Effects of Perceived Discrimination on Mental Health and Mental ...

Effects of Perceived Discrimination on Mental Health and Mental Health Services Utilization Among Gay, Lesbian, Bisexual and Transgender Persons Diana Burgess Richard Lee Alisia Tran Michelle van Ryn

ABSTRACT. Objectives. Previous research has found that lesbian, gay, bisexual and transgender (LGBT) individuals are at risk for a variety of mental health disorders. We examined the extent to which a recent experience of a major discriminatory event may contribute to poor mental health among LGBT persons. Methods. Data were derived from a cross-sectional strata-cluster survey of adults in Hennepin County, Minnesota, who identified as LGBT (n = 472) or heterosexual (n = 7,412). Results. Compared to heterosexuals, LGBT individuals had poorer mental health (higher levels of psychological distress, greater likelihood of having a diagnosis of depression or anxiety, greater perceived mental health needs, and greater use of mental health services), more substance use (higher levels of binge drinking, greater likelihood of being a smoker and greater number of cigarettes smoked per day), and were more likely to report unmet mental healthcare needs. LGBT individuals were also more likely to report having experienced a major incident of discrimination over the past year than heterosexual individuals. Although perceived discrimination was associated with almost all of the indicators of mental health and utilization of mental health care that we examined, adjusting for discrimination did not significantly reduce mental health disparities between heterosexual and LGBT persons. Conclusion. LGBT individuals experienced more major discrimination and reported worse mental health than heterosexuals, but discrimination did not account for this disparity. Future research should explore additional forms of discrimination and additional stressors associated with minority sexual orientation that may account for these disparities. KEYWORDS. Discrimination, homosexuality, mental health, minority groups/psychology, prejudice.

Recent research has shown that lesbian, gay, bisexual, and transgender (LGBT) individuals experience elevated rates of mental health disor-

ders relative to heterosexuals, even after controlling for variables such as age, race, educational background, and cohabitation/marital status

Diana Burgess, PhD, is affiliated with the Center for Chronic Disease Outcomes Research, Veterans Affairs Medical Center, Minneapolis, MN and the University of Minnesota, Department of Internal Medicine. Richard Lee, PhD, and Alisia Tran are affiliated with the University of Minnesota, Department of Psychology. Michelle van Ryn, MPH, PhD, is affiliated with the University of Minnesota, Department of Family Medicine and Community Health, and School of Public Health. Address correspondence to: Diana Burgess, PhD, Center for Chronic Disease Outcomes Research (CCDOR), VA Medical Center (152/2E), One Veterans Drive, Minneapolis, MN 55417 (E-mail: [email protected]). Diana Burgess is supported by a Merit Review Entry Program Award from VA HSR & D. Journal of LGBT Health Research, Vol. 3(4) 2007 Available online at http://www.haworthpress.com C 2007 by The Haworth Press. All rights reserved. doi: 10.1080/15574090802226626

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(S. D. Cochran, Mays, & Sullivan, 2003; King et al., 2003). For example, gay men have been found to experience higher prevalence of major depression, panic attacks, and symptoms of poor mental health than otherwise similar heterosexual men (S. D. Cochran, Keenan, Schober, & Mays, 2000; King et al., 2003), and a co-twin control study found a significant association between homosexuality and suicidal ideation (Herrell et al., 1999). Similarly, compared to otherwise similar heterosexual women, lesbian and bisexual women have been found to experience greater prevalence of generalized anxiety disorder, psychological distress, alcohol and drug dependency disorders, and more days of poor mental health within the past 30 days (S. D. Cochran et al., 2000; King et al., 2003; Sloane et al., 2003). Lesbians, gays, and bisexuals have also been found to be more likely to be smokers and to have used recreational drugs or alcohol compared to otherwise similar heterosexuals (Gruskin, Hart, Gordon, & Ackerson, 2001; King et al., 2003; Tang et al., 2004), although not all studies have found such differences (Warner et al., 2004). Although many of the determinants of elevated rates of mental disorders among LGBT individuals are unknown, researchers have identified psychosocial stress caused by stigmatization and the associated exposure to prejudice and discrimination as a major contributor (B. N. Cochran & Cauce, 2006; Meyer, 2003b). From a stress and coping framework, repeated experiences of discrimination have been shown to be sources of chronic stress, resulting in damage to the immune system, inflammatory disorders, and cardiovascular disease, as well as mental health disorders and cognitive impairment (see Mays et al., 2007, for a review). Indeed, a large body of work examining the impact of racial discrimination on mental and physical health has documented that experiences of discrimination are associated with poorer mental health (e.g., depression, anxiety, psychological distress), and physical health (e.g., hypertension, self-rated health; Mays, Cochran, & Barnes, 2007; Williams, Neighbors, & Jackson, 2003). Individuals may also cope with the stress of discrimination through the

