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Acknowledgments
We would like to thank the following for their contributions to the project:
Margaret Unwin, PACE Chief Executive Ofcer, and Ruth Overton, Head of
Communications, for line managing the project and for their support, guidance and
insight in regard to various aspects of project development and implementation.
Flávio Silva, Research Administrator, for the assistance provided throughout the
project, including but not limited to assistance with the development of research
instruments and with data collection, as well as with monitoring of recruitment for
all phases of the research.
Tim Franks, former PACE Chief Executive Ofcer, for contributions to project conception,
implementation and development, and for line managing it during its initial phases.
Maggie Lay, former Research Coordinator, for early planning, development and
management of the project, particularly for conducting the literature review and
coordinating the rst phase qualitative study.
Emily Trip, Research Assistant, for contributing to data collection for the survey and
assistance with planning, implementing and data cleaning for the second phase
qualitative study.
Kiran Bains, Research Intern, for updating the literature review and for assistance
in performing analyses of rst qualitative phase data; Victoria Hotchin, Research
Volunteer, and César Gonzalez, Research Intern, for assistance in performing analyses
of rst qualitative phase data; and Teemu Toivainen, Research Volunteer, for support
in running survey data analyses.
Current and previous members of the project’s Lay Panel, for their feedback and
suggestions, as well as for assistance with data collection.
Participants in all phases of the study, for their time and for generously sharing their
experiences.
Interviewers from the rst and second phase qualitative studies, for their assistance
in data collection.
Ander Arenaza, Adrian Cox, Tim Eastwood, Kate Emmett, Rose McLoughlin, Caroliz
Pérez-Acevedo, Quay Tran, and other PACE members of staff, volunteers and interns
for support and assistance in various phases of the research project.
Organisations which helped with participant recruitment, including B-eat, Millivres
Prowler Group, Positive East, Terrance Higgins Trust, University of East London,
amongst others.
And nally, The Big Lottery, for funding this project.
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Nuno Nodin, Elizabeth Peel, Allan Tyler and Ian Rivers
iv The RaRE Research Report: Risk and Resilience Explored
Section title
Participants said they wanted to
help LGB&T young people who
feel suicidal by sharing their
experiences. They wanted to ght
prejudice around mental health
issues and help to normalise
sexual and gender diversity.
Foreword
I am delighted to be able to present this report to you, which is the
result of ve years painstaking work. The RaRE research, funded with
vision by the Big Lottery, has broken new ground for a small voluntary
sector organisation like PACE. Our collaboration with some of the most
qualied academics in the eld, and the diligence of the RaRE research
team, has enabled us to produce a piece of thoughtful research which
expands on current knowledge about LGB&T mental health.
LGB&T mental health is poorer than that of the mainstream population
as a result of the impacts of heteronormativity on LGB&T people’s lives.
Our research looked at three particular aspects: gay and bisexual men’s
body image, lesbian and bisexual women’s relationship with alcohol,
and suicide in young LGB&T people.
Over 2000 people completed our survey and participated in the in-
depth interviews. The rich data they provided paints a vivid picture
of what helps lesbians, gay men, bisexuals and Trans* people develop
positive mental health as well as the factors that create risks to
becoming a psychologically healthy human being.
The RaRE project was never just about nding out facts; the intention
is that it should be used to inform and inuence service providers and
policy makers so that they are better able to provide for the broad
mental health needs of the LGB&T community than is currently the
case. PACE believes that developing more responsive mainstream
services for LGB&T people should be a priority for all NHS and social
care providers and we think there is a need for a national LGB&T
mental health strategy, to enable providers to build their capacity to
tackle specic LGB&T needs and better support LGB&T people.
We also believe there will continue to be a need for LGB&T-specic
services provided by and within LGB&T organisations, even when the
mainstream sector can honestly demonstrate it is meeting LGB&T
people’s needs.
I hope you will enjoy reading the report and that it will enable you to
take some action in your particular area of work, in order to improve
the outcomes for LGB&T people with mental health issues.
If you have any thoughts, observations, questions or comments we
would be very pleased to hear your feedback.
With best wishes,
Margaret Unwin, PACE CEO
Tables
Table 1 - Predictors of suicide attempt for young LGB people 48
Table 2 - Predictors of suicide ideation for young LGB people 49
Table 3 - Predictors of self-harm experience for young LGB people 51
Table 4 - Predictors of self-harm ideation for young LGB people 51
Table 5 - Predictors of hazardous alcohol use for lesbian
and bisexual women 57
Table 6 - Disagrees or strongly disagrees with being satised with features
of their bodies and behaviour affecting the body, by sexual
orientation (men only) 65
Table 7 - Predictors of body image dissatisfaction for gay and bisexual men 64
Figures
Figure 1 - Comparing suicide indicators LGB vs hetero young people 47
Figure 2 - Comparing self-harm indicators LGB vs hetero young people 48
Figure 3 - Comparing suicide indicators Cis vs Trans* young people 49
Figure 4 - Comparing self-harm indicators Cis vs Trans* young people 50
Figure 5 - Hazardous alcohol use (LGB vs Heterosexual women) 56
Figure 6 - Hazardous alcohol use (LG vs Bisexual vs Heterosexual women) 56
Figure 7 - Dependent alcohol use (LGB vs Heterosexual women) 57
Figure 8 - Dependent alcohol use (LG vs Bisexual vs Heterosexual women) 57
Figure 9 - Alcohol to intoxication (LGB vs Heterosexual women) 58
Figure 10 - Alcohol to intoxication (LG vs B vs Heterosexual women) 58
Contents
Executive summary 5
Introduction 8
Literature review 11
1. Aims and scope of the review 11
2. Socio-political context for LGB&T people 11
3. Evidence of health inequalities in LGB&T people 12
4. Suicide and self-harm among young LGB&T people 13
5. Alcohol misuse among lesbian and bisexual women 19
6. Body image issues, including eating concerns, among gay and bisexual
men 26
Rationale for the study 33
Methods 34
1. Ethical approval 35
2. First qualitative study (P1Q) 35
3. Quantitative study (Survey) 36
4. Second qualitative study (P2Q) 40
5. Analysis 43
Results 45
1. The study samples 45
2. Findings 47
Discussion 71
Suicide and self-harm 71
Alcohol misuse 73
Body image and eating concerns 76
General discussion 77
Limitations of the study 78
Conclusions 80
Recommendations 81
Glossary 82
References 85
Appendices 93
5The RaRE Research Report: Risk and Resilience Explored
Executive summary
The RaRE Study research project 2010 – 2015 is a 5-year collaboration
between PACE, the LGBT+ mental health charity and an academic
panel drawn from three UK universities. The study looked at risk and
resilience factors for three mental health issues that affect LGBT+
people disproportionally:
1. Suicide attempts and self-harm for young LGBT+ people under 26
2. Alcohol misuse in lesbian and bisexual women
3. Body image issues for gay and bisexual men
Data was collected between 2011 and 2014, through two sets of
interviews with 58 people in total and a national survey of 2078 people
in England.
Key Findings – Suicide and Self-harm for Young
LGB&T People
Young LGB and Trans*1 people under 26 are more
likely to attempt suicide and to self-harm than their
heterosexual and cisgender2 peers.
What Risk Factors did RaRE nd?
People who attempted suicide while young reported factors that
appear to correlate closely with suicidal thoughts or attempts.
These were: negative experiences of coming out; homophobic and
transphobic bullying; and struggles about being LGB or Trans* within
the family, at school and in peer groups.
In addition, participants reported that a lack of awareness and
training means responses from medical or professional staff can feel
inadequate. Inclusive resources, which reect the lives and issues of
young LGB&T people, are sparse outside of LGBT+ specialist services.
1 ‘Trans*’ will be used throughout the report as an umbrella term for people whose gender identi-
ty and/or gender expression diverges in some way from the sex they were assigned at birth.
2 ‘Cisgender’ refers to all people whose gender matches the sex they were assigned at birth.
34%
of young LGB
people had made
at least one
suicide attempt in
their lives...
...as compared to
18%
of heterosexual
young people
6The RaRE Research Report: Risk and Resilience Explored
What Resilience Factors did RaRE nd?
Participants reported that support and understanding from family
and signicant others helped them to develop self-worth. In addition,
connection to other LGB&T people and communities create a sense of
belonging, which helps build resilience.
Positive interventions and responses from medical and professional
staff are crucial, to help young LGB&T people recover more quickly
after a suicide attempt.
Key Findings – Alcohol misuse for lesbian and
bisexual women
No signicant differences in dependent alcohol use or
hazardous drinking were found when comparing lesbian
and bisexual women with heterosexual women. Some
minor differences in patterns of drinking were found.
What Risk Factors did RaRE nd?
The study found that the risk of problematic drinking amongst lesbian
and bisexual women is often associated with prevailing heterosexism.
It appears lesbian and bisexual women use alcohol in an attempt
to manage feelings of fear, anxiety and guilt about their sexual
orientation. Negative reactions from professionals can limit lesbian and
bisexual women’s engagement with treatment and support, including
causing them to disengage with treatment altogether.
What Resilience Factors did RaRE nd?
The study found that recovery from alcohol abuse is helped by good
support from partners, family and others. It appears that an important
strategy to regain control is creating life structures. Interaction with
practitioners who are knowledgeable, aware and inclusive in their
approach is key, as are LGBT-specic resources such as support groups.
Executive summary
48%
of Trans* young
people had made
at least one
suicide attempt in
their lives...
...as compared to
26%
of cisgender
young people
7The RaRE Research Report: Risk and Resilience Explored
Key Findings – Body image issues for gay and bisexual
men
The study found that gay and bisexual men are more
dissatised with their bodies and their health than
heterosexual men.
What Risk Factors did RaRE nd?
RaRE found that early experiences of ‘feeling different’ appear to create
vulnerability and are a key factor in developing low self-worth for
gay and bisexual men. Gay and bisexual men experience signicant
pressure to conform to the ‘ideal’ body type; they are also more
sensitive towards social and media messages about this ideal when
compared with heterosexual men. These messages are internalised
from peers at school, family, media and other men on the scene.
What Resilience Factors did RaRE nd?
Gay and bisexual men reported that before they can make positive
changes about their body image or eating concerns, they need to
acknowledge that there is an issue and this is sometimes triggered
by a crisis in their life. Self-motivation and support from people who
understand is essential to recovery. Also important is more formal
therapy, self-help and organised programmes, including specically for
gay and bisexual men.
Executive summary
8The RaRE Research Report: Risk and Resilience Explored
Introduction
PACE, the LGBT+ mental health charity, was funded by the Big Lottery to
undertake research into three mental health issues found to be more
prevalent among lesbian, gay, bisexual and Trans* (LGB&T) people.
These issues are:
• Attempted suicide and self-harm among LGB&T young people
• Drinking problems among lesbian and bisexual women
• Body image issues and eating concerns among gay and bisexual
men
The study’s main aims were to:
1. nd out who is most at risk of developing the aforementioned
health issues;
2. ascertain what the risk and protective factors are and whether
and how these vary between LGB&T people and their heterosex-
ual and cisgender counterparts;
3. identify common risk and protective factors for LGB&T people
across the three health inequalities;
4. identify whether there is a need for a LGB&T-specic approach
to mental health promotion capable of reducing the researched
inequalities.
The desired outcomes of the RaRE study were improved targeting of
services to LGB&T people at risk of developing mental health issues
with a focus on the aforementioned three issues; earlier prevention
initiatives; and more effective support for LGB&T people experiencing
these problems.
The RaRE study was designed as a multi-phase study using a mixed-
methods approach. In total there were ve research phases to the
project:
1. A stakeholders’ survey to ascertain stakeholder issues and con-
cerns regarding the problems under study (the current report
will not cover the ndings from this survey, a separate report of
this phase was produced and is available on request; Lay & Silva,
2010);
2. An extensive and up to date literature review about LGB&T men-
tal health research, specically focusing on the three key issues
under study;
9The RaRE Research Report: Risk and Resilience Explored
3. First qualitative phase (P1Q): in-depth interviews of 35 LGB&T
adults living in England with a history of the problems under
study;
4. A comparative England-wide survey of 2078 LGB&T and non-LG-
B&T adults with and without a history of the problems under
study to ascertain how sexual orientation and gender identity
articulates with risk and resilience factors;
5. Second qualitative phase (P2Q): in-depth interviews with 23
LGB&T individuals with atypical risk and resilience proles, i.e.,
those exposed to potential high risk but who did not suffer the
expected negative mental health outcomes; and conversely those
who developed a mental health issue but presented low or no
risk exposure.
The RaRE Study was undertaken using the Community Based
Participatory Research (CBPR) approach (Israel, Schulz, Parker & Beker,
1998; Speer & Christens, 2013). CBPR places an “emphasis on the
participation of non-academic researchers in the process of creating
knowledge” (Israel et al. , 1998, p.177), often incorporating local and
community specic theories, recognising the strengths and weaknesses
of all those involved. It draws from critical theory and constructivist
theories and uses qualitative and quantitative theory to better
understand the phenomenon under study.
In the case of the RaRE study, PACE beneted from the support from
academics from University of Worcester, Brunel University London and
London South Bank University. However, a key feature of the RaRE study
is the active engagement of volunteers within the community through
a lay panel that operated as an advisory body to make sure research
methods and materials, such as survey questions and dissemination
materials, were appropriate and adjusted to the needs and interests
of their target populations. Other volunteers and interns were also
frequently involved in the development of the project, often being
motivated by a combination of the desire to contribute to the LGB&T
community and an interest in research and mental health.
The RaRE study was managed and coordinated by a researcher
employed by PACE. The Coordinator was supported by a part time
Project Administrator, temporary specialist workers at various stages
and, as mentioned, a number of volunteers and interns assisting on
various research and dissemination tasks. The project had an advisory
panel consisting of the research team, three academic partners and
lay members with an interest in the problems under study, engaging
PACE’s Chief Executive Ofcer and the Head of Communications at key
stages in the project. This group was engaged in all aspects of decision
making and quality assurance in accordance with the Community Based
Participatory Research model.
Introduction
10
This report starts with an overview of the literature review carried
out which provided a background and informed the project. It then
outlines the methodology used for the three phases of the research
before presenting the key ndings of all phases in the results section.
The last section is a discussion of all phases of the research, weaving
together common threads as well as highlighting divergent issues
of the ndings from the three mental health issues under study.
The limitations of the study are exposed and future directions of
the research suggested before ending with general conclusions and
recommendations.
PACE and the research team recognise the diversity within the LGB&T+
community and the limitations of analysis in which bisexuals, Trans*
people and people identifying with other sexual orientations and
gender identities are not separated from lesbian and gay people. For
the purposes of this report, survey responses from bisexual people
were analysed together with those of lesbian and gay people (with
the exception of some analysis of women’s drinking behaviours) and
only ndings directly related to suicide and self-harm indicators are
reported for Trans* individuals separately. This was done in order to
limit this report in size and scope, considering it already covers a wide
range of issues by using diverse methodologies.
However, the RaRE study will conduct further analyses and produce
research outputs which will look into the ndings within these broad
categories of sexual orientation and gender identity more in detail.
Introduction
The RaRE Research Report: Risk and Resilience Explored
11The RaRE Research Report: Risk and Resilience Explored
Literature review
1. Aims and scope of the review
This literature review was undertaken to help dene the terms, scope
and parameters of the study; to identify relevant concepts and theories;
to guide the choice of methodologies, such as sampling methods,
instruments, and data analysis; to ascertain what is known about the
nature and aetiology of the three health issues across heterosexual,
cisgender, and LGB&T groups; and to provide a context into which
to place the study’s ndings. It is not a comprehensive review of the
literature or a critical analysis.
This review focused on papers published in psychology journals,
although a broader range of research outputs from other disciplines
were also briey reviewed, such as from sociology, psychiatry and
anthropology. In recognition of the impact of culture on these health
issues the focus was principally on European, North-American and
Australian publications. The search was limited to papers published
within ten years of the commencement of the review (late 2010),
although some particularly inuential works from before 2000 were
also reviewed. Other sources reviewed included UK Government
policies and legislation and some relevant LGB&T publications.
2. Socio-political context for LGB&T people
Legislation and policy can impact greatly on LGB&T mental health.
Britain has only fairly recently begun to address inequalities legally
by improving the rights of LGB&T people in an attempt to counter
discrimination. However, there is a cultural and historical background
that inuenced how many, particularly older, LGB&T people grew up in
relation with their sexual orientation or gender identity.
Homosexual acts in private between men aged over twenty-one in
private were decriminalised in 1967 in England and Wales, in 1981 in
Scotland and 1982 in Northern Ireland. However, in 1988 the British
Government made a regressive step in implementing Section 28 of the
Local Government Act (1988). This made it illegal for a Local Authority
to: ‘intentionally promote homosexuality or promote the teaching
in schools of the acceptability of homosexuality as a pretend family
relationship.’ The Act was eventually repealed in 2003 in England.
In 2004 the Civil Partnership Act was passed, which conferred similar
rights as heterosexual couples to same-sex couples and, later, marriage
12 The RaRE Research Report: Risk and Resilience Explored
between same-sex partners was approved, in 2013 for England
and Wales and in 2014 for Scotland. The Equalities Act of 2010
made it illegal to discriminate against anyone based on a range of
characteristics, including sexual orientation and gender reassignment
status.
Despite these improvements, LGB&T people continue to report a wide
range of negative experiences related to discrimination and prejudice.
There is evidence that these experiences link to the health inequalities
being explored and may also constitute some of the barriers to
addressing these inequalities.
3. Evidence of health inequalities in LGB&T people
The RaRE project was inspired by a meta-analysis by King et al.
(2008) which evidenced inequalities in the experience of mental
health issues by LGB&T people. Although it is generally now regarded
that same-sex attraction is compatible with psychological health
(King, 2004; McFarlane, 1998) LGB people have in fact been found
to be at higher risk of mental disorder, suicidal ideation, substance
misuse, and deliberate self-harm when compared to heterosexual
people (King et al., 2008). LGB people have double the risk of suicide
attempts; the risk for depression and anxiety disorders over a period
of twelve months or a lifetime were at least one and a half times
higher in LGB people as was alcohol and other substance dependence
over twelve months.
Research indicates that being LGB or having a Trans* identity is not in
itself associated with mental distress and increased rates of mental
illness, but that negative impact of transphobic, homophobic and
heterosexist cultural norms that spur the discrimination, bullying,
marginalisation and stigmatisation of LGB&T people may be. A
term used to summarise the psychological effect of these social
phenomena is ‘minority stress’ (Eisenberg & Wechsler, 2003; Meyer,
2003).
A brief review of the literature published in 2003-2009, conducted
prior to the study found that although some research had been
undertaken on the predictive and risk factors for these health issues,
little research had explored resilience or protective factors. There had
also been little research undertaken in the UK on LGB&T people’s
mental health compared to the United States (Chakraborty, McManus,
Brugha, Bebbington & King, 2011).
Literature review
13The RaRE Research Report: Risk and Resilience Explored
4. Suicide and self-harm among young LGB&T people
There is evidence to suggest that LGB&T young people may be more
vulnerable to suicidal ideation and attempts than their heterosexual
counterparts (e.g. Clements-Nolle, Marx & Katz, 2008; Hatzenbuehler,
2011; Hatzenbuehler, Keyes & McLaughlin, 2011; Langhinrichsen-
Rohling, Lamis & Malone, 2010; Mathy, 2003). For instance Shields,
Whitaker, Glassman, Franks and Howard (2012), using data from a
representative sample of LGB and heterosexual high school students
in the US, found that LGB young people were 3.9 times more likely to
make suicide plans, and 3.6 times more likely to attempt suicide. As
death certicates do not record victim’s sexual orientation, it is not
possible to ascertain whether LGB&T people are more likely to die
by suicide, although Plöderl et al. (2013) reviewed the literature and
argued that this may well be the case.
Although completed suicide is more common in older LGB&T age
groups, suicide attempts are more common among bisexual, homosexual
and transgender young people (Mathy, 2003; Wang, Häusermann,
Wydler, Mohler-Kuo & Weiss, 2012; Xavier, Honnold, & Bradford, 2007).
Boeninger, Masyn, Feldman and Conger (2010) found mid adolescence
(16/17 years of age) was a time of greatest risk for suicide attempt
among adolescents with boys’ risk remaining high longer than girls’. In
one of the few studies focussing on Trans* young people using gender
identity services in the NHS in the UK, similar results have been found in
natal males versus natal females (Skagerberg, Parkinson & Carmichael,
2013).
4.1. Nomenclature of suicide
There is a range of terms used in clinical practice and research in
relation to suicide including suicidal distress, suicidal ideation, suicidal
behaviour (including suicide attempt, suicidal ‘gesture’ and parasuicide)
and completed suicide. For the purpose of this study, we use O’Carroll
et al’s (1996) denition of suicide attempts as being: (a) self-initiated,
potentially injurious behaviour; (b) presence of intent to die; and (c)
non-fatal outcome (suicide being used only for cases in which death
results). The term self-harm is used to denote the absence of the intent
to die (Silverman, Berman, Sanddal, O’Carroll & Joiner, 2007a; 2007b).
4.2. Risk factors for suicide and self-harm
Risk factors have been dened as ‘variables that are associated with
an increased probability that an outcome will occur’ (Van Orden et al.,
2010, p.576) whereas causal processes explain an outcome.
A systematic review of the literature on suicide risk and protective
factors (McLean, Maxwell, Platt, Harris & Jepson, 2008) found a number
Literature review
14 The RaRE Research Report: Risk and Resilience Explored
of factors relevant to adolescents generally: sexual abuse, eating
disorders, personality factors including, extroversion, neuroticism,
impulsivity, irritability, anger, aggression, hostility, hopelessness and
anxiety; attention decit hyperactivity disorder (ADHD); and poor
problem-solving skills. Although there is some overlap between
general and sexual minority young people’s suicide risk factors, we
will focus on the latter on our review. Warner, et al. (2004) found in
their study of LGB mental health, ‘variables associated with attempted
suicide were being female (OR1.7, 95% CI 1.2–2.5), having been
attacked in the past 5 years (OR 1.4, 95% CI 1.1–1.9) and having been
insulted at school (OR1.4, 95% CI 1.1–2.0)’ (p.483).
4.2.1. Demographic factors
Some studies have suggested that young gay and bisexual males have
higher rates of suicide attempts than lesbian and bisexual women
(King et al., 2008; Remafedi et al.,1998). However, gender has not
always been found to be signicant for LGB young people (Blosnich
& Bossarte, 2012; van Bergen, Bos, Lisdonk, Keusenkamp & Sandfort,
2013) and one study by Eisenberg and Resnick (2006) looking at
sexually active young people has found that LB females had higher
suicide attempts and ideation than GB male young people.
Some research suggests that those who identify as bisexual (Needham
& Austin, 2010; Plöderl, Kralovec & Fartacek, 2010), those questioning
or unsure of their sexual orientation (Birkett, Espelage & Keonig,
2009; Lucassen et al., 2011; Zhao, Montoro, Igartua & Thombs, 2010)
as well as those with attraction to both sexes may be at highest
risk (e.g. Langhinrichsen-Rohling et al., 2010; Lucassen et al., 2011).
