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Effects of Perceived Discrimination on Mental Health and Mental Health

Services Utilization Among Gay, Lesbian, Bisexual and Transgender Persons

Article  in  Journal of LGBT Health Research · February 2007

DOI: 10.1080/15574090802226626 · Source: PubMed

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 Effects of Perceived Discrimination on Mental Health
and Mental Health Services Utilization Among Gay,
Lesbian, Bisexual and Transgender Persons
Diana Burgess
Richard Lee
Alisia Tran
Michelle van Ryn

ABSTRACT. Objectives. Previous research has found that lesbian, gay, bisexual and transgender
(LGBT) individuals are at risk for a variety of mental health disorders. We examined the extent to
which a recent experience of a major discriminatory event may contribute to poor mental health among
LGBT persons.
Methods. Data were derived from a cross-sectional strata-cluster survey of adults in Hennepin
County, Minnesota, who identified as LGBT (n = 472) or heterosexual (n = 7,412).
Results. Compared to heterosexuals, LGBT individuals had poorer mental health (higher levels of
psychological distress, greater likelihood of having a diagnosis of depression or anxiety, greater per-
ceived mental health needs, and greater use of mental health services), more substance use (higher levels
of binge drinking, greater likelihood of being a smoker and greater number of cigarettes smoked per
day), and were more likely to report unmet mental healthcare needs. LGBT individuals were also more
likely to report having experienced a major incident of discrimination over the past year than hetero-
sexual individuals. Although perceived discrimination was associated with almost all of the indicators
of mental health and utilization of mental health care that we examined, adjusting for discrimination
did not significantly reduce mental health disparities between heterosexual and LGBT persons.
Conclusion. LGBT individuals experienced more major discrimination and reported worse mental
health than heterosexuals, but discrimination did not account for this disparity. Future research should
explore additional forms of discrimination and additional stressors associated with minority sexual
orientation that may account for these disparities.

KEYWORDS. Discrimination, homosexuality, mental health, minority groups/psychology, prejudice.

Recent research has shown that lesbian, gay, ders relative to heterosexuals, even after control-
bisexual, and transgender (LGBT) individuals ling for variables such as age, race, educational
experience elevated rates of mental health disor- background, and cohabitation/marital status

Diana Burgess, PhD, is affiliated with the Center for Chronic Disease Outcomes Research, Veterans Affairs
Medical Center, Minneapolis, MN and the University of Minnesota, Department of Internal Medicine. Richard
Lee, PhD, and Alisia Tran are affiliated with the University of Minnesota, Department of Psychology. Michelle
van Ryn, MPH, PhD, is affiliated with the University of Minnesota, Department of Family Medicine and
Community Health, and School of Public Health.
Address correspondence to: Diana Burgess, PhD, Center for Chronic Disease Outcomes Research
(CCDOR), VA Medical Center (152/2E), One Veterans Drive, Minneapolis, MN 55417 (E-mail:
Diana.Burgess@va.gov).
Diana Burgess is supported by a Merit Review Entry Program Award from VA HSR & D.
Journal of LGBT Health Research, Vol. 3(4) 2007
Available online at http://www.haworthpress.com


