Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, London
Department of Psychiatry, Imperial College, London
Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, London
Department of HIV & Sexual Health Psychology, London, UK
Correspondence: Dr Michael King, Department of Psychiatry and Behavioural Sciences, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK. E-mail: m.king{at}rfc.ucl.ac.uk
Declaration of interest None. Funding detailed in Acknowledgements.
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ABSTRACT |
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Aims To compare psychological status, quality of life and use of mental health services by lesbians and gay men with heterosexual people.
Method Cross-sectional study in England and Wales using snowball sampling.
Results Participants: 656 gay men, 505 heterosexual men, 430 lesbians and 588 heterosexual women. Gay men were more likely than heterosexual men to score above threshold on the Clinical Interview Schedule, indicating greater levels of psychological distress (RR 1.24, 95% CI 1.071.43), as were lesbians compared with heterosexual women (RR 1.30, 95% CI 1.111.52). Gay men and lesbians were more likely than heterosexuals to have consulted a mental health professional in the past, deliberately harmed themselves and used recreational drugs. Lesbians were more likely to have experienced verbal and physical intimidation and to consume more alcohol than heterosexual women.
Conclusions Awareness of mental health issues for gay men and lesbians should become a standard part of training for mental health professionals, who need to be aware of the potential for substance misuse and self-harm in this group and of the discrimination experienced by many lesbians.
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INTRODUCTION |
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Five per cent of the British population is estimated to be gay or lesbian (Johnson et al, 2001), but recruiting a probabilistic sample is unlikely to achieve sufficient numbers (Gilman et al, 2001) or candid responses. Probabilistic sampling in predominantly gay and lesbian neighbourhoods has been used in the USA, but it is limited because most gay people do not live in such neighbourhoods. In England and Wales they live more commonly in urban areas (Johnson et al, 2001) but gay neighbourhoods are unusual. Snowball sampling is a useful strategy when no adequate sampling frame exists and the target population is dispersed (Gilbert, 1993).
Our hypothesis was that gay men and lesbians in England and Wales differed from heterosexual men and women in terms of mental health, quality of life and experiences of mental health services.
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METHOD |
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Identification of gay and lesbian people
We asked participants to indicate their sexual identity as gay or lesbian
(homosexual), bisexual or straight (heterosexual), a choice that determined
the group in which they were analysed. We also used a six-point scale based on
the Kinsey scales to assess same-sex attraction
(McWhirter et al,
1990). A score of 1 indicated attraction only to the opposite sex;
2, mostly to the opposite sex; 3, both sexes equally; 4, mostly same sex; 5,
same sex only; 6 indicated where respondents were unsure.
Recruitment
Snowball sampling begins by identifying participants through advertising or
direct contacts and asking each participant to recruit others. It is able to
reach individuals who do not visit gay or lesbian venues or who might not
respond to advertisements. In order to reach a wide range of first contacts we
recruited participants by:
The research was described as the National Well Being Study
or Sexuality and Well Being Study and included sexuality as one
of the factors being explored. We gave three postcards advertising the study
to each first-wave participant to pass on to other people who would be
prepared to take part. No requirement was made about sexuality and thus
participants identified their sexual orientation only during the interview.
The only inclusion criterion was age 16 years and over. Our main outcome was
psychiatric status as measured by the revised Clinical Interview Schedule
(Lewis et al, 1988),
a structured assessment used to assess mental health in two successive
national surveys in Britain (Meltzer
et al, 1995;
Singleton et al,
2000). The interview enquires about the presence and severity of
14 non-psychotic psychiatric symptoms during the week prior to interview:
somatic complaints associated with low mood or anxiety; fatigue; problems with
memory and/or concentration; sleep disturbance; irritability; worry about
physical health; depressed mood; depressive thoughts; non-health-related
worry; generalised anxiety; phobic anxiety; panic attacks; compulsive
behaviours; and obsessional thoughts. It may be analysed as a continuous
score, along a single continuum of severity, or as a dichotomous variable
(case threshold 12) (Lewis et
al, 1988).
After collecting standard demographic information, we asked participants to complete the following measures:
The interview was programmed into a laptop computer and took approximately 60 min to complete. Computerised questions have advantages over face-to-face interviews for the collection of potentially embarrassing data (Millsten & Irwin, 1983; Turner et al, 1998). Informed consent was obtained in writing and each participant received £10 to offset the costs of taking part. The study was approved by the Royal Free Hospital ethical practices subcommittee.
