Several lines of evidence suggest that the elevated psychiatric morbidity well-documented among nonheterosexuals compared to heterosexuals is largely unaccounted for in terms of stigma, prejudice, discrimination and victimization.
Stigma, prejudice, and victimization are the most obvious candidates as to the reason why nonheterosexuals are more likely to be mentally ill. To prove that these factors are responsible for elevated mental disorders among nonheterosexuals, one has to satisfy five requirements:
- Show that nonheterosexuals are more likely to be mentally ill compared to heterosexuals.
- Show that nonheterosexuals are more likely to experience stigma, prejudice, and victimization compared to heterosexuals.
- Show that mental illness is associated with stigma, prejudice, and victimization.
- Show that if one controls for stigma, prejudice, and victimization, the association between nonheterosexuality and increased odds of mental illness disappears.
- A fifth requirement that will be addressed shortly.
Are these requirements met?
Requirement 1: mental illnesses among homosexuals and bisexuals
Data from representative, population-based surveys as well as clinical samples clearly show that homosexual and bisexual individuals are more likely to be mentally ill than heterosexual individuals.
Requirement 2: The victimization of homosexuals and bisexuals
Few would doubt that the second requirement is satisfied, and those looking for a good summary of the evidence in this regard should read a review by Meyer,1 but note the following caveat:
Requirement 3: The relation between victimization and mental illness
Evidence for the third requirement is not clear. For instance, African-Americans do not manifest elevated mood and anxiety disorders compared to American whites.2, 3 Besides, African-Americans manifest higher self-esteem than whites.4, 5 Similarly, it is not difficult to come across a random sample of people where the obese have worse physical health than the normal but similar emotional health, in spite of experiencing weight-related stigma, prejudice, and discrimination.6
If stigma against homosexuality is responsible for the allegedly low self-esteem of homosexuals compared to heterosexuals, then what about the self-esteem of pedophiles? There is much greater stigma against pedophilia than homosexuality. Whereas several heterosexuals tolerate homosexuals and some even accept homosexuals, few non-pedophiles tolerate pedophiles and hardly any accept pedophiles or condone pedophilic activity. Pedophilic acts in private are criminal irrespective of consent whereas consenting homosexual acts between adults in private are non-criminal in the typical Western society. Although consenting homosexual acts between adults in private were officially criminal in several parts of the U.S. until 2003, the law in this regard was rarely enforced over the past few decades, and homosexual activists were waiting for a homosexual couple to be prosecuted under anti-sodomy statutes so as to have these statutes declared unconstitutional, whereas during the same period, pedophilic acts were (still are) criminal and the law in this regard was (still is) rigorously enforced. Additionally, pedophiles do not have sources of social support. If a pedophile seeks a clinical psychologist or psychiatrist in the U.S. for help and tells the mental health professional that he has molested children or views child pornography, the mental health professional is required to report this pedophile to law enforcement, failing which this mental health professional would have to pay a fine, spend time in jail, and lose his license to practice his profession. Therefore, according to the logic of several homosexuals and homophiles, pedophiles should have rock-bottom self-esteem. Is this the case? In the 1994 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM; 1994 edition was specifically DSM-IV) published by the American Psychiatric Association (APA), the APA defined a pedophile as mentally ill if the pedophile felt uncomfortable at his pedophilia but not if he was comfortable with his pedophilia (assuming the absence of other diagnoses in the DSM). In the 2000 edition of the DSM (DSM-IV-TR), the APA classified pedophiles as mentally ill, irrespective of how comfortable they were with their orientation. The APA noted that pedophiles are often comfortable with who they are and may even have high self-esteem. Far from thinking that there is something wrong with them, several pedophiles think that there is something wrong with those who think that there is something wrong with pedophiles.
In light of the above, does one expect stigma against homosexuality to notably reduce self-esteem in homosexuals? Research shows that homosexuals do not manifest lower self-esteem than heterosexuals,7, 8, 9, 10 in spite of their worse mental health.
In a comparison of heterosexual women with their nonheterosexual sisters, compared to heterosexual women, bisexual women manifested worse current mental health but similar self-esteem, whereas homosexual women manifested similar current mental health, greater past use of psychotherapy, a trend toward greater current psychotherapy use, and higher self-esteem.11 The absence of worse current mental health among the homosexual women compared to their heterosexual sisters may have resulted from the absence of a DSM-based diagnosis or improved mental health resulting from past psychotherapeutic treatment.
