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Same-Sex Sexual Behavior and Psychiatric Disorders
Findings From the Netherlands Mental Health Survey and Incidence Study (NEMESIS)
Theo G. M. Sandfort, PhD;
Ron de Graaf, PhD;
Rob V. Bijl, PhD;
Paul Schnabel, PhD
Arch Gen Psychiatry. 2001;58:85-91.
ABSTRACT
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Background It has been suggested that homosexuality is associated with psychiatric
morbidity. This study examined differences between heterosexually and homosexually
active subjects in 12-month and lifetime prevalence of DSM-III-R mood, anxiety, and substance use disorders in a representative
sample of the Dutch population (N = 7076; aged 18-64 years).
Methods Data were collected in face-to-face interviews, using the Composite
International Diagnostic Interview. Classification as heterosexual or homosexual
was based on reported sexual behavior in the preceding year. Five thousand
nine hundred ninety-eight (84.8%) of the total sample could be classified:
2.8% of 2878 men and 1.4% of 3120 women had had same-sex partners. Differences
in prevalence rates were tested by logistic regression analyses, controlling
for demographics.
Results Psychiatric disorders were more prevalent among homosexually active
people compared with heterosexually active people. Homosexual men had a higher
12-month prevalence of mood disorders (odds ratio [OR] = 2.93; 95% confidence
interval [CI] = 1.54-5.57) and anxiety disorders (OR = 2.61; 95% CI = 1.44-4.74)
than heterosexual men. Homosexual women had a higher 12-month prevalence of
substance use disorders (OR = 4.05; 95% CI = 1.56-10.47) than heterosexual
women. Lifetime prevalence rates reflect identical differences, except for
mood disorders, which were more frequently observed in homosexual than in
heterosexual women (OR = 2.41; 95% CI = 1.26-4.63). The proportion of persons
with 1 or more diagnoses differed only between homosexual and heterosexual
women (lifetime OR = 2.61; 95% CI = 1.31-5.19). More homosexual than heterosexual
persons had 2 or more disorders during their lifetimes (homosexual men: OR
= 2.70; 95% CI = 1.66-4.41; homosexual women: OR = 2.09; 95% CI = 1.07-4.09).
Conclusion The findings support the assumption that people with same-sex sexual
behavior are at greater risk for psychiatric disorders.
INTRODUCTION
FOR A LARGE part of the past century, homosexuality itself was seen
as a mental disorder. In 1973, the American Psychiatric Association removed
homosexuality from its list of mental disorders. This removal came about because
of support from research findings1, 2, 3, 4
and as a result of a persistent plea by both professionals and activists.5
In response to the former psychiatric stigmatization of homosexuality
and ideologically inspired by a social movement aiming to achieve greater
acceptance of homosexual people, some authors subsequently stressed the equality
in mental health status of homosexual and heterosexual people.6, 7
Others suggested that the mental health status of homosexual people might
be impaired owing to various stresses, either temporary or in specific subgroups.8 Some authors expected an upsurge in suicidal behaviors,
especially in adolescence and young adulthood, as a consequence of the stresses
experienced during the coming-out process.1, 9, 10
Levels of substance abuse were also expected to be higher in gay men and lesbians
as compared with heterosexual people.11, 12
Furthermore, negative health consequences such as body image dissatisfaction
and eating disorders also came to be seen as related to the specific lifestyle
and subculture of openly gay and lesbian people.8, 13
Although many studies have assessed the mental health status of homosexual
men and women, the results are still inconclusive. This is predominantly due
to a variety of methodological problems, characteristic of most studies done
since the 1960s, such as the use of convenience samples, small sample sizes,
lack of adequate comparison groups, failure to control for potentially confounding
factors, application of nonstandardized research instruments, and questionable
external validity.14, 15, 16, 17
Recent studies applying a more rigorous methodology showed that there
is substantial support for the existence of orientation-related differences
in mental health status. In a population-based study among adolescents, suicidal
intent and actual suicide attempts were related to homosexuality in males
but not females.18 Young people with a homosexual
or bisexual orientation were found to be at increased risk of major depression,
generalized anxiety disorder, conduct disorder, substance abuse/dependence,
and suicidal behaviors.19 Middle-aged men who
reported ever having had male sex partners were at a higher lifetime risk
for various suicidal symptoms compared with their heterosexual counterparts,
even after controlling for substance abuse and depressive symptoms.20 A small increased risk among homosexually active populations
in 1-year psychiatric morbidity was found in a sample of the US population,
with homosexually active men more likely than other men to experience major
depression and panic attack syndromes and homosexually active women more likely
than other women to be classified as having alcohol or other drug dependence.21 However, these studies still have various limitations.10, 14, 22
Our study aims to explore differences in the prevalence of DSM-III-R psychiatric disorders in relation to homosexuality and to
overcome some of the limitations of the earlier studies. It does so by using
a large, representative sample of the Dutch population selected without reference
to sexual orientation and allowing for separate analyses for men and women.
