but also an important effect modifier in the stress process. First, characteristics of minority identity can augment or weaken the impact of stress box g.

In exploring evidence for minority stress two methodological approaches can be discerned: Studies of within-group processes shed light on stress processes, such as those depicted in Figure 1 , by explicitly examining them and describing variability in their impact on mental health outcomes among minority group members.

Studies of between-groups differences test whether minority individuals are at greater risk for disease than nonminority individuals; that is, whether LGB individuals have higher prevalences of disorders than heterosexual individuals. On the basis of minority stress formulations one can hypothesize that LGB people would have higher prevalences of disorders because the putative excess in exposure to stress would cause an increase in prevalence of any disorder that is affected by stress Dohrenwend, Typically, in studying between-groups differences, only the exposure minority status and outcomes prevalences of disorders are assessed; minority stress processes that would have led to the elevation in prevalences of disorders are inferred but unexamined.

Thus, within-group evidence illuminates the workings of minority stress processes; between-groups evidence shows the hypothesized resultant difference in prevalence of disorder. Ideally, evidence from both types of studies would converge. Within-group studies have attempted to address questions about causes of mental distress and disorder by assessing variability in predictors of mental health outcomes among LGB people.

These studies have identified minority stress processes and often demonstrated that the greater the level of such stress, the greater the impact on mental health problems. Within-group studies have typically measured mental health outcomes using psychological scales e. In reviewing this evidence in greater detail I arrange the findings as they relate to the stress processes introduced in the conceptual framework above.

As has already been noted, this synthesis is not meant to suggest that the studies reviewed below stemmed from or referred to this conceptual model; most did not. Antigay prejudice has been perpetrated throughout history: Institutionalized forms of prejudice, discrimination, and violence have ranged from Nazi extermination of homosexuals to enforcement of sodomy laws punishable by imprisonment, castration, torture, and death Adam, In , Amnesty International reported that lesbian, gay, bisexual, and transgender LGBT people are subject to widespread human rights abuses, torture, and ill treatment, ranging from loss of dignity to assault and murder.

Many of these abuses are conducted with impunity and sanctioned by governments and societies through formal mechanisms such as discriminatory laws and informal mechanisms, including prejudice and religious traditions Amnesty International, Surveys have documented that lesbians and gay men are disproportionately exposed to prejudice events, including discrimination and violence.

For example, in a probability study of U. Some research has suggested variation by ethnic background as well, although the direction of the findings is not clear. Research has suggested that LGB youth are even more likely than adults to be victimized by antigay prejudice events, and the psychological consequences of their victimization may be more severe.

Surveys of schools in several regions of the United States showed that LGB youth are exposed to more discrimination and violence events than their heterosexual peers. Several such studies, conducted on population samples of high school students, converge in their findings and show that the social environment of sexual minority youth in U. Compared with heterosexual youth, LGB youth are at increased risk for being threatened and assaulted, are more fearful for their safety at school, and miss school days because of this fear Safe Schools Coalition of Washington, Gay men and lesbians are also discriminated against in the workplace.

The authors noted that victimization interferes with perception of the world as meaningful and orderly. Antigay bias crimes had greater mental health impact on LGB persons than similar crime not related to bias, and bias-crime victimization may have short- or long-term consequences, including severe reactions such as posttraumatic stress disorder Herek et al. Goffman discussed the anxiety with which the stigmatized individual approaches interactions in society. Allport described vigilance as one of the traits that targets of prejudice develop in defensive coping.

This concept helps to explain the stressful effect of stigma. Like other minority group members, LGB people learn to anticipate—indeed, expect—negative regard from members of the dominant culture. To ward off potential negative regard, discrimination, and violence they must maintain vigilance. By definition such vigilance is chronic in that it is repeatedly and continually evoked in the everyday life of the minority person.

As a result of this conflict, self-perception is likely to be at least somewhat unstable and vulnerable. Maintaining stability and coherence in self-concept is likely to require considerable energy and activity. Branscombe, Ellemers, Spears, and Doosje described four sources of threat relevant to the discussion of stress due to stigma. Categorization threat involves threat that a person will be categorized by others as a member of a group against his or her will, especially when group membership is irrelevant within the particular context e.

