Faculty Peer Reviewed
Gay men and lesbian women are members of a stigmatized minority group and evidence suggests that they may disproportionately utilize mental health services. This increased use of mental health services may be related to the concept of minority stress: that stigma, prejudice, discrimination, and violence create a hostile and stressful social environment that can contribute to mental health problems. Examples of external stressors that pose threats to mental health in gay and lesbian patients include verbal and physical violence, housing and job discrimination, lack of legal rights to protection in medical emergencies, and institutionalized discriminatory policies such as rejection of blood donations from gay men, anti-gay ballot initiatives, and lack of legal acknowledgment of same-sex couples’ relationships. Some of these stressors can occur on a daily basis; whenever a gay man or lesbian woman meets a new person, he or she must choose whether or not to “come out” to that new person. These situations can generate fear of rejection, hostility, or even violence. Even if a gay man or lesbian has not been a direct victim of violence, there is still significant stress generated by the perceived threat of physical danger evoked by hearing about murders and tortures of lesbian, gay, bisexual, and transgender (LGBT) individuals in the news. These external stressors and negative societal attitudes may generate internal stressors such as self-image problems ranging from lack of self-confidence to overt self-hatred.[3,4] Research shows that gay and lesbian persons have greater rates of depression, suicidal ideation and attempts, and substance abuse problems than their heterosexual counterparts [1,5-11], and that gay men—though not lesbians—have higher rates of body dissatisfaction and eating disorders. It is possible that the combination of these external and internal stressors is partly responsible. In order to effectively treat their gay and lesbian patients, physicians must ask all patients about their sexual orientation and sexual practices and be aware of resources such as hotlines, shelters, substance abuse treatment programs, LGBT-experienced psychiatrists, and legal assistance.
The Urban Men’s Health Study published in 2004 reported that homosexual men had a rate of depression that was 17.2% greater than adult men in general. Another study by Cochran and Mays reported that, in addition to depression, homosexual men were also more likely to have panic attacks. A large UK-based survey of psychological well-being demonstrated that there was also an increased risk for depression and mental distress among lesbians. Given these data, it is advisable for physicians to screen their gay and lesbian patients for depression and mental distress using the Patient Health Questionnaire-9 (PHQ-9) or other screening tool.
An analysis of the National Health and Nutrition Examination Survey III (NHANES III) by Cochran and Mays revealed that there was a significantly higher prevalence of suicidal ideation and suicide attempts among homosexual men than among their heterosexual counterparts. The National Lesbian Health Care Study found that more than half of their study sample had experienced thoughts of suicide at some time and 18% had attempted suicide. This compares to 33% and 4%, respectively, for women in the United States, as reported in the Epidemiologic Catchment Area Study. Therefore, it is critically important to screen all gay and lesbian patients for suicidal ideation and be familiar with institutional protocols for managing suicidal patients.
The Urban Men’s Health Study published in 2001 demonstrated that among urban gay men both recreational drug (52%) and alcohol use (85%) were highly prevalent, and that alcohol-related problems (12%) and frequent drug use (19%) were not uncommon. In a review of substance use in LGBT populations, Hughes and Eliason reported that, while rates of heavy drinking among lesbians and heterosexual women were comparable, lesbians reported more alcohol-related problems. Another survey, conducted at the Millennium March in Washington DC, asked lesbians about the use of recreational drugs within their circle of close friends. In this survey, 11.4% of participants reported monthly use, 5.9% reported weekly use, and 20.8% reported use 1-2 times a year. These data suggest that both gay and lesbian patients are at increased risk for alcohol and other substance abuse and therefore warrant appropriate screening.
Research conducted by Herzog et al. revealed that lesbians were significantly more satisfied with their body appearances than the heterosexual women in the study: 72% of heterosexual women wanted to lose weight, whereas 48% of homosexual women wanted to lose weight. In another study comparing homosexual and heterosexual men, Herzog demonstrated that gay men tended to be more dissatisfied with their bodies and had a greater desire to be thin. Notably, when the men in this study were asked to report their ideal body weight, nearly a quarter of the gay men selected an ideal weight that was underweight, while none of the heterosexual men did. Based on the results of this study, gay men tend to be at a higher risk for body dissatisfaction, whereas lesbian women tend to have a lower risk. This high prevalence of unrealistic body ideals in gay men correlates with a higher prevalence of eating disorders, as evidenced in a study by Feldman and Meyer. As one might have predicted from the results of the body dissatisfaction studies, lesbians were not at an increased risk for eating disorders. It would therefore be appropriate to screen gay male patients for eating disorders. The SCOFF questionnaire is a five-question survey that has been validated as an effective screening tool for anorexia nervosa and bulimia nervosa in men and women, with 100% sensitivity and 87.5% specificity.
