Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual
Populations: Conceptual Issues and Research Evidence
Ilan H. Meyer
In this article the author reviews research evidence on the prevalence of mental disorders in lesbians, gay
men, and bisexuals (LGBs) and shows, using meta-analyses, that LGBs have a higher prevalence of
mental disorders than heterosexuals. The author offers a conceptual framework for understanding this
excess in prevalence of disorder in terms of minority stress—explaining that stigma, prejudice, and
discrimination create a hostile and stressful social environment that causes mental health problems. The
model describes stress processes, including the experience of prejudice events, expectations of rejection,
hiding and concealing, internalized homophobia, and ameliorative coping processes. This conceptual
framework is the basis for the review of research evidence, suggestions for future research directions, and
exploration of public policy implications.
The study of mental health of lesbian, gay, and bisexual (LGB)
populations has been complicated by the debate on the classifica-
tion of homosexuality as a mental disorder during the 1960s and
early 1970s. That debate posited a gay-affirmative perspective,
which sought to declassify homosexuality, against a conservative
perspective, which sought to retain the classification of homosex-
uality as a mental disorder (Bayer, 1981). Although the debate on
classification ended in 1973 with the removal of homosexuality
from the second edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM; American Psychiatric Association,
1973), its heritage has lasted. This heritage has tainted discussion
on mental health of lesbians and gay men by associating—even
equating—claims that LGB people have higher prevalences of
mental disorders than heterosexual people with the historical an-
tigay stance and the stigmatization of LGB persons (Bailey, 1999).
However, a fresh look at the issues should make it clear that
whether LGB populations have higher prevalences of mental dis-
orders is unrelated to the classification of homosexuality as a
mental disorder. A retrospective analysis would suggest that the
attempt to find a scientific answer in that debate rested on flawed
logic. The debated scientific question was, Is homosexuality a
mental disorder? The operationalized research question that per-
vaded the debate was, Do homosexuals have high prevalences of
mental disorders? But the research did not accurately operational-
ize the scientific question. The question of whether homosexuality
should be considered a mental disorder is a question about classi-
fication. It can be answered by debating which behaviors, cogni-
tions, or emotions should be considered indicators of a mental
disorder (American Psychiatric Association, 1994). To use post-
modernist understanding of scientific knowledge, such a debate on
classification concerns the social construction of mental disor-
der—what we as a society and as scientists agree are abnormal
behaviors, cognitions, and emotions. The answer, therefore, de-
pends on scientific and social consensus that evolves and is subject
to the vicissitudes of social change (Gergen, 1985, 2001).
This distinction between prevalences of mental disorders and
classification in the DSM was apparent to Marmor (1980), who in
an early discussion of the debate said,
The basic issue . . . is not whether some or many homosexuals can be
found to be neurotically disturbed. In a society like ours where
homosexuals are uniformly treated with disparagement or con-
tempt—to say nothing about outright hostility—it would be surprising
indeed if substantial numbers of them did not suffer from an impaired
self-image and some degree of unhappiness with their stigmatized
status....Itis manifestly unwarranted and inaccurate, however, to
attribute such neuroticism, when it exists, to intrinsic aspects of
homosexuality itself. (p. 400)
If LGB people are indeed at risk for excess mental distress and
disorders due to social stress, it is important to understand this risk,
as well as factors that ameliorate stress and contribute to mental
health. Only with such understanding can psychologists, public
health professionals, and public policymakers work toward design-
ing effective prevention and intervention programs. The relative
silence of psychiatric epidemiological literature regarding the
mental health of LGB populations may have aimed to remove
stigma, but it has been misguided, leading to the neglect of this
Recently, researchers have returned to the study of mental health
of LGB populations. Evidence from this research suggests that
compared with their heterosexual counterparts, gay men and les-
bians suffer from more mental health problems including sub-
stance use disorders, affective disorders, and suicide (Cochran,
2001; Gilman et al., 2001; Herrell et al., 1999; Sandfort, de Graaf,
Bijl, & Schnabel, 2001). Researchers’ preferred explanation for the
cause of the higher prevalence of disorders among LGB people is
that stigma, prejudice, and discrimination create a stressful social
Work on this article was funded by Grant G13LM007660 from the
National Library of Medicine. I thank Drs. Karestan Koenen, Bruce Link,
Gerald Oppenheimer, and Sharon Schwartz for their insightful comments
on an earlier version of this article and Dr. Ken Cheung for statistical
Correspondence concerning this article should be addressed to Ilan H.
Meyer, Department of Sociomedical Sciences, Mailman School of Public
Health, Columbia University, 722 West 168th Street, New York, New
York 10032. E-mail: email@example.com
Psychological Bulletin Copyright 2003 by the American Psychological Association, Inc.
2003, Vol. 129, No. 5, 674– 697 0033-2909/03/$12.00 DOI: 10.1037/0033-2909.129.5.674
environment that can lead to mental health problems in people who
belong to stigmatized minority groups (Friedman, 1999). This
hypothesis can be described in terms of minority stress (Brooks,
1981; Meyer, 1995). In this article I review research evidence on
prevalences of mental disorders and show, using meta-analyses,
that LGB people have higher prevalences of mental disorders than
heterosexual people. I offer a conceptual framework for under-
standing this excess in prevalence of disorder in terms of minority
stress. The model describes stress processes, including the expe-
rience of prejudice events, expectations of rejection, hiding and
concealing, internalized homophobia, and ameliorative coping
processes. This conceptual framework is the basis for a review of
research evidence, suggestions for future research directions, and
exploration of public policy implications.
The Stress Concept
In its most general form, recent stress discourse has been con-
cerned with external events or conditions that are taxing to indi-
viduals and exceed their capacity to endure, therefore having
potential to induce mental or somatic illness (Dohrenwend, 2000).
Stress can be described as “any condition having the potential to
arouse the adaptive machinery of the individual”(Pearlin, 1999a,
p. 163). This general form also reflects the phenomenological
meaning of stress, which refers to physical, mental, or emotional
pressure, strain, or tension (Random House Webster’s Dictionary,
1992). Some have used an engineering analogy, explaining that
stress can be assessed as a load relative to a supportive surface
(Wheaton, 1999). Stress researchers have identified both individ-
ual and social stressors. In psychological literature, stressors are
defined as events and conditions (e.g., losing a job, death of an
intimate) that cause change and that require that the individual
adapt to the new situation or life circumstance. Stress researchers
have studied traumatic events, eventful life stressors, chronic
stress, and role strains, as well as daily hassles and even nonevents
as varied components of stress (Dohrenwend, 1998a).
The concept of social stress extends stress theory by suggesting
that conditions in the social environment, not only personal events,
are sources of stress that may lead to mental and physical ill
effects. Social stress might therefore be expected to have a strong
impact in the lives of people belonging to stigmatized social
categories, including categories related to socioeconomic status,
race/ethnicity, gender, or sexuality. According to these formula-
tions, prejudice and discrimination related to low socioeconomic
status, racism, sexism, or homophobia—much like the changes
precipitated by personal life events that are common to all peo-
ple—can induce changes that require adaptation and can therefore
be conceptualized as stressful (Allison, 1998; Barnett, Biener, &
Baruch, 1987; Clark, Anderson, Clark, & Williams, 1999; Meyer,
1995; Mirowsky & Ross, 1989; Pearlin, 1999b).
The notion that stress is related to social structures and condi-
tions is at once intuitively appealing and conceptually difficult. It
is appealing because it recalls the commonplace experience that
environmental and social conditions can be stressful. Also, it rests
on rich foundations of psychological and sociological theory that
suggest the person must be seen in his or her interactions with the
social environment (Allport, 1954). It is conceptually difficult
because the notion of stress, in particular as conceived of by
Lazarus and Folkman (1984), has focused on personal rather than
social elements (Hobfoll, 1998). I return to the discussion of this
tension between the social and the personal, or objective and
subjective, conceptualizations of stress.
One elaboration of social stress theory may be referred to as
minority stress to distinguish the excess stress to which individuals
from stigmatized social categories are exposed as a result of their
social, often a minority, position. The foundation for a model of
minority stress is not found in one theory, nor is the term minority
stress commonly used. Rather, a minority stress model is inferred
from several sociological and social psychological theories. Rele-
vant theories discuss the adverse effect of social conditions, such
as prejudice and stigma, on the lives of affected individuals and
groups (e.g., Allport, 1954; Crocker, Major, & Steele, 1998;
Goffman, 1963; Jones et al., 1984; Link & Phelan, 2001).
Social theorists have been concerned with the alienation from
social structures, norms, and institutions. For example, the impor-
tance of social environment was central to Durkheim’s (1951)
study of normlessness as a cause of suicide. According to
Durkheim, people need moral regulation from society to manage
their own needs and aspirations. Anomie, a sense of normlessness,
lack of social control, and alienation can lead to suicide because
basic social needs are not met. Pearlin (1982) has emphasized the
relevance of Merton’s (1957/1968) work to stress theory, explain-
ing that “according to Merton, society stands as a stressor . .. by
stimulating values that conflict with the structures in which they
are to be acted upon”(p. 371). The minority person is likely to be
subject to such conflicts because dominant culture, social struc-
tures, and norms do not typically reflect those of the minority
group. An example of such a conflict between dominant and
minority groups is the lack of social institutions akin to hetero-
sexual marriage offering sanction for family life and intimacy of
LGB persons. More generally, Moss (1973) explained that inter-
actions with society provide the individual with information on the
construction of the world; health is compromised when such
information is incongruent with the minority person’s experience
in the world.
Social psychological theories provide a rich ground for under-
standing intergroup relations and the impact of minority position
on health. Social identity and self-categorization theories extend
psychological understanding of intergroup relations and their im-
pact on the self. These theories posit that the process of categori-
zation (e.g., distinction among social groups) triggers important
intergroup processes (e.g., competition and discrimination) and
provides an anchor for group and self-definition (Tajfel & Turner,
1986; Turner, 1999). From a different perspective, social compar-
ison and symbolic interaction theorists view the social environ-
ment as providing people with meaning to their world and orga-
nization to their experiences (Stryker & Statham, 1985).
Interactions with others are therefore crucial for the development
of a sense of self and well-being. Cooley (1902/1922) referred to
the other as the “looking glass”(p. 184) of the self. Symbolic
interaction theories thus suggest that negative regard from others
leads to negative self-regard. Similarly, the basic tenet of social
evaluation theory is that human beings learn about themselves by
comparing themselves with others (Pettigrew, 1967). Both these
theoretical perspectives suggest that negative evaluation by oth-
PREJUDICE, SOCIAL STRESS, AND MENTAL HEALTH
ers—such as stereotypes and prejudice directed at minority per-
sons in society—may lead to adverse psychological outcomes.
Similarly, Allport (1954) described prejudice as a noxious envi-
ronment for the minority person and suggested that it leads to
adverse effects. In discussing these effects, which he called “traits
due to victimizations,”(p. 142) Allport (1954) suggested that the
relationship between negative regard from others and harm to the
minority person is self-evident: “One’s reputation, whether false or
true, cannot be hammered, hammered, hammered, into one’s head
without doing something to one’s character”(p. 142).
Beyond theoretical variations, a unifying concept may emerge
from stress theory. Lazarus and Folkman (1984) described a con-
flict or “mismatch”(p. 234) between the individual and his or her
experience of society as the essence of all social stress, and Pearlin
(1999b) described ambient stressors as those that are associated
with position in society. More generally, Selye (1982) described a
sense of harmony with one’s environment as the basis of healthy
living; deprivation of such a sense of harmony may be considered
the source of minority stress. Certainly, when the individual is a
member of a stigmatized minority group, the disharmony between
the individual and the dominant culture can be onerous and the
resultant stress significant (Allison, 1998; Clark et al., 1999). I
discuss other theoretical orientations that help explain minority
stress below in reviewing specific minority stress processes.