However, some research has found no signicant differences according
to (sexual minority) identity (e.g. Hatzenbuehler, 2011). Finally, earlier
age of same-sex attraction for LGB young people (Mustanski & Liu,
2013) and additionally an earlier identication as a sexual minority
for lesbian and bisexual women (Corliss, Cochran, Mays, Greenland &
Seeman, 2009) have been associated with attempting suicide. A study
of adults (Plöderl, Kralovec & Fartacek, 2010) and another one of young
people (Moon, Fornili & O’Briant, 2007) found that those with bisexual
behaviour were more likely to attempt suicide with some intent to die
than heterosexual participants.
4.2.2. Familial and social risk factors
A study of lesbian and bisexual women found that emotional abuse
by the family was also a signicant predictor of suicide attempt risk,
though they did not focus on young people (Corliss et al., 2009). Family
problems have also been linked to greater suicide ideation in LGB
young adults by Blosnich and Bossarte (2012), and to suicide attempts
Literature review
A study of
lesbian and
bisexual women
found that
emotional abuse
by the family was
also a signicant
predictor of
suicide attempt
risk.
15The RaRE Research Report: Risk and Resilience Explored
in their bisexual sample, who also reported a greater presence of family
problems than any other group.
Adams, Dickinson and Asiasiga (2013) identied that mental health
issues were stigmatised in LGB&T communities and that suicidal
behaviour was seen as an almost acceptable way to deal with the
experience of minority stress, which may impact the attitudes and
behaviour of LGB&T young people in this regard.
4.2.3. Social isolation, exclusion and rejection
A study by Van Orden (2010) identied that, ‘social isolation is one
of the strongest and most reliable predictors of suicidal ideation,
attempts, and lethal suicidal behavior across the lifespan’ (p.582).
Bisexual young people and those questioning their sexual orientation
have been found to have less social support than other groups, which
could be linked to greater suicide risk (Espelage, Aragon, Birkett &
Keonig, 2008; Langhinrichsen-Rohling et al., 2010). Additionally,
negative social support has been associated with greater risk of suicide
attempt in LGB young people (Rosario, Schrimshaw & Hunter, 2005).
A study by Fenaughty and Harre (2003) identied coming out
(disclosure particularly) as one of the most stressful experiences for
gay young people. This may relate to rejection or fear of rejection, by
friends and family which has also been shown to be a risk factor for
suicide attempts particularly among LGB young people. Ryan (2009)
found an eight-fold increased prevalence of reported suicide attempt
among those that had experienced frequent rejecting behaviours by
their parents or caregivers in adolescence compared with those whose
parents were more accepting. Parental rejection in LGB young people
contributed to their overrepresentation in those who are homeless (Ray,
2006). Additionally, Dahl and Galliher (2012) interviewed LGB&T young
people brought up in a Christian religious context and found that they
experienced increased social strain on relationships, as some people
were rejected by family for religious reasons, similar to the ndings of
Reed and Valenti (2013) in their study with young black lesbians.
4.2.4. Discrimination and hostility
Homophobic, biphobic and transphobic hate crime is still a relevant
problem in Britain today. A survey identied that one in every six gay,
lesbian and bisexual people have been the victim of a hate crime or
incident in the previous three years (Stonewall & Yougov, 2013). A study
by Mays and Cochran (2001) found that discrimination perceived by LGB
people may partially explain their greater psychiatric morbidity risk.
King et al. (2008) speculated that hostility, stigma and discrimination
experienced by LGB people contribute to the higher levels of
psychiatric morbidity.
Literature review
16 The RaRE Research Report: Risk and Resilience Explored
The suicide risk amongst transgender young people has received
little attention. A study of correlates of life-threatening behaviours
in American transgender young people found childhood gender non-
conformity, negativity about their own transgender status, parental
verbal abuse, parental physical abuse and two of three aspects of body
esteem all to be more common in those who had a history of suicidal
behaviours (D’Augelli et al., 2005). Indeed some research suggests it
may be gender non-conformity rather than having an LGB&T identity
per se that may confer greater vulnerability to suicidal ideation and
attempts (Fitzpatrick, Euton, Jones & Schmidt, 2005; LeVasseur et al.,
2013).
Several studies have suggested that LGB&T young people and adults
are at higher risk of physical, emotional and sexual violence compared
to heterosexuals, with increased risk of suicide ideation and attempts
(Blosnich & Bossarte, 2012; Clements-Nolle et al., 2008; Roberts,
Rosario, Corliss, Koenan & Austin, 2012a; Testa et al., 2012).
A number of studies have identied that LGB&T students may also
be more likely to experience victimisation and bullying at school, and
linked this to increased depression, suicide ideation and attempts in
these young people (Espelage et al., 2008; Hatzenbuehler & Keyes,
2011; Robinson & Espelage, 2012; van Bergen et al., 2013). Plöderl
(2009) found that suicidal ideation was more frequent among both
those students who were victims of bullying and students who bullied
others.
4.2.5. Mental health problems
Several studies have linked increased prevalence of depression
in sexual minority young people and transgender adults, and in
turn associated this with increased suicide ideation and attempts
(Clements-Nolle et al., 2008; Harris, 2013; Langhinrichsen-Rohling et
al., 2010; Marshal, et al., 2011; Mustanski & Liu, 2013; Rosario et al.,
2005). Unsurprisingly, this may also be associated with the increased
prevalence of abuse, discrimination and victimisation, as well as social
isolation in these young people (e.g. Marshal et al., 2011; Martin-Storey
& Crosnoe, 2012; Mustanski & Liu, 2013). Similarly, increased anxiety
and insecurity has also been identied as a risk factor for suicidality in
LGB young people (Rosario et al., 2005; Straiton, Roen & Hjelmeland,
2012; Walker & Longmire-Avital, 2013).
Alcohol misuse has been identied as a suicide risk factor in sexual
minority young people (Hatzenbuehler, 2011). A diagnosis of alcohol
use disorder is associated with a high-risk for multiple suicide attempts
and research highlights the need to target this group with suicide
prevention initiatives (Boenisch et al., 2010). Additionally acute alcohol
intoxication has been found to be associated with increased lethality of
suicide attempt (Sher et al., 2009).
Literature review
Several studies
have suggested
that LGB&T
young people
and adults are
at higher risk
of physical,
emotional and
sexual violence
compared to
heterosexuals.
17The RaRE Research Report: Risk and Resilience Explored
Kosky et al. (1990) reported that in the general adolescent population
those with suicidal ideas were ‘clinically indistinguishable’ from those
who attempt suicide. However, a review of the evidence by Haas et al.
(2011) concluded that ‘reported suicidal ideation does not appear to be
a stable predictor of LGB suicidal behaviour’ (p.19).
4.3. Suicide resilience
Psychological resilience has been described as the capacity of people
to cope with stress and adversity. Resilience may be seen as the ability
of an individual to bounce back to a previous level of functioning, or
being able to steel oneself against the effects of adversity and function
better than expected in adverse circumstances. Resilience is usually
understood as a process rather than a personality trait.
Resilience factors in relation to suicide are those that promote survival
from suicidal behaviour in people exposed to risk (McLean et al.,
2008). Very little research has been undertaken on factors that protect
individuals from suicidality compared to those that put them at risk.
4.3.1. Demographic factors
Several factors may interact to put certain participants at reduced risk
of suicide relative to other groups. For example Blosnich and Bossarte
(2012) found that Black and Hispanic bisexual young people were at
lower risk of self-harm, and Hispanic young people additionally at lower
risk of suicide ideation than White participants. However, O’Donnell,
Meyer and Schwartz (2011) found that these two ethnic groups had
greater lifetime suicidality as adults, than White participants, which was
not explained by depression or substance misuse. Nevertheless, there
has been a paucity of research into LGB&T young people of colour, so
it is difcult to draw any conclusions about what impact ethnicity has
on suicide risk and resilience as arguably they may be at risk of being
doubly oppressed due to ethnic and sexual orientation and/or gender
minority status.
LGB young people with exclusively same-sex partners have been found
to have a similar low risk of suicidality as the heterosexual comparison
group (Eisenberg & Resnick, 2006), unlike identifying as LGB in itself
which conferred greater suicide risk.
4.3.2. Psychological factors
Identity development has been argued by participants of some
qualitative studies as key to resilience for LGB&T people (Dahl &
Galliher, 2012; Harper, Brodsky & Bruce, 2012; Reed & Valenti, 2013;
Singh, 2013; Singh, Hays & Watson, 2011), though this could take
Literature review
Psychological
resilience has
been described
as the capacity
of people to cope
with stress and
adversity.
18 The RaRE Research Report: Risk and Resilience Explored
considerable emotional investment in non-accepting contexts (such
as a religious ones, e.g. Dahl & Galliher, 2012). This was achieved
by some young people through identity exploration in a ‘safe’
space, then strengthened by investing in more difcult contexts, for
example, by coming out or ghting prejudice in those contexts (Dahl
& Galliher, 2012; Reed & Valenti, 2013). However, some participants
also identied ‘identity disclosure management’ as important to
stay resilient, by ‘passing as straight’ or taking extra care around
homophobic people (Harper et al. 2012; Reed & Valenti, 2013).
Two studies found that having greater optimism and hope helped
transgender people become more resilient to the stressors they faced
(Moody & Smith, 2013; Singh et al., 2011). Moody and Smith (2013)
also found that greater emotional stability was associated with lesser
suicide ideation and behaviour.
Also related to this is the nding that greater instrumentality and
personal agency may be protective, although again the research
sampled adults only – the trans women and the general population
respectively (Gonzalez, Bockting, Beckman & Duràn, 2012; Straiton et
al., 2012). Interestingly, studies with LGT people of colour have shown
that challenging heterosexism, self-advocacy and activism, as well as
seeking support (i.e. mobilising personal resources) have been linked
with increased resilience (Harper et al., 2012; Lehavot & Simoni, 2011;
Reed & Valenti, 2013; Singh et al., 2011; Singh, 2013).
Greater self-care has been identied as a resilience factor by young gay
males in one qualitative study (Harper et al., 2012), and Trans* adults
in another (Singh et al., 2011). Participants in the latter also discussed
the importance of embracing self-worth. Similarly, greater self-esteem
has been identied as another potential protective factor against
suicide risk in LGB young people by Rosario et al. (2005). In turn, recent
research in LGB&T adults suggests that forgiveness, especially of the
self, may enhance self-esteem (Greene & Britton, 2013).
4.3.3. Social support
Eisenberg and Resnick (2006) found that family connectedness,
believing one is cared for by adults and feeling safe in school, improves
resilience. Ryan, Russell, Huebner, Diaz and Sanchez (2010) similarly
found that family acceptance is a buffer against suicidality in LGB&T
young people, and this has been supported by other studies (DiFulvio,
2011; Espelage et al., 2008; Moody & Smith, 2013; Mustanski & Liu,
2013; Needham & Austin, 2010; Riley, Clemson, Sitharthan & Diamond,
2013). Participants in studies by DiFulvio (2011), Harper et al. (2012)
and Reed and Valenti (2013) spoke about how social support by other
key people, including family and friends, as well as certain individuals
from within the LGB&T communities, helped them through acceptance
and by encouraging them toward ‘authenticity’ and self-acceptance.
Literature review
Two studies
found that having
greater optimism
and hope helped
transgender
people become
more resilient to
the stressors they
faced.
19The RaRE Research Report: Risk and Resilience Explored
McCallum and McLaren (2010) studied LGB adolescents belonging to
a young peoples group (for under 18 year olds) and found that having
a sense of belonging to the general community was protective against
suicidality but only so when young people had a greater sense of
belonging to the LGB&T community.
In the US a growing number of schools have established a gay-straight
alliance (GSA), and growing evidence suggests this may somewhat
protect LGB&T students from suicidality (Poteat, Sinclair, DiGiovanni,
Keonig & Russell, 2012). It has also been associated with an increased
sense of high school belonging, decreased victimisation, depression and
psychological distress, providing a safe space for LGB&T students and
enabling them to challenge homophobic behaviour (Heck, Flentje &
Cochran, 2011; Mayberry, Chenneville & Currie, 2013). Not surprisingly,
the presence of inclusive anti-bullying and discrimination policies
may also be protective as it is associated with lowered risk of suicide
attempts in sexual minority young people, particularly gay and lesbian
young people (Hatzenbuehler, 2011; Hatzenbuehler & Keyes, 2013).
4.3.4. Religiosity
Religiosity may have a complex relationship with suicide risk and
resilience in LGB&T young people. Dahl and Galliher (2012) discussed
how incorporating religious values into their identity, lifestyle and
aspirations (e.g. through doing activities to help others, monogamy and
importance of family) aided young people’s resilience. Walker (2013)
surveyed African American LGB adults and found that in those with
high internalised homo-negativity, high religiosity was a protective
factor for overall mental health.
5. Alcohol misuse among lesbian and bisexual women
Research using large population based samples has consistently
demonstrated a higher frequency and intensity of alcohol use among
lesbian and bisexual women in ‘Western’ industrialised societies,
as well as among those with same-sex attraction and experience. A
systematic review and meta-analysis of studies of mental disorders
by King et al. (2008) reported a higher risk of alcohol and substance
dependence in LGB people compared to their heterosexual
counterparts. However, the risk of dependence was particularly acute
in lesbian and bisexual women who had a four- fold relative risk of
alcohol dependence over a twelve month period.
Rosario (2008) analysed a small number of large scale population-
based studies that have consistently documented that women who
identify as lesbian or bisexual (as well as women with same-sex
attractions and same-sex sexual experience) report higher levels of
alcohol, tobacco and marijuana use than heterosexual women. Albeit
Literature review
Large scale
population-
based studies
documented
that women
who identify
as lesbian or
bisexual report
higher levels
of alcohol,
tobacco and
marijuana use
than heterosexual
women.
20 The RaRE Research Report: Risk and Resilience Explored
Bloomeld, Wicki, Wilsnack, Hughes and Gmel (2011) found that
lesbians in New Zealand and the US drink more than heterosexual
women, but this did not hold in Great Britain.
The largest survey of women’s health needs and experiences (over six
thousand women) to have taken place outside the US was commissioned
by Stonewall in the UK (Hunt & Fish, 2008). They reported that about
40% of lesbian and bisexual women drink alcohol three or more times a
week compared with a quarter of women in general.
5.1. Terminology
The Diagnostic and Statistical Manual for Mental Disorders (DSM-5) denes
a range of ‘Addictions and Related Disorders’ which includes alcohol use
disorder. Contrary to the separation between abuse and dependence in
the previous edition of the manual, these are now considered to be part
of a spectrum that classies substance use, including alcohol, according
to the number of criteria met (American Psychiatric Association, 2013).
The International Classication of Diseases-10 (ICD-10; World Health
Organization, 1992) lists the following symptoms for alcohol dependence:
withdrawal syndrome; using alcohol to relieve or avoid withdrawal
symptoms; impaired control of drinking, or unsuccessful efforts to cut
down use; neglect of normal activities; continuing to drink despite negative
consequences; large amounts of time spent imbibing and/or recovering from
use; and a compulsion to drink. If tolerance and withdrawal are present then
drug dependence is associated with physical dependence.
Studies concerned with alcohol abuse have used a number of terms
to describe it including: problem drinking, hazardous drinking, alcohol
misuse, alcohol abuse, alcoholism, alcohol dependence, and alcohol use
disorders (which subsume alcohol abuse and alcohol dependence). In the
RaRE study we used the term ‘problem drinking’ in some of our participant
recruitment materials. This term is the most inclusive and would therefore
enable us to obtain a broad spectrum of narratives relating to problematic
alcohol consumption. However, alternative terms, such as alcohol misuse
and problematic drinking will also be used throughout the report as
equivalents, and hazardous or dependent drinking will be used in the
context of analyses in which specic instruments and criteria were used
(following Hequembourg, Livingston & Parks, 2013).
5.2. Risk factors
5.2.1. Sexual orientation and gender conformity
Different studies have suggested that self-identity may be important,
as lesbians, bisexual and heterosexual-identied women with same-
sex partners were all found to be at higher risk of alcohol misuse than
Literature review
21The RaRE Research Report: Risk and Resilience Explored
their heterosexual counterparts, particularly heterosexual women with
different sex partners (Ziyadeh et al., 2007; Drabble, Trocki, Hughes,
Korcha & Lown, 2013). Further research also suggests that bisexual
women may be at higher risk of alcohol misuse than lesbians (Drabble
et al., 2013; Fredriksen-Goldsen, Kim, Barkan, Balsam and Mincer, 2010;
Hughes, Szalacha, Johnson et al., 2010; Lanfear, Akins & Mosher, 2013).
A large US study (Cochran & Mays, 2009) comparing the prevalence
of mental health problems between people of different sexual
orientations found that lesbians were more frequently diagnosed with
major depression than exclusively heterosexual women. In contrast,
bisexual women were more likely than exclusively heterosexual women
to meet criteria for several disorders, including alcohol dependency.
Heterosexual women who had sex with other women had a greater
prevalence of alcohol dependency than exclusively heterosexual
women.
The degree of gender non-conformity amongst lesbian and bisexual
women has been found to impact on their drinking patterns. For
example, Rosario (2008) found that young lesbians with a more ‘butch’
self-presentation were found to use alcohol, tobacco and marijuana
more frequently and to drink alcohol in greater volumes than young
‘femme’ women. Further research found that butch lesbian and bisexual
women were more likely to be victimised, including by their families,
which in turn was associated with greater substance misuse (Condit,
Kitaji, Drabble & Trocki, 2011; Lehavot & Simoni, 2011).
5.2.2. Age
Following a review of longitudinal studies of alcohol consumption,
Molander (2010) argued that there generally may be age-related
decreases in drinking. Austin (2010) explored age differences in
risk factors for problematic alcohol use among 1,141 self-identied
lesbians. They found that the age group that used alcohol most
frequently and intensively was the 19-29 age group (versus 30-49 and
>50 year olds). However, in other studies lesbians reported drinking
alcohol more heavily and later into old age than their heterosexual
counterparts (reviewed by Pettinato, 2008).
Age may interact with other factors. Talley, Sher and Littleeld (2010)
found that college students endorsing a minority sexual identity at the
start of their college education reported greater frequency of binge
drinking and drunkenness compared to their heterosexual counterparts,
whereas those who only endorsed a sexual minority identication at
the end did not.
Studies by Hughes, Johnson, Wilsnack and Szalacha (2007) and Ziyadeh
et al. (2007) have found that parental or other adult heavier drinking
at home were risk factors for greater alcohol abuse for sexual minority
Literature review
The degree of
gender non-
conformity
amongst lesbian
and bisexual
women has been
found to impact
on their drinking
patterns.
22 The RaRE Research Report: Risk and Resilience Explored
women, but Hughes et al. (2007) also found that this was fully mediated
by earlier age of drinking onset. Additionally, they found that those with
earlier sexual debuts were also at increased risk of alcohol abuse.
5.2.3. Socio-economic status
Greater education, particularly having a college degree, has been found
to be a risk factor for alcohol misuse in lesbian and bisexual women, as
well as in other samples (e.g. Drabble et al., 2013). It may be that alcohol
misuse is normalised at university, though people may also ‘age-out’ of
drinking heavily (Lanfear et al., 2013).
The higher prevalence of alcohol use among older lesbians may be
partially explained by their greater earnings. Lesbian women have been
documented to earn more than heterosexual women irrespective of their
marital status (Antecol, 2008). In contrast, a study focusing on younger
participants found that having a yearly income below $37,000 was a risk
factor for greater alcohol misuse in lesbian and bisexual women (Hughes,
Szalacha & McNair, 2010, age range 25-30 yrs).
5.2.4. Mental health and self esteem
Greater perceived stress and poorer overall mental health has been
linked to greater alcohol misuse in lesbian and bisexual women (Hughes
et al., 2010), though it is equally possible that alcohol misuse can
cause or exacerbate these issues. Research in LGB young people and
sexual minority women suggests that higher distress is associated with
increased alcohol misuse (Hughes et al., 2007; Newcomb et al., 2012).
King’s (2008) meta-analysis of studies on mental health inequalities
in LGB&T people found a higher 12-month and lifetime prevalence of
anxiety in all LGB groups compared with heterosexuals. There is some
evidence that social anxiety can lead to the use of alcohol as a coping
strategy (Bacon, 2010). Social anxiety disorder was found in one study
with the general population to precede alcohol dependence in almost
four fths (79.7%) of co-morbid cases (Schneier, 2010), helping to
establish this as a causal risk factor.
Self-esteem appears to have a complex relationship with alcohol
misuse in LB adolescent girls (Ziyadeh et al., 2007). Low academic self-
esteem was associated with greater alcohol misuse, but so was high
social self-esteem, which may be due to greater access to alcohol, such
as in parties, whereas low social self-esteem and athletic self-esteem
appeared to be protective.
Literature review
Research in LGB
young people
and sexual
minority women
suggests that
higher distress is
associated with
increased alcohol
misuse.
23The RaRE Research Report: Risk and Resilience Explored
5.2.5. ‘Internalised homophobia’ and heterosexism
LGB individuals have been considered to be at greater risk for alcohol
abuse because of ‘internalised homophobia’. Internalised homophobia
has been dened as ‘the gay person’s direction of negative social
attitudes toward the self, leading to a devaluation of the self and
resultant internal conicts and poor self-regard‘ (Meyer & Dean, 1998, p.
161, cited by Span, 2009). However, little research has investigated the
nature of the relationship between alcohol and internalised homophobia
and the ndings have been inconsistent (Span, 2009). For example, a
study that explored age differences in problematic drinking concluded
that similarly with heterosexual populations, depression and stress
were strong predictors of problematic alcohol use among lesbians
(Austin, 2010). Span (2009) found that men and women who reported
experiencing little depression and internalised homophobia were those
who drank most frequently. They suggested that these individuals may
be least likely to seek psychological services (for depressive symptoms)
and appear to be at lower risk for psychological problems but may have
a greater risk of problematic drinking and alcohol use disorders (Span,
2009). A qualitative study that explored the impact of homophobia on
young LGB people in the UK reported a coorelation between the distress
arising from homophobia with suicide attempts, self-harm practices, risky
sexual practices, and excessive alcohol consumption and drug-taking
(McDermott, Roen & Scoureld, 2008).
Amadio’s (2006) study explored the relationship between internalised
heterosexism (IH) and alcohol consumption. Their results showed
relationships between certain drinking issues and IH, but only in females.
The positive association with IH in lesbians, but not gay men, was
between the number of days participants reported being very high or
drunk over the past year. In both genders, however, no association was
found between binge or heavy drinking and IH, or in the number of days
alcohol was consumed over the past year. Other studies have also found
that increased IH is associated with increased alcohol misuse in LGB
people (Hequembourg & Dearing, 2013) and sexual minority women
(Lehavot & Simoni, 2011). Additionally Hequembourg and Dearing (2013)
found that increased proneness to shame was also a risk factor for
alcohol misuse, which may also be linked to internalised heterosexism
and experiences of discrimination and victimisation in LB women.
