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Arch Sex Behav
DOI 10.1007/s10508-017-1099-x
ORIGINAL PAPER
The Relationship Between Indicators of Depression and Anxiety
and Sexual Orientation in Canadian Women
Lanna J. Petterson1 • Doug P. VanderLaan2,3 • Tonje J. Persson4 • Paul L. Vasey1
Received: 3 December 2015 / Revised: 3 October 2017 / Accepted: 10 October 2017
Springer Science+Business Media, LLC 2017
Abstract Previous studies examining the associations between
women’s sexual orientation and mental health have obtained
inconsistent results. Whereas some studies have suggested that
statusasalesbianorbisexualwomanmaybeassociatedwithgreater
mental health risk, others have suggested that bisexual women may
be specifically vulnerable to mental health problems. The current
study examined two competing models in a non-clinical sample of
Canadian women (N = 278). The first model predicted that women
who reported bisexual attraction would endorse more indicators of
depression and anxiety compared to women who reported monosexuality(eithersame-oropposite-sexattraction).Thesecondmodel
predicted that women who reported relatively greater same-sex
attraction would exhibit elevated indicators of depression and
anxiety comparedto women who reported opposite-sex attraction.
Consistent with Model 1, greater bisexual attraction predicted
greaterendorsement ofindicatorsofdepressionandanxietycompared to greater same-sex or opposite-sex attraction. These findings suggest that, in women, bisexuality may be associated with
higher risk of depression and anxiety than monosexuality. Future
researchmaybenefitfromexploringriskfactorspotentiallyuniqueto
the mental health of bisexual women.
& Lanna J. Petterson
l.petterson@uleth.ca
1
Department of Psychology, University of Lethbridge,
Lethbridge, AB T1K 3M4, Canada
2
Department of Psychology, University of Toronto Mississauga,
Mississauga, ON, Canada
3
Underserved Populations Research Program, Child, Youth and
Family Division, Centre for Addiction and Mental Health,
Toronto, ON, Canada
4
Department of Psychology, Concordia University, Montreal,
QC, Canada
Keywords Sexual orientation Depression Anxiety Mental health Bisexuality
Introduction
Research examining the association between mental health and
sexualorientationminoritystatus,irrespectiveofgender,hassuggested that lesbian, gay, and bisexual (LGB) individuals may be
at greater risk of poor mental wellness and mental health problems, including greater depression and anxiety symptoms, than
heterosexual individuals (Abelson, Lambevski, Crawford, Bartos,
&Kippax,2006;Balsam,Beauchaine,Mickey,&Rothblum,2005;
Booker, Rieger, & Unger, 2017; Burton, Marshal, Chisolm, Sucato,
& Friedman, 2013; Cochran & Mays, 2000a, b; Cochran, Sullivan,
& Mays, 2003; Conron, Mimiaga, & Landers, 2010; Fergusson,
Horwood, & Beautrais, 1999; Frisell, Lichtenstien, Rahman, &
Långerström, 2010; Gilman et al., 2001; Jorm, Korten, Rodgers,
Jacomb, & Christensen, 2002; King et al., 2003, 2008; Sandfort,
Bakker, Schellevis, & Vanwesenbeeck, 2006; Zietsch, Verweij,
Bailey, Wright, & Martin, 2011; Zietsch et al., 2012). However,
results have been less consistent when women’s mental health
has been studied independently (discussed below). Given that the
associationbetweenwomen’ssexualorientationandmentalhealth
has varied across studies, additional research is needed to examine
the relationship between sexual orientation and mental health outcomes.
Somestudiesindicatethatlesbianwomenexhibitworsemental
health outcomes than heterosexual women (e.g., Bolton & Sareen,
2011; Kerr, Santurri, & Peters, 2013). Yet, this only appears to be
the case for certain aspects of mental health and may vary based on
measures of sexual orientation. For example, Sandfort, de Graaf,
Bijl,andSchnabel(2001)foundthatlesbianwomenwereatgreater
risk of depression, but not anxiety, compared to heterosexual
women. Bostwick, Boyd, Hughes, and McCabe(2010)found that
123
Arch Sex Behav
although women who identified as lesbian had a higher prevalence
of mood and anxiety disorders than those who identified as heterosexual, women who reported only same-sex sexual partners had a
lower prevalence of mood and anxiety disorders.
A number of studies have found that both bisexual and lesbian women experience greater mental health risk compared to
heterosexualwomen,butbisexualwomenexperiencegreatermental health risk compared to both heterosexual and lesbian women
(Bolton & Sareen, 2011; Bostwick et al., 2010; Conron et al., 2010;
Fredriksen-Goldsen, Kim, Barkan, Balsam, & Mincer, 2010; Kerr
et al., 2013; Udry & Chantala, 2002). These negative outcomes
include more anxiety, anger, depressive symptoms, self-injury,
suicidal ideation, and suicide attempts. However, other studies
have found that bisexual and lesbian women report similar mental health outcomes, but ones that are worse when compared to
heterosexual women (Koh & Ross, 2006; Warner et al., 2004).