Rosario et al.12 studied the relationship between recent gay-related stressors and emotional distress in a sample of 140 homosexual and bisexual adolescent males and females, and repeated the assessment after 6 months and 12 months. Discomfort with homosexuality was not significantly related to gay-related stressors at any assessment. Negative attitudes toward homosexuality were significantly related to gay-related stressors only at baseline (r = 0.16). The hypothesis that gay-related stressors would be associated with subsequent emotional distress was unsupported (details below).
Details of the Rosario et al. study:
Gay-related stressors: arguments/trouble with family, friends, teacher, classmates, boss/supervisor, workmates; trouble with police; gay-bashing in the form of physical assault), negative attitudes toward homosexuality, and discomfort with homosexuality.
Emotional distress: Anxiety symptoms, depressive symptoms, and conduct problems.
Details:In univariate analyses, this hypothesis was supported in 9/27 (33%) of the relations, and the reverse hypothesis, i.e., emotional distress being responsible for subsequent gay-related stressors, was supported in 6/27 (22%) of the relations (this, in spite of not controlling for Type I errors or potential covariates). In multivariate analyses, this hypothesis was supported in 4/27 (15%) of the relations, and the reverse hypothesis was supported in 2/27 (7%) of the relations.
If a homosexual is uncomfortable with his homosexuality, it is assumed that he has “internalized” homophobia, but the very diagnosis of “internalized homophobia” is made when a homosexual is found uncomfortable with his homosexuality – some great logic from homosexuals indeed. If a Nigerian came across several Chinese individuals that had a low opinion of Nigerians, one would expect the Nigerian to dislike the Chinese rather than “internalize” the attitude of the Chinese toward him and start disliking himself. Yet, homosexuals disliking their homosexuality are alleged to have “internalized” negative societal attitudes toward homosexuality. If a homosexual experiences assault or discrimination resulting from his homosexuality and comes to believe that he deserves to be assaulted or discriminated against because of his homosexuality, then one could say that this homosexual has internalized negative attitudes toward homosexuality, but how many such homosexuals do we come across? Homosexuals who are victimized because of their homosexuality do not come to believe that they deserve to be victimized because they are homosexual but experience anger over their victimization instead.
Throughout history, several homosexuals have feared being “outed,” or arrested, or prosecuted, or publicly humiliated, but should this necessarily lead to self-hate? “Fear of being punished is not the same thing as a conviction that one deserves punishment.”13
It is not difficult to think of several reasons why a homosexual could dislike his/her homosexuality without any influence of societal attitudes. For instance, if a homosexual desired to rectally penetrate another man but found the idea of coming in contact with fecal matter repulsive or desired receptive penetration by large objects but feared anal damage, he would surely experience some distress over his unusual desires. Furthermore, homosexuals experiencing sexual desires that border on obsession-compulsion or having a strong sexual interest in highly attractive individuals, most of whom are heterosexual, may dislike their homosexuality.
Nobody except masochists like to be called insulting names, and people would rather have others approve of their behaviors. However, many individuals delight in behaviors that are not socially approved, or couldn’t care less about what others think. Given the large number of homosexuals participating in gay pride parades, often delighting in offending heterosexuals, many homosexuals appear proud of what they do, i.e., other than being happy with their behavior and desires, many have disdain for heterosexuality.
Are discrimination and prejudice making homosexuals promiscuous? Discrimination and prejudice should make individuals desire emotional warmth, i.e., a stable relationship rather than superficial promiscuous acts.
It is difficult to see how stigma, prejudice, and victimization are responsible for the association between nonheterosexuality and disorders such as schizophrenia and borderline personality disorder (see here). The argument that stigma, prejudice, and victimization are responsible for the relative overrepresentation of nonheterosexuals among paraphiles defies any stretch of the imagination (see the sexuality section). Furthermore, do stigma, prejudice, and victimization account for why nonheterosexual youth are relatively overrepresented among individuals that start cocaine use, marijuana use, smoking, and drinking before age 13 years (see here)? In this regard, recall that homosexuals often use drugs to enhance sexual pleasure (see here).