5.2.6. Interpersonal rejection, discrimination and abuse
A study by Hughes, Szalacha, Johnson et al. (2010) found levels of
‘hazardous drinking’ among heterosexual women to be signicantly
lower than among sexual minority women. Using multivariate analysis,
controlling for demographic characteristics and early onset of drinking,
they reported signicant differences in the level of hazardous drinking
that could be attributed to the interactive effects of sexual identity and
sexual victimisation.
Literature review
24 The RaRE Research Report: Risk and Resilience Explored
A study by Wilsnack et al. (2008) found that exclusively heterosexual
women had the lowest rates on all measures of hazardous drinking,
and that these women also reported less childhood sexual abuse, less
early alcohol use, and less depression. Bisexual women reported more
hazardous drinking and depression than those who were mostly or
exclusively lesbian. In line with that, McDermott et al. (2008) reported
that the higher rate of childhood abuse in lesbian and bisexual
women was a mediating factor in excess tobacco and alcohol use
in adolescence relative to heterosexual women (McDermott et al.,
2008). Drabble et al. (2013) additionally found that childhood physical
abuse (CPA) also increased the risk of hazardous drinking, and that the
presence of both childhood sexual abuse and CPA had a cumulative
effect on alcohol misuse in the sexual minority group.
It must be noted that lesbians and bisexual women may face multiple
forms of intersectional discrimination – for instance related to ethnicity
or age. Hence Condit et al. (2011) found that women of colour reported
greater alcohol misuse after experiencing racial discrimination and
due to awareness of racial discrimination in wider society. A study
that explored the impact of multiple discrimination (including race/
ethnicity, sexual orientation and gender) on mental health in the
US (McLaughlin, 2010), found an increased incidence of psychiatric
disorders (including substance abuse) among those who experienced
discrimination, including racial discrimination in the past year. Further
research by Lehavot and Simoni (2011) suggests that even when social
support is taken into account LGB related victimisation remains a small
but statistically signicant risk factor for alcohol misuse in sexual
minority women.
Few studies have examined the impact of institutional discrimination
on the mental wellbeing of lesbian, gay or bisexual (LGB) people. A
recent exception to this is a study undertaken by Hatzenbuehler (2010)
that compared States in the US that had markers of institutional
discrimination. They found the relationship between LGB status and
psychiatric disorders (including alcohol problems) was ‘signicantly
weaker’ among those living in States with policies providing protection
to LGB people (Hatzenbuehler, 2010, p.2279).
A qualitative study by Condit et al. (2011) sought to examine stressors
which may lead to alcohol misuse in lesbians and bisexual women,
who identied family rejection as a risk factor. These women had
experienced rejection and a lack of support when coming out, a
heteronormative silence regarding their identity, being forced out of
their homes, as well as abuse and criticism.
Participants in Condit et al. (2011) also identied relationship
dissolution as leading to greater alcohol misuse. However, some also
identied alcohol misuse as a cause of their decisions to end previous
relationships. This was also related to intimate partner violence (IPV),
though establishing causality with regard to alcohol misuse and IPV
Literature review
Bisexual women
reported more
hazardous
drinking and
depression
than those who
were mostly
or exclusively
lesbian.
25The RaRE Research Report: Risk and Resilience Explored
can be complex – i.e. alcohol misuse can precipitate incidents of IPV
as well as experiencing IPV be a stressor for risky drinking (Lewis,
Milletich, Kelley & Woody, 2012).
However as with most research in this area the cross-sectional designs
of these studies preclude any rm conclusions about causality.
5.3. Resilience
5.3.1. Deance and acceptance
Adopting a deant ‘out and proud’ stance was reported to be an
attempt by the LGB individuals interviewed in a study by Amadio
(2006) to overcome the sense of shame their LGB status brought upon
them. Alternatively Bowleg, Craig and Burkholder (2004) using a non-
representative sample of African American lesbians found that having a
strong lesbian identity predicted greater active coping.
Rosario (2009) found that rather than disclosure of a minority sexual
orientation itself being associated with substance abuse, it is the
number of accepting and rejecting responses to disclosure that are
important in understanding substance abuse among LGB young
people. They found that accepting reactions could act as a buffer
against the effects of rejecting reactions in disclosure scenarios.
Experiencing acceptance appears to be an important factor in
building resilience to homo-negativity (and potentially alcohol use
disorders). Ryan, Russell, Huebner, Diaz and Sanchez (2010) similarly
found that family acceptance was protective against substance misuse
in LGB young people.
Doty (2010) found that higher levels of sexual orientation support were
associated with less emotional distress and acted as a buffer protecting
against the impact of ‘sexuality stress’ on emotional distress amongst
LGB young people.
Factors that may appear to bolster resilience may also act as a risk.
A qualitative study found that socialising with other lesbians in
gay venues provided a number of psychosocial benets. However,
participants described bar attendance as also having a health trade
off, in that it exposed individuals to the temptation to drink (Gruskin,
2006). Participants in research by Condit et al. (2011) also identied
the alcohol-centrism of activities in the LGB community as problematic,
and some found it easier to abstain if going to a specic venue for a
purpose (e.g. entertainment).
Literature review
26 The RaRE Research Report: Risk and Resilience Explored
5.3.2. Guilt proneness and religiousness
Hequembourg and Dearing (2013) found that having increased guilt-
proneness was negatively associated with alcohol misuse among LGB
adults, and that lesbians had the greatest guilt-proneness of their sample.
One US study (Haber, 2007) explored the impact of religious afliation
on alcohol consumption amongst a large sample of daughters of
alcoholic parents. They found that afliation to religions that did
not accept alcohol consumption as normal accounted for most of
the protective inuence of religious afliation. Research by Rostosky,
Danner and Riggle (2008), however, suggested that greater religiosity
did have a protective effect against alcohol use and misuse in young
heterosexual adults over time, but this was not the case for their LGB
counterparts. The LGB sample also had lesser religious involvement,
which may explain, to an extent, why they may not adhere to
expectations regarding alcohol use.
5.3.3. Help seeking and treatment issues
A study that compared the treatment preferences and perceived
barriers to seeking treatment by ‘worried drinkers’ of various sexual
orientations (Green, 2011) reported few differences between genders
or sexual orientations. However, heterosexual respondents considered
stigma as a barrier more often than LGB respondents. Green speculated
that this might be explained by LGB communities possibly having a
more accepting view of psychotherapy than heterosexual communities.
In support of this Grella, Greenwell, Mays and Cochran (2009), using
a probability sample in California, found that lesbians and bisexual
women were more likely to seek treatment for emotional and mental
health problems than heterosexual women.
Wilsnack et al. (2008) suggested that the higher rates of childhood
sexual abuse, early drinking, and depression among sexual minority
women should be considered as important factors when clinicians are
assessing and treating alcohol related problems or when developing
prevention and early intervention strategies.
6. Body image issues, including eating concerns,
among gay and bisexual men
The primary focus in research on body image has been on women
and girls in relation to eating disorders (Thompson, Heinberg, Altabe
& Tantleff-Dunn, 1999) and has resulted in an extensive scholarship.
By comparison, body image disorder in males has received far less
attention in the past two decades (McCabe, Ricciardelli & Karantzas,
2010) with only some of that research specically examining gay and
bisexual men’s body image concerns or how these may differ from their
Literature review
Body image
disorder in males
has received far
less scholarly
attention in
the past two
decades.
27The RaRE Research Report: Risk and Resilience Explored
heterosexual counterparts. Denitions of ‘body image’ and approaches
to its study are varied and the term ‘body image’ is often used to mean
different things by different researchers (Cash, 2004). This can create
confusion and variability across studies (Grogan, 1999). For many, the
focus is entirely on perceptions of one’s own body attractiveness and
perceptions of body size, specically thinness (Pruzinsky & Cash, 2004).
Of particular concern to health practitioners in this context are issues
around body satisfaction and body esteem, body image disorders, and
associated spectrums of body dissatisfaction and risky behaviours.
Body image, as a concept, ‘refers to the mental picture one has of his or
her body at any given moment in time’ (Kaiser, 1990, p.98) or ‘a person’s
perceptions, thoughts, and feelings about his or her body [including]
body size estimation (perceptions), evaluation of body attractiveness
(thoughts), and emotions associated with body shape and size
(feelings)’ (Grogan, 1999, p.1). As part of the RaRE Study, there was a
conscious effort to adopt and develop a denition of body image that
encompassed contemporary usage that includes ‘our experiences of our
physical appearance [recognising] that embodiment entails more than
self-perceived aesthetics’ (Cash & Pruzinsky, 2004, p.510).
From a data-led denition that can be used across a range of health
and social-care environments, the RaRE Study uses a theoretical
position of embodiment that – as well as aesthetic considerations
– includes levels of competence (e.g. physical tness, athletic ability,
kinesthetics) and experiences of the functioning body (e.g. sensation,
perception, the ageing processes) which many conceptualisations
of body image often fail to capture (Cash & Pruzinsky, 2004). To
encourage engagement across a range of audiences at the various
stages of design, data collection, analysis and dissemination, as well
as to improve strategies of assessment (Thomson, 2004), the RaRE
Study uses two specic foci: body satisfaction (and dissatisfaction;
Tylka, 2011; Pruzinsky & Cash, 1990) and cognitive-behavioural
investment (Thomson, 2004) such as drive for changes to muscularity
or thinness (Kelley, Neufeld & Musher-Eizenman, 2010; Tod, Morrison
& Edwards, 2012). Specic experiences of distress are discussed
in relation to current theoretical models and the language of
participants themselves, such as ‘body dysmorphia’, ‘body esteem’,
and ‘eating disorders’ (Pruzinsky & Cash, 2004). This has allowed the
data to be collected and analysed from ‘cognitive-behavioural and
feminist perspectives’ whilst maintaining reexivity about discursively
constructing the medicalised body (Olivardia, 2004).
6.1. Body image disorders
Disturbances in body image have been dened as having three aspects:
perceptual, attitudinal and behavioural (Thompson et al., 1999). There
are a number of psychological/psychiatric diagnostic- type constructs
and terms used to describe and dene body image concerns. These
Literature review
28 The RaRE Research Report: Risk and Resilience Explored
include body image dissatisfaction; body image disorder; body
dysmorphic disorder (BDD); and muscle dysmorphia (MD), a sub-type
of BDD. Whilst distinct, these constructs share some characteristics and
it is important for the purposes of our study to clarify these terms and
distinctions.
Lambrou, Veale and Wilson (2011) described people with body
dysmorphic disorder (BDD) as having an unrealistic ideal as to how
they should look. BDD symptoms include a preoccupation with the
belief that a specic body part is defective or deformed in some way.
The preoccupation is excessive enough to cause distress or signicant
functional impairment, such as in the social or employment sphere.
BDD is distinctive from the body shape dissatisfaction of anorexia
nervosa or the body delusions of a psychotic disorder. BDD shares
characteristics with obsessive compulsive disorder (OCD) but with
some signicant differences. According to a study by Phillips and Diaz
(1997), BDD patients are more likely to have suicidal ideation and are
at greater risk of developing major depression or social phobia than
participants with OCD.
Muscle dysmorphia (MD) is dened as having a persistent belief that
one’s muscles may be small and insufcient, despite having enough
muscularity. Along with a heightened drive for muscularity, men with
MD tend to feel ashamed of their bodies, and hence avoid their bodies
being exposed to others. They frequently compare their bodies with
other men’s and seek reassurance about their appearance (e.g. Chaney,
2008, Maida & Armstrong, 2005). These men also manifest symptoms
of body dissatisfaction, body dysmorphic disorder and OCD, hostility,
depression, anxiety, and perfectionism (Maida and Armstrong, 2005). A
study that compared men with BDD who had either muscle dysmorphia
(MD) or BDD without MD found greater psychopathology amongst
those with muscle dysmorphia. This included higher rates of suicide
attempt, higher rates of any substance use disorder, anabolic steroid
abuse, and poorer quality of life (Pope, Pope, Menard & Fay, 2005).
Another relevant concept is that of body fat dissatisfaction. In many
afuent societies there is a growing trend towards greater proportions
of society experiencing being overweight or obese, both as adults
and in childhood (Health and Social Care Information Centre, 2014;
National Institute of Diabetes and Digestive and Kidney Diseases,
2012). Alongside that trend, dissatisfaction with body fat and pressures
to attain a leaner body are also high. Even very young children express
body fat dissatisfaction and it has been reported in boys as young as
six (McCabe & Riciardelli, 2004). A study of 256 ethnically diverse,
British boys and girls aged 11-14 years found that the majority were
dissatised with their bodies in terms of fatness (Duncan, 2006),
indicating that the issue is not only common for girls, but also for
boys. A study by Bergeron and Tylka (2007) concluded that body fat
dissatisfaction may be of great importance to males’ psychological
Literature review
29The RaRE Research Report: Risk and Resilience Explored
well-being even after taking account of their ‘drive for muscularity’.
They also concluded that for men, body fat dissatisfaction is empirically
distinct from the drive for muscularity.
To develop an ideal body type, people engage in body change
behaviours such as dieting, binging and purging, exercise (which can
be excessive to the point of injury) and the use of performance and
body enhancing drugs including anabolic androgenic steroids (AAS),
which are usually obtained illegally (Grieve, Truba & Bowsersox, 2009).
Prolonged use of AAS in particular can pose potentially serious mental
and physical health risks (Thiblin & Petersson, 2005).
6.2. Prevalence of body image issues
A specic desire to be more muscular is common in Western men. In the
United States, for example, the vast majority of undergraduate males (up
to 90%) in one study expressed this desire (Frederick, Buchanan, Sadehgi-
Azar, Peplau & Haselton, 2007). At about the same time, Rief et al. (2006)
reported a prevalence rate of BDD (as dened by DSM-IV) in the general
population of 1.7%. However, they concluded that these reported rates
are likely to underestimate the true prevalence as the study excluded
those with weight concerns, some of whom may have had BDD.
Some studies have found that gay men have greater body dissatisfaction
than heterosexual men (Peplau et al., 2009; Tiggemann, Martins &
Kirkbride, 2007). Wrench and Knapp (2008) found that compared to
their lesbian and bisexual counterparts they found signicantly higher
levels of body image xation in gay and bisexual males as well as more
negative attitudes towards and dislike of fat people, ‘weight locus of
control’, discrimination against others’ weight/ physique, and depression.
Additionally some evidence suggests that there may be a higher incidence
of BDD amongst gay men compared to heterosexual men; however,
an obvious tension is the omission of bisexual men, or the conation
of bisexual identity with either a gay or straight identity (Barker et al.,
2012). For example, the following studies do not include bisexual men.
Kaminski, Chapman, Haynes and Own (2005) found that compared to their
heterosexual counterparts, gay men reported dieting more, being more
fearful of becoming obese, and were more dissatised with their bodies
generally as well as with their muscularity. They were also more likely to
hold distorted beliefs about the importance of having an ideal physique.
This has also been supported by others who also found that gay men
were more pre-occupied with being overweight, had lower appearance
evaluations and more negative feelings about their bodies (Lakkis,
Ricciardelli & Williams, 1999; Peplau et al., 2009; Tiggemann et al., 2007).
Tiggemann et al. (2007) studied gay and bisexual men separately, and
found that although they both had a thinner and more muscular ideal,
gay men still had signicantly thinner preferences than bisexuals and
Literature review
Compared to
their heterosexual
counterparts,
gay men
reported dieting
more, being
more fearful of
becoming obese,
and were more
dissatised with
their bodies
generally as
well as with their
muscularity.
30 The RaRE Research Report: Risk and Resilience Explored
rated themselves as the least muscular of the group. By contrast, Davids
and Green (2011) found that body dissatisfaction levels in bisexual men
were similar to those in gay men, so additionally such an inconsistency
in ndings may need to be further investigated.
6.3. Risks and predisposing factors
6.3.1. Personality and other associated factors
A literature review that explored studies of the psychopathology of BDD
(Pavan, Simonato, Marini, Mazzoleni & Pavan, 2008) identied a wide
range of factors that may predispose individuals to developing BDD.
These include ‘asthenia/ hyposthenia (lack of strength), a tendency toward
self-criticism, insecurity, and perfectionism and OCD’ (p.474). A study by
Lambrou et al. (2011) reported that men with BDD have a more critical
eye and greater appreciation of aesthetics than control groups, this ability
being applied when evaluating their own appearance. They also found that
individuals with BDD valued physical appearance three times more than
control groups and that this may be to a dysfunctional degree.
Meyer, Blissett and Oldeld (2001) found that gay men who identied more
with ‘femininity’ were more likely to restrict their diet. Another study by
Lakkis et al. (1999) found more specically that, after the inuence of sexual
orientation was controlled for in heterosexual and gay men, traits negatively
associated with ‘femininity’ such as lower levels of assertiveness and self-
esteem and greater expressions of passivity and dependence signicantly
predicted a higher drive for thinness, dietary restraint and bulimia.
6.3.2. Loneliness, poor self-esteem and shame
Studies have found associations between poor self-esteem, loneliness,
and MD among gay and bisexual men (Chaney, 2008), between body
dissatisfaction and body fat dissatisfaction and lower self-esteem in
gay and bisexual men, and between poorer self-esteem and muscle
dissatisfaction for gay men only (Tiggemann et al., 2007).
Downs (2005) posits that a sense of shame for simply ‘being gay’ thwarts gay
men’s development of an ‘authentic’ (self-accepting) self and results from
difculties living in a heterosexist culture that denigrates sexual minority
people. He suggests that body dissatisfaction (and BDD) and the compulsive
need to improve physical appearance is an expression of this internal shame.
6.3.3. Bullying
Experiencing body-related comments in childhood is also a predictor
of poor self-esteem in adult men. One study found a strong association
between being a victim of childhood bullying and muscle dysmorphia
Literature review
A sense of shame
for simply ‘being
gay’ thwarts
gay men’s
development of
an ‘authentic’ self
and results from
difculties living
in a heterosexist
culture that
denigrates sexual
minority people.
31The RaRE Research Report: Risk and Resilience Explored
and concurrent anxiety, low self-esteem, and depressive and obsessive-
compulsive symptoms in men (Wolke & Sapouna, 2008). Calogero, Park,
Rahemtulla & Williams (2010) reported that it was the expectation of
rejection for their appearance rather than actual rejection that causes
the distress that may lead to behaviours associated with BDD.
6.3.4. Pressure to conform
Pressure to conform to culturally constructed body image ideals is
known to contribute to the development of muscle dysmorphia (Grieve,
Truba & Bowsersox, 2009) as well as to body dissatisfaction and body
dysmorphia. A review of studies that explored the impact of the media
on body ideals and body dissatisfaction found that young men were
negatively affected by viewing idealized images of male bodies.
6.4. Prevention: resilience and risk reduction
Prevention of body image disorder has received little research attention
compared to explorations of risk and predisposing factors. Prevention
is not just about reducing or removing risk factors, such as bullying,
but includes bolstering individuals’ coping mechanisms for dealing
with adversity and life’s stresses. An aspect of coping is psychological
resilience dened as, ‘the capacity to recover from extremes of trauma
and stress’ (Atkinson, Martin & Rankin, 2009).
6.4.1. Better appearance evaluation and social comparison
Having a better appearance evaluation is unsurprisingly associated
with better body image and thus may be protective against BDD
(Peplau et al., 2009), possibly as it may also increase self-esteem;
however, it is worth noting that better body image may equally be
responsible for a better appearance evaluation, which cannot be tested
in a cross-sectional survey.
Social comparison may also be protective against BDD (Davids &
Green, 2011). This may be because it gives a person a ‘reality check’ for
their body image ideals, and perception of their own attractiveness in
comparison to other gay and bisexual men.
6.4.2. Positive identication with ‘masculinity’ and drive for
muscularity
In a recent study, heterosexual men perceived their bodies to be less
muscular and reported lower condence in their physical abilities after
they felt that their ‘masculinity’ had been threatened compared to men
whose masculinity had been afrmed (Hunt, Gonsalkorale & Murray,
Literature review
32 The RaRE Research Report: Risk and Resilience Explored
2013). However, when men were asked to report on anxiety related to
appearance and intentions to increase muscularity following a threat
to masculinity, results indicate that men reported less appearance-
anxiety and drive for muscularity when threatened rather than afrmed.
The relationship between appearance anxiety, drive for muscularity
and attitudes to ‘masculinity’ requires further exploration, particularly
where attention to appearance is often considered ‘feminine’, even –
paradoxically – when related to muscularity. Complexity where gender-
roles and sexual orientation intersect must also be considered, for
example for bisexual or gay men.
In contrast, having greater drive for muscularity was found to be
protective against body dissatisfaction in bisexual men (Tiggemann
et al., 2007). In this study, the cohort of bisexual men sampled
rated themselves as more muscular than the gay male sub-sample,
and the gay men in the study had a thinner ideal, so what may aid
resilience is a desired body image that is perceived to be more
realistically achievable.
Literature review
The RaRE Research Report: Risk and Resilience Explored 33
The reviewed literature highlights the challenges, as well as some
opportunities, that LGB&T people face in their daily lives and in their
communities in relation to their mental health. While the social and
cultural environment has changed signicantly in Britain over recent
decades, there are indicators that LGB&T people still struggle with
discrimination and abuse in various contexts, with the potential to
contribute to the development of mental health problems. In fact,
previous research suggests that to a large extent risk seems to rise
from exposure to external (i.e. societal) factors, while resilience may
derive from a combination of a supportive environment, the acceptance
of oneself and the attachment to the LGB&T community.
However, while international research has highlighted some of these
issues, little is known about mental health risk and resilience factors
for LGB&T people living in Britain. Our study aimed to address this gap
by gathering both qualitative and quantitative data and by using it to
produce a detailed portrait of this reality.
The choice of the specic mental health issues under study was
informed by previous research suggesting higher prevalence rates
amongst LGB&T people (e.g., King et al., 2008) but also by the
experience gathered from three decades of experience that PACE
has as a charity providing support for the mental health needs of
the LGB&T community. The RaRE study delivers evidence of that
experience as a community sector organisation and also identies
priority intervention areas, adjusted to the real needs of the
community, both at PACE and beyond.
While being quite different from each other (and despite the
potential for morbidity overlaps between them), all three issues under
study can cause severe suffering and negatively impact the LGB&T
community as well as the families and friends of those affected. It is
our understanding that increasing the knowledge about these issues
will contribute to the improvement of the well-being of the LGB&T
community and of society overall.
Rationale for the study
Previous research
suggests that to
a large extent
risk seems to rise
from exposure to
external factors,
while resilience
may derive from
a combination
of a supportive
environment,
the acceptance
of oneself and
the attachment
to the LGB&T
community.
34 The RaRE Research Report: Risk and Resilience Explored
Methods
The RaRE study is a multi-phase study using a mixed-methods design
drawing from both qualitative and quantitative methodological
research approaches. This is done not with the aim of triangulation
to avoid ‘specious certainty’ (Robson, 1993) but rather to provide
‘complementary components’ to the study.
Excluding the stakeholders survey, which was the very rst phase of
the project and that will not be covered by this report, there were
three data collection phases, each one informing the next. All of them
beneted from the extensive literature review conducted for the study
(summarised for this report) and from the research team’s expertise
and feedback. All phases were cross-sectional.