C 2007 by The Haworth Press. All rights reserved.
doi: 10.1080/15574090802226626 1
2 JOURNAL OF LGBT HEALTH RESEARCH
(S. D. Cochran, Mays, & Sullivan, 2003; King
et al., 2003). For example, gay men have been
found to experience higher prevalence of major
depression, panic attacks, and symptoms of poor
mental health than otherwise similar hetero-
sexual men (S. D. Cochran, Keenan, Schober,
& Mays, 2000; King et al., 2003), and a
co-twin control study found a significant as-
sociation between homosexuality and suici-
dal ideation (Herrell et al., 1999). Similarly,
compared to otherwise similar heterosexual
women, lesbian and bisexual women have
been found to experience greater prevalence
of generalized anxiety disorder, psychological
distress, alcohol and drug dependency disor-
ders, and more days of poor mental health
within the past 30 days (S. D. Cochran et al.,
2000; King et al., 2003; Sloane et al., 2003).
Lesbians, gays, and bisexuals have also been
found to be more likely to be smokers and to have
used recreational drugs or alcohol compared
to otherwise similar heterosexuals (Gruskin,
Hart, Gordon, & Ackerson, 2001; King et al.,
2003; Tang et al., 2004), although not all stud-
ies have found such differences (Warner et al.,
2004).
Although many of the determinants of
elevated rates of mental disorders among
LGBT individuals are unknown, researchers
have identified psychosocial stress caused by
stigmatization and the associated exposure to
prejudice and discrimination as a major con-
tributor (B. N. Cochran & Cauce, 2006; Meyer,
2003b). From a stress and coping framework,
repeated experiences of discrimination have
been shown to be sources of chronic stress,
resulting in damage to the immune system,
inflammatory disorders, and cardiovascular
disease, as well as mental health disorders and
cognitive impairment (see Mays et al., 2007,
for a review). Indeed, a large body of work
examining the impact of racial discrimination
on mental and physical health has documented
that experiences of discrimination are associated
with poorer mental health (e.g., depression, anx-
iety, psychological distress), and physical health
(e.g., hypertension, self-rated health; Mays,
Cochran, & Barnes, 2007; Williams, Neighbors,
& Jackson, 2003). Individuals may also cope
with the stress of discrimination through the
use of substances like alcohol and cigarettes
and, indeed, discrimination has been associated
with increased consumption of cigarettes and
alcohol (Mays et al., 2007; Williams et al.,
2003). Another pathway by which perceived
discrimination may harm health, which has
garnered much less attention by researchers, has
been its role in diminishing the likelihood that
individuals will seek needed medical and mental
health treatment. There is emerging evidence
that perceived discrimination is associated with
a lower likelihood that individuals will seek
and obtain needed health care services such
as preventive health care (Trivedi & Ayanian,
2006; Van Houtven et al., 2005). However, there
remains a need for additional studies examining
the effect of perceived discrimination on individ-
uals’ reluctance to seek care, including studies
that examine unmet mental health care needs.
LGBT persons are exposed to very high levels
of harassment and discrimination (Herek, Gillis,
& Cogan, 1999; Meyer, 2003b), both directly
and through portrayals in the media and arts.
Moreover, in contrast to other socially stigma-
tized groups, LGBT persons have less protection
from discrimination under the law. Federal law
does not prohibit discrimination based on sexual
orientation, and only 20 states offer protection
against such discrimination (Task Force, 2008).
Negative attitudes towards gays and lesbians also
may be particularly virulent because many re-
ligious groups openly condemn homosexuality
and view homosexuality as an immoral lifestyle
choice. Consistent with this, negative attitudes
toward homosexuality are greater among indi-
viduals who possess a more traditional religious
ideology and those with higher levels of church
attendance (Herek, 1984, 1987, 1998; Herek &
Capitanio, 1996).
There are few studies examining the effect of
discrimination on the mental health of the LGBT
population (S. D. Cochran et al., 2001), particu-
larly relative to the numerous studies focused on
African Americans and other racial minorities
(e.g., Williams et al., 2003). However, the few
extant studies have documented the deleterious
effect of discrimination on the mental health of
persons of minority sexual orientation. For ex-
ample, LGBT men and women who have ex-
perienced antigay hate crimes are more likely to
 Burgess et al.
experience depressive symptoms than those who
have experienced nonbias-related crimes (Herek
et al., 1999). Experiences of perceived discrim-
ination also have been found to be associated
with higher rates of depressive symptoms among
a convenience sample of Asian and Pacific Is-
lander gay men (Yoshikawa, Wilson, Chae, &
Cheng, 2004) and similarly have been found
to be associated with symptoms of mental dis-
tress (anxiety, depression, and suicidal ideation)
among gay and bisexual Latino men (Diaz, Ay-
ala, & Bein, 2004; Diaz, Ayala, Bein, Henne, &
Marin, 2001). Other studies of homosexual men
have found perceived discrimination to be asso-
ciated with risky behavior, including unsafe sex
(Wong & Tang, 2004; Yoshikawa et al., 2004).
In addition, in one study, reported experiences
of discrimination mediated the relationship be-
tween sexual orientation and psychiatric mor-
bidity (Mays & Cochran, 2001), suggesting that
greater prevalence of discrimination experienced
by nonheterosexuals may account for dispari-
ties in mental health. This study, however, was
limited by a small sample of homosexual and
bisexual respondents (n = 73).
Unfortunately, much of the existing research
in this area has been fraught with methodological
problems, including the reliance on convenience
samples “who may be very different than the
general LGB population to which one wants to
generalize” (Meyer, 2003a, p. 685; see also B.
N. Cochran & Cauce, 2006; Mays & Cochran,
2001), and small sample sizes. The validity of
other studies has also been limited by the use
of an indirect measure of sexual orientation in
which sexual orientation is inferred from same-
gender sexual activity, rather than being asked
directly. This is problematic because sexual ori-
entation is a broader construct than sexual be-
havior. Assessing sexual behavior may include
heterosexual individuals who engage in same-
gender sexual behavior, but who do not experi-
ence the same type of social stigma compared
to those identifying as gay, lesbian, bisexual, or
transgender. Last, with the exception of the study
by Mays and Cochran (2001), discussed previ-
ously, most of the research examining the ef-
fects of harassment and discrimination on men-
tal health has lacked heterosexual comparison
groups, making it difficult to determine whether
3
higher rates of mental health disorders among
LGBT individuals, relative to heterosexuals, are
due to greater exposure to discrimination and
harassment.
This study makes important contributions to
the epidemiological research on sexuality, so-
cial bias, and mental health by using data from a
population-based survey of adults in Hennepin
County, MN to: (a) investigate the prevalence of
mental health symptoms and diagnoses and dis-
criminatory experiences among a relatively large
sample of self-identified gay, lesbian, bisexual,
and transgender individuals (n = 472) versus
heterosexual individuals (n = 7412); (b) exam-
ine the effect of sexual orientation on utilization
and underutilization of mental health services;
and (c) explore the extent to which experienc-
ing one or more discriminatory events in the
past year mediates potential disparities in men-
tal health between LGBT and heterosexual indi-
viduals. Given the mixed evidence as to whether
LGBT individuals are more or less likely to seek
mental health treatment relative to heterosexuals
(Bakker, Sandfort, Vanwesenbeeck, van Lindert,
& Westert, 2006; S. D. Cochran et al., 2003; King
et al., 2003; White & Dull, 1997), this study
explores both participant reports of receipt of
clinical diagnoses for mental health problems as
well as their subjective reports of mental health
symptoms. Our primary hypothesis is that men-
tal health problems and underutilization of men-
tal health care would be greater among LGBT
individuals compared to heterosexual individu-
als and that perceived discrimination would me-
diate the effect of sexual orientation on mental
health problems and underutilization of mental
health care.
METHODS
The present study is a secondary analysis
of a larger study, the Survey of the Health of
Adults, the Population and the Environment
(SHAPE) (Hennepin County Community Health
Department and Bloomington Division of Pub-
lic Health, 2003). The SHAPE survey was a