Requirement 4: Controlling for the usual suspects
Few studies have assessed what happens to the association between nonheterosexuality and increased odds of mental illnesses when discrimination and victimization are statistically controlled for. Let us address some studies that come close to addressing this issue.
Table 1: Increased odds of homosexuals scoring above the threshold of the CIS Men Women OR (95% CI) OR (95% CI) Homosexual orientation 1.42 (1.12-1.81) 1.53 (1.18-1.98) Sexuality adjusted for demographic factors 1.37 (1.05-1.80) 1.47 (1.10-1.96) Sexuality adjusted for health and lifestyle 1.54 (1.18-2.00) 1.58 (1.19-2.09) Sexuality adjusted for reported discrimination 1.38 (1.07-1.78) 1.45 (1.10-1.89) Sexuality adjusted for all other predictors 1.48 (1.09-2.01) 1.50 (1.09-2.07)
Details of the Jorm et al. study:
Childhood adversity measures: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. Homosexuals more often reported emotional trouble in at least one parent, substance misuse in the father, and conflict in the home. Bisexuals more often reported emotional trouble in the mother.
The effect sizes from Herek et al.:
Those who experienced any bias crime in the past 5 years tended to display more psychological distress compared to other participants, but the effect sizes (Cohen's d) were very small: in multivariate analysis, the effect size was 0.017, p <0.001; in univariate analyses, the significant (p < 0.001) effect sizes were 0.027 for depression, 0.047 for traumatic stress, 0.025 for anxiety, and 0.033 for anger; bias crimes did not influence positive affect. Controlling for predictors of victimization such as age, employment status, “outness,” sex, and income did not change these finds. A closer examination of these results revealed that the significant finds above applied to bias crimes that occurred within the past two years, but not for bias crimes that occurred 3-5 years ago, although there was a trend in the same direction. Moreover, the significant finds above applied to homosexuals but not bisexuals. The authors could not statistically analyze the effect of multiple bias crimes since only a handful of the participants reported multiple bias crimes.
Table 2: Prevalence of smoking [at least weekly] in a sample of adolescents. H MH HB U M G Number 5475 369 62 143 225 % smoke
OR (95% CI)
OR (95% CI)
Notes: G = girls, B = boys, H = exclusively heterosexual, MH = mostly heterosexual, HB = homosexual or bisexual, U = unsure sexual orientation, M = missing sexual orientation. The response rate for girls was 68% and that for boys was 58%. Smoking statistics reveal at least weekly use. Percent-wise, almost twice as many HB males smoked at least weekly compared to exclusively heterosexual males, but this difference was not significant. HB males are more into illegal drugs, and it cannot be assumed that HB males in this sample do not have a higher rate of substance use.
Details of the MIDUS study:
Lifetime-experiences of discrimination: Types of lifetime discrimination assessed [an asterisk indicates higher prevalence among HB individuals, (tm) and (tf) imply a non-significant trend toward a higher prevalence among HB men and women, respectively]: not hired for a job(tm, tf), not given a job promotion(tm, tf), fired from job*, discouraged by teacher from continuing education, denied a scholarship(tm, tf), prevented from renting or buying a home, denied a bank loan, forced out from neighborhood by neighbors(tm), denied or given inferior medical care (tf), denied or given inferior services (by plumber, mechanic or equivalent), hassled by police (tm, tf), and any of the above*.
Day-to-day experiences of discrimination: Types of day-to-day discrimination assessed [an asterisk indicates higher prevalence among HB individuals, (tm) and (tf) imply a non-significant trend toward a higher prevalence among HB men and women, respectively]: people act as if you are not as good as they are*, people act as if they think that you are not smart(tf), treated with less respect than other people*, treated with less courtesy than other people*, people act as if they are afraid of you*, get poorer service than others do at restaurants or stores(* for women only), people act as if they think you are dishonest, you are called names or insulted*, you are threatened or harassed*, any of the above*.
Table 3: Lifetime discrimination (L-D), day-to-day discrimination (D-D) and odds of manifesting worse mental health in the MIDUS survey. (29) The data report adjusted* odds ratio [OR (95% CI)].
L-D + D-D**
Any psychiatric disorder
Self-rated fair or poor mental health
High current distress
Notes: *adjusted for demographics other than sexual orientation; ** note that none of these values are significantly different from 1.00; however, note the trend. The variable of main interest is the “any psychiatric disorder” category, which barely missed significance (p = 0.06), almost certainly due to inadequate sample size. Note that female HB individuals did not report elevated current mental distress compared to heterosexual women.