Distinctiveness threat is an opposite threat, relating to denial of distinct group membership when it is relevant or significant also Brewer, For example, Ethier and Deaux found that Hispanic American students at an Ivy League university were conflicted, divided between identification with White friends and culture and the desire to maintain an ethnic cultural identity. Research evidence on the impact of stigma on health, psychological, and social functioning comes from a variety of sources.

In a cross-cultural study of gay men, Ross found that anticipated social rejection was more predictive of psychological distress outcomes than actual negative experiences. This finding is not consistent across various ethnic groups: Experimental social psychological research has highlighted other processes that can lead to adverse outcomes. This research may be classified as somewhat different from that related to the vigilance concept discussed above. Vigilance is related to feared possible even if imagined negative events and may therefore be classified as more distal along the continuum ranging from the environment to the self.

Stigma threat, as described below, relates to internal processes that are more proximal to the self. This research has shown that expectations of stigma can impair social and academic functioning of stigmatized persons by affecting their performance Crocker et al. Unlike the concept of life events, which holds that stress stems from some concrete offense e.

In a study of women who felt stigmatized by abortion, Major and Gramzow demonstrated that concealment was related to suppressing thoughts about the abortion, which led to intrusive thoughts about it, and resulted in psychological distress. LGB people may conceal their sexual orientation in an effort to either protect themselves from real harm e.

Hetrick and Martin described learning to hide as the most common coping strategy of gay and lesbian adolescents, and noted that. Hiding and fear of being identified do not end with adolescence. For example, studies of the workplace experience of LGB people found that fear of discrimination and concealment of sexual orientation are prevalent Croteau, and that they have adverse psychological, health, and job-related outcomes Waldo, These studies showed that LGB people engage in identity disclosure and concealment strategies that address fear of discrimination on one hand and a need for self-integrity on the other.

Studies have shown that suppression, such as hiding secrets, is related to adverse health outcomes and that expressing and disclosing traumatic events or characteristics of the self improve health by reducing anxiety and promoting assimilation of the revealed characteristics Bucci, ; Stiles, Research evidence in gay men supports these formulations. Cole and colleagues found that HIV infection advanced more rapidly among gay men who concealed their sexual orientation than those who were open about their sexual orientation Cole et al. In another study among HIV-negative gay men, those who concealed their sexual orientation were more likely to have health problems than those who were open about their sexual orientation Cole et al.

In addition to suppressed emotions, concealment prevents LGB people from identifying and affiliating with others who are gay. This effect has been demonstrated by Frable, Platt, and Hoey in day-to-day interactions. The researchers assessed self-perceptions and well-being in the context of the immediate social environment. College students with concealable stigmas, such as homosexuality, felt better about themselves when they were in an environment with others who were like them than when they were with others who are not similarly stigmatized.

In addition, if LGB people conceal their sexual orientation, they are not likely to access formal and informal support resources in the LGB community. In the most proximal position along the continuum from the environment to the self, internalized homophobia represents a form of stress that is internal and insidious. Thoits , p. Clinicians use the term internalized homophobia to refer to the internalization of societal antigay attitudes in lesbians and gay men e.

After they accept their stigmatized sexual orientation, LGB people begin a process of coming out. Optimally, through this process they come to terms with their homosexuality and develop a healthy identity that incorporates their sexuality Cass, , ; Coleman, — ; Troiden, Internalized homophobia signifies the failure of the coming out process to ward off stigma and thoroughly overcome negative self-perceptions and attitudes Morris et al.

Coming out

Although it is most acute early in the coming out process, it is unlikely that internalized homophobia completely abates even when the person has accepted his or her homosexuality. Williamson reviewed the literature on internalized homophobia and described the wide use of the term in gay and lesbian studies and gay-affirmative psychotherapeutic models.

Much of the literature on internalized homophobia has come from theoretical writings and clinical observations, but some research has been published. Despite a long history of interest in the prevalence of mental disorders among gay men and lesbians, methodologically sound epidemiological studies are rare.

