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Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
Mental Health and Clinical Correlates in Lesbian, Gay, Bisexual, and Queer Young Adults a
b
a
Jon E. Grant JD MD MPH , Brian L. Odlaug MPH , Katherine Derbyshire BS , Liana R. N. c
d
Schreiber BA , Katherine Lust PhD MPH & Gary Christenson MD
d
a
Department of Psychiatry and Behavioral Neuroscience , University of Chicago , Chicago , Illinois b
Department of Public Health, Faculty of Health and Medical Sciences , University of Copenhagen , Copenhagen , Denmark c
Division of Epidemiology and Community Health, School of Public Health , University of Minnesota , Minneapolis , Minnesota d
Boynton Health Services , University of Minnesota , Minneapolis , Minnesota Accepted author version posted online: 23 Sep 2013.Published online: 07 Dec 2013.
To cite this article: Jon E. Grant JD MD MPH , Brian L. Odlaug MPH , Katherine Derbyshire BS , Liana R. N. Schreiber BA , Katherine Lust PhD MPH & Gary Christenson MD (2014) Mental Health and Clinical Correlates in Lesbian, Gay, Bisexual, and Queer Young Adults, Journal of American College Health, 62:1, 75-78, DOI: 10.1080/07448481.2013.844697 To link to this article: http://dx.doi.org/10.1080/07448481.2013.844697
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 62, NO. 1
Brief Report
Downloaded by [The University of Manchester Library] at 04:44 12 October 2014
Mental Health and Clinical Correlates in Lesbian, Gay, Bisexual, and Queer Young Adults Jon E. Grant, JD, MD, MPH; Brian L. Odlaug, MPH; Katherine Derbyshire, BS; Liana R. N. Schreiber, BA; Katherine Lust, PhD, MPH; Gary Christenson, MD
Abstract. Objective: This study examined the prevalence of mental health disorders and their clinical correlates in a university sample of lesbian, gay, bisexual, and queer (LGBQ) students. Participants: College students at a large public university. Methods: An anonymous, voluntary survey was distributed via random e-mail generation to university students during April and May of 2011. LGBQ students were compared with their heterosexual counterparts on psychological and physical status as well as academic performance. Results: LGBQ students reported worse depressive symptoms, higher levels of perceived stress, considered themselves less attractive, and were more likely to be overweight. LGBQ students were significantly more likely to report histories of affective, substance use, and certain anxiety disorders as well as compulsive sexual behavior and compulsive buying. Conclusions: The higher rates of many psychiatric conditions among LGBQ students underscore the need for universities to provide LGBQ students a nonjudgmental environment to discuss sexual orientation and health issues.
1.5 to 3.0 times higher in LGBQ individuals compared with their heterosexual counterparts.1 For many LGBQ individuals, these mental health problems start in adolescence or young adulthood, yet few studies exist examining this age cohort. One national study of 27,454 college students found that LGBQ students were more likely to endorse depressive symptoms (eg, feeling hopeless, lonely), suicidal thoughts and that these mental health symptoms negatively impacted their academic performance.2 The reason for these mental health disparities is not absolutely clear but may be related to the social stigma, discrimination, and adverse childhood experience faced by LGBQ individuals.3–5 In addition, a wealth of research has examined the association of various health issues, including risky sexual behavior, with identity development, homonegativity, and outness in the LGBQ community.6 Poor mental and physical health have been hypothesized to result from internalization of negative attitudes and assumptions about LGBQ people by LGBQ people themselves, leading to feelings of guilt, inferiority, and lack of self-worth.6,7 The relationship between health and views regarding one’s sexual identity, however, are complicated by multiple variables—race/ethnicity, age, and environment where one was raised—to name only a few.6–9 Previous research highlights the higher prevalence of mental health disorders among LGBQ individuals, but less is known about certain disorders (eg, impulse control disorders) and the wider range of health effects that may be associated with these mental disorders. Therefore, this study sought to examine both the prevalence of a wide range of mental health disorders and associated health issues in LGBQ college students. We hypothesized that LGBQ young adults would exhibit higher rates of most mental health disorders, including impulse control disorders, and have poorer self-esteem and greater impairments in academic performance.