American history is rife with narratives recounting the ill effects
of prejudice toward members of minority groups and of their
struggles to gain freedom and acceptance. That such conditions are
stressful has been suggested regarding various social categories, in
particular for groups defined by race/ethnicity and gender (Barnett
& Baruch, 1987; Mirowsky & Ross, 1989; Pearlin, 1999b; Swim,
Hyers, Cohen, & Ferguson, 2001). The model has also been
applied to groups defined by stigmatizing characteristics, such as
heavyweight people (Miller & Myers, 1998), people with stigma-
tizing physical illnesses such as AIDS and cancer (Fife & Wright,
2000), and people who have taken on stigmatizing marks such as
body piercing (Jetten, Branscombe, Schmitt, & Spears, 2001). Yet,
it is only recently that psychological theory has incorporated these
experiences into stress discourse explicitly (Allison, 1998; Miller
& Major, 2000). There has been increased interest in the minority
stress model, for example, as it applies to the social environment
of Blacks in the United States and their experience of stress related
to racism (Allison, 1998; Clark et al., 1999).
In developing the concept of minority stress, researchers’un-
derlying assumptions have been that minority stress is (a)
unique—that is, minority stress is additive to general stressors that
are experienced by all people, and therefore, stigmatized people
are required an adaptation effort above that required of similar
others who are not stigmatized; (b) chronic—that is, minority
stress is related to relatively stable underlying social and cultural
structures; and (c) socially based—that is, it stems from social
processes, institutions, and structures beyond the individual rather
than individual events or conditions that characterize general stres-
sors or biological, genetic, or other nonsocial characteristics of the
person or the group.
Reviewing the literature on stress and identity, Thoits (1999)
called the investigation of stressors related to minority identities a
“crucial next step”(p. 361) in the study of identity and stress.
Applied to lesbians, gay men, and bisexuals, a minority stress
model posits that sexual prejudice (Herek, 2000) is stressful and
may lead to adverse mental health outcomes (Brooks, 1981; Coch-
ran, 2001; DiPlacido, 1998; Krieger & Sidney, 1997; Mays &
Cochran, 2001; Meyer, 1995).
Minority Stress Processes in LGB Populations
There is no consensus about specific stress processes that affect
LGB people, but psychological theory, stress literature, and re-
search on the health of LGB populations provide some ideas for
articulating a minority stress model. I suggest a distal–proximal
distinction because it relies on stress conceptualizations that seem
most relevant to minority stress and because of its concern with the
impact of external social conditions and structures on individuals.
Lazarus and Folkman (1984) described social structures as “distal
concepts whose effects on an individual depend on how they are
manifested in the immediate context of thought, feeling, and
action—the proximal social experiences of a person’s life”(p.
321). Distal social attitudes gain psychological importance through
cognitive appraisal and become proximal concepts with psycho-
logical importance to the individual. Crocker et al. (1998) made a
similar distinction between objective reality, which includes prej-
udice and discrimination, and “states of mind that the experience
of stigma may create in the stigmatized”(p. 516). They noted that
“states of mind have their grounding in the realities of stereotypes,
prejudice, and discrimination”(Crocker et al., 1998, p. 516), again
echoing Lazarus and Folkman’s conceptualization of the proximal,
subjective appraisal as a manifestation of distal, objective envi-
ronmental conditions. I describe minority stress processes along a
continuum from distal stressors, which are typically defined as
objective events and conditions, to proximal personal processes,
which are by definition subjective because they rely on individual
perceptions and appraisals.
I have previously suggested three processes of minority stress
relevant to LGB individuals (Meyer, 1995; Meyer & Dean, 1998).
From the distal to the proximal they are (a) external, objective
stressful events and conditions (chronic and acute), (b) expecta-
tions of such events and the vigilance this expectation requires, and
(c) the internalization of negative societal attitudes. Other work, in
particular psychological research in the area of disclosure, has
suggested that at least one more stress process is important: con-
cealment of one’s sexual orientation. Hiding of sexual orientation
can be seen as a proximal stressor because its stress effect is
thought to come about through internal psychological (including
psychoneuroimmunological) processes (Cole, Kemeny, Taylor, &
Visscher, 1996a, 1996b; DiPlacido, 1998; Jourard, 1971; Penne-
Distal minority stressors can be defined as objective stressors in
that they do not depend on an individual’s perceptions or apprais-
als—although certainly their report depends on perception and
attribution (Kobrynowicz & Branscombe, 1997; Operario & Fiske,
2001). As objective stressors, distal stressors can be seen as
independent of personal identification with the assigned minority
status (Diamond, 2000). For example, a woman may have a
romantic relationship with another woman but not identify as a
lesbian (Laumann, Gagnon, Michael, & Michaels, 1994). Never-
theless, if she is perceived as a lesbian by others, she may suffer
from stressors associated with prejudice toward LGB people (e.g.,
antigay violence). In contrast, the more proximal stress processes
are more subjective and are therefore related to self-identity as
lesbian, gay, or bisexual. Such identities vary in the social and
personal meanings that are attached to them and in the subjective
stress they entail. Minority identity is linked to a variety of stress
processes; some LGB people, for example, may be vigilant in
interactions with others (expectations of rejection), hide their iden-
tity for fear of harm (concealment), or internalize stigma (inter-
As early as 1954, Allport suggested that minority members
respond to prejudice with coping and resilience. Modern writers
have agreed that positive coping is common and beneficial to
members of minority groups (Clark et al., 1999). Therefore, mi-
nority status is associated not only with stress but with important
resources such as group solidarity and cohesiveness that protect
minority members from the adverse mental health effects of mi-
nority stress (Branscombe, Schmitt, & Harvey, 1999; Clark et al.,
1999; Crocker & Major, 1989; Kessler, Price, & Wortman, 1985;
Miller & Major, 2000; Postmes & Branscombe, 2002; Shade,
1990). Empirical evidence supports these contentions. For exam-
ple, in a study of Black participants Branscombe, Schmitt, and
Harvey (1999) found that attributions of prejudice were directly
related to negative well-being and hostility toward Whites but also,
through the mediating role of enhanced in-group identity, to pos-
itive well-being. In a separate study, Postmes and Branscombe
(2002) found that among Blacks, a racially segregated environ-
ment contributed to greater in-group acceptance and improved
well-being and life satisfaction.
The importance of coping with stigma has also been asserted in
LGB populations. Weinberg and Williams (1974) noted that “oc-
cupying a ‘deviant status’need not necessarily intrude upon [gay
men’s] day-to-day functioning”(p. 150) and urged scientists to
“pay more attention to the human capacity for adaptation”(p. 151).
Through coming out, LGB people learn to cope with and overcome
the adverse effects of stress (Morris, Waldo, & Rothblum, 2001).
Thus, stress and resilience interact in predicting mental disorder.
LGB people counteract minority stress by establishing alternative
structures and values that enhance their group (Crocker & Major,
1989; D’Emilio, 1983). In a similar vein, Garnets, Herek, and Levy
(1990) suggested that although antigay violence creates a crisis
with potential adverse mental health outcomes, it also presents
“opportunities for subsequent growth”(p. 367). Among gay men,
personal acceptance of one’s gay identity and talking to family
members about AIDS showed the strongest positive associations
with concurrent measures of support and changes in support sat-
isfaction (Kertzner, 2001). Similarly, in a study of LGB adoles-
cents, family support and self-acceptance ameliorated the negative
effect of antigay abuse on mental health outcomes (Hershberger &
A distinction between personal and group resources is often not
addressed in the coping literature. It is important to distinguish
between resources that operate on the individual level (e.g., per-
sonality), in which members of minority groups vary, and re-
sources that operate on a group level and are available to all
minority members (Branscombe & Ellemers, 1998). Like other
individuals who cope with general stress, LGB people use a range
of personal coping mechanisms, resilience, and hardiness to with-
stand stressful experiences (Antonovsky, 1987; Masten, 2001;
Ouellette, 1993). But in addition to such personal coping, group-
level social structural factors can have mental health benefits
(Peterson, Folkman, & Bakeman, 1996). Jones et al. (1984) de-
scribed two functions of coping achieved through minority group
affiliations: to allow stigmatized persons to experience social
environments in which they are not stigmatized by others and to
provide support for negative evaluation of the stigmatized minority
group. Social evaluation theory suggests another plausible mech-
anism for minority coping (Pettigrew, 1967). Members of stigma-
tized groups who have a strong sense of community cohesiveness
evaluate themselves in comparison with others who are like them
rather than with members of the dominant culture. The in-group
may provide a reappraisal of the stressful condition, yielding it less
injurious to psychological well-being. Through reappraisal, the
in-group validates deviant experiences and feelings of minority
persons (Thoits, 1985). Indeed, reappraisal is at the core of gay-
affirmative, Black, and feminist psychotherapies that aim to em-
power the minority person (Garnets & Kimmel, 1991; hooks,
1993; Shade, 1990; Smith & Siegel, 1985).
The distinction between personal and group-level coping may
be somewhat complicated because even group-level resources
(e.g., services of a gay-affirmative church) need to be accessed and
used by individuals. Whether individuals can access and use
group-level resources depends on many factors, including person-
ality variables. Nevertheless, it is important to distinguish between
group-level and personal resources because when group-level re-
sources are absent, even otherwise-resourceful individuals have
deficient coping. Group-level resources may therefore define the
boundaries of individual coping efforts. Thus, minority coping
may be conceptualized as a group-level resource, related to the
group’s ability to mount self-enhancing structures to counteract
stigma. This formulation highlights the degree to which minority
members may be able to adopt some of the group’s self-enhancing
attitudes, values, and structures rather than the degree to which
individuals vary in their personal coping abilities. Using this
distinction, it is conceivable that an individual may have efficient
personal coping resources but lack minority-coping resources. For
example, a lesbian or gay member of the U.S. Armed Forces,
where a “don’t ask, don’t tell”policy discourages affiliation and
attachments with other LGB persons, may be unable to access and
use group-level resources and therefore be vulnerable to adverse
health outcomes, regardless of his or her personal coping abilities.
Finally, it is important to note that coping can also have a stressful
impact (Miller & Major, 2000). For example, concealing one’s
stigma is a common way of coping with stigma and avoiding
negative regard, yet it takes a heavy toll on the person using this
coping strategy (Smart & Wegner, 2000).
Stress and Identity
Characteristics of minority identity—for example, the promi-
nence of minority identity in the person’s sense of self—may also
be related to minority stress and its impact on health outcomes.
Group identities are essential for individual emotional functioning,
as they address conflicting needs for individuation and affiliation
(Brewer, 1991). Characteristics of identity may be related to men-
tal health both directly and in interaction with stressors. A direct
effect suggests that identity characteristics can cause distress. For
example, Burke (1991) said that feedback from others that is
PREJUDICE, SOCIAL STRESS, AND MENTAL HEALTH
incompatible with one’s self-identity—a process he called identity
interruptions—can cause distress. An interactive effect with stress
suggests that characteristics of identity would modify the effect of
stress on health outcomes. For example, Linville (1987) found that
participants with more complex self-identities were less prone to
depression in the face of stress. Thoits (1999) explained, “Since
people’s self conceptions are closely linked to their psychological
states, stressors that damage or threaten self concepts are likely to
predict emotional problems”(p. 346). On the other hand, as
described above, minority identity may also lead to stronger affil-
iations with one’s community, which may in turn aid in buffering
the impact of stress (Branscombe, Schmitt, & Harvey, 1999;
Brown, Sellers, Brown, & Jackson, 1999; Crocker & Major, 1989).
