Seriya NC Poti aot 1687 ‘ov tariogetann oreo7e2 BMC Psychiatry CEs Cras Sexual orientation and symptoms of Om common mental disorder or low wellbeing: combined meta-analysis of 12 UK population health surveys Joanna Semiyen', Michael King’, Justin Varney" and Gareth Hagger-Johnson™” Abstract Background: Previous sues have Inca nctested rk of mental sore symptoms sulde and substance misuse in sbian gay and bse (LG) aout, compared to heterosousl adits Our ans were to deterrine an ‘strate ofthe esecktion between Sena onentaton Key and poor mental heath and wellbeing 2mong ‘dul fam 12 populston surveys in the UK. and to conser whether eects afered for sactc subgroup ofthe population Methods: Indus data vce pooled fram the Bish Chor Study 2012, Heath Survey for England 2011, 2012 and 2013, Scotish Heath Suey 200610 2013, Lona Sud of Young People in Engand 2008/10 and Understanding Society 2011/12 Indu parame met-anass was usd to poo estimates fom each study allowing for beweer-suayvaraton Results: Of 94818 prtcipats, |. 8 dete as esting 09 9 a isn 08 % a ‘ether and 972 2 hetero, Aajsting fora range af covariates ats who dented 3 lesbarvgny had higher prevalence of common mertal serdar when compared to heterosouals but he asiocaton was diferent in diferent 392 ‘10Ups apparent for hake under 35 (OR= 1.78 95 % Cl 140226), weer a age 39-549 OR= 142, 9555 C110, "aA but stongest at age S5+ (R= 205, 8 6 C 129,331), Tese eles were stronger for Beal ads sma for those dentving as other ard senlror low web) ‘Conchsions nthe UK LG adults have higher prevalence of pocr mental heath and ly welbeng When compared toheteroseua, patio younge and oder LGB atts Sexi cretion deny shoudl be mesa outing heath sues sd in admnsratve data nthe Un oder infience national nd local poicy development and Sevice diver These eu retrate the nee for loa goverment NFS provides and pubic hesth poy makes to consider haw toads nequals h mental heath among these minors FOURS Keywords Ace dcr Depression Heath sures Homer, Metal dices Mewanahsis Mood diodes, | Neve dsrdes ext oretaton Sexy CO) siomed cena! 2SeniynetoANC oto abi 167 Background Around 1-2 % ofthe United Kingdom adult poplation ‘lent at lesbian, gay or bien (LGB) [1,2] and 5% 1s non-hetrosexua 2), although Because sexal orien tation comprises identity behaviour and atracton [], the chosen definition used can fad to variably in these ‘atinain We kom tht seul minority poplin ex pelencepooter physical heth (| and engage Ine health Behaviours sucha smoking and hazardous drink {ng (Sl. These Inequsitles may emerge in adolescence and cay adulthood, then persist throughout the f= courte (6 ‘Symptoms of poor mental health (eg anxiety, depres tion) and low welling (eg, at having posve mental healt” [7]) are common In the adult population but there i established evidence that adults who ently a lesbian, gay o bisexual are at higher risk of experiencing theve symptoms than ade who identify ax heteroex al A systematic review ofthe prealenc of mental is fore substance abuse, suicidal and selfharm in LGB. people showed that these populations experience a fester incidence of depression, anxiety, sida and fubsance misuse [8] than hetrosexain Metals following this reve found that LGB people. were round twice a ikl to hae atempted suede in thie [edie and have around 15 times higher prevalence of depression and anxiety disorders. in the preceding 12 months, Awocilons between rlnorty sexta ere tation and poorer mental health have persed overtime ith eecent studies showing the same efits a oer Studies (9), Such disparities are thought to emerge early fm adlecence and pris into adulthood [10 Population-based evidence of poorer mental heh in LGB peopl hasbeen found in seme fom the United. Sts [Il, 12}, Netherands [9] and England [13} A though these findings are_ restricted thigh income counties data fom Tow inome countries are inlay valable [4], Population surveys involving comprehen sive psyehiaui ierviews have showa increased 3k of feommon mental dsorders among LGB adits (2 13) Similar reauts have ben found tn linia, community fand convenience samples (13, 15-17], Unal recently however, sexual erentation was not recorded routinely in UK population