Itisessentialtohaveaclearunderstandingofhowmentalhealth
disparities are patterned within the population to inform the development of evidenced-based prevention and intervention efforts. In
the absence of replicated studies, there is a risk of developing
strategies for prevention and intervention that are ill-informed
and may target groups inappropriately. At best, a failure to garner a clear understanding of mental health patterning within the
population may lead to ineffective allocation of resources (such
aspersonnelandfunding).Atworst,suchafailuremaylessenattention to those groups who are most in need of mental health support.
With this in mind, the current study investigated the association between women’s sexual orientation and indicators of
major depressive disorder (MDD) and generalized anxiety disorder (GAD). Specifically, the focus of the study was to examine
the relationship between these mental health domains and the continuous Kinsey rating scale of sexual orientation in women to garnerinsightsintohowmentalhealthindicatorsaredistributedacross
this continuum without artificially creating sexual orientation
groupings.
Two competing predictions were tested based on the existing
mental health and sexual orientation literature.
Prediction 1 Women with bisexual attraction will report more
indicators of depression and anxiety than women with monosexual attraction (attraction to either same- or opposite-sex individuals). The first prediction was derived from previous findings
indicating that bisexual women experience the highest risk of
depression and anxiety (e.g., Bolton & Sareen, 2011; Bostwick
et al., 2010; Conron et al., 2010; Fredriksen-Goldsen et al., 2010;
Kerr et al., 2013; Udry & Chantala, 2002). If correct, the association between women’s sexual orientation, along the heterosexual–
bisexual–lesbiancontinuum,andindicatorsofdepressionandanxiety would show a negative quadratic relationship (i.e., an inverted
U-shape).
Prediction 2 Variation away from exclusive opposite-sex
attraction is associated with greater endorsement of indicators
of depression and anxiety. The second prediction was derived
123
frompreviousfindingsindicatingthatlesbianandbisexualwomen
may both experience higher risk of depression and anxiety than
heterosexual women (e.g., Cochran et al., 2003; Fergusson et al.,
1999; Frisell et al., 2010; Gilman et al., 2001; King et al., 2008;
Koh & Ross, 2006; Sandfort et al., 2006; Warner et al., 2004;
Zeitsch et al., 2011, 2012). If correct, the association between
women’s sexual orientation, along the heterosexual–bisexual–
lesbiancontinuum,andindicatorsofdepressionandanxietyshould
show a positive linear relationship.
Method
Participants
Atotalof278womenwereincludedinthepresentstudy.AKinseytypescalewasusedtoassessparticipantsexualorientation(Kinsey,
Pomeroy, & Martin, 1948). This measure asked participants to
select which response option most accurately described their
sexual feelings over the last year. Participants were given the
response range from 0 (‘‘sexual feelings toward the opposite
sex only’’) to 6 (‘‘sexual feelings toward the same sex only’’), as
well as the option of‘‘no sexual feelings.’’Of the total sample,
19.8%(n = 55)reportedaKinsey0rating(‘‘sexualfeelingstoward
the opposite sex only’’); 18.0% (n = 50) reported Kinsey 1 rating
(‘‘most sexual feelings toward the opposite sex, but an occasional fantasy about the same sex’’); 16.9% (n = 47) reported a
Kinsey 2 rating (‘‘most sexual feelings toward the opposite sex,
but some definite fantasy about the same sex’’); 15.1% (n = 42)
reportedaKinsey3rating(‘‘sexualfeelingsequallydividedbetween
males and females; no strong preference foroneor theother’’); 6.8%
(n = 19)reportedaKinsey4rating(‘‘mostsexualfeelingstowardthe
same sex, but some definite sexual feelings toward the opposite
sex’’);8.6%(n = 24)reportedaKinsey5rating(‘‘mostsexualfeelings toward the same sex, but an occasional fantasy about the
oppositesex’’); and14.7% (n = 41)reportedaKinsey 6rating(‘‘sexual feelings toward the same sex only’’).
This study was conducted via an online survey that was advertised to 757 university distribution lists and community organizations throughout Canada, and through the social networking site,
Facebook. Individuals were informed that the survey would containquestionspertainingtosexuality,personality,andfamilyrelations. Facebook uses an algorithm that determines to whom the
advertisement will appear. The survey’s advertisement was targeted to English-speaking Canadian men and women who were
18 years of age and older. Additionally, to ensure that adequate
numbersofnon-heterosexualparticipantswereobtained,weselected
the option to target women who were interested in women or in men
and men who were interested in men or in women. Because participantrecruitment fromuniversitydistributionlistsandcommunity
organizations was limited (2.2%), the sample largely reflects the
responses of participants who were collected through Facebook
(97.8%).