Comment: Clearly, we have run into major problems with the third and fourth requirements, and this is not good since we need to satisfy a fifth requirement, too.
To understand the fifth requirement, one needs to start with the obvious, namely that to discriminate against, harass or commit violence against homosexuals and bisexuals, one needs to identify them first. In some cases, it is not possible to tell whether someone is a homosexual or bisexual unless this person “outs” himself/herself. In other cases, one infers nonheterosexuality via appearance and mannerisms. In a large, representative study of high school students in California, 7.5% of the respondents reported harassment because they were perceived to be nonheterosexual (see this report). This figure notably exceeds the number of students who would be expected to have “outed” themselves as nonheterosexual to their peers, which suggests that several nonheterosexuals experience victimization because of their appearance and mannerisms. The possibility exists that a factor, say factor X, is responsible for both 1) increased odds of a physical appearance and mannerisms more characteristic of nonheterosexuals than heterosexuals and 2) elevated odds of mental illness among nonheterosexuals. Therefore, if several people are disgusted/bothered by the physical appearance and mannerisms especially likely to result from factor X, nonheterosexuals will experience elevated victimization, which will worsen their heightened mental problems, but not be responsible for the heightened mental problems in the first place. Hence, the fifth requirement is to provide reasonable evidence that factor X is not operating. One need not bother with satisfying the fifth requirement among nonheterosexuals that cannot be assumed to be nonheterosexual by virtue of their appearance and mannerisms; i.e., their victimization for being nonheterosexual could occur only after they have “outed” themselves. For the remaining nonheterosexuals, one would need to make a reasonable case that the components of their physical appearance and mannerisms that suggest nonheterosexuality or otherwise invite derision are not related to pathology. Some of the reasons why this would be difficult to argue are briefly listed below and explained in detail in a book:
In summary, the claim that stigma, prejudice, and victimization are responsible for the elevated mental health problems of homosexuals largely appears to be an empty claim and is unlikely to be proven.
- ^ Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull 2003;129(5):674-97.
- ^ Robins LN, Regier DA. Psychiatric disorders in America: the epidemiologic catchment area study. New York: Free Press, 1991.
- ^ Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III--R psychiatric disorders in the United States: results from the National Comorbidity Study. Arch Gen Psychiatry 1994;51(1):8-19.
- ^ Gray-Little B, Hafdahl AR. Factors influencing racial comparisons of self-esteem: a quantitative review. Psychol Bull 2000;126(1):26-54.
- ^ Twenge JM, Crocker J. Race and self-esteem: meta-analyses comparing whites, blacks, hispanics, asians, and American Indians and comment on Gray-Little and Hafdahl (2000). Psychol Bull 2002;128(3):371-408.
- ^ Doll HA, Petersen SE, Stewart-Brown SL. Obesity and physical and emotional well-being: associations between body mass index, chronic illness, and the physical and mental components of the SF-36 questionnaire. Obes Res 2000;8(2):160-70.
- ^ Savin-Williams R. Self-esteem. In: Dynes WR, ed. Encyclopedia of homosexuality. Chicago and London: St James Press, 1990.
- ^ Savin-Williams RC. An exploratory study of pubertal maturation timing and self-esteem among gay and bisexual male youths. Dev Psychol 1995;31(1):56-64.
- ^ Rotheram-Borus MJ, Rosario M, Van Rossem R, et al. Prevalence, course, and predictors of multiple problem behaviors among gay and bisexual male adolescents. Dev Psychol 1995;31(1):75-85.
- ^ Yelland C, Tiggemann M. Muscularity and the gay ideal: body dissatisfaction and disordered eating in homosexual men. Eat Behav 2003;4(2):107-16.
- ^ Rothblum ED, Factor R. Lesbians and their sisters as a control group: demographic and mental health factors. Psychol Sci 2001;12(1):63-9.
- ^ Rosario M, Schrimshaw EW, Hunter J, et al. Anxiety symptoms, depressive symptoms, and conduct problems among gay, lesbian, and bisexual youths: a longitudinal examination. J Consult Clin Psychol 2002;70(4):967-75.