The rst of these phases was an exploratory qualitative study (P1Q)
during which LGB&T people who experienced the mental health issues
under study were recruited and interviewed about their lives and
experiences of risk, resilience and recovery. The purpose of this phase
was to gain insight into the lived experiences of these people so as to
better understand which factors played a role in the development of
their mental health issues and in their recovery.
The second phase was a national survey. The purpose of this survey
was to collect data that would allow comparison of LGB&T and
heterosexual & cisgender people’s risk and resilience factors. Therefore,
it was targeted at adults (ages 18+) of all sexual orientations and
gender identities from across England.
The third phase of the study (P2Q) was qualitative and its purpose was
to gather a more nuanced picture of the realities of LGB&T people’s
mental health. We were particularly interested in understanding
atypical risk and resilience proles, i.e., those who might have
experienced traumatic experiences while growing up but did not
develop mental health issues later in life, as well as those who did
not have those types of experiences but did have mental health issues
later in life, developing one of the three issues under study. Informally
we called the rst of the two subgroups the ‘resilience’ group and the
second one the ‘risk’ group. Although the methodology for this phase
will be presented in this report, no results from it will be presented or
discussed here.
In this section we provide the relevant details of the methodology used
for each of the research phases of the study.
The RaRE study
is a multi-phase
study using a
mixed-methods
design drawing
from both
qualitative and
quantitative
methodological
research
approaches.
35The RaRE Research Report: Risk and Resilience Explored
1. Ethical approval
Ethical Approval for the RaRE Study as a whole was obtained from
the Ethics Committee of Aston University in April 20103. Additional
Ethics approval for P2Q was obtained from Worcester University in
December 2013.
2. First qualitative study (P1Q)
2.1. Selection criteria
To be included in this phase of the study, individuals had to be 18
years of age or older, identify as LGB or Trans*, have experience from
one of the three mental health issues under study but have been in
recovery from them at least ve years prior to enrolment in the study.
In the case of the suicide group, their rst suicide attempt was to have
occurred after they were aged from 12 years up to and including age
24. At least six years must have passed since their last serious attempt.
The study specically prioritised participants whose attempt had been
life threatening whether or not it had been committed with intention
to die.
2.2. Recruitment
Participants in this phase of the study were recruited through
advertisements on LGB&T media, handout and poster distribution
in specic locations in and around London, systematic and strategic
emailing and follow up, and word of mouth. They then underwent an
initial screening with the research coordinator to conrm they met
selection criteria. If they did they were sent further information about
the study and given a buffer period of no less than 48 hours. After
this time they were contacted and asked if they were still available to
participate in the interview. If they were, they were scheduled to come
in for the interview.
Recruitment took place between July 2011 and March 2012.
2.3. Data collection
In-depth, semi-structured interviews with LGB&T people with a history
of issues under study were used to collect data. All participants were
informed about the aims of the study, topics under study and potential
3 When the researched commenced Prof Elizabeth Peel was at Aston University, later having
moved to University of Worcester.
Methods
36 The RaRE Research Report: Risk and Resilience Explored
risks of participating. Written consent was obtained prior to the
interview. After giving consent, participants completed a demographic
questionnaire. They were also given the option of withdrawing from the
interview at any point without an explanation.
The interviews were carried out face-to-face or over the phone. All
were audio recorded using a digital recorder. After the interviews took
place the audio les were downloaded to a secure drive and deleted
from the recording devices. Interviews were transcribed, checked for
transcription errors and cleaned of identiers.
2.4. Instruments
2.4.1. Demographic questionnaire
This questionnaire included a series of questions about demographic
information, including sexual orientation and gender identity, for
purposes of gathering descriptive information about the participants
and about the sample for reporting purposes.
2.4.2. Interview guide
The interview guide was developed by the research team informed by
the literature review and main research questions, therefore covering
background factors that might have contributed to the development of
the mental health issues under study, access to support and recovery
factors, among others (Appendix 1). Altogether the guide included
11 questions organised thematically (e.g. ‘What do you think may
have played a part in causing your alcohol misuse issues or making
it worse?’, ‘Can you think of anything that might have helped prevent
your attempted suicide?’) and included at the end the possibility for
interviewees to add anything relevant they considered had not been
covered in the interview.
3. Quantitative study (Survey)
3.1. Selection criteria
Selection criteria for the RaRE study’s survey included being aged 18 or
older and living in England. Since comparisons between heterosexual
& cisgender and LGB & Trans* people were to be made, people from
all sexual orientations and gender identities were asked to take part.
Publicity materials were designed taking that into account. Only
completed surveys were included in the nal dataset.
Methods
Since
comparisons
between
heterosexual &
cisgender and
LGB & Trans*
people were to
be made, people
from all sexual
orientations and
gender identities
were asked to
take part.
37The RaRE Research Report: Risk and Resilience Explored
3.2. Survey Development
Initial versions of the survey were informed by the literature review,
content analysis of interviews from the Phase 1 Qualitative Study
(P1Q), other surveys evaluating similar issues and by research team
expertise. There was a systematic and rigorous process of revision by
different stakeholders: RaRE team, Academic Panel, Lay Panel and PACE
colleagues. The nal draft was pilot tested by an independent panel of
volunteers recruited for the purpose. The survey was was programmed
on Survey Monkey software and this process led to nal adjustments to
ensure it was simple to read and to complete. The online version was
further tested by the study team, Academic and Lay Panel members as
well as by other PACE staff members. There was then a nal process
by which the online version and the paper version of the survey were
systematically compared and adjusted so that they mirrored each other,
hence reaching a nal version of the complete scale (Appendix 2).
Standardised components of the survey included the General Health
Questionnaire (GHQ-12; Goldberg & Williams, 1988; binary scoring), the
Multidimensional Scale of Perceived Social Support (MDSSPSS; Zimet,
Dahlem, Zimet & Farley, 1988), Rosenberg’s Self-esteem Scale (RSS;
Rosenberg, 1965), the Importance of Gay/Bisexual Community Activities
scale (IGBCA; Herek & Glunt, 1995; adapted by changing ‘gay/bisexual’
to ‘LGBT’) and the Alcohol Use Disorders Identication Test (AUDIT;
Babor, Higgins-Biddle, Saunders & Monteiro, 2001; Donovan, Kivlahan,
Doyle, Longabaugh & Greeneld, 2006). Academic panel expertise and
literature review informed questions about body image, self-harm and
suicide as well as various other survey items.
For body image a new instrument was developed: the 16 item four
point (Strongly disagree, Disagree, Agree and Strongly agree) RaRE
Body Satisfaction Scale (RBSS), which asked participants how satised
they were with various aspects of their bodies (e.g. their height,
their faces, etc.) and body-related behaviours (how much they eat or
exercise). An additional ve point scale was developed which measured
how participants rated the inuence from various people (e.g. parents,
siblings, childhood friends or classmates, people in the media, your
doctor) and sources on the way they think about their bodies (from
‘Had no inuence at all’ to ‘Had a great inuence’, and including a ‘Not
applicable’ option).
Both body image scales underwent a principal component analysis
with Varimax rotation which identied two subfactors for each.
For the RBSS, factor 1 was related to the bodily aspects that can
be inuenced through tness (health, physical tness, weight,
body shape, body fat, muscularity, food, exercise); factor 2 was
related with bodily features that could be seen as more xed
physical characteristics determined by the late teens and difcult
or impossible to change later in life without cosmetic or surgical
interventions (height, face and features, teeth, hair, body hair, genitals,
Methods
38 The RaRE Research Report: Risk and Resilience Explored
age). The item ‘How much alcohol I drink’ did not have loading on
either of the factors and therefore was excluded. For the instrument
about social inuence on feelings about the body, factor 1 included
people from the close social network and health professionals
(parents/carers, siblings, friends, romantic partners), and factor
2 included the remaining, including people in the larger social
environment (childhood friends and classmates, people in your daily
life, people in your leisure time and people in the media).
Regarding suicide or self-harm, questions were developed that asked
participants whether they had experienced or thought about either of
those two behaviours in the previous year or ever in their lives.
3.3. Recruitment
Alongside the development of the survey, the RaRE study team
developed a national recruitment strategy that would ensure
widespread visibility and completion of the survey by a diverse range of
people.
Calculations were made during initial phases of the study to determine
sampling for each of the study phases. For the RaRE study national
survey a minimum of 1200 participants was shown to be sufcient
in order to perform all necessary statistical analyses. However, we
targeted at recruiting a bigger sample in order to ensure inclusion of a
diverse range participants, some of which are considered hard-to-reach
groups (e.g. people from BME backgrounds, disabled people, older
people). Recruitment took place between June and November 2013.
3.3.1. Emailing and partnerships
The rst wave of recruitment consisted of an email to PACE staff
members and volunteers asking them to forward information
about the survey to their contact networks. This was followed by
emailing PACE’s partner organisations asking them to advertise the
survey through their networks and resources, e.g. emailing their
own contact lists, publicising the survey in their newsletters, etc.
New partnerships were established by the RaRE study team with
organisations that had a potential of reaching broad or strategic
audiences. For those organisations that were willing to distribute
print publicity materials to their clients, packages were sent that
contained yers and posters. Various other contact databases
available at PACE were used in continuing emailing waves that
publicised the survey. Unique Survey Monkey collector links were
allocated to most of these organisations, allowing the monitoring of
the recruitment that came through them.
Methods
39The RaRE Research Report: Risk and Resilience Explored
3.3.2. Web advertising
Strategic websites were selected and contacted to assist with
advertising of the survey through web banners, short news pieces in
newsletters and other forms of online advertisement. Some of the
types of websites used were women’s and men’s health and wellbeing
organisations, LGB&T organisations, mental health related websites,
etc. A series of promotional images were developed reecting concepts
of the study for the purpose of increasing visibility and in order to
create a recognisable and consistent image for the study.
3.3.3. Social Media
Social media networks like Facebook and Twitter were used to recruit
participants in two ways. On one hand, PACE’s accounts on these
websites were used to post regular messages with a link to the survey
asking people to complete the survey as well as to share it with their
networks. On the other hand, paid Facebook advertising campaigns
proved to be very effective recruitment strategies in their ability to
target specic groups that were underrepresented in the sample.
Facebook’s marketing tool allowed for targeting specic proles of
people to be exposed to our advert, this way targeting groups from
which we had low numbers, as identied by our monitoring of the
recruitment. Some of the groups that we targeted using this strategy
were bisexual men, people in geographically remote areas, and others.
3.3.4. Events
Non-LGB&T as well as LGB&T specic events were selected for
attendance by team members for study advertisement and survey
collection. RaRE stalls where people could learn about the study,
complete a survey and take yers and posters were used at Black Pride
2013 and at two London universities’ student fairs. Furthermore, yers
and posters were sent to LGB&T and health promotion events across
the country to increase visibility of the project. RaRE team members
also attended various conferences in 2013, where preliminary results
of earlier phases of the project were presented, awareness was raised
about the survey and people were presented with the web link and
asked to complete the survey online.
3.3.5. Print advertising
At various stages of the recruitment phase print advertisement
campaigns were carried out to increase visibility and to reach people
that were not active on the Internet. Over 6,200 yers and 215 posters
were distributed in strategic places in the city of London, including in
Soho, as well as in Brighton and at other smaller Pride events across
Methods
40 The RaRE Research Report: Risk and Resilience Explored
England. Electronic versions of the survey were also sent out via email
so that recipients could print and distribute them (postcards were
emailed out 19 times and posters 82 times). Additionally, press releases
were also sent out to 18 general and LGB&T specic media outlets.
study that allowed identication on
3.4. Recruitment monitoring
Each recruitment method was allocated a unique collector link
on Survey Monkey, hence allowing monitoring and informing the
renement of the recruitment strategy in two ways. One of them was
to verify the success of the strategies used so that ineffective ones
could be tweaked and made more efcient or abandoned. The other
way that monitoring was used was to check whether specic subgroups
of interest were falling behind in representation, e.g. bisexual men
or women with a history of alcohol abuse. If that was the case, new
strategies were devised to target those subgroups. New strategies were
assigned new collector links to monitor their effectiveness.
3.5. Informed Consent
Completed surveys were accepted only if participants had ticked the
informed consent box in the rst part of the survey. The informed
consent sheet consisted of information about the study topic, source of
funding, which organisation was running the study and condentiality.
It explained the options people had to withdraw from the study and
the risks and benets of being involved.
4. Second qualitative study (P2Q)
4.1. Selection criteria
For this phase of the research we were interested in interviewing
individuals who had experienced traumatic events while growing
up but who did not develop mental health issues later in life (the
‘resilience’ group); as well as those who did not experienced traumatic
events growing up but did develop mental health issues (the ‘risk’
group). For the second group we were also interested in interviewing
individuals who, meeting those criteria, also developed one of the
three key mental health issues of the study: had attempted suicide
while growing up (identifying as LGB or Trans*); had abused alcohol
(identifying as a lesbian, gay or bisexual woman); and had excessive
body image preoccupations (identifying as a gay or bisexual man).
To participate in the study all individuals had to be 18 years of age or
older.
Methods
41The RaRE Research Report: Risk and Resilience Explored
4.2. Recruitment
In the rst phase of the recruitment process individuals who had
participated in the survey and had provided their contact details and
given agreement to taking part in the following phase of the research
(P2Q) were contacted in several waves. This continued throughout
the recruitment process. However this method proved insufcient to
recruit the targeted number of participants (n=20). For that reason,
alternative methods of participant recruitment were devised. Posters
and leaets were distributed across key London locations; emails were
sent out and social media resources were used to recruit additional
participants. Paid Facebook campaigns targeted at specic segments
of the population (e.g. lesbian and bisexual women living in London
with an interest in alcohol or in alcoholic anonymous support groups)
generated additional participants.
Monitoring was used throughout the recruitment process to ensure
diversity in the sample with regard to gender, sexual orientation,
ethnicity and age. When the recruitment target was reached, a further
effort was made to achieve a similar number of participants per mental
health issue in the ‘risk’ subset of the sample. A total of 23 participants
were recruited in this way.
Recruitment took place between February and April 2014.
4.3. Procedures
A recruitment survey was created, developed and made available
online. The purpose of this survey was to collect information from
people available to participate in the study in order to identify those
who ted the selection criteria stated above. People who showed an
interest in participating in the study were directed to the survey and
asked to complete it. The data collected in this way was regularly
downloaded and subjected to a standardised ltering process that
excluded those whose replies indicated they did not t the criteria.
The research coordinator then checked the remaining participants
and if they did match the selection criteria they were shortlisted for
telephone screening. A member of the research team then telephoned
the potential participant and asked a standardised series of questions
intended to conrm their suitability to the study goals. If they were
suitable, they were sent further information about the study via email
and given 48 hours to reect on their further participation in the
study. After 48 hours they were contacted again and asked if they were
still available to participate in the study and, if they were, they were
scheduled for interview.
Interviews were carried out face-to-face or by telephone. In both
cases written consent was obtained prior to the start of the interview.
The interviews were semi-structured, with the interviewers being
Methods
42 The RaRE Research Report: Risk and Resilience Explored
instructed to ask the main questions in the guide but also to explore
other relevant aspects of the interviewees’ experience and perceptions
as appropriate. The interviews were recorded using a digital recorder
(two recorders, in the case of face-to-face interviews). Interviewers were
always debriefed about the interviews with a member of the research
team after the interview took place. This allowed the identication
of any practical, ethical or scientic issues that had been identied,
allowing for additional measures to be put in place to address them,
if and when needed. The audio les and transcription processing
procedures were similar to those undertaken for P1Q.
4.4. Instruments
4.4.1. Recruitment instruments
Several instruments were created and used to recruit P2Q participants.
These will be briey outlined here, but full details and the instruments
used are available from the research team.
Pre-recruitment survey: this online survey was linked with the main
study survey and asked participants a series of questions to ascertain
their suitability and also their availability for participation in P2Q. At
the end of the paper version of the survey participants were provided
with details about P2Q and asked to leave their email addresses if
they were available to participate in it. Both these forms of P2Q pre-
recruitment lasted during all of the survey’s recruitment process, from
June to November 2013.
Recruitment survey: this online survey was a more detailed and
expanded version of the previous one and used upon launch of
recruitment for P2Q. Many of the questions it included (e.g. those
to ascertain body image issues or suicide attempt experience) were
either copied or adapted from the main study survey. It also included
more detailed questions about participant’s availability and contact
details. It was available from February to April 2014.
Inclusion Criteria Assessment Tool: this instrument was used as a
guide during telephone interviews to conrm whether shortlisted
individuals met the selection criteria. It asked similar questions
about traumatic experiences while growing up and later in life, as
well as about experience of the mental health issues under study.
As necessary interviewees were asked to self-dene their concept
of the topics under study (e.g. excessive alcohol use or traumatic
events), but ultimately allowing for interviewer expertise to make a
decision about inviting participants for enrolment in the study. This
instrument was used throughout the recruitment process for P2Q,
from February to April 2014.
Methods
43The RaRE Research Report: Risk and Resilience Explored
4.4.2. Interview guide
Four interview guides were developed, one for each of the subgroups
of interest for this phase of the research: one for the ‘resilience’ group
and three for the ‘risk’ groups (Appendix 3). These were adapted to
the research interests of each subgroup and, in the case of the ‘risk’
subgroup, to the mental health issues experienced by participants.
However, all of the guides included a common set of questions
that covered key issues under study, and all of the three of the ‘risk’
subgroup had a similar structure.
All interview guides were developed by the research team informed
by the literature review and main research questions, particularly
considering the purpose of this phase of the study. A semi-structured
interview schedule was used.
5. Analysis
5.1. Qualitative studies
All interviews underwent a process of thematic analysis, conducted
as per Braun and Clarke’s (2006) guidelines. The transcripts were rst
coded in sequence using a data-driven approach, identifying new codes
based on the content of the interviews and guided by the research
questions. Codes identied later in the process were added to earlier
interviews where applicable.
When all interviews had been coded, the codes were examined,
evaluated for similarity, and grouped together in structure, with
tentative names assigned to the code groups. Codes with few source
references were moved, merged, renamed or deleted after close re-
reading of the code content. The code sets were then further grouped
into overarching potential themes, and separated into risk and
resilience factors, informed by scientic literature on the topics of
analysis.
The model emerging from this process was then streamlined by
examining the meaning of the central codes and the relationships
between them, and then further reducing the model to overarching
central themes.
For condentiality and reporting purposes all participants were
assigned aliases.
Methods
All interview
guides were
developed by
the research
team informed
by the literature
review and
main research
questions.
44 The RaRE Research Report: Risk and Resilience Explored
5.2. Quantitative study
For descriptive statistics, Chi-Square analyses were carried out for
comparisons of all the categorical variables; ANOVAs or T-tests were
used for comparisons of the continuous variables, as appropriate. A
signicance level of .05 was used as the threshold for all analyses;
however, some marginally signicant results are also reported, where
they seem to be particularly pertinent to the issues under study.
For identifying the risk and resilience factors, backward stepwise
logistic regressions were used in order to raise statistically signicant
risk or resilience factors predicting the outcome (Menard, 2010). This
procedure is commonly used in exploratory research, including in
psychiatric research, and has been used in sexual minorities mental
health research (Paul et al., 2002). The more relaxed signicance level
of .1 when excluding the variables instead of the conventional .05
was used since too strict criteria may eliminate predictors that may be
signicant when all the other irrelevant predictors are removed (Paul
et al., 2002). For variables with many outcome values (more than 5),
quartiles were used to reduce the number of outcomes choices to four;
this prevents empty cells when calculating regression coefcients.
These variables were age as well as the total scores for the MDSSPSS,
the GHQ-12 and the RSS.
Variables to include in each of the models were only selected after
extensive literature review on identied risk and resilience factors
for each of the three topics being researched. In the rst step of the
regressions, all the variables were added to the model. In the second
step all the non-signicant variables (p>.1) were removed and the
regressions ran again. In the third step, the sample was split between
hetero and LGB+ participants in order to compare whether there were
differences between the variables explaining the outcome.
Methods
45The RaRE Research Report: Risk and Resilience Explored
Results
1. The study samples
1.1. P1Q sample
A total of 35 individuals (15 females; 19 males; one genderqueer) who
met the selection criteria were interviewed for this phase of the research.
Their average age was 38.6 years (SD=7.5). In terms of sexual orientation:
two identied as bisexual, 17 as gay, 11 as lesbian and ve as ‘other’
(e.g. queer or questioning). Two identied as being trans* (one as a trans
women and one as trans man). Just over a quarter (25.7%) indicated they
had a disability. The majority identied as being white (91.3%).
Of the total sample, the majority (n=17, of which 10 males and
sevenfemales) including both cisgender and trans* participants were
recruited and took part in the study due to their experiences of suicide
while young. Nine gay and bisexual men were recruited due to their
experiences of body image issues and nine lesbian and bisexual women
were recruited due to their experiences of alcohol misuse.
Twenty-three interviews were conducted face-to-face and the
remaining 12 over the phone for reasons such as simplifying access for
participants and for allowing inclusion of participants living outside of
London and with limited ability to travel.
1.2. The survey sample
Between June and November 2013, a total of 2,078 valid surveys were
collected. Of all participants, 700 (36.5%) identied as heterosexual,
and 1,320 (63.5%) as LGB+, of which 29.9% were gay, 16.8% lesbians,
16.7% bisexual and 2.8% identied with having an alternative sexual
orientation (e.g. pansexual, asexual, queer).
The average age of LGB+ identied participants was 38.3 years (SD=12.3) and
of heterosexuals 37.2 (SD=13.5); this difference was not statistically signicant.
There were more female participants in the heterosexual sample (75.7%) than
in the LGB+ sample (42.9%), and more participants who identied with having
an alternative gender (e.g. genderqueer, FAAB or female assigned at birth, etc.)
in the LGB+ sample (3.7%) than in the heterosexual sample (0.9%). In both
groups the percentage of non-white identied participants (LGB+ = 12.9%;
Het= 15%) was similar to that of the English national population (approx. 15%;
Ofce for National Statistics, 2011).
46 The RaRE Research Report: Risk and Resilience Explored
More GLB participants indicated they were single (45.8%) when
compared with heterosexuals (34.1%). With regard to disability,
signicantly more GLB+ participants (18.6%) considered themselves to
have a disability when compared with heterosexuals (10%).
In total, 120 participants from the RaRE survey sample identied as Trans*.
There are signicantly more Trans* participants who did not identify as having
a female or a male gender identity (45%) when compared with cisgender
participants (0.9%). The average age of Trans* identied participants was
38.4 (SD=13.3) which is not statistically different from the average age of
the cisgender identied participants (37.7; SD =12.7). Less Trans* participants
identify as being BME (10.8%) when compared with cisgender participants
(14%), however, this difference is not statistically signicant.
More Trans* participants i ndicated being single (54.2%) when
compared with cisgender participants (41.3%). Also signicantly more
Trans* participants considered themselves to be disabled (33.3%)
compared with cisgender participants (14.8%).
In terms of overall geographical distribution, London was the region
with the most participants (43.9%), but all other regions of England
were represented in the sample with the smallest representation being
from the North East (4.3% or 89 participants).
Details about the demographics of the survey sample can be found in
Appendix 4.
