ABSTRACT Human sexuality plays a major role in an individual’s existence and functioning. In addition, rightly or wrongly sexuality often defines people and also affects social attitudes. These attitudes, if negative, can contribute to stigma and prevent people from help

Sexuality and mental health: Issues and what next?

Gurvinder Kalraa, Antonio Ventrigliob & Dinesh Bhugrac

aFlynn Inpatient Psychiatric Unit, La Trobe Regional Hospital (LRH), LRH Mental Health Services, Traralgon, Victoria, Australia; bDepartment of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy;

c Health Service and Population Research Department, Institute of

Psychiatry, King’s College London, De Crespigny Park, London, UK

ABSTRACT Human sexuality plays a major role in an individual’s existence and functioning. In addition, rightly or wrongly sexuality often defines people and also affects social attitudes. These attitudes, if negative, can contribute to stigma and prevent people from help seeking if they are suffering from mental health problems. Recent changes in policy towards same-sex relationships have been positive in many countries including the UK and the USA, whereas in others such as Russia and Uganda attitudes have become more negative and punitive. Sexual activity is seen as having both pleasurable and procreational functions which contribute to society’s attitudes to homosexual behaviour. Inevitably, individual responses to their own sexuality and sexual behaviour will be influenced by social attitudes. To ensure that those with various sexual variations can access psychiatric services without discrimination, various levels of interventions are needed. Here we discuss different levels of intervention and organizational change that may make it possible. Social organization and institutional organization of services need to be sensitive, especially as rates of many mental disorders are high in individuals who may be sexually variant. Those providing services need to understand their own negative attitudes as well as prejudices to ensure that services are emotionally accessible.

ARTICLE HISTORY Received 11 May 2015 Accepted 10 September 2015 Published online 6 November 2015

KEYWORDS Homosexuality, mental health services, sexual varia- tion, organisations

Introduction

Sexuality is an integral and crucial part of any individ- ual’s personal identity that defines individuals as distinct from others. Sexual orientation and sexual acts enable individuals to connect with others at varying levels of intimacy. Sexuality or sexual orientation needs to be differentiated from sexual act or sexual behaviour as well as sexual fantasy. Often sexual orientation and sexual behaviour are seen as synonymous. This is a mistake that is often made in policy, thereby adding to negative attitudes.

Although sexuality as such is a much wider concept, it has recreational (pleasure-based) or procreational (reproductive) functions. Recreational sex is seen as a purely pleasurable activity. However, seeing sexuality simply as a procreational activity reduces the function of sexuality to a very simplistic view. Not surprisingly this function has been used as being against the laws of nature and thus often as an argument for legal and religious discrimination against sexual variation. Being gay or lesbian was widely considered to be a mental illness until the American Psychiatric Association (APA) removed homosexuality from the list of mental illnesses

from the Diagnostic and Statistical Manual in 1973, following the Stonewall riots and also by changing public opinion, but it continues to be treated as abnormality and illness in many parts of the world even now.

In this paper we discuss the need to understand the various mental health issues that gay individuals face both as part of the minority lesbian, gay, bisexual, and transgender (LGBT) group and consequently by experi- encing higher than expected levels of psychiatric dis- orders. We do not aim to cover issues related to LGBT adolescents or older individuals. We present some ways forward about what can be done to help them in the capacity of mental health professionals.

Challenges

In the 1980s the emergence of the epidemic of HIV/ AIDS brought both stigma and awareness of alternative sexuality to the fore. Its impacts on the lives of gay men in the 1980s – those who died and those who survived – cannot be measured. It did raise awareness but also increased stigma against gay men in particular who in many cases decided not to seek help. People who grew

CONTACT Gurvinder Kalra kalragurvinder@gmail.com Flynn Inpatient Psychiatric Unit, La Trobe Regional Hospital (LRH), LRH Mental Health Services, Traralgon, Victoria, Australia 3844. Tel: +61 351 738 647

� 2015 Institute of Psychiatry

up in heteronormative environments until now started to become more aware of same sex behaviours and the perceived role that the alternative sexuality was playing in the emerging epidemic. Policymakers for a long time ignored the epidemic and it was only with the death of Rock Hudson in the USA that policymakers started to respond. Thereafter increased funding in research development and health care delivery started to make an impact. However, what started as concerns for the physical and sexual health of this population gradually became a struggle for validation of their sexual identities. As mentioned above, although homosexuality had been removed from the DSM-III by the American Psychiatric Association, the spread of AIDS led to both a moral panic and increased stigma against minority sexualities.