- ^ Norton R. (2002) [http://www.infopt.demon.co.uk/extracts.htm])
- ^ King M, McKeown E, Warner J, et al. Mental health and quality of life of gay men and lesbians in England and Wales: controlled, cross-sectional study. Br J Psychiatry 2003;183(6):552-8.
- ^ Jorm AF, Korten AE, Rodgers B, et al. Sexual orientation and mental health: results from a community survey of young and middle-aged adults. Br J Psychiatry 2002;180(5):423-7.
- ^ Lock J, Steiner H. Gay, lesbian, and bisexual youth risks for emotional, physical, and social problems: results from a community-based survey. J Am Acad Child Adolesc Psychiatry 1999;38(3):297-304.
- ^ Herek GM, Gillis JR, Cogan JC. Psychological sequelae of hate-crime victimization among lesbian, gay, and bisexual adults. J Consult Clin Psychol 1999;67(6):945-51.
- ^ Paul JP, Catania J, Pollack L, et al. Suicide attempts among gay and bisexual men: lifetime prevalence and antecedents. Am J Public Health 2002;92(8):1338-45.
- ^ Fergusson DM, Horwood LJ, Beautrais AL. Is sexual orientation related to mental health problems and suicidality in young people? Arch Gen Psychiatry 1999;56(10):876-80.
- ^ Garofalo R, Wolf RC, Wissow LS, et al. Sexual orientation and risk of suicide attempts among a representative sample of youth. Arch Pediatr Adolesc Med 1999;153(5):487-93.
- ^ Herrell R, Goldberg J, True WR, et al. Sexual orientation and suicidality: a co-twin control study in adult men. Arch Gen Psychiatry 1999;56(10):867-74.
- ^ Gruskin EP, Hart S, Gordon N, et al. Patterns of cigarette smoking and alcohol use among lesbians and bisexual women enrolled in a large health maintenance organization. Am J Public Health 2001;91(6):976-9.
- ^ Wichstrom L, Hegna K. Sexual orientation and suicide attempt: a longitudinal study of the general Norwegian adolescent population. J Abnorm Psychol 2003;112(1):144-51.
- ^ Austin SB, Ziyadeh N, Fisher LB, et al. Sexual orientation and tobacco use in a cohort study of US adolescent girls and boys. Arch Pediatr Adolesc Med 2004;158(4):317-322.
- ^ Remafedi G. Adolescent homosexuality: psychosocial and medical implications. Pediatrics 1987;79(3):331-7.
- ^ Stall RD, Greenwood GL, Acree M, et al. Cigarette smoking among gay and bisexual men. Am J Public Health 1999;89(12):1875-8.
- ^ Garofalo R, Wolf RC, Kessel S, et al. The association between health risk behaviors and sexual orientation among a school-based sample of adolescents. Pediatrics 1998;101(5):895-902.
- ^ Rosario M, Hunger J, Gwadz M. Exploration of substance use among lesbian, gay, and bisexual youth: prevalence and correlates. J Adolesc Res 1997;12:454-76.
- ^ Russell ST, Driscoll AK, Truong N. Adolescent same-sex romantic attractions and relationships: implications for substance use and abuse. Am J Public Health 2002;92(2):198-202.
- ^ Faulkner AH, Cranston K. Correlates of same-sex sexual behavior in a random sample of Massachusetts high school students. Am J Public Health 1998;88(2):262-6.
- ^ Mays VM, Cochran SD. Mental health correlates of perceived discrimination among lesbian, gay, and bisexual adults in the United States. Am J Public Health 2001;91(11):1869-76.
- ^ Troiano RP, Frongillo EA, Jr., Sobal J, et al. The relationship between body weight and mortality: a quantitative analysis of combined information from existing studies. Int J Obes Relat Metab Disord 1996;20(1):63-75.
- ^ Bailey JM, Zucker KJ. Childhood sex-typed behavior and sexual orientation: a conceptual analysis and quantitative review. Dev Psychol 1995;31(1):43-55.
- ^ Freund K, Langevin R, Satterberg J, et al. Extension of the gender identity scale for males. Arch Sex Behav 1977;6(6):507-19.
- ^ Bailey JM, Kim P, Hills A, et al. Butch, femme, or straight-acting? Partner preferences of gay men and lesbians. J Person Soc Psychol 1997;73(5):960-73.