Many gay and lesbian patients confront a variety of internal and external stressors that pose significant threats to their mental wellbeing. Research shows that these men and women are at increased risk for certain mental disorders and their sequelae. Recommendations for effective care include asking all patients about their sexual orientation and sexual practices; screening gay and lesbian patients for depression, suicidal ideation, and alcohol and substance abuse; screening gay males for eating disorders; and being aware of resources for gay and lesbian patients such as hotlines, shelters, substance abuse treatment programs, LGBT-experienced psychiatrists, and legal assistance. The Healthy People 2010 Companion Document for LGBT Health (www.glma.org) contains listings of national resources as well as resources in each state.
Commentary by Dr. Victor Rodack
Patients who identify themselves as gay or lesbian are often sensitive to discomfort their presumed life-styles arouse in treating physicians; it would be helpful for primary care doctors to be able to explicitly ask about sexual behavior, including number of partners and venues frequented, without apprehension, surprise, or distaste. Gay men should be offered anal Papanicolaou testing. Throat cultures should be examined for gonococcal infection. This presumes that a rapport has been established in which the patient is comfortable enough to acknowledge his sexual behavior, regardless of how he self-identifies. An initial history should include questions about the patient’s comfort and acceptance of his own sexuality and sexual behavior. And as with all patients, referral to mental health resources should be suggested if there is any indication of dysfunction.
Benjamin Cox is a 4th year medical student at NYU Langone Medical Center
Peer reviewed by Victor Rodack, MD, Medicine, Psychiatry, NYU Langone Medical Center
Image courtesy of Wikimedia Commons
1. Cochran SD, Mays VM. Relation between psychiatric syndromes and behaviorally defined sexual orientation in a sample of the US population. Am J Epidemiol. 2000;151(5):516-523. http://aje.oxfordjournals.org/content/151/5/516.abstract
2. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674–697. http://http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2072932/
3. Meyer IH. Minority stress and mental health in gay men. J Health Soc Behav. 1995;36(1):38-56.
4. Shidlo A. Internalized homophobia: conceptual and empirical issues in measurement. In: Greene B, Herek G, eds. Psychological Perspectives on Lesbian and Gay Issues: Vol. 1. Lesbian and Gay Psychology: Theory, Research, and Clinical Applications. Thousand Oaks, CA: Sage Publications, 1994.
5. Mills TC, Paul J, Stall R, et al. Distress and depression in men who have sex with men: The Urban Men’s Health Study. Am J Psychiatry. 2004;161(2):278-285. http://http://ajp.psychiatryonline.org/cgi/content/abstract/161/2/278
6. Warner J, McKeown E, Griffin M, et al. Rates and predictors of mental illness in gay men, lesbians and bisexual men and women: Results from a survey based in England and Wales. Br J Psychiatry. 2004;185:479-485. http://www.ncbi.nlm.nih.gov/pubmed/15572738
7. Cochran SD, Mays VM. Lifetime prevalence of suicide symptoms and affective disorders among men reporting same-sex sexual partners: Results from the NHANES III. Am J Public Health. 2000;90(4):573–578.
8. Bradford J, Ryan C, Rothblum ED. National Lesbian Health Care Survey: implications for mental health care. J Consult Clin Psychol. 1994;62(2):228-242. http://www.ncbi.nlm.nih.gov/pubmed/8201059
9. Stall R, Paul JP, Greenwood G, et al. Alcohol use, drug use and alcohol-related problems among men who have sex with men: the Urban Men’s Health Study. Addiction. 2001;96(11):1589–1601.
10. Hughes T, Eliason M. Substance use and abuse in lesbian, gay, bisexual and transgender population. J Prim Prev. 2002;22(3):261–295.
11. K-Y Brand Liquid Community Health Survey. Conducted at the Millennium March, Washington, DC. April 29-30, 2000.
12. Feldman MB, Meyer IH. Eating disorders in diverse lesbian, gay, and bisexual populations. Int J Eat Disord. 2007;40(3):218-226.
13. Robins LN, Regier DA. Psychiatric Disorders in America: The Epidemiologic Catchment Area Study. New York, NY: Free Press, 1991.
14. Herzog DB, Newman KL, Yeh CJ, Warshaw M. Body image satisfaction in homosexual and heterosexual women. Int J Eat Disord. 1992;11(4):391–396.
15. Herzog DB, Newman KL, and Warshaw M. Body image dissatisfaction in homosexual and heterosexual males. J Nerv Ment Dis. 1991;179(6):356-359.
16. Morgan JF, Reid F, and Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ. 1999;319(7223):1467-1468. http://www.ncbi.nlm.nih.gov/pubmed/10582927