Keywords: academic, impulse control, lesbian, gay, bisexual, and queer (LGBQ), mental health, university
R
esearch suggests that lesbian, gay, bisexual, and queer (LGBQ) individuals are at higher risk for a range of mental health disorders. Epidemiological data from the United States and the United Kingdom have shown that rates of depressive, anxiety, and substance use disorders are Dr Grant and Ms Derbyshire are with the Department of Psychiatry and Behavioral Neuroscience at the University of Chicago in Chicago, Illinois. Mr Odlaug is with the Department of Public Health, Faculty of Health and Medical Sciences, at the University of Copenhagen in Copenhagen, Denmark. Ms Schreiber is with Division of Epidemiology and Community Health, School of Public Health, at the University of Minnesota in Minneapolis, Minnesota. Dr Lust and Dr Christenson are with the Boynton Health Services at the University of Minnesota in Minneapolis, Minnesota. Copyright © 2014 Taylor & Francis Group, LLC
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METHODS
tic validity and reliability.11 Other valid and reliable scales included the Patient Health Questionnaire (PHQ-9; Cronbach alpha is .860 with 9 items), a client-administered, 9item measure of depressive symptoms12,13 and the Perceived Stress Scale (Cronbach alpha is .856 with 10 items), a 10question client-administered scale asking about stress during the prior 30 days.14
Survey Description The survey was distributed via random e-mail generation to a sample of 6,000 students enrolled at a large midwestern university over a 2-month period in the spring of 2011. The Institutional Review Board (IRB) for the university approved the study and the informed consent. Students consented to the survey by reading an introductory page with IRB-approved language about the content of the survey, noting the fact that they were not required to participate, and clicking on a “begin survey” link. This study was carried out in accordance with the ethical standards established by the 2008 Declaration of Helsinki. To incentivize participation, however, weekly drawings were held for portable music players and for a $250, $500, and $1,000 gift card at the conclusion of the survey for those who began the survey. (Note: Completion of the survey was not required to be eligible for prize drawings.)
Statistical Analysis Students were categorized based on their response to the question of sexual orientation. Means were compared using unpaired t tests. Categorical variables were compared using chi-square or Fisher’s exact tests where appropriate. An alpha of .05 was established and used for clinical significance. RESULTS A total of 2,108 (35.1%; M age 22.6 ± 5.1 [range: 18–58]; 78.8% Caucasian; 41.8% male) students completed the survey. Respondent demographics were not significantly different from the overall demographic profile of the university (41.4% male; 79.5% Caucasian). Of the 2,108 participants that completed the survey, 2,011 participants were included in the final data due to lack of reliable data. Not all participants answered each question on the survey; therefore, there are some discrepancies of each n value. Of the 2,011 students, 112 (5.6%) (n = 60; 53.6% females) identified as LGBQ. There were no significant demographic differences between the LGBQ and the heterosexual students. Academic, physical, and mental health comparison results are presented in Table 1. LGBQ individuals reported significantly worse depressive symptoms (PHQ-9 scores), higher levels of perceived stress, considered themselves significantly less attractive than their heterosexual peers, and were significantly more likely to be overweight (Table 1). In terms of categorical psychiatric diagnosis, LGBQ students were significantly more likely to report histories of major depressive disorder (32.1% compared with 15.2%; χ 2
Assessments Although there are problems with how one defines sexual orientation, this survey categorized students based on their self-identification: heterosexual, gay, lesbian, bisexual, or unsure. As we wanted to compare heterosexual with LGBQ students, those who marked “unsure” were excluded from the analyses. In addition to self-identified sexual orientation, students completed a series of questions regarding demographic variables and questions concerning academic performance, body mass index (BMI) (based on reported height and weight), perceived attractiveness, and physical activity. In terms of mental health disorders, students were asked about lifetime diagnoses of psychiatric disorders and completed the Minnesota Impulsive Disorders Interview (MIDI) to assess impulse control disorders.10 Although originally developed as a clinician-administered tool, the MIDI has been used in a self-report version in a previous study of impulse control disorders in college students and has good diagnos-
TABLE 1. Academic and Health Indices Grouped by Sexual Orientation LGBQ Variable College GPA§ Meet adult CDC recommendations for physical activity (%) Body mass index§ PHQ-9 (score: 0–27)§ Perceived stress (score: 0–40) Perceived attractiveness (score: 0–10)§
Heterosexual
Test statistic
M
SD
N
M
SD
N
t
3.33 53.8∗
0.60
110 57
3.35 55.8∗
0.48
1878 993
0.819
25.24 6.41 18.02 6.34
5.86 5.20 7.26 1.80
103 100 99 105
23.64 4.72 15.87 6.87
4.44 4.38 6.63 1.42
1768 1650 1666 1765
−2.72 −3.173 −3.115 2.925
χ2 0.17
df
SE
p value
116.5 1
0.534
.414 .68
108.9 107.7 1763 111.9
0.587 0.531 0.689 0.179
.008 .002 .002 .004
Note. LGBQ = lesbian, gay, bisexual, and queer; GPA = grade point average; CDC = Centers for Disease Control and Prevention; PHQ-9 = Patient Health Questionnaire. Boldface indicates statistical significance of alpha of .05. ∗ Pearson’s chi-square. §Equality of variances not assumed based on Levene’s test.