The study categorizes people as homosexual or heterosexual based on recent
rather than lifetime behavior, the latter being a more diffuse categorization
than the former.23 The study uses a validated
and standardized instrument to assess psychiatric disorders, applied in face-to-face
interviews. By looking at both lifetime and 12-month prevalence, we were able
to assess the relationship between homosexuality and mental health more precisely
than most other studies.
SUBJECTS AND METHODS
SUBJECTS
The data used for this study are part of the Netherlands Mental Health
Survey and Incidence Study (NEMESIS), which assessed psychiatric disorders
in a representative sample of the Dutch population aged 18 to 64 years. NEMESIS
was conducted with the approval of the Internal Review Board of the Trimbos
Institute, Utrecht, the Netherlands. A detailed description of the design
of the study and the major outcomes have been previously published.24, 25
NEMESIS has applied a multistage, stratified, random-sampling procedure
of households in the Netherlands. One respondent was randomly selected in
each household. The interviewers made a minimum of 10 calls or visits to an
address at different points in time and days of the week to make contact.
To optimize response and to compensate for possible seasonal influences, the
initial fieldwork was extended over the entire period from February through
December 1996.
A total of 7076 persons were interviewed. Respondents provided verbal
consent after having been informed about the aims of the study. The interviewer
entered data into a computer during the interview. According to the method
of assessment, the response was 64.2% (of the households eligible for interview)
or 69.7% (of the persons eligible for interview). Persons who declined to
take part in the full interview were asked to furnish several key pieces of
data. Of these persons, 43.6% agreed to do so. The psychiatric morbidity (estimated
with the General Health Questionnaire,26 taking
into account sex, age, and urbanicity) of these nonresponders did not significantly
differ from that of the respondents.
DIAGNOSES
The instrument used to determine DSM-III-R
diagnoses was the Composite International Diagnostic Interview (CIDI),27, 28 designed for use by trained interviewers
who are not clinicians. The CIDI has acceptable interrater reliability,29 acceptable test-retest reliability30
and acceptable validity for practically all diagnoses, with the exception
of acute psychotic presentations.31 The diagnoses
were generated during data processing.
The following DSM-III-R diagnoses were recorded:
mood disorders (depression, dysthymia, bipolar disorder), anxiety disorders
(panic disorder, agoraphobia, social phobia, simple phobia, obsessive-compulsive
disorder, generalized anxiety disorder), psychoactive substance use disorders
(alcohol or other drug abuse and dependence, including sedatives, hypnotics,
and anxiolytics). Although eating disorders and schizophrenia and other nonaffective
psychotic disorders were recorded as well, these data are not presented here
because of their low prevalence.
The assessment of psychiatric symptoms took place before subjects were
asked about their sexual behavior, thus minimizing the chance of contamination.
The fieldwork was done by 90 interviewers, experienced in systematic
data collection and extensively trained in recruiting respondents and computer-assisted
interviewing.
SEXUAL BEHAVIOR
Respondents were asked verbally whether they had sexual contact in the
preceding year and the gender of their partner(s). If the respondent had had
sex with someone of the same gender (exclusively or not), he or she was categorized
as homosexual. Other sexually active people were categorized as heterosexual.