Arch Sex Behav
Measures
In addition to information on sexual orientation, biographic information was collected pertaining to the participant’s age (in years),
socioeconomic status during childhood, annual income, level of
education completed, religious affiliation, and religiosity. Indicators of depression and anxiety in childhood and adulthood were
assessed through measures that we created based on the diagnostic
criteria in the DSM-IV-TR (American Psychiatric Association
[APA], 2000). Participants were provided with items that were
based on the diagnostic criteria for MDD, GAD, agoraphobia,
SAD,PD,OCD,andspecificphobiasaspartofalargerstudy.However, because our analysis pertained to 278 participants, which is
relatively small for the intended analysis, we limited our focus to
examiningonlytheMDD(6items)andGAD(9items)items.Additionally, we did not have any predictions for the present study
regarding childhood expression of mental health. As such, only
the adulthood MDD and GAD items were included in the present
analysis. The adulthood DSM items asked participants how accurately the descriptions reflected their experiences since the age of
18 years. Participants used a 5-point Likert-type scale that ranged
from 1 (‘‘strongly disagree’’) to 5 (‘‘strongly agree’’). The standardized inter-item reliability (alpha)forthe 13 itemsthat wereused in
the final analysis was .91 for the sample (Note: two items were
dropped during principal component analysis; see below).
Statistical Analysis
Analyses were conducted using SPSS Statistics version 23. Principal component analysis (PCA) was used to reduce the indicators
of depression and generalized anxiety (based on the MDD and
GADitems)toacorecomponent.Componentscoreswerederived
using the regression method. The standardized component scores
wereusedasacompositemeasureoftheitemsforfurtheranalyses.
A curvilinear estimation was conducted (with Kinsey rating
included as a continuous variable) to examine the relationship
between participants’ Kinsey ratings and indicators of depression/generalized anxiety component scores. Primarily, this analysis was used to test (1) whether greater non-monosexual sexual
attraction was predictive of greater endorsement of indicators of
depression and generalized anxiety or (2) whether greater attraction to the same sex was predictive of greater endorsement of
indicators of depression and generalized anxiety. A nonsignificant linear relationship, but a significant quadratic relationship,
would furnish support for Prediction 1, whereas a significant
linear relationship would furnish support for Prediction 2.
Thecurvilinearestimationwaslimited,however,inwhatinformation it could yield regarding the strength of the relationship
between the Kinsey ratings and indicators of depression/generalized anxiety. As such, two hierarchical linear regressions were conducted. The first examined the relative predictive contribution of
the linear term and the quadratic term by first including the linear
term and then adding the quadratic term to the model. This analysis
provided insight into which term (i.e., either the linear term described in Prediction 2 or the quadratic term described in Prediction 1)
was better fit to the data. The second examined how well the quadratic Kinsey rating variable predicted indicators of depression
and generalized anxiety, to test the goodness of fit of the negative
quadratic model proposed in Prediction 2. Biographic variables
were entered first for both hierarchical linear regressions.
Results
Principal Component Analysis
PCA was conducted to assess whether core components underlay
items related to depression and generalized anxiety. Two MDD
items (‘‘I experienced rapid weight loss or weight gain’’and‘‘I feel
as though my regular movements are slow’’) were excluded from
subsequentanalysisbecausepreliminarybivariatecorrelationanalysis revealed several correlation coefficients that were below r =
.30 for these items (low correlation coefficients may suggest that
the items are relatively distinct from the other items). The remaining 13 items were included in the PCA.
The Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy was .89, and Bartlett’s test of sphericity was significant at
p\.001, indicating that PCA was appropriate (Bartlett, 1954;
Kaiser, 1974). All KMO values for the individual items were .83
or higher. A scree plot using PCA extraction indicated that a onecomponent solution was most appropriate. One component was
extracted using the maximum likelihood procedure. The loading
coefficients, displayed in Table 1, yielded the interpretable component: indicators of depression/generalized anxiety. The indicators of depression/generalized anxiety component accounted for
44.17%ofthevariance.Theextractedcomponentscoresweresaved
as a variable using the regression method. Component scores are
standardized. Participant scores for the indicators of depression/
generalized anxiety component scores ranged from - 2.18 to
2.02 (M = 0; SD = .96).
Regression Analyses
Curvilinear Estimation
The curvilinear estimation of the indicators of depression/generalized anxiety component scores by Kinsey score is presented
in Fig. 1. Inconsistent with Prediction 2, statistical significance
was not obtained for the linear equation, F(1, 276) = 2.93, p =
.088, R2 = .01. However, consistent with Prediction 1, statistical
significance was achieved when the final equation included a
quadratic term, F(2, 275) = 6.58, p = .002, R2 = .05. The curve
reached its peak between Kinsey ratings of 3 and 4.