use of substances like alcohol and cigarettes and, indeed, discrimination has been associated with increased consumption of cigarettes and alcohol (Mays et al., 2007; Williams et al., 2003). Another pathway by which perceived discrimination may harm health, which has garnered much less attention by researchers, has been its role in diminishing the likelihood that individuals will seek needed medical and mental health treatment. There is emerging evidence that perceived discrimination is associated with a lower likelihood that individuals will seek and obtain needed health care services such as preventive health care (Trivedi & Ayanian, 2006; Van Houtven et al., 2005). However, there remains a need for additional studies examining the effect of perceived discrimination on individuals’ reluctance to seek care, including studies that examine unmet mental health care needs. LGBT persons are exposed to very high levels of harassment and discrimination (Herek, Gillis, & Cogan, 1999; Meyer, 2003b), both directly and through portrayals in the media and arts. Moreover, in contrast to other socially stigmatized groups, LGBT persons have less protection from discrimination under the law. Federal law does not prohibit discrimination based on sexual orientation, and only 20 states offer protection against such discrimination (Task Force, 2008). Negative attitudes towards gays and lesbians also may be particularly virulent because many religious groups openly condemn homosexuality and view homosexuality as an immoral lifestyle choice. Consistent with this, negative attitudes toward homosexuality are greater among individuals who possess a more traditional religious ideology and those with higher levels of church attendance (Herek, 1984, 1987, 1998; Herek & Capitanio, 1996). There are few studies examining the effect of discrimination on the mental health of the LGBT population (S. D. Cochran et al., 2001), particularly relative to the numerous studies focused on African Americans and other racial minorities (e.g., Williams et al., 2003). However, the few extant studies have documented the deleterious effect of discrimination on the mental health of persons of minority sexual orientation. For example, LGBT men and women who have experienced antigay hate crimes are more likely to

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experience depressive symptoms than those who have experienced nonbias-related crimes (Herek et al., 1999). Experiences of perceived discrimination also have been found to be associated with higher rates of depressive symptoms among a convenience sample of Asian and Pacific Islander gay men (Yoshikawa, Wilson, Chae, & Cheng, 2004) and similarly have been found to be associated with symptoms of mental distress (anxiety, depression, and suicidal ideation) among gay and bisexual Latino men (Diaz, Ayala, & Bein, 2004; Diaz, Ayala, Bein, Henne, & Marin, 2001). Other studies of homosexual men have found perceived discrimination to be associated with risky behavior, including unsafe sex (Wong & Tang, 2004; Yoshikawa et al., 2004). In addition, in one study, reported experiences of discrimination mediated the relationship between sexual orientation and psychiatric morbidity (Mays & Cochran, 2001), suggesting that greater prevalence of discrimination experienced by nonheterosexuals may account for disparities in mental health. This study, however, was limited by a small sample of homosexual and bisexual respondents (n = 73). Unfortunately, much of the existing research in this area has been fraught with methodological problems, including the reliance on convenience samples “who may be very different than the general LGB population to which one wants to generalize” (Meyer, 2003a, p. 685; see also B. N. Cochran & Cauce, 2006; Mays & Cochran, 2001), and small sample sizes. The validity of other studies has also been limited by the use of an indirect measure of sexual orientation in which sexual orientation is inferred from samegender sexual activity, rather than being asked directly. This is problematic because sexual orientation is a broader construct than sexual behavior. Assessing sexual behavior may include heterosexual individuals who engage in samegender sexual behavior, but who do not experience the same type of social stigma compared to those identifying as gay, lesbian, bisexual, or transgender. Last, with the exception of the study by Mays and Cochran (2001), discussed previously, most of the research examining the effects of harassment and discrimination on mental health has lacked heterosexual comparison groups, making it difficult to determine whether

