Centre for Mental Health Research, Australian National University, Canberra, Australia
Correspondence: Professor A. F. Jorm, Centre for Mental Health Research, Australian National University, Canberra 0200, Australia. Tel: +61 2 61258414; fax: +61 2 61250733; e-mail: Anthony.Jorm.{at}anu.edu.au
Declaration of interest Funding was provided by the National Health and Medical Research Council, the Australian Rotary Health Research Fund and the Australian Brewers' Foundation.
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ABSTRACT |
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Aims To assess separately the mental health of homosexual and bisexual groups compared with heterosexuals.
Method A community survey of 4824 adults was carried out in Canberra, Australia. Measures covered anxiety, depression, suicidality, alcohol misuse, positive and negative affect and a range of risk factors for poorer mental health.
Results The bisexual group was highest on measures of anxiety, depression and negative affect, with the homosexual group falling between the other two groups. Both the bisexual and homosexual groups were high on suicidality. Bisexuals also had more current adverse life events, greater childhood adversity, less positive support from family, more negative support from friends and a higher frequency of financial problems. Homosexuals reported greater childhood adversity and less positive support from family.
Conclusions The bisexual group had the worst mental health, although homosexual participants also tended to report more distress.
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INTRODUCTION |
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METHOD |
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Questionnaire
Participants were asked to complete a questionnaire that covered
socio-demographic characteristics, anxiety and depression, substance use,
cognitive function, well-being, physical health, health habits, use of health
services, personality, coping, early-life psychosocial risk factors, current
psychosocial risk factors and nutrition. This was done under the supervision
of a professional interviewer. Some basic physical tests also were carried out
(e.g. blood pressure, grip strength, visual acuity, lung functioning) and the
participants were asked to provide a cheek swab from which DNA could be
extracted. The components of the questionnaire relevant to the present paper
are described below.
Sexual orientation was assessed by the question Would you currently consider yourself to be predominantly: heterosexual, homosexual, bisexual, don't know. As described below, this question was answered privately on a palmtop computer, with the interviewer not seeing the response.
Anxiety and depression symptoms were assessed by the Goldberg et al (1988) anxiety and depression scales, which give scores of 0-9 for number of symptoms of anxiety and depression. Alcohol misuse was assessed by the Alcohol Use Disorders Identification Test (AUDIT), which gives scores of 0-40 (Saunders et al, 1993). Suicidality was measured by a five-item scale of suicidal thoughts and actions over the past year (Lindelow et al, 1997). Emotional well-being was measured with the Positive and Negative Affect Scales (PANAS), which give scores of 10-50 (Watson et al, 1988). Physical health was measured by the Physical Component Summary of the SF-12, which is scaled to have a mean of 50 and a standard deviation of 10, with higher scores reflecting better physical health (Ware et al, 1996).
Social support was assessed by a questionnaire that has sub-scales measuring positive support from family (range 0-6), negative support from family (0-9), positive support from friends (0-6) and negative support from friends (0-9) (Schuster et al, 1990). The social support questionnaire also has scales for partner support, but these were not used in the present analyses because many of the 20- to 24-year-olds did not have a partner. Current adverse life events were assessed using the List of Threatening Experiences, which asks about 12 adverse life events over the previous 6 months (Brugha et al, 1985). Owing to a programming error, current life event data were not collected on participants aged 40- to 44 years who did not have a partner.
Childhood adversity was measured by an 18-point scale covering lack of affection from mother and father, drinking or drug use by mother or father, nervous or emotional trouble or depression in mother or father, conflict in the household, divorce or separation of parents and ten different types of parental mistreatment. This scale was constructed by the authors based on an earlier scale (Jorm et al, 1999).
Socio-economic status was indicated by education and financial problems. Education was measured by years of completed full-time education. People with financial problems replied Sometimes or Often to the question Have you or your family had to go without things you really needed in the last year because you were short of money?.
Survey procedure
Persons selected at random from the electoral roll were sent a letter
informing them about the survey and saying that an interviewer would contact
them soon to see whether they wanted to participate. If a person agreed to
participate, the interviewer arranged to meet him or her at some convenient
location, usually the participant's home or the Centre for Mental Health
Research. Most of the interview was self-completed on a Hewlett-Packard 620LX
palmtop personal computer using the Surveycraft software (version 8.0.81;
Surveycraft Pty Ltd, Australia) for computer-assisted personal interviewing.
However, testing by the interviewer was required for the physical tests, some
of the cognitive tests and the cheek swab. Ethical approval for this study was
given by the Australian National University Human Research Ethics
Committee.
Statistical analysis
Regression models were used to investigate differences in mental health
according to sexual orientation. Continuous dependent variables were analysed
using multiple linear regression, variables that had highly skewed counts were
analysed using negative binomial regression and dichotomous variables were
analysed using logistic regression. Predictor variables included sexual
orientation (dummy coded with heterosexual as the reference category), age
group and gender for the initial modelling. Interaction terms were examined by
using likelihood ratio tests to compare models and were retained if
significant at the P<0.05 level. To facilitate the interpretation
of significant differences between sexual orientation groups, marginal means
and their 95% confidence intervals were estimated and a Wald test was used for
pairwise comparisons. Covariates known to be risk factors for mental health
problems were each examined in the same manner and their marginal means
compared. Models incorporating the risk factors into the prediction of mental
health problems then were developed following the same procedures. Analyses
were conducted using SPSS-10 and Stata-7 for Windows.