Sample size and analysis
Although our main outcome was the threshold score on the Clinical Interview
Schedule, we focused on the General Health Questionnaire in our power
calculations as a precaution against the possibility that many participants
might agree to complete a postal questionnaire rather than a computerised
interview. We expected 25% of heterosexual participants to score above the
threshold of the General Health Questionnaire
(Goldberg & Huxley, 1992).
To detect a difference of at least ±5% (i.e. 20% or 30%) with the gay
and lesbian population at 80% power and set at 0.5, required 1250
participants in each group. A sample of 1250 gay and lesbian participants
provides an estimate of prevalence of psychiatric disorder within 95%
confidence limits of ±2.5%.
Data for men and women were kept separate in the analysis. We report medians and interdecile ranges for scores on the rating scales. We used the chi-squared statistic to compare proportions, and the MannWhitney U-test and the t-test for analysis of non-parametric and parametric continuous variables. Where each test is applied is indicated by reporting of means (s.d.) or medians (interdecile range). We first determined relative risks for scoring above the usual threshold of 11/12 on the Clinical Interview Schedule in the gay and lesbian group compared with the heterosexual group and adjusted them for age. We then used odds ratios to adjust for groups of variables that might confound or mediate this relationship. Adjusting for such factors requires use of logistic regression and odds ratios. The blocks of variables entered were as follows: demographic variables were age, employment v. unemployment, White v. other ethnicity, having a partner, living alone or with others, and recruitment in the first v. subsequent waves; health and lifestyle factors were the Short Form 12 physical scale score, scoring 2 or more on the Social Support Questionnaire (indicating dissatisfaction), scoring 8 or more on the AUDIT questionnaire (indicating hazardous drinking) and having used recreational drugs in the preceding month; discrimination factors were reports of physical attack, property damage or verbal insults in the preceding 5 years, and verbal or physical bullying at school. The data were analysed using Stata version 7.
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RESULTS |
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Self-identification as gay, lesbian or straight (heterosexual) accorded closely with reported sexual attraction on the adapted Kinsey scale. Almost all the heterosexual men (494; 99%) were attracted principally to women, 596 (95%) of gay men to other men, 573 (98%) of heterosexual women to men, and 408 (96%) of lesbians to other women. (Small variations in totals are due to missing data for 4 heterosexual men, 27 gay men, 2 heterosexual women and 6 lesbians.)
Six snowball waves of recruitment were obtained, with 841 (40%) recruited in the first and 1239 (60%) in the subsequent waves. Gay men and lesbians were more likely than heterosexual men and women to be recruited in the first wave, as were participants who reported they were White and those aged 1624 years (Table 1). Participants came from a wide area of England and Wales (Table 2).
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Demography
Heterosexual people were older and less likely to describe their ethnicity
as White than their gay and lesbian counterparts, whereas the latter were more
likely to report being in employment (Table
3). Although 3543% of respondents were economically
inactive (Table 3), only 111
(22%) heterosexual men, 112 (19.4%) gay men, 68 (11.6%) heterosexual women and
65 (15.3%) lesbians were unemployed, seeking work. Gay men and lesbians were
less likely to have a partner and were more likely to live alone than the
heterosexual participants.
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Psychological and social measures
Homosexual men recorded significantly higher scores (indicating
psychological distress) than heterosexual men on the Clinical Interview
Schedule, General Health Questionnaire and the mental sub-scale of the Short
Form 12 (Table 4). Lesbians
recorded higher scores than heterosexual women on the Clinical Interview
Schedule, Short Form 12 mental sub-scale and the AUDIT questionnaire
(Table 4). Gay and lesbian
participants were more likely than heterosexual participants to have used
recreational drugs (Table 4). Lesbians were more likely than heterosexual women to report having experienced
verbal and physical harassment for whatever reason
(Table 4). Reported levels of
violence, verbal insults and bullying at school were similar in both groups of
men, whereas property offences were reported more often by heterosexual men.
Nevertheless, the latter commonly regarded their sexuality as the provocation
for such experiences (Table 5).