Homosexually active men and exclusively heterosexually active subjects are
subsequently referred to in this article as homosexual and heterosexual persons,
respectively. Sexual orientation itself was not assessed.
Of the total of 7076 persons, 30 respondents did not answer the questions
regarding their sexual behavior. Of the remaining 7046, 85.2% reported having
been sexually active. More men than women reported having been sexually active
(87.7% vs 83.0%;  21 = 30.1; P<.001). Of the 6003 sexually active respondents, 5 lacked the necessary
data to classify them as heterosexual or homosexual, leaving 5998 persons
for the present analysis. Of the men, 2.8% (n = 82) had had sex with male
partners (6 of these men also had sex with women in the respective period).
Of the women, 1.4% (n = 43) had had sex with female partners (6 of them also
had sex with men). More men than women reported homosexual behavior (21 = 15.9; P<.001).
STATISTICAL ANALYSIS
To assess differences in prevalence rates, adjusted odds ratios (ORs)
were computed separately for men and women. Age, level of education, residency,
and not having a steady partner were controlled for in these analyses, given
that these variables were positively related to prevalence rates in the total
sample.22 Odds ratios were also calculated without
controlling for relationship status, given that relationship status is more
likely to be a consequence of rather than an antecedent to homosexual and
heterosexual behavior.
RESULTS
CHARACTERISTICS OF THE SAMPLE
Homosexual and heterosexual respondents differed on education and relationship
status (Table 1). Both homosexual
men and women had a relatively higher educational level than heterosexual
men and women. Both homosexual men and women less frequently reported being
currently in a steady relationship than heterosexual men and women. Homosexual
and heterosexual men differed on residency status. Homosexual men were more
likely than heterosexual men to live in urban areas.
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Table 1. Demographic Characteristics by Sexual Behavior in Preceding
Year
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MEN
Compared with heterosexual men, homosexual men had significantly higher
12-month and lifetime rates of mood and anxiety disorders (Table 2 and Table 3).
Inspection of the specific mood disorders revealed that compared with heterosexual
men, homosexual men had a much larger chance of having had 12-month and lifetime
bipolar disorders and a higher chance of having had lifetime major depression
but no significant differences were seen regarding dysthymia. Regarding the
specific anxiety disorders, the lifetime prevalence was significantly higher
in homosexual men than in heterosexual men for all but generalized anxiety
disorder. The biggest differences were found in obsessive-compulsive disorder
and agoraphobia. The 12-month prevalences of agoraphobia, simple phobia, and
obsessive-compulsive disorder were higher in homosexual men than in heterosexual
men. Regarding substance use disorders, the only significant difference was
found in lifetime alcohol abuse. This is the only disorder more frequently
observed in heterosexual men than in homosexual men. Homosexual men were not
more likely than heterosexual men to report 1 or more 12-month and lifetime
disorders. More homosexual men than heterosexual men had 2 or more disorders,
both lifetime and in the preceding year.
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Table 2. Twelve-Month Prevalence of DSM-III-R
Disorders by Sexual Behavior in Preceding Year
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Table 3. Lifetime Prevalence of DSM-III-R
Disorders by Sexual Behavior in Preceding Year
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Not controlling for relationship status resulted in an increase in the
various ORs (data not shown). Furthermore, some differences in 12-month and
lifetime prevalence became statistically significant. If relationship status
was not controlled for, the lifetime and 12-month prevalence rates of 1 or
more disorders were higher in homosexual men than in heterosexual men (OR
= 1.72, 95% confidence interval [CI] = 1.10-2.70 and OR = 1.99, 95% CI = 1.23-3.20,
respectively).
WOMEN
There were no significant differences between homosexual and heterosexual
women in the 12-month prevalence of mood and anxiety disorders. On a lifetime
basis, homosexual women had a significantly higher prevalence of general mood
disorders and major depression than did heterosexual women. The lifetime prevalence
of anxiety disorders did not differ between homosexual and heterosexual women.