collaborative public health surveillance project
of Hennepin County Community Health Depart-
ment, the Minneapolis Department of Health
and Family Support, and the Bloomington
4 JOURNAL OF LGBT HEALTH RESEARCH
Public Health Division, Minnesota, with the
primary aim of providing estimates on major
health indicators for 16 urban and suburban
regions within Hennepin County, for six ethnic
and racial groups: American Indians, Southeast
Asians, U.S.-born Blacks, African-born Blacks,
Hispanics or Latinos, and Whites. The study
consisted of telephone interviews conducted
on a disproportionate stratified random sample
of 9,959 adults residing in Hennepin County,
Minnesota during 2002. More details about the
survey methods can be found in the SHAPE
Methodology Report (Hennepin County Com-
munity Health Department and Bloomington
Division of Public Health, 2003).
Respondents were selected at random through
a two-stage process. First, households were ran-
domly selected from a telephone list contain-
ing published and unpublished numbers; next,
one adult was randomly selected from each
household for a telephone interview. In total,
15,237 households were contacted and 10,098
interviews were completed, representing a re-
sponse rate of 66.3% for the county as a
whole. Sexual orientation was ascertained by
the following question, “Do you consider your-
self . . . ‘heterosexual or straight,’ ‘gay or les-
bian,’ ‘bisexual,’ ‘transgender,’ ‘not sure,’ ‘don’t
know’?” This investigation focuses on only
those respondents who reported their sexual ori-
entation (total N = 7,884).
Measures
Perceived discrimination was measured by
adapting the Experience of Discrimination
(EOD) questions from the Coronary Artery Risk
Development in Young Adults study that were
originally developed by Krieger (1990; Krieger
& Sidney, 1996). Respondents were first asked if
they had ever experienced any of the following
during the past 12 months: getting a job, being
at work, medical care, getting housing, getting
a mortgage or loan, applying for social services
or public assistance, dealing with the police. For
each situation that they experienced, they were
then asked if they experienced discrimination.
After providing their perceptions of discrimina-
tion for each of the seven situations, respondents
were then asked the reason or reasons that they
felt discriminated against and were given choices
of race, color, ethnicity, or country of origin; age;
gender; sexual orientation; disability; religion;
something else; or don’t know. Although there
has not been extensive documentation of the psy-
chometric properties of this early version of the
EOD, a recent evaluation of a subsequent ver-
sion of the EOD has shown the measure to have
high scale reliability, test–retest reliability, and
construct reliability, and to be superior to single-
item discrimination scales (Krieger, Smith,
Naishadham, Hartman, & Barbeau, 2005). In
this study, perceived discrimination was defined
as having perceived oneself to have been dis-
criminated in any of the specified situations over
the past year.
Mental Health Indicators. We included sev-
eral indicators of poor mental health: mental
health diagnoses, psychological distress, per-
ceived need for mental health care, and utiliza-
tion of mental health services. Respondents were
asked whether “a doctor or other health profes-
sional has ever told you that you had any of the
following conditions,” which included “depres-
sion” and “anxiety or panic attack.” Those who
answered affirmatively were classified as hav-
ing had a mental health diagnosis (of depression
or anxiety). Psychological distress was assessed
by the following question: “Thinking about your
mental health, which includes stress, depression,
and problems with emotions, for how many days
during the past 30 days was your mental health
not good?” Perceived need for mental health
care was assessed by the following question,
“In the past 12 months was there a time when
you wanted to talk with or seek help from a
health professional about stress, depression or
problems with emotions?” Use of mental health
services was assessed with questions asking
whether, over the past 12 months, participants
sought help from (a) a mental health provider or
counselor, or (b) self-help or support groups.
Substance Use. We also examined the two
available measures of substance use: smoking
and binge drinking. Smoking status was ascer-
tained by a question asking respondents whether
they smoked cigarettes “everyday, some days,
or not at all?” and recoding respondents who
smoked “everyday” and “some days” as smok-
ers, and those who smoked “not at all” as
 Burgess et al.
nonsmokers. We also examined smokers’ self-
reported average number of cigarettes smoked
per day. We classified respondents as binge
drinkers if they reported having five or more
drinks on a single occasion within the past 30
days.
Unmet Mental Health Care Needs. We ex-
amined unmet mental health care needs dur-
ing the past 12 months, via questions adapted
from the Behavioral Risk Factor Surveillance
System (Prevention, 2001). Respondents were
classified as having unmet mental health care
needs if they reported yes to both of the follow-
ing questions: “In the past 12 months, was there
a time when you wanted to talk with or seek
help from a health professional about stress, de-
pression, or problems with emotions?” and, “Did
you delay or not get the care you thought you
needed?”
Covariates. We included age, gender, race/
ethnicity, education, and poverty level as co-
variates because they have been shown to be
associated with mental health, mental health uti-
lization, and/or perceived discrimination in pre-
vious research. Prevalence of depression, for
instance, has been shown to be greater among
women and low-income individuals, and lower
among Asians, Hispanics, and Blacks (Hasin,
Goodwin, Stinson, & Grant, 2005; Kessler
et al., 1993). Prevalence of psychological dis-
tress has been shown to be greater among
women, non-White, and lower socioeconomic
status individuals (Fiscella & Franks, 1997;
Myer, Stein, Grimsrud, Seedat, & Williams,
2008; Turner & Marino, 1994). Receipt of men-
tal health treatment, on the other hand, has
been shown to be greater among women and
lower among non-Hispanic Whites and lower
socioeconomic individuals (Elhai & Ford, 2007;
Hasin et al., 2005; Kessler et al., 2005; Wa-
mala, Merlo, Bostrom, & Hogstedt, 2007). Sev-
eral of these covariates have also been associ-
ated with perceived discrimination. Perceived
discrimination has consistently been shown to
be higher among non-Whites, although the rela-
tionship between perceived discrimination and
other socio-demographic variables (age, income,
education) is less clear cut (Clark, Anderson,
Clark, & Williams, 1999; Kessler, Mickelson, &
Williams, 1999; Vines et al., 2006). We also in-
5
cluded insurance status because lesbian women
have been found to be less likely to have health
insurance (S. D. Cochran et al., 2001; Diamant,
Wold, Spritzer, & Gelberg, 2000), which may
affect utilization of mental health services. Fi-
nally, we included English language proficiency
as a covariate, because it has been associated
with disparities in mental health care utilization
(Sentell, Shumway, & Snowden, 2007). For this
measure, respondents who were interviewed in
any of the four translated languages (Hmong,
Vietnamese, Spanish, or Somali) were classified
as having limited English language proficiency.
Statistical Analysis. Logistic and multiple re-
gression methods were used to estimate the rela-
tionships between sexual orientation and mental
health indicators and perceived discrimination,
controlling for gender, age, race/ethnicity, mari-
tal status, educational attainment, income, insur-
ance status, and English language proficiency.1
Because race/ethnicity is highly correlated with
perceived discrimination, we repeated analyses
with only non-Hispanic White respondents to
control for potential confounding, an approach
taken by Mays and Cochran (2001). We report
these analyses after our presentation of the re-
sults using the whole sample. In some instances,
we also report results from unadjusted com-
parisons (χ 2 and ANOVA) to provide descrip-
tive information about our sample, such as the
prevalence of discrimination and mental health
disorders.
RESULTS
Demographic Characteristics
Demographic characteristics of the sample by
sexual orientation status and results of statisti-
cal tests are presented in Table 1. Of the 4,529
(57.4%) women and 3,355 (42.6%) men com-
prising the final sample (total N = 7,884), 3,051
(90.9%) men and 4,361 (96.3%) women identi-
fied as heterosexual, whereas 304 (9.1%) men
and 168 (3.7%) women identified as LGBT. In
total, 356 respondents (4.5%) identified as gay
or lesbian, 110 (1.4%) identified as bisexual, and
6 (.1%) identified as transgender. Compared to
heterosexuals, those identifying as LGBT were
6 JOURNAL OF LGBT HEALTH RESEARCH