Lesbians were much less likely than gay men to attribute verbal harassment in
adulthood or intimidation at school to their sexuality. More than a quarter of
gay men and almost a third of lesbians reported that they had ever harmed
themselves deliberately, compared with one in seven heterosexual participants;
65% of gay men and 48% of lesbians who reported having harmed themselves cited
their sexual orientation as wholly or partly the motive.
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Sexuality and psychological distress
The Clinical Interview Schedule was completed by 1134 men (98%) and 999
women (98%). Prevalence of scoring above the standard threshold of 11/12 for
common mental disorder was 44% (277) in gay men and 35% (178) in heterosexual
men (2(1)=8.28, P=0.004). Figures for women were 44% (184) in
lesbians and 34% (197) in heterosexual women (
2(1)=10.34,
P=0.001). Thus, gay men and lesbians were at greatest risk of scoring in the
higher range on this instrument (Table
6). After stratification for age, this was significant for gay men
and lesbians aged 2534 years. When we explored the relationship between
sexual orientation and common mental disorder by adjusting for groups of
variables that might confound it, the increased odds for gay and lesbian
participants to score above the Clinical Interview Schedule threshold were not
affected (Table 7).
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Gay men were more likely than heterosexual men (OR 2.9, 95% CI 2.23.7) and lesbians were more likely than heterosexual women (OR 2.8, 95% CI 2.13.6) to have consulted a mental health professional (see Table 4). This difference was not affected by adjustment for Clinical Interview Schedule score. Gay men were also more likely than their heterosexual counterparts to have sought advice from their general practitioners for emotional difficulties (Table 4).
Sixty-three gay men (10%) and 14 lesbians (3%) had considered seeking
treatment to change their sexual orientation, of whom 15 men and 2 women had
actually received it. Sixty-two per cent of gay men who had considered seeking
help to change their sexual orientation scored above the threshold of the
Clinical Interview Schedule compared with 39% of those who had not done so
(2(1)=9.58, P=0.002; data missing for 3 men). The
figures for women were 54% and 42% respectively (P=0.41; data missing
for 1 woman).
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DISCUSSION |
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Strengths and limitations of the study
The main strength of our research is the power of the study. No European
study in mental health has recruited over a thousand gay and lesbian
participants. The main limitation, however, is the method of recruitment.
Although there is little alternative to snowball sampling to obtain these
numbers, the prevalence of mental disorders was much higher than expected. In
the two national studies in Britain that used the Clinical Interview Schedule,
prevalence rates were approximately 12% in men and 20% in women
(Meltzer et al, 1995;
Singleton et al,
2000). Although the most important finding in our study concerns
the differential in rates rather than the prevalence in each group, why common
mental disorder was more common than expected in the heterosexual participants
is not clear. Although providing respondents with a small sum of money for
their expenses might have played a part by attracting people experiencing
difficult circumstances, the amount given was small. Our sample contained
fewer people aged over 55 years than the national population and since this
older group has the lowest rate of psychiatric disorder
(Meltzer et al, 1995)
this might have contributed to the higher rate. It is difficult to see how
snowball sampling would have differentially affected prevalence of psychiatric
disorder in the gay and heterosexual groups.
It could also be argued that our study might have been more relevant to gay and lesbian participants. However, sexuality was only one of several factors mentioned in our advertisements about the research and thus first-wave gay and lesbian participants should not have been more motivated to take part. We cannot know whether this possible bias occurred in subsequent recruitment waves. However, we had no difficulty recruiting heterosexual participants and thus salience of the study did not seem to affect entry to the study.
Our definition of homosexual or heterosexual is also important. Same-sex attraction and behaviour occur in a social context and we would argue that participants' own view of their sexuality is the most valid construct. In making comparisons between gay and heterosexual people, we were not assuming that the latter constitute a standard of normality. Rather, placing the mental health of gay men and lesbians within the context of the wider population is useful for the purposes of comparison and for service planning.
Self-harm
The increased risk of contemplating suicide and actually harming oneself in
gay and bisexual people has previously been reported in the USA
(Fergusson et al,
1999; Herrell et al,
1999; Russell & Joyner,
2001) and requires much greater attention, particularly in
adolescents (Muehrer, 1995).