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higher rates of mental health disorders among LGBT individuals, relative to heterosexuals, are due to greater exposure to discrimination and harassment. This study makes important contributions to the epidemiological research on sexuality, social bias, and mental health by using data from a population-based survey of adults in Hennepin County, MN to: (a) investigate the prevalence of mental health symptoms and diagnoses and discriminatory experiences among a relatively large sample of self-identified gay, lesbian, bisexual, and transgender individuals (n = 472) versus heterosexual individuals (n = 7412); (b) examine the effect of sexual orientation on utilization and underutilization of mental health services; and (c) explore the extent to which experiencing one or more discriminatory events in the past year mediates potential disparities in mental health between LGBT and heterosexual individuals. Given the mixed evidence as to whether LGBT individuals are more or less likely to seek mental health treatment relative to heterosexuals (Bakker, Sandfort, Vanwesenbeeck, van Lindert, & Westert, 2006; S. D. Cochran et al., 2003; King et al., 2003; White & Dull, 1997), this study explores both participant reports of receipt of clinical diagnoses for mental health problems as well as their subjective reports of mental health symptoms. Our primary hypothesis is that mental health problems and underutilization of mental health care would be greater among LGBT individuals compared to heterosexual individuals and that perceived discrimination would mediate the effect of sexual orientation on mental health problems and underutilization of mental health care.

METHODS The present study is a secondary analysis of a larger study, the Survey of the Health of Adults, the Population and the Environment (SHAPE) (Hennepin County Community Health Department and Bloomington Division of Public Health, 2003). The SHAPE survey was a collaborative public health surveillance project of Hennepin County Community Health Department, the Minneapolis Department of Health and Family Support, and the Bloomington

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Public Health Division, Minnesota, with the primary aim of providing estimates on major health indicators for 16 urban and suburban regions within Hennepin County, for six ethnic and racial groups: American Indians, Southeast Asians, U.S.-born Blacks, African-born Blacks, Hispanics or Latinos, and Whites. The study consisted of telephone interviews conducted on a disproportionate stratified random sample of 9,959 adults residing in Hennepin County, Minnesota during 2002. More details about the survey methods can be found in the SHAPE Methodology Report (Hennepin County Community Health Department and Bloomington Division of Public Health, 2003). Respondents were selected at random through a two-stage process. First, households were randomly selected from a telephone list containing published and unpublished numbers; next, one adult was randomly selected from each household for a telephone interview. In total, 15,237 households were contacted and 10,098 interviews were completed, representing a response rate of 66.3% for the county as a whole. Sexual orientation was ascertained by the following question, “Do you consider yourself . . . ‘heterosexual or straight,’ ‘gay or lesbian,’ ‘bisexual,’ ‘transgender,’ ‘not sure,’ ‘don’t know’?” This investigation focuses on only those respondents who reported their sexual orientation (total N = 7,884).

Measures Perceived discrimination was measured by adapting the Experience of Discrimination (EOD) questions from the Coronary Artery Risk Development in Young Adults study that were originally developed by Krieger (1990; Krieger & Sidney, 1996). Respondents were first asked if they had ever experienced any of the following during the past 12 months: getting a job, being at work, medical care, getting housing, getting a mortgage or loan, applying for social services or public assistance, dealing with the police. For each situation that they experienced, they were then asked if they experienced discrimination. After providing their perceptions of discrimination for each of the seven situations, respondents were then asked the reason or reasons that they

felt discriminated against and were given choices of race, color, ethnicity, or country of origin; age; gender; sexual orientation; disability; religion; something else; or don’t know. Although there has not been extensive documentation of the psychometric properties of this early version of the EOD, a recent evaluation of a subsequent version of the EOD has shown the measure to have high scale reliability, test–retest reliability, and construct reliability, and to be superior to singleitem discrimination scales (Krieger, Smith, Naishadham, Hartman, & Barbeau, 2005). In this study, perceived discrimination was defined as having perceived oneself to have been discriminated in any of the specified situations over the past year. Mental Health Indicators. We included several indicators of poor mental health: mental health diagnoses, psychological distress, perceived need for mental health care, and utilization of mental health services. Respondents were asked whether “a doctor or other health professional has ever told you that you had any of the following conditions,” which included “depression” and “anxiety or panic attack.” Those who answered affirmatively were classified as having had a mental health diagnosis (of depression or anxiety). Psychological distress was assessed by the following question: “Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?” Perceived need for mental health care was assessed by the following question, “In the past 12 months was there a time when you wanted to talk with or seek help from a health professional about stress, depression or problems with emotions?” Use of mental health services was assessed with questions asking whether, over the past 12 months, participants sought help from (a) a mental health provider or counselor, or (b) self-help or support groups. Substance Use. We also examined the two available measures of substance use: smoking and binge drinking. Smoking status was ascertained by a question asking respondents whether they smoked cigarettes “everyday, some days, or not at all?” and recoding respondents who smoked “everyday” and “some days” as smokers, and those who smoked “not at all” as