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RESULTS |
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The estimated marginal means of the mental health and well-being measures for the different sexual orientation groups, adjusted for age and gender, are shown in Table 1. Interaction terms between age and gender were retained for all models. The interaction between sexual orientation and age group was significant and so retained in the model for alcohol misuse, and the interaction of sexual orientation and gender was significant for positive affect. No three-way interaction terms were significant. There were significant differences between the sexual orientation groups on all measures of mental health, but not on positive affect. For measures showing a significant difference across the groups there was a similar pattern: the bisexual group had significantly poorer mental health than the homosexual group, except for suicidality. In turn, the homosexual group had significantly poorer mental health than the heterosexual group for anxiety, depression, suicidality and negative affect.
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Regression models also were developed for the risk factors for worse mental health. The only significant interaction effects were a sexual orientation-by-age interaction for negative support from family and for years of education, and a gender-by-age interaction for positive support from friends. Table 2 shows the results. Pairwise comparisons showed that, compared with the heterosexual group, the bisexual group had more childhood adversity, more current adverse life events, less positive support from family, more negative support from friends, more years of education (40- to 44-year-olds) and more often had financial difficulties. The bisexual group also had more adverse life events and more often had financial difficulties than the homosexual group. When the homosexual group was compared with the heterosexual group, they had more childhood adversity, less positive support from family and more years of education (40- to 44-year-olds).
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Risk factors for poorer mental health were entered into the regressions to see whether they could explain the mental health differences between the sexual orientation groups. A similar pattern emerged in that differences between the three groups remained significant for all mental health measures except alcohol misuse. Pairwise comparisons, however, revealed that, except for suicidality, the differences between the homosexual and heterosexual groups were no longer significant, whereas the differences between the bisexual and other groups remained significant and of similar magnitude. For suicidality, there was no significant difference between homosexuals and bisexuals, but both were significantly different from heterosexuals.
To get a better understanding of the nature of the childhood adversity reported by homosexual and bisexual participants, an exploratory analysis was carried out on individual items of the childhood adversity scale. For most items, the endorsement rate was too low to permit meaningful analysis, so the analysis was restricted to items endorsed by at least 10% of participants. Logistic regression analysis showed that the homosexual group more often reported emotional trouble in the mother or father, substance misuse in the father and conflict in the home. The only significant difference for the bisexual group was for emotional trouble in the mother.
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DISCUSSION |
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Mental health of homosexual participants
The homosexual group also tended to have worse mental health compared with
the heterosexual group, which was most evident on the measure of suicidality.
This finding confirms earlier studies showing a higher risk for suicidal
ideation and suicide attempts in homosexual individuals. In contrast to the
bisexual group, the worse mental health of the homosexual group could be
explained in terms of associated risk factors for all measures except
suicidality.
Prevalence of sexual orientations
The prevalence of homosexuality and bisexuality combined was 2.7% for young
men, 4.5% for young women, 2.4% for middle-aged men and 2.7% for middle-aged
women. Most other mental health surveys have found rates of around 1.5-3%,
despite variation in the method of assessing sexual orientation
(Fergusson et al,
1999; Herrell et al,
1999; Cochran & Mays,
2000a,b;
Sandfort et al,
2001), although higher rates have been reported
(Bagley & Tremblay, 1997).
The higher prevalence of homosexual or bisexual orientation in young women in
the present study is unusual and contrasts with other studies, which generally
report a higher prevalence in men. However, this finding is consistent with
the results of a recent British survey that found that women aged 16-24 years
reported a higher prevalence of recent homosexual partners than did men of the
same age, whereas men reported a higher prevalence at ages 25-34 and 35-44
years (Johnson et al,
2001). This survey also found a strong increase in reports by
women of homosexual partners compared with a similar survey carried out 10
years earlier, suggesting a greater willingness by women to engage in or
report homosexual relationships.
Another notable trend in our data was that bisexuality was more common than homosexuality in the younger adults, whereas the opposite was true of the middle-aged group. It is possible that bisexual identification becomes less common with age as uncertainties about sexual orientation become resolved. However, because these are different cohorts rather than a longitudinally followed sample, it is impossible to be sure of developmental trends.
Limitations
The present study has several limitations that must be acknowledged. First,
it is not clear how the respondents interpreted the single question used to
assess sexual orientation (e.g. in terms of fantasy or current behaviour) or
whether the terms heterosexual, homosexual and
bisexual were always understood correctly. Second, the
participation rate was not high, which may have introduced unknown biases in
the sample. Third, HIV status was not assessed, although there were no
differences on a global measure of physical health that would reflect any
major health problems. Fourth, some potentially important risk factors, such
as feelings of stigma or experiences of discrimination, were not measured.
These factors were not covered because the data came from a general mental
health survey that was not specifically designed to investigate differences
associated with sexual orientation. Finally, because this is a cross-sectional
study, it is impossible to know whether the greater exposure to risk factors
in the bisexual group is a cause or consequence of bisexual orientation.
Despite these limitations, the study is the first to show the importance of distinguishing bisexuals from homosexuals in researching mental health.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication August 28, 2001. Revision received January 23, 2002. Accepted for publication January 25, 2002.
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