Disproportionate exposure to early-life adversity and sexual orientation disparities in psychiatric morbidity☆
Introduction
Lesbian, gay, and bisexual (LGB) populations exhibit markedly elevated rates of psychiatric disorders compared to heterosexuals (Cochran and Mays, 1994, Fergusson et al., 1999, Gilman et al., 2001, Sandfort et al., 2001). These disparities emerge early in the life course; higher rates of both internalizing and externalizing psychopathology have been documented among LGB adolescents relative to their heterosexual peers, including depression, anxiety, and substance abuse (Corliss et al., 2008, Fergusson et al., 1999, Hatzenbuehler et al., 2008, Russell et al., 2002, Russell and Joyner, 2001, Safren and Heimberg, 1999, Ziyadeh et al., 2007). Population-based data indicate that adolescents who identify as gay, lesbian, or bisexual are between 3 and 4 times more likely to meet the diagnostic criteria for an internalizing disorder and between 2 and 5 times more likely to meet the criteria for an externalizing disorder than heterosexual adolescents (Fergusson et al., 1999). Rates of suicidal ideation and suicide attempt are also notably elevated among LGB adolescents as compared to heterosexuals, with most studies suggesting that at least one-third of sexual minority adolescents have contemplated suicide or made a suicide attempt (D’Augelli et al., 2001, Fergusson et al., 1999, Garofalo et al., 1999, Mustanski et al., 2010, Russell and Joyner, 2001). Despite the consistency of evidence regarding sexual orientation disparities in mental health, the mechanisms that explain the higher rates of psychiatric problems among LGB youths and adults have only recently become the focus of systematic empirical investigation (Hatzenbuehler, 2009). Indeed, the Institute of Medicine (2010) recently issued a report calling for increased research attention to the health of sexual minorities.
The most frequently invoked explanation for sexual orientation disparities in mental health is social stress, or the increased exposure to stressful social experiences related to membership in a socially disadvantaged and marginalized group (Meyer, 1995, Meyer, 2003a, Meyer, 2003b, Radkowsky and Siegel, 1997). Central to the social stress theory is the assertion that aspects of the social environment that foster and perpetuate stigma against sexual minority populations compromise their mental health (Hatzenbuehler, 2010, Meyer, 2003b). Indeed, LGB individuals experience high levels of discrimination at both individual (Diaz et al., 2001, Mays and Cochran, 2001, McLaughlin et al., 2010b) and institutional levels (Hatzenbuehler et al., 2009, Hatzenbuehler et al., 2010), including verbal and physical assaults, unfair treatment in housing and employment, and discriminatory marriage policies. Adolescents with same-sex attraction are more likely than adolescents with opposite-sex attraction to be victims of violence at school and in their communities (Faulkner and Cranston, 1998, Robin et al., 2002, Russell et al., 2001). Exposure to stigma, discrimination, and victimization are robust predictors of mental health problems and suicide attempts among LGB individuals (D’Augelli et al., 2005, Diaz et al., 2001, Hatzenbuehler, 2010, McLaughlin et al., 2010b, Rosario et al., 2002).
Emerging evidence suggests that LGB youths may also experience disproportionate victimization within their family and romantic relationships, and these early-life exposures are likely to further increase their risk for psychopathology. Several studies have observed higher levels of child physical and sexual abuse, as well as intimate partner violence (IPV), among LGB individuals relative to heterosexuals (Balsam et al., 2005, Corliss et al., 2002, Matthews et al., 2002, Tjaden et al., 1999). LGB adolescents are also at elevated risk of experiencing homelessness (Cochran et al., 2002, Fournier et al., 2009, Kruks, 1991, Van Leeuwen et al., 2006) partially due to expulsion following disclosure of their sexual orientation (Kruks, 1991). Homelessness may also result from victimization by caregivers or romantic partners (Cochran et al., 2002). Although these types of adverse childhood experiences are known risk factors for psychopathology among general population samples (Buckner and Bassuk, 1997, Campbell, 2002, Green et al., 2010, Kessler et al., 1997, McLaughlin et al., 2010a), few studies have examined whether exposure to early-life adversity and victimization explains, at least in part, the associations between sexual orientation and psychopathology. The one previous study examining this question found that exposure to child abuse partially explained sexual orientation disparities in tobacco and alcohol use in lesbian and bisexual women (Jun et al., 2010). This study provided important insights, but examined only two substance use outcomes using data from a community-based sample of female nurses, limiting generalizability of the results. Moreover, prior research has largely relied on convenience samples of LGB youths, which can cause biased inferences regarding the prevalence and mental health consequences of early-life adversities among LGB populations.
In the current report, we examine whether the prevalence of child abuse, housing adversity, and IPV is elevated among LGB youths relative to heterosexuals in a national sample of adolescents and young adults. We further evaluate whether exposure to these sorts of adverse early-life experiences is related to mental health problems in LGB youths. We hypothesized that greater exposure to these adversities would partially explain sexual orientation disparities in psychopathology.
Section snippets
Sample
Data are drawn from the National Longitudinal Study of Adolescent Health (Add Health), a longitudinal study of a nationally representative adolescent sample (Bearman, Jones, & Udry, 1995). The first wave was conducted in 1995 and included adolescents in grades 7–12 (n = 90,118) selected using a multi-stage stratified cluster sampling strategy. Adolescents completed in-school interviews, and a core sub-sample (n = 20,745; response rate 78.9%) completed in-depth home interviews. Adolescents in this
Sexual orientation and mental health
The prevalence or mean value of each mental health outcome among heterosexual, homosexual, and bisexual respondents is shown in Table 2. Elevated rates of every psychiatric outcome considered here were observed among LGB respondents relative to heterosexuals.
Associations between sexual orientation and mental health were examined in a series of multivariable regression models that adjusted for socio-demographics (see first column of Table 4). Lesbian/gay respondents were more likely to
Discussion
Gay/lesbian and bisexual individuals are more than twice as likely to meet the diagnostic criteria for a psychiatric disorder as compared to heterosexuals (Meyer, 2003b). Chronic experiences of stigma and discrimination have frequently been invoked as explanations for sexual orientation disparities in mental health (Meyer, 1995, Meyer, 2003a, Meyer, 2003b, Radkowsky and Siegel, 1997). In addition to these social stressors, research has also shown that LGB populations have higher rates of
Acknowledgements
This research uses data from Add Health, a program project directed by Kathleen Mullan Harris and designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris at the University of North Carolina at Chapel Hill. Special acknowledgment is due Ronald R. Rindfuss and Barbara Entwisle for assistance in the original design. Information on how to obtain the Add Health data files is available on the Add Health website (http://www.cpc.unc.edu/addhealth).
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This research was funded by grant P01-HD31921 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, with cooperative funding from 23 other federal agencies and foundations. No direct support was received from grant P01-HD31921 for this analysis. Analysis was funded by grant MH092526 the National Institute of Mental Health.