123
Arch Sex Behav
Table 1 Component loadings for indicators of depression and generalized anxiety
Component 1
Generalized Anxiety Disorder
I often feel restless or on edge
.72
I tire easily by daily activity
.69
I frequently forget what I have been previously been
thinking about or am unable to concentrate
.72
I am frustrated or bothered by things to a greater extent .60
than others seemed to be
I frequently have tense or tight muscles that are not
caused by physical activity
.59
I am unable to fall asleep easily or, if I do fall asleep, I
have difficulty remaining asleep
.58
Major Depression
I feel sad or empty frequently
.72
I lost interest in things that I had previously been
interested in
.59
I experience rapid weight loss or weight gain
–
I have uncommon sleep patterns (slept excessively or
infrequently)
.64
I am often fatigued by daily activities
I feel as though my regular movements are slow
.68
–
I have a lowered sense of self worth
.66
Covariate Analysis
I have difficulty making decisions or concentrating
.78
I frequently have morbid thoughts
.63
Fig. 1 Indicators of
depression/generalized anxiety
component scores as a function of
Kinsey ratings
123
Consequently, the curvilinear estimate suggested that, as Kinsey ratings increased from Kinsey 0 (exclusive heterosexual
attraction),participantsscoredhigherontheindicatorsofdepression/
generalized anxiety component. However, this positive relation
peaked around the Kinsey 3–4 range (approximately equal attraction to men and women), after which point the inverse was found.
As Kinsey ratings increased from Kinsey 4, participants scored
lowerontheindicatorsofdepression/generalizedanxietycomponent. Thus, subsequent analysis primarily focused on examining
whether a shift toward bisexual attraction significantly predicted
elevated indicatorsofdepression/generalizedanxietycomponent
scores,whilecontrollingforseveralpotentiallyconfoundingvariables.
Because the subsequent analysis was conducted using linear
regression, the Kinsey rating variable required modification to
evaluate adherence to a negative quadratic model. To do so, the
Kinsey rating variable was centered around 3.5 and then squared,
basedonthecurveestimations(Fig. 1).Doingsomodifiedthescale
to range from bisexual attraction(low) to exclusive attraction to
either men or women (high).
Covariate analysis was conducted to determine whether the biographic variables varied within the sample in a patterned manner,
which could influence the variables of interest. Sexual orientation
groups were formed to facilitate biodemographic comparisons.
Descriptive statistics pertaining to biographic variables are shown
Arch Sex Behav
Table 2 Descriptive statistics regarding participants’ biographic information by sexual orientation group
Heterosexual women
n = 105
Bisexual women
n = 108
Lesbian women
n = 65
Religiosity: % (n)
Not religious
52.38 (55)
70.37 (76)
66.15 (43)
Some degree of religiosity
47.62 (50)
29.63 (32)
33.85 (22)
Christianity
57.14 (60)
39.81 (43)
63.08 (41)
Other
42.86 (45)
60.19 (65)
36.92 (24)
18.10 (19)
24.07 (26)
24.62 (16)
40 (42)
39.81 (43)
41.54 (27)
41.90 (44)
36.11 (39)
33.85 (22)
37.01 (17.31)
23.57 (9.70)
28.06 (12.95)
Religious affiliation: % (n)
Childhood socioeconomic status: % (n)
Upper/upper middle
Middle
Lower/lower middle
Age (in years): M (SD)
Education: (starting at Grade 1) M (SD)
Annual income (in CAD): M (SD)
15.07 (3.38)
13.61 (2.41)
14.03 (2.21)
25,101.56 (23,401.47)
15,211.10 (15,787.11)
17,294.23 (16,107.66)
Table 3 Mean (SD) indicators of depression/generalized anxiety component scores (standardized) by Kinsey rating
Kinsey 0 rating
n = 55
Kinsey 1 rating
n = 50
Kinsey 2 rating
n = 47
Kinsey 3 rating
n = 42
Kinsey 4 rating
n = 19
Kinsey 5 rating
n = 24
Kinsey 6 rating
n = 41
- .33 (1.03)
- .03 (.93)
.03 (.95)
.33 (.88)
.27 (.72)
.11 (.87)
- .08 (1.02)
inTable 2bysexual orientationgroup: heterosexualwomen (Kinsey0–1),bisexualwomen(Kinsey2–4),andlesbianwomen(Kinsey
5–6).1 Participants differed significantly regarding their response to
the biographic variables: religiosity (dummy coded as not religious
and some degree of religiosity), v2(2) = 7.82, p = .020; religious
affiliation (dummy coded as Christian vs.‘‘other’’), v2(2) = 10.73,
p = .005; age, Brown–Forsythe statistic F(2, 222.65) = 26.41, p\
.001; education, Brown–Forsythe statistic F(2, 252.23) = 8.25,
p\.001;andannualincome,Brown–ForsythestatisticF(2,245.41)=
8.09, p\.001. Participants did not differ significantly in terms
of socioeconomic status during childhood, v2(4) = 2.00, p =
.737.