Prominence (or salience), valence, and level of integration with
the individual’s other identities may be relevant to stress (Deaux,
1993; Rosenberg & Gara, 1985; Thoits, 1991, 1999). Prominence
of identity may exacerbate stress because “the more an individual
identifies with, is committed to, or has highly developed self-
schemas in a particular life domain, the greater will be the emo-
tional impact of stressors that occur in that domain”(Thoits, 1999,
p. 352). In coming out models, and in some models of racial
identity, there has been a tendency to see minority identity as
prominent and ignore other personal and social identities (Cross,
1995; de Monteflores & Schultz, 1978; Eliason, 1996). However
minority identities, which may seem prominent to observers, are
often not endorsed as prominent by minority group members
themselves, leading to variability in identity hierarchies of minor-
ity persons (Massey & Ouellette, 1996). For example, Brooks
(1981) noted that the stress process for lesbians is complex be-
cause it involves both sexual and gender identities. LGB members
of racial/ethnic minorities also need to manage diverse identities.
Research on Black and Latino LGB individuals has shown that
they often confront homophobia in their racial/ethnic communities
and alienation from their racial/ethnic identity in the LGB com-
munity (Diaz, Ayala, Bein, Jenne, & Marin, 2001; Espin, 1993;
Loiacano, 1993). Rather than view identity as stable, researchers
now view identity structures as fluid, with prominence of identity
often shifting with social context (Brewer, 1991; Crocker &
Quinn, 2000; Deaux & Ethier, 1998).
Valence refers to the evaluative features of identity and is tied to
self-validation. Negative valence has been described as a good
predictor of mental health problems, with an inverse relationship to
depression (Allen, Woolfolk, Gara, & Apter, 1999; Woolfolk,
Novalany, Gara, Allen, & Polino, 1995). Identity valence is a
central feature of coming out models, which commonly describe
progress as improvement in self-acceptance and diminishment of
internalized homophobia. Thus, overcoming negative self-
evaluation is the primary aim of the LGB person’s development in
coming out and is a central theme of gay-affirmative therapies
(Coleman, 1981–1982; Diaz et al., 2001; Loiacano, 1993; Malyon,
1981–1982; Meyer & Dean, 1998; Rotheram-Borus & Fernandez,
1995; Troiden, 1989).
Finally, more complex identity structures may be related to
improved health outcomes. Distinct identities are interrelated
through a hierarchal organization (Linville, 1987; Rosenberg &
Gara, 1985). In coming out models, integration of the minority
identity with the person’s other identities is seen as the optimal
stage related to self-acceptance. For example, Cass (1979) saw the
last stage of coming out as an identity synthesis, wherein the gay
identity becomes merely one part of this integrated total identity.
In a optimal identity development, various aspects of the person’s
self, including but not limited to other minority identities such as
those based on gender or race/ethnicity, are integrated (Eliason,
Summary: A Minority Stress Model
Using the distal–proximal distinction, I propose a minority
stress model that incorporates the elements discussed above. In
developing the model I have emulated Dohrenwend’s (1998b,
2000) stress model to highlight minority stress processes. Dohren-
wend (1998b, 2000) described the stress process within the context
of strengths and vulnerabilities in the larger environment and
within the individual. For the purpose of succinctness, I include in
my discussion only those elements of the stress process unique to
or necessary for the description of minority stress. It is important
to note, however, that these omitted elements—including advan-
tages and disadvantages in the wider environment, personal pre-
dispositions, biological background, ongoing situations, and ap-
praisal and coping—are integral parts of the stress model and are
essential for a comprehensive understanding of the stress process
(Dohrenwend, 1998b, 2000).
The model (Figure 1) depicts stress and coping and their impact
on mental health outcomes (box i). Minority stress is situated
within general environmental circumstances (box a), which may
include advantages and disadvantages related to factors such as
socioeconomic status. An important aspect of these circumstances
in the environment is the person’s minority status, for example
being gay or lesbian (box b). These are depicted as overlapping
boxes in the figure to indicate close relationship to other circum-
stances in the person’s environment. For example, minority stres-
sors for a gay man who is poor would undoubtedly be related to his
poverty; together these characteristics would determine his expo-
sure to stress and coping resources (Diaz et al., 2001). Circum-
stances in the environment lead to exposure to stressors, including
general stressors, such as a job loss or death of an intimate (box c),
and minority stressors unique to minority group members, such as
discrimination in employment (box d). Similar to their source
circumstances, the stressors are depicted as overlapping as well,
representing their interdependency (Pearlin, 1999b). For example,
an experience of antigay violence (box d) is likely to increase
vigilance and expectations of rejection (box f). Often, minority
status leads to personal identification with one’s minority status
(box e). In turn, such minority identity leads to additional stressors
related to the individual’s perception of the self as a stigmatized
and devalued minority (Miller & Major, 2000). Because they
involve self-perceptions and appraisals, these minority stress pro-
cesses are more proximal to the individual, including, as described
above for LGB individuals, expectations of rejection, concealment,
and internalized homophobia (box f).
Of course, minority identity is not only a source of stress but
also an important effect modifier in the stress process. First,
characteristics of minority identity can augment or weaken the
impact of stress (box g). For example, minority stressors may have
a greater impact on health outcomes when the LGB identity is
prominent than when it is secondary to the person’s self-definition
(Thoits, 1999). Second, LGB identity may also be a source of
strength (box h) when it is associated with opportunities for
affiliation, social support, and coping that can ameliorate the
impact of stress (Branscombe, Schmitt, & Harvey, 1999; Crocker
& Major, 1989; Miller & Major, 2000).
Empirical Evidence for Minority Stress in LGB
In exploring evidence for minority stress two methodological
approaches can be discerned: studies that examined within-group
processes and their impact on mental health and studies that
compared differences between minority and nonminority groups in
prevalence of mental disorders. Studies of within-group processes
shed light on stress processes, such as those depicted in Figure 1,
by explicitly examining them and describing variability in their
impact on mental health outcomes among minority group mem-
bers. For example, such studies may describe whether LGB people
who have experienced antigay discrimination suffer greater ad-
verse mental health impact than LGB people who have not expe-
rienced such stress (Herek, Gillis, & Cogan, 1999). Studies of
between-groups differences test whether minority individuals are
at greater risk for disease than nonminority individuals; that is,
whether LGB individuals have higher prevalences of disorders
than heterosexual individuals. On the basis of minority stress
formulations one can hypothesize that LGB people would have
higher prevalences of disorders because the putative excess in
exposure to stress would cause an increase in prevalence of any
disorder that is affected by stress (Dohrenwend, 2000). Typically,
in studying between-groups differences, only the exposure (minor-
ity status) and outcomes (prevalences of disorders) are assessed;
minority stress processes that would have led to the elevation in
prevalences of disorders are inferred but unexamined. Thus,
within-group evidence illuminates the workings of minority stress
processes; between-groups evidence shows the hypothesized re-
sultant difference in prevalence of disorder. Ideally, evidence from
both types of studies would converge.
Research Evidence: Within-Group Studies of Minority
Within-group studies have attempted to address questions about
causes of mental distress and disorder by assessing variability in
predictors of mental health outcomes among LGB people. These
studies have identified minority stress processes and often dem-
onstrated that the greater the level of such stress, the greater the
impact on mental health problems. Such studies have shown, for
example, that stigma leads LGB persons to experience alienation,
lack of integration with the community, and problems with self-
acceptance (Frable, Wortman, & Joseph, 1997; Greenberg, 1973;
Grossman & Kerner, 1998; Malyon, 1981–1982; Massey & Ouel-
lette, 1996; Stokes & Peterson, 1998). Within-group studies have
typically measured mental health outcomes using psychological
scales (e.g., depressive symptoms) rather than the criteria-based
mental disorders (e.g., major depressive disorder). These studies
have concluded that minority stress processes are related to an
array of mental health problems including depressive symptoms,
substance use, and suicide ideation (Cochran & Mays, 1994;
Figure 1. Minority stress processes in lesbian, gay, and bisexual populations.
PREJUDICE, SOCIAL STRESS, AND MENTAL HEALTH
D’Augelli & Hershberger, 1993; Diaz et al., 2001; Meyer, 1995;
Rosario, Rotheram-Borus, & Reid, 1996; Waldo, 1999). In review-
ing this evidence in greater detail I arrange the findings as they
relate to the stress processes introduced in the conceptual frame-
work above. As has already been noted, this synthesis is not meant
to suggest that the studies reviewed below stemmed from or
referred to this conceptual model; most did not.
Prejudice events. Similar to research with African Americans
and other ethnic minority groups (Kessler, Mickelson, & Williams,
1999), researchers have described antigay violence and discrimi-
nation as core stressors affecting gay and lesbian populations
(Garnets et al., 1990; Herek & Berrill, 1992; Herek, Gillis, &
Cogan, 1999; Kertzner, 1999). Antigay prejudice has been perpe-
trated throughout history: Institutionalized forms of prejudice,
discrimination, and violence have ranged from Nazi extermination
of homosexuals to enforcement of sodomy laws punishable by
imprisonment, castration, torture, and death (Adam, 1987). With
the formation of a gay community, as LGB individuals became
more visible and more readily identifiable by potential perpetra-
tors, they increasingly became targets of antigay violence and
discrimination (Badgett, 1995; Herek & Berrill, 1992; Human
Rights Watch, 2001; Safe Schools Coalition of Washington, 1999).
In 2001, Amnesty International reported that lesbian, gay, bisex-
ual, and transgender (LGBT) people are subject to widespread
human rights abuses, torture, and ill treatment, ranging from loss
of dignity to assault and murder. Many of these abuses are con-
ducted with impunity and sanctioned by governments and societies
through formal mechanisms such as discriminatory laws and in-
formal mechanisms, including prejudice and religious traditions
(Amnesty International, 2001).
Surveys have documented that lesbians and gay men are dis-
proportionately exposed to prejudice events, including discrimina-
tion and violence. For example, in a probability study of U.S.
adults, LGB people were twice as likely as heterosexual people to
have experienced a life event related to prejudice, such as being
fired from a job (Mays & Cochran, 2001). In a study of LGB adults
in Sacramento, CA, approximately 1/5 of the women and 1/4 of the
men experienced victimization (including sexual assault, physical
assault, robbery, and property crime) related to their sexual orien-
tation (Herek et al., 1999). Some research has suggested variation
by ethnic background as well, although the direction of the find-
ings is not clear. For instance, among urban adults aged 25 to 37
who reported having same-sex sexual partners, Krieger and Sidney
(1997) found that 1/2 of Whites compared with 1/3 of Blacks
reported discrimination based on sexual orientation. On the other
hand, in a study of HIV-positive gay men in New York City,
Siegel and Epstein (1996) found that African American and Puerto
Rican men had significantly more gay-related minority stressors
than Caucasian men.
Research has suggested that LGB youth are even more likely
than adults to be victimized by antigay prejudice events, and the
psychological consequences of their victimization may be more
severe. Surveys of schools in several regions of the United States
showed that LGB youth are exposed to more discrimination and
violence events than their heterosexual peers. Several such studies,
conducted on population samples of high school students, con-
verge in their findings and show that the social environment of
sexual minority youth in U.S. high schools is characterized by
discrimination, rejection, and violence (Faulkner & Cranston,
1998; Garofalo, Wolf, Kessel, Palfrey, & DuRant, 1998). Com-
pared with heterosexual youth, LGB youth are at increased risk for
being threatened and assaulted, are more fearful for their safety at
school, and miss school days because of this fear (Safe Schools
Coalition of Washington, 1999). For example, in a random sample
of Massachusetts high schools students, LGB students more often
than heterosexual students had property stolen or deliberately
damaged (7% vs. 1%), were threatened or injured with a weapon
(6% vs.1%), and were in physical fight requiring medical treat-
ment (6% vs. 2%; Safe Schools Coalition of Washington, 1999). A
national survey of LGBT youth conducted by the advocacy orga-
nization Gay, Lesbian, and Straight Education Network (GLSEN;
1999) reported that those surveyed experienced verbal harassment
(61%), sexual harassment (47%), physical harassment (28%), and
physical assault (14%). The overwhelming majority of LGBT
youth (90%) sometimes or frequently heard homophobic remarks
at their schools, with many (37%) reporting hearing these remarks
from faculty or school staff (GLSEN, 1999).
