Empirical Research On Depression With Lgb Women And

It is difficult to determine rates of depression in the LGB population, because definitions of sexual orientation are inconsistent and/or unsophisticated in published reports. Many studies that define participants as lesbian or gay according to their self-reported sexual histories indicate higher rates of major depression (Cochran & Mays, 2000a, 2000b; Gilman et al., 2001; Sandfort, de Graaf, & Schnabel, 2001) and other acute psychological disorders. However, use of sexual behavior as a definition of sexual orientation is problematic (Cochran, Sullivan, & Mays, 2003). Consider the possible difference in reports of psychological distress between a man who is heterosexu-ally married but has secret, frequent sexual contact with men and an openly gay man with a loving, accepting family. The former is not likely to identify himself as a gay man, but he would be so classified in research that uses sex ual history as the defining factor. Furthermore, the heterosexually married man is more likely to have psychological distress about his hidden sexual life than is the openly gay man, yet his data would be included in the sample of gay men, subsequently increasing the rates of distress. Interpretation of such data is murky at best.

In response to this dilemma, Cochran et al. (2003) evaluated data from the MacArthur Foundation National Survey of Midlife Development in the United States (MIDUS; Brim et al., 1996). The MIDUS survey asked respondents to report whether their sexual orientation was heterosexual, gay, lesbian, or bisexual. To increase power in their analyses, Cochran and colleagues grouped gay and bisexual men and lesbian and bisexual women into two groups and compared them to heterosexual respondents. They report that gay and bisexual men were three times more likely to meet criteria for major depression than were heterosexual men, and that a large proportion of gay or bisexual men meeting criteria for one disorder were comorbid for two or more Axis I disorders. Higher rates of depression were not reported for lesbian or bisexual women, although higher rates of generalized anxiety disorder were reported, and they were more likely to be comorbid for two or more disorders than were heterosexual women meeting criteria for one disorder. The authors cites literature on the impact of stress and adversity on psychopathology as a possible explanation for these findings. Increased rates of certain psychological problems have been observed in LGB populations and are likely due to the stresses of being members of a marginalized group. Meyer (2003) also proposed a model of minority stress to account for the increased rates ofpsychological problems experienced by LGB individuals.

Although the report of higher rates of depression and anxiety in the Cochran et al. (2003) study is cause for concern about appropriate treatment of LGB people, it cannot be overlooked that more than half of the LGB sample (58%) in the MIDUS study did not meet criteria for any of the five disorders assessed, suggesting that most LGB individuals successfully form positive self-identity and live contented, "normal" lives. Those who do not internalize negative views about being LGB. This has been referred to as "internalized homophobia" (Malyon, 1981-1982); some behavioral psychologists prefer the term "homonegativity" to "homophobia," because disapproval or prejudice against a particular group may not qualify as a phobia per se, although it remains a socially undesirable behavior (Bernstein, 1994). It is unclear how rates of depression and anxiety are correlated to internalized homonegativity.

The impact of social environment on LGB adults often begins prior to adulthood. Several studies have looked at rates of suicidality in LGB youth. Although suicidality does not always indicate depression, the higher rates of suicide and attempted suicide in LGB (and most likely transgender) youth

(Remafedi, French, Story, Resnick, & Blum, 1998) are cause for concern. In a study of 350 LGB youth in a sample from the United States, Canada, and New Zealand, D'Augelli, Hershberger, and Pilkington (2001) found that 25% of the youth reported having seriously thought of suicide in the past year, and 22% of those said that the suicidal thoughts were related to their sexual orientation. Those youth who scored higher on measures of homonegativity, those whose parents did not know about their sexual orientation, and those whose parents rejected them were more likely to have attempted suicide. Safren and Heimberg (1999) compared a sample of LGB and heterosexual youth on factors related to depression, hopelessness, and suicidality. Initially they found group differences between the LGB youth and their heterosexual counterparts on these factors. However, when the investigators did further analyses, it appeared that the differences in the two groups were better accounted for by the effects of stress, social support, and coping through acceptance than by sexual orientation.

Hershberger and D'Augelli (1995) found a relationship between victimization and mental health problems in LGB youth. Family support and self-acceptance mediated the impact of victimization on mental health. D'Augelli (2002), in a study of 542 youth from community settings, found that over 33% of LGB youth reported a past suicide attempt, 75% had been verbally abused, and 15% reported having been physically attacked because of their sexual orientation. More symptoms were related to their parents not knowing about their sexual orientation or to both parents having a negative reaction to their child disclosing an LGB sexual orientation.

Harassment does not necessarily end for LGB people when they leave adolescence behind. In adults, experiencing heterosexism in the workplace is associated with higher levels of depression. Smith and Ingram (2004) found that reports of heterosexism in the workplace were infrequent, although they were related to emotional distress when they occurred. Just as social support has been shown to mediate emotional distress in LGB youth (Safren & Heimberg, 1999), being "out" or open about being lesbian or bisexual and participating in a lesbian or bisexual community has been associated with greater emotional well-being (Morris, Waldo, & Rothblum, 2001). Others have suggested that having a positive gay identity, being more "out," and being connected to an LGB community may be a protective factor for all LGB people when facing heterosexism (Smith & Ingram, 2004).

In summary, the literature suggests that most LGB youth and adults are well adjusted and manage to cope effectively with the stresses of being members of a sexual minority. Nevertheless, LGB youth are at greater risk for depression and suicidality, and LGB adults are at greater risk of depression and anxiety disorders than their heterosexual counterparts. It appears that mediating factors other than sexual orientation significantly contribute to this finding. LGB patients who receive more social support from family and community are better protected from depression and other emotional difficulties. Family reactions to disclosure of an LGB sexual orientation may be particularly important to LGB youth in both positive and negative ways. In general, it appears that accepting one's sexual orientation and disclosing it openly to others is associated with better emotional well-being. This is not the case with every LGB patient, however. Therapists need to allow patients to determine how they identify and how public they wish to be about their identity, while supporting those patients who may wish to disclose to others but do not do so out of fear.

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