1.3. P2Q sample
A total of 23 individuals (13 females, nine males and one ‘other’) who
met the selection criteria were interviewed for this phase of the study.
The average age of participants was 36.2 (SD=11.5). In terms of sexual
orientation, eight identied as lesbian, seven as gay, ve as bisexual
and two as ‘other’. Two identied as being trans* (one a trans woman
and another a crossdresser heterosexual man). Of the total sample,
10 matched the inclusion criteria and were interviewed due to their
experiences tting into the ‘resilience’ subgroup (ve females, four males
and one ‘other’), including both trans* identied participants; of the ‘risk’
subgroup, ve were recruited due to their experiences of suicide and
self-harm (four females and one male), four gay and bisexual men due
to their experiences of body image issues and four lesbian and bisexual
women due to their experiences of alcohol misuse.
The majority of participants in the sample identied as white (91.3%);
two identied as having a disability. In terms of geographic distribution,
the majority lived in London (12), with the remaining participants being
distributed across the rest of England.
We conducted 11 interviews face to face and the remaining 12 over the phone.
Results
Signicantly
more GLB+
participants
(18.6%)
considered
themselves
to have a
disability when
compared with
heterosexuals
(10%).
47The RaRE Research Report: Risk and Resilience Explored
2. Findings
2.1. Suicide and self-harm among young LGB&T people
2.1.1. Descriptives
In the subset of survey participants aged 26 and under (n=485),
when compared with their heterosexual counterparts by using
Chi-Square analyses, LGB4 young people have significantly higher
rates of lifetime suicide attempts, as well as of lifetime and
previous year suicide ideation (Figures 1 & 2). For the same
subset, young LGB participants have significantly higher rates of
lifetime and previous year self-harm ideation and experiences.
The only non-significant result for this group of comparisons is
for suicide attempt in the previous year.
In the subset of participants aged 26 and under (n=485), when
compared with their cisgender counterparts, Trans* individuals
have signicantly higher rates of both lifetime and previous year
suicide attempts and ideation. For the same subset, young Trans*
participants have signicantly higher rates of lifetime and previous
year self-harm ideation and experiences5 (Figures 3 & 4).
4 This analysis excludes participants identied as having an “other” sexual orientation.
5 Sexual orientation was not controlled in this analysis, and therefore both groups will include
participants who identify as LGB or heterosexual.
Results
Figure 1 - Comparing suicide indicators LGB vs hetero young people
* p≤.01
LGB
(n=289)
Hetero
(n=196)
17.9%
33.9%
6.1% 10.0%
48.0%
69.9%
20.4%
34.6%
Suicide
attempt at
least once*
Suicide
attempt
previous year
Suicide
thought at
least once*
Suicide
thought
previous year*
48 The RaRE Research Report: Risk and Resilience Explored
2.1.2. Predictors of suicide and self-harm indicators for young LGB
people
Suicide attempt
A backward stepwise logistic regression was performed to ascertain
the effects of self-esteem, family support (two variables were used for
this purpose: ‘I get emotional help and support from my family’ and
‘My family is willing to help me make decisions’ from a Likert scale,
converted into quartiles to allow inclusion in the model) and income
on the likelihood that young LGB+6 young people have attempted
suicide. The logistic regression model was statistically signicant (χ2(4,
n=218) = 36.89, p<.001) and explained between 15.6% (Cox and Snell R
square) and 21.7% (Nagelkerke R square) of the variance and correctly
6 Includes all participants not identifying as heterosexual, including ‘other’, but does not control
for gender identity due to low numbers of young Trans* participants in the sample.
Results
Table 1 - Predictors of suicide attempt for young LGB people
LGB+ Hetero
Self-esteem (—)
Income (—)
Perception of family helping
to make decisions (—)
Self-esteem (—)
Income (—)
Note – A plus or minus sign indicates the direction of the relationship
found between the independent variable (suicide attempt) and the
predictors listed
Figure 2 - Comparing self-harm indicators LGB vs hetero young people
LGB
(n=289)
Hetero
(n=196)
38.3%
17.9%
46.4%
27.0%
57.1%
41.9%
28.4%
73.0%
Self-harm
done at
least once*
Self-harm
done previous
year*
Self-harm
thought at
least once*
Self-harm
thought
previous year*
* p≤.01
49The RaRE Research Report: Risk and Resilience Explored
classied 71.1% of cases. Lower levels of income (β -.319, p<.005), self-
esteem (β -.582, p<.001) and family support on decision making (β -.488,
p<.01) were associated with an increased likelihood of making a suicide
attempt. Emotional help and support from family was not found to be
signicant.
For young heterosexual people, the logistic regression model was also
statistically signicant (χ2(4, n=146) = 36.41, p<.001) and explained
between 22.1% (Cox and Snell R square) and 36.3% (Nagelkerke R
square) of the variance and correctly classied 82.9% of cases. For this
group it was found that lower levels of income (β -.400, p<.05) and self-
esteem (β -1.193, p<.001) were associated with an increased likelihood
of suicide attempts. None of the family support measures were found to
be signicant in this model.
Suicide ideation
A backward stepwise logistic regression was performed to ascertain
the effects of self-esteem, income, social support, relevance of faith or
believe and perception of having been different while growing up on
the likelihood that young heterosexual and LGB+ young people have
Results
Table 2 - Predictors of suicide ideation for young LGB people
LGB+ Hetero
Self-esteem (—)
Self-esteem (—)
Income (—)
Social support (—)
Consider themselves to have
been different (—)
Figure 3 - Comparing suicide indicators Cis vs Trans* young people
Trans*
(n=27)
Cis
(n=458)
26.2%
48.1%
7.2%
29.8%
59.4%
88.9%
27.1%
59.3%
Suicide
attempt at
least once*
Suicide
attempt
previous year*
Suicide
thought at
least once*
Suicide
thought
previous year*
* p≤.01
50 The RaRE Research Report: Risk and Resilience Explored
had suicidal ideation. The logistic regression model was statistically
signicant (χ2(5, n=217) = 42.03, p<.001) and explained between 17.6%
(Cox and Snell R square) and 25% (Nagelkerke R square) of the variance
and correctly classied 76% of cases. Lower levels of self-esteem
(β -.754, p<.001) were associated with an increased likelihood of having
experienced suicidal ideation. None of the other variables in the
model were statistically signicant (decreased income was marginally
signicant, β -.193, p<.08).
For young heterosexual people, the logistic regression model was also
statistically signicant (χ2(5, n=144) = 63.09, p<.001) and explained
between 35.5% (Cox and Snell R square) and 47.3% (Nagelkerke R
square) of the variance and correctly classied 78.5% of cases. Lower
levels of self-esteem (β -.728, p<.001), income (β -.277, p<.05), social
support (β -.767, p<.001) and not having been considered different
when growing up (β -1.046, p<.05) were associated with an increased
likelihood of having experienced suicidal ideation. Faith or belief was
not signicant in the model.
Self-harm experience
A backward stepwise logistic regression was performed to ascertain the
effects of self-esteem, family support (two variables were used for this
purpose: ‘I get emotional help and support from my family’ and ‘I can
talk about my problems with my family’ from a Likert scale, converted
into quartiles to allow inclusion in the model), relevance of faith or
belief at home while growing up and income on the likelihood that
LGB+ young people would have experience of self-harming. The logistic
regression model was statistically signicant (χ2(5, n=218) = 46.20,
p<.001) and explained between 19.1% (Cox and Snell R square) and
25.6% (Nagelkerke R square) of the variance and correctly classied
Results
Figure 4 - Comparing self-harm indicators Cis vs Trans* young people
Trans*
(n=27)
Cis
(n=458)
47.4%
22.1%
63.5%
33.8%
85.2%
70.4%
59.3%
92.6%
Self-harm
done at
least once*
Self-harm
done previous
year*
Self-harm
thought at
least once*
Self-harm
thought
previous year*
* p≤.01
51The RaRE Research Report: Risk and Resilience Explored
71.6% of cases. All variables were signicant in the model. Lower levels
of self-esteem (β -.738, p<.001), income (β -.23, p<.02) and a perception
of being less able to talk with family members about problems (β
-.489, p<.02) was associated with an increased likelihood of having
self-harmed. The greater importance of faith or belief at home while
growing up (β .281, p<.02) and perception of getting emotional support
from family (β .365, p<.05) also increased the likelihood of having self-
harmed.
For young heterosexual people, the logistic regression model was
also found to be statistically signicant (χ2(5, n=146) = 49.34, p<.001)
and explained between 28.7% (Cox and Snell R square) and 38.5%
(Nagelkerke R square) of the variance and correctly classied 76% of
cases. For this group it was found that lower levels of self-esteem
(β -1.068, p<.001) and a perception of being less able to talk to family
about problems (β -.606, p<.01) were associated with an increased
likelihood of self-harm.
Self-harm ideation
A backward stepwise logistic regression was performed to ascertain the
effects of self-esteem, being able to talk about problems with family
and having been considered to be different while growing up on the
likelihood that LGB+ young people have thought about self-harming.
The logistic regression model was statistically signicant (χ2(3, n=287)
= 45.82, p<.001) and explained between 14.8% (Cox and Snell R square)
and 21.4% (Nagelkerke R square) of the variance and correctly classied
74.2% of cases. Lower levels of self-esteem (β -.867, p<.001) were
Results
Table 3 - Predictors of self-harm experience for young LGB people
LGB+ Hetero
Self-esteem (—)
Perception of being able to talk
to family about problems (—)
Perception of getting emotion-
al support from family (+)
Importance of faith or belief at
home while growing up (+)
Income (—)
Self-esteem (—)
Perception of being able to talk
to family about problems (—)
Table 4 - Predictors of self-harm ideation for young LGB people
LGB+ Hetero
Self-esteem (—)
Self-esteem (—)
Perception of being able to talk
to family about problems (—)
52 The RaRE Research Report: Risk and Resilience Explored
associated with an increased likelihood of self-harm ideation. None of
the other two variables in the model were statistically signicant.
For young heterosexual people, the logistic regression model was also
statistically signicant (χ2(3, n=193) = 83.15, p<.001) and explained
between 35% (Cox and Snell R square) and 46.8% (Nagelkerke R
square) of the variance and correctly classied 80.3% of cases. Lower
levels of self-esteem (β -1.268, p<.001) and a perception of being less
able to talk about problems with family (β -.292, p<.05) were associated
with an increased likelihood of having thought about self-harm.
Perception of being different while growing up was not found to be
statistically signicant in this model.
No regression analyses were possible between Trans* and cisgender
young people due to low number of participants in the former group.
Additional ndings about the Trans* sub-sample of the survey will be
reported in further publications from the RaRE Study.
2.1.3. Qualitative results (P1Q)
Brief description of the subsample
For P1Q of the research 17 people (six females, 10 males and one
genderqueer) were interviewed due to their experiences of attempted
suicide while young. One identied as bisexual, nine as gay, four as
lesbian and three as ‘other’. Their average age was 37.5 years (SD=8.1).
The majority identied as white (13), indicated not having any religion
(12) and being single (11). Four indicated being disabled.
Risk issues
There is strong evidence to suggest that cumulative factors for
suicidality among LGB&T young people are closely related to negative
experiences from others associated with coming out. Furthermore,
all the interviewees, with one exception, experienced homophobic or
transphobic distress while growing up. With that particular exception,
there are indications that becoming aware of being LGB or T translated
into periods of difculty and uncertainty.
The narratives of most of our interviewees are marked by constant
struggles in the face of homophobic or transphobic realities, generally
experienced in the interviewees’ family network, schools and circle of
peers. As we go on to show, this was particularly the case in interactions
with individuals with strong religious or heterosexist backgrounds.
Moreover, having a distant relationship with their family increased the
levels of anguish among our interviewees when young at the crucial
moment when they were coming to terms with their sexual orientation.
Results
53The RaRE Research Report: Risk and Resilience Explored
Most of the participants in this phase of the study experienced
homophobic bullying while they were at school. The consequences
of this form of bullying can be dramatic: Sirus, a 28 year old gay man
originally from Southern Europe, attempted suicide when he was only
eleven years old. Others suffered abuse on the basis of a perception of
their gender identity rather than because of their sexual orientation.
In this respect, the two Trans* individuals interviewed for this research,
Nicky, age 36, and Maureen, age 26, were both victims of bullying for
their gender non-conformity. Both tried to conform to the pressures
they were put under by trying to ‘pass’ for their gender assigned at birth,
but this did not deect the bullying.
A sense of incomprehension about the way they were treated led our
interviewees to feel isolated and to suffer from low self-esteem. In
order to face these adverse scenarios, they implemented behaviours
such as drinking, truancy, smoking, self-harming, binge-eating, not
talking to anyone, crying and attempted at performing normative
gender, pretending to be who they were not.
Based on our evidence, to a large extent, LGB&T young people
suicidality seems to be predicted by a tortuous coming out experience
and it is possible to identify certain triggers that can lead to suicide
ideation and attempts. It appears that homophobia or transphobia
might lead to suicidal ideation, but specic triggers may precipitate
the act itself. These triggers may be of an emotional nature, as was the
case with Ian (52, gay), who attempted suicide at the age of 18, after
the death of his mother from cancer:
I was gay and growing up in a very hostile environment; there was a lot
of conict with my father about it. […] There was a lot of aggression, a
lot of homophobic stuff coming at me from my father [...] And this was
like in a climate where I guess there were no gay positive role models,
I didn’t know any other gay people, I thought there was something
wrong with me and I remember feeling that really strongly […]. It’s
complicated because round about the same time, my mum in my rst
year of university died so the whole thing culminated in it. But, I know
sort of prior to– anything sort of happened to mum, I had a lot of
negative self-harm thinking that was in place, all through my teenage
years really. And I just felt that that [suicide] was the only solution, and
there was nobody to– well I wasn’t prepared to speak to anyone about
it. (Ian)
Maureen, a trans-woman originally from Eastern Europe, was raised in
a hostile environment, bullied in her social circle, physically abused by
her stepfather, and reprimanded by her mother because of being Trans*.
The escape she found from this reality was attempting suicide at the
age of 20, after drinking.
I couldn’t go to my parents. I wanted to become self-sufcient, which–
it wasn’t happening. Nobody to talk to, the community boxing you up
Results
Most of the
participants
in this phase
of the study
experienced
homophobic
bullying while
they were at
school.
‘I just felt that
that [suicide] was
the only solution,
and there was
nobody to– well I
wasn’t prepared
to speak to
anyone about it.’
(Ian)
54 The RaRE Research Report: Risk and Resilience Explored
and they’re just not happy with you. I couldn’t live my life, they started
all the time boxing me in; no, you are not a girl, and you can’t live as
a girl […] I got very depressed with everything and then I saw the fast
moving car, then I saw another one straight after so I decided to jump
underneath it. (Maureen)
All interviewees but one considered the medical or professional
response they received just after their suicide attempt to be inadequate.
In some cases they could not open up, nding barriers to express
their emotions to health professionals, but also health professionals
being unprepared for dealing with their specic needs; in other
cases, there was an inappropriate response from professionals. Ryan
(45, gay), who attempted suicide when he was 24, remembered
reading his psychiatrist’s report as he left it accidentally on his desk:
“this dishevelled young man smelling slightly of alcohol” and “with
effeminate tendencies”. An opportune and adequate intervention
not only could have helped our interviewees to have a more prompt
recovery from their suicide crisis, but also more opportunity to have a
less traumatic and scarring coming out process.
Recovery and resilience
When asked about the circumstances that could have helped the
participants in our study to prevent their suicidality all pointed out particular
issues related to their own experiences and challenges as LGB&T young
people. These related to issues of rejection or fear of rejection by lovers,
peers, friends and most importantly family. Difcult coming out experiences
increased strain on young people’s social networks and their mental health,
a situation aggravated by the lack of appropriate resources and support.
Our ndings suggest a lack of awareness and training around issues
particularly relevant to LGB&T young people as hindering mental
health service provision for this group during their suicide crisis. In
effect, some of the people we interviewed said that the professional
help they received in schools, hospitals, and general consultant
practices was totally inadequate, while others highlighted the need for
early and opportune interventions including LGB&T specic services. In
relation to this, some interviewees expressed that family understanding
regarding their sexual orientation, and feeling safe in school would
have had a positive impact on their well-being.
It should be noted that for most interviewees, the help and support
they received was obtained by connecting with signicant others and by
embracing self-worth. In some cases, this support came from their family in
the aftermath of their suicide attempt, and in other cases interacting with
other LGB&T people made a signicant positive impact on their lives. Esther
(32, queer), who suffered homophobic bullying after coming out at school
and attempted suicide at age 17, remembered her rst LGB&T pride in
London:
Results
A lack of
awareness and
training around
issues particularly
relevant to
LGB&T young
people as
hindering mental
health service
provision for this
group during
their suicide
crisis.
Interacting with
other LGB&T
people made
a signicant
positive impact
on their lives.
55The RaRE Research Report: Risk and Resilience Explored
I was very aware that I was part of the stereotype, the depressed gay
teenager and so it was nice to be around people that weren’t that and
it was just nice to be around so many LGB&T people all in one go and
people having a nice time. It felt good. […] I had a lot of people kind
of telling me, including my mum in particular, “oh you’re destined to be
lonely” and “those types of relationships never work” and I guess going
there made me realise- actually “you’re talking crap”. (Esther)
Having a sense of belonging to the LGB&T community can be protective
against suicidality, by strengthening individual identity and possibly
making young people feel part of a collective identity. However, not all
our interviewees had this opportunity. For some, in depth planning was
required: waiting to become an adult and leave the family home, while
in the meantime focusing on school or hobbies. For example, Ian found
refuge in reading novels by gay writers, while Robin, a 33 year old gay/
queer man, focused on gure skating practices. Interestingly, all our
interviewees, by sharing their experiences with us reported seeking
to help LGB&T young people who feel suicidal. Their view was that
by doing so, they not only support other LGB&T people, but also ght
prejudice around mental health issues, and normalise sexual diversity.
2.2. Alcohol misuse among lesbian and bisexual women
2.2.1. Descriptives
There are no signicant differences in our survey sample between
levels of hazardous or dependent alcohol use as measured by the
AUDIT between heterosexual women (n=470) and LGB women (n=534)
(Chi-Square analyses; Figures 5 & 7). Comparisons were also run by
breaking down the LGB group (bisexual vs lesbian and gay identied
women), but even then no differences were found between these and
heterosexual women (Figures 6 & 8).
However there were signicant differences in patterns of frequency
of drinking to intoxication amongst the women (Figure 9), the
data suggesting that more LGB women drink once a month (17.5%)
when compared with heterosexual women (13.7%) and that more
heterosexual women (36.2%) never drink when compared with LGB
women (27.8%) (Figure 9). When separating bisexual women from
lesbian and gay women (Figure 10) there are marginally signicant
differences, with bisexual women drinking more once a month and 2/3
times a month, particularly when compared with heterosexual women;
signicantly more heterosexual women indicating never drinking
when compared with LG women; and more LG women indicating never
drinking when compared with bisexual women (Figure 10). However, in
both analyses the effect size was small or very small, respectively.
Results
56 The RaRE Research Report: Risk and Resilience Explored
2.2.2. Predictors of hazardous alcohol use for lesbian and bisexual
women
A backward stepwise logistic regression was performed to ascertain the
effects of age, general health (GHQ-12), importance of faith or belief
and size of the place of origin (town or city, suburb, small town or rural
area) on the likelihood that lesbian and bisexual women would have a
hazardous pattern of alcohol use (AUDIT). The logistic regression model
was statistically signicant (χ2(6, n=555) = 42.28, p<.001) and explained
between 7.3% (Cox and Snell R square) and 10% (Nagelkerke R square)
of the variance and correctly classied 66.8% of cases. Being of a
younger age (β -.315, p<.001), lower levels of self-reported well-being7
(β .219, p<.01) and the increased relevance of faith or belief currently
(β .147, p<.05) were associated with an increased likelihood of
hazardous drinking. Additionally, living in a small town (β -.523, p<.05) or
7 Higher scores on the GHQ-12 denote poorer health/well-being.
Results
Figure 5 - Hazardous alcohol use (LGB vs Heterosexual women)
Non hazardous
Hazardous
62.9%68.1%
χ2(1, n=1004) = 2.72, p<.10 (n.s.)
LGB women
(n=534)
Heterosexual women
(n=470)
31.9%
37.1%
Figure 6 - Hazardous alcohol use (LG vs Bisexual vs Heterosexual women)
Non hazardous
Hazardous
68.1% 64.2% 60.0%
Bisexual women
(n=170)
Lesbian and gay women
(n=324)
Heterosexual women
(n=470)
31.9% 35.8% 40.0%
χ2(2, n=964) = 3.89, p<.14 (n.s.)
57The RaRE Research Report: Risk and Resilience Explored
suburb (β -.802, p<.01) was associated with a decrease in the likelihood
of hazardous drinking8.
For heterosexual women, the logistic regression model was also
statistically signicant (χ2(6, n=469) = 31.79, p<.001) and explained
8 Living in a large town or city was used as the reference category.
Results
Table 5 - Predictors of hazardous alcohol use for lesbian and
bisexual women
LGB+ Hetero
Age (—)
General health/well-being (—)
Current relevance of faith or
belief (+)
Living in small town or suburb (—)
Age (—)
General health/well-being (—)
Current relevance of faith or
belief (+)
Figure 7 - Dependent alcohol use (LGB vs Heterosexual women)
Non dependent
Dependent
LGB women
(n=534)
Heterosexual women
(n=470)
96.0% 95.5%
4.5%4.0%
χ2(1, n=1004) = .04, p<.84 (n.s.)
Figure 8 - Dependent alcohol use (LG vs Bisexual vs Heterosexual women)
Non dependent
Dependent
Bisexual women
(n=170)
Lesbian and gay women
(n=324)
Heterosexual women
(n=470)
96.0%
4.0%
95.7%
4.3%
95.3%
4.7%
χ2(2, n=964) = 0.14, p=.93 (n.s.)
58 The RaRE Research Report: Risk and Resilience Explored
between 6.6% (Cox and Snell R square) and 9.2% (Nagelkerke R
square) of the variance and correctly classied 68.9% of cases. For
this group it was found that being of a younger age (β -.290, p<.001)
lower levels of self-reported well-being (β .251, p<.01) and the
increased relevance of faith or belief currently (β .242, p<.005) were
associated with an increased likelihood of hazardous drinking. None
of the other variables in the model were statistically signicant.
2.2.3. Qualitative results (P1Q)
Brief description of the subsample
During P1Q of the research 9 women (one of which identifying as
‘female/genderqueer’) were interviewed due to their experiences of
problem drinking. Seven identied as lesbian, one as gay, and one
as queer. Their average age was 39.6 years (SD=6.5). All identied as
white; six indicated not being religious and being single. Two indicated
having a disability.