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JOURNAL OF AMERICAN COLLEGE HEALTH
Mental Health and Clinical Correlates in LGBQ Students
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= 22.5; df = 1; p < .0001) and social anxiety disorder (12.5% compared with 3.5%; χ 2 = 22.15; df = 1; p < .0001). In addition, compulsive sexual behavior (5.8% compared with 1.7%; Fisher’s exact = .013) and compulsive buying (7.7% compared with 3.4%; χ 2 = 5.042; df = 1; p < .025) were significantly more common in LGBQ students. COMMENT The rate of LGBQ identification in our study (5.6%) is generally similar to those reported in other university and community samples (4.8% to 8.7%).1,5 Although the LGBQ students reported similar academic achievements and levels of physical exercise as their heterosexual counterparts, they were more likely to be overweight, depressed, and have higher levels of stress. In terms of mental health disorders, rates of depression and anxiety were higher in the LGBQ students. These findings are generally consistent with other research in either LGBQ adolescents or adults.2,5 Although substantial previous research has examined compulsive sexual behavior in the LGBQ population,15–19 our study compared rates of compulsive sexual behavior in students based on sexual orientation and found that LGBQ students had significantly higher rates of compulsive sexual behavior. LGBQ students also had higher rates of compulsive buying. Taken together, these findings lend themselves to various but not necessarily mutually exclusive interpretations. One such interpretation suggests that college environments foster various forms of stigma associated with sexual orientation and thereby prevent the LGBQ young adults from fully engaging in the college experience.18 Thus, LGBQ students may experience high rates of social ostracism, stress, and depression. The findings of higher rates of compulsive buying, compulsive sexual behavior, and arguably overeating (suggested by the higher BMI scores) could all reflect a reaction to the stress, depression, and social isolation associated with sexual orientation. In effect, the behaviors become ways in which the LGBQ students cope with these underlying emotional and psychiatric issues. This theory of the associations between LGBQ students and unhealthy behaviors, of course, requires research substantiation. Another interpretation of these findings could be that internalized homonegativity (defined as the incorporation of the negative societal views of homosexuality into the person)19 predates the college experience, and results in shame and the development of a maladaptive form of coping, such as compulsive sexual behavior, substance misuse, overeating, and out-of-control spending.6 The maladaptive behaviors might, in turn, lead to greater social stress, depression, and anxiety. Family rejective reactions to sexual orientation have been found to increase depression and attempted suicide about 5.9- and 8.4-fold, respectively, in adolescents.7 Additionally, given the recent research on bullying among gay youth and the long-term mental health effects of victimization,7,20–22 this interpretation may call for early educational, social, and political interventions to prevent the victimization from family and peers. VOL 62, JANUARY 2014
Although a recent meta-analysis suggests that society may be becoming increasingly accepting of homosexuality, it remains important that research continue to investigate the construct of internalized homonegativity in differing demographics.8 Race/ethnicity, gender, and environment may be important features to examine.6–9 One study found, for example, that less acculturated males had a greater difficulty integrating homosexuality into their social identity, indicative of greater internalized homonegativity, due to beliefs of gay and bisexual men as hypersexual and less masculine.9 This study provides only a snapshot of these associations. It cannot determine causality. Future studies should approach the topic of LGBQ mental health from a longitudinal perspective. That way, public health preventive efforts can focus on possible causal elements and answer questions about appropriate preventative elements. For example, should prevention focus on making college environments more inclusive, thereby possibly minimizing the social stigma faced by LGBQ youth and the resultant maladaptive coping response by LGBQ young adults? Or, alternatively, should prevention efforts begin at a much younger age to decrease internalized homonegativity and thereby prevent the development of poor self-esteem in LGBQ youth?
Limitations There are several limitations with this study. First, subjects were surveyed anonymously and no direct interviews were conducted. This may have led to either over- or underreporting of various mental health issues. Second, no temporal relationship between recognition of sexual orientation and these other variables such as self-esteem or depression were assessed. Whether these emotional factors lead to, result from, or are completely unrelated to sexual orientation cannot be definitely stated. Third, size of the overall survey response prevented a well-powered analysis of the LGBQ students. In addition, although the Institute of Medicine report on the health of LGBQ individuals recommends that LGBQ groups be investigated separately rather than combined,23 we did not have a large enough sample size to comply with this recommendation. Therefore, some conclusions may not apply to the group as a whole.