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nonsmokers. We also examined smokers’ selfreported average number of cigarettes smoked per day. We classified respondents as binge drinkers if they reported having five or more drinks on a single occasion within the past 30 days. Unmet Mental Health Care Needs. We examined unmet mental health care needs during the past 12 months, via questions adapted from the Behavioral Risk Factor Surveillance System (Prevention, 2001). Respondents were classified as having unmet mental health care needs if they reported yes to both of the following questions: “In the past 12 months, was there a time when you wanted to talk with or seek help from a health professional about stress, depression, or problems with emotions?” and, “Did you delay or not get the care you thought you needed?” Covariates. We included age, gender, race/ ethnicity, education, and poverty level as covariates because they have been shown to be associated with mental health, mental health utilization, and/or perceived discrimination in previous research. Prevalence of depression, for instance, has been shown to be greater among women and low-income individuals, and lower among Asians, Hispanics, and Blacks (Hasin, Goodwin, Stinson, & Grant, 2005; Kessler et al., 1993). Prevalence of psychological distress has been shown to be greater among women, non-White, and lower socioeconomic status individuals (Fiscella & Franks, 1997; Myer, Stein, Grimsrud, Seedat, & Williams, 2008; Turner & Marino, 1994). Receipt of mental health treatment, on the other hand, has been shown to be greater among women and lower among non-Hispanic Whites and lower socioeconomic individuals (Elhai & Ford, 2007; Hasin et al., 2005; Kessler et al., 2005; Wamala, Merlo, Bostrom, & Hogstedt, 2007). Several of these covariates have also been associated with perceived discrimination. Perceived discrimination has consistently been shown to be higher among non-Whites, although the relationship between perceived discrimination and other socio-demographic variables (age, income, education) is less clear cut (Clark, Anderson, Clark, & Williams, 1999; Kessler, Mickelson, & Williams, 1999; Vines et al., 2006). We also in-

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cluded insurance status because lesbian women have been found to be less likely to have health insurance (S. D. Cochran et al., 2001; Diamant, Wold, Spritzer, & Gelberg, 2000), which may affect utilization of mental health services. Finally, we included English language proficiency as a covariate, because it has been associated with disparities in mental health care utilization (Sentell, Shumway, & Snowden, 2007). For this measure, respondents who were interviewed in any of the four translated languages (Hmong, Vietnamese, Spanish, or Somali) were classified as having limited English language proficiency. Statistical Analysis. Logistic and multiple regression methods were used to estimate the relationships between sexual orientation and mental health indicators and perceived discrimination, controlling for gender, age, race/ethnicity, marital status, educational attainment, income, insurance status, and English language proficiency.1 Because race/ethnicity is highly correlated with perceived discrimination, we repeated analyses with only non-Hispanic White respondents to control for potential confounding, an approach taken by Mays and Cochran (2001). We report these analyses after our presentation of the results using the whole sample. In some instances, we also report results from unadjusted comparisons (χ 2 and ANOVA) to provide descriptive information about our sample, such as the prevalence of discrimination and mental health disorders.

RESULTS Demographic Characteristics Demographic characteristics of the sample by sexual orientation status and results of statistical tests are presented in Table 1. Of the 4,529 (57.4%) women and 3,355 (42.6%) men comprising the final sample (total N = 7,884), 3,051 (90.9%) men and 4,361 (96.3%) women identified as heterosexual, whereas 304 (9.1%) men and 168 (3.7%) women identified as LGBT. In total, 356 respondents (4.5%) identified as gay or lesbian, 110 (1.4%) identified as bisexual, and 6 (.1%) identified as transgender. Compared to heterosexuals, those identifying as LGBT were

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TABLE 1. Characteristics of the SHAPE Sample by Sexual Orientation

∗ Female,

% (N) age (SD) ∗ Non-Hispanic white, % (N) ∗ Education Less than high school, % (N) High school, % (N) Some college, % (N) College or higher, % (N) Income .05, ns; getting medical care, χ 2 (5518) = .18, p > .05, ns; getting housing, χ 2 (1197) = .57, p > .05, ns; getting a mortgage or loan, χ 2 (1648) = .00, p > .05, ns; applying for social services or public assistance, χ 2 (577) = .14, p > .05, ns; and dealing with the police, χ 2 (1687) = .64, p > .05, ns. Reported reasons for discrimination differed by sexual orientation. Among the LGBT respondents who reported experiencing discrimination, 51% reported that the discrimination was due to their sexual orientation. The rest attributed the discrimination to gender (21%); race, ethnicity, or country of origin (21%); age (9%); religion