Pearson correlations were conducted to determine whether
thebiographicvariablesthatdifferedbetweengroupscorrelatedwith
the focal variables (df = 276 for all correlations). The biographic
variablesthatdifferedbetweengroupsandcorrelatedwiththemodified Kinsey score were religious affiliation (negatively correlated:
r = - .20, p = .001), religiosity (positively correlated: r = .22, p\
.001), education (positively correlated: r = .19, p = .001), annual
income (positively correlated: r = .22, p\.001), and age (positively correlated: r = .44, p\.001). The biographic variables that
differedbetweengroupsandcorrelatedwiththeindicatorsofdepres1
Groups were formed only for covariate analysis. Kinsey scores were
combined to ensure that groups had adequate numbers of participants to
make comparisons.
sion/generalized anxiety component were education (negatively
correlated:r = - .22,p\.001)andannualincome(negativelycorrelated: r = - .18, p = .002). No other correlations achieved statistical significance (all other p-values ranged from p = .278 to p =
.64). Thus, because religiosity, religious affiliation, age, education,
and annual income may have a confounding influence on associationsbetweensexualorientationandmentalhealth,theywerecontrolled for in subsequent analysis.
Multiple Regression Analysis
Mean indicators of depression/generalized anxiety component
scores by Kinsey rating are shown in Table 3. Two multiple hierarchicalregressionswereconductedtoexaminewhetherthedegree
to which participants reported bisexual attraction predicted indicatorsofdepression/generalizedanxiety.Forbothregressions,the
biographic variables—education, annual income, age, religiosity
(dummy coded as not religious and somewhat religious), and religious affiliation (dummy coded as Christianity or other)—were
entered into the first block of the regression model using forced
entry.
For the first regression, the linear Kinsey score term wasadded
in thesecond step, and the quadratic Kinsey score term wasadded
in the third step. Table 4 shows the models of the biographic variables, the linearterm, and thequadratic term predicting indicators
of depression/generalized anxiety component scores. When all
123
Arch Sex Behav
Table 4 Regression analyses predicting indicators of depression/generalized anxiety component scores
B (95% CI)
SE of B
b
p
sr2i
Step 1a
Constant
.84 (.23, 1.45)
.31
Education
- .07 (- .11, - .03)
.02
- .20
.007
.001
.04
Income
.02
\.01 (\.01,\.01)
\.01
- .16
.017
Age
.01 (\- .01, .01)
\.01
.09
.195
.01
Religiosity
.09 (- .15, .33)
.12
.05
.459
\.01
Religious affiliation
.13 (- .12, .37)
.12
.07
.307
\.01
.78 (.17, 1.40)
.31
Step 2b
Constant
.013
Education
- .07 (- .11, - .03)
.02
- .19
.002
.03
Income
Age
\.01 (\.01,\.01)
.01 (\- .01, .02)
\.01
\.01
- .15
.11
.023
.118
.02
.01
Religiosity
.11 (- .13, .35)
.12
.06
.371
\.01
Religious affiliation
.15 (- .09, .40)
.12
.08
.226
\.01
Kinsey score
.04 (- .02, .10)
.03
.09
.159
.01
Constant
.81 (.21, 1.41)
.31
Education
- .06 (- .10, - .02)
.02
- .18
.004
.03
Income
\.01 (\.01,\.01)
\.01
- .15
.022
.02
Age
.01 (\- .01, .02)
.01
.17
.016
.02
Religiosity
.15 (- .09, .39)
.12
.08
.208
.01
Religious affiliation
.11 (- .13, .36)
.12
.06
.358
\.01
Kinsey score
- .01 (- .07, .06)
.03
- .02
.83
\.01
Kinsey score squared
- .05 (- .09, - .02)
.02
- .24
.002
Step 3c
.009
.03
Bold terms are those that have been entered at each step. Regression coefficients (B), 95% confidence intervals (CI) for B, standardized regression
coefficients (b), t-test significances (p), and semi-partial correlations (sr2i ) for biographic variables and the linear and quadratic Kinsey score terms
predicting indicators of depression/general anxiety component scores are shown in the table. Model summary statistics for the models are indicated by
superscripts
a
b
c
R2 = .08; adjusted R2 = .06; F-ratio (5, 272) = 4.45, p = .001
R2 = .08; adjusted R2 = .06; F-ratio (6, 271) = 4.05, p = .001; DR2 = .01; DF (1, 271) = 1.99, p = .159
R2 = .12; adjusted R2 = .09; F-ratio (7, 270) = 5.06, p\.001; DR2 = .03; DF (1, 270) = 10.28, p = .002
seven variables were included, four were shown to predict indicators of depression/generalized anxiety component scores: education(negativerelationship;b = - .18,sr2i = .03,p = .004),annual
income (negative relationship; b = - .15, sr2i = .02, p = .022), age
(positive relationship; b = .17, sr2i = .02, p = .016), and Kinsey
score squared (negative relationship [with low scores indicating
greaterbisexual attraction andhighscores indicating greatermonosexual attraction]; b = - .24, sr2i = .03, p = .002). This analysis
indicated that 11.6% of the variability in indicators of depression/
generalized anxiety component scores was predicted by the five
biographicvariables,thelinearterm,andthequadraticterm.Whereas
the addition of the linear term did not significantly improve the
fit of the model (the inclusion of the term increased the amount
of variance accounted for by less than 1%), the addition of the
quadratic term did significantly improve the fit of model (the
inclusion of the term increased the amount of variance accounted
for by 3.37%).