health surveys [5] and remains poorly recorded in rational data collection fom service sch 5 the UKS Increased Access to Psjchologcal Therapies AGAPT) services. Thi ack of recording of sextl erent. tn presents challenges when targeted or toring iter ‘eniions to LGB adults and in partic, subgroups of UGB adults wah specie service needs [18,19]. Fe studies have considered which subgroups of the LGB. dul population are most at isk of poor mental eal (Gor example by age group, sex ethnic minority satis for educational atainment) The sim of our study was therefore to evaluate whether the association between sexual orientation identity and mental hea (common ‘ental disorder and lw welling) was diferent in ferent subgroup ofthe non-heterosexl identified aul population inthe United Kingdom, using newly ralale pooled data fom 12 population health surveys. Method Design and setting Parlpants were frm the Bish Cohort Study (BCS) 2012 (20), Health Survey for England (HSE) 2011 (2, 2012 [22] and 2013 [23), Scouieh Health Survey (SHS) 2008 to 2013 [24], the Longitudinal Study of Young People in England (LSYPE) 2009/10 [5] and Understand lng Society (US) 2011/12 25), denied by searching the UK Data Series (earch terms seal oventation, ‘iy lesbian, sexual sexual). Al studles elected dat using either home vs interviews, slf- completion ‘questionnaires, tephone interviews, web surveys oF & combination (deals ineladng sampling designs and in ‘uson/exclasion eters ae avalable fom the UK Dat Archive). Our stay population comprised adults with table dita on secu erienation Meni, pone fof mental heath and wellbeing, and stady cova. Partpants and matrls Paricpants For all studi inked in our analysis, par pants were rected though random of Suatlied random sampling of their target poplation Sexual remain idenity Sexual orientation ently was recorded in sell completion questonnales in all Included studles using Standardised wording recommended by the Office of National Stasis (ONS) (1). Patipans were asked “Which af the following option best descrtes how you think of yoursel Response options were ‘Heterosexual or Staght "Gay or Lesbian ‘Bisex Other or res Parcipants who refised to anower thie queion were eluded frm our ana, om the basis that they could ‘ot be assigned to any sexual exenation ident ca gory Table {shows the refusal rate acros al studies. Symptoms of common mental disorder “Meeting the threshld for symptoms of mental health eas defined a5 scoring 4 or higher on the General Health Questionnaire 12 (GHQ-12) [2, 6) For HSE, cases were defined as moderatly/severely depressed. 08 ‘he EOD sbeale which measices very sir ment halth symptoms [22, 27-29], Both nsvuments have been vaidte forthe detection of clinically signfcant symptoms af mental disorder [7,25 30, 3. Senstity tales (described below) evaluated whether ferences tween thas insirument inlonced the rte,SeniynetoANC oto abi 167 Paget Table 1 ccs ftv Toaie=Bal8 BR hor Sa anyon OE Se Han Domina or a ee eto ty en 05 oo wo 65 M6 2 e283 OF posses) xs 198 lomwetterg ene 8) 311 a6 9527 9 m6 wo D7 me TB hon teoe 60) 196 1688 T6100 1619 RED RION 96 IER 1H EO 16100 kivereay? at se ss may moma 21 ze as ee Umesnydegee 9 Bl XI 6S DK) 6S BAD MD wT 2 ata oe ea oe ry en che on he pcg nd Unerngg ey vg ey— "wean ah ent sn ae ove welbeing score ow wellbeing was defined as fling Inthe lowest sx specie quartile of ores on the. Warwick ainburgh ‘Mental Welbelng Sale (WEMWBS) (7) ln the analyte sample for our sty, om the basis that there is eure tno cabled threthold for deSning ow welling’ in ‘he adalt popalition. The WENIWBS has bon validted. sa measure of ‘positive mental eat which covers Wider range of concepts than the absence of mental dis ede including the subjective experience of happiness tnd fe satsiction, pychologial functioning and se realiation ovaits CCovaristes wore selected on the basis that they are Known to be asocated with sexta orientation Kent and with symptoms of metal health and wellbeing (Le. fe potential confounding fctor). Covariates were ha fmonised scrom euler t9 ensure comparably. sex (male or female, ethnic group (White vs. ethnic minor 4), education stainment (a ve-point eae ranging. fiom ‘none’ to. University degree, smoking satis (current. ever smoker) longing ines siebiity (es oF no) and marid or co habiing (ys 0 Bo). Statistical analysts [Bivariate asocations between sexs orientation identi and mental beah were evaluated using tests or ch quire ties, For the min stay random effects tmetoenlyis with Lge nogreaion ‘was sed to salute the mocition between sel eet ide fy categories, mental health and wellbeing, ousting for covariates In preliminary analyse, we found that the proportion of vatlance Ia the effects scouted for by becween-stdy variation range from 0 % €0 53% (asa proportion of total study variance), leading us to use fandom effects meta-analysis to poo sty specie ods fatoe aod their standard evra: Rents wee obtained fst adjusted for age and sx, then after addtional a fnstment for covariates. We aio examined wheter sex, ge and educatonal atanmentsgncanty modified the sociation between sextal orientation entity groups and mental heath, to identity population sub [roups with higher relative rss of poor mental eat. In seaivty anaises to evaluate seven possible sources of bis, we checked whether results fered ma- ‘erly when using the alternative ‘one stag’ appeonch to indvidual particpant met-analysis (32. This in volves analing all data simultaneously with a andor ‘fect for study, rather than pooling results fom each tudy separately. We ako evaasted whether resus fered when using only the GHO-12 not the EQSD, in case dileences beowen these instruments influenced the resus, Because some tudes used oversampling of ome populition groups and ad other complex serey sign features, we compared rests Separately for Un festanding Society (he study with the largest contribu Ing sample sac) before and after accounting forthe survey design, using sampling weights We so rean ‘models replacing the corte Smid or cohabiting?SeniynetoANC oto abi 167 with maser cl partnered’ to check whether these ‘Mec the estimates inthe fly adjusted model, All tages were conducted ving tata veton 132 tla approval For all of the orignal studles used, ethical approval was provided by 2 univerty of local reteareh this committee (See UK Data Service for deals for each dy) Wrten informed const was provided by all partpants All data are aalable from the UK Data Serie Results and discussion (OF the 94818 parspants in the analyte sample (hose ‘ith avalible data on semua orentatlon ident, mental Tete and covariates), 972 1 a heterotexal, 11 5 ‘ented slesbiun/gy, 09 6 os bisexual and 08 % a5, ‘other (Table People meeting the thresh of cam ‘on mental order o ow wellbeing were iglcanty Aiferent across all study variables (sing bivariate Ces for chiagare tests they were Younger comprised more females and had lower levels of ecational tainment, more current smokers, more longtaning ines Ability and fever marced/o-habling particpants than ‘hose below the threshold (Table 2) Sigecandy higher ropotons of those who Kentied a esbln/gy, lex tal and ‘other’ were found among those who met the ‘ental disorder thesold. ‘Compared to heterosexuals, participants identifying as lesbian ay were more ikl to have poor metal health, were signcanly younge, comprised more men fewer tiie minoitic, higher lees of educational tas ment, more smokers and fewer who were maried oF ‘cabng (Table 3), Compared to heterosexuals partic pants Kenting as bsexaal had sil patterns to les bian/gay partcipanes excep no significant diferences were found for sex or educational attainment. Adon aly, there was sigiiantiy higher proportion with longstanding inessiailty among tnsexual parc pants compared to heterosexal participants. Pari nts Identifying as ‘other’ were sgniiandy diferent ‘ross all study variables compared to heterosexuals, ex ‘pt forthe proportion of smaters which was sina ‘Across each ofthe 12 surveys the proportion of par seipants dein as esbianlgay ranged fom 07 to 1.9% bisexual ranged from 05 to 17 Ye ther’ rom 02 to 14% Tabe 1 shows the sample Hie that each stad conubuted tothe study, and diferences across studies for study variables. including the relia rate for the question abou sen oventatlo wena. ‘There was evidence that effects difeed for men! women (p for interaion=(L02) and by age group (fe Interaction <1) bat not fr ethnic minoity ae (> for interaction =030) or educational atainment = 019). Diferences for meniwomen genesly showed stronger effets for men but in the same direction for ten and women. Dilences atest ape groupe were ‘ore pronounced, leading us to separate age Bru for the sate analy and show menfwcenen partly in ‘Addon ile I: Table SL. esl fom the main pooled analysis ae shown ia ‘Table 3. Inthe under 35 age group, lebln/gay Kenly vas associated with increased ik of symptoms of com ton mental dordet adjusting fora ange of covariates (OR~206, 95 CI 160,26) when compared to het ovens inthe same age group. The asiocation was ‘ot significant inthe 35-589 age group (OR 103, 95% C1 O71, 148). The diction ofthe elect was con stent with small intense ink but there was insu Scent Hatiicl power in this subgroup to estimate ht effect with confidence In the age goup 55+ howeves, lesbian’any identity was associated with more than twice the rk (OR=2.1, 95 8 Cl 116, 383) of these symp. toms than the heterosexal reference group. Peters swore snl in eaten to lw welsing. es asic by ‘he WENA, withthe sociation weaker at midi Bisceul identity was nsociated with increased sk of poor mental heath symptoms when compared to hee rovers across all age group, witha salar pater of effect mediation: In the under 35 age group (OF 231, 95 % CL 18,290), lowest at age 35 0 54.9 (OR ~ 180,95 % CL 129,250} and suonges at age 35+ (245, 95 % C1158, 879), adjusting fora range of covariates in relation to symptoms of common mental dcede. Pat ‘exns were bros sil fr low wellbeing, withthe a> ‘ciation weakest tide “The group who sented as ‘other showed smaller ef feet sins with wider confidence inter but the pa term was consistent with an increase in rsk of meeting the thresheld for disordered symptoms in all tree groups when compared to heterosexuals In each ogo troupe under 35 (OR = 1.86 094, 409, 35-349 (OR= 15, 95 % Cl 093, 286), age 55+ (OR =127, 95 % CL 87,186), Saisie power was not suficientes imate these mall eflcts confidently, because of the limited sample size in these subgroups. This group were more lly than heterosexuals 1o have low welbelng, eros all three age groups, with weaker effets scen In der als In sentivty analyses, the pattern of results was the same after using the ‘one sage’ approach to alae the pooled daa We also rean the models aftr excluding tudes ing the EQSD rather thn the GHQ-12. The fesuls were not materially diferent, with lowest lathe Fisks Seen at midlife and highest in older adults. We aso ‘eran model for the ‘Understanding Society cohort ater dst forthe complex survey design using smpling sigh The same paters of ruts was ace, Kel“able 2 Chaco sty rites coping acai to metal hth ard wing “ogee cre re ee exceed ‘enero por piarspecie} sae an? sewer waist 7088 wan wate sees etn 8) 3 oo) 19 2 ae www ew 2 os oo! 08 o 3 om as cents a? ray) seer ee sow eee lergsardegiinstn) S19 Sum) 388 SH ano) atm) Mereatarteng 5138s scant {9916100 ans tsSeniynetoANC oto abi 167 Paget Table 3 nancies of sarin ideiid 2s lesbarvon bons) ad ‘her compared to heeosnss Sree amen menal dead) 168 2 a a ost ee 8 no m2 om moma) law wttery ae m2 27 eT ee) 4001256075 pce re ee ee er use a“ ra cow saat cri oo 2 oon? a)? aa rey dae 20 as a a) Longa tes 32 37 re er ee) wee nt matali different when autig foe ‘mareed ‘or cl partnered Istad of ‘maried o co-haling By pooling dat rom 12 population health saves, we were able to shove that lesbian, gu, bisxual and other” ‘ented adults (non heterosexual) were around twice 2 Ully to report symptoms of poor mental heh be ‘sxe depression) tha heterosexual aduls. This result twa les strong infra participants (ee Table 4). The lowest relative risks were Seen at midlife, with increased lk strongest im young non heterosexual adults and ies for older non-heterosexal els. Overall, ies: sal (vs. heterosextal) aduks had the highest sk of meeting the threshold for dsordered spmpeoms ‘This study i the fist to po! sexual orientation iden- ay data om 12 surveys, wih data collected inthe United Kingdom, wing indvidal participant meta aml to determine the association with mental eal (common mental disorder and welling) symptoms ‘This appoech provides aunt power to examine sb groups whichis often not possble win each study because of low numbers. We were able to eralate wheter the asiocation difered for meniwomen ss levels of educational atainment, for ethnic minors and across the age range. The dit conned a hetero sexual comparison group, ten not ealsbe in conven face samples A. Standardised question was used (0 ecord sexual orientation identity, allowing comparabil fy across stds. An important Dading was ats num ber of partpants selected ‘other’ but not heterosexual. 