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TABLE 3. Mental Health Disorders, Substance Abuse, and Unmet Mental Health Needs by Sexual Orientation LGBT Depression diagnosis, % (N ) Anxiety/panic attack diagnosis, % (N ) Mean number of poor mental health days in past 30 days (SD) Perceived need for mental health services, % (N) Saw mental health provider, % (N) Attended a self-help group, % (N) Smoker, % (N) Mean number of cigarettes smoked daily (SD) Engaged in binge drinking in past 30 days, % (N) Unmet mental health needs (among those reported needing mental health services), %(N)

33.0 (155) 20.8 (98) 4.50 (7.59) 40.7 (191) 30.3 (143) 17.8 (84) 34.0 (160) 1.64 (.96) 24.2 (113) 42.9 (82)

Heterosexual 15.6 (1152)a,b 9.7 (714)a,b 2.81 (6.46)a,b 23.7 (1755)a,b 14.2 (1050)a,b 10.4 (765)a,b 23.2 (1712)a,b 1.41 (.81)a,b 16.7 (1223)a 34.7 (606)a,b

Notes. a Effect of sexual orientation significant at p < .05 in unadjusted analyses. b Effect of sexual orientation significant at p < .05 after controlling for the effects of gender, age, race/ethnicity, marital status, educational attainment, income, insurance status, and English language proficiency.

(3%); and disability (5%). Among the heterosexual respondents who reported experiencing discrimination, only 2% reported sexual orientation as a reason for the discrimination. Instead, the most prevalent perceived cause of discrimination among heterosexuals was race, ethnicity or country of origin (50%). Other perceived reasons for the discrimination among heterosexuals were age (16%), gender (19%), disability (5%), and religion (3%). Effect of Sexual Orientation on Mental Health, Substance Use and Underutilization of Mental Health Services. Table 3 presents differences in mental health, substance use, and underutilization of mental health care by sexual orientation. In unadjusted analyses, LGBT individuals had a greater number of poor mental health days, F (1,7805) = 29.70, p ≤ .001; higher likelihood of receiving a diagnosis of depression, χ 2 (7850) = 96.06, p ≤ .001, or anxiety, χ 2 (7841) = 58.96, p ≤.001; higher perceived need for mental health care, χ 2 (7865) = 68.42, p ≤ .001; greater likelihood of having seen a mental health provider χ 2 (7878)= 89.72, p ≤ .001, or having attended a support group, χ 2 (7854)= 25.43, p ≤ .001; greater likelihood of being a smoker, χ 2 (7858) = 28.77, p ≤ .001; greater number of cigarettes smoked, F (1,7806) = 34.39, p ≤ .001; higher likelihood of binge drinking during

the past 30 days, χ 2 (7792) = 17.39, p ≤ .001, and were more likely to have unmet mental health care needs, χ 2 (1938) = 5.11, p ≤ .05. After controlling for gender, age, race/ ethnicity, marital status, educational attainment, income, insurance status, and English language proficiency, most of these variables remained significant. LGBT respondents reported a greater number of poor mental health days than heterosexual respondents (β = .06, t = 4.69, p ≤ .001) and were more likely to have received a diagnosis of depression (adjusted OR = 1.68; 95% CI = 1.50, 1.89) or anxiety (adjusted OR = 1.56; 95% CI = 1.36, 1.78) and to report that they needed mental health care over the past 12 months (adjusted OR = 1.52; 95% CI = 1.37, 1.70). Compared to heterosexuals, LGBT respondents were more likely to report that they saw a mental health provider (adjusted OR = 1.62; 95% CI = 1.42, 1.80) and to report that they attended a self-help or support group (adjusted OR = 1.39; 95% CI = 1.21, 1.59). LGBT individuals also reported higher levels of substance use. They were more likely to be smokers (adjusted OR = 1.21; 95% CI = 1.08, 1.35) and reported smoking more cigarettes per day relative to heterosexual respondents (β = .05, t = 3.37, p ≤ .01). However, LGBT individuals were no more likely than heterosexual individuals to have engaged in binge drinking