Gay men and lesbians are also discriminated against in the
workplace. Waldo (1999) demonstrated a relationship between
employers’organizational climate and the experience of hetero-
sexism in the workplace, which was subsequently related to ad-
verse psychological, health, and job-related outcomes in LGB
employees. Badget’s (1995) analysis of national data showed that
gay and bisexual male workers earned from 11% to 27% less than
heterosexual male workers with the same experience, education,
occupation, marital status, and region of residence.
Garnets et al. (1990) described psychological mechanisms that
could explain the association between victimization and psycho-
logical distress. The authors noted that victimization interferes
with perception of the world as meaningful and orderly. In an
attempt to restore order to their perception of the world, survivors
ask “Why me?”and often respond with self-recrimination and
self-devaluation. More generally, experiences of victimization take
away the victim’s sense of security and invulnerability. Health
symptoms of victimization include “sleep disturbances and night-
mares, headaches, diarrhea, uncontrollable crying, agitation and
restlessness, increased use of drugs, and deterioration in personal
relationship”(Garnets et al., 1990, p. 367). Antigay bias crimes
had greater mental health impact on LGB persons than similar
crime not related to bias, and bias-crime victimization may have
short- or long-term consequences, including severe reactions such
as posttraumatic stress disorder (Herek et al., 1999; McDevitt,
Balboni, Garcia, & Gu, 2001).
Stigma: Expectations of rejection and discrimination. Goff-
man (1963) discussed the anxiety with which the stigmatized
individual approaches interactions in society. Such an individual
“may perceive, usually quite correctly, that whatever others pro-
fess, they do not really ‘accept’him and are not ready to make
contact with him on ‘equal grounds’” (Goffman, 1963, p. 7).
Allport (1954) described vigilance as one of the traits that targets
of prejudice develop in defensive coping. This concept helps to
explain the stressful effect of stigma. Like other minority group
members, LGB people learn to anticipate—indeed, expect—neg-
ative regard from members of the dominant culture. To ward off
potential negative regard, discrimination, and violence they must
maintain vigilance. The greater one’s perceived stigma, the greater
the need for vigilance in interactions with dominant group mem-
bers. By definition such vigilance is chronic in that it is repeatedly
and continually evoked in the everyday life of the minority person.
Crocker et al. (1998) described this as the “need to be constantly
‘on guard’. . . alert, or mindful of the possibility that the other
person is prejudiced”(p. 517). Jones et al. (1984) described the
effect of societal stigma on the stigmatized individual as creating
a conflict between self-perceptions and others-perceptions. As a
result of this conflict, self-perception is likely to be at least
somewhat unstable and vulnerable. Maintaining stability and co-
herence in self-concept is likely to require considerable energy and
This exertion of energy in maintaining one’s self-concept is
stressful, and would increase as perceptions of others’stigmatiza-
tion increase. Branscombe, Ellemers, Spears, and Doosje (1999)
described four sources of threat relevant to the discussion of stress
due to stigma. Categorization threat involves threat that a person
will be categorized by others as a member of a group against his
or her will, especially when group membership is irrelevant within
the particular context (e.g., categorization as a woman when ap-
plying for a business loan). Distinctiveness threat is an opposite
threat, relating to denial of distinct group membership when it is
relevant or significant (also Brewer, 1991). Threats to the value of
social identity involves undermining of the minority group’s val-
ues, such as its competence and morality. A fourth threat, threat to
acceptance, emerges from negative feedback from one’s in-group
and the consequent threat rejection by the group. For example,
Ethier and Deaux (1994) found that Hispanic American students at
an Ivy League university were conflicted, divided between iden-
tification with White friends and culture and the desire to maintain
an ethnic cultural identity.
Research evidence on the impact of stigma on health, psycho-
logical, and social functioning comes from a variety of sources.
Link (1987; Link, Struening, Rahav, Phelan, & Nuttbrock, 1997)
showed that in mentally ill individuals, perceived stigma was
related to adverse effects in mental health and social functioning.
In a cross-cultural study of gay men, Ross (1985) found that
anticipated social rejection was more predictive of psychological
distress outcomes than actual negative experiences. However, re-
search on the impact of stigma on self-esteem, a main focus of
social psychological research, has not consistently supported this
theoretical perspective; such research often fails to show that
members of stigmatized groups have lower self-esteem than others
(Crocker & Major, 1989; Crocker et al., 1998; Crocker & Quinn,
2000). One explanation for this finding is that along with its
negative impact, stigma has self-protective properties related to
group affiliation and support that ameliorate the effect of stigma
(Crocker & Major, 1989). This finding is not consistent across
various ethnic groups: Although Blacks have scored higher than
Whites on measures of self-esteem, other ethnic minorities have
scored lower than Whites (Twenge & Crocker, 2002).
Experimental social psychological research has highlighted
other processes that can lead to adverse outcomes. This research
may be classified as somewhat different from that related to the
vigilance concept discussed above. Vigilance is related to feared
possible (even if imagined) negative events and may therefore be
classified as more distal along the continuum ranging from the
environment to the self. Stigma threat, as described below, relates
to internal processes that are more proximal to the self. This
research has shown that expectations of stigma can impair social
and academic functioning of stigmatized persons by affecting their
performance (Crocker et al., 1998; Farina, Allen, & Saul, 1968;
Pinel, 2002; Steele, 1997; Steele & Aronson, 1995). For example,
Steele (1997) described stereotype threat as the “social–
psychological threat that arises when one is in a situation or doing
something for which a negative stereotype about one’s group
applies”(p. 614) and showed that the emotional reaction to this
threat can interfere with intellectual performance. When situations
of stereotype threat are prolonged they can lead to “disidentifica-
tion,”whereby a member of a stigmatized group removes a domain
that is negatively stereotyped (e.g., academic success) from his or
her self-definition. Such disidentification with a goal undermines
the person’s motivation—and therefore, effort—to achieve in this
domain. Unlike the concept of life events, which holds that stress
stems from some concrete offense (e.g., antigay violence), here it
is not necessary that any prejudice event has actually occurred. As
Crocker (1999) noted, because of the chronic exposure to a stig-
matizing social environment, “the consequences of stigma do not
require that a stigmatizer in the situation holds negative stereo-
types or discriminates”(p. 103); as Steele (1997) described it, for
the stigmatized person there is “a threat in the air”(p. 613).
Concealment versus disclosure. Another area of research on
stigma, moving more proximally to the self, concerns the effect of
concealing one’s stigmatizing attribute. Paradoxically, concealing
one’s stigma is often used as a coping strategy, aimed at avoiding
negative consequences of stigma, but it is a coping strategy that
can backfire and become stressful (Miller & Major, 2000). In a
study of women who felt stigmatized by abortion, Major and
Gramzow (1999) demonstrated that concealment was related to
suppressing thoughts about the abortion, which led to intrusive
thoughts about it, and resulted in psychological distress. Smart and
Wegner (2000) described the cost of hiding one’s stigma in terms
of the resultant cognitive burden involved in the constant preoc-
cupation with hiding. They described complex cognitive pro-
cesses, both conscious and unconscious, that are necessary to
maintain secrecy regarding one’s stigma, and called the inner
experience of the person who is hiding a concealable stigma a
“private hell”(p. 229).
LGB people may conceal their sexual orientation in an effort to
either protect themselves from real harm (e.g., being attacked,
getting fired from a job) or out of shame and guilt (D’Augelli &
Grossman, 2001). Concealment of one’s homosexuality is an im-
portant source of stress for gay men and lesbians (DiPlacido,
1998). Hetrick and Martin (1987) described learning to hide as the
most common coping strategy of gay and lesbian adolescents, and
individuals in such a position must constantly monitor their behavior
in all circumstances: how one dresses, speaks, walks, and talks be-
come constant sources of possible discovery. One must limit one’s
friends, one’s interests, and one’s expression, for fear that one might
be found guilty by association....Theindividual who must hide of
necessity learns to interact on the basis of deceit governed by fear of
discovery....Each successive act of deception, each moment of
monitoring which is unconscious and automatic for others, serves to
reinforce the belief in one’s difference and inferiority. (pp. 35–36)
Hiding and fear of being identified do not end with adolescence.
For example, studies of the workplace experience of LGB people
found that fear of discrimination and concealment of sexual ori-
entation are prevalent (Croteau, 1996) and that they have adverse
PREJUDICE, SOCIAL STRESS, AND MENTAL HEALTH
psychological, health, and job-related outcomes (Waldo, 1999).
These studies showed that LGB people engage in identity disclo-
sure and concealment strategies that address fear of discrimination
on one hand and a need for self-integrity on the other. These
strategies range from passing, which involves lying to be seen as
heterosexual; covering, which involves censoring clues about
one’s self so that LGB identity is concealed; being implicitly out,
which involves telling the truth without using explicit language
that discloses one’s sexual identity; and being explicitly out (Grif-
fin, 1992, as cited in Croteau, 1996).
Another source of evidence comes from psychological research
that has shown that expressing emotions and sharing important
aspects of one’s self with others—through confessions and disclo-
sures involved in interpersonal or therapeutic relationships, for
example—are important factors in maintaining physical and men-
tal health (Pennebaker, 1995). Studies have shown that suppres-
sion, such as hiding secrets, is related to adverse health outcomes
and that expressing and disclosing traumatic events or character-
istics of the self improve health by reducing anxiety and promoting
assimilation of the revealed characteristics (Bucci, 1995; Stiles,
1995). In one class of studies, investigators have shown that
repression and inhibition affect immune functions and health out-
comes, whereas expression of emotions, such as writing about
traumatic experiences, produces improvement in immune func-
tions, decreases in physician visits, and reduced symptoms for
diseases such as asthma and arthritis (Petrie, Booth, & Davison,
1995; Smyth, Stone, Hurewitz, & Kaell, 1999). Research evidence
in gay men supports these formulations. Cole and colleagues found
that HIV infection advanced more rapidly among gay men who
concealed their sexual orientation than those who were open about
their sexual orientation (Cole et al., 1996a). In another study
among HIV-negative gay men, those who concealed their sexual
orientation were more likely to have health problems than those
who were open about their sexual orientation (Cole et al., 1996b)
In addition to suppressed emotions, concealment prevents
LGB people from identifying and affiliating with others who
are gay. Psychological literature has demonstrated the positive
impact of affiliation with other similarly stigmatized persons on
self-esteem (Crocker & Major, 1989; Jones et al., 1984; Post-
mes & Branscombe, 2002). This effect has been demonstrated
by Frable, Platt, and Hoey (1998) in day-to-day interactions.
The researchers assessed self-perceptions and well-being in the
context of the immediate social environment. College students
with concealable stigmas, such as homosexuality, felt better
about themselves when they were in an environment with others
who were like them than when they were with others who are
not similarly stigmatized. In addition, if LGB people conceal
their sexual orientation, they are not likely to access formal and
informal support resources in the LGB community. Thus, in
concealing their sexual orientation LGB people suffer from the
health-impairing properties of concealment and lose the ame-
liorative self-protective effects of being “out.”
Internalized homophobia. In the most proximal position along
the continuum from the environment to the self, internalized ho-
mophobia represents a form of stress that is internal and insidious.
In the absence of overt negative events, and even if one’s minority
status is successfully concealed, lesbians and gay men may be
harmed by directing negative social values toward the self. Thoits
(1985, p. 222) described such a process of self-stigmatization,
explaining that “role-taking abilities enable individuals to view
themselves from the imagined perspective of others. One can
anticipate and respond in advance to others’reactions regarding a
contemplated course of action.”
Clinicians use the term internalized homophobia to refer to the
internalization of societal antigay attitudes in lesbians and gay men
(e.g., Malyon, 1981–1982). Meyer and Dean (1998) defined inter-
nalized homophobia as “the gay person’s direction of negative
social attitudes toward the self, leading to a devaluation of the self
and resultant internal conflicts and poor self-regard”(p. 161).