1s nt cleat what participants intended in making hit choice Ie cul reflect lak of understanding or ieacy problem, 4 reluctance or refit to be categorised by ny ofthe moce specie options or self-dentifation 28 fn dent not ined helt Isao worth noe ing that ths group contuned the highest proportion of ethnic minorities, high levels of longstanding ness ftalty and tended to be older. Future heath surveys could callet addtional detail on semal erentation ‘ent In det to clr what this entegory means to patcpans "The main lintation of our study was that results do not generalise Beyond somal orientation Meni. Results thay Reve dfired if sexual erentation groupe were de find inter of sexual behaviour or sexs traction, beens adults with seresex bebarour or tte aex twacton do not necesuly Ment a6 nor heterosexual (2,33) When separating age groups, our modes had stastcal power 380 % to detect odds ratios larger than 15 (assuming Ln a comparion group and 99% in a heterosexual comparison group, a simple sizeof 8000, Resquare of 10 and p= 005}, but didnot have sf dent tatstical power to detect stale effect ses such 1 those seen in the ‘ater group. farther lmiation thatthe quation dil not ad about change in Menity ‘overtime: Sexual orientation identy can changeover ve, and change in seal deny cht do pact on meatal health [34] We did not consider longitudinal ‘changes in mental health overtime (35). Akhough we onsgerd age set, ethnic mina satus and eda tional attainment as posible fet modifiers of the as0- dation between serial orientation Went and mental ‘order symptoms, farther work could explore regional Aifezences, a well as people with dsabiles and other groups In the non-heterosexual population who might femoce vulnerable than others. Given clear evidence of heterogeneity in the refs rate forthe question asked shout texaal oenation ‘identity (Table 1). there is a ‘eed to evauate methodologal diferences across stud ter andthe potential for bis according to mode of sar vey administration (eg, face to face intervie, telephone Interview. selfcompletion questionnaire, web survey) ‘There were 54 subgroups comparisons tested (Table 4 and’ Additional fe 1: Table SI). We would therefore fexpet around tc tests to be sgntiant a p=0.05 bySeniynetoANC oto abi 167 Table 4 205195 rence ena for pan mere Nath andow welbng by on ofeton ety 205 298 us Toe 35 ma 50 ‘a5 GrOI2moe E00 Wray Adtaly——Mevraty Asn tly aly Soares dime Shane” heat ge” mee! Ra esse 2 v8 us 1 ae 26 ey ns m9 rae ates kas aLa0 a) Dogs 74287 aa nas ase =) m2 m2 zam) izes cn Ices cess tease =r worsen Meiraty——Atity Mealy Ansty ney ray ioorsse aed” Shes’ ger” lnc’ ‘stir i" 1s vor on is ry =e fige7a—gaser) manson au.2sy aah zen 435220, Nec dees Reece scene alent (oassna sectarian rn cance Stttial power was suleienly high fr eal ting the lager eect sas observed here but not smaller eect including dose seen fo the othe? group. es imporeant to note however, that all he subgroups we considered are important fom a public health per ectve inorder to allocate resources and tage services {0 subgroups of the LGB adult population who have dierent service needs (18,19) Our araljis was ss sectional rather than longituinl, meaning. that we fonsdered prevalence of poor mental health or low wellbeing, bit not incidence Heated prevalence fora Specie subgroup could be a function of higher inc dence ot longer duration of nes. Finally, the EQ-5D) provides a ery limited measare of mental disorder, com- rising only one question on psychologlel symptoms hat confates ansity with depresion. Results were similar however, when excluding studies Using Cus ‘Our results are constent with evidence