The interest in mental health of lesbians and gay men has been clouded by shifts in the social environment within which it was embedded. Before the declassification of homosexuality as a mental disorder, gay-affirmative psychologists and psychiatrists sought to refute arguments that homosexuality should remain a classified disorder by showing that homosexuals were not more likely to be mentally ill than heterosexuals Bayer, At the time, some writers insisted that homosexuals were more likely than heterosexuals to be ill and that this demonstrated that homosexuality should be classified as a mental disorder, but many of these studies were based on biased samples, for example of prison populations or clinical primarily psychoanalytic observations Marmor, An exception to authors of earlier studies is Evelyn Hooker, who in several studies that became influential during the debate on the status of homosexuality, found that homosexual and heterosexual subjects were indistinguishable in psychological projective testing e.

Most of the early studies used symptom scales that assessed psychiatric symptoms rather than prevalence of classified disorders. An exception was a study by Saghir, Robins, Welbran, and Gentry a, b , which assessed criteria-defined prevalences of mental disorders among gay men and lesbians as compared with heterosexual men and women. In the social atmosphere of the time, research findings were interpreted by gay-affirmative researchers conservatively, so as to not erroneously suggest that lesbians and gay men had high prevalences of disorder.

Among studies that assessed symptomatology, several showed slight elevation of psychiatric symptoms among LGB people, although these levels were typically within a normal range see Gonsiorek, ; Marmor, Thus, most reviewers have concluded that research evidence has conclusively shown that homosexuals did not have abnormally elevated psychiatric symptomatology compared with heterosexuals see Marmor, More recently, there has been a shift in the popular and scientific discourse on the mental health of lesbians and gay men.

Gay-affirmative advocates have begun to advance a minority stress hypothesis, claiming that discriminatory social conditions lead to poor health outcomes Dean et al. The articles were accompanied by three editorials Bailey, ; Friedman, ; Remafedi, All three editorials suggested that homophobia and adverse social conditions are a primary risk for mental health problems of LGB people.

This shift in discourse is also reflected in the gay-affirmative popular media. To assess evidence for the minority stress hypothesis from between-groups studies, I examined data on prevalences of mental disorders in LGB versus heterosexual populations. The minority stress hypothesis leads to the prediction that LGB individuals would have higher prevalences of mental disorder because they are exposed to greater social stress.

To the extent that social stress causes psychiatric disorder, the excess in risk exposure would lead to excess in morbidity Dohrenwend, I included studies if they were published in an English-language peer-reviewed journal, reported prevalences of diagnosed psychiatric disorders that were based on research diagnostic criteria e.

Studies that reported scores on scales of psychiatric symptoms e. Selecting studies for review can present problems—studies reporting statistically significant results are typically more likely to be published than studies with nonsignificant results. This can result in publication bias, which overestimates the effects in the research synthesis Begg, There are some reasons to suspect that publication bias is not a great threat to the present analysis.

First, Begg noted that publication bias is more of a concern in instances in which numerous small studies are being conducted. This is clearly not the case with regard to population surveys of LGB individuals and the mental health outcomes as defined here—the studies I rely on are few and large. This is, in part, because of the great costs involved in sampling LGB people and, in part, because the area has not been extensively studied since the declassification of homosexuality as a mental disorder.

In the area of LGB mental health, showing nonsignificant results—that LGBs do not have higher prevalences of mental disorders—would have provided as much a proof of a theory as showing significant results; therefore, bias toward publication of positive results is unlikely. In reviewing the data I consider classes of mental disorders that are commonly discussed in the psychiatric epidemiology literature Kessler et al. Consistent with this literature, I consider separately prevalence of lifetime disorders, those occurring at any time over the lifetime, and prevalence of current disorders, typically those occurring in 1-year period.

I examine the prevalence of any mental disorder and the prevalences of general subclasses of disorders, including mood disorders, anxiety disorders, and substance use disorders. The inclusion of only major classes of disorders allows for greater parsimony in interpreting the results than would be allowed by an examination of each individual disorder.

It is a sufficient test of the minority stress hypothesis because minority stress predictions are general and uniform across types of disorders. The included disorders are those that are most prevalent in population samples and that are most often the subject of psychiatric epidemiological studies.