After they accept their stigmatized sexual orientation, LGB people
begin a process of coming out. Optimally, through this process
they come to terms with their homosexuality and develop a healthy
identity that incorporates their sexuality (Cass, 1979, 1984;
Coleman, 1981–1982; Troiden, 1989). Internalized homophobia
signifies the failure of the coming out process to ward off stigma
and thoroughly overcome negative self-perceptions and attitudes
(Morris et al., 2001). Although it is most acute early in the coming
out process, it is unlikely that internalized homophobia completely
abates even when the person has accepted his or her homosexu-
ality. Because of the strength of early socialization experiences,
and because of continued exposure to antigay attitudes, internal-
ized homophobia remains an important factor in the gay person’s
psychological adjustment throughout life. Gay people maintain
varying degrees of residual antigay attitudes that are integrated
into their self-perception that can lead to mental health problems
(Cabaj, 1988; Hetrick & Martin, 1984; Malyon, 1981–1982; Nun-
gesser, 1983). Gonsiorek (1988) called such residual internalized
homophobia “covert,”and said, “Covert forms of internalized
homophobia are the most common. Affected individuals appear to
accept themselves, yet sabotage their own efforts in a variety of
Williamson (2000) reviewed the literature on internalized ho-
mophobia and described the wide use of the term in gay and
lesbian studies and gay-affirmative psychotherapeutic models. He
noted the intuitive appeal of internalized homophobia to “almost
all gay men and lesbians”(Williamson, 2000, p. 98). Much of the
literature on internalized homophobia has come from theoretical
writings and clinical observations, but some research has been
published. Despite significant challenges to measuring internalized
homophobia and lack of consistency in its conceptualization and
measurement (Mayfield, 2001; Ross & Rosser, 1996; Shidlo,
1994; Szymanski & Chung, 2001), research has shown that inter-
nalized homophobia is a significant correlate of mental health
including depression and anxiety symptoms, substance use disor-
ders, and suicide ideation (DiPlacido, 1998; Meyer & Dean, 1998;
Williamson, 2000). Research has also suggested a relationship
between internalized homophobia and various forms of self-harm,
including eating disorders (Williamson, 2000) and HIV-risk-taking
behaviors (Meyer & Dean, 1998), although Shidlo (1994) failed to
show this relationship. Nicholson and Long (1990) showed that
internalized homophobia was related to self-blame and poor cop-
ing in the face of HIV infection/AIDS. Other research showed that
internalized homophobia was related to difficulties with intimate
relationships and sexual functioning (Dupras, 1994; Meyer &
Dean, 1998; Rosser, Metz, Bockting, & Buroker, 1997).
Research Evidence: Between-Groups Studies of
Prevalence of Mental Disorder
Despite a long history of interest in the prevalence of mental
disorders among gay men and lesbians, methodologically sound
epidemiological studies are rare. The interest in mental health of
lesbians and gay men has been clouded by shifts in the social
environment within which it was embedded. Before the 1973
declassification of homosexuality as a mental disorder, gay-
affirmative psychologists and psychiatrists sought to refute argu-
ments that homosexuality should remain a classified disorder by
showing that homosexuals were not more likely to be mentally ill
than heterosexuals (Bayer, 1981). At the time, some writers in-
sisted that homosexuals were more likely than heterosexuals to be
ill and that this demonstrated that homosexuality should be clas-
sified as a mental disorder, but many of these studies were based
on biased samples, for example of prison populations or clinical
(primarily psychoanalytic) observations (Marmor, 1980). An ex-
ception to authors of earlier studies is Evelyn Hooker, who in
several studies that became influential during the debate on the
status of homosexuality, found that homosexual and heterosexual
subjects were indistinguishable in psychological projective testing
(e.g., Hooker, 1957).
Most of the early studies used symptom scales that assessed
psychiatric symptoms rather than prevalence of classified disor-
ders. An exception was a study by Saghir, Robins, Welbran, and
Gentry (1970a, 1970b), which assessed criteria-defined preva-
lences of mental disorders among gay men and lesbians as com-
pared with heterosexual men and women. The authors found
“surprisingly few differences in manifest psychopathology”be-
tween homosexuals and heterosexuals (Saghir et al., 1970a, p.
1084). In the social atmosphere of the time, research findings were
interpreted by gay-affirmative researchers conservatively, so as to
not erroneously suggest that lesbians and gay men had high preva-
lences of disorder. Thus, although Saghir and colleagues (1970a)
were careful not to claim that gay men had higher prevalences of
mental disorders than heterosexual men, they noted that they did
find “that whenever differences existed they showed the homo-
sexual men having more difficulties than the heterosexual con-
trols,”including, “a slightly greater overall prevalence of psychi-
atric disorder”(p. 1084). Among studies that assessed
symptomatology, several showed slight elevation of psychiatric
symptoms among LGB people, although these levels were typi-
cally within a normal range (see Gonsiorek, 1991; Marmor, 1980).
Thus, most reviewers have concluded that research evidence has
conclusively shown that homosexuals did not have abnormally
elevated psychiatric symptomatology compared with heterosexu-
als (see Marmor, 1980). This conclusion has been widely accepted
and has been often restated in most current psychological and
psychiatric literature (Cabaj & Stein, 1996; Gonsiorek, 1991).
More recently, there has been a shift in the popular and scientific
discourse on the mental health of lesbians and gay men. Gay-
affirmative advocates have begun to advance a minority stress
hypothesis, claiming that discriminatory social conditions lead to
poor health outcomes (Dean et al., 2000; Krieger & Sidney, 1997;
Mays & Cochran, 2001; Meyer, 2001; Rosario et al., 1996). In
1999, the journal Archives of General Psychiatry published two
articles (Fergusson, Horwood, & Beautrais, 1999; Herrell et al.,
1999) that showed that as compared with heterosexual people,
LGB people had higher prevalences of mental disorders and sui-
cide. The articles were accompanied by three editorials (Bailey,
1999; Friedman, 1999; Remafedi, 1999). One editorial heralded
the studies as containing “the best published data on the associa-
tion between homosexuality and psychopathology,”and concluded
that “homosexual people are at a substantially higher risk for some
forms of emotional problems, including suicidality, major depres-
sion, and anxiety disorder”(Bailey, 1999, p. 883). All three edi-
torials suggested that homophobia and adverse social conditions
are a primary risk for mental health problems of LGB people. This
shift in discourse is also reflected in the gay-affirmative popular
media. For example, in an article titled “The Hidden Plague”
published in Out, a gay and lesbian lifestyle magazine, Andrew
Solomon (2001) claimed that compared with heterosexuals “gay
people experience depression in hugely disproportionate num-
bers”(p. 38) and suggested that the most probable cause is soci-
etal homophobia and the prejudice and discrimination associated
To assess evidence for the minority stress hypothesis from
between-groups studies, I examined data on prevalences of mental
disorders in LGB versus heterosexual populations. The minority
stress hypothesis leads to the prediction that LGB individuals
would have higher prevalences of mental disorder because they are
exposed to greater social stress. To the extent that social stress
causes psychiatric disorder, the excess in risk exposure would lead
to excess in morbidity (Dohrenwend, 2000).
I identified relevant studies using electronic searches of the
PsycINFO and MEDLINE databases. I included studies if they
were published in an English-language peer-reviewed journal,
reported prevalences of diagnosed psychiatric disorders that were
based on research diagnostic criteria (e.g., DSM), and compared
lesbians, gay men, and/or bisexuals (variably defined) with het-
erosexual comparison groups. Studies that reported scores on
scales of psychiatric symptoms (e.g., Beck Depression Inventory)
and studies that provided diagnostic criteria on LGB populations
with no comparison heterosexual groups were excluded. Selecting
studies for review can present problems—studies reporting statis-
tically significant results are typically more likely to be published
than studies with nonsignificant results. This can result in publi-
cation bias, which overestimates the effects in the research syn-
thesis (Begg, 1994). There are some reasons to suspect that pub-
lication bias is not a great threat to the present analysis. First, Begg
(1994) noted that publication bias is more of a concern in instances
in which numerous small studies are being conducted. This is
clearly not the case with regard to population surveys of LGB
individuals and the mental health outcomes as defined here—the
studies I rely on are few and large. This is, in part, because of the
great costs involved in sampling LGB people and, in part, because
the area has not been extensively studied since the declassification
of homosexuality as a mental disorder. Second, publication is
typically guided by an “advocacy style,”where statistical signifi-
cance is used as “‘proof’of a theory”(Begg, 1994, p. 400). In the
area of LGB mental health, showing nonsignificant results—that
LGBs do not have higher prevalences of mental disorders—would
have provided as much a proof of a theory as showing significant
results; therefore, bias toward publication of positive results is
In reviewing the data I consider classes of mental disorders that
are commonly discussed in the psychiatric epidemiology literature
PREJUDICE, SOCIAL STRESS, AND MENTAL HEALTH
(Kessler et al., 1994; Robins & Regier, 1991). Consistent with this
literature, I consider separately prevalence of lifetime disorders,
those occurring at any time over the lifetime, and prevalence of
current disorders, typically those occurring in 1-year period. I
examine the prevalence of any mental disorder and the prevalences
of general subclasses of disorders, including mood disorders, anx-
iety disorders, and substance use disorders. The inclusion of only
major classes of disorders allows for greater parsimony in inter-
preting the results than would be allowed by an examination of
each individual disorder. It is a sufficient test of the minority stress
hypothesis because minority stress predictions are general and
uniform across types of disorders. The included disorders are those
that are most prevalent in population samples and that are most
often the subject of psychiatric epidemiological studies. Excluded
disorders were rarely if ever studied in population samples of LGB
individuals, so their exclusion does not lead to bias in selection of
available literature. The classes of disorders excluded were disor-
ders usually first diagnosed in infancy, childhood, or adolescence;
delirium, dementia, and amnestic and other cognitive disorders;
mental disorders due to a general medical condition; schizophrenia
and other psychotic disorders; somatoform disorders; factitious
disorders; dissociative disorders; sexual and gender identity disor-
ders; eating disorders; sleep disorders; impulse-control disorders;
adjustment disorders; and personality disorders.
The studies (Atkinson et al., 1988; Cochran & Mays, 2000a,
2000b; Fergusson et al., 1999; Gilman et al., 2001; Mays &
Cochran, 2001; Pillard, 1988; Saghir et al., 1970a, 1970b; Sandfort
et al., 2001) and their results are reported in Table 1. In drawing a
conclusion about whether LGB groups have higher prevalences of
mental disorders one should proceed with caution. The studies are
few, methodologies and measurements are inconsistent, and trends
in the findings are not always easy to interpret. Although several
studies show significant elevation in prevalences of disorders in
LGB people, some do not. Yet, an overall trend appears clear. This
pattern must lead us to conclude similarly to Saghir et al. (1970a,
1970b) that whenever significant differences in prevalences of
disorders between LGB and heterosexual groups were reported,
LGB groups had a higher prevalence than heterosexual groups.