inter- rationally [9, 11-13] that nor-heterosexual adults are At ncreted' risk of ental beath symptoms com pare to heterosexuals, but provide important new in fights by suggesting, that jounger and older noo: heterosexual adults are particulary vulnerable (com pared to those at mid-lfe. The eros-seclonal nature ofthe data however, means that we cannot determine If these are aging, period, oF cohort (generational) effects, These findings could reflect an exiting obser ‘ation that saseepabity to poor mental health se Alced in older adults [22] which may offer individual fonbeteroverul adults some advantage in compar ton to thet younger pers. ‘Our study dd not etluate explanations for the asac ations between serial orientation identity and mental health, Wat i mechanisms or mediating sarables. “Mechanisms underying) an association between LGB forentation and poor mental helt outcomes ae not ‘anderson fly, but cha sn ange that the ex perience of dierminatory and stimatied experiences that can lead to increased mental donde, a8 might carly expose to adversity 11] Minonty stress theory {36 suggests hut ntral and extemal manifestations of Prejudice, victimization, and discrimination create ob- ferved health diferences because these experiences are Imtemalised. Chronic stress brought about by internals sng alga may therfore lead people who enyaSeniynetoANC oto abi 167 ronhetrosexl to experince poorer mental eal tnd welbeing [37,38], unhealthy behaviours [5] and wore physical heh], Certainly fn LGB youth, x dence points to an increased risk of harassment and vie timiston compared to heteomeual yuh [39] and that the negative impact can be melted by postive at ‘ude 40) and fry support [Many LGB adits do ‘ot dlose thelr oxulerentation to hestheare profes sionals, which could delay access to testment [42,43] ‘This stuy relnfores the eed for clincans to ensure that they provide erie in which LGB patients can lndoos tei sexual erentation and recive anppeetie nd integrated are. Pablic health police to adres health nequaitice#e- quire an evidence base that clarifies the extent of the Problem. Popultion data on sexual orientation ident, ‘which will provide policy makers and commissioners with the evidence they ned have only recent become ‘valable In the United Kingdom a limited number of Ait sts. Sex orientation needs to become a pat of ‘outine dats ellction so that inequaies in poot men fa heh can be more fll understood. This stay em- pPhasbes the nocd for continued, and expanded, ‘llection of seul orientation inal large health surveys ed cohort studs to understand beter the Hie couse fisks and impucts on outcomes for ths population froup. The eros sectional data ured in tht sallow {sto determine prevalence of poor mental eal in tis population. Future resarch 1 needed to determine whether these patterns ack over Une is lonptudizal ata, Longitudinal data will abo allow ws to monitor the Incidence of new mental healt problems rather than Drevalence of existing symptoms, which might vary In ‘kiran, Puther recarch is needed to coneder what the underlying mechanisms of these associations ate, and how interventions ean be designed that remove i quails in mental health between adults who Went 5 heterosexual and those who entity as lesbian, gay, TMeeaal or ‘the. Conclusions Adie identifying as bia, gy, bier o ‘the’ fae at increased risk of poor mental heh and low ‘wellbeing compared to those entifing as etroseral +The asoeition varie aero the life course, with the lowest lative ik een ln dead the highest aang older adults. + Our study used eos sectional data utabl for ‘smting prevalence but fture studies should ‘consider loud patterns uch 38 onset and eristence af new mental heh probes) and nity vechanians pear rata eres ees mare - Std tren yn no ath adic gstmeacistnieeteame « ESI cee eect Secieeetrmmece ae SaatSeniynetoANC oto abi 167 eer men ome Fee ciey ste ome tn Seamer steer SE ceencemateneiont SES cetera See samen See eeaceice, Socecenatncraranecyes Sear Sere oc eet eee SEE Tee wanes acncmpute Seabees cts Sperenetnoarncetate BEE, oe mionioeonc hie Pir Sees otctraeenanteatas a sruresticee 22 Hanns cee ee ah eee 2. 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