Regarding the preceding year, homosexual women reported a substantially higher
rate of substance use disorders than did heterosexual women, although differences
in the specific substance use disorders were not significant. Lifetime prevalence
of both alcohol and other drug dependence was also significantly higher in
homosexual women than in heterosexual women. Although more homosexual women
than heterosexual women reported 1 or more DSM-III-R
diagnoses, lifetime and in the preceding year, only the former difference
was significant. Homosexual women were more likely than heterosexual women
to have had 2 or more disorders during their lifetime but not in the preceding
year.
If relationship status was not controlled for, ORs increased and the
differences in 12-month alcohol dependence and lifetime social phobia were
also significant. Both 12-month and lifetime prevalences of 1 or more disorders
were higher in homosexual women than in heterosexual women (OR = 2.09, 95%
CI = 1.08-4.05 and OR = 3.16, 95% CI = 1.61-6.18, respectively).
COMMENT
This study found a higher prevalence of various psychiatric disorders
in homosexual people compared with heterosexual people, both regarding the
preceding 12 months as well as on a lifetime basis. These differences seem
to be gender specific with a higher prevalence of substance use disorders
in homosexual women and a higher prevalence of mood and anxiety disorders
in homosexual men, both compared with their heterosexual counterparts.
The interpretation of these findings requires consideration of some
potential limitations, which could have cumulatively either inflated or deflated
actual differences in prevalence rates.25 Among
those people contacted, there could have been a nonresponse related to homosexual
behavior. Although nonresponse to specific questions was negligible owing
to the computer-assisted interviewing, subjects might have differed in their
reporting behavior. Compared with heterosexual men, homosexual men might have
been less reluctant to admit specific complaints. Although some demographics
were statistically controlled for, the possibility remains that at least part
of the observed differences are accounted for by some other uncontrolled confounding
variables. Finally, the study might underestimate the differences between
homosexual and heterosexual people owing to the limited number of homosexual
subjects and the consequently broad CIs of the ORs.
When compared with other studies of sexual orientation and mental health,
ours has several strengths. We used a large representative sample rather than
a convenience sample and selected without reference to sexual orientation.
The sample size allowed for separate analyses for men and women. The importance
of this is shown by our findings. Furthermore, the outcome variables studied
were assessed with a reliable and standardized diagnostic instrument, and
sexual behavior was assessed only after questions regarding psychiatric disorders
were answered. This study not only looked at lifetime prevalence of psychiatric
disorders but prevalence in the preceding year as well, testing the relationship
with homosexuality more critically. In doing this, the findings suggest that
homosexuality is not only associated with mental health problems during adolescence
and early adulthood, as has been suggested,20
but also in later life. Finally, this study did not group people together
based on lifetime experiences, a common practice to make up for small numbers,
but looked at subjects' recent sexual behavior. Although various studies have
demonstrated discrepancies between homosexual behavior and homosexual orientation
or homosexual self-labeling,23, 32, 33
we think that recent homosexual behavior is a better indicator of homosexual
self-labeling than any lifetime homosexual involvement.
It is unclear to what extent findings from this Dutch study can be generalized
to other cultures or nations. Compared with other Western countries, the Dutch
social climate toward homosexuality has long been and remains considerably
more tolerant.34, 35, 36
To the extent that the level of social acceptance of homosexuality induces
differences in mental health status in relation to homosexuality, the observed
differences might be greater in other Western countries than in the Netherlands.
The strategy to control for demographic variables in assessing differences
between heterosexual and homosexual people could be debated. Some of these
demographic differences, which were found in other representative studies
as well and seem to be structural,23, 33, 37
could be considered a consequence of and not an antecedent to people's homosexuality.
The larger proportion of homosexual men in urban regions compared with rural
areas is usually understood as a consequence of a tendency to migrate from
places with high levels of social control to more congenial social environments.23, 38 The finding that homosexual people
are less often involved in steady relationships than heterosexual people is
seen as resulting from the limited opportunities homosexual people have to
find an intimate partner, lesser legal and social support for developing and
maintaining homosexual relationships compared with that for heterosexual relationships,
and differing norms and values regarding sexuality and personal relationships.39, 40, 41, 42 It could
be argued that not controlling for these demographic variables, which results
in more significant differences in prevalence rates of specific disorders
and in higher ORs, provides a more accurate estimate of the actual differences
in prevalence rates between homosexual and heterosexual people.