To evaluate this general impression I conducted a meta-analysis
using the Mantel–Haenszel (M-H) procedure for synthesis of cat-
egorical data (Fleiss, 1981; Shadish, Cook, & Campbell, 2002;
Shadish & Haddock, 1994) using the statistical software Epi Info
(Version 1.12, Statcalc procedure; Centers for Disease Control and
Prevention, 2001). This procedure provides a M-H weighted odds
ratio (OR) and confidence intervals (CIs) on aggregates of indi-
vidual studies. For each class of disorder I calculated the M-H
weighted OR from studies that provided relevant data. In addition,
I conducted stratified analyses that combined results for (a) men
versus women and (b) studies that used nonrandom versus random
sampling techniques. The analyses provided M-H weighted ORs
for each stratum. The results of this meta-analysis for prevalences
of lifetime and current disorders are shown in Figure 2; they affirm
the impression given by an examination of Table 1. The results are
compelling for all disorders, for each of the subclasses of disorders
examined, and for lifetime and current disorders. For example, for
the five studies providing data on any lifetime mental disorders,
the combined M-H weighted OR was 2.41, with a 95% CI of 1.91
to 3.02. This indicates that compared with heterosexual men and
women, gay men and lesbians are about 2.5 times more likely to
have had a mental disorder at any point over their lifetime. The
analyses that stratified the observations by gender showed no
divergence from the results of the unstratified analyses. The M-H
weighted OR (95% CI) for a lifetime occurrence of any disorder
was 2.07 (1.57, 2.74) for men and 3.31 (2.19, 5.06) for women; for
mood disorders, 2.66 (2.07, 3.64) for men, 2.46 (1.71, 3.69) for
women; for anxiety disorders, 2.43 (1.78, 3.30) for men, 1.63
(1.09, 2.47) for women; and for substance use disorders, 1.45
(1.10, 1.91) for men and 3.47 (2.22, 5.50) for women. The results
on prevalences of current disorders were similar, but they showed
that for substance use disorders, the combined M-H weighted OR
for men (1.37, 95% CI 0.96, 1.95) was not significant and lower
than that for women (OR 3.50, 95% CI 2.23, 5.81).
Results of the analyses that stratified the observations on life-
time prevalences of disorders by randomization in sampling design
are presented in Figure 3. They show that for mood disorders,
anxiety disorders, and substance use disorders, an increase in risk
to the LGB group is evident in the randomized studies only. As the
figure shows, for each of these subgroups of disorders, the M-H
weighted OR was significant in the analysis of studies that used
random samples, but not in the analysis of studies that used
nonrandom samples (an OR is not significant when the 95% CI
includes 1.00). These analyses could not be conducted for current
prevalences of disorder because an insufficient number of nonran-
domized studies provided such data.
Whether gay men have higher prevalence of suicidal behavior
has also been debated in recent years. Some reviewers have con-
tended that suicide is highly prevalent among LGB populations,
especially youth (Gibson, 1989). In support of this, several studies
found elevated lifetime prevalences of suicide ideation and at-
tempts in LGB populations (Bell & Weinberg, 1978; D’Augelli &
Hershberger, 1993; Kruks, 1990; Noell & Ochs, 2001; Pillard,
1988; Remafedi, Farrow, & Deisher, 1991; Rotheram-Borus,
Hunter, & Rosario, 1994; Saghir et al., 1970a, 1970b; Schneider,
Farberow, & Kruks, 1989; Schneider, Taylor, Hammen, Kemeny,
& Dudley, 1991). However, such studies have been criticized for
severe methodological limitations including selection bias and
measurement issues (Muehrer, 1995; Savin-Williams, 2001). For
example, many studies used samples of youth recruited from social
service organizations, who may be more vulnerable than the gen-
eral population of LGB youth to mental health problems (Muehrer,
More recently, studies that used improved methodologies,
such as random probability sampling, clearer definitions, and
improved measurements of suicidality, also found strong evi-
dence for elevation in suicide-related problems among LGB
persons. A higher risk for suicide ideation and attempts among
LGB groups seems to start at least as early as high school. For
example, in a representative sample of Massachusetts high
school students, Garofalo et al. (1998) found that LGB youth
(including other youths who were not sure of their sexual
orientation) were three times more likely than their heterosex-
ual peers to report a suicide attempt in the year prior to the
survey. When stratified by gender, sexual orientation was an
independent predictor of suicide attempts among boys but not
girls. Other probability surveys support the conclusion that
LGB youth are at increased risk for suicide attempts (Bagley &
Tremblay, 1997; Faulkner & Cranston, 1998; Remafedi, French,
Story, Resnick, & Blum, 1998; Safren & Heimberg, 1999). A cohort
study in New Zealand found that LGB youth were five to six times
more likely than heterosexual youth to report suicide ideation and
attempts over their lifetime (Fergusson et al., 1999). Similar findings
have been reported among adults in the United States, where gay men
were more than twice as likely as heterosexual men to report lifetime
suicide attempts (Cochran & Mays, 2000a; Gilman et al., 2001; Paul
et al., 2002). A 1999 study of the Vietnam Era Twin Registry used
particularly convincing methodology to study differences in suicidal-
ity between twins (Herrell et al., 1999); it found that gay or bisexual
men were six times more likely than their heterosexual twins to have
Taken together, the evidence from these studies supports the
minority stress hypothesis that LGB populations are vulnerable to
suicide ideation and attempt—although the evidence on adult
lesbian and bisexual women is not as clear. Also not clear from
studies of suicide ideation and attempt is whether LGB persons are
at higher risk for suicide-related mortality. Suicide attempts and
ideation are alarming in their own right, but their relationship to
completed suicide is not straightforward; for example, not all
attempters do so with the intent to die or injure themselves severely
enough to cause death (Moscicki, 1994). Nevertheless, regardless of
its relationship to completed suicide, suicide ideation and attempt is a
serious personal and public health concern that need to be studied for
its own merit (Moscicki, 1994; Moscicki et al., 1988).
Two studies assessed the risk for completed suicides among gay
men (Rich, Fowler, Young, & Blenkush, 1986; Shaffer, Fisher,
Hicks, Parides, & Gould, 1995). These studies assessed the prev-
alence of homosexuality among completed suicides and found no
overrepresentation of gay and bisexual men, concluding that LGB
populations are not at increased risk for suicide. Thus, findings
from studies of completed suicides are inconsistent with studies
finding that LGB groups are at higher risk of suicide ideation and
attempts than heterosexuals. However, there are many challenges
to interpreting these data (McDaniel, Purcell, & D’Augelli, 2001;
Muehrer, 1995). Among these difficulties are that (a) these studies
attempt to answer whether gay individuals are overrepresented in
suicide deaths by comparing it against an expected population
prevalence of homosexuality, but with no proper population data
on LGB individuals, it is a matter of some conjunction to arrive at
any such estimate and (b) because these studies rely on postmor-
tem classification of sexual orientation, their reliability in assess-
ing prevalence of gay individuals among suicide deaths is ques-
tionable. Even if the deceased person was gay, postmortem
autopsies are likely to underestimate his or her homosexuality
because homosexuality is easily concealable and often is con-
cealed. Considering the scarcity of studies, the methodological
challenges, and the greater potential for bias in studies of com-
pleted suicide, it is difficult to draw firm conclusions from their
apparent refutation of minority stress theory.
Do LGB People Have Higher Prevalences of Mental
As described above, the preponderance of the evidence suggests
that the answer to the question, “Do LGB people have higher
prevalences of mental disorders?”is yes. The evidence is compel-
ling. However, the answer is complicated because of methodolog-
ical limitations in the available studies. The studies whose evi-
dence I have relied on (discussed as between-groups studies) fall
into two categories: studies that targeted LGB groups using non-
probability samples and studies that used probability samples of
the general populations that allowed identification of LGB versus
heterosexual groups. In the first type, the potential for error is great
because researchers relied on volunteers who may be very differ-
ent than the general LGB population to which one wants to
generalize (Committee on Lesbian Health Research Priorities,
1999; Harry, 1986; Meyer & Colten, 1999; Meyer, Rossano, Ellis,
& Bradford, 2002). It is plausible that interest in the study topic
attracts volunteers who are more likely to have had—or at least, to
disclose—more mental health problems than nonvolunteers. This
may be particularly problematic in studies of LGB youth (e.g.,
Fergusson et al., 1999). As a group, LGB youth respondents in
studies may represent only a portion of the total underlying pop-
ulation of LGB youth—those who are “the out, visible, and early
identifiers”(Savin-Williams, 2001, p. 983)—therefore biasing es-
timates of characteristics of the elusive target population. Also, the
studies I reviewed compared the LGB group with a nonrandom
sample of heterosexuals, introducing further bias, because the
methods they used to sample heterosexuals often differed from
those used to sample than the LGB groups. The potential for bias
is particularly glaring in studies that compared a healthy hetero-
sexual group with a group of gay men with HIV infection and
AIDS (e.g., Atkinson et al., 1988).
The second group of studies used population-based surveys.
Such studies greatly improve on the methodology of the first type
of studies because they used random sampling techniques, but they
too suffer from methodological deficiencies. This is because none
of these studies was a priori designed to assess mental health of
LGB groups; as a result, they were not sophisticated in the mea-
surement of sexual orientation. The studies classified respondents
as homosexual or heterosexual only on the basis of past sexual
behavior—in 1 year (Sandfort et al., 2001), in 5 years (Gilman et
al., 2001), or over the lifetime (Cochran & Mays, 2000a)—rather
than using a more complex matrix that assessed identity and
attraction in addition to sexual behavior (Laumann et al., 1994).
The problem of measurement could have increased potential error
due to misclassification, which in turn could have led to selection
bias. The direction of bias due to selection is unclear, but it is
plausible that individuals who were more troubled by their sexu-
ality would be overrepresented—especially as discussed above for
youth—leading to bias in reported estimates of mental disorder.
However, the reverse result, that people who were more secure and
healthy were overrepresented, is also plausible.
The studies also suffer because they included a very small
number of LGB people. The small sample sizes resulted in little
power to detect differences between the LGB and heterosexual
groups, which led to lack of precision in calculating group differ-
ences in prevalences of disorders. This means that only differences
of high magnitude would be detected as statistically significant,
which might explain the inconsistencies in the research evidence.