Conclusions LGBQ young adults appear to suffer from multiple psychiatric issues to a greater degree than their heterosexual counterparts. College administrators, teachers, and health care providers should be aware of the often significant distress associated with LGBQ young adults. In particular, this study has implications for mental health providers. The significantly higher rates of many psychiatric conditions noted in our sample underscores the need for clinicians and other care providers to provide LGBQ young adults a nonjudgmental and approachable environment in which to discuss their sexual orientation and health issues. 77
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FUNDING This research was supported in part by a Center for Excellence in Gambling Research grant by the National Center for Responsible Gaming, an American Recovery and Reinvestment Act (ARRA) Grant from the National Institute on Drug Abuse (1RC1DA028279–01) to Dr Grant, and internal funding from Boynton Health Services, University of Minnesota. CONFLICT OF INTEREST DISCLOSURE Dr Grant has received research support from NIDA, NCRG, Forest Pharmaceuticals, Roche Pharmaceuticals, Psyadon Pharmaceuticals, Transcept Pharmaceuticals, and the University of South Florida. He has also received royalties from American Psychiatric Publishing Inc, Oxford University Press, Norton, and McGraw Hill Publishers. Mr. Odlaug reports having consulted for Lundbeck Pharmaceuticals, having received a research grant from the Trichotillomania Learning Center and honoraria and royalties from Oxford University Press. Dr Lust and Dr Christenson report employment with Boynton Health Services. Ms Schreiber and Ms Derbyshire report no conflicts of interest relevant to the content of this article. The authors confirm that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of the United States and received approval from the Institutional Review Board of a large midwestern university. NOTE For comments and further information, address correspondence to Jon E. Grant, JD, MD, MPH, Professor, Department of Psychiatry and Behavioral Neuroscience, University of Chicago Pritzker School of Medicine, 5841 S. Maryland Avenue, MC 3077, Chicago, IL 60637, USA (e-mail: jongrant@ uchicago.edu). REFERENCES 1. Chakraborty A, McManus S, Brugha TS, Bebbington P, King M. Mental health of the non-heterosexual population of England. Br J Psychiatry. 2011;198:143–148. 2. Oswalt SB, Wyatt TJ. Sexual orientation and differences in mental health, stress, and academic performance in a national sample of U.S. college students. J Homosex. 2011;58: 1255–1280. 3. Andersen JP, Blosnich J. Disparities in adverse childhood experiences among sexual minority and heterosexual adults: results from a multi-state probability-based sample. PLoS ONE. 2013;8:e54691. 4. Meyer IH, Schwartz S, Frost DM. Social patterning of stress and coping: does disadvantaged social statuses confer more stress and fewer coping resources? Soc Sci Med. 2008;67:368–379. 5. Burton CM, Marshal MP, Chisolm DJ, Sucato GS, Friedman MS. Sexual minority-related victimization as a mediator of mental health disparities in sexual minority youth: a longitudinal analysis. J Youth Adolesc. 2013;42:394–402.
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6. Ross MW, Berg RC, Schmidt AJ, et al. Internalised homonegativity predicts HIV-associated risk behavior in European men who have sex with men in a 38-country cross-sectional study: some public health implications of homophobia. BMJ Open. 2013;3(2):e001928. doi: 10.1136/bmjopen-2012-001928. 7. Ryan C, Huebner D, Diaz RM, et al. Family rejection is a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics. 2009;123:346–352. 8. Newcomb ME, Mustanski B. Moderators of the relationship between internalized homophobia and risky sexual behavior in men who have sex with men: a meta-analysis. Arch Sex Behav. 2011;40:189–199. 9. Wilkerson J, Brooks AK, Ross, M. Sociosexual identity development and sexual risk taking of acculturating collegiate gay and bisexual men. J Coll Student Dev. 2010;51:279–296. 10. Grant JE. Impulse Control Disorders: A Clinician’s Guide to Understanding and Treating Behavioral Addictions. New York, NY: Norton; 2008. 11. Odlaug BL, Grant JE. Impulse-control disorders in a college sample: results from the self-administered Minnesota Impulse Disorders Interview (MIDI). Prim Care Companion J Clin Psychiatry. 2010;12(2):PCC.09m00842. doi: 10.4088/PCC.09m00842whi. 12. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–613. 13. Kroenke K, Spitzer RL. The PHQ-9: a new depression and diagnostic severity measure. Psychiatr Ann. 2002;32:509–521 14. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24:386–396. 15. Parsons JT, Grov C, Golub SA. Sexual compulsivity, cooccurring psychosocial health problems, and HIV risk among gay and bisexual men: further evidence of a syndemic. Am J Public Health. 2012;102:156–162 16. Grov C, Golub SA, Mustanski B, Parsons JT. Sexual compulsivity, state affect, and sexual risk behavior in a daily diary study of gay and bisexual men. Psychol Addict Behav. 2010;24:487–497. 17. Kelly BC, Bimbi DS, Nanin JE, Izienicki H, Parsons JT. Sexual compulsivity and sexual behaviors among gay and bisexual men and lesbian and bisexual women. J Sex Res. 2009;46:301–308. 18. Jorm AF, Korten AE, Rodgers B, Jacomb PA, Christensen H. Sexual orientation and mental health: results from a community survey of young and middle-aged adults. Br J Psychiatry. 2002;180:423–427. 19. Ross MW, Rosser BR. Measurement and correlates of internalized homophobia: a factor analytic study. J Clin Psychol. 1996;52:15–21. 20. Friedman MS, Marshal MP, Guadamuz TE, et al. A meta-analysis of disparities in childhood sexual abuse, parental physical abuse, and peer victimization among sexual minority and sexual nonminority individuals. Am J Public Health. 2011;101:1481–1494. 21. Martin-Storey A, Crosnoe R. Sexual minority status, peer harassment, and adolescent depression. J Adolesc. 2012;35:1001–1011. 22. Poteat VP, Mereish EH, Digiovanni CD, Koenig BW. The effects of general and homophobic victimization on adolescents’ psychosocial and educational concerns: the importance of intersecting identities and parent support. J Couns Psychol. 2011;58:597–609. 23. Institute of Medicine The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academy of Sciences; 2011. Received: 29 March 2013 Accepted: 9 September 2013
JOURNAL OF AMERICAN COLLEGE HEALTH
Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
Mental Health and Clinical Correlates in Lesbian, Gay, Bisexual, and Queer Young Adults a
b
a
Jon E. Grant JD MD MPH , Brian L. Odlaug MPH , Katherine Derbyshire BS , Liana R. N. c
d
Schreiber BA , Katherine Lust PhD MPH & Gary Christenson MD
d
a
Department of Psychiatry and Behavioral Neuroscience , University of Chicago , Chicago , Illinois b
Department of Public Health, Faculty of Health and Medical Sciences , University of Copenhagen , Copenhagen , Denmark c
Division of Epidemiology and Community Health, School of Public Health , University of Minnesota , Minneapolis , Minnesota d
Boynton Health Services , University of Minnesota , Minneapolis , Minnesota Accepted author version posted online: 23 Sep 2013.Published online: 07 Dec 2013.