Excluded disorders were rarely if ever studied in population samples of LGB individuals, so their exclusion does not lead to bias in selection of available literature. The classes of disorders excluded were disorders usually first diagnosed in infancy, childhood, or adolescence; delirium, dementia, and amnestic and other cognitive disorders; mental disorders due to a general medical condition; schizophrenia and other psychotic disorders; somatoform disorders; factitious disorders; dissociative disorders; sexual and gender identity disorders; eating disorders; sleep disorders; impulse-control disorders; adjustment disorders; and personality disorders.

The studies Atkinson et al. In drawing a conclusion about whether LGB groups have higher prevalences of mental disorders one should proceed with caution.

The Stress Concept

The studies are few, methodologies and measurements are inconsistent, and trends in the findings are not always easy to interpret. Although several studies show significant elevation in prevalences of disorders in LGB people, some do not. Yet, an overall trend appears clear. This pattern must lead us to conclude similarly to Saghir et al. Prevalence of Mental Disorders: ORs are adjusted for various control variables when provided in the original article. This procedure provides a M-H weighted odds ratio OR and confidence intervals CIs on aggregates of individual studies.

For each class of disorder I calculated the M-H weighted OR from studies that provided relevant data. In addition, I conducted stratified analyses that combined results for a men versus women and b studies that used nonrandom versus random sampling techniques. The analyses provided M-H weighted ORs for each stratum. The results of this meta-analysis for prevalences of lifetime and current disorders are shown in Figure 2 ; they affirm the impression given by an examination of Table 1.

The results are compelling for all disorders, for each of the subclasses of disorders examined, and for lifetime and current disorders. For example, for the five studies providing data on any lifetime mental disorders, the combined M-H weighted OR was 2. This indicates that compared with heterosexual men and women, gay men and lesbians are about 2. The analyses that stratified the observations by gender showed no divergence from the results of the unstratified analyses.

The results on prevalences of current disorders were similar, but they showed that for substance use disorders, the combined M-H weighted OR for men 1. Odds ratios were recalculated from aggregated data using the Statcalc procedure of the statistical software Epi Info Centers for Disease Control and Prevention, This procedure does not adjust for demographics characteristics or any other control variables e. These statistics are provided to allow synthesis of the risk for lesbian, gay, and bisexual versus heterosexual respondents in the studies, but they cannot be used as accurate estimates of adjusted population odds ratios.

Results of the analyses that stratified the observations on lifetime prevalences of disorders by randomization in sampling design are presented in Figure 3. They show that for mood disorders, anxiety disorders, and substance use disorders, an increase in risk to the LGB group is evident in the randomized studies only. These analyses could not be conducted for current prevalences of disorder because an insufficient number of nonrandomized studies provided such data.

Whether gay men have higher prevalence of suicidal behavior has also been debated in recent years. Some reviewers have contended that suicide is highly prevalent among LGB populations, especially youth Gibson, However, such studies have been criticized for severe methodological limitations including selection bias and measurement issues Muehrer, ; Savin-Williams, For example, many studies used samples of youth recruited from social service organizations, who may be more vulnerable than the general population of LGB youth to mental health problems Muehrer, More recently, studies that used improved methodologies, such as random probability sampling, clearer definitions, and improved measurements of suicidality, also found strong evidence for elevation in suicide-related problems among LGB persons.

A higher risk for suicide ideation and attempts among LGB groups seems to start at least as early as high school. For example, in a representative sample of Massachusetts high school students, Garofalo et al. When stratified by gender, sexual orientation was an independent predictor of suicide attempts among boys but not girls.

A cohort study in New Zealand found that LGB youth were five to six times more likely than heterosexual youth to report suicide ideation and attempts over their lifetime Fergusson et al. A study of the Vietnam Era Twin Registry used particularly convincing methodology to study differences in suicidality between twins Herrell et al. Taken together, the evidence from these studies supports the minority stress hypothesis that LGB populations are vulnerable to suicide ideation and attempt—although the evidence on adult lesbian and bisexual women is not as clear.