Results
Figure 9 - Alcohol to intoxication (LGB vs Heterosexual women) LGB
women
(n=587)
Heterosexual
women
(n=533)
Everyday2+ times
a week
Once
a week
2-3 times
a month
Once
a month
Once a year
or less
Never
36.2%
28.5%
13.7% 8.4% 7.5% 5.6% 0.0%
27.8% 29.6%
17.5%
10.4% 7.8% 6.1% 0.7%
χ2(6, n=1120) = 13.93, p=.03, Cramer’s V=.11
Figure 10 - Alcohol to intoxication (LG vs B vs Heterosexual women) LG
women
(n=357)
Bisexual
women
(n=189)
Heterosexual
women
(n=533)
Everyday2+ times
a week
Once
a week
2-3 times
a month
Once
a month
Once a year
or less
Never
36.2%
13.7%
8.4%
8.1%
7.5% 5.6%
0.0%
5.3%
16.8%
28.5%
29.4% 28.0%
19%
14.8%
6.3%
0.0%
1.1%
6.3%
8.7%
30.5
25.4%
χ2(12, n=1079) = 25.88, p=.01, Cramer’s V=.01
59The RaRE Research Report: Risk and Resilience Explored
Risk factors
For the lesbian, bisexual and queer women we interviewed in relation
to problematic alcohol use, drinking seemed to have developed as
a consequence of a number of factors. Many of these factors related
to a social and family culture of heavy drinking, sometimes marked
by a relaxed attitude towards alcohol and some of its negative
consequences and by a permissive or even reinforcing approach to
early onset of drinking within the family. For many participants, this
context is later reinforced by exposure to environments where drinking
plays an important role in socialising, such as when going out with
work colleagues, and by pub culture in general, as described by Linda
(35, lesbian):
[A]nd the other thing is work drinks, it’s always work drinks it’s never
work coffee. And I had a couple of colleagues who’d constantly question
“what are you drinking?” and look at me odd, you know “a pint of Coke?!”
So that’s difcult, it’s almost like there’s something wrong with you if
you don’t drink. Because I smoke but I don’t drink and people just can’t
understand that at all. It’s like “why don’t you quit smoking and carry on
drinking?” you know. Because my smoking doesn’t affect everybody in
my life, I can go outside and smoke. (Linda)
Traumatic experiences were another set of reasons provided by some
of the participants to explain their problematic alcohol use. These
experiences were of a varied nature and occurred at different periods
of their lives, from childhood to adulthood. Some of these experiences
were associated with growing up in families where the young people
faced particular challenges, e.g. having a parent suffering from mental
health issues or from alcoholism; or having supported a friend through
cancer, amongst others. Two participants suffered from a sexual assault.
In both cases the assault happened while they were drunk, but then
they continued to use alcohol to manage the intense anxiety caused by
the incidents. Julie (33, lesbian), was assaulted by a male taxi driver on
her birthday while travelling abroad:
I was struggling with what had happened and not being able to
remember it and the fact I was drunk when it happened so then when
I got really drunk, which I was doing all the time, I was getting a lot
of anxiety and stress and guilt about doing it in pretty much every
situation but it was the only way... I had a dependency so I kept doing
it. (Julie)
Jane (40, lesbian), was sexually assaulted by a woman while under
the effect of alcohol. She subsequently developed depression and
attempted suicide as a consequence of the experience and considers it
to have affected her ability to form stable and lasting relationships in
the future.
Results
60 The RaRE Research Report: Risk and Resilience Explored
Alcohol was often used as an unhealthy mechanism to deal with
negative feelings, such as guilt and depression and to boost condence.
Some participants talked of using alcohol as a ‘coping strategy’, for
instance to help them be able to feel interesting and relaxed when
socialising. Others, like Siobhan (50, lesbian), described alcohol as a
‘crutch’:
I think I just learned to use it as a crutch to support me when times got
emotionally tough and yeah I just woke up to realise what I was doing
wasn’t healthy. It probably means I’ll do it again at some point but I
hope not, that is my hope. I do drink still but not to excess, to oblivion.
(Siobhan)
This theme of using alcohol to manage uncomfortable or unwanted
feelings is particularly signicant in relation to concerns around same
sex attraction. This was often the case during adolescence and young
adulthood when these women were rst becoming aware of their
sexuality and sometimes linking with feared reactions to their coming
out. Simone (36, lesbian), talks about her experience:
Q: And what sort of other things do you think may have played a part
or made it worse along the way?
Simone: I don’t know for sure but I think that the additional pressure
of growing up and sort of knowing that being gay was not considered
to be a good thing may have intensied that: the need to push down
difcult stuff. (Simone)
A few participants also talk about how they used alcohol specically
to deal with family expectations and pressures around their sexuality,
as well as with the anxieties caused by the possibility of disclosure.
Marian, a 30 year old ‘gay’ women, described how she was only able
to tell her brother that she was dating a woman while she was drunk,
and for Yvonne (43, lesbian), drinking helped her cope with the guilt
following her coming out to her family:
Q: How do you think being a lesbian may have affected your alcohol
problems?
Yvonne: I felt at the time my parents, or my mother, was alive I’d broken
her spirit and her hope for me as a young woman because there was
a lot of peer pressure surrounding me getting married and having
grandkids, so the white wedding and everything like that. So when I did
come out there was the disappointment. I’d let my parents down and
having to deal with their excuses of why I might be a lesbian. So again
it’s upsetting and guilt and I didn’t live up to their expectations so
drink again basically blanked all that out. So I can deal with it as long
as I’ve got a drink. I think that’s basically it. (Yvonne)
Results
61The RaRE Research Report: Risk and Resilience Explored
Several of the women also discussed how the gay and lesbian scene is
heavily based around consumption of alcohol, therefore alcohol plays a
dual role in enabling community attachment and a sense of belonging,
at the same time as reinforcing a continued pattern of drinking. Claire
(44, lesbian), found the gay scene an accepting environment where the
sight of a woman drinking heavily was not judged harshly:
British culture and attitude to alcohol [is unhelpful]. It’s encouraged.
The media encourage it, it’s everywhere. It’s how we socialise. The gay
scene is awful for it. There are pills everywhere. Women especially are
heavy drinkers. It’s perfectly normal to drink pints in a gay club and it
certainly wasn’t when I went to heterosexual clubs. But I could easily
order pints and nobody would give me a second look in a gay club,
whereas heterosexuals had to look dainty and have half a lager. But it
was a big drinking culture on the gay scene so that was my experience
of it. So you can blend in and not stand out too much as well on that
scene and it suited me. (Claire)
Recovery and resilience
For many of our interviewees, recovery from alcohol abuse was a long
process marked by struggles to control or to stop drinking and often
impacted by the support, or lack thereof, received from partners, family
members and other people. This support was frequently mentioned as
one of the most relevant aspects of the recovery process, alongside the
gain of a sense of control over their drinking and their lives. Formal
help, such as that provided by therapists and self-help groups, was
also key in this process, although barriers, both real and perceived,
to disclosing intimate matters, particularly their sexual orientation,
sometimes tempered the engagement with these structured sources of
support.
The rst steps towards recovery were often acknowledging the problem
and seeking help. Both these occurred as a consequence of their
own reexions and actions, as well as from pressures and incentives
from supportive family members and partners. For several of the
interviewees it was their partner or sometimes isolated more distant
family member who provided much needed support that helped them
to stop problematic drinking. Close friends also proved helpful around
the practical aspects of recovery:
Q: What other things have you found helpful along the way?
Simone: [Pause] I have had friends listening to me and accepting me
when I said: “I don’t drink anymore, I can’t drink” - friends agreeing to
meet me in cafes to begin with rather than pubs and clubs. My family
not pouring me wine” (Simone)
Results
‘But I could easily
order pints and
nobody would
give me a second
look in a gay
club, whereas
heterosexuals
had to look
dainty and have
half a lager.’
(Claire)
62 The RaRE Research Report: Risk and Resilience Explored
Family and partners also played a part as internal motivators, with
some of the women discussing how becoming aware of the impact of
their behaviour on those close to them was relevant in their decision
to stop drinking. The turning point, in some cases, was associated with
‘hitting rock bottom’ or with a revelation of sorts (‘waking up’). One
woman talked about needing ‘incredible will power’ in order to be able
to recover. In all cases the language used reveals an arduous, often
long, process.
As many found that a lack of control in certain aspects of life had led to
alcohol abuse, conversely a few also discussed how regaining control
and incorporating structure into their lives became an important
strategy in recovery. This sometimes involved not stopping drinking
altogether but developing strict rules of when drinking could happen.
Participants accessed various kinds of formal help but sometimes
engagement with the treatment process was limited by a variety of
issues. Important among these was an uneasiness or unwillingness
to discuss some of the issues that were closely linked with the
problematic drinking in the rst place, such as experiences of abuse
and struggles in coming to terms with their own sexual orientation.
Some were altogether unable to disclose having a drinking problem
to mental health professionals. Others had negative reactions and
experiences from the professionals they disclosed their bisexual or
lesbian identity to, leading to the abandonment of the treatment
altogether.
I went to my GP and said I was really, really miserable. I actually told
her, she was one of the rst people that I told that I was a lesbian
which was a bit hard for me and she suggested that I see a psychiatrist.
So she put me in touch with the community mental health team and
they at that time diagnosed me as having a borderline personality
disorder, which I really don’t think I have. I think at the time I was very
confused about my sexuality and that is something that was never
really addressed in those early days. (Isabell, 45, queer)
CBT was generally considered to be helpful, but alternative forms of
support such as Buddhism, meditation, yoga, mindfulness, spirituality
were also mentioned by some. However, most of the interviewees
eventually found helpful support in specialised units and help groups,
some of which were LGB&T specic, providing a sense of community
support in the recovery process not found elsewhere.
[I]t was really important to go to a lesbian and gay [AA meeting]
because I realised I carried some shame about my own sexuality –
internalised homophobia – and needed to be with other gay people
before I mentioned relationships or mention[ed] a girlfriend in a
straight or mainstream meeting of Alcoholics Anonymous. It took me a
couple of years to get to the point where I could mention my girlfriend
and not give a shit. (Simone)
Results
Sometimes
engagement with
the treatment
process was
limited by an
uneasiness or
unwillingness to
discuss some of
the issues that
were closely
linked with the
problematic
drinking in the
rst place, such
as experiences
of abuse and
struggles in
coming to terms
with their sexual
orientation.
63The RaRE Research Report: Risk and Resilience Explored
Others accessed 12-steps programmes and groups, and some had
mixed views about this support. For some it provided the help they
needed, giving them alternative types of social support in the recovery
process. For Yvonne, referring back to the AA programme allows her to
stay ‘on the tracks’ even years after stopping drinking. However, others
did not appreciate the ‘religious’ component to the 12-steps programme
and considered it to be unhelpful overall.
Q: Sure, and you also mentioned that it sounds like AA has been an
important support for you.
Marian: It has – I have a love-hate relationship with AA to be honest. It
has been amazing in that there is somewhere to go and great people.
It is just wonderful to have all these meetings where people are so
supportive and all round lovely and if you live in London it’s brilliant
but I do nd some of them – I don’t nd the spirituality hard, but they
say it is about spirituality rather than God but actually God is a big part
of AA and I am an atheist and I still struggle with that. (Marian, 30, gay)
Additional support from family, partners, friends and from formal
resources that helped them gain a sense of control in their lives and to
control their previous drinking patterns, participants mentioned a range
of additional strategies that contributed to recovery and to keeping a
balanced life. Claire (44, lesbian) used music and reading as relevant
sources of insight into what she was experiencing in specic moments
of her recovery. Linda learned to play the drums and changed careers:
Q: So after the Smart help and the CBT and the new relationship, you
found things to make you feel as a good as the alcohol did, as a coping
strategy?
Linda: I did yeah. I’ve bought a drum kit; I’m learning to play drums.
And I just, I left the Home Ofce and I’m now committed to starting a
new career as a carer, you know more giving I guess. I think the only
thing that would make me go back to drink now is if I decided life
wasn’t worth living and I can’t see that happening because that’s such
a drop from where I am now. I don’t think I’d ever fool myself into
thinking that drink would make life better, I’d have to want to die to
start drinking again. (Linda)
All of the women interviewed were able to recover from their
problematic drinking and move on. Their narratives, thoughmarked
by deeply troubled experiences, illustrated a sense of hope, and the
possibility of recovery.
Results
64 The RaRE Research Report: Risk and Resilience Explored
2.3. Body image issues (including eating concerns)
among gay and bisexual men
2.3.1. Descriptives
The gay and bisexual men (n=721) were compared with the
heterosexual men (n=165) in our survey sample on a number of items
about different features of their bodies (e.g. their muscularity, body
fat, or genitals) and about behaviours that may affect their bodies (e.g.
how much they eat, drink, or exercise). Comparisons were made by
dichotomising all items of the RBSS (strongly disagree and disagree vs
strongly agree and agree) and then by running Chi-Square analyses.
When compared with the heterosexual men, the gay and bisexual men
presented higher percentages of dissatisfaction (replying to disagreeing
or strongly disagreeing with being satised) across all categories
presented (Table 6). The majority of these differences are statistically
signicant (highlighted in the table). The only items for which
comparisons were not signicant were those regarding health, physical
tness, face and features, teeth and amount of alcohol consumed.
Results
Table 6 - Disagrees or strongly disagrees with being satised with features of their
bodies and behaviour affecting the body, by sexual orientation (men only)
Items Hetero (n=165) GB (n=721)
a. My health 36.4% 42.7%
b. My physical tness 53.9% 60.9%
c. My weight* 45.5% 59.6%
d. My height** 9.1% 16.5%
e. My body shape* 40.0% 59.2%
f. My face and features (eyes, ears, nose) 18.8% 25.1%
g. My teeth 38.8% 44.5%
h. My hair** 23.0% 32.6%
i. My body hair** 20.6% 30.8%
j. My genitals** 20.0% 29.1%
k. My age* 15.8% 29.8%
l. My body fat* 46.1% 61.7%
m. My muscularity* 40.6% 58.1%
n. How much I eat** 32.1% 44.8%
o. How much alcohol I drink 24.8% 26.4%
p. How much I exercise** 52.7% 62.7%
* p<.001 ** p<.02
65The RaRE Research Report: Risk and Resilience Explored
2.3.2. Predictors of body image dissatisfaction for gay and
bisexual men
A backward stepwise logistic regression was performed to ascertain the
effects of self-esteem, self-perceived masculinity and social inuences
to thinking about one’s body (e.g. people in their daily lives, people
they encountered in their leisure activities, the media, and friends
and classmates from their childhood) on the likelihood that gay and
bisexual men would be dissatised with their bodies. The logistic
regression model was statistically signicant (χ2(3, n=728) = 104.01,
p<.001) and explained between 13.3% (Cox and Snell R square) and
17.8% (Nagelkerke R square) of the variance and correctly classied
66.6% of cases. Lower levels of self-esteem (β -.633, p<.001) and the
increased inuence of others (in society at large) on feelings about the
body (β .254, p<.001) were associated with an increased likelihood of
men being dissatised with their bodies. Self-perceived masculinity
was not found to be statistically signicant in the model.
For heterosexual men, the logistic regression model was also
statistically signicant (χ2(3, n=163) = 25.58, p<.001) and explained
between 14.5% (Cox and Snell R square) and 19.8% (Nagelkerke
R square) of the variance and correctly classied 68.1% of cases.
Lower levels of self-esteem (β -.750, p<.001) were associated with an
increased likelihood of these men being dissatised with their bodies.
None of the other variables in the model were statistically signicant.
2.3.3. Qualitative results
Brief description of the subsample
For P1Q of the research, nine men were interviewed due to their
experiences of body image issues (including eating concerns). Seven
identied as gay, one as bisexual, and one as ‘other’. Average age was
39.6 years (SD=7.9). The majority identied as white (8), indicated not
having any religion (8) and being single (6). Three indicated having a
disability.
Results
Table 7 - Predictors of body image dissatisfaction for gay and
bisexual men
LGB+ Hetero
Self-esteem (—)
Inuence from social environ-
ment (people in daily life, lei-
sure time, media & childhood
friends and classmates) (+)
Self-esteem (—)
66 The RaRE Research Report: Risk and Resilience Explored
Risk factors
Analysis of this subsample of participants suggests that the
vulnerability created by early experiences of feeling different appears
to be a key factor in the development of feelings of low self-worth, as
well as a susceptibility to outside pressures to conform to a masculine
body ideal. As a result, participants reported engaging in compensatory
and escapist strategies to reduce these negative feelings. While the
experience of feeling different may be common to many LGB&T
people, for the gay men participating in our study the unique pressures
regarding policing of the masculine body seemed to have resulted in
forms of body control and abuse.
All participants in this phase of the study speak about negative
experiences of ‘feeling different’ from a young age, deriving from
a variety of experiences, most commonly remembered as negative
relationships with parents or family members and the experience of
bullying or rejection by peers at school. For some, it emerged through
a self-consciousness related to perceived physical differences or
difculties. The experience of ‘feeling different’ often proceeded – as
well as coincided with – participants’ explicit awareness of their sexual
orientation, with homophobic messages received through the media
and wider society contributing to their negative feelings. David (51,
gay), describes a feeling of alienation from his parents associated with
his interests in typically non-masculine activities.
There was a huge elephant in the room about me, because they
thought I was not interested in anything boyish from a young age. I
wanted to do something arty which was out of the ordinary. And so I
just felt that I was not right, a sort of cuckoo in the nest really. (David)
Many participants were deeply impacted by bullying at school, which
often centred on their physical appearance as well as their sexuality,
resulting in a lasting insecurity around these areas. In addition,
many participants had few or no friends with which to share their
experiences, and felt a general sense of rejection from their peers.
Messages about masculine body ideals were experienced by all
participants via peers at school as children, and later in adulthood
through mainstream and LGBT-specic media, and in the gay scene,
especially in the context of clubbing culture. The pressure to ‘look
good’ was pervasive and, in many cases, destructive for participants’
self-worth. The overall feeling described was oppressive and
regulatory, with participants having a sense of being pushed out of
environments where their body did not t the prescribed dimensions.
A key experience for all participants was that of ‘comparing bodies’
– evaluating their own body in relation to that of their partner, other
desirable men or simply the image of men presented within LGBT or
mainstream media. Many participants described this as a unique aspect
of same-sex relationships; the complication of being attracted to an
Results
Many
participants were
deeply impacted
by bullying at
school, which
often centred on
their physical
appearance
as well as
their sexuality,
resulting in a
lasting insecurity
around these
areas.
67The RaRE Research Report: Risk and Resilience Explored
idealised masculine body while also feeling their own body judged
against this standard. Alan (43, gay), describes how comparing bodies
with his partner impacted on his self-worth:
I got into a relationship with a guy, it lasted a very long time, who…and
it’s really weird, I don’t kind of know how it happened, who actually had
a very good, I thought who had a really good body, much better than
mine… There was something about the way he looked that was just
a way of me feeling bad about myself. You know…I think that kind of
made it worse in a funny sort of strange kind of fucked up kind of way.
(Alan)
Many participants commented on the lack of sexual minority male
role models presented in mainstream media, singling out stereotypical
examples who conformed to a slim and muscular body type. Some were
critical of the unrealistic images seen in mainstream magazines and
of the lack of variety in representations of body types when it came to
LGBT specic media. Growing up, John (28, gay), felt unable to identify
with the body types of gay men he saw represented in the media: ‘Well
I actually understood what I might be part of but then there was no
one in there who related to me because they were all slim... I just didn’t
feel I tted into it’. He also saw the media as inuential in determining
viewers’ feelings of self-worth and encouraging conformity to a body
ideal.
Most participants described negative experiences with regard to
judgement of bodies within the gay scene, particularly when clubbing.
Alan talked about the difculty in avoiding messages about the
body within gay culture and how this impacted the expression of his
sexuality:
It really affected my ability to be gay. Because gay is all about how you
look. And it was quite a difculty there and tension there and the whole
kind of you know, “look good with your shirt off” kind of culture and the
whole Boyz magazine and the gay clubbing magazine and all of that
lifestyle… (Alan)
Some participants reected on similarities with the experiences of
bullying they had at school, and described the pressure to conform by
other gay and bisexual men to be a form of bullying in itself. Trevor, (39,
gay), described the pressures he feels going out on the gay scene:
I’ve gone to bars where you go in and basically the muscle boys, if
you’re not a muscle boy, will not even notice you. And they spill pints
on you, they don’t even say sorry and there’s this real kind of arrogance
and then I get, I feel victimised so then I get very angry. So I hate going
to places like that. (Trevor)
These common, early experiences of feeling different that men
associated with the negative messages received from parents and
peers, combined with later negative messages about the body received
Results
‘I’ve gone to bars
where you go
in and basically
the muscle boys,
if you’re not a
muscle boy, will
not even notice
you. And they
spill pints on
you, they don’t
even say sorry
and there’s
this real kind
of arrogance.’
(Trevor)
68 The RaRE Research Report: Risk and Resilience Explored
through mainstream and LGBT-specic media and culture, were
highlighted by participants who had gone on to struggle with a very
low sense of self-worth. Many directly reported low self-esteem, while
others, particularly those who were victims of bullying, described
a deep sense of shame about themselves and their bodies. Most
participants in this phase of the study described a strong need for
approval and acceptance from their peers and many referred to not
feeling ‘good enough’ as they were.
Finally, participants found it difcult to speak about their problems,
which added to the perception of a lack of adequate support targeted
to men, especially sexual minority men. Some described being unable
to relate to the information available on body disorders, which was
targeted primarily at girls and women rather than men. Those who
did approach health services for assistance often experienced long
delays waiting for therapy, and then found their concerns to be poorly
understood or supercially treated.
Resilience and recovery factors
For participants who had suffered from body disorders as a result of
their difcult early life experiences, the resilience to overcome their
problems emerged at a later stage in life after considerable damage
had already taken place. For most participants, change was a gradual
process, requiring impetus from within. They described experiences
of personal crises, acknowledgement that they had a problem, self-
reection and a desire for change in their life as motivating factors.
With some exceptions, internal motivation seemed to be the key driver
in participants attempting to nd help. Support was found through
personal relationships, therapy and organised programmes, sometimes
targeted specically at gay and bisexual men. Some participants relied
on self-help guidance or independently generated strategies for solving
their problems, describing a sense of self-reliance.
Many participants described going through an internal process of
coming to terms with the extent of their problems and wanting
to overcome them. Carl, a 40 year old man identifying his sexual
orientation as ‘other’, had developed an understanding of body image
disorders and steroid abuse in men through his work. He found that he
then was able to ‘address that in myself, rather than go out and pump
iron and do all these things’.
A number of participants described having reached a personal crisis
point, after enduring years of psychological distress. Immediately
following the breakdown, these participants accessed treatment,
mostly medical, and not always successfully. In all cases though, the
experience appeared to serve as a precipitating factor in seeking or
being open to receiving more effective support in the future.
Results
Some described
being unable
to relate to the
information
available on
body disorders,
which was
targeted
primarily at girls
and women
rather than men.
69The RaRE Research Report: Risk and Resilience Explored
Many participants described a point at which they consciously made a
decision to change, marking the start of their recovery process. Trevor
suffered a nervous breakdown where he ‘lost pretty much everything’
and made the decision to change his life:
I think it came from being at my lowest that I’ve ever been and I
actually took a leap of faith in myself and said, “If I don’t look at these
things now it’s never going to get any better… I was in a very, very bad
state and something in me just said you have to let go of all of this
and let it come up, let it surface and when it surfaces it needs to be
looked at and you might not like what you look at but you’ve got to do
it. (Trevor)
The help participants sought and found came in different forms. For
many, counselling and support programmes and groups were benecial.
