During the 1960s and early 1970s, some argued that homosexuals were as mentally healthy as heterosexuals. However, confronted by considerable evidence from the late 1990s onward that homosexuals and bisexuals are at least two- to three-fold more likely to manifest mood disorders, anxiety disorders, and substance use disorders compared to heterosexuals, homosexual activists and homophiles have promptly started blaming stigma, prejudice, and victimization for elevated psychiatric morbidity among nonheterosexuals. Preliminary considerations suggest that elevated psychiatric morbidity among nonheterosexuals is not readily explicable in terms of stigma, prejudice and victimization.

A meta-analysis

Meyer1 conducted a meta-analysis of the data from several population-representative studies2, 3, 4, 5, 6, 7 plus some earlier studies based on nonrepresentative samples.8, 9, 10, 11 The nonheterosexual vs. heterosexual weighted OR (95% CI) statistics for lifetime disorders were (OR = odds ratio; number of times more likely):

  • Any disorder: 2.07 (1.57-2.74) for men and 3.31 (2.19-5.06) for women.
  • Mood disorders: 2.66 (2.07-3.64) for men and 2.46 (1.71-3.69) for women.
  • Anxiety disorders: 2.43 (1.78-3.30) for men and 1.63 (1.09-2.47) for women.
  • Substance use disorders: 1.45 (1.10-1.91) for men and 3.47 (2.22-5.50) for women.

The figures for current mental disorders were similar, except for a non-significant trend toward elevated substance use disorders among nonheterosexual men (OR = 1.37, 95% CI = 0.96-1.95).

The nonrepresentative samples showed nonheterosexuals as mentally healthier; nonheterosexual vs. heterosexual weighted OR (95% CI) statistics comparing random vs. nonrandom samples for lifetime disorders were:

  • Any disorder: 2.47 (1.88-3.22) vs. 2.23 (1.44-3.53).
  • Mood disorders: 2.68 (2.12-3.34) vs. 1.49 (0.84-2.64).
  • Anxiety disorders: 1.86 (1.44-2.41) vs. 1.94 (0.93-4.44).
  • Substance use disorders: 2.17 (1.68-2.77) vs. 1.43 (0.72-2.86).

Some of the population-representative studies used by Meyer have reported a non-significant tendency for an elevated prevalence of a specific group of mental disorders among male or female nonheterosexuals, whereas others have reported a significant find for the same. This is readily seen as a consequence of inadequate sample size since the meta-analysis makes it clear that substance use disorder, mood disorders and anxiety disorders are much more prevalent among nonheterosexuals than heterosexuals, especially multiple mental disorders in the same person (5- to 6-fold more prevalent among nonheterosexuals). Easily half of homosexuals/bisexuals will have some mental illness in their lifetime and one in five will experience multiple mental disorders.

Additional studies

Some other studies published from late-1990s onward that have shown increased psychiatric morbidity (pertaining to mood disorders, anxiety disorders and substance use) among homosexuals and bisexuals compared to heterosexuals:

  • A higher prevalence of suicide attempts/ideation among male homosexuals compared to their male heterosexual twins, even after controlling for substance use and depressive symptoms other than suicidality.12
  • The MacArthur Foundation National Survey of Midlife Development in the United States (MIDUS) study; population-representative sample.13
  • An analysis of 11,876 homosexual and bisexual women revealed a higher prevalence of alcohol and tobacco use among them compared to heterosexual women.14
  • In an investigation of 4,501 female physicians, among whom 115 were identified as homosexual and 4,177 as heterosexual based on sexual behavior and self-identification, the homosexuals were more likely to have experienced depression.15
  • In a sample of 93,311 women from the Women's Health Initiative cohorts, ages 50-79 years, 0.6% were homosexual (half identified as lifetime homosexuals, and the rest identified as homosexual after age 45), and 0.8% bisexual. Homosexual and bisexual women had higher socioeconomic status than heterosexual women and better access to health care, yet reported higher alcohol use and smoking, poorer mental health (depression; 11.1% of heterosexual women, 15.4% of bisexual women, 16.5% of homosexual women.), and other risk factors for reproductive cancers and cardiovascular disease, a pattern similar to that of young homosexual and bisexual women.16
  • The Country Lesbian Mailing List study from New Zealand; the lesbians reported greater psychiatric morbidity than New Zealand women in general in spite of being predominantly white, highly educated, urban, and between 25 and 50 years of age.17
  • King et al. English/Welsh study; snowball sample.18 There are no reasons to believe that snowballing could have resulted in the homosexual-heterosexual discrepancy, especially since the majority of the participants were recruited without any reference to sexuality.

Axis II disorders (personality disorders)

Random, population-based studies have generally not assessed the prevalence of personality disorders among homosexuals and bisexuals. Part of this has to do with the fact that given the low prevalence of both homosexuality/bisexuality and most personality disorders in the general population, probability samples will not be able to assess whether there is a link between a nonheterosexual outcome and personality disorders unless the sample size were huge.

Anyway, it is well-known that about half of mentally ill people manifest personality disorders (DSM-IV-TR, 2000). For instance, antisocial personality disorder characterizes about 3% of the general male population and 1% of the general female population (may be a low estimate), but between 3-30% of clinical samples (higher rates for forensic samples and substance users), whereas borderline personality disorder characterizes 10% of psychiatric outpatients, 20% of psychiatric inpatients, and 30-60% of individuals with personality disorders (DSM-IV-TR, 2000). Therefore, given that homosexuals manifest a higher prevalence of Axis I disorders (drug abuse, mood disorders, anxiety disorders, etc.), it would be very surprising if they didn't manifest elevated personality disorders also.

