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. Author manuscript; available in PMC: 2016 Jul 1.
Published in final edited form as: Am J Prev Med. 2015 May 18;49(1):29–40. doi: 10.1016/j.amepre.2015.01.024

Self-Reported Mental Disorders and Distress by Sexual Orientation

Results of the Minnesota College Student Health Survey

Julia M Przedworski 1, Nicole A VanKim 1, Marla E Eisenberg 1, Donna D McAlpine 1, Katherine A Lust 1, Melissa N Laska 1
PMCID: PMC4476922  NIHMSID: NIHMS663862  PMID: 25997903

Abstract

Introduction

Sexual minority college students (i.e., those not identifying as heterosexual, or those reporting same-sex sexual activity) may be at increased risk of poor mental health, given factors such as minority stress, stigma, and discrimination. Such disparities could have important implications for students’ academic achievement, future health, and social functioning. This study compares reports of mental disorder diagnoses, stressful life events, and frequent mental distress across five gender-stratified sexual orientation categories.

Methods

Data were from the 2007–2011 College Student Health Survey, which surveyed a random sample of college students (N=34,324) at 40 Minnesota institutions. Data analysis was conducted in 2013–2014. The prevalence of mental disorder diagnoses, frequent mental distress, and stressful life events were calculated for heterosexual, discordant heterosexual, gay or lesbian, bisexual, and unsure students. Logistic regression models were fit to estimate the association between sexual orientation and mental health outcomes.

Results

Lesbian, gay, and bisexual students were more likely to report any mental health disorder diagnosis than heterosexual students (p<0.05). Lesbian, gay, bisexual, and unsure students were significantly more likely to report frequent mental distress compared to heterosexual students (OR range, 1.6–2.7). All sexual minority groups, with the exception of unsure men, had significantly greater odds of experiencing two or more stressful life events (OR range, 1.3–2.8).

Conclusions

Sexual minority college students experience worse mental health than their heterosexual peers. These students may benefit from interventions that target the structural and social causes of these disparities, and individual-level interventions that consider their unique life experiences.

Introduction

Mental disorders are one of the most common health conditions, affecting approximately one in four adults in the U.S., and can have significant repercussions on future health, well-being, and social functioning.1–3 Growing evidence suggests that lesbian, gay, and bisexual (LGB) individuals face a disproportionate burden of poor mental health compared to heterosexuals.4–9 This disparity has been attributed in part to minority stress, or the particular stress LGB people experience due to stigma and discrimination of having a marginalized identity relative to society’s heterosexual norm.10–14 These group-specific stressors may also increase LGB individuals’ vulnerability to general psychological processes that increase risk of psychopathology.15–18

However, gaps persist in knowledge regarding the mental health of sexual minority (i.e., non-heterosexual) populations. More evidence is needed on mental health among sexual minority youth,10 particularly emerging adults (aged 18–25 years). The developmental stage of emerging adulthood is considered a “sensitive period” for mental health, an opportunity for intervention resulting in more salutary life trajectories.19,20 Nearly half of emerging adults attend college, representing a critical mass for whom to address mental health issues.21 Moreover, poor mental health during college can have serious implications for students’ academic achievement.22–24

Sexual minority college students are at increased risk of poor mental health, including depression and suicidality.25–27 Kerr and colleagues25 found that lesbian and bisexual college women reported significantly worse mental health status, including anxiety, anger, depressive symptoms, and suicidal ideation, than heterosexual women. Oswalt and Wyatt27 found higher levels of anxiety, depression, and panic attacks among LGB and unsure students. Sexual minority status is associated with increased risk of experiencing stressful life events among college students27 and young adults in general.28 Sexual minority college students have also been found to utilize more mental health services than heterosexual students.25,27

Knowledge on sexual minority mental health has been hampered by several limitations.5,13,29 Population-based studies of sexual minority adolescents and young adults have primarily examined depression, anxiety, and suicidality, while other mood and anxiety disorders remain underexamined.10 Many studies used non-probability samples, thus potentially biasing findings.4,30,31 Owing to limited sample sizes, many studies combined non-heterosexual individuals into one group, potentially obscuring differences between subgroups (e.g., between gay and bisexual individuals).32 Finally, limited research exists on the mental health of non–LGB identified sexual minority groups, including those with same-sex sexual behavior who do not identify as LGB, and individuals who are unsure of their sexual identity.32,33

The purpose of this study, therefore, is to compare self-reported mental disorder diagnoses, stressful life events, and frequent mental distress across five sexual orientation categories, stratified by gender, using a large probability sample of college students.34–38 It is hypothesized that sexual minority men and women are more likely to be diagnosed with a mental disorder, report frequent mental distress, and experience stressful life events compared with their heterosexual counterparts.

