Much of what we know about the health of sexual minorities (lesbian, gay, bisexual, queer, two-spirit (LGBQ2), and other non-heterosexual groups) fails to account for meaningful differences within sexual minority populations.
While recent decades have seen major advances in the visibility of gay and lesbian people, bisexual people remain a largely invisible group, despite being the largest sexual identity-based group within the LGBQ community.
Perhaps because of this invisibility – in addition to the various forms of biphobia and monosexism* bisexual people encounter in both heterosexual and LGBQ communities – a number of studies have suggested that bisexual people experience higher rates of depression, anxiety, and suicide than do their lesbian and gay counterparts.
To better understand the evidence for these within-sexual minority health disparities, we conducted a systematic review of studies published to-date on this topic.
* Monosexism refers to the assumption of sexual orientation to a single gender (i.e., gay or straight).
Summary of research
We identified a total of 85 publications that reported on one of the following outcomes: depression, anxiety, thoughts of suicide, or suicide attempts. Most of the studies were conducted in North America between 1995 and 2014.
We then used meta-analysis, a research method for pooling data from multiple studies, to quantify differences in rates of each of these outcomes between three groups: bisexual, lesbian/gay, and heterosexual.
A consistent gradient was apparent for all of the outcomes examined:
- bisexual groups reported the highest rates of depression, anxiety, and suicide ideation/attempt,
- lesbian/gay groups reported the next highest rates, and
- heterosexual groups reported the lowest rates.
This pattern was consistent across age groups (adolescents, young adults, and adults), and for both women and men, though the differences in rates between bisexual and lesbian/gay groups was greater for women than for men. Not enough studies provided data on other gender groups to allow us to examine transgender or other gender minority people separately.
Implications for practice
The strength and consistency of the gradients in mental health inequities that bisexual people are facing is concerning. We propose three steps that sexual health providers and community workers can take in response.
- Affirm bisexuality in the clients you are serving. You can do this by using inclusive and open questions. For example, ask clients about the genders of their sex partners and don’t assume that clients are exclusively having sex with partners of a same or different gender identity. Language matters. These practices help to create a space in which bisexual and other non-monosexual** clients feel welcome to open up about their sexuality, and perhaps also any mental health concerns they may have.
- Support social and structural interventions that celebrate bisexual identity. These may include campaigns, such as the one below, or the implementation of bisexual support groups—which are scarce in British Columbia, and elsewhere.
- Seek new opportunities to integrate mental health referrals within local sexual health services. Research suggests that many clients of sexual health clinics—notably including sexual and gender minorities—feel more at ease discussing mental health concerns with sexual health providers than with primary care providers, family, or friends.
**Non-monosexual includes pansexual, queer, and other folks who are attracted to people of more than one gender.
For further information
Ross, et al. Prevalence of depression and anxiety among bisexual people compared to gay, lesbian, and heterosexual individuals: A systematic review and meta-analysis. Journal of Sex Research 2018;55(4-5). https://www.tandfonline.com/doi/full/10.1080/00224499.2017.1387755
Salway, et al. A systematic review and meta-analysis of disparities in the prevalence of suicide ideation and attempt among bisexual populations. Archives of Sexual Behavior 2018;e-pub. http://rdcu.be/H24d
Re:searching for LGBTQ Health: http://lgbtqhealth.ca/resources/bisexualityandhealth.php
Bisexual Resource Center: http://biresource.org/resources/brochures-and-handouts/
This Is Our Community, bisexual anti-stigma campaign: https://www.rainbowhealthontario.ca/bisexual-health/
- San Francisco Human Rights Commission. Bisexual Invisibility: Impacts and Recommendations. Retrieved from: http://sf-hrc.org/sites/default/files/Documents/HRC_Publications/Articles/Bisexual_Invisiblity_Impacts_and_Recommendations_March_2011.pdf
- Everyday Feminism. Monosexism: Batting the Biases of Bi/Panphobia. Retrived from: https://everydayfeminism.com/2013/11/monosexism/
- SmartSexResource. Syndemic service integration: Are sexual health clinics appropriate settings for addressing clients’ unmet mental health care needs? Retrieved from: https://smartsexresource.com/health-providers/blog/201802/syndemic-service-integration-are-sexual-health-clinics-appropriate
We wish to thank the other members of our systematic review team who made this work possible: Lesley Tarasoff, Jenna MacKay, Charles Fehr, Blake Hawkins, Joseph Burley, and Shayan Asadi.