Mental Health and Suicidal Behavior: The Role of Sexual Orientation

A large body of epidemiological research has identified factors that put members of sexual minorities at risk for mental health problems, including depression, anxiety, and suicidal behavior. Research usually associates interpersonal discrimination with poor mental health outcomes among lesbian, gay, and bisexual people (LGB), including symptom rates well above those of heterosexual people for depression and anxiety,^1-4 emotional distress,^5,6 low self-esteem, ⁷ panic disorders, ⁸ suicide, and the risk of suicide.^4,9,10 Therefore, it is clear that mental health problems are more prevalent among sexual minorities than among heterosexuals ¹¹ due to exposure to social discrimination. ¹² In fact, sexual minority status seems to influence the probability of experiencing emotional stress and the likelihood of having or having had mental health problems, such as depression, eating disorders, and suicidal ideation in the past 12 months.^13,14

The minority stress model^15,16 posits that stigma, prejudice, and discrimination may increase psychological distress in sexual minority populations. As individuals develop a sense of self by interacting with others in society, repeated exposure to negative social interactions and stigma causes a higher risk for mental disorders; this is the case especially among LGB vulnerable groups such as bisexual, younger, and older individuals,^17,18 since they may face double or triple discrimination (e.g., biphobia and ageism). ¹⁹ These types of interaction translate into higher rates of mental health disorders among self-identified bisexual individuals, as well as among younger and older LGB individuals, including depression, anxiety disorders, substance abuse, and suicidal behavior. ²⁰

Suicide is one of the leading causes of death worldwide and represents a severe public health concern, since suicide rates have increased by 60% over the past 45 years, ²¹ despite the fact that there is a problem with masked suicides within registered undetermined deaths. ²² Although the etiology of suicidal behavior is multifactorial, several studies have demonstrated that sexual orientation has often played an important role in suicidal behavior, ²³ indicating that LGB people are at risk for suicidal behavior due to perceived stigma and psychopathology, especially anxiety and depression. However, protective determinants, such as community belonging, may reduce the risk. ²⁴

Further investigations of the influence of social contexts or norms on mental health disparities among sexual minorities are needed, but evidence shows that cultural effects do occur. For example, a study conducted in Portugal and Spain showed that Spanish sexual minority men presented higher levels of depressive symptoms than Portuguese sexual minority men ²⁵ ; thus, demonstrating that mental health meanings and experiences must be understood as intersecting with other salient personal, ethnic, cultural, and social identities. Hence, these variables may amplify the effects of victimization on adverse outcomes, ²⁶ leading to higher levels of depression, suicidal ideation, and suicide attempts. ²⁷ Cultural and social factors have the most direct role in the causation of mental problems, most likely because of the influence of specific variables in social and cultural contexts, including family support, coping styles, stigma, and access to health-care facilities. ²⁸

Two main systematic reviews on the documentation of the quality of mental health indicators among sexual minorities, with analysis combining data from over 230 studies and over 21,000 participants, have reported systematically poorer levels of mental health and higher levels of suicidal behavior among sexual minorities when compared to heterosexual groups.^29,30 Challenges such as stigma associated with sexual minorities, discrimination, lack of social and family support, social rejection, poverty, and violence are among the factors that may lead to mental health problems, since the impact of minority status on this vulnerable population is severe.

Inequality in the prevalence of mental health disorders among sexual minorities has been confirmed in many recent studies.^{9,17,18,20,29,30-32} These reports of increased rates of depression, anxiety, suicidal ideation, and attempts, and the likelihood of suicidal behavior for sexual minority individuals also suggested that bisexual individuals are more at risk for depression, anxiety, suicidal ideation, and the likelihood of suicidal behavior than gay and lesbian or heterosexual individuals. Previous studies have reported that bisexual people tend to experience more mental health problems,^1,33 due to a double stigma perpetuated by both heterosexual and gay and lesbian individuals.

Bisexuals are more likely to hide their sexual orientation to protect themselves from discrimination and stigma, which results in poorer psychological wellbeing and higher levels of internalized homonegativity.^34,35 In this sense, it seems that in comparison with gays or lesbians, bisexuals experience high levels of the three main stressors that make up the minority stress model: internalized homonegativity, stigma, and discrimination.^15,16,36

Mental health professionals should be aware that sexual orientation mediates suicidal behavior and that LGB subgroups vary when it comes to mental health functioning. It is also crucial to encourage professionals to reduce stigma and discrimination against LGB people and develop resilience and positive coping strategies ³⁷ to create a more favorable clinical environment and help sexual minority people identify risk factors for depression, anxiety, and suicidal behavior. This could help health and LGB organizations fight discrimination and bolster specific prevention programs aimed at sexual minority people.

On the other hand, the existence of positive values and social support mechanisms available in some societies indicates that the role of political and legislative measures in the lives of LGB individuals in contemporary society does not seem to contribute to safer psychosocial circumstances directly.^38,39 Hence, there is a need to reiterate local political and legislative efforts to normalize LGB identities, fighting continued institutional heterosexism and interpersonal intolerance. Mental health providers and mental health policymakers need to consider these guidelines if they are to address inequalities in mental health among these minority groups.

The circumstances around deaths by suicide among LGB individuals also require further investigation. A recent study of LGB youth ⁴⁰ found that the disparity between LGB and non-LGB suicides was greatest at younger ages, and each LGB subgroup had its own specific risk profile for suicide; for example, bisexual males were generally more likely to use firearms, have psychiatric diagnoses, have prior suicidality, and have family problems contributing to their deaths. Nevertheless, there is a problem with the codification of the cause of death by suicide among sexual minority individuals, since there is no routine or systematic collection of information about individuals’ sexual orientation and gender identity at the time of death. ⁴¹ Thus, the conclusion that a quarter of youth who die by suicide self-identify as LGB may be inflated. ⁴²

It becomes clear that giving attention to the mediating role of sexual orientation in the study of the relationship between mental health and suicidal behavior is an essential task, with relevant implications for health and social interventions and policy measures aimed at prevention. On the other hand, LGB-specific crisis services should play an important role in the improvement of mental health problems and suicide prevention, ⁴³ since many health-care providers are unprepared to treat LGB individuals. ⁴⁴

Although sexual minority populations in several Western countries currently enjoy an unprecedented degree of political and social acceptance, this is not the case for many countries across the globe. In fact, in several countries where legal, religious, and social norms restrict LGB identities through negative societal attitudes and discrimination, little is known on the impact of this stigmatization on mental health and suicidal behavior. Moreover, contributions on this topic would significantly impact the understanding of the many aspects of mental health and suicidal behavior among sexual minority people, from how mental health is perceived by mental health professionals and mental health systems to positively influencing the lives of LGB individuals. A tremendous amount of work remains to be done to reduce the overwhelming rates of mental health challenges and suicidal behavior that LGB individuals experience.

Focusing on enhancing the effectiveness of primary care and related services, while investing in prevention programs, resources, and research, should contribute to diminishing mental health disparities and allow further inclusion of sexual minority individuals. Sexual orientation needs to become a part of routine data collection so that inequalities in mental health and suicidal behavior can be more fully understood and addressed.