Also not clear from studies of suicide ideation and attempt is whether LGB persons are at higher risk for suicide-related mortality. Suicide attempts and ideation are alarming in their own right, but their relationship to completed suicide is not straightforward; for example, not all attempters do so with the intent to die or injure themselves severely enough to cause death Moscicki, Nevertheless, regardless of its relationship to completed suicide, suicide ideation and attempt is a serious personal and public health concern that need to be studied for its own merit Moscicki, ; Moscicki et al.

These studies assessed the prevalence of homosexuality among completed suicides and found no overrepresentation of gay and bisexual men, concluding that LGB populations are not at increased risk for suicide. Thus, findings from studies of completed suicides are inconsistent with studies finding that LGB groups are at higher risk of suicide ideation and attempts than heterosexuals. Among these difficulties are that a these studies attempt to answer whether gay individuals are overrepresented in suicide deaths by comparing it against an expected population prevalence of homosexuality, but with no proper population data on LGB individuals, it is a matter of some conjunction to arrive at any such estimate and b because these studies rely on postmortem classification of sexual orientation, their reliability in assessing prevalence of gay individuals among suicide deaths is questionable.

Even if the deceased person was gay, postmortem autopsies are likely to underestimate his or her homosexuality because homosexuality is easily concealable and often is concealed. Considering the scarcity of studies, the methodological challenges, and the greater potential for bias in studies of completed suicide, it is difficult to draw firm conclusions from their apparent refutation of minority stress theory.

The evidence is compelling. However, the answer is complicated because of methodological limitations in the available studies. The studies whose evidence I have relied on discussed as between-groups studies fall into two categories: It is plausible that interest in the study topic attracts volunteers who are more likely to have had—or at least, to disclose—more mental health problems than nonvolunteers. This may be particularly problematic in studies of LGB youth e.

Also, the studies I reviewed compared the LGB group with a nonrandom sample of heterosexuals, introducing further bias, because the methods they used to sample heterosexuals often differed from those used to sample than the LGB groups. The potential for bias is particularly glaring in studies that compared a healthy heterosexual group with a group of gay men with HIV infection and AIDS e.

The second group of studies used population-based surveys. Such studies greatly improve on the methodology of the first type of studies because they used random sampling techniques, but they too suffer from methodological deficiencies. This is because none of these studies was a priori designed to assess mental health of LGB groups; as a result, they were not sophisticated in the measurement of sexual orientation.

The studies classified respondents as homosexual or heterosexual only on the basis of past sexual behavior—in 1 year Sandfort et al. The problem of measurement could have increased potential error due to misclassification, which in turn could have led to selection bias. The direction of bias due to selection is unclear, but it is plausible that individuals who were more troubled by their sexuality would be overrepresented—especially as discussed above for youth—leading to bias in reported estimates of mental disorder.

However, the reverse result, that people who were more secure and healthy were overrepresented, is also plausible. The studies also suffer because they included a very small number of LGB people.

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The small sample sizes resulted in little power to detect differences between the LGB and heterosexual groups, which led to lack of precision in calculating group differences in prevalences of disorders. This means that only differences of high magnitude would be detected as statistically significant, which might explain the inconsistencies in the research evidence.

It should be noted, however, that if inconsistencies were the result of random error, one would expect that in some studies the heterosexual group would appear to have higher prevalences of disorders. This was not evident in the studies reviewed. My use of a meta-analytic technique to estimate combined ORs somewhat corrects this deficiency, but it is important to remember that a meta-analysis cannot overcome problems in the studies on which it is based.

It is important, therefore, to interpret results of meta-analyses with caution and a critical perspective Shapiro, One problem, which can provide a plausible alternative explanation for the findings about prevalences of mental disorders in LGB individuals, is that bias related to cultural differences between LGB and heterosexual persons inflates reports about history of mental health symptoms cf. It is plausible that cultural differences between LGB and heterosexual individuals cause a response bias that led to overestimation of mental disorders among LGB individuals. This would happen if, for example, LGB individuals were more likely to report mental health problems than heterosexual individuals.