Methods

Data were from the 2007–2011 College Student Health Survey (CSHS). The CSHS is an online health survey administered by University of Minnesota’s Boynton Health Service to a random sample of 2- and 4-year college students at Minnesota institutions. Students from 40 institutions were sampled from enrollment rosters and invited to participate through postcard mailings and e-mails. Additional details on the survey have been previously described39,40 and are publicly available online (www.bhs.umn.edu/surveys/index.htm). All survey procedures for the CSHS were approved by the University of Minnesota IRB. Secondary analyses of anonymous data conducted in this study were exempt from IRB review.

Among the 40 institutions that participated in the CSHS, 17 participated in a single year and 23 participated in multiple years between 2007 and 2011. To reduce potential bias from a single student participating in the survey more than once, an additional year of data from a single school was included if: (1) the institutional participation in CSHS was ≥3 years apart; (2) <50% of students were sampled for participation; and (3) the probability of a student participating more than once in the survey was <2%, calculated using information from the National Center for Education Statistics,41 the sampling probability, and response rate at each school, as has been done previously.42,43 The merged data set had 34,392 students from 40 institutions with an overall response rate of 42%, similar to response rates reported in other studies of college populations.44–48

Measures

Consistent with previous research,42,49 an overall sexual orientation variable was created by combining sexual behavior and sexual identity measures, resulting in the following: (1) heterosexual (identified as heterosexual and engaged in only different-sex sexual behavior or did not engage in sexual behavior in the past year); (2) discordant heterosexual (identified as heterosexual and engaged in same-sex or both-sex sexual behavior in the past year); (3) gay or lesbian; (4) bisexual; and (5) unsure. Participants fell into one of these last three categories based only on sexual identity, independent of their sexual behavior.

Mental disorder diagnoses were assessed by asking: For each condition, indicate whether you have been diagnosed within the past 12 months: anorexia, anxiety, attention deficit, bipolar, bulimia, depression, obsessive-compulsive, panic attacks, post-traumatic stress, seasonal affective, and social phobia/performance anxiety (yes/no for each). A measure of any mental disorder diagnosis was created for respondents who indicated any of the 11 disorders, while ≥2 mental disorder diagnoses represented those who reported two or more disorders.

Frequent mental distress (FMD) was assessed with the 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? Participants who indicated poor mental health on ≥14 days were classified as having FMD.50

Respondents were asked if they had experienced a variety of stressful life events in the past year, including: failing a class, being diagnosed with a serious physical illness, divorce or separation, termination of a personal relationship (excluding marriage), academic probation, excessive credit card debt, being arrested, being fired or laid off from a job, roommate/housemate conflict, and parental conflict (yes/no for each). Indicator variables were created for any stressful life event and two or more stressful life events.

Mental health service utilization was assessed using: Where do you go for mental health services while in school? A variety of locations were provided, including school health service, student counseling service, hospital, community clinic, HMO, and private practice. Respondents who reported obtaining mental health services at any location were grouped into a single category. Sociodemographic covariates included school type (2- vs. 4-year), health insurance status (has insurance or not), age, relationship status (single, married/domestic partner, engaged/committed, separated/divorced/widowed), student status (first-time undergraduate, other undergraduate, graduate), race/ethnicity (white and non-white), having children (no/yes), international student (no/yes), living arrangements (parent’s home, rent or share rent, residence hall, own a house, and other), hours worked for pay (0–10 hours, 11–30 hours, and ≥31 hours), and credit card debt (none or any).51

Statistical Analyses

Participants who reported ages <18 years or >99 years (n=11), were missing gender data (n=54), were transgender (n=53), or provided implausible responses on three or more of seven key variables (n=3) were dropped from analyses. The final analytic sample had 34,324 participants.