The process of coming out for gay individuals is a highly critical time in their lives and has been shown to be associated with increased drug and alcohol use, unsafe sex practices, self-harm, suicide attempts and completed suicide. It is common to pathologize people on the basis of their varying sexual orientation and attraction (Bartlett et al., 2001; Kalra, 2012). These stigmatizing attitudes by society are often reflected by health profes- sionals too. An additional factor which often gets ignored is the perceived and real power held by the mental health professional, which can then act as a major factor in alienating individuals and also stopping them from seeking help. This stigmatizing attitude can be both open and discreet. Such fear of pathologization often leads to under-utilization of health services, increased sexual and mental health issues and impacts on overall quality of lives. An interesting report named Enough is Enough published by the Victorian Gay and Lesbian Rights Lobby in Australia (Victorian Gay and Lesbian Rights Lobby, 2000) showed that discrimination could be experienced in a range of places including educational institutions, workplace, accommodation, and health services. Discrimination was also more commonly experienced by people from rural than metropolitan areas. This finding has clear and major implications in terms of policy-making and implementation at multiple levels including health care delivery. Discrimination and attitudes about alternative sexuality are more likely to be difficult in the older individuals. As is often the case, older individuals are not seen as having sexual needs and alternative sexualities can create more negative attitudes in these groups.

On the other hand, bisexual individuals may identify themselves as neither heterosexual nor homosexual and are likely to be excluded by both the mainstream and gay and lesbian support networks; transgender individuals tend to be the most marginalized of the LGBT

population. Along with the unmet mental health needs of this population it has been observed that the rates of homelessness in LGBT youth is higher due to reasons such as the individuals running away from families who reject them due to their sexual orientation or gender identity, or them being evicted out of their homes by their families (Keuroghlian et al., 2014). Often the mean age of becoming homeless in such youths is as young as 14 years and has been considered to be a coping strategy (Rosario et al., 2012) even before parents reject their sexuality or the individual rejects their parents fearing potential stigma and resulting rejection. High rates of infection and malnutrition can accompany homelessness.

Risk factors

Research has suggested certain specific risk factors that this population shares for poor mental health and suicidality (Crisp & McCave, 2007) including stigma and discrimination at all levels in society, fear of and experiences of violence, rejection from family and friends, homelessness, drug and alcohol use, suicidality and completed suicides among friends. Sexual orienta- tion has been shown as a risk factor for suicidal behaviour (King et al., 2008; Nicholas & Howard, 1998; Silenzio et al., 2007) and such behaviour is reportedly most likely to occur after the person has self-identified as gay but before having a same sex experience and publicly identifying as gay (Nicholas & Howard, 1998) or coming out. Co-morbidity of mental and physical illness and additional impact of alternative sexualities can contribute further stress. Detailed epidemiological findings in different psychiatric disorders are described by Cabaj and Stein (1996) and Levounis et al (2012). Being a minority adds stress related to isolation and alienation but also may add to external and internal stigma.

There is an expanse of literature that demonstrates a higher rate of such difficulties including psychosocial distress, leading to negative mental health outcomes in sexually variant individuals (Diamant & Wold, 2003). A meta-analysis by King et al. (2008) showed a higher risk of depression and anxiety disorders over a period of 12 months or lifetime in LGB populations. The findings of this meta-analysis do raise valid concerns given that this meta-analysis covered a vast literature database includ- ing grey literature databases over a prolonged period from 1966–2005. The papers included had clearly defined criteria for sexual orientation and mental health outcomes. The authors included studies with varied sampling methods such as snowballing in order to allow for differences in reluctance to disclose sexual orientation by participants.