Although our data cannot identify the reasons for this susceptibility, it
would seem to have less to do with confusion about sexuality than confusion
about how to express it openly in society
(Herdt & Boxer, 1993). No
study has examined whether gay and lesbian people have elevated rates of
completed suicide, but there are indications from medical examiners' reports
of suicides in males that this may be the case
(Bagley, 1992).
Discrimination
Experiences of violence and verbal abuse as an adult and intimidation at
school were reported frequently by both groups of men and women, a finding
that underscores the need for comparison groups in studying these risks in gay
and lesbian people (Kessler et
al, 1999). Reports that gay and lesbian people are vulnerable
to such experiences because of their sexuality are often taken at face value
and are not judged in the context of the prevalence of such events in society.
Nevertheless, our data show that lesbians are at greater risk of verbal or
physical violence than heterosexual women. Contrary to other reports,
perceived discrimination did not attenuate the association between
psychological distress and sexual orientation.
Use of services
Gay men and lesbians are greater users of mental health services in primary
and secondary care than heterosexual men and women. We need to know more about
the quality of treatment they receive, particularly because mental health
professionals may be insensitive or even hostile to their needs
(Golding, 1997;
Project for Advice Counselling and
Education, 1998). Psychoanalysts in particular may continue to
hold outdated views on homosexuality and pathology
(Bartlett et al, 2001;
Friedman & Lilling, 2001). We shall report later on a qualitative sub-study, in which 23 of the gay and
lesbian participants provided accounts of their experiences of mental health
services.
Interpretation
There are several potential explanations for our findings. It may be that
prejudice in society against gay men and lesbians leads to greater
psychological distress and higher use of services than in the heterosexual
population (Savin-Williams,
1994). It is also possible that gay people might place greater
emphasis on the value of psychological therapy in helping them through these
hardships. Conversely, gay men and lesbians may have lifestyles that make them
vulnerable to psychological disorder. Such lifestyles may include increased
use of drugs and alcohol. Until the past 25 years, homosexuality was
considered to be a deviation from normal development that was accompanied by
psychological symptoms (King &
Bartlett, 1999). There is no evidence, however, for other
developmental or physical abnormalities in gay men and lesbians that would
lend support to the view that it is a developmental error
(Bailey, 1999). In a further
stage of our study we shall examine predictors of psychological distress
within the gay and lesbian sample.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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The study was funded by the Community Fund in collaboration with Mind, the mental health charity.
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REFERENCES |
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![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Bagley, C. (1992) Changing profiles of a typology of youth suicide in Canada. Canadian Journal of Public Health, 83, 169 -170.[Medline]
Bailey, J. M. (1999) Homosexuality and mental
illness. Archives of General Psychiatry,
56, 883
-884.
Barbor, T. F., de la Fuente, J. R. & Saunders, J. (1989) The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Health Care. Geneva: World Health Organization.
Bartlett, A., King, M. & Phillips, P.
(2001) Straight talking: an investigation of the attitudes
and practice of psychoanalysts and psychotherapists in relation to gays and
lesbians. British Journal of Psychiatry,
179, 545
-549.
Cochran, S. D. & Mays, V. (2000) Lifetime
prevalence of suicide symptoms and affective disorders among men reporting
same-sex sexual partners: results from NIHANES III. American
Journal of Public Health, 90, 573
-578.
Coyle, A. (1993) A study of psychological well-being among gay men using the GHQ30. British Journal of Clinical Psychology, 32, 218 -220.[Medline]
Fergusson, D. M., Horwood, L. J. & Beautrais, A. L.
(1999) Is sexual orientation related to mental health
problems and suicidality in young people? Archives of General
Psychiatry, 56, 876
-880.
Friedman, R. C. & Lilling, A. A. (2001) An empirical study of the beliefs of psychoanalysts about scientific and clinical dimensions of male homosexuality. Journal of Homosexuality, 32, 79 -89.
Gilbert, N. (1993) Researching Social Life. London: Sage.
Gilman, S. E., Cochran, S., Mays, V., et al (2001) Risk of psychiatric disorders among individuals reporting same-sex sexual partners in the national comorbidity survey. American Journal of Public Health, 91, 933 -939.[Abstract]
Goldberg, D. & Huxley, P. (1992) Common Mental Disorders. London: Routledge.