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over the past 30 days (adjusted OR = 90; 95% CI = .79, 1.02). Finally, LGBT individuals were more likely than heterosexual individuals to report unmet mental health care needs (adjusted OR = 1.19; 95% CI = 1.01, 1.42). Does Perceived Discrimination Account for the Influence of Sexual Orientation on Mental Health and Mental Health Utilization? To test the hypothesis that experiencing one or more major discriminatory events in the past year would mediate the effect of sexual orientation on mental health, we conducted separate hierarchical logistic or multiple regression analyses, depending on whether the dependent variable was categorical or continuous. In the first block, we adjusted for gender, age, race/ethnicity, marital status, educational attainment, income, insurance status, and English language proficiency; we entered sexual orientation in the second block; and we entered discrimination in the third block. We also tested the interaction between sexual orientation and discrimination to determine if discrimination functions differently for LGBT and heterosexual individuals. This interaction term was statistically significant only in the model predicting for subjective mental health. After the inclusion of socio-demographic variables and sexual orientation, discrimination was associated with having received a diagnosis of depression (adjusted OR = 2.12; 95% CI = 1.82, 2.48) or anxiety (adjusted OR = 2.15; 95% CI = 1.80, 2.57), perceived mental health needs (adjusted OR = 2.33; 95% CI = 2.04, 2.67), having seen a mental health provider (adjusted OR = 1.72; 95% CI = 1.47, 2.03), and having attended a self-help group (adjusted OR = 2.11; 95% CI = 1.77, 2.52). Discrimination was also associated with being a smoker (adjusted OR = 1.58; 95% CI = 1.38, 1.82) and number of cigarettes smoked per day (β = .09, t = 7.37, p ≤ .0005), but was not associated with binge drinking (adjusted OR = 1.15; 95% CI = .97, 1.36). In addition, discrimination was associated with unmet mental health needs (adjusted OR = 1.30; 95% CI = 1.04, 1.63). As mentioned, there was a significant interaction between discrimination and sexual orientation for number of poor mental health days (β = .05, t = 2.27, p ≤ .05), such that discrimination was associated with

more poor mental health days for heterosexual respondents (β = .14, t = 10.74, p ≤ .0005) but not for LGBT respondents (β = .02, t =.31, p > .05, ns). In contrast to expectations, hierarchical regression equations revealed that adding the perceived discrimination variable to the model did not significantly change the relation between sexual orientation and any of the mental health and substance abuse indicators, nor did it change the relation between sexual orientation and unmet mental health needs. Effect of Sexual Orientation on Discrimination, Mental Health, Substance Use, and Unmet Mental Healthcare Needs Among Non-Hispanic Whites. When we repeated the unadjusted analyses using the subsample of non-Hispanic Whites, the effect of sexual orientation on discrimination was more pronounced. Among non-Hispanic Whites, 26.4% of LGBT respondents (n = 105) reported experiencing at least one situation of discrimination in the past year, in contrast to 17.3% (n = 852) of heterosexual respondents, χ 2 (5332) = 20.77, p ≤ .001. Among nonHispanic Whites, LGBT respondents were more likely to report experiencing discrimination in the workplace, 19.1% (n = 71) versus 11,2% (n = 490), χ 2 (4750) = 20.74, p ≤ .0005, and in encounters with the police, 21.7 % (n = 26) versus 12.9% (n = 140), χ 2 (1205) = 6.99, p ≤ .01. There were no significant differences between LBGT and heterosexual respondents for discrimination in any of the other situations. In multivariate analyses examining the effect of discrimination, mental health, and substance use, results for the sample of non-Hispanic Whites mirrored the results for the entire sample, with two exceptions: after adjusting for covariates, LGBT status was not significantly associated with being a smoker (adjusted OR = 1.12; 95% CI = .97, 1.30) and was not significantly associated with unmet mental health needs (adjusted OR = 1.40; 95% CI = .97, 1.41).

DISCUSSION This study is one of the few population-based studies to examine the effects of perceived discrimination on the mental health and mental

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health utilization of LGBT individuals. Consistent with previous research, in comparison to similar heterosexual persons, LGBT persons consistently scored poorer on a variety of mental health indicators, which included more self-reported symptoms of poor mental health, a greater perceived need for mental health services, greater use of mental health services and higher levels of smoking, as well as formal psychiatric diagnoses (depression and anxiety disorders). LGBT persons were also more likely than their heterosexual counterparts to smoke, smoked a greater number of cigarettes, and were more likely to report an episode of binge drinking in the past 30 days (in the unadjusted analysis), which suggests the use of substances as a way to cope with stresses associated with minority sexual orientation. A strength of this study is its examination of a broad range of mental health indicators, which offsets some of the limitations posed by specific measures. For instance, our measure of substance abuse was limited to a fairly insensitive indicator (binge drinking), and thus we may not have fully captured the responses to the stress of discrimination in the form of alcohol consumption. Another limitation concerns our measure of psychiatric diagnoses, which assessed lifetime diagnoses. This is problematic because the measure of perceived discrimination assessed discriminatory incidents over the past year. Moreover, the use of psychiatric diagnoses as an indicator of poor mental health may be problematic, given the evidence that a high percent of individuals do not seek formal care for mental disorders (Kessler et al., 2005) and that failure to seek necessary health care has been shown to be greater among individuals who have previously experienced discrimination (Wamala et al., 2007). Indeed, LGBT individuals in this sample were also more likely to report unmet mental health needs than heterosexual individuals, a finding that is particularly troubling, given the higher prevalence of mental health disorders in this population. Given the limitations of specific measures, it is the pattern of results across a variety of measures of mental health rather than any single result that lends credence to the broader conclusion that poor mental health is a correlate of perceived discrimination.