Because of the study's cross-sectional design, it is not possible to
adequately address the question of the causes of the observed differences.
Differences observed in the preceding year might be a consequence of earlier
differences, since ever having had a specific disorder might predispose people
to subsequent disorders.43
Because the acquired immunodeficiency syndrome can have an important
effect on homosexual men and their mental health status,44
we asked all respondents about their human immunodeficiency virus (HIV) serostatus.
Only one person, a heterosexual woman, reported a positive HIV status. This
result reflects the very low prevalence of HIV infection and acquired immunodeficiency
syndrome in the general population as well as among homosexual men in the
Netherlands.45 Given that no homosexual man
reported being infected with HIV, we do not believe that HIV infection can
account for the observed mental health differences in this study.
The observed differences may result both from biological and social
factors and an interaction between them. Biological and genetic factors in
the causes and development of homosexuality46, 47, 48, 49, 50
might also predispose homosexual people to developing psychiatric disorders.
This is in line with the higher prevalence of bipolar disorder we found in
homosexual men compared with heterosexual men, which is generally considered
to be largely congenital.51 The effects of social
factors on the mental health status of homosexual men and women have been
well documented in studies, which found a relationship between experiences
of stigma, prejudice, and discrimination and mental health status.52, 53, 54, 55, 56, 57, 58, 59, 60, 61
Furthermore, controlling for psychological predictors of present distress
seems to eliminate differences in mental health status between heterosexual
and homosexual adolescents.62 The mediating
role of relationship status suggests that higher prevalence rates of some
disorders in homosexual people compared with heterosexual people could also
be caused by loneliness.
The differential pattern of differences for men and women can also be
interpreted in various ways. First, an effect of sexual orientation in women
might be more difficult to demonstrate since women already show higher levels
of mood and anxiety disorders than men regardless of sexual preference.24 Homosexual women could also be less exposed to social
stressors than homosexual men, given that attitudes toward homosexual men
are generally more negative than attitudes toward homosexual women.63 The fact that homosexual men showed higher prevalence
rates of disorders that are characteristic for women in general, whereas homosexual
women showed higher prevalence rates of disorders that are characteristic
for men in general, is in line with the theory that sex-atypical levels of
prenatal androgens play a major role in the causes and development of homosexuality.14
In conclusion, this study offers evidence that homosexuality is associated
with a higher prevalence of psychiatric disorders. The outcomes are in line
with findings from earlier studies in which less rigorous designs have been
employed. The processes underlying the established differences need further
study. Research into these processes should be able to disentangle the potential
interplay of various factors—social, attitudinal, behavioral, and biological—instead
of testing one specific factor. The most promising design for such a study
requires a large sample of both men and women, and is longitudinal and cross-cultural.
AUTHOR INFORMATION
Accepted for publication July 20, 2000.
NEMESIS is conducted by the Netherlands Institute of Mental Health and
Addiction (Trimbos Institute), Utrecht, the Netherlands. Financial support
has been received from the Netherlands Ministry of Health, Welfare and Sports,
The Hague; the Medical Sciences Department of the Netherlands Organization
for Scientific Research, The Hague; and the National Institute for Public
Health and Environment, Utrecht.
Data from this article were presented at the Twenty-Fifth Annual Meeting
of the International Academy of Sex Research, Stony Brook, NY, June 24, 1999.
We thank Henny Bos for her help in preparing this study and Jeffrey
Weiss, PhD, and Daniel Weishut for their comments on previous versions.
From Utrecht University (Drs Sandfort and Schnabel), the Netherlands
Institute of Social Sexological Research (Dr Sandfort), and the Netherlands
Institute of Mental Health and Addiction (Drs de Graaf and Bijl), Utrecht,
the Netherlands; and the Social and Cultural Planning Office of the Netherlands,
The Hague (Dr Schnabel).
Corresponding author: Theo G. M. Sandfort, PhD, Department of Clinical
Psychology, Utrecht University, PO Box 80140, 3508 TC Utrecht, the Netherlands
(e-mail: t.sandfort{at}fss.uu.nl).
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