To cite this article: Jon E. Grant JD MD MPH , Brian L. Odlaug MPH , Katherine Derbyshire BS , Liana R. N. Schreiber BA , Katherine Lust PhD MPH & Gary Christenson MD (2014) Mental Health and Clinical Correlates in Lesbian, Gay, Bisexual, and Queer Young Adults, Journal of American College Health, 62:1, 75-78, DOI: 10.1080/07448481.2013.844697 To link to this article: http://dx.doi.org/10.1080/07448481.2013.844697
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 62, NO. 1
Brief Report
Downloaded by [The University of Manchester Library] at 04:44 12 October 2014
Mental Health and Clinical Correlates in Lesbian, Gay, Bisexual, and Queer Young Adults Jon E. Grant, JD, MD, MPH; Brian L. Odlaug, MPH; Katherine Derbyshire, BS; Liana R. N. Schreiber, BA; Katherine Lust, PhD, MPH; Gary Christenson, MD
Abstract. Objective: This study examined the prevalence of mental health disorders and their clinical correlates in a university sample of lesbian, gay, bisexual, and queer (LGBQ) students. Participants: College students at a large public university. Methods: An anonymous, voluntary survey was distributed via random e-mail generation to university students during April and May of 2011. LGBQ students were compared with their heterosexual counterparts on psychological and physical status as well as academic performance. Results: LGBQ students reported worse depressive symptoms, higher levels of perceived stress, considered themselves less attractive, and were more likely to be overweight. LGBQ students were significantly more likely to report histories of affective, substance use, and certain anxiety disorders as well as compulsive sexual behavior and compulsive buying. Conclusions: The higher rates of many psychiatric conditions among LGBQ students underscore the need for universities to provide LGBQ students a nonjudgmental environment to discuss sexual orientation and health issues.
1.5 to 3.0 times higher in LGBQ individuals compared with their heterosexual counterparts.1 For many LGBQ individuals, these mental health problems start in adolescence or young adulthood, yet few studies exist examining this age cohort. One national study of 27,454 college students found that LGBQ students were more likely to endorse depressive symptoms (eg, feeling hopeless, lonely), suicidal thoughts and that these mental health symptoms negatively impacted their academic performance.2 The reason for these mental health disparities is not absolutely clear but may be related to the social stigma, discrimination, and adverse childhood experience faced by LGBQ individuals.3–5 In addition, a wealth of research has examined the association of various health issues, including risky sexual behavior, with identity development, homonegativity, and outness in the LGBQ community.6 Poor mental and physical health have been hypothesized to result from internalization of negative attitudes and assumptions about LGBQ people by LGBQ people themselves, leading to feelings of guilt, inferiority, and lack of self-worth.6,7 The relationship between health and views regarding one’s sexual identity, however, are complicated by multiple variables—race/ethnicity, age, and environment where one was raised—to name only a few.6–9 Previous research highlights the higher prevalence of mental health disorders among LGBQ individuals, but less is known about certain disorders (eg, impulse control disorders) and the wider range of health effects that may be associated with these mental disorders. Therefore, this study sought to examine both the prevalence of a wide range of mental health disorders and associated health issues in LGBQ college students. We hypothesized that LGBQ young adults would exhibit higher rates of most mental health disorders, including impulse control disorders, and have poorer self-esteem and greater impairments in academic performance.