For other participants, talking to family and friends or others who
understood body image concerns was benecial. Some found that being
self-reliant was the most effective tool for recovery, while others used
outside sources including self-help literature.
Almost all participants described a supportive relationship where
someone had helped them in overcoming their problems, either with a
family member, partner, friend, or another supportive person. In many
cases, participants found speaking with others who had experienced a
similar problem to be especially helpful, and sometimes this was useful
in leading them towards other forms of support.
Simon’s atmates had noticed his eating disorder and were ‘dropping
subtle hints’ until he became aware of the extent of the problem. He
was then able to turn to these people for support in overcoming the
disorder. ‘After that I reached out to them and spoke to them and said
I can’t actually stop because I got to a point where I thought I was
in control of the eating thing but I realised that I wasn’t’ (Simon, 28,
bisexual). His friends then helped him to develop a strategy to deal
with his eating problem.
Most participants undertook some form of therapy as treatment for
their body image concerns. Whilst not all experiences were successful
in aiding recovery, in those that were participants described key
aspects of recovery as including identication with other members
of the support group or a process of identication with the therapist.
Support groups targeted specically toward gay and bisexual men
were mentioned as helpful by participants who had accessed them.
Along with reporting that they had learned to see themselves and
their behaviour from a new perspective, the men in this phase of the
study reported that experiences with targeted support led to increased
self-esteem and greater self-acceptance. For some this was possible by
allowing themselves to feel vulnerable around others who had gone
through similar experiences.
Results
Almost all
participants
described a
supportive
relationship
where someone
had helped them
in overcoming
their problems,
whether this was
with a family
member, partner,
friend, or another
supportive
person.
Some participants explicitly rejected outside support, preferring to
rely on their own resources in achieving recovery; however, most of
these efforts followed or coincided with other forms of therapy. Some
found strategies to manage their problems directly or prevent them
from resurfacing, for instance by adopting techniques or practices to
change their mind-set and focus. After his decision to stop drinking
and improve his physical health, Asad (39, gay, Pakistani) developed a
strategy of noticing the positive and important aspects of his day to day
life, through journal writing:
I started to write a gratitude list for want of a better phrase and making
a point of looking for the great things that are happening in life, from
the benign to the super exciting and I guess gradually over time that
readjusted the focus – how I viewed the world around me and myself
and where I could t into that world round me. It almost became a
little like a drug because as I did that better and better things started
happening. (Asad)
For most participants, some form of self-acceptance had emerged over
time, through the course of self-reection and analysis, or following
support and a sense of acceptance from various others.
Results
70 The RaRE Research Report: Risk and Resilience Explored
‘I started to write
a gratitude list
for want of a
better phrase
and making a
point of looking
for the great
things that are
happening in life,
from the benign
to the super
exciting and I
guess gradually
over time that
readjusted the
focus.’ (Asad)
71The RaRE Research Report: Risk and Resilience Explored
Discussion
Suicide and self-harm
Findings from the RaRE Study survey show signicant differences
between the rates of previous year and lifetime suicide attempt
and ideation, as well as of self-harm experience and ideation when
comparing LGB and heterosexual young people and when comparing
Trans* and cisgender young people in our sample. Across all
comparisons both LGB and Trans* young people were shown to have
higher rates of the majority of indicators, in some cases with double
or more of the rates of their comparison groups. The only exception to
this pattern regards previous year suicide attempts when comparing
young LGB and heterosexual participants, in which despite the higher
rate for those identifying as LGB, the differences were not signicant.
Nevertheless, the lifetime rates of suicide attempts for LGB young
people are almost twice as high as those of young heterosexual
respondents. This could mean that attempted suicide might happen
more often at younger ages, later levelling out as young people get
older, for instance, due to establishing ties and obtaining support from
the LGB&T community, as suggested by previous research (Harper
et al., 2012; Reed & Valenti, 2013; McCallum & McLaren, 2010). Of
note however is that suicide ideation remains signicantly higher
amongst LGB young people in our sample, including within the year
previous to the survey, which is consistent with ndings by Haas et al.
(2011) according to which suicidal ideation and behaviour seem to be
unrelated.
All rates of young Trans* people in our sample are particularly high
when compared with their cisgender counterparts, with about half
reporting lifetime suicide attempts and over 80% indicating lifetime
suicide ideation and self-harm ideation and experience. These ndings
are consistent with ndings that suggest increased suicide risk for
Trans* young people (D’Augelli et al., 2005; Wang et al., 2012; Xavier et
al., 2007), possibly associated with gender non-conformity (Fitzpatrick
et al., 2005; LeVasseur et al., 2013). Taken together, the above ndings
seem to suggest that sexual and gender minority young people still
experience signicantly more self-harm and suicidal distress than their
non-minority counterparts.
Regression analyses allowed insight into some of the factors that are
associated with this reality for both LGB and heterosexual people alike
(numbers of young Trans* participants in our sample did not provide
enough power for regression analyses for this subset of participants).
A noteworthy, albeit unsurprising, nding is that for young people
72 The RaRE Research Report: Risk and Resilience Explored
regardless of sexual orientation low self-esteem is a signicant
predictor of suicide attempt and self-harm ideation and experience.
Whereas the reasons underlying the low self-esteem might be different
for heterosexuals, for LGB young people this may be associated with
shame-proneness and greater internalised heterosexism as suggested
by the study by Greene and Britton (2013), with the reverse picture, that
of forgiveness of the self, contributing to enhance self-esteem amongst
LGB&T adults (Rosario et al., 2005).
Some aspects of family support, or lack thereof, were also identied
as relevant in our analyses. For young LGB people a low perception of
family helping them to make decisions is a predictor of suicide attempt.
This nding potentially links with fears and experiences of rejection
or hostility related with coming out to parents and others, which have
been shown to be associated with suicide risk in this group (Espelage
et al., 2008; Langhinrichsen-Rohling et al., 2010; Ryan et al., 2009;
Rosario et al., 2005).
A more complex picture is that associated with the self-harm
experience, for which we found as predictors both a high perception of
getting emotional support from family and a low perception of being
able to talk to family about problems. Taken in conjunction with the
high importance of faith or belief at home while growing up as another
of the predictors, the picture is that of emotionally expressive but
potentially conservative family environments which limit young LGB
people’s perception of being able to talk about issues that may concern
them, such as their sexuality. In turn, this might lead them to use
unhealthy strategies for dealing with emotional distress, such as self-
harming. As mentioned above, other research has already reported on
the inuence of negative family support or reactions to coming out, but
some has also specically focused on LGB young people being rejected
by their families due to holding particular religious beliefs (Dahl &
Galliher, 2012; Reed & Valenti, 2013).
Low income was shown to be a predictor of suicide attempt and self-
harm experience for LGB and heterosexuals alike, as it was for suicide
ideation for heterosexuals alone. This nding is not consistent with
research which has shown that for lesbian and gay identied young
adults, family socioeconomic status was a protective factor for suicide
attempt (Ryan et al., 2010). However, for young LGB people nancial
resources might be relevant in order to become more independent
from their families with lack of nances being associated with having
to remain in environments which do not allow for the expression of
their sexual orientation.
The ndings from the rst qualitative phase of this research, in which
LGB&T people who attempted suicide when young were interviewed
about their experiences, largely corroborate and amplify the ndings
from the survey, as just discussed. Problematic coming out experiences
due to the reactions of family and others were identied as key risk
Discussion
Taken in
conjunction
with the high
importance of
faith or belief
at home while
growing up, the
picture is that
of emotionally
expressive
but potentially
conservative
family
environment
which limits
young LGB
people’s
perception of
being able to
talk about issues
that may concern
them, such as
their sexuality.
73The RaRE Research Report: Risk and Resilience Explored
factors for suicidality, leading to a negative impact on feelings of self-
worth. These negative experiences were potentially more impactful
within heterosexist or religious contexts, increasing the strain our
participants experienced while young and their feelings about their
sexual orientation. Additionally specic factors were identied as
triggering suicidal incidents, particularly those associated with
increased emotional strain, such as the death of a loved one or being
the victim of violence, on a background of pre-existing distress. The
experience of negative reactions from others seem to be particularly
intense in the case of the Trans* individuals interviewed for which
repeated experiences of transphobic bullying and violence may help
understand the signicantly high rates of suicide attempts and self-
harm found in this group.
Also signicant are the experiences of dealing with health
professionals, who can demonstrate a lack of appropriate knowledge,
even prejudice. This in turn impacted on processes of recovery, even if
it lead some to make decisions not to try and attempt suicide in the
future so as not to experience any of that again.
Alcohol misuse
Comparisons within our survey sample between heterosexual and LB
women in levels of hazardous and dependent alcohol use revealed
no signicant differences between these two groups. This nding is
contrary to the research that suggests higher patterns of problematic
drinking amongst lesbian and bisexual women (e.g. King et al., 2008;
Rosario, 2008), which informed the inclusion of this specic topic in the
current research. However, another comparative study had also reported
such a difference to exist in other countries (US and New Zealand) but
not in Great Britain (Bloomeld et al., 2011). A recent UK study had also
suggested higher levels of problematic patterns of drinking for LGB
people (Bufn, Roy, Williams & Yorston, 2012), albeit using an external
dataset (British Crime Survey) for comparisons with the general
population. It may be the case that in the UK the pub and drinking
culture contributes to the levelling out of problematic drinking in
women regardless of sexual orientation, making it different in the UK,
in comparison with other countries where this issue has been studied.
Only minor differences were found between specic patterns of
drinking, with LB women being more likely to drink to intoxication
once a month and less likely to never drink when compared with
heterosexual women. This nding is consistent with ndings according
to which LB women have slightly different patterns in their frequency
of drinking than heterosexual women (e.g. according to Hunt and Fish,
2008, about 40% of lesbian and bisexual women drink alcohol three
or more times a week compared with a quarter of women in general)
but is not signicant overall and does not add to our understanding of
problematic drinking amongst sexual minority women.
Discussion
It may be the
case that in the
UK the pub and
drinking culture
contributes to
the levelling out
of problematic
drinking across
the feminine
population
regardless
of sexual
orientation.
74 The RaRE Research Report: Risk and Resilience Explored
For this topic we also decided to break comparative analyses down
further, as according to some studies, sexual orientation and identity
may be a relevant factor associated with alcohol misuse in women,
with bisexual women more at risk of having alcohol-related issues
(Drabble et al., 2013; Fredriksen-Goldsen et al., 2010; Hughes,
Szalacha, Johnson et al., 2010; Lanfear, Akins & Mosher, 2013). However,
in our analyses, even when separating lesbian and bisexual women,
the lack of differences between sub-groups of women remained.
Considering that we did not control for sexual behaviour, it may be the
case that a signicant number of women in our sample who identify as
heterosexual had same-sex partners, a group identied with increased
risk of alcohol misuse (Ziyadeh et al., 2007; Drabble et al., 2013), hence
potentially confounding the ndings.
Our regression analyses conrmed other studies’ ndings that age is a
relevant factor for alcohol use (e.g. Austin, 2010; Molander, 2010), with
younger age associated with higher rates of drinking. However, this was
found to be a common factor for heterosexual, as well as for lesbian
and bisexual women, which again from our quantitative analyses
suggests more commonality, rather than dissimilar patterns, between
women, whatever their sexual orientation. As suggested by others,
drinking at younger ages might be associated with drinking culture at
university which would be common for lesbian and bisexual as well
as for heterosexual women (Drabble et al., 2013; Lanfear et al., 2013);
otherwise coming of age rituals and leisure activities for younger
people, common across the sexual orientation spectrum, are heavily
associated with alcohol consumption, despite potentially with nuances
between groups that might not necessarily have been captured by
using a survey method (more on this below when discussing the
qualitative ndings).
Two other variables to come out as signicant predictors of hazardous
alcohol use for both groups were low general health/well-being and
high current relevance of faith or belief. With regard to the rst of these
two, it is a somewhat unsurprising nding, considering the signicant
association that alcohol misuse has been shown to have with poor
mental health for sexual minorities (Hughes et al., 2007; Hughes,
Szalacha & McNair, 2010; King, 2008; Newcomb et al., 2012) as well as
for the general population (Schneier, 2010). This relationship seems to
be two-sided, with poor mental health potentially leading to alcohol
use and with alcohol use causing deteriorating mental health and well-
being.
The link between the high relevance of religion and problematic
drinking for both groups studied is potentially a more challenging
one to contextualise, considering for instance the ndings by Rostosky
et al. 2008), suggesting greater religiosity has a protective effect
against alcohol use and misuse for heterosexual but not for LGB
young adults. In our sample, not only does this effect seem to be
reversed, with greater relevance of religion associated with greater
Discussion
75The RaRE Research Report: Risk and Resilience Explored
levels of hazardous drinking for LGB women, but a similar effect is
also found for heterosexual women. One potential explanation in
the case of lesbian, gay and bisexual women is that a more active
involvement with religion is the cause of distress due to many religious
contexts not being accepting of sexual diversity, hence generating a
conict between sexual identities and religious beliefs that might be
temporarily relieved by drinking. For heterosexual women there might
be other sources of inuence to justify this nding that are unrelated
with sexual orientation, however being beyond the scope of our study.
The only factor found to be specic for sexual minority women in
the regression analyses was in relation to the place where they live,
with living in a suburb or small town being associated with a lower
likelihood of drinking hazardously. Larger urban contexts are more
likely to provide the leisure resources, such as bars and clubs, where
lesbian, gay and bisexual women gather and socialise, with large
availability of alcohol and peer-pressure to drink, which might help
justify this nding.
Of note, the effect sizes for the regression analyses for these groups
were low, and therefore both the ndings and their interpretations
should be made with caution.
The ndings from the rst qualitative study corroborate some of
these results and interpretations, while providing a more nuanced
perspective on the factors associated with problematic drinking for
sexual minority women. Thematic analysis of the interviews suggested
that family as well as social condoning of drinking associated with
negative or traumatic experiences both at home and in other contexts
were some of the earliest and most relevant factors to set the path for
alcohol misuse as a teenager and an adult. Alcohol was also described
as a crutch to deal with negative emotions or experiences and to feel
more condent. Associated with this theme but specic to this group
was the use of alcohol to mitigate anxieties surrounding their sexuality
in the context of a repressive environment or one that expected them
to be heterosexual, particularly while young. Additionally, the theme
of alcohol being an important part in some LGB social environments,
particularly in the scene, was also identied in the analysis.
Recovery was often described as a challenging process, sometimes
marked by relapses, and heavily based on support received from
partners, family members and others in more formal structures,
such as self-help groups and therapy. Sexual orientation sometimes
affected women’s ability to fully engage with these resources. This was
either due to concerns of the reactions of professionals if they were
to disclose their sexual orientation, which as explained above, often
linked closely with the reasons behind drinking, or to the women’s
experiences of inappropriate responses from professionals upon
disclosure.
Discussion
The only factor
found to be
specic for
sexual minority
women was in
relation to the
place where they
live, with living
in a suburb or
small town being
associated with a
lower likelihood
of drinking
hazardously.
Alcohol was
also described
to be used as a
crutch to deal
with negative
emotions or
experiences and
to feel more
condent.
76 The RaRE Research Report: Risk and Resilience Explored
Support from LGB&T specic organisations and resources were often
mentioned as valued sources of support and key to successful recovery
processes. Additional strategies, such as mindfulness, yoga or nding
means of self-expression were considered helpful, as was regaining a
sense of control over their lives, something that was lost during times
of excessive drinking.
Body image and eating concerns
The RaRE Study developed an instrument that explores satisfaction
and attitudes to change across a diverse range of bodily sites to
understand health and physical concerns for men. Findings identied
that more than half of all men (gay, bisexual and heterosexual)
expressed dissatisfaction with their physical tness and how much
they exercise. On six out of the 16 item RaRE Body Satisfaction Scale
(RBSS), dissatisfaction was reported by approximately 60% of all gay
and bisexual men. More than 60% of GB men disagreed or strongly
disagreed that they were satised with ‘How much I exercise’, ‘My body
fat’, and ‘Physical tness’ and just under 60% of GB men indicated
dissatisfaction with ‘My weight’, ‘My body shape’, and ‘Muscularity’. By
comparison, men who identied as heterosexual expressed satisfaction
in greater numbers, with more than half agreeing or strongly agreeing
to all of the items except ‘My physical tness’ and ‘How much I
exercise’. In fact, compared to heterosexual men, GB men expressed
dissatisfaction in greater numbers to statistical signicance on 11 of
the 16 items.
These ndings are not surprising when considering the research that
has highlighted the concerns that men in general have in regard to
their bodies, for instance, by expressing a desire to be more muscular
(Frederick et al., 2007) and also the research which has evidenced
gay men’s higher tendency to be dissatised with their bodies when
compared with heterosexual men (Kaminski et al., 2005; Peplau et al.,
2009; Tiggemann et al., 2007).
Regression analysis identied as a unique predictor of gay and bisexual
men’s body dissatisfaction, a high relevance placed on the inuence
from the social environment in the ways they feel about their bodies.
This suggests that sexual minority men may be more susceptible to
images of bodily ideals seen in the media, but also to real men around
them, including in gyms and in other daily contexts. This is contrary to
ndings by Davis and Green (2011) who found that social comparison
may protect against the development of body image problems.
However, their study focused on pathological expressions of excessive
preoccupation with the body such as BDD, which was not specically
targeted by our research. It may be that our participants are more
susceptible to the pressures to conform, such as those found in specic
spaces that are aimed at gay and bisexual men.
Discussion
More than half
of all men (gay,
bisexual and
heterosexual)
expressed
dissatisfaction
with their
physical tness
and how much
they exercise.
Regression
analysis
identied
as unique
predictor of gay
and bisexual
men’s body
dissatisfaction a
high relevance
placed on
the inuence
from the social
environment in
the ways they
feel about their
bodies.
77The RaRE Research Report: Risk and Resilience Explored
Some of these ndings and hypotheses are corroborated by our
qualitative ndings. According to these, early experiences of bullying
and of feeling different within the family and amongst peers were key
factors in the development of low self-worth, as well as in creating
a susceptibility towards pressures to conform to a masculine body
ideal for the gay and bisexual men interviewed. The resilience and
recovery factors identied were a combination of nding motivation to
change, along with connecting with sources of help, such as personal
relationships, therapy, organised programmes, eventually leading to
self-acceptance. Between the risk and the resilience ndings, there is
a triangulation that suggests the existence of contrasting themes that
open up interesting paths for increasing the understanding around
body dissatisfaction for gay and bisexual men. For example, low self-
worth is a risk factor and self-acceptance is a factor of resilience. In
contrast, high self-worth offsets risk and lack of self-acceptance hinders
resilience to negative feelings, thoughts and behaviours related to
one’s own body. Importantly and with implications for intervention,
our ndings indicate that resilience can be developed throughout the
person’s lifespan, whether as preventative or as part of an intervention
to distress and harm.
Body image has an impact on how people think, feel, and behave,
as well as being impacted by thought, feelings and behaviours. This
applies to all people, regardless of gender and sexual orientation.
Research that has explored and developed our understandings of
body image has mosty focussed on cisgender girls and women (e.g.
Thompson et al., 1999), a pattern which is repeated in popular culture
and media; however, boys and men are also subject to the materiality of
the body, as are people who may identify their gender differently to the
codas of ‘male’ and ‘female’.
Similarities and differences between genders – and within genders –
are constantly reproduced in English culture and society, no less within
our systems of social welfare and healthcare. As sexual orientation is
dened in terms of gendered bodies (e.g. heterosexual, bisexual, same-
sex), patterns of similarities and differences can be seen between (and
within) groupings related to people’s genders and sexual orientations.
Ongoing analysis within the RaRE Study will include an analysis of the
data for gay men and bisexual men separately, where initial analysis
has been produced for ‘gay and bisexual men’ as a single group.
General discussion
Our ndings suggest that while some similarities may exist between the
risk and resilience factors of LBG people and those of heterosexual people
(with less information to discuss if the same might apply in relation with
Trans* people when compared with cisgender people), there is evidenced
that a range of unique factors strongly inuence the experiences of mental
Discussion
78 The RaRE Research Report: Risk and Resilience Explored
health and well-being for sexual minority people. More often than not
these are a consequence of negative reactions or of the expectation of
such reactions from signicant others, such as family and friends, as well
as from health professionals. Additionally, experiences of discrimination,
bullying and violence associated with their sexual orientation and gender
identity seem to be commonplace and came across as impacting the well-
being of many of those who took part in our research, leading to feelings
of loneliness and isolation, often being associated with the development
of poor mental health in its various guises. The analyses we carried out of
Trans* people seem to suggest that this group is particularly vulnerable to
this set of circumstances due to the transphobic reactions they are often
exposed to in various contexts, including within the family.
Self-esteem particularly was identied as a relevant aspect associated
with the issues studied, both in quantitative and in qualitative analyses.
To a certain extent this is unsurprising, considering the amount of
evidence suggesting that low self-esteem is strongly associated with
mental health (e.g. Chaney, 2008; Rosario et al., 2005; Tiggemann et
al., 2007). However, despite this knowledge, the recurrent presence of
low self-esteem as an important predictor of issues such as self-harm,
alcohol use or body dissatisfaction in our ndings suggests that greater
awareness and interventions to boost young people’s self-esteem might
still play an important role in the prevention of emotional distress both
during younger ages and later in life. Despite the fact that self-esteem
was found in many cases to be a relevant factor for heterosexuals
and for LGB people alike, our qualitative ndings provide insight into
what might be specic of the latter. For many of those interviewed,
experiences of bullying, discrimination, isolation and loneliness, among
others closely link with the development of feelings of low self-worth
which in turn contribute to experiences of poor mental health.
Many of those interviewed stated that nding help was not an easy
process and often required overcoming emotional barriers (e.g. concerns
around the potential reactions of professionals to disclosing their sexual
orientation) and practical ones, such as lack of appropriate reactions to
issues specic to sexual minorities or the sheer lack of LGB&T support,
considered a relevant need for many. On the other hand, the support
from those participants referred to as close to them, such as partners,
friends and family members as well as sensible professionals or other
formal resources (e.g. support groups and specialised units) were
considered keys to the recovery process despite the challenges faced.
Limitations of the study
The RaRE Study used a robust and systematic approach to the
understanding of three key mental health issues that affect the
LGB&T community, involving a wide range of stakeholders and various
research and data collection phases. However, the choice of specic
issues comes at the expense of disregarding other relevant mental
Discussion
79The RaRE Research Report: Risk and Resilience Explored
health issues that also affect the LGB&T community, such as drug use,
depression or anxiety, which in our analyses could only be accounted
for in rough and approximate ways (for instance, when participants
mentioned them in the context of open questions in the survey or
when asked about experiences of mental health as part of the P2Q
recruitment process). A wider look at the context and at the interactions
existing between various mental health conditions that affect LGB&T
people continues to be relevant and should not be disregarded.
There were also challenges in combining the three topic areas as
they span a range of health issues, although the research did identify
commonalities in terms of risk and resilience patterns and frameworks.