It should be noted, however, that if inconsistencies were the result
of random error, one would expect that in some studies the
heterosexual group would appear to have higher prevalences of
disorders. This was not evident in the studies reviewed. The small
PREJUDICE, SOCIAL STRESS, AND MENTAL HEALTH
Prevalence of Mental Disorders: Summary of Findings From Studies That Compared Lesbian, Gay, and Bisexual Populations With Heterosexual Peers
Study Sample Subgroup Prevalence
Mood and anxiety Substance use Any
Saghir et al. (1970a)
Homosexuals primarily from three Chicago
and San Francisco “homophile”
organizations (N89 men, 57 women)
and never-married heterosexuals (N
35 men, 43 women) primarily from
an apartment complex in Chicago
Men Lifetime Mood: 1.2 (0.4, 3.2);
1.2 (0.3, 6.0)
1.4 (0.3, 6.7) 1.5 (0.6, 3.5)
Saghir et al. (1970b)
Homosexuals primarily from three Chicago
and San Francisco “homophile”
organizations (N89 men, 57 women)
and never-married heterosexuals (N
35 men, 43 women) primarily from
an apartment complex in Chicago
Women Lifetime Mood: 1.5 (0.6, 3.6);
0.96 (0.3, 3.2)
5.9 (0.7, 133.1) 3.9 (1.5, 10)
Predominantly homosexual men (N51)
and predominantly heterosexual men (N
50) aged 25–35, recruited through
Men Lifetime No significant
Drug use: 1.2
(0.3, 5.0) 1.7 (0.7, 4.0)
Atkinson et al. (1988)
Homosexual men (N56) recruited from
cohort followed for an AIDS study in
San Diego, CA and healthy heterosexual
Men Lifetime MDD: 4.4
(0.8, 30.3); GAD:
15.1 (1.9, 321.0)
Alcohol abuse and
4.8 (1.3, 18.2)
Fergusson et al. (1999)
New Zealand cohort of youth age 21 who
said they were homosexual, gay, lesbian,
or bisexual (N28; 11 men, 17
women) and heterosexual males and
Men and women
combined Lifetime MDD: 4.0 (1.8, 9.3);
Substance abuse and
Cochran & Mays
(2000a) NHANES-III men age 17–39 who reported
any lifetime same-sex sexual partners
(weighted N78); and those who
reported opposite-sex sexual partners
Men Lifetime Mood: 2.5 (0.9, 7.2)
Cochran & Mays
(2000b) NHSDA men (N98) and women (N
96) age 18 or older who reported same-
sex sexual partners in the year prior to
interview and those who reported
opposite-sex sexual partners (N3,922
men, 5,792 women)
Men 1-year MDD: 2.9 (1.4, 6.3);
1.3 (0.5, 3.2);
2.0 (0.9, 4.9)
2.3 (1.3, 3.9)
Women 1-year MDD: 1.8 (0.7, 4.3);
2.8 (1.2, 7.0);
3.3 (1.2, 8.7)
1.6 (0.8, 3.5)
Table 1 (continued)
Study Sample Subgroup Prevalence
Mood and anxiety Substance use Any
Gilman et al. (2001) NCS men (N74) and women (N51)
aged 15–54 who reported same-sex
sexual partners and those who reported
opposite-sex partners (N2,310
men, 2,475 women) in 5 years prior to
Mood: 1.7 (0.9, 3.0);
Substance use: 1.5
(0.8, 2.8) 1.4 (0.8, 2.4)
Mood: 2.0 (1.1, 3.5);
Substance use: 2.4
(1.3, 4.4) 1.8 (1.1, 2.9)
Mood: 1.6 (0.7, 3.4);
Substance use: 1.2
(0.7, 2.2) 1.5 (0.9, 2.4)
Mood: 3.4 (1.8, 6.3);
Substance use: 3.1
2.6 (1.4, 4.7)
Sandfort et al. (2001) NEMESIS Dutch population survey of
adults 18–64 years old who reported
same-sex sexual behavior (N82
men, 43 women) and those who reported
opposite-sex sexual beavior (N2,796
men, 3,077 women) in the year prior to
Men Lifetime Mood: 3.1 (1.9, 5.0);
Substance use: 0.8
(0.5, 1.3) 1.3 (0.8, 2.1)
Women Lifetime Mood: 2.4 (1.3, 4.6);
Substance use: 3.4
(1.6, 7.3) 2.6 (1.3, 5.2)
Men 1-year Mood: 2.9 (1.5, 5.6);
Substance use: 0.9
(0.5, 1.7) 1.5 (0.9, 2.5)
Women 1-year Mood: 1.0 (0.4, 2.6);
Substance use: 4.0
(1.6, 10.5) 1.7 (0.8, 3.3)
Mays & Cochran
(2001) U.S.-representative adults aged 25–74 in
the MIDUS study who identified as
homosexual or bisexual (N41
men, 32 women) and heterosexual (N
1,382 men, 1,462 women)
1-year 2.2 (1.2, 3.8)
Note. Findings are presented as odds ratios (ORs; with 95% confidence intervals) in reference to the heterosexual comparison group. ORs are adjusted for various control variables when provided
in the original article. Significant results, marked in bold, are defined as
95% (lower bound for the 95% confidence interval 1.00). MDD major depressive disorder; CA California; GAD
generalized anxiety disorder; NHANES National Health and Nutrition Examination Survey; NHSDA National Household Survey of Drug Abuse; NCS National Comorbidity Survey;
NEMESIS Netherlands Mental Health Survey and Incidence Study; MIDUS Midlife Development in the United States.
The study used diagnostic definitions from the Research Diagnostic Criteria.
ORs were recalculated from published data using the statistical software Epi Info (Centers for Disease Control and
In the case of MDD, Pillard (1988) did not provide data to allow recalculation of ORs, but the author reported that “there were no significant differences between the HT
[heterosexual] and HM [homosexual] men”(p. 54).
ORs were recalculated from published data using the statistical software Epi Info (Centers for Disease Control and Prevention, 2001). Original
results and tests of significance were calculated for four subgroups of gay men, including men with AIDS (n15), men with AIDS-related complex (ARC; n13), HIV-seropositive men with no
AIDS or ARC (n17), and HIV-seronegative men (n11). In recalculating the ORs, I combined these four subgroups and compared their prevalence of disorders with that of the heterosexual men
(n22). Using this analysis, I report that the authors found a significant increase in any disorder among gay men, but this finding is not reported in the original article.
In the original article
prevalences of disorders were reported for male and female respondents combined because the small number of respondents did not allow stratification by gender. Lifetime prevalence for any disorder
was not reported, but the gay group had a higher prevalence of comorbid disorders (two or more diagnoses; OR 5.9 [2.4, 14.8]).
ORs were calculated using the statistical software Epi Info (Centers
for Disease Control and Prevention, 2001). Data for lifetime prevalences, which were not reported in the original article, were provided by S. E. Gilman (personal communication, October 16,
There is a discrepancy between the level of significance reported here for the calculated OR and the level of significance reported in the original article. In the original, the authors reported
that 19.5% (SE 7.8) of women with same-sex sexual partners and 7.2% (SE 0.5) of women with opposite-sex sexual partners had any substance use disorder, but this difference is not indicated
as reaching significance at the .05 level.
PREJUDICE, SOCIAL STRESS, AND MENTAL HEALTH
number of LGB respondents in these studies also resulted in low
power to detect (or statistically control for) patterns related to
race/ethnicity, education, age, socioeconomic status, and, some-
times, gender. My use of a meta-analytic technique to estimate
combined ORs somewhat corrects this deficiency, but it is impor-
tant to remember that a meta-analysis cannot overcome problems
in the studies on which it is based. It is important, therefore, to
interpret results of meta-analyses with caution and a critical per-
spective (Shapiro, 1994).
One problem, which can provide a plausible alternative expla-
nation for the findings about prevalences of mental disorders in
LGB individuals, is that bias related to cultural differences be-
tween LGB and heterosexual persons inflates reports about history
of mental health symptoms (cf. Dohrenwend, 1966; Rogler, Mro-
czek, Fellows, & Loftus, 2001). It is plausible that cultural differ-
ences between LGB and heterosexual individuals cause a response
bias that led to overestimation of mental disorders among LGB
individuals. This would happen if, for example, LGB individuals
were more likely to report mental health problems than heterosex-
ual individuals. There are several reasons why this may be the
case: In recognizing their own homosexuality and coming out,
most LGB people have gone through an important self-defining
period when increased introspection is likely. This could lead to
greater ease in disclosing mental health problems. In addition, a
coming out period provides a focal point for recall that could lead
to recall bias that exaggerates past difficulties. Related to this,
studies have suggested that LGB people are more likely than
heterosexual people to have received professional mental health
services (Cochran & Mays, 2000b). This too could have led LGB
people to be less defensive and more ready than heterosexual
people to disclose mental health problems in research. Of course,
increased use of mental health services could also reflect a true
elevation in prevalences of mental disorders in LGB people,
though the association between mental health treatment and pres-
ence of diagnosed mental disorders is not strong (Link & Dohren-
wend, 1980). To the extent that such response biases existed, they
Figure 2. Combined Mantel–Haenszel weighted odds ratios and 95% confidence intervals for lifetime and
1-year prevalence of mental disorders in lesbian, gay, and bisexual versus heterosexual populations. Each
calculated combined Mantel–Haenszel weighted odds ratio is displayed between the upper and lower bounds of
its respective 95% confidence interval. Odds ratios were recalculated from aggregated data using the Statcalc
procedure of the statistical software Epi Info (Centers for Disease Control and Prevention, 2001). This procedure
does not adjust for demographics characteristics or any other control variables (e.g., sampling weights) that may
be necessary to arrive at unbiased population estimates. These statistics are provided to allow synthesis of the
risk for lesbian, gay, and bisexual versus heterosexual respondents in the studies, but they cannot be used as
accurate estimates of adjusted population odds ratios.
would have led researchers to overestimate the prevalence of
mental disorders in LGB groups. Research is needed to test these
Over the past 2 decades, significant advances in psychiatric
epidemiology have made earlier research on prevalence of mental
disorders almost obsolete. Among these advances are the recog-
nition of the importance of population-based surveys (rather than
clinical studies) of mental disorders, the introduction of an im-
proved psychiatric classification system, and the development of
more accurate measurement tools and techniques for epidemiolog-
ical research. Two large-scale psychiatric epidemiological surveys
have already been conducted in the United States: the Epidemio-
logical Catchment Area Study (Robins & Regier, 1991) and the
National Comorbidity Survey (Kessler et al., 1994). Similar stud-
ies need to address questions about patterns of stress and disorder
in LGB populations (Committee on Lesbian Health Research
Priorities, 1999; Dean et al., 2000).
Using random sampling methodologies for large-scale studies of
LGB populations is challenging and costly, but it is not impossible.
Recent research has demonstrated the utility of innovative meth-
odologies for population studies of LGB individuals (Binson et al.,
1995; Binson, Moskowitz, Anderson, Paul, & Catania, 1996;
Meyer & Colten, 1999; Meyer et al., 2002). New research must
therefore continue to use random sampling to study LGB groups,
combined with sophisticated measurements of sexual orientation, a
larger number of respondents, and a direct test of hypotheses about
patterns in prevalences of disorders and their causes. An ideal
study design would combine evidence from the investigation of
within- and between-groups differences. Such a study would as-
sess both the differences in prevalences of disorders and the causal
role of stress processes in explaining excess risk for disorder in the
LGB group. If in a random population sample the prevalence of
disorders would be found to be higher among LGB respondents
than among their heterosexual peers and if stress mechanisms
explained the excess in this prevalence of disorder, then minority
stress predictions would be strongly supported.
To understand causal relations, research also needs to explain
the mechanisms through which stressors related to prejudice and
Figure 3. Combined Mantel–Haenszel weighted odds ratios and 95% confidence intervals for lifetime
prevalence of mental disorders in studies of lesbian, gay, and bisexual versus heterosexual populations that used
random and nonrandom samples. Each calculated combined Mantel–Haenszel weighted odds ratio is displayed
between the upper and lower bounds of its respective 95% confidence interval. Odds ratios were recalculated
from aggregated data using the Statcalc procedure of the statistical software Epi Info (Centers for Disease
Control and Prevention, 2001). This procedure does not adjust for demographics characteristics or any other
control variables (e.g., sampling weights) that may be necessary to arrive at unbiased population estimates. These
statistics are provided to allow synthesis of the risk for lesbian, gay, and bisexual versus heterosexual
respondents in the studies, but they cannot be used as accurate estimates of adjusted population odds ratios.
PREJUDICE, SOCIAL STRESS, AND MENTAL HEALTH
discrimination affect mental health. Krieger (2001) called for an
ecosocial perspective in social epidemiology, which would explain
how social factors are embodied and lead to disease. Discussing
racism, she explained,
Biological expressions of racial discrimination . . . refer to how people
literally embody and biologically express experiences of racial op-
pression and resistance, from conception to death, thereby producing
racial/ethnic disparities in morbidity and mortality across a wide
spectrum of outcomes. (Krieger, 2000, p. 63)
Limitations and Challenges
The conclusion I propose—that LGB individuals are exposed to
excess stress due to their minority position and that this stress
causes an excess in mental disorders—is inconsistent with research
and theoretical writings that can be described as a minority resil-
ience hypothesis, which claims that stigma does not negatively
affect self-esteem (Crocker et al., 1998; Gray-Little & Hafdahl,
2000; Twenge & Crocker, 2002). As such, my conclusion is also
inconsistent with studies that showed that Blacks do not have
higher prevalences of mental disorders than Whites, as is expected
by minority stress formulations (Kessler et al., 1994; Robins &
Regier, 1991). Further research must address this apparent contra-
diction. One area for the study of differences between minority
stress in LGB and Black individuals concerns the socialization of
minority group members. LGB individuals are distinct from
Blacks in that they are not born into their minority identity but
acquire it later in life. Because of this, LGB individuals do not
have the benefit of growing up in a self-enhancing social environ-
ment similar to that provided to Blacks in the process of social-
ization. Experiences with positive racial identity may be protective
to Blacks both directly, by contributing to high self-esteem, and
indirectly, by facilitating self-protective mechanisms associated
with stigma (Crocker & Major, 1989; Gray-Little & Hafdahl,
2000; Twenge & Crocker, 2002). This distinction may lead to a
greater impact of minority stress among LGB individuals as com-
pared with race/ethnic minorities. Studying this distinction be-
tween LGB individuals and Blacks may reveal important aspects
of the effect of stigma on mental health.