There are several reasons why this may be the case: In recognizing their own homosexuality and coming out, most LGB people have gone through an important self-defining period when increased introspection is likely. This could lead to greater ease in disclosing mental health problems. In addition, a coming out period provides a focal point for recall that could lead to recall bias that exaggerates past difficulties. This too could have led LGB people to be less defensive and more ready than heterosexual people to disclose mental health problems in research.

To the extent that such response biases existed, they would have led researchers to overestimate the prevalence of mental disorders in LGB groups. Research is needed to test these propositions. Over the past 2 decades, significant advances in psychiatric epidemiology have made earlier research on prevalence of mental disorders almost obsolete.

Among these advances are the recognition of the importance of population-based surveys rather than clinical studies of mental disorders, the introduction of an improved psychiatric classification system, and the development of more accurate measurement tools and techniques for epidemiological research. Two large-scale psychiatric epidemiological surveys have already been conducted in the United States: Using random sampling methodologies for large-scale studies of LGB populations is challenging and costly, but it is not impossible. Recent research has demonstrated the utility of innovative methodologies for population studies of LGB individuals Binson et al.

New research must therefore continue to use random sampling to study LGB groups, combined with sophisticated measurements of sexual orientation, a larger number of respondents, and a direct test of hypotheses about patterns in prevalences of disorders and their causes. An ideal study design would combine evidence from the investigation of within- and between-groups differences. Such a study would assess both the differences in prevalences of disorders and the causal role of stress processes in explaining excess risk for disorder in the LGB group.

If in a random population sample the prevalence of disorders would be found to be higher among LGB respondents than among their heterosexual peers and if stress mechanisms explained the excess in this prevalence of disorder, then minority stress predictions would be strongly supported. To understand causal relations, research also needs to explain the mechanisms through which stressors related to prejudice and discrimination affect mental health. Krieger called for an ecosocial perspective in social epidemiology, which would explain how social factors are embodied and lead to disease. Discussing racism, she explained,.

Krieger, , p. The conclusion I propose—that LGB individuals are exposed to excess stress due to their minority position and that this stress causes an excess in mental disorders—is inconsistent with research and theoretical writings that can be described as a minority resilience hypothesis , which claims that stigma does not negatively affect self-esteem Crocker et al.

As such, my conclusion is also inconsistent with studies that showed that Blacks do not have higher prevalences of mental disorders than Whites, as is expected by minority stress formulations Kessler et al. Further research must address this apparent contradiction. One area for the study of differences between minority stress in LGB and Black individuals concerns the socialization of minority group members. LGB individuals are distinct from Blacks in that they are not born into their minority identity but acquire it later in life.

Because of this, LGB individuals do not have the benefit of growing up in a self-enhancing social environment similar to that provided to Blacks in the process of socialization. Studying this distinction between LGB individuals and Blacks may reveal important aspects of the effect of stigma on mental health. There are several important limitations to my review. First, throughout the article I discuss LGB individuals as if they were a homogenous group. That is clearly not the case. In ignoring the heterogeneity of the group I may have glossed over some important distinctions relevant to the discussion of minority stress.

Similarly, lesbians and bisexual women confront stigma and prejudice related to gender in addition to sexual orientation. For example, Brooks described affiliation with feminist organizations as a significant source of support and coping for lesbians. Finally, the review, and the studies I cite, fails to distinguish bisexual individuals from lesbian and gay individuals. Another limitation is that the review ignores generational and cohort effects in minority stress and the prevalence of mental disorder. Cohler and Galatzer-Levy critiqued analyses that ignore important generational and cohort effects.

They noted great variability among generations of lesbians and gay men. An analysis that accounts for these generational and cohort changes would greatly illuminate the discussion of minority stress. Clearly, the social environment of LGB people has undergone remarkable changes over the past few decades. Still, even Cohler and Galatzer-Levy limited their description of the new gay and lesbian generation to a primarily liberal urban and suburban environment.

Evidence from current studies of youth has confirmed that the purported shifts in the social environment have so far failed to protect LGB youth from prejudice and discrimination and its harmful impact Safe Schools Coalition of Washington, In reviewing the literature I described minority stressors along a continuum from the objective prejudice events to the subjective internalized homophobia , but this presentation may have obscured important conceptual distinctions. Two general approaches underlie stress discourse: One views stress as objective, the other as subjective, phenomena.