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LGBT individuals were also more likely to report having experienced an incident of discrimination over the past year, relative to heterosexual individuals. In the entire sample, LGBT individuals were more likely to report experiencing discrimination in the workplace over the past year relative to heterosexual individuals but were not more likely to report discrimination in other settings (e.g., dealing with the police, getting housing). When the sample was restricted to non-Hispanic Whites, however, sexual minority status was also associated with discrimination in dealing with the police. This pattern of discrimination is similar to what was reported in a national study by Mays and Cochran (2001), who, in their examination of lifetime experiences of discrimination, found that sexual minority individuals were more likely to report being fired from a job, but did not report significantly greater levels of discrimination for any of the other 10 domains examined. Although perceived discrimination was associated with almost all indicators of poor mental health, adjusting for discrimination did not significantly reduce mental health disparities between heterosexual and LGBT persons. The finding that experiencing a major discriminatory event in the past year did not mediate the effect of being LGBT on mental health is inconsistent with results of a national study conducted in 1995 (Mays & Cochran, 2001) in which perceived discrimination attenuated the relation between sexual orientation and three mental health indicators. However, Mays and Cochran’s (2001) study used two measures of discrimination that assessed lifetime occurrences of major discrimination (e.g., workplace discrimination, being denied housing) and the frequency of everyday discrimination, such as “being treated with less courtesy or respect than others; receiving poorer services than others at restaurants or stores; being called names, insulted, threatened, or harassed; or having people act afraid of the respondent or as if the respondent was dishonest, not smart, or not as good as they were” (p. 1870). Although the measure of discrimination used in our analyses, having experienced discrimination over the past year, was associated with almost all of the indexes of poor mental health

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that we examined, this measure may not have fully captured the range of stressors experienced, or stress responses exhibited. by LGBT individuals. Conceptual models examining the particular stressors experienced by LGBT persons, such as Meyer’s minority stress model include not only “external objective stressful events and conditions” (such as discrimination) but also “expectations of such events and the vigilance this expectation requires, and the internalization of negative attitudes, and concealment of one’s sexual orientation” (Meyer, 2003b, p. 676). Measures of perceived discrimination such as the one used in this survey were not designed to capture the stressors associated with being vigilant and stressors associated with hiding one’s discrimination (i.e., indirect experiences of heterosexism). Other measures, such as Waldo’s (1999) measure of heterosexist experiences, which capture a range of negative situations that LGBT individuals may experience because of their sexual orientation, such as direct, as well as indirect, experiences (e.g., feeling that one needed to “act straight”), capture a broader range of social stressors specific to sexual minorities that may account for disparities in mental health. In addition, our measure of perceived discrimination included discrimination on the basis of a number of factors (e.g., age, disability, ethnicity) and, therefore, was not limited to discrimination based solely on sexual orientation. We did not use the measure of discrimination based solely on sexual orientation because it was so highly correlated with sexual orientation and, therefore, posed problems for the comparative nature of our statistical analysis. Another limitation of our study is the fact that we did not assess whether individuals disclosed their sexual orientation within the situations that they experienced discrimination. Disclosure of sexual orientation is particularly relevant to understand the social stressors experienced by sexual minority persons in the workplace, because the factors that predict perceived discrimination in the workplace (e.g., organizational policies barring discrimination based on sexual orientation) may be the same factors that make it less likely that sexual minority individuals will disclose their sexual identity/orientation.

