The inclusion, for the first time, of a question about sexual orientation in a regularly-conducted national health survey in the US has allowed researchers to establish that people who define themselves as lesbian, gay or bisexual do have considerably higher rates of mental ill-health than the general population.
The 2013 and 2014 National Health Interview Surveys (NHIS) found that gay men were nearly three times as likely to have symptoms of ‘severe psychological distress’ as heterosexual men and were also more likely to smoke and to drink heavily. Bisexual men were even more strongly affected.
In the case of women, those defining as lesbian were more likely to be heavy smokers and drinkers. Bisexual women were more likely to have severe psychological distress. Lesbian and bisexual women, unlike men, were also somewhat more likely to suffer from poor physical health.
The NHIS is 60 years old next year, having been conducted every year since 1957. Households throughout the US are randomly selected to answer a core questionnaire on basic health and disability, and one member of each household over 18 is then randomly selected to answer another, more detailed survey that includes information on specific health conditions, health behaviours, and access to healthcare. Completion rates for the general survey and more detailed survey are about 75% and 81% respectively.
The detailed survey was the one that included, for the first time, a question on sexual orientation in 2013. Respondents were asked whether they thought of themselves as heterosexual; lesbian or gay; bisexual; something else; didn’t know; or refused to answer. Gender identity was not asked about, so this is an LGB survey rather than an LGBT one.
This study compares answers from lesbian/gay and bisexual respondents with heterosexual ones on a number of health indices: self-rated heath, disability, the presence of one or more chronic conditions, psychological distress, drinking and smoking.
The detailed Sample Adult surveys from 2013 and 2014 were amalgamated. Altogether 68,814 adults answered the surveys. Of these, 2566 said they were something other than heterosexual or refused to answer (3.7% or one person in 27); 1808 said they were non-heterosexual (i.e. lesbian/gay, bisexual or ‘something else’’ – 2.6% or one in 38). Of these, 1149 said they were lesbian/gay (1.7% or one in 60) and 515 bisexual (0.7% or one in 133).
Lesbians, gays and bisexuals were more likely to be aged under 26 than heterosexuals and less likely to be aged over 65. Although there was no difference in ethnicity according to sexual orientation, LGB people were less likely not to have been interviewed in English. Gay/bisexual men, though not lesbians/bisexual women, were more likely to have a bachelor’s degree or higher.
Gay/bisexual men were not more likely to be unemployed than heterosexuals and did not differ in income; in women there was an interesting difference between lesbians and bisexual women. While both, perhaps unsurprisingly, were less likely to be unemployed than heterosexual women, lesbians were more likely to be in full-time jobs and have high income while bisexual women were more likely to have part-time jobs and low income. This may be an age effect, as non-heterosexual women under 35 were considerably more likely to describe themselves as bisexual rather than lesbian, whereas women over this age were more likely to describe themselves as lesbian than bisexual. Lesbian and bisexual women were more likely to have no health insurance and to have been unable to afford medical care in the last year than other women; there was no difference in men.
There were few differences in physical health between men of different sexual orientations. Lesbian and bisexual women were more likely to have multiple chronic conditions than heterosexual women, and lesbians were slightly more likely to complain of poor physical heath.
This was very much not the case when they were asked about psychological distress. In multivariate analysis, controlling for other factors like age, gay men were 2.8 times more likely to say they had severe psychological distress than heterosexual men, and bisexual men 4.7 times more likely. Bisexual women, though not lesbians, were 3.7 times more likely.
Gay men and bisexual women were twice as likely to be heavy drinkers, and lesbians and bisexual men three times as likely, as heterosexuals.
And gay men and lesbians were twice as likely to smoke, and bisexual men and lesbians twice as likely to be heavy smokers, than heterosexuals.
Although a number of previous surveys of the health of LGBT people have been done before in the US, they have either been self-referred, or studies of small clinics or locality populations. So, while these surveys generally reported higher rates of mental distress in LGBT people than the national average, there was no denominator and no direct comparison. This is the first national survey that establishes for sure that self-described LGB people are more likely to have severe psychological distress.
It also confirms another finding from previous surveys, namely that bisexual people – who may be less certain of their sexuality and more socially isolated – are more severely affected than lesbian or gay men.
It is worth defining 'severe psychological distress': it means that respondents said there had been more than 13 days in the last month when they had felt “nervous, hopeless or worthless; too sad to be cheered up; restless or fidgety; or that everything was an effort.” In other words, we are talking about a significant burden in terms of mood and subjective ability.
The researchers comment that “this study finds substantial health disparities in LGB adults in the US, potentially due to the stressors that LGB people experience as a result of interpersonal and structural discrimination.”
They draw particular attention to the fact that, as is not the case in other minorities, there was no significant association between income, education or ethnicity and psychological distress; it seems to hit people of all backgrounds and classes and therefore may be caused by non-economic stressors.
“Health practitioners should pay particular attention to the current and future health outcomes of this small, diverse and vulnerable population,” they conclude.
Gonzales G et al. Comparison of health and health risk factors between lesbian, gay and bisexual adults and heterosexual adults in the United States: Results from the National Health Interview Survey. JAMA Intern Medicine, early online publication. doi:10:1001/jamainternmed.2016.3432. June 2016.