In a representative sample of Australians, about 6.5% had one or more personality disorders (Axis II disorders) in lifetime.19 The prevalence of personality disorders is unlikely to exceed 10% of the population. Several studies have reported greater values for homosexual men:

  • In a sample of individuals seeking HIV-testing, and consecutively seen at an outpatient clinic, 13% of HIV-positive male homosexuals had personality disorders, and they had the same mental health profile as homosexual men without HIV infection.20, 21
  • In a sample of men consecutively seen on the same day every week for one year at a genito-urinary medicine clinic, 29% of the men predominantly had sex with other men. 23/61 (38%) of MSM and 16/57 (28%) of heterosexual men had personality disorders. Inadequate sample size is the likely reason why the difference in the prevalence of personality disorders is non-significant.22
  • In a sample of male homosexuals “living outside the high-prevalence epicenters of the AIDS epidemic,” and recruited from county health departments, homosexual organizations, word-of-mouth, and newspaper advertisements, 19/58 (33%) of HIV-positive homosexuals and 8/53 (15%) of homosexuals without HIV infection had personality disorders.23 The homosexuals with personality disorders were more likely to have Axis I disorders.
  • In a sample of male homosexual volunteers, 19% of both HIV-positive homosexuals (n = 110) and homosexuals without HIV infection (n = 52) had personality disorders.24 The homosexuals with personality disorders were more likely to have Axis I disorders.

The studies above should not be dismissed as the result of nonrepresentative samples because, once again, with a well-documented higher prevalence of Axis I disorders among homosexual men, they are expected to have a higher prevalence of personality disorders or vice versa (shown in two studies cited above). Additionally, in a longitudinal study, controlling for HIV infection status and history of Axis I disorders, homosexual men with personality disorders were about 4-fold more likely to develop an Axis I disorder than homosexuals without personality disorders at baseline.25 See also evidence for an overrepresentation of homosexuals and bisexuals among people with borderline personality disorder.

Points to ponder

The authors of the male twin-control study (Herrell et al., 1999) noted a similar prevalence of suicide attempts among male homosexuals across different birth cohorts in the U.S., i.e., changing social environment? Why did it not go down with increasing tolerance of homosexuality among Americans?

In the MIDUS study, controlling for HIV infection did not improve the mental health of nonheterosexuals (7% of nonheterosexual men and 0.4% of heterosexual men reported treatment for HIV/AIDS). In one assessment, although HIV-positive male homosexuals manifested slightly increased odds of depression and anxiety disorders compared to HIV-negative male homosexuals, progression in HIV-related illness did not worsen the mood disorders of the HIV-positive homosexuals.26 In another assessment, HIV-positive heterosexuals did not have worse mental health than HIV-negative heterosexuals.27 Additionally, in an unselected 1980s sample of 56 homosexual men who were mostly HIV-positive, the prevalence of lifetime mental disorders was high compared to heterosexual controls and the general male population: 39.3% had an alcohol or non-opiate drug abuse diagnosis, 39.3% had generalized anxiety disorder, and 30.3% had major depression; but such disorders often preceded diagnosed medical illness or knowledge of HIV status.28 Therefore, it does not appear that an increased prevalence of HIV infection can explain the worsened mental health of homosexual and bisexual men.

None exceed the Dutch when it comes to tolerance of homosexuality. The Dutch are a remarkably tolerant people: they allow euthanasia, prostitution, marijuana smoking, same-sex marriage, and tolerate pedophiles. Yet, why as evidenced by the NEMESIS study (Sandfort et al., 1999) do Dutch homosexuals/bisexuals manifest a mental health picture similar to their American counterparts? In the NEMESIS study, compared to heterosexual men, male homosexuals/bisexuals were about 7 times more likely to manifest bipolar disorder and 6 times more likely to manifest obsessive-compulsive disorder in their lifetime; note that this was a representative sample. Bipolar disorder is a mood disorder where subjects alternate between depression and a manic or euphoric state. Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by time consuming obsessions and compulsions that may cause marked distress or significant impairment. Note that both bipolar disorder29, 30 and OCD31, 32, 33 are strongly influenced by genes. How can so-called homophobia explain a higher frequency of outcomes such as OCD, bipolar disoder and personality disorders among homosexuals?

In the New Zealand Country Lesbian Mailing List study (Welch et al., 2000) as well as the National Lesbian Health Care Survey (1,925 lesbians; 73% were either in counseling or had received counseling in the past by a professional mental health counselor)34, lesbians had greater psychiatric morbidity than heterosexual women and also experienced higher rates of childhood molestation. However, it has been shown in a longitudinal birth cohort study that even if one controls for sexual abuse, the two-fold greater likelihood of women experiencing depression or anxiety disorders compared to men is largely unaltered.35 In addition, much childhood molestation is familial. In some families, genetics associated with non-specific disturbances may also increase the odds of sexual interest in daughters, young sisters or nieces among males, and the same genetics may also increase the odds of mental disturbances among the female relatives of such men, irrespective of whether these women are molested. Therefore, the molestation of these women by their male relatives may either exacerbate mental problems or not make any additional contributions to their mental problems, yet appear to be [spuriously] causally related to the mental problems of these women. Furthermore, in the National Lesbian Health Care Survey, “Only 12 percent of respondents indicated that they were concerned about people knowing that they were lesbian.” Therefore, societal acceptance of female homosexuality appears hardly relevant to explaining the mental problems of this group of homosexual women.

It has not been proven that so-called homophobia is responsible for causing the increased prevalence of mental problems among homosexuals.36 Meyer, whose meta-analysis is cited toward the beginning, tried to make a case for anti-homosexual/bisexual prejudice, discrimination and victimization as culprits, but a detailed analysis of the data refutes this argument.


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