Keywords: academic, impulse control, lesbian, gay, bisexual, and queer (LGBQ), mental health, university
R
esearch suggests that lesbian, gay, bisexual, and queer (LGBQ) individuals are at higher risk for a range of mental health disorders. Epidemiological data from the United States and the United Kingdom have shown that rates of depressive, anxiety, and substance use disorders are Dr Grant and Ms Derbyshire are with the Department of Psychiatry and Behavioral Neuroscience at the University of Chicago in Chicago, Illinois. Mr Odlaug is with the Department of Public Health, Faculty of Health and Medical Sciences, at the University of Copenhagen in Copenhagen, Denmark. Ms Schreiber is with Division of Epidemiology and Community Health, School of Public Health, at the University of Minnesota in Minneapolis, Minnesota. Dr Lust and Dr Christenson are with the Boynton Health Services at the University of Minnesota in Minneapolis, Minnesota. Copyright © 2014 Taylor & Francis Group, LLC
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METHODS
tic validity and reliability.11 Other valid and reliable scales included the Patient Health Questionnaire (PHQ-9; Cronbach alpha is .860 with 9 items), a client-administered, 9item measure of depressive symptoms12,13 and the Perceived Stress Scale (Cronbach alpha is .856 with 10 items), a 10question client-administered scale asking about stress during the prior 30 days.14
Survey Description The survey was distributed via random e-mail generation to a sample of 6,000 students enrolled at a large midwestern university over a 2-month period in the spring of 2011. The Institutional Review Board (IRB) for the university approved the study and the informed consent. Students consented to the survey by reading an introductory page with IRB-approved language about the content of the survey, noting the fact that they were not required to participate, and clicking on a “begin survey” link. This study was carried out in accordance with the ethical standards established by the 2008 Declaration of Helsinki. To incentivize participation, however, weekly drawings were held for portable music players and for a $250, $500, and $1,000 gift card at the conclusion of the survey for those who began the survey. (Note: Completion of the survey was not required to be eligible for prize drawings.)
Statistical Analysis Students were categorized based on their response to the question of sexual orientation. Means were compared using unpaired t tests. Categorical variables were compared using chi-square or Fisher’s exact tests where appropriate. An alpha of .05 was established and used for clinical significance. RESULTS A total of 2,108 (35.1%; M age 22.6 ± 5.1 [range: 18–58]; 78.8% Caucasian; 41.8% male) students completed the survey. Respondent demographics were not significantly different from the overall demographic profile of the university (41.4% male; 79.5% Caucasian). Of the 2,108 participants that completed the survey, 2,011 participants were included in the final data due to lack of reliable data. Not all participants answered each question on the survey; therefore, there are some discrepancies of each n value. Of the 2,011 students, 112 (5.6%) (n = 60; 53.6% females) identified as LGBQ. There were no significant demographic differences between the LGBQ and the heterosexual students. Academic, physical, and mental health comparison results are presented in Table 1. LGBQ individuals reported significantly worse depressive symptoms (PHQ-9 scores), higher levels of perceived stress, considered themselves significantly less attractive than their heterosexual peers, and were significantly more likely to be overweight (Table 1). In terms of categorical psychiatric diagnosis, LGBQ students were significantly more likely to report histories of major depressive disorder (32.1% compared with 15.2%; χ 2
Assessments Although there are problems with how one defines sexual orientation, this survey categorized students based on their self-identification: heterosexual, gay, lesbian, bisexual, or unsure. As we wanted to compare heterosexual with LGBQ students, those who marked “unsure” were excluded from the analyses. In addition to self-identified sexual orientation, students completed a series of questions regarding demographic variables and questions concerning academic performance, body mass index (BMI) (based on reported height and weight), perceived attractiveness, and physical activity. In terms of mental health disorders, students were asked about lifetime diagnoses of psychiatric disorders and completed the Minnesota Impulsive Disorders Interview (MIDI) to assess impulse control disorders.10 Although originally developed as a clinician-administered tool, the MIDI has been used in a self-report version in a previous study of impulse control disorders in college students and has good diagnos-
TABLE 1. Academic and Health Indices Grouped by Sexual Orientation LGBQ Variable College GPA§ Meet adult CDC recommendations for physical activity (%) Body mass index§ PHQ-9 (score: 0–27)§ Perceived stress (score: 0–40) Perceived attractiveness (score: 0–10)§
Heterosexual
Test statistic
M
SD
N
M
SD
N
t
3.33 53.8∗
0.60
110 57
3.35 55.8∗
0.48
1878 993
0.819
25.24 6.41 18.02 6.34
5.86 5.20 7.26 1.80
103 100 99 105
23.64 4.72 15.87 6.87
4.44 4.38 6.63 1.42
1768 1650 1666 1765
−2.72 −3.173 −3.115 2.925
χ2 0.17
df
SE
p value
116.5 1
0.534
.414 .68
108.9 107.7 1763 111.9
0.587 0.531 0.689 0.179
.008 .002 .002 .004
Note. LGBQ = lesbian, gay, bisexual, and queer; GPA = grade point average; CDC = Centers for Disease Control and Prevention; PHQ-9 = Patient Health Questionnaire. Boldface indicates statistical significance of alpha of .05. ∗ Pearson’s chi-square. §Equality of variances not assumed based on Levene’s test.