& Williams, P. (1988) A User's Guide to the General Health Questionnaire. Windsor: NFER-Nelson.
Golding, J. (1997) Without Prejudice: the MIND Lesbian, Gay and Bisexual Health Awareness Research. London: MIND.
Herdt, G. & Boxer, A. (1993) Children of Horizons: How Gay and Lesbian Teens are Leading a New Way Out of the Closet. Boston: Beacon Press.
Herrell, R., Goldberg, J., True, W. R., et al
(1999) Sexual orientation and suicidality: a co-twin study in
co-twin adult man. Archives of General Psychiatry,
56, 867
-874.
Hershberger, S. L. & D'Augelli, A. R. (1995) The impact of victimisation on the mental health and suicidality of lesbian, gay, and bisexual youths. Developmental Psychology, 67, 65 -74.
Johnson, A. M., Mercer, C. H., Erens, B., et al (2001) Sexual behaviour in Britain: partnerships, practices and HIV risk behaviours. Lancet, 358, 1835 -1842.[CrossRef][Medline]
Kessler, R. C., Mickelson, K. D. & Williams, D. R. (1999) The prevalence, distribution and mental health correlates of perceived discrimination in the United States. Journal of Health and Social Behaviour, 40, 208 -230.[Medline]
King, M. B. & Bartlett, A. (1999) British psychiatry and homosexuality. British Journal of Psychiatry, 175, 106 -113.[Abstract]
Lewis, G., Pelosi, A. J., Glover, E., et al (1988) The development of a computerized assessment for minor psychiatric disorder. Psychological Medicine, 18, 737 -745.[Medline]
Lock, J., Steiner, H. (1999) Gay, lesbian and bisexual youth risks for emotional, physical and social problems: results from community-based survey. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 297 -304.[Medline]
Mays, V. M. & Cochran, S. D. (2000) Mental health correlates of perceived discrimination among lesbian, gay and bisexual adults in the United States. American Journal of Public Health, 91, 1869 -1876.
McWhirter, D. P., Sanders, S. A. & Reinisch, J. M. (1990) Homosexuality/Heterosexuality. New York: Oxford University Press.
Meltzer, H., Gill, B. & Petticrew, M. (1995) The Prevalence of Psychiatric Morbidity Among Adults Aged 1664 in Private Households in Great Britain. London: HMSO.
Millsten, G. M. & Irwin, C. E. (1983) Acceptability of computer-acquired sexual histories in adolescent girls. Journal of Paediatrics, 103, 815 -819.
Muehrer, P. (1995) Suicide and sexual orientation: a critical summary of recent research and directions for future research. Suicide and Life-threatening Behavior, 25, 72-81.[Medline]
Pillard, R. (1998) Sexual orientation and mental disorder. Psychiatric Annals, 18, 51-56.
Project for Advice Counselling and Education (1998) Diagnosis: Homophobic (The Experience of Lesbians, Gay Men and Bisexuals in Mental Health Services). London: PACE.
Russell, S. T. & Joyner, K. (2001)
Adolescent sexual orientation and suicide risk: evidence from a national
study. American Journal of Public Health,
91, 1276
-1281.
Sarason, I. G., Sarason, B. R., Shearin, E. N., et al (1987) A brief measure of social support: practical and theoretical implications. Journal of Social and Personal Relationships, 4, 497 -510.
Savin-Williams, R. C. (1994) Verbal and physical abuse as stressors in the lives of lesbian, gay male, and bisexual youths: associations with school problems, running away, substance abuse, prostitution, and suicide. Journal of Clinical and Consulting Psychology, 62, 261 -269.[CrossRef]
Singleton, N., Bumpstead, R., O'Brien, M., et al (2000) Psychiatric Morbidity Among Adults Living in Private Households. London: HMSO.
Turner, C. F., Ku, L. & Rogers, S. M.
(1998) Adolescent sexual behaviour, drug use and violence:
increased reporting with computer survey technology.
Science, 280, 867
-873.
Ware, J.E., Kosinski, M. & Keller, S.D. (1996) A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity. Medical Care, 34, 220 -233.[CrossRef][Medline]
Received for publication April 3, 2003. Revision received June 26, 2003. Accepted for publication July 22, 2003.
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