TABLE 1. Characteristics of the SHAPE Sample by Sexual Orientation

LGBT (n = 472) Heterosexual (n = 7412)

∗ Female, % (N) 35.6 (168) 58.8 (4361)

∗ Mean age (SD) 38.9 (10.55) 40.0 (12.54)
∗ Non-Hispanic white, % (N) 87.7 (414) 70.0 (5192)
∗ Education

Less than high school, % (N) 2.6 (12) 7.3 (530)

High school, % (N) 12.1 (5) 21.3 (1550)
Some college, % (N) 28.1 (130) 31.1 (2260)
College or higher, % (N) 56.9 (263) 40.3 (2930)
Income <200% of federal poverty level, % (N) 17.4 (80) 24.3 (1641)
Lacks health insurance 12.1 (57) 10.2 (753)

Note. *Unadjusted estimates significant at p ≤ .05.

TABLE 2. Perceived Discrimination by Sexual Orientation

Type of Discrimination LGBT Heterosexual

Applying for a job, % (N) 24.8 (37) 22.2 (419)

∗ At work, % (N) 20.6 (86) 14.8 (872)
Getting medical care, % (N) 4.2 (15) 4.7 (242)
Getting housing, % (N) 11.5 (10) 14.4 (160)
Getting a mortgage or loan, % (N) 8.6 (9) 8.5 (131)
Applying for social services or public assistance, % (N) 16.7 (5) 19.4 (106)
Dealing with the police, % (N) 24.8 (34) 21.9 (339)
Any of the above, % (N) 29.0 (131) 23.6 (1606)

Note. *Unadjusted estimates significant at p ≤ .05.