Another limitation of the research, particularly regarding the results
presented and discussed in this report, is the lack of more ndings
for specic sexual orientation and gender identity groups, including
but not limited to bisexual and Trans* people. These groups often
have specicities in regards to their experiences around mental
health that require more detailed analyses and larger debates. These
analyses go beyond the original scope of the RaRE research project
as it was designed in 2009. In order to keep manageable the size and
the breadth of this document we decided to report here only what
was then planned. However, further analyses will be conducted and
research outputs produced making use of all the data collected.
The recruitment processes for all three phases of the research were
purposely strategic and focused on specic populations of interest,
more so in the case of the qualitative studies, but also for the national
survey for which there was a need to include enough numbers of
participants from smaller and harder to access groups (e.g. bisexual
men, older people, disabled people) to allow some of the analyses
of interest. Furthermore, given the nature of PACE and also of the
topic of the research, it is possible that there is a disproportion
amongst research participants of people with experience of or who
are sensitive towards mental health issues, as well as of people with
an LGB&T community attachment. It is also possible that the survey
attracted heterosexual people who are sympathetic towards the
LGB&T community, even if the publicity materials for the survey were
designed to minimise their sexual minority focus. This potential bias is
suggested, for instance, in the rates of suicide experience and ideation
for the heterosexual cohort, which are higher than expected when
compared with those of the general population (The NHS Information
Centre for Health and Social Care, 2009).
Ultimately our ndings can only be considered valid for our samples
and are also subject to the specicities of the social and cultural
contexts where the research was conducted.
Discussion
80 The RaRE Research Report: Risk and Resilience Explored
Conclusions
The RaRE Study was able to gather signicant evidence about specic
mental health issues that affect LGB&T people. It used a Community
Based Participatory Research, which had the strength of bringing
together the community knowledge and sensitivity with the expertise
and rigour of academia in addressing delicate but relevant topics.
Despite addressing mental health issues, the project had an important
focus on factors that may contribute to recovery and resilience, hence
keeping a positive outlook at the multiple and sometimes creative
ways that people nd to obtain and maintain a sense of well-being.
Further ndings and analyses will provide more detail and additional
insights, as well as recommendations in regard to the mental health
needs of LGB&T people.
Also importantly, the project’s survey collected data from a large group
of heterosexual people, which allowed for comparisons to be made
within the same sample, increasing the reliability of the ndings from
that phase of the study. The use of a mixed methods approach further
contributed to a nuanced portrait of the topics under analysis.
The study has corroborated previous research that suggests poorer
mental health for people who identify with a minority sexual
orientation or gender identity, but it has found specic areas for
which this might not necessarily be the case (e.g. problematic alcohol
use amongst lesbian and bisexual women when compared with
heterosexual women). It also identied a range of factors that seem to
contribute or that are strongly associated with the mental health issues
studied, thus adding to a better understanding of the support and
interventions needed for this population.
81The RaRE Research Report: Risk and Resilience Explored
In relation to the general ndings of the research, there are a number
of recommendations:
• Training and awareness of health professionals is essential to
ensure appropriate care to the mental health and other health
care needs of people of various sexual orientations and gender
identities
• General and mental health services should ensure that they are
proactive in their efforts to be LGB&T friendly, both physically and
virtually, thus assuring their sexual minority users that it is safe
to disclose their sexual orientation or gender identity without
concerns of being treated inappropriately by members of staff
• Sexual diversity awareness and training should be implemented
in all schools, for staff and students alike, thus creating inclusive
educational environments that do not tolerate discrimination or
homophobic, biphobic or transphobic bullying of any sort
• Condence and self-esteem support should be made available for
young LGB&T people at risk, allowing them to develop skills that
are key to helping them withstand adverse circumstances and
prevent the development of mental health issues as they grow up
• There is a need for more LGB&T specic social environments that
do not centre around alcohol and that offer alternatives to the
pub and drinking culture
• Mainstream as well as LGB&T specic media need to become
more inclusive of diverse representations of the male body which
go beyond conventions of beauty and tness
• Family support is a key factor for recovery from many mental
health issues that affect LGB&T people; more awareness and
information needs to be provided, for instance through media
campaigns and increased visibility of sexual minority people, for
the purpose of achieving a more inclusive and accepting society
Recommendations
82 The RaRE Research Report: Risk and Resilience Explored
Glossary
Alcohol abuse – A pattern of excessive alcohol consumption which has
a signicant impact on the performance of activities such as working,
attending school, childcare, amongst others.
Alcohol dependency – A range of behaviours, thoughts, feelings and
physical symptoms associated with continuous alcohol use. Typically,
someone who is dependent on alcohol will want to continue drinking
despite the negative effects or consequences associated with this
behaviour.
Asexual – A person whose identity is non-sexually oriented. They may
have ‘emotional orientations’ towards same-sex or different-sex others,
or not. This is a contemporary and emerging self-identication.
Biphobia – A range of negative attitudes, feelings and behaviours
towards bisexuality and bisexual people as a social group or as
individuals.
Bisexual – A person who has an emotional and/or sexual attraction
toward more than one gender.
Body dysmorphic disorder (BDD) – A condition in which people develop
an unrealistic ideal as to how they should look. BDD symptoms include
a preoccupation with the belief that a specic body part is defective or
deformed in some way.
Body fat dissatisfaction – A feeling of being dissatised with the
amount of fat in one’s body.
Cisgender – A person whose gender identity is the same as the sex they
were assigned at birth; someone who is not Trans*.
Coming out – Refers to the experiences of some, but not all, LGBT
people as they explore or disclose their sexual orientation and/or their
gender identity.
Diagnostic and Statistical Manual for Mental Disorders (DSM-5) -
The 5th edition of the Diagnostic and Statistical Manual of Mental
Disorders. This manual is published by the American Psychiatric
Association and includes extensive descriptions, denitions and
diagnostic criteria (amongst other information) for mental disorders.
Discrimination – Detrimental treatment experienced on the grounds of
some aspect of a person’s identity or presentation.
Gay – Most commonly refers to men who have an emotional and/or
sexual attraction to men. However, some Lesbians identify as “Gay” or
“Gay Women”.
Gay-Straight alliance – School and university-based organizations,
common in the US, intended to provide a safe, supportive environment
for sexual minority students, members of staff and their straight allies.
83The RaRE Research Report: Risk and Resilience Explored
Hate crime – A crime committed on the basis of the actual or perceived
ethnicity, religion, gender identity, disability, age or sexual orientation
of a person.
Heteronormativity – The belief that heterosexuality is the only ‘natural’
and ‘normal’ expression of human sexual orientation and that it is
inherently superior (and healthier) to other types of sexual orientation.
Heterosexual – An individual who has an emotional and/or sexual
attraction to persons of the other gender. Heterosexual people are
sometimes referred to as ‘straight’.
Homophobia – A range of negative attitudes, feelings and behaviours
toward homosexuality or towards people who are identied or
perceived as being lesbian and gay; although sometimes it is also used
in the context of similar reactions towards bisexual or transgender
people.
Homosexual – A term mostly used by external authorities (e.g. doctors,
police, newspaper writers) to refer to an individual who has a sexual
and/or emotional attraction towards persons of the same sex. This
term is often now rejected by LGBT people as being too clinical and the
terms ‘lesbian’, ‘gay’ or ‘queer’ are preferred.
International Classication of Diseases (ICD-10) – The 10th edition of
a medical classication list produced by the World Health Organization
(WHO). It contains codes for diseases, signs and symptoms, abnormal
ndings, complaints, social circumstances, and external causes of injury
or diseases, including mental health issues.
Instrumentality – A personality trait associated with being objective
and focused in a competitive way, and to easily be able to make
decisions; it is sometimes associated with a stereotypical masculine
identity.
Lesbian – A woman who has an emotional and/or sexual attraction to
other women.
LGB&T – Acronyms for lesbian, gay, bisexual and Trans*. Increasingly
including ‘Q’ for Questioning and/or Queer (LGBTQ) and ‘I’ to include
Intersex (LGBTQQI).
Minority Stress – The psychological effect on LGB&T people of
transphobic, biphobic, homophobic and heterosexist cultural
norms that spur the discrimination, bullying, marginalisation and
stigmatisation of LGB&T people.
Muscle dysmorphia – Having a persistent belief that one’s muscles may
be small and insufcient, despite having enough muscularity.
Personal agency – The subjective awareness that one is initiating,
executing, and controlling one’s own will and actions.
Queer – A term used by some people to dene their sexual orientation
or gender identity. Queer tends to be dened by what it is not – i.e. not
having a prescribed view of gender identity and sexual orientation. Queer
is also sometimes used to indicate a commitment to ‘non-normative’
gender and sexual uidity (rather than to xed categories of person).
Glossary
84 The RaRE Research Report: Risk and Resilience Explored
Glossary
Questioning – A term used by some, mostly young, people in regard to
their sexual orientation or gender identity. They may use it because
they are experiencing lesbian, gay, bisexual, and/or Trans* feelings
or urges, but have not yet identied their gender identity or sexual
orientation.
Self-harm – Self-initiated, potentially injurious behaviour without
intent to die.
Suicide attempt – Self-initiated, potentially injurious behaviour with
intent to die which has a non-fatal outcome.
Trans* – An umbrella term for people whose gender identity and/
or gender expression diverges in some way from the sex they were
assigned at birth, including those who identify as transsexual, non-
binary gendered or cross-dressers, amongst others (see also ‘Trans’).
Trans (without the asterisk) – Is best applied to trans men and trans
women, while the asterisk makes special note in an effort to include
all non-cisgender gender identities, including transgender, transsexual,
transvestite, genderqueer, genderuid, non-binary, genderless, agender,
non-gendered, third gender, two-spirit, bigender, and trans man and
trans woman. Sometimes referred to as ‘T’.
Transphobia – A reaction of fear, loathing, and discriminatory treatment
of people whose identity or gender presentation (or perceived gender
or gender identity) does not ‘match’, in the societally accepted way, the
sex they were assigned at birth; the response of other members of
society that results in trans people experiencing hatred, discrimination
or inequality.
Trans Man/FTM – A person who was assigned female at birth but
has a male gender identity and therefore proposes to transition, is
transitioning or has transitioned to live as a man, often with the
assistance of hormone treatment and perhaps various surgical
procedures.
Trans Woman/MTF – A person who was assigned male at birth but
has a female gender identity and therefore proposes to transition,
is transitioning or has transitioned to live as a woman, often with
the assistance of hormone treatment and perhaps various surgical
procedures.
85The RaRE Research Report: Risk and Resilience Explored
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Appendices
Appendix 1: P1Q Interview guide
Q1 Please tell me a little about yourself [prompt: whatever you
would like to tell me].
Q2 Please tell me about your [suicide attempt as a young person] /
experience of [nature of health issue].
Q3 What do you think may have played a part in causing [this
problem] or making it worse?
Q4 How do you think being [LGBT or Q] may have affected [this
problem]?
Q5 Could you tell me about anywhere or anyone that you
approached for help? [Prompt that this can be from informal
sources, such as friends and family, as well as professional
sources].
Q6 What do you think inuenced your decisions about seeking help
or not seeking help?
Q7 What did you nd helpful? [Relevant too are their own coping
strategies or incidental events, such as getting into a ‘good’
relationship].
Q8 What did you nd unhelpful?
Q9 Can you think of anything that might have helped prevent [this
problem]?
Q10 What might have made you better able to cope with [this
problem]?
Q11 Is there anything else you’d like to tell us?
94 The RaRE Research Report: Risk and Resilience Explored
Appendix 2: The RaRE Survey (Paper version)
Appendices
95The RaRE Research Report: Risk and Resilience Explored
Appendices
96 The RaRE Research Report: Risk and Resilience Explored
Appendices
97The RaRE Research Report: Risk and Resilience Explored
Appendices
98 The RaRE Research Report: Risk and Resilience Explored
Appendix 3: P2Q Interview guide
# Question Probe
1 Can you tell me a bit about why were
you interested in this phase of the
study?
-
2i We want to hear from people who
believe they have good mental health
even though they lived through difcult
or traumatic situations in their past.
2.1. How do you think you t into this
prole? [or ‘In what ways...’]
2.2. Can you tell me a bit more about it?
2.3. What do you think contributed to
that?
2.4. What do you think could have
made it any different?
2ii We want to hear from people who
experienced mental health issues
but consider that they have not lived
through difcult or traumatic situations
in their past.
2.1. How do you think you t into this
prole?
2.2. Can you tell me a bit more about it?
2.3. What do you think contributed to
that?
2.4. What do you think could have
made it any different?
3a What are your experiences with alco-
hol?
3.1. How do you think that compares to
other LGBT people?
3.2. How do you think that compares to
the general population, or specically to
non-LGBT people?
3b What are your experiences with body
image issues?
3.1. How do you think that compares to
other LGBT people?
3.2. How do you think that compares to
the general population, or specically to
non-LGBT people?
3c What are your experiences with suicid-
al thoughts/behaviours?
3.1. How do you think that compares to
other LGBT people?
3.2. How do you think that compares to
the general population, or specically to
non-LGBT people?
4a What would you say can cause prob-
lematic alcohol use in LGBT people?
4.1. What informed your opinion?
4.2. What else?
4.3. Is there anything more you can
think of?
4.4. How does that compare to your
own experience?
5a What would you say could prevent
problematic alcohol use in LGBT peo-
ple?
5.1. What informed your opinion?
5.2. What else?
5.3. Is t here anything more you can
think of?
5.4. How does that compare to your
own experience?
Appendices
99The RaRE Research Report: Risk and Resilience Explored
# Question Probe
4b What would you say can cause suicidal
thoughts and/or behaviour in LGBT
people?
4.3. Is there anything more you can
think of?
4.4. How does that compare to your
own experience?
5b What would you say could prevent
suicidal thoughts and/or behaviour in
LGBT people?
5.1. What informed your opinion?
5.2. What else?
5.3. Is there anything more you can
think of?
5.4. How does that compare to your
own experience?
4c What would you say can cause body
image problems in LGBT people?
4.1. What informed your opinion?
4.2. What else?
4.3. Is there anything more you can
think of?
4.4. How does that compare to your
own experience?
5c What would you say could prevent
body image problems in LGBT people?
5.1. What informed your opinion?
5.2. What else?
5.3. Is there anything more you can
think of?
5.4. How does that compare to your
own experience?
6a Initial ndings from our survey indicate
that 42% of LB women on our sample
drink to intoxication at least once a
month as opposed to 35% of the hetero-
sexual women.
6.1. How does your experience t with
that?
6b Initial ndings from our survey indicate
that 16% of the gay and bisexual men
on our sample were strongly dissatised
with their body image as opposed to
7% of the heterosexual male partici-
pants
6.1. How does your experience t with
that?
6c Initial ndings from our survey indicate
that 27% of LGB participants have
seriously attempted to take their lives
as opposed to 16% of heterosexual
participants.
They also show that 40% of Trans*
participants have seriously attempted to
take their lives as opposed to 22% of
non-trans participants.
6.1. How does your experience t with
that?
7 Is there anything else about what we
just discussed that you would like to
add?
-
Appendices
100 The RaRE Research Report: Risk and Resilience Explored
Appendix 4: Survey demographics
By sexual orientation
Age
Hetero (n=700) GL (n=949) Bisexuals (n=302)
Mean 37.24 39.31 36.04
SD 13.47 12.17 12.21
Range 18-76 18-83 18-77
Your gender
Hetero (n=700) GL (n=949) Bisexuals (n=302)
Female 75.7% (530) 36.9% (350) 60.6% (183)
Male 23.4% (164) 61.4% (583) 34.4% (104)
Other 0.9% (6) 1.7% (16) 5.0% (15)
Relationship status
Hetero (n=700) GL (n=949) Bisexuals (n=302)
Single 34.1% (239) 46.8% (444) 41.4% (125)
Relationship 34.4% (241) 34.8% (330) 39.4% (119)
Legally recognised 28.7% (201) 15.6% (148) 13.6% (41)
Other 2.7% (19) 2.8% (27) 5.6% (17)
Do you have parental responsibilities?
Hetero (n=700) GL (n=948) Bisexuals (n=302)
Yes 34.0% (238) 8.0% (76) 20.2% (61)
No 66.0% (462) 91.9% (872) 79.8% (241)
Do you consider yourself to be disabled?
Hetero (n=700) GL (n=949) Bisexuals (n=302)
Yes 10.0% (70) 16.1% (153) 23.8% (72)
No 90.0% (630) 83.9% (796) 76.2% (230)
Ethnic group
Hetero (n=700) GL (n=949) Bisexuals (n=302)
White 85.0% (595) 87.9% (834) 86.1% (260)
Mixed/multiple 3.9% (27) 4.3% (41) 7.6% (23)
Asian/Asian British 5.0% (35) 2.6% (25) 2.0% (6)
Black/African/… 4.7% (33) 3.4% (32) 3.0% (9)
Other 1.4% (10) 1.8% (17) 1.3% (4)
101The RaRE Research Report: Risk and Resilience Explored
In which region in England do you live in?
Hetero (n=700) GL (n=949) Bisexuals (n=302)
East Midlands 7.9% (55) 7.0% (66) 7.3% (22)
East of England 5.1% (36) 5.2% (49) 5.0% (15)
London 30.3% (212) 52.8% (501) 46.0% (139)
North East 7.4% (52) 2.5% (24) 3.0% (9)
North West 7.0% (49) 7.7% (73) 6.0% (18)
South East 15.4% (108) 13.2% (125) 15.2% (46)
South West 8.7% (61) 3.3% (31) 6.3% (19)
West Midlands 9.0% (63) 4.1% (39) 6.6% (20)
Yorkshire and the
Humber
8.6% (60) 4.0% (38) 4.6% (14)
Other 0.6% (4) 0.3% (3) 0.0% (0)
Where did you grow up?
Hetero (n=700) GL (n=949) Bisexuals (n=301)
Rural 14.6% (102) 19.1% (181) 19.5% (59)
Small town 36.6% (256) 29.7% (282) 26.5% (80)
Suburb 17.3% (121) 17.9% (170) 25.2% (76)
Large town / city 31.6% (221) 33.3% (316) 28.5% (86)
Where do you live now?
Hetero (n=698) GL (n=948) Bisexuals (n=302)
Rural 10.3% (72) 5.8% (55) 4.0% (12)
Small town 26.1% (183) 13.7% (130) 15.2% (46)
Suburb 15.7% (110) 11.6% (110) 16.2% (49)
Large town / city 47.6% (333) 68.8% (653) 64.6% (195)
Highest educational qualication
Hetero (n=700) GL (n=948) Bisexuals (n=302)
GCSE / O-Levels /
CSE
10.9% (76) 7.9% (75) 5.0% (15)
Bachelor’s Degree 30.6% (214) 30.9% (293) 33.1% (100)
Professional quali-
cation
11.3% (79) 11.1% (105) 10.9% (33)
A-Levels 14.6% (102) 11.7% (111) 11.9% (36)
Master’s Degree 18.0% (126) 23.2% (220) 21.5% (65)
PHD 3.0% (21) 3.2% (30) 4.6% (14)
BTEC, ONC, HNC,
HND
6.7% (47) 6.6% (63) 7.6% (23)
Other 5.0% (35) 5.4% (51) 5.3% (16)
102 The RaRE Research Report: Risk and Resilience Explored
By gender identity
Age
Trans* (n=120) Cis (n=1958)
Mean 38.4 37.7
SD 13.3 12.7
Range 18 - 68 18 - 83
Your gender
Trans* (n=120) Cis (n=1958)
Female 30.0% (36) 55.7% (1090)
Male 25.0% (30) 43.4% (850)
Other 45.0% (54) 0.9% (18)
Do you identify as:
Trans man 27 (22.7%)
Trans woman 46 (38.7%)
Other 46 (38.7%)
Relationship status
Trans* (n=120) Cis (n=1958)
Single 54.2% (65) 41.3% (808)
Relationship 23.3% (28) 35.4% (694)
Legally recognised 14.2% (17) 19.7% (385)
Other 8.3% (10) 3.6% (71)
Do you have parental responsibilities?
Trans* (n=120) Cis (n=1957)
Yes 15.8% (19) 19.0% (371)
No 84.2% (101) 81.0% (1586)
Do you consider yourself to be disabled?
Trans* (n=120) Cis (n=1958)
Yes 33.3% (40) 14.8% (1669)
No 66.7% (80) 85.2% (289)
Ethnic group
Trans* (n=120) Cis (n=1958)
White 89.2% (107) 86.0% (1684)
Mixed/multiple 7.5% (9) 4.9% (95)
Asian/Asian British 1.7% (2) 3.6% (71)
Black/African/… 1.7% (2) 3.8% (74)
Other 0.0% (0) 1.7% (34)
Appendices
103The RaRE Research Report: Risk and Resilience Explored
In which region in England do you live in?
Trans* (n=120) Cis (n=1958)
East Midlands 13.3% (16) 6.7% (132)
East of England 4.2% (5) 5.2% (101)
London 34.2% (41) 44.5% (872)
North East 5.8% (7) 4.2% (82)
North West 7.5% (9) 7.3% (142)
South East 17.5% (21) 13.9% (272)
South West 3.3% (4) 6.0% (117)
West Midlands 6.7% (8) 6.1% (119)
Yorkshire and the Humber 7.5% (9) 5.8% (114)
Other 0.0% (0) 0.4% (7)
Where did you grow up?
Trans* (n=120) Cis (n=1958)
Rural 13.3% (16) 17.7% (347)
Small town 32.5% (39) 31.0% (607)
Suburb 24.2% (29) 19.2% (375)
Large town / city 30.0% (36) 32.1% (628)
Where do you live now?
Trans* (n=120) Cis (n=1958)
Rural 7.5% (9) 6.9% (136)
Small town 17.5% (21) 18.0% (353)
Suburb 18.3% (22) 13.5% (264)
Large town / city 56.7% (68) 61.4% (1202)
Highest educational qualication
Trans* (n=120) Cis (n=1957)
GCSE / O-Levels / CSE 11.7% (14) 8.2% (160)
Bachelor’s Degree 27.5% (33) 31.3% (612)
Professional qualication 8.3% (10) 10.7% (210)
A-Levels 16.7% (20) 12.9% (252)
Master’s Degree 12.5% (15) 22.0% (430)
PHD 6.7% (8) 3.3% (65)
BTEC, ONC, HNC, HND 10.8% (13) 6.5% (128)
Other 5.8% (7) 5.1% (100)
Appendices
© PACE 2015
ISBN: 978-0-9932385-0-5
Published by PACE - Project for Advocacy Counselling and Education
PACE is a trading name for Project for Advocacy Counselling and Education
and is registered in England and Wales, Company Limited by Guarantee.
(Registered charity number: 801271)
pace
phone: 020 7700 1323
email: info@pacehealth.org.uk
web: www.pacehealth.org.uk
address: Ground Floor
54-56 Euston Street
London, NW1 2ES
United Kingdom
PACE is the LGBT+ mental health charity.
We offer face to face and online services across England,
including counselling, group work and advocacy.
We also carry out research and work with mainstream
services to improve their LGBT+ clients’ experiences.