Wald chi-square tests were used to assess differences in prevalence of mental health measures and stressful life events across sexual orientation. Unadjusted and adjusted (including all aforementioned covariates) gender-stratified logistic regression models were used to assess the relationship between sexual orientation and five mental health outcomes: (1) any mental disorder diagnosis; (2) ≥2 mental disorder diagnoses; (3) FMD; (4) any stressful life event; and (5) two or more stressful life events. Sexual minority students were more likely to utilize mental health services than non-minority students; therefore, an additional model was fit including mental health service utilization as a covariate. A significant interaction between sexual orientation and gender for a number of outcomes (results not presented) further supported the gender-stratified analysis. SEs were adjusted for school clustering. Analyses were conducted between August 2013 and May 2014, using STATA, version 11.

Results

Sample characteristics are presented in Tables 1 and 2 for women and men, respectively. Most students were heterosexual (women, 93.0%; men, 93.1%); among women, 0.8% were discordant heterosexual, 1.2% were gay or lesbian, 3.5% were bisexual, and 1.6% were unsure. Among men, 0.9% were discordant heterosexual, 2.9% were gay, 1.6% were bisexual, and 1.6% were unsure. Nearly two thirds attended a 4-year institution (65.0%) and most were white (83.3%). The median age for female and male students was 22 years.

Table 1.

Sample Prevalence of Sociodemographic Characteristics Among Females by Sexual Orientation

Heterosexual Discordant heterosexual Gay Bisexual Unsure
n=20,177 n=166 n=258 n=757 n=346
Variable (Wald χ2, df, p) 93.0% 0.8% 1.2% 3.5% 1.6%
Age, median 22 23 26 22 21
School type (44.5, 4, <0.001)
 4-year (ref) 64.2% 68.1% 71.7% 62.8% 50.3%
 2-year 35.8% 31.9% 28.3% 37.3% 49.7%*
Insurance (18.9, 4, <0.001)
 Yes (ref) 93.2% 90.9% 92.6% 89.3% 89.2%
 No 6.8% 9.2% 7.5% 10.7%* 10.9%*
Relationship status (193.8, 12, <0.001)
 Single (ref) 36.8% 34.9% 30.6% 39.6% 57.5%
 Married/Dom. Partner 21.8% 23.5% 26.4%* 15.2%* 12.7%*
 Engaged/Committed 37.8% 37.4% 41.9%* 42.8% 28.3%*
 Separated/Divorced/Widowed 3.6% 4.2% 1.2% 2.4%* 1.5%*
Student status (185.8, 8, 0.001)
 First-time undergrad (ref) 20.2% 15.7% 17.4% 21.5% 32.1%
 Other undergrad 67.9% 71.7% 64.3% 69.5% 61.9%*
 Graduate student 11.9% 12.7% 18.2%* 9.0%* 6.1%*
Race/ethnicity (93.3, 4, <0.001)
 White (ref) 84.7% 83.7% 86.1% 83.0% 61.0%
 Non-white 15.3% 16.3% 14.0% 17.0% 39.0%*
Has children (36.3, 4, <0.001)
 No (ref) 77.0% 72.9% 90.3% 81.8% 79.2%
 Yes 23.1% 27.1% 9.7%* 18.2%* 20.8%
International student (98.4, 4, <0.001)
 No (ref) 97.1% 98.2% 98.1% 97.8% 89.0%
 Yes 3.0% 1.8% 2.0% 2.3% 11.0%*
Living arrangement (227.3, 16, <0.001)
 Parent’s Home (ref) 15.7% 9.0% 8.9% 17.7% 28.3%
 Rent or Share Rent 41.7% 56.6%* 45.4%* 47.8% 34.7%*
 Residence Hall 15.8% 7.2% 15.5% 18.9% 19.9%
 Own A House 22.9% 21.7%* 25.2%* 11.4%* 10.7%*
 Other 3.8% 5.4%* 5.0%* 4.2% 6.4%
Hours worked for pay (73.1, 8, <0.001)
 0–10 hours (ref) 40.5% 31.5% 38.7% 42.6% 52.6%
 11–30 hours 36.7% 41.8%* 31.6% 38.0% 32.5%*
 31+ hours 22.8% 26.7%* 29.7% 19.4% 14.9%*
Credit card debt (42.6, 4, <0.001)
 Not applicable/None (ref) 61.0% 58.4% 55.8% 62.0% 76.5%
 Any 39.0% 41.6% 44.2% 38.0% 23.5%*
Mental health service utilization (180.4, 4, <0.001)
 Yes (ref) 25.5% 34.3% 50.8% 45.2% 37.1%
 No 74.5% 65.7%* 49.2%* 54.8%* 62.9%*
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Note: Data from the Minnesota College Student Health Survey, 2007–2011.