more likely to be younger, t (7882) = 1.94, p ≤
.05; male, χ 2 (7884) = 98.07, p < .001; better
educated, χ 2 (7732)= 67.79, p ≤ .0005; non-
Hispanic white, χ 2 (7884) = 67.39, p ≤ .001;
and less likely to be poor (i.e., they were less
likely to have household incomes ≤ 200% of
the Federal Poverty level, χ 2 (7210) = 11.19,
p ≤ 001. LGBT and heterosexual respondents
did not differ significantly on whether they had
insurance, χ 2 (7877) = 1.80, ns.
Prevalence of Perceived Discrimination
Among LGBT and Heterosexual Respondents.
As can be seen in Table 2, LGBT respon-
dents reported a higher number of situations
of major discrimination than heterosexual re-
spondents (M = .43, SD = .80 vs. M = .33,
SD = .87, F [1,7264] = 8.74, p ≤ .01), and
29.0% of the LGBT sample reported experienc-
ing at least one situation of discrimination in
the past year, in contrast to 23.3% of the het-
erosexual sample, χ 2 (7884) = 6.99, p ≤ .01.
However, this was driven by reports of discrimi-
nation at work, specifically, which was higher
among LGBT persons than heterosexual per-
sons (21% vs. 15%; χ 2 [6320] = 10.37, p ≤
.001). LGBT and heterosexual respondents were
equally likely to report experiencing discrim-
ination in other domains: applying for a job,
χ 2 (2038) = .56, p > .05, ns; getting medical
care, χ 2 (5518) = .18, p > .05, ns; getting hous-
ing, χ 2 (1197) = .57, p > .05, ns; getting a mort-
gage or loan, χ 2 (1648) = .00, p > .05, ns; ap-
plying for social services or public assistance,
χ 2 (577) = .14, p > .05, ns; and dealing with the
police, χ 2 (1687) = .64, p > .05, ns.
Reported reasons for discrimination differed
by sexual orientation. Among the LGBT respon-
dents who reported experiencing discrimination,
51% reported that the discrimination was due to
their sexual orientation. The rest attributed the
discrimination to gender (21%); race, ethnicity,
or country of origin (21%); age (9%); religion
 Burgess et al.
TABLE 3. Mental Health Disorders, Substance Abuse, and Unmet Mental Health Needs by Sexual
Orientation
Depression diagnosis, % (N )
Anxiety/panic attack diagnosis, % (N )
Mean number of poor mental health days in past 30 days (SD)
Perceived need for mental health services, % (N)
Saw mental health provider, % (N)
Attended a self-help group, % (N)
Smoker, % (N)
Mean number of cigarettes smoked daily (SD)
Engaged in binge drinking in past 30 days, % (N)
Unmet mental health needs (among those reported needing mental
health services), %(N)
Notes. a Effect of sexual orientation significant at p < .05 in unadjusted analyses.
b Effect of sexual orientation significant at p < .05 after controlling for the effects of gender, age, race/ethnicity, marital status, educational
attainment, income, insurance status, and English language proficiency.
(3%); and disability (5%). Among the hetero-
sexual respondents who reported experiencing
discrimination, only 2% reported sexual orien-
tation as a reason for the discrimination. Instead,
the most prevalent perceived cause of discrimi-
nation among heterosexuals was race, ethnicity
or country of origin (50%). Other perceived rea-
sons for the discrimination among heterosexuals
were age (16%), gender (19%), disability (5%),
and religion (3%).
Effect of Sexual Orientation on Mental
Health, Substance Use and Underutilization
of Mental Health Services. Table 3 presents
differences in mental health, substance use,
and underutilization of mental health care by
sexual orientation. In unadjusted analyses,
LGBT individuals had a greater number of
poor mental health days, F (1,7805) = 29.70,
p ≤ .001; higher likelihood of receiving a
diagnosis of depression, χ 2 (7850) = 96.06, p ≤
.001, or anxiety, χ 2 (7841) = 58.96, p ≤.001;
higher perceived need for mental health
care, χ 2 (7865) = 68.42, p ≤ .001; greater
likelihood of having seen a mental health
provider χ 2 (7878)= 89.72, p ≤ .001, or having
attended a support group, χ 2 (7854)= 25.43,
p ≤ .001; greater likelihood of being a smoker,
χ 2 (7858) = 28.77, p ≤ .001; greater number
of cigarettes smoked, F (1,7806) = 34.39, p ≤
.001; higher likelihood of binge drinking during
7
LGBT Heterosexual
33.0 (155) 15.6 (1152)a,b
20.8 (98) 9.7 (714)a,b
4.50 (7.59) 2.81 (6.46)a,b
40.7 (191) 23.7 (1755)a,b
30.3 (143) 14.2 (1050)a,b
17.8 (84) 10.4 (765)a,b
34.0 (160) 23.2 (1712)a,b
1.64 (.96) 1.41 (.81)a,b
24.2 (113) 16.7 (1223)a
42.9 (82) 34.7 (606)a,b
the past 30 days, χ 2 (7792) = 17.39, p ≤ .001,
and were more likely to have unmet mental
health care needs, χ 2 (1938) = 5.11, p ≤ .05.
After controlling for gender, age, race/
ethnicity, marital status, educational attainment,
income, insurance status, and English language
proficiency, most of these variables remained
significant. LGBT respondents reported a
greater number of poor mental health days than
heterosexual respondents (β = .06, t = 4.69,
p ≤ .001) and were more likely to have received
a diagnosis of depression (adjusted OR = 1.68;
95% CI = 1.50, 1.89) or anxiety (adjusted
OR = 1.56; 95% CI = 1.36, 1.78) and to report
that they needed mental health care over the
past 12 months (adjusted OR = 1.52; 95% CI =
1.37, 1.70). Compared to heterosexuals, LGBT
respondents were more likely to report that they
saw a mental health provider (adjusted OR =
1.62; 95% CI = 1.42, 1.80) and to report that
they attended a self-help or support group
(adjusted OR = 1.39; 95% CI = 1.21, 1.59).
LGBT individuals also reported higher levels
of substance use. They were more likely to be
smokers (adjusted OR = 1.21; 95% CI = 1.08,
1.35) and reported smoking more cigarettes per
day relative to heterosexual respondents (β =
.05, t = 3.37, p ≤ .01). However, LGBT indi-
viduals were no more likely than heterosexual
individuals to have engaged in binge drinking
8 JOURNAL OF LGBT HEALTH RESEARCH
over the past 30 days (adjusted OR = 90; 95%
CI = .79, 1.02). Finally, LGBT individuals were
more likely than heterosexual individuals to
report unmet mental health care needs (adjusted
OR = 1.19; 95% CI = 1.01, 1.42).