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Mental Health and Clinical Correlates in LGBQ Students
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= 22.5; df = 1; p < .0001) and social anxiety disorder (12.5% compared with 3.5%; χ 2 = 22.15; df = 1; p < .0001). In addition, compulsive sexual behavior (5.8% compared with 1.7%; Fisher’s exact = .013) and compulsive buying (7.7% compared with 3.4%; χ 2 = 5.042; df = 1; p < .025) were significantly more common in LGBQ students. COMMENT The rate of LGBQ identification in our study (5.6%) is generally similar to those reported in other university and community samples (4.8% to 8.7%).1,5 Although the LGBQ students reported similar academic achievements and levels of physical exercise as their heterosexual counterparts, they were more likely to be overweight, depressed, and have higher levels of stress. In terms of mental health disorders, rates of depression and anxiety were higher in the LGBQ students. These findings are generally consistent with other research in either LGBQ adolescents or adults.2,5 Although substantial previous research has examined compulsive sexual behavior in the LGBQ population,15–19 our study compared rates of compulsive sexual behavior in students based on sexual orientation and found that LGBQ students had significantly higher rates of compulsive sexual behavior. LGBQ students also had higher rates of compulsive buying. Taken together, these findings lend themselves to various but not necessarily mutually exclusive interpretations. One such interpretation suggests that college environments foster various forms of stigma associated with sexual orientation and thereby prevent the LGBQ young adults from fully engaging in the college experience.18 Thus, LGBQ students may experience high rates of social ostracism, stress, and depression. The findings of higher rates of compulsive buying, compulsive sexual behavior, and arguably overeating (suggested by the higher BMI scores) could all reflect a reaction to the stress, depression, and social isolation associated with sexual orientation. In effect, the behaviors become ways in which the LGBQ students cope with these underlying emotional and psychiatric issues. This theory of the associations between LGBQ students and unhealthy behaviors, of course, requires research substantiation. Another interpretation of these findings could be that internalized homonegativity (defined as the incorporation of the negative societal views of homosexuality into the person)19 predates the college experience, and results in shame and the development of a maladaptive form of coping, such as compulsive sexual behavior, substance misuse, overeating, and out-of-control spending.6 The maladaptive behaviors might, in turn, lead to greater social stress, depression, and anxiety. Family rejective reactions to sexual orientation have been found to increase depression and attempted suicide about 5.9- and 8.4-fold, respectively, in adolescents.7 Additionally, given the recent research on bullying among gay youth and the long-term mental health effects of victimization,7,20–22 this interpretation may call for early educational, social, and political interventions to prevent the victimization from family and peers. VOL 62, JANUARY 2014
Although a recent meta-analysis suggests that society may be becoming increasingly accepting of homosexuality, it remains important that research continue to investigate the construct of internalized homonegativity in differing demographics.8 Race/ethnicity, gender, and environment may be important features to examine.6–9 One study found, for example, that less acculturated males had a greater difficulty integrating homosexuality into their social identity, indicative of greater internalized homonegativity, due to beliefs of gay and bisexual men as hypersexual and less masculine.9 This study provides only a snapshot of these associations. It cannot determine causality. Future studies should approach the topic of LGBQ mental health from a longitudinal perspective. That way, public health preventive efforts can focus on possible causal elements and answer questions about appropriate preventative elements. For example, should prevention focus on making college environments more inclusive, thereby possibly minimizing the social stigma faced by LGBQ youth and the resultant maladaptive coping response by LGBQ young adults? Or, alternatively, should prevention efforts begin at a much younger age to decrease internalized homonegativity and thereby prevent the development of poor self-esteem in LGBQ youth?
Limitations There are several limitations with this study. First, subjects were surveyed anonymously and no direct interviews were conducted. This may have led to either over- or underreporting of various mental health issues. Second, no temporal relationship between recognition of sexual orientation and these other variables such as self-esteem or depression were assessed. Whether these emotional factors lead to, result from, or are completely unrelated to sexual orientation cannot be definitely stated. Third, size of the overall survey response prevented a well-powered analysis of the LGBQ students. In addition, although the Institute of Medicine report on the health of LGBQ individuals recommends that LGBQ groups be investigated separately rather than combined,23 we did not have a large enough sample size to comply with this recommendation. Therefore, some conclusions may not apply to the group as a whole.