123
Forthesecondregression,thequadraticKinseyscoreterm was
added in the secondstep. This analysis indicated that 11.59% of
the variability in indicators of depression and generalized anxiety
component scores was predicted by the five biographic variables
and the quadratic term (adjusted R2 = .10; F-ratio for Step 2 [6,
271] = 5.92, p\.001). The inclusion of the quadratic term in
Step 2 improved the model’s goodness of fit (DR2 = .04; DF [1,
271] = 12.34, p = .001).
Discussion
The current study evaluated the association between women’s
sexual orientation and indicators of depression and anxiety. One
component was shown to underlie the items related to depression
andgeneralizedanxiety.Componentscoresservedasacomposite
measure of the MDD and GAD items for subsequent analysis.
Arch Sex Behav
Consistent with the first prediction, the extent to which participants endorsed indicators of depression and generalized anxiety was predicted by the degree to which they reported attraction
to both sexes, as opposedtoonesex or the other. Inconsistent with
thesecondprediction,theextenttowhichparticipantsendorsedindicators of depression and anxiety was not predicted by the degree to
whichtheyreportedgreatersame-sexsexualattraction,asopposed
to opposite-sex sexual attraction. Hence, the current study is more
in line with the prediction that bisexuality, compared to monosexuality, predicts greater depression and anxiety (e.g., Bolton &
Sareen, 2011; Bostwick et al., 2010; Conron et al., 2010; Fredriksen-Goldsen et al., 2010; Kerr et al., 2013; Persson, Pfaus, &
Ryder, 2015; Udry & Chantala, 2002) than the prediction that
non-heterosexual attraction predicts depression and anxiety
(Cochran et al., 2003; Fergusson et al., 1999; Frisell et al., 2010;
Gilman et al., 2001; King et al., 2008; Koh & Ross, 2006; Sandfort et al., 2006; Warner et al., 2004; Zeitsch et al., 2011, 2012).
Importantly, however, our analysis indicated that much of the
varianceinindicatorsofdepressionandgeneralizedanxietyremained
unaccounted for by participants’ endorsement of (non)monosexual
sexualfeelingsandthebiographicvariables.Assuch,itappearsthat
additional factors are tied to women’s depression and generalized
anxiety, which may be either related to sexual orientation or independent from it. That said, it appears the degree to which women
experience non-monosexual sexual feelings is related to this aspect
of mental health.
It is possible that bisexual women scored higher than heterosexual women on indicators of depression and anxiety because
theyexperiencegreaterstressassociatedwiththeirminoritysexual
orientation status. The minority stress hypothesis has been suggestedasapossibleexplanationforLGBindividuals’mentalhealth
risk (Meyer, 1995, 2003). In line with this idea, features of minority
stress(e.g.,perceivedorexpecteddiscriminationandvictimization,
internalized homonegativity, anticipated social rejection, and concealment of one’s sexual orientation identity) have been associated
withnegativementalhealthoutcomes(e.g.,Balsam&Mohr,2007;
Hatzenbuehler, Nolen-Hoeksema, & Erickson, 2008; Lea, de Wit,
& Reynolds, 2014; Lewis, Derlega, Griffin, & Krowinski, 2003;
Mays&Cochran,2001;Pachankis,Cochran,&Mays,2015;Vanden Berghe, Dewaele, Cox, & Vincke, 2010).
Consistent with minority stress hypothesis, LGB adults and
youth living in regions of the USA that are more supportive of the
LGB community and that grant protection against LGB discrimination are mentally healthier than those living in other regions
(Hatzenbuehler, 2011; Hatzenbuehler, Keyes, & Hasin, 2009).
Additionally, mental healthcare visits and costs for gay and
bisexual men decreased following the legalization of gay
marriage in the USA, suggesting that mental health improved
when institutional discrimination was abated (Hatzenbuehler,
O’Cleirigh, Grasso, Mayer, Safren, & Bradford, 2012).
Hatzenbuehler (2009) expanded on this hypothesis by proposing thatincreased stigma-related stress(i.e., stress that can result
from experiencing stigma based on one’s minority status) can
lead to increased problems associated with emotional regulation,
social andinterpersonal relationships,and cognitiveprocesses—
psychological processes that are associated with elevated mental
health risk, regardless of an individual’s sexual orientation. These
generalpsychologicalprocessesaresuggestedtomediatetherelationship between minority stress and LGB individual’s preponderance of adverse mental health outcomes. For instance, deficits
in emotional regulation mediated the relationship between sexual minority statusand bothdepressionand anxiety among adolescents (Hatzenbuehler et al., 2008).