Does Perceived Discrimination Account for
the Influence of Sexual Orientation on Mental
Health and Mental Health Utilization? To test
the hypothesis that experiencing one or more
major discriminatory events in the past year
would mediate the effect of sexual orientation
on mental health, we conducted separate hierar-
chical logistic or multiple regression analyses,
depending on whether the dependent variable
was categorical or continuous. In the first block,
we adjusted for gender, age, race/ethnicity, mari-
tal status, educational attainment, income, insur-
ance status, and English language proficiency;
we entered sexual orientation in the second
block; and we entered discrimination in the third
block. We also tested the interaction between
sexual orientation and discrimination to deter-
mine if discrimination functions differently for
LGBT and heterosexual individuals. This in-
teraction term was statistically significant only
in the model predicting for subjective mental
health.
After the inclusion of socio-demographic
variables and sexual orientation, discrimination
was associated with having received a diagnosis
of depression (adjusted OR = 2.12; 95% CI =
1.82, 2.48) or anxiety (adjusted OR = 2.15; 95%
CI = 1.80, 2.57), perceived mental health needs
(adjusted OR = 2.33; 95% CI = 2.04, 2.67),
having seen a mental health provider (adjusted
OR = 1.72; 95% CI = 1.47, 2.03), and having
attended a self-help group (adjusted OR = 2.11;
95% CI = 1.77, 2.52). Discrimination was also
associated with being a smoker (adjusted OR =
1.58; 95% CI = 1.38, 1.82) and number of
cigarettes smoked per day (β = .09, t = 7.37,
p ≤ .0005), but was not associated with binge
drinking (adjusted OR = 1.15; 95% CI = .97,
1.36). In addition, discrimination was associated
with unmet mental health needs (adjusted OR =
1.30; 95% CI = 1.04, 1.63). As mentioned, there
was a significant interaction between discrimi-
nation and sexual orientation for number of poor
mental health days (β = .05, t = 2.27, p ≤ .05),
such that discrimination was associated with
more poor mental health days for heterosexual
respondents (β = .14, t = 10.74, p ≤ .0005)
but not for LGBT respondents (β = .02, t =.31,
p > .05, ns).
In contrast to expectations, hierarchical re-
gression equations revealed that adding the per-
ceived discrimination variable to the model did
not significantly change the relation between
sexual orientation and any of the mental health
and substance abuse indicators, nor did it change
the relation between sexual orientation and un-
met mental health needs.
Effect of Sexual Orientation on Discrimina-
tion, Mental Health, Substance Use, and Unmet
Mental Healthcare Needs Among Non-Hispanic
Whites. When we repeated the unadjusted analy-
ses using the subsample of non-Hispanic Whites,
the effect of sexual orientation on discrimination
was more pronounced. Among non-Hispanic
Whites, 26.4% of LGBT respondents (n = 105)
reported experiencing at least one situation of
discrimination in the past year, in contrast to
17.3% (n = 852) of heterosexual respondents,
χ 2 (5332) = 20.77, p ≤ .001. Among non-
Hispanic Whites, LGBT respondents were more
likely to report experiencing discrimination in
the workplace, 19.1% (n = 71) versus 11,2%
(n = 490), χ 2 (4750) = 20.74, p ≤ .0005, and
in encounters with the police, 21.7 % (n = 26)
versus 12.9% (n = 140), χ 2 (1205) = 6.99, p ≤
.01. There were no significant differences be-
tween LBGT and heterosexual respondents for
discrimination in any of the other situations. In
multivariate analyses examining the effect of dis-
crimination, mental health, and substance use,
results for the sample of non-Hispanic Whites
mirrored the results for the entire sample, with
two exceptions: after adjusting for covariates,
LGBT status was not significantly associated
with being a smoker (adjusted OR = 1.12; 95%
CI = .97, 1.30) and was not significantly asso-
ciated with unmet mental health needs (adjusted
OR = 1.40; 95% CI = .97, 1.41).
DISCUSSION
This study is one of the few population-based
studies to examine the effects of perceived
discrimination on the mental health and mental
 Burgess et al.
health utilization of LGBT individuals. Con-
sistent with previous research, in comparison
to similar heterosexual persons, LGBT persons
consistently scored poorer on a variety of
mental health indicators, which included more
self-reported symptoms of poor mental health,
a greater perceived need for mental health
services, greater use of mental health services
and higher levels of smoking, as well as formal
psychiatric diagnoses (depression and anxiety
disorders). LGBT persons were also more likely
than their heterosexual counterparts to smoke,
smoked a greater number of cigarettes, and
were more likely to report an episode of binge
drinking in the past 30 days (in the unadjusted
analysis), which suggests the use of substances
as a way to cope with stresses associated with
minority sexual orientation.
A strength of this study is its examination
of a broad range of mental health indicators,
which offsets some of the limitations posed by
specific measures. For instance, our measure of
substance abuse was limited to a fairly insen-
sitive indicator (binge drinking), and thus we
may not have fully captured the responses to
the stress of discrimination in the form of alco-
hol consumption. Another limitation concerns
our measure of psychiatric diagnoses, which as-
sessed lifetime diagnoses. This is problematic
because the measure of perceived discrimina-
tion assessed discriminatory incidents over the
past year. Moreover, the use of psychiatric di-
agnoses as an indicator of poor mental health
may be problematic, given the evidence that a
high percent of individuals do not seek formal
care for mental disorders (Kessler et al., 2005)
and that failure to seek necessary health care
has been shown to be greater among individuals
who have previously experienced discrimination
(Wamala et al., 2007). Indeed, LGBT individu-