The subjective view defines stress as an experience that depends on the relationship between the individual and his or her environment. The distinction between objective and subjective conceptualization of stress is often ignored in stress literature, but it has important implications for the discussion of minority stress Meyer, Link and Phelan distinguished between individual discrimination and structural discrimination.

Most research on social stress has been concerned with individual prejudice. For example, individuals who are not hired for a job are unlikely to be aware of discrimination especially in cases in which it is illegal. They are motivated by self-protection to detect discrimination but also by the wish to avoid false alarms that can disrupt social relations and undermine life satisfaction. For all these reasons, structural discrimination may be best documented by differential group statistics including health and economic statistics rather than by studying individual perceptions alone Adams, The distinction between objective and subjective approaches to stress is important because each perspective has different philosophical and political implications Hobfoll, The subjective view of stress highlights individual differences in appraisal and, at least implicitly, places more responsibility on the individual to withstand stress.

It highlights, for example, processes that lead resilient individuals to see potentially stressful circumstances as less or not at all stressful, implying that less resilient individuals are somewhat responsible for their stress experience. Because, according to Lazarus and Folkman , coping capacities are part of the appraisal process, potentially stressful exposures to situations for which individuals possess coping capabilities would not be appraised as stressful.

Both views of the stress process allow that personality, coping, and other factors are important in moderating the impact of stress; the distinction here is in their conceptualization of what is meant by the term stress. Thus, the subjective view implies that by developing better coping strategies individuals can and should inoculate themselves from exposure to stress. Arising from the objective—subjective distinction are questions related to the conceptualization of the minority person in the stress model as a victim versus a resilient actor.

As they discuss minority stress, researchers inevitably describe members of minority groups as victims of oppressive social conditions, and they have been criticized for this characterization.

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But I do deny that they define the complexity of Harlem. Current observers continue to call for researchers to move from viewing minority group members as passive victims of prejudice to viewing them as actors who interact effectively with society Clark et al. The benefits of this perspective are clear: The tension between the view of the minority person as a victim versus a resilient actor is important to note. Viewing the minority person as a resilient actor is consistent with values of American society: However, holding such a view of minority persons can be perilous.

The peril lies in that the weight of responsibility for social oppression can shift from society to the individual. Viewing the minority person as a resilient actor may come to imply that effective coping is to be expected from most, if not all, of those who are in stressful or adverse social conditions. Failure to cope, failure of resilience, can therefore be judged as a personal, rather than societal, failing. This is especially likely when one considers the distinction described above between subjective and objective conceptualization of stress.

When the concept of stress is conceptualized, following Lazarus and Folkman , as dependent on—indeed, determined by—coping abilities, then by definition, stress for which there is effective coping would not be appraised as stressful. As researchers are urged to represent the minority person as a resilient actor rather than a victim of oppression, they are at risk of shifting their view of prejudice, seeing it as a subjective stressor—an adversity to cope with and overcome—rather than as an objective evil to be abolished.

This peril should be heeded by psychologists who by profession study individuals rather than social structures and are therefore at risk of slipping from a focus on objective societal stressors to a focus on individual deficiencies in coping and resiliency Masten, I proposed a minority stress model that explains the higher prevalence of mental disorders as caused by excess in social stressors related to stigma and prejudice. Studies demonstrated that social stressors are associated with mental health outcomes in LGB people, supporting formulations of minority stress.

Evidence from between-groups studies clearly demonstrates that LGB populations have higher prevalences of psychiatric disorders than heterosexuals. Nevertheless, methodological challenges persist. To date, no epidemiological study has been conducted that planned to a priori study the mental health of LGB populations. To advance the field, it is necessary that researchers and funding agencies develop research that uses improved epidemiological methodologies, including random sampling, to study mental health within the context of the minority stress model.

I discussed two conceptual views of stress; each implies different points for public health and public policy interventions.

The objective view, which highlights the objective properties of the stressors, points to remedies that would aim to alter the stress-inducing environment and reduce exposure to stress. If the stress model is correct, both types of remedies can lead to a reduction in mental health problems, but they have different ethical implications. The former places greater burden on the individual, the latter, on society.