Conclusions LGBQ young adults appear to suffer from multiple psychiatric issues to a greater degree than their heterosexual counterparts. College administrators, teachers, and health care providers should be aware of the often significant distress associated with LGBQ young adults. In particular, this study has implications for mental health providers. The significantly higher rates of many psychiatric conditions noted in our sample underscores the need for clinicians and other care providers to provide LGBQ young adults a nonjudgmental and approachable environment in which to discuss their sexual orientation and health issues. 77
Grant et al
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FUNDING This research was supported in part by a Center for Excellence in Gambling Research grant by the National Center for Responsible Gaming, an American Recovery and Reinvestment Act (ARRA) Grant from the National Institute on Drug Abuse (1RC1DA028279–01) to Dr Grant, and internal funding from Boynton Health Services, University of Minnesota. CONFLICT OF INTEREST DISCLOSURE Dr Grant has received research support from NIDA, NCRG, Forest Pharmaceuticals, Roche Pharmaceuticals, Psyadon Pharmaceuticals, Transcept Pharmaceuticals, and the University of South Florida. He has also received royalties from American Psychiatric Publishing Inc, Oxford University Press, Norton, and McGraw Hill Publishers. Mr. Odlaug reports having consulted for Lundbeck Pharmaceuticals, having received a research grant from the Trichotillomania Learning Center and honoraria and royalties from Oxford University Press. Dr Lust and Dr Christenson report employment with Boynton Health Services. Ms Schreiber and Ms Derbyshire report no conflicts of interest relevant to the content of this article. The authors confirm that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of the United States and received approval from the Institutional Review Board of a large midwestern university. NOTE For comments and further information, address correspondence to Jon E. Grant, JD, MD, MPH, Professor, Department of Psychiatry and Behavioral Neuroscience, University of Chicago Pritzker School of Medicine, 5841 S. Maryland Avenue, MC 3077, Chicago, IL 60637, USA (e-mail: jongrant@ uchicago.edu). REFERENCES 1. Chakraborty A, McManus S, Brugha TS, Bebbington P, King M. Mental health of the non-heterosexual population of England. Br J Psychiatry. 2011;198:143–148. 2. Oswalt SB, Wyatt TJ. Sexual orientation and differences in mental health, stress, and academic performance in a national sample of U.S. college students. J Homosex. 2011;58: 1255–1280. 3. Andersen JP, Blosnich J. Disparities in adverse childhood experiences among sexual minority and heterosexual adults: results from a multi-state probability-based sample. PLoS ONE. 2013;8:e54691. 4. Meyer IH, Schwartz S, Frost DM. Social patterning of stress and coping: does disadvantaged social statuses confer more stress and fewer coping resources? Soc Sci Med. 2008;67:368–379. 5. Burton CM, Marshal MP, Chisolm DJ, Sucato GS, Friedman MS. Sexual minority-related victimization as a mediator of mental health disparities in sexual minority youth: a longitudinal analysis. J Youth Adolesc. 2013;42:394–402.
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6. Ross MW, Berg RC, Schmidt AJ, et al. Internalised homonegativity predicts HIV-associated risk behavior in European men who have sex with men in a 38-country cross-sectional study: some public health implications of homophobia. BMJ Open. 2013;3(2):e001928. doi: 10.1136/bmjopen-2012-001928. 7. Ryan C, Huebner D, Diaz RM, et al. Family rejection is a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics. 2009;123:346–352. 8. Newcomb ME, Mustanski B. Moderators of the relationship between internalized homophobia and risky sexual behavior in men who have sex with men: a meta-analysis. Arch Sex Behav. 2011;40:189–199. 9. Wilkerson J, Brooks AK, Ross, M. Sociosexual identity development and sexual risk taking of acculturating collegiate gay and bisexual men. J Coll Student Dev. 2010;51:279–296. 10. Grant JE. Impulse Control Disorders: A Clinician’s Guide to Understanding and Treating Behavioral Addictions. New York, NY: Norton; 2008. 11. Odlaug BL, Grant JE. Impulse-control disorders in a college sample: results from the self-administered Minnesota Impulse Disorders Interview (MIDI). Prim Care Companion J Clin Psychiatry. 2010;12(2):PCC.09m00842. doi: 10.4088/PCC.09m00842whi. 12. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–613. 13. Kroenke K, Spitzer RL. The PHQ-9: a new depression and diagnostic severity measure. Psychiatr Ann. 2002;32:509–521 14. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24:386–396. 15. Parsons JT, Grov C, Golub SA. Sexual compulsivity, cooccurring psychosocial health problems, and HIV risk among gay and bisexual men: further evidence of a syndemic. Am J Public Health. 2012;102:156–162 16. Grov C, Golub SA, Mustanski B, Parsons JT. Sexual compulsivity, state affect, and sexual risk behavior in a daily diary study of gay and bisexual men. Psychol Addict Behav. 2010;24:487–497. 17. Kelly BC, Bimbi DS, Nanin JE, Izienicki H, Parsons JT. Sexual compulsivity and sexual behaviors among gay and bisexual men and lesbian and bisexual women. J Sex Res. 2009;46:301–308. 18. Jorm AF, Korten AE, Rodgers B, Jacomb PA, Christensen H. Sexual orientation and mental health: results from a community survey of young and middle-aged adults. Br J Psychiatry. 2002;180:423–427. 19. Ross MW, Rosser BR. Measurement and correlates of internalized homophobia: a factor analytic study. J Clin Psychol. 1996;52:15–21. 20. Friedman MS, Marshal MP, Guadamuz TE, et al. A meta-analysis of disparities in childhood sexual abuse, parental physical abuse, and peer victimization among sexual minority and sexual nonminority individuals. Am J Public Health. 2011;101:1481–1494. 21. Martin-Storey A, Crosnoe R. Sexual minority status, peer harassment, and adolescent depression. J Adolesc. 2012;35:1001–1011. 22. Poteat VP, Mereish EH, Digiovanni CD, Koenig BW. The effects of general and homophobic victimization on adolescents’ psychosocial and educational concerns: the importance of intersecting identities and parent support. J Couns Psychol. 2011;58:597–609. 23. Institute of Medicine The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academy of Sciences; 2011. Received: 29 March 2013 Accepted: 9 September 2013
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