als in this sample were also more likely to report
unmet mental health needs than heterosexual in-
dividuals, a finding that is particularly troubling,
given the higher prevalence of mental health dis-
orders in this population. Given the limitations
of specific measures, it is the pattern of results
across a variety of measures of mental health
rather than any single result that lends credence
to the broader conclusion that poor mental health
is a correlate of perceived discrimination.
9
LGBT individuals were also more likely
to report having experienced an incident of
discrimination over the past year, relative to
heterosexual individuals. In the entire sample,
LGBT individuals were more likely to report
experiencing discrimination in the workplace
over the past year relative to heterosexual
individuals but were not more likely to report
discrimination in other settings (e.g., dealing
with the police, getting housing). When the
sample was restricted to non-Hispanic Whites,
however, sexual minority status was also asso-
ciated with discrimination in dealing with the
police. This pattern of discrimination is similar
to what was reported in a national study by Mays
and Cochran (2001), who, in their examination
of lifetime experiences of discrimination, found
that sexual minority individuals were more
likely to report being fired from a job, but
did not report significantly greater levels of
discrimination for any of the other 10 domains
examined. Although perceived discrimination
was associated with almost all indicators of poor
mental health, adjusting for discrimination did
not significantly reduce mental health disparities
between heterosexual and LGBT persons.
The finding that experiencing a major dis-
criminatory event in the past year did not me-
diate the effect of being LGBT on mental
health is inconsistent with results of a national
study conducted in 1995 (Mays & Cochran,
2001) in which perceived discrimination attenu-
ated the relation between sexual orientation and
three mental health indicators. However, Mays
and Cochran’s (2001) study used two measures
of discrimination that assessed lifetime occur-
rences of major discrimination (e.g., workplace
discrimination, being denied housing) and the
frequency of everyday discrimination, such as
“being treated with less courtesy or respect than
others; receiving poorer services than others at
restaurants or stores; being called names, in-
sulted, threatened, or harassed; or having people
act afraid of the respondent or as if the respon-
dent was dishonest, not smart, or not as good as
they were” (p. 1870).
Although the measure of discrimination used
in our analyses, having experienced discrimi-
nation over the past year, was associated with
almost all of the indexes of poor mental health
10 JOURNAL OF LGBT HEALTH RESEARCH
that we examined, this measure may not have
fully captured the range of stressors experi-
enced, or stress responses exhibited. by LGBT
individuals. Conceptual models examining the
particular stressors experienced by LGBT per-
sons, such as Meyer’s minority stress model
include not only “external objective stressful
events and conditions” (such as discrimination)
but also “expectations of such events and the
vigilance this expectation requires, and the in-
ternalization of negative attitudes, and conceal-
ment of one’s sexual orientation” (Meyer, 2003b,
p. 676). Measures of perceived discrimination
such as the one used in this survey were not de-
signed to capture the stressors associated with
being vigilant and stressors associated with hid-
ing one’s discrimination (i.e., indirect experi-
ences of heterosexism). Other measures, such
as Waldo’s (1999) measure of heterosexist expe-
riences, which capture a range of negative sit-
uations that LGBT individuals may experience
because of their sexual orientation, such as di-
rect, as well as indirect, experiences (e.g., feel-
ing that one needed to “act straight”), capture
a broader range of social stressors specific to
sexual minorities that may account for dispari-
ties in mental health. In addition, our measure
of perceived discrimination included discrimi-
nation on the basis of a number of factors (e.g.,
age, disability, ethnicity) and, therefore, was not
limited to discrimination based solely on sex-
ual orientation. We did not use the measure of
discrimination based solely on sexual orienta-
tion because it was so highly correlated with
sexual orientation and, therefore, posed prob-
lems for the comparative nature of our statistical
analysis.
Another limitation of our study is the fact
that we did not assess whether individuals dis-
closed their sexual orientation within the sit-
uations that they experienced discrimination.
Disclosure of sexual orientation is particularly
relevant to understand the social stressors expe-
rienced by sexual minority persons in the work-
place, because the factors that predict perceived
discrimination in the workplace (e.g., organiza-
tional policies barring discrimination based on
sexual orientation) may be the same factors that
make it less likely that sexual minority individu-
als will disclose their sexual identity/orientation.
Hence, individuals who experience a workplace
climate that leads them to hide their sexual ori-
entation may not directly experience discrim-
ination, but may nonetheless experience the
deleterious psychological consequences of het-
erosexism in the workplace. A related limitation
of the available dataset was the omission of ques-
tions assessing how respondents coped with the
discrimination they experienced, which has been
shown to moderate the relation between adverse
events (including discrimination) and physical
and psychological health (Clark et al., 1999;
Noh, Beiser, Kaspar, Hou, & Rummens, 1999;
Noh & Kaspar, 2003).
Our operationalization of LGBT also has
certain strengths and limitations. An important
strength is that our self-report measure was
specifically worded to assess sexual identity, un-