There are several important limitations to my review. First,
throughout the article I discuss LGB individuals as if they were a
homogenous group. That is clearly not the case. In ignoring the
heterogeneity of the group I may have glossed over some impor-
tant distinctions relevant to the discussion of minority stress.
Perhaps one of the most important is a distinction between a single
minority identity of White gay and bisexual men and multiple
minority identities of gay and bisexual men who are also members
of race/ethnic minorities and therefore subject to stigma related to
their race/ethnicity (Eliason, 1996). Some studies found ethnicity/
race differences in stress and social support among LGB popula-
tions, with members of ethnic minorities confronting racism in a
White LGB community and homophobia in their ethnic commu-
nities of origin (Chan, 1995; Espin, 1993; Fullilove & Fullilove,
1999). Similarly, lesbians and bisexual women confront stigma
and prejudice related to gender in addition to sexual orientation.
Just as racial/ethnic identity and gender provide additional sources
of stress, they provide additional resources for coping with stigma.
For example, Brooks (1981) described affiliation with feminist
organizations as a significant source of support and coping for
lesbians. Finally, the review, and the studies I cite, fails to distin-
guish bisexual individuals from lesbian and gay individuals. Re-
cent evidence suggests that this distinction is important and that
bisexuals may be exposed to more stressors and may have greater
mental health problems than lesbians or gay men (Jorm, Korten,
Rodgers, Jacomb, & Christensen, 2002).
Another limitation is that the review ignores generational and
cohort effects in minority stress and the prevalence of mental
disorder. Cohler and Galatzer-Levy (2000) critiqued analyses that
ignore important generational and cohort effects. They noted great
variability among generations of lesbians and gay men. They
described an older generation, which matured prior to the gay
liberation movement, as the one that has been most affected by
stigma and prejudice, a middle-aged generation, which brought
about the gay liberation movement, as the one that benefited from
advances in civil rights of and social attitudes toward LGB indi-
viduals, and a younger generation, including the present generation
of young adults, as having an unparalleled “ease about sexuality”
(p. 40). An analysis that accounts for these generational and cohort
changes would greatly illuminate the discussion of minority stress.
Clearly, the social environment of LGB people has undergone
remarkable changes over the past few decades. Still, even Cohler
and Galatzer-Levy (2000) limited their description of the new gay
and lesbian generation to a primarily liberal urban and suburban
environment. Evidence from current studies of youth has con-
firmed that the purported shifts in the social environment have so
far failed to protect LGB youth from prejudice and discrimination
and its harmful impact (Safe Schools Coalition of Washington,
The Objective Versus Subjective Approaches to the
Definition of Stress
In reviewing the literature I described minority stressors along a
continuum from the objective (prejudice events) to the subjective
(internalized homophobia), but this presentation may have ob-
scured important conceptual distinctions. Two general approaches
underlie stress discourse: One views stress as objective, the other
as subjective, phenomena. The objective view defines stress, in
particular life events, as real and observable phenomena that are
experienced as stressful because of the adaptational demands they
impose on most individuals under similar circumstances (Dohren-
wend, Raphael, Schwartz, Stueve, & Skodol, 1993). The subjec-
tive view defines stress as an experience that depends on the
relationship between the individual and his or her environment.
This relationship depends on properties of the external event but
also, significantly, on appraisal processes applied by the individual
(Lazarus, 1991; Lazarus & Folkman, 1984).
The distinction between objective and subjective conceptualiza-
tion of stress is often ignored in stress literature, but it has impor-
tant implications for the discussion of minority stress (Meyer,
2003). Link and Phelan (2001) distinguished between individual
discrimination and structural discrimination. Individual discrimi-
nation refers to personal perceived experiences with discrimina-
tion, whereas structural discrimination refers to a wide range of
“institutional practices that work to the disadvantage of . . . mi-
nority groups even in the absence of individual prejudice or
discrimination”(Link & Phelan, 2001, p. 372). Most research on
social stress has been concerned with individual prejudice. When
I discussed the objective end of the continuum of minority stress,
I implied that it is less dependent on individual perception and
appraisal, but clearly, individual reports of discrimination depend
on individual perception, which is associated with the person’s
perspective and opportunity to perceive prejudice. For example,
individuals who are not hired for a job are unlikely to be aware of
discrimination (especially in cases in which it is illegal). In addi-
tion, there are strong motivations to perceive and report discrim-
ination events that vary with individual psychological and demo-
graphic characteristics (Kobrynowicz & Branscombe, 1997;
Operario & Fiske, 2001). Contrada et al. (2000) suggested that
members of minority groups have contradictory motivations with
regard to perceiving discrimination events: They are motivated by
self-protection to detect discrimination but also by the wish to
avoid false alarms that can disrupt social relations and undermine
life satisfaction. Contrada et al. also suggested that in ambiguous
situations people tend to maximize perceptions of personal control
and minimize recognition of discrimination. Thus, structural dis-
crimination, which characterizes differences between minority and
nonminority groups, are not always evident in the within-group
assessments reviewed above (Rose, 1985; Schwartz & Carpenter,
1999). For all these reasons, structural discrimination may be best
documented by differential group statistics including health and
economic statistics rather than by studying individual perceptions
alone (Adams, 1990).
The distinction between objective and subjective approaches to
stress is important because each perspective has different philo-
sophical and political implications (Hobfoll, 1998). The subjective
view of stress highlights individual differences in appraisal and, at
least implicitly, places more responsibility on the individual to
withstand stress. It highlights, for example, processes that lead
resilient individuals to see potentially stressful circumstances as
less (or not at all) stressful, implying that less resilient individuals
are somewhat responsible for their stress experience. Because,
according to Lazarus and Folkman (1984), coping capacities are
part of the appraisal process, potentially stressful exposures to
situations for which individuals possess coping capabilities would
not be appraised as stressful. (Both views of the stress process
allow that personality, coping, and other factors are important in
moderating the impact of stress; the distinction here is in their
conceptualization of what is meant by the term stress.) Thus, the
subjective view implies that by developing better coping strategies
individuals can and should inoculate themselves from exposure to
stress. An objective view of social stress highlights the properties
of the stressful event or condition—it is stressful regardless of the
individual’s personality characteristics (e.g., resilience) or his or
her ability to cope with it. Arising from the objective–subjective
distinction are questions related to the conceptualization of the
minority person in the stress model as a victim versus a resilient
The Minority Person as Victim Versus Resilient Actor
As they discuss minority stress, researchers inevitably describe
members of minority groups as victims of oppressive social con-
ditions, and they have been criticized for this characterization.
More than 3 decades ago, the novelist Ralph Ellison articulated
this critique in his discussion of sociological accounts of the
“deforming marks of oppression”(as cited in Thomas & Sillen,
1972/1991, p. 46) on the life of African Americans in Harlem:
I don’t deny that these sociological formulas are drawn from life. But
I do deny that they define the complexity of Harlem....[T]here is
something else in Harlem, something subjective, willful, and com-
plexly and compellingly human. It is that “something else”which
makes for our strength, which makes for our endurance and our
promise. (Ellison, as cited in Thomas & Sillen, 1972/1991, p. 46)
Current observers continue to call for researchers to move from
viewing minority group members as passive victims of prejudice
to viewing them as actors who interact effectively with society
(Clark et al., 1999; Crocker & Major, 1989). With this shift, it has
been argued, researchers would acknowledge “the power minority
groups have with respect to prejudice”(Shelton, 2000). The ben-
efits of this perspective are clear: It reflects real and important
coping processes that have been described above and affirms the
strengths of minority group members and their institutions—insti-
tutions that have been resiliently, sometimes heroically, fought for
and won (D’Emilio, 1983).
The tension between the view of the minority person as a victim
versus a resilient actor is important to note. Viewing the minority
person as a resilient actor is consistent with values of American
society: It reflects and preserves “a Western view of the world that
emphasizes control, freedom, and individualized determination”
(Hobfoll, 1998, p. 21). However, holding such a view of minority
persons can be perilous. The peril lies in that the weight of
responsibility for social oppression can shift from society to the
individual. Viewing the minority person as a resilient actor may
come to imply that effective coping is to be expected from most,
if not all, of those who are in stressful or adverse social conditions.
Failure to cope, failure of resilience, can therefore be judged as a
personal, rather than societal, failing.
This is especially likely when one considers the distinction
described above between subjective and objective conceptualiza-
tion of stress. When the concept of stress is conceptualized, fol-
lowing Lazarus and Folkman (1984), as dependent on—indeed,
determined by—coping abilities, then by definition, stress for
which there is effective coping would not be appraised as stressful.
As researchers are urged to represent the minority person as a
resilient actor rather than a victim of oppression, they are at risk of
shifting their view of prejudice, seeing it as a subjective stres-
sor—an adversity to cope with and overcome—rather than as an
objective evil to be abolished. This peril should be heeded by
psychologists who by profession study individuals rather than
social structures and are therefore at risk of slipping from a focus
on objective societal stressors to a focus on individual deficiencies
in coping and resiliency (Masten, 2001).
I proposed a minority stress model that explains the higher
prevalence of mental disorders as caused by excess in social
stressors related to stigma and prejudice. Studies demonstrated that
social stressors are associated with mental health outcomes in LGB
people, supporting formulations of minority stress. Evidence from
between-groups studies clearly demonstrates that LGB populations
have higher prevalences of psychiatric disorders than heterosexu-
als. Nevertheless, methodological challenges persist. To date, no
PREJUDICE, SOCIAL STRESS, AND MENTAL HEALTH
epidemiological study has been conducted that planned to a priori
study the mental health of LGB populations. To advance the field,
it is necessary that researchers and funding agencies develop
research that uses improved epidemiological methodologies, in-
cluding random sampling, to study mental health within the con-
text of the minority stress model.
I discussed two conceptual views of stress; each implies differ-
ent points for public health and public policy interventions. The
subjective view, which highlights individual processes, suggests
that interventions should aim to change the appraisal process, the
person’s way of evaluating their condition and coping with stress
and adversity. The objective view, which highlights the objective
properties of the stressors, points to remedies that would aim to
alter the stress-inducing environment and reduce exposure to
stress. If the stress model is correct, both types of remedies can
lead to a reduction in mental health problems, but they have
different ethical implications. The former places greater burden on
the individual, the latter, on society. Kitzinger (1997) warned
psychologists that a subjective, individualistic focus could lead to
ignoring the need for important political and structural changes:
If [psychologists’] aim is to decrease “stress”and to increase the “ego
strength”of the victim, do they risk forgetting that it is the perpetrator,
not the victim, who is the real problem? What political choices are
they making in focusing on the problems of the oppressed rather than
on the problem of the oppressor? (p. 213)
I endorsed this perspective in illuminating distinctions between
viewing the minority person as victim or resilient actor.
However, denying individual agency and resilience would ig-
nore an impressive body of social psychological research that
demonstrates the importance and utility of coping with stigma
(Branscombe & Ellemers, 1998; Crocker & Major, 1989; Miller &
Major, 2000; Miller & Myers, 1998). My discussion of objective
versus subjective stress processes is not meant to suggest that there
must be a choice of only one of the two classes of intervention
options. Researchers and policymakers should use the stress model
to attend to the full spectrum of interventions it suggests (Ouel-
lette, 1998). The stress model can point to both distal and proximal
causes of distress and to directing relevant interventions at both the
individual and structural levels.
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Received May 6, 2002
Revision received February 10, 2003
Accepted February 11, 2003 䡲
PREJUDICE, SOCIAL STRESS, AND MENTAL HEALTH