464 G. KALRA ET AL.

The rates of substance use such as cigarette smoking and alcohol (including risky single occasion drinking, RSOD) have also been shown to be much higher in LGBT populations (Hagger-Johnson et al., 2013). Fergusson et al. (2005) have pointed out that these associations are more marked for men than women. Broader social and cultural attitudes towards alternative sexuality affect not only rates of mental illness but obviously attitudes to help seeking and sexual activity. It is inevitable that socio-economic and educational status will play a role in self-identification of gender, gender role, and emotional distress, which may or may not be linked with gender role. In a fascinating study, Hatzenbuehler et al. (2009) investigated the modifying effect of state-level policies on the association between mental health and sexuality in a survey of 34,653 participants of whom 577 were identified as LGBT individuals. In the states where there were no policies providing protection to LGBT individuals in place, the rates of any mood disorder were nearly twice (20.4%) in comparison with the heterosexual sample (10.2%), anxiety disorder 30.1% in comparison with 16.1%, and substance abuse was 40.8% compared with 20.9%, but alcohol use was almost two and half times and drug disorders were five times more common in LGBT individuals. Psychiatric co-morbidity among LGBT individuals was three and half times higher. In a later study, Hatzenbuehler et al. (2012) also found that, after the legalization of same-sex marriage, sexual minority men had a significant decrease in mental health care visits as well as a reduction in hospital visits related to physical ill-health, in comparison with data 12 months prior to legalization. This reduction thus seems to suggest that social factors play an important role in the mental and physical health of sexual minority individuals.

Results from the Longitudinal Study of the Health of Australian Women (McNair et al., 2005) showed that 38% of same-sex-attracted female respondents between the ages of 22–27years had experienced depression compared to only 19% of heterosexual female respond- ents, and also experienced higher levels of anxiety (17.1% versus 7.9%). This was found after adjustments were done for age, region of residence and education. The study, however, does not point out whether depression occurred independently of coming out or recognizing the same sex feelings in these women. In the same study, sexually variant women i.e. women who self-identified as bisexual or lesbian, were more likely to have tried to harm or kill themselves in the previous 6 months. Higher rates of self-harm and suicidal thoughts have been linked to violence and harassment in same-sex-attracted indi- viduals (Hillier et al., 2005), confirming findings from

other parts of the world. Both population-based and twin studies from different countries have found that LGB people are three to six times more likely to attempt suicide than heterosexual people (Herrell et al., 1999). This risk is further increased in culturally and linguis- tically diverse (CALD) background populations (Haas et al., 2011).

Sexually variant women were also significantly more likely to report cigarette smoking (Hughes & Jacobson, 2003), risky alcohol use (7% compared to 3.9%), marijuana use (58.2% versus 21.5%), use of other illicit drugs (40.7% versus 10.2%) and injecting drug use (10.8% versus 1.2%) (Hillier et al., 2004). In a popula- tion-based telephonic survey in Los Angeles (Diamant & Wold, 2003), depressed women who identified them- selves as lesbians were more likely to be using an antidepressant medication and reported significantly more days of poor mental health compared to hetero- sexual women. Not entirely surprisingly, these mental health disparities are not only found in adults but also in adolescence and young adults, with sexual minority youths (age 5 18 years) reporting significantly higher suicidality and depression symptoms (Marshal et al., 2011). In an interesting longitudinal study, Fergusson et al., (1999) followed up a birth cohort of 1265 children born in Christchurch (New Zealand) over a 21-year period. At 21years of age, 1007 sample members were questioned about their sexual orientation, with 2.8% subjects being classified as being of gay, lesbian or bisexual orientation. Data was gathered on a range of psychiatric disorders including suicidal ideation and attempts over the period from age 14–21years and it was observed that gay, lesbian and bisexual young people were at increased risk of major depression, generalized anxiety disorder, conduct disorder, nicotine dependence, other substance abuse and dependence, multiple dis- orders, suicidal ideation and suicidal attempts. More recently Needham (2012) showed that these disparities persist over time, as the youth transitions into adulthood. Data for this study were collected from four waves of the National Longitudinal Study of Adolescent Health, with the respondents being in grades 7–12 at wave 1 and aged 24–32 at wave 4. A particular strength of the study is that it captures the respondents’ trajectories as the ones who consistently report heterosexual attraction versus those who consistently report LGB attraction, those who report a transition to LGB attraction and those who report a transition to heterosexual attraction. Sexually variant individuals show similar problems with respect to their physical health (Frost et al., 2015) including greater likelihood of sexually transmitted infections, such as HIV/AIDS (Halkitis et al., 2004). Such p