like some previous studies that defined sexual
orientation in terms of same-gender sexual be-
havior (see S. D. Cochran et al., 2003, for a dis-
cussion). The operationalization of sexual ori-
entation solely in terms of same-gender sexual
behavior has been critiqued on the grounds that it
is, on one hand, too narrow, failing to index indi-
viduals who have a minority sexual orientation
in the absence of sexual behavior, and, on the
other hand, it is too broad, indexing individuals
who may consider themselves to be heterosex-
ual despite their behavior (S. D. Cochran et al.,
2003). However, a limitation of our operational-
ization is that, due to our small sample of sex-
ual minority individuals, we collapsed bisexual,
lesbian, gay, and transgender respondents into
a single category. Hence, we were not able to
explore potentially important differences within
the LGBT population and examine subgroups,
such as bisexual individuals and transgender in-
dividuals, who may be particularly at risk for
mental health problems (Jorm, Korten, Rodgers,
Jacomb, & Christensen, 2002) and stigmatiza-
tion (Nemoto, Operario, Keatley, Nguyen, &
Sugano, 2005). Additionally, the small number
in the LGBT sample did not allow us to exam-
ine the effect of multiple stigmatized statuses,
such as race/ethnicity, on perceived discrimina-
tion and mental health, or allow us to test for
generational and cohort effects.
Our findings were also limited by the fact
that the data were derived from respondents in
 Burgess et al.
Hennepin County, Minnesota. Minnesota is one
of only 20 states that ban discrimination based on
sexual orientation, and one of only 13 states with
an explicitly transgender-inclusive nondiscrim-
ination law (Task Force, 2008). Because leg-
islative policies toward discrimination based on
sexual orientation, as well as individual or-
ganizational policies, have been shown to be
associated with antigay discrimination and
heterosexism (Ragins & Cornwell, 2001;
Waldo, 1999), Minnesota’s relatively progres-
sive stance on LGBT issues may explain why
LGBT individuals were not more likely than
heterosexuals to experience discrimination in
other domains. Likewise, it seems plausible that
the prevalence of discrimination and the psy-
chological consequences of discrimination may
be lower for LGBT respondents in our sample
relative for individuals in other parts of the
country. This hypothesis could be tested using a
national sample and a multilevel approach that
includes institutional-level measures expected
to be associated with discrimination, such as
the presence of state laws that protect LGBT
employees from discrimination, as well as
individual-level perceptions of discrimination
(Ragins & Cornwell, 2001).
Despite these limitations, this study makes
several important contributions to the under-
standing of mental health among LGBT indi-
viduals. In addition to being one of the few
population-based studies that examines the im-
pact of perceived discrimination on mental
health and mental healthcare utilization among
LGBT individuals, to our knowledge, this is the
only published study to investigate the effect of
sexual orientation and recent experience of a
major discriminatory event on underutilization
of mental health care services. Although LGBT
individuals were more likely to perceive them-
selves as needing mental health care and were
more likely to utilize mental health services, they
were also more likely than heterosexual individ-
uals to report that they did not receive mental
health services, or that such services were de-
layed. This is particularly striking, given that mi-
nority sexual orientation was not associated with
elevated discrimination in the healthcare setting.
These results support the notion that experiences
of discrimination, in addition to being a life stres-
11
sor that harms mental health and increases sub-
stance use, also has a negative impact on mental
health by increasing the likelihood that individu-
als will avoid seeking needed mental health care
services, perhaps until issues become more criti-
cal or urgent. It may be the case that experiences
of discrimination may engender negative expec-
tations among stigmatized groups about how
they will be treated within larger institutional
systems, making them wary of entering those sit-
uations. Future research in laboratory and field
settings are needed to test the hypothesis that per-
ceived discrimination in a particular domain can
affect individuals’ expectations of discrimina-
tion in a broader range of settings. Given that re-
searchers have also found that lesbians are more
likely than heterosexual women to underuti-
lize needed preventive health services (Stevens,
1992; Valanis et al., 2000; White & Dull, 1997),
it further would be useful to examine the ex-
tent to which perceived discrimination may be
a factor in such treatment seeking and utiliza-
tion decisions. Researchers might also examine
the factors that attenuate the negative association
between perceived discrimination and underuti-
lization of needed mental health care. For ex-
ample, does this association disappear if LGBT
individuals have the option of seeking mental
health services from organizations specifically
designed to help individuals of minority sexual
orientation?
In sum, these results illustrate how, within the
LGBT population, perceived discrimination is
a significant risk factor for mental health disor-
ders, as well as underutilization of needed mental
health care services. Hence, interventions to im-
prove the mental health of this population need
to be attuned to the deleterious impact of the
social stressors associated with sexual minority
status.
NOTE
1. We also conducted analyses that included a gen-
der × sexual orientation interaction term in the second
block. This interaction term was not significant for any
analysis so we did not include this term in our final
analyses.
12 JOURNAL OF LGBT HEALTH RESEARCH
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