The finding that bisexual women scored higher than lesbian
womenonindicatorsofdepressionandanxietycouldbeexplained
by an elevated frequency of experiencing stigma or discrimination
by the heterosexual majority and other monosexual sexual minorityindividuals,knownas‘‘doublediscrimination.’’Ithasbeenfound,
for example, that heterosexual individuals, gay men, and lesbian
women report more negative attitudes toward bisexual individuals
than toward both gay men and lesbian women (Friedman et al.,
2014;Herek,2002;Zivony&Lobel,2014).Thus,bisexualwomen
maybeatahigherriskofstigmatizationthanlesbianwomen,which
in turn may account for their elevated scores for indicators of depression and anxiety. Additionally, bisexual women with oppositesex partners experience greater depression symptoms than lesbians,andthisrelationshipismediatedbyexperiencesofrejection
and social exclusion by gay men and lesbians (Dyar, Feinstein, &
London, 2014).
Alternatively, although not mutually exclusive, research has
suggested that greater exposure to adverse life events may partially account for poorer mental health among lesbian, gay, and
bisexual individuals (Frisell et al., 2010; Mays & Cochran, 2001;
Wamala,Boström,& Nyqvist,2007).Forexample,Balsam,Rothblum, and Beauchaine (2005) found that gay, lesbian, and bisexual
men and women were more likely to have experienced victimization, such as childhood abuse, domestic abuse, psychological maltreatment,andsexual coercion thanheterosexual men and women.
Additionally,however,bisexualmenandwomenweremorelikely
to have experienced non-intercourse sexual coercion and rape than
gay men and lesbian women. Other research has found that lesbian
and bisexual women report more abuse, chronic abuse, and sexual
abuse during adolescence than heterosexual women (Austin et al.,
2008).
Persson et al. (2015)demonstrated that non-monosexual women
reported moresymptoms ofanxietyand depression,moreriskysexual behavior, more childhood abuse, and lower levels of sexual
orientation disclosure than monosexual women. Further, they
found that elevated risky sexual behavior and decreased sexual
orientation disclosure mediated the relationship between sexual orientation and depression and anxiety. Childhood abuse
did not moderate the relationship between sexual orientation
and depression or anxiety.
In sum,these findingssuggest that poorermental health among
bisexual women may be partly related to risky sexual behavior and
sexual orientation concealment. Other research has also suggested
123
Arch Sex Behav
that sexual orientation disclosure may be associated with mental
health.Forexample,Juster,Smith,Ouellet,Sindi,andLupien(2013)
foundthatdisclosedsexualorientationminorityindividualsreported
fewer psychiatric symptoms compared to those who were non-disclosed. The findings discussed above may all be relevant to explainingloweredmentalhealthamongbisexualindividualsandshouldbe
taken into account when potential interventions are considered.
Our findings further highlight the increased risk of depression
and anxiety among bisexual women. Research has found that bisexual men and women are less likely than gay men and lesbian women
to disclose their sexual orientation to their healthcare providers or to
use available healthcare services (Durso & Meyer, 2013; Kerr et al.,
2013). Therefore, bisexual men and women may not receive health
careappropriatetotheirspecificneeds.Additionally,theirhealthcare
providers may not target them as an at-risk group. The present findings, based on a community sample, underline the importance of
implementing prevention and intervention strategies specifically targeted toward bisexual individuals.
Limitations and Future Directions
The present study assessed sexual orientation based on the participant’s response to a single measure of sexual orientation. Specifically,sexualorientationwasmeasuredviaparticipant’sself-reported
sexual feelings, as opposed to sexual orientation identity or sexual
behavior.This may havebeen problematic for two reasons. First,the
participants might have varied in their interpretation of what may be
considered ‘‘sexual feelings.’’ Although potentially imprecise, this
measure is arguably beneficial because it permits the consideration
ofwomenwho experience sexual attractions toorfantasies/thoughts
about one sex (or both sexes) without acting or identifying in a manner to express these sexual feelings. Additionally, measures such as
sexual behavior and sexual identity are limited to an extent because
behavior and identity can be constrained by cultural factors and
individual circumstances.
The relationship between mental health and sexual orientation
may vary based on which facets of individuals’ sexual orientation
aredirectlyexaminedandthecompositionofeachsexual orientation group (e.g., Bostwick et al., 2010). For instance, women who
engage in bisexual sexual behavior may face different degrees of
social acceptance than women who have bisexual sexual feelings
butdonotactonthem.Namely,behaviorallybisexualwomenmay
experience social rejection, stigmatization, and discrimination from
the heterosexual majority and the lesbian community, whereas
women who experience sexual feelings for both men and women
butdonotactonthemmaynotexperiencethesamenegativesocial
reaction. Women who experience bisexual attraction but who do
not act on these feelings may be differently affected by their sexual
orientation(e.g.,theymayengageinvigilantself-monitoringtoconceal their feelings; they may experience sexual dissatisfaction; or
they may feel that they are unable to express part of themselves).