Hence, individuals who experience a workplace climate that leads them to hide their sexual orientation may not directly experience discrimination, but may nonetheless experience the deleterious psychological consequences of heterosexism in the workplace. A related limitation of the available dataset was the omission of questions assessing how respondents coped with the discrimination they experienced, which has been shown to moderate the relation between adverse events (including discrimination) and physical and psychological health (Clark et al., 1999; Noh, Beiser, Kaspar, Hou, & Rummens, 1999; Noh & Kaspar, 2003). Our operationalization of LGBT also has certain strengths and limitations. An important strength is that our self-report measure was specifically worded to assess sexual identity, unlike some previous studies that defined sexual orientation in terms of same-gender sexual behavior (see S. D. Cochran et al., 2003, for a discussion). The operationalization of sexual orientation solely in terms of same-gender sexual behavior has been critiqued on the grounds that it is, on one hand, too narrow, failing to index individuals who have a minority sexual orientation in the absence of sexual behavior, and, on the other hand, it is too broad, indexing individuals who may consider themselves to be heterosexual despite their behavior (S. D. Cochran et al., 2003). However, a limitation of our operationalization is that, due to our small sample of sexual minority individuals, we collapsed bisexual, lesbian, gay, and transgender respondents into a single category. Hence, we were not able to explore potentially important differences within the LGBT population and examine subgroups, such as bisexual individuals and transgender individuals, who may be particularly at risk for mental health problems (Jorm, Korten, Rodgers, Jacomb, & Christensen, 2002) and stigmatization (Nemoto, Operario, Keatley, Nguyen, & Sugano, 2005). Additionally, the small number in the LGBT sample did not allow us to examine the effect of multiple stigmatized statuses, such as race/ethnicity, on perceived discrimination and mental health, or allow us to test for generational and cohort effects. Our findings were also limited by the fact that the data were derived from respondents in

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Hennepin County, Minnesota. Minnesota is one of only 20 states that ban discrimination based on sexual orientation, and one of only 13 states with an explicitly transgender-inclusive nondiscrimination law (Task Force, 2008). Because legislative policies toward discrimination based on sexual orientation, as well as individual organizational policies, have been shown to be associated with antigay discrimination and heterosexism (Ragins & Cornwell, 2001; Waldo, 1999), Minnesota’s relatively progressive stance on LGBT issues may explain why LGBT individuals were not more likely than heterosexuals to experience discrimination in other domains. Likewise, it seems plausible that the prevalence of discrimination and the psychological consequences of discrimination may be lower for LGBT respondents in our sample relative for individuals in other parts of the country. This hypothesis could be tested using a national sample and a multilevel approach that includes institutional-level measures expected to be associated with discrimination, such as the presence of state laws that protect LGBT employees from discrimination, as well as individual-level perceptions of discrimination (Ragins & Cornwell, 2001). Despite these limitations, this study makes several important contributions to the understanding of mental health among LGBT individuals. In addition to being one of the few population-based studies that examines the impact of perceived discrimination on mental health and mental healthcare utilization among LGBT individuals, to our knowledge, this is the only published study to investigate the effect of sexual orientation and recent experience of a major discriminatory event on underutilization of mental health care services. Although LGBT individuals were more likely to perceive themselves as needing mental health care and were more likely to utilize mental health services, they were also more likely than heterosexual individuals to report that they did not receive mental health services, or that such services were delayed. This is particularly striking, given that minority sexual orientation was not associated with elevated discrimination in the healthcare setting. These results support the notion that experiences of discrimination, in addition to being a life stres-

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sor that harms mental health and increases substance use, also has a negative impact on mental health by increasing the likelihood that individuals will avoid seeking needed mental health care services, perhaps until issues become more critical or urgent. It may be the case that experiences of discrimination may engender negative expectations among stigmatized groups about how they will be treated within larger institutional systems, making them wary of entering those situations. Future research in laboratory and field settings are needed to test the hypothesis that perceived discrimination in a particular domain can affect individuals’ expectations of discrimination in a broader range of settings. Given that researchers have also found that lesbians are more likely than heterosexual women to underutilize needed preventive health services (Stevens, 1992; Valanis et al., 2000; White & Dull, 1997), it further would be useful to examine the extent to which perceived discrimination may be a factor in such treatment seeking and utilization decisions. Researchers might also examine the factors that attenuate the negative association between perceived discrimination and underutilization of needed mental health care. For example, does this association disappear if LGBT individuals have the option of seeking mental health services from organizations specifically designed to help individuals of minority sexual orientation? In sum, these results illustrate how, within the LGBT population, perceived discrimination is a significant risk factor for mental health disorders, as well as underutilization of needed mental health care services. Hence, interventions to improve the mental health of this population need to be attuned to the deleterious impact of the social stressors associated with sexual minority status.

NOTE 1. We also conducted analyses that included a gender × sexual orientation interaction term in the second block. This interaction term was not significant for any analysis so we did not include this term in our final analyses.

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