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Kitzinger warned psychologists that a subjective, individualistic focus could lead to ignoring the need for important political and structural changes:. What political choices are they making in focusing on the problems of the oppressed rather than on the problem of the oppressor? I endorsed this perspective in illuminating distinctions between viewing the minority person as victim or resilient actor. My discussion of objective versus subjective stress processes is not meant to suggest that there must be a choice of only one of the two classes of intervention options.

Researchers and policymakers should use the stress model to attend to the full spectrum of interventions it suggests Ouellette, The stress model can point to both distal and proximal causes of distress and to directing relevant interventions at both the individual and structural levels. Ken Cheung for statistical consultation. National Center for Biotechnology Information , U. Author manuscript; available in PMC Nov 9. Author information Copyright and License information Disclaimer. Correspondence concerning this article should be addressed to Ilan H. The publisher's final edited version of this article is available at Psychol Bull.

See other articles in PMC that cite the published article. Abstract In this article the author reviews research evidence on the prevalence of mental disorders in lesbians, gay men, and bisexuals LGBs and shows, using meta-analyses, that LGBs have a higher prevalence of mental disorders than heterosexuals. This distinction between prevalences of mental disorders and classification in the DSM was apparent to Marmor , who in an early discussion of the debate said, The basic issue … is not whether some or many homosexuals can be found to be neurotically disturbed.

The Stress Concept In its most general form, recent stress discourse has been concerned with external events or conditions that are taxing to individuals and exceed their capacity to endure, therefore having potential to induce mental or somatic illness Dohrenwend, Minority Stress One elaboration of social stress theory may be referred to as minority stress to distinguish the excess stress to which individuals from stigmatized social categories are exposed as a result of their social, often a minority, position.

Minority Stress Processes in LGB Populations There is no consensus about specific stress processes that affect LGB people, but psychological theory, stress literature, and research on the health of LGB populations provide some ideas for articulating a minority stress model. Stress-Ameliorating Factors As early as , Allport suggested that minority members respond to prejudice with coping and resilience. A Minority Stress Model Using the distal—proximal distinction, I propose a minority stress model that incorporates the elements discussed above. Open in a separate window. Minority stress processes in lesbian, gay, and bisexual populations.

Within-Group Studies of Minority Stress Processes Within-group studies have attempted to address questions about causes of mental distress and disorder by assessing variability in predictors of mental health outcomes among LGB people. Expectations of rejection and discrimination Goffman discussed the anxiety with which the stigmatized individual approaches interactions in society.

Hetrick and Martin described learning to hide as the most common coping strategy of gay and lesbian adolescents, and noted that individuals in such a position must constantly monitor their behavior in all circumstances: Internalized homophobia In the most proximal position along the continuum from the environment to the self, internalized homophobia represents a form of stress that is internal and insidious.

Between-Groups Studies of Prevalence of Mental Disorder Despite a long history of interest in the prevalence of mental disorders among gay men and lesbians, methodologically sound epidemiological studies are rare. Table 1 Prevalence of Mental Disorders: Using this analysis, I report that the authors found a significant increase in any disorder among gay men, but this finding is not reported in the original article.

Data for lifetime prevalences, which were not reported in the original article, were provided by S. Gilman personal communication, October 16, In the original, the authors reported that Suicide Whether gay men have higher prevalence of suicidal behavior has also been debated in recent years. Recent attention to bullying of LGBTQ youth and teens in the United States gives an indication that many youth and teens remain closeted throughout their educational years and beyond for fear of disapproval from parents, friends, teachers, and community members.

To remain in the closet offers an individual a layer of protection against ridicule and bullying. From Wikipedia, the free encyclopedia. This article is about the term describing nondisclosure of sexual behavior, sexual orientation or gender identity. For other uses, see Closet disambiguation and In the closet disambiguation. Homosexuality Bisexuality pansexuality polysexuality Demographics Biology Environment. Academic fields and discourse. Queer studies Lesbian feminism Queer theory Transfeminism Lavender linguistics. The Epistemology of the Closet.

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