Future studies should opt to employ several measures of sexual
123
orientation to further disentangle the relationship between sexual
orientation and mental health. Additionally, future studies should
ask participants whether their friends, family, and broader social
groups are aware of their sexual orientation status, whether they
have felt supported, and whether they have experienced negative
responses (or have had negative thoughts) related to their sexual
orientation.
It is important to note that the present sample was drawn from
a Canadian population. The social and political climate of Canada
tends to be relatively tolerant and accepting of minority sexual
orientation individuals, relative to many other cultural groups
(Anderson & Fetner, 2008; Widmer, Treas, & Newcombe, 1998).
Lesbian, gay, and bisexual individuals may be protected from
negativementalhealthoutcomeswhenpoliciesareimplementedto
protect these individuals (e.g., institutional policies that protect
sexual orientation minority category individualsandban employment discriminationbased on sexual orientation)(Hatzenbuehler,
Keyes,&Deborah,2009).Consequently,sexualorientationminority individuals in Canada may experience less stigmatization and
discrimination as a result of their sexual orientation status and,
thus, less negative mental health outcomes compared to those
living in places less protective of sexual minority rights. It is possible that, because Canada is relatively accepting of sexual minority rights, our results may represent a conservative estimate of
negative mental health outcomes of lesbian and bisexual women.
Hence, caution must be exercised when extrapolating the present
findings to less accepting populations. It would be desirable if
future research replicated the current study using samples drawn
from other sociocultural settings.
Furthermore, because our sample was self-selected there may
have been a recruitment bias. Such a recruitment bias could, arguably,haveintroducedconfoundsthatmayhaveartificiallyimpacted
the results. In other words, those who elected to participate may differ from those who declined to participate and, thus, those who participated may not be fully representative of Canadian women. If so,
this bias might have contributed to biographic differences that could
have impacted the variables of interest (i.e., indicators of depression
and anxiety and Kinsey scale ratings). Nevertheless, it is important
tonotethatanumberofbiographicvariableswereincludedascovariates, thus mitigating the potential influence of such additional factors
on the variables of interest.
Of additional note, the study advertisement was sent to 757
universitydistribution listsandcommunityorganizationsthroughout Canada, but this endeavor was not fruitful. As such, we would
encourage future researchers who are seeking to recruit community samples for mental health research to consider alternative
participant recruitment methods to prevent low response rates.
However, it is important to note that no incentive was provided
for participation (e.g., monetary compensation, entry into a gift
card draw) in the present study. Participant response rates may
have been higher if participants were incentivized to participate.
Overall, thecurrent findingsshouldbe interpreted with caution.
Our analyses pertained to a non-clinical sample and employed
Arch Sex Behav
measurement items that were based on diagnostic criteria but were
not employedtodeterminewhetherparticipantsmetthediagnostic
thresholdforclinicaldiagnosis.Instead,theseitemswereemployed
to assay participants’ emotional or physiological states that are associatedwiththeDSMdisorders.Thus,thecurrentfindingsshouldnot
beextrapolatedtoclinicalpopulationsandcannotspeaktotherateof
diagnosable conditions within the sample. Furthermore, the current
assessmentdidnotaccountforspecificcircumstances(e.g.,physical
ailments, life events) that could influence participants’ responses.
Such measures may limit the clinical implications of the findings;
however, the current study provides direction to clinical research by
examining the existence of trends that may be present among the
general population that may be otherwise unaccounted for.
Acknowledgements We thank all of the individuals who agreed to participateinourstudy.VariousstagesofthisresearchweresupportedbytheUniversity of Lethbridge; by a Social Sciences and Humanities Research Council of
Canada (SSHRC) Masters Scholarship and a Lethbridge Public Interest
Research Group Research Grant to LJP; by a Canadian Institutes of Health
Research (CIHR) Postdoctoral Fellowship to DPV; by a CIHR Doctoral
Award to TJP; and by a CIHR Catalyst Grant (Methods and Measures for
Gender, Sex, and Health; Grant No. 45546) and an Alberta Innovates Health
Solutions Sustainability Fund Grant (Grant No. 43528) to PLV.
Compliance with Ethical Standards
Conflict of interest Theauthorsdeclarethattheyhavenoconflictofinterest.
Ethical Statement TheUniversityofLethbridgeHumanSubjectsResearch
Committee approved this research. Participants were required to provide
informed consent prior to taking part in the study. All procedures performed in studies involving human participants were in accordance with the
ethical standards of the institutional research committee and with the Canadian Tri-Council Policy Statement 2 (2014): Ethical Conduct for Research
Involving Humans.
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