Boldface indicates statistical significance (p-value <0.05)

*

statistically different from “Heterosexual” at p<0.05, adjusted for school clustering

Table 2.

Sample Prevalence of Sociodemographic Characteristics Among Males by Sexual Orientation

Heterosexual Discordant heterosexual Gay Bisexual Unsure
n=11,630 n=106 n=361 n=201 n=200
Variable (Wald χ2, df, p) 93.1% 0.9% 2.9% 1.6% 1.6%
Age, median 22 22 23 22 21
School type (10.0, 4, 0.04)
 4-year (ref) 67.0% 62.3% 69.5% 62.7% 58.0%
 2-year 33.0% 37.7% 30.5% 37.3% 42.0%*
Insurance (86.3, 4, <0.001)
 Yes (ref) 90.3% 95.2% 86.4% 93.0% 79.1%
 No 9.7% 4.8% 13.7%* 7.0% 20.9%*
Relationship status (212.1, 12, <0.001)
 Single (ref) 49.5% 33.0% 62.3% 62.2% 72.5%
 Married/Dom. Partner 18.0% 27.4%* 11.4%* 15.4% 10.0%*
 Engaged/Committed 30.9% 38.7%* 24.7%* 21.4%* 16.0%*
 Separated/Divorced/Widowed 1.5% 0.9% 1.7% 1.0% 1.5%
Student status (31.5, 8, <0.001)
 First-time undergrad (ref) 22.3% 20.8% 19.1% 24.9% 30.0%
 Other undergrad 67.0% 70.8% 65.4% 69.7% 61.0%*
 Graduate student 10.7% 8.5% 15.5%* 5.5%* 9.0%
Race/ethnicity (100.0, 4, <0.001)
 White (ref) 82.2% 82.1% 82.8% 73.6% 54.8%
 Non-white 17.9% 17.9% 17.2% 26.4%* 45.2%*
Has children (49.1, 4, <0.001)
 No (ref) 86.4% 77.4% 98.9% 88.1% 94.0%
 Yes 13.6% 22.6%* 1.1%* 11.9% 6.0%*
International student (46.4, 4, <0.001)
 No (ref) 95.1% 93.4% 96.4% 92.5% 83.0%
 Yes 4.9% 6.6% 3.6%* 7.5%* 17.0%*
Living arrangement (137.8, 16, <0.001)
 Parent’s Home (ref) 18.3% 14.2% 13.0% 20.5% 30.5%
 Rent or Share Rent 45.7% 47.2% 48.5% 48.5% 34.5%*
 Residence Hall 17.9% 12.3% 20.8% 17.5% 17.0%*
 Own A House 15.4% 20.8% 13.6% 10.5%* 9.5%*
 Other 2.9% 5.7%* 4.2%* 3.0% 8.5%*
Hours worked for pay (23.6, 8, 0.003)
 0–10 hours (ref) 48.9% 38.7% 40.7% 51.2% 50.3%
 11–30 hours 32.0% 37.7% 36.3%* 30.4% 38.1%
 31+ hours 19.1% 23.6% 23.0%* 18.4% 11.7%
Credit card debt (34.8, 4, <0.001)
 Not applicable/None (ref) 67.8% 58.5% 54.9% 65.2% 78.5%
 Any 32.2% 41.5% 45.2%* 34.8% 21.5%*
Mental health service utilization (82.1, 4, <0.001)
 Yes (ref) 22.1% 29.4% 33.3% 38.7% 29.2%
 No 77.9% 70.6% 66.7%* 61.3%* 70.8%*
Open in a new tab

Note: Data from the Minnesota College Student Health Survey, 2007–2011.

Boldface indicates statistical significance (p<0.05)

*

statistically different from “Heterosexual” at p<0.05, adjusted for school clustering

The prevalence of mental disorder diagnoses, FMD, any stressful life event, and ≥2 stressful life events across sexual orientation are presented in Table 3 for women and Table 4 for men. LGB students were significantly more likely to report FMD and, with a few exceptions, more likely to have been diagnosed with a mental health disorder in the past year than their heterosexual peers. Compared to heterosexual women, bisexual women had significantly higher prevalence of mental disorders for all 11 diagnoses; gay or lesbian women were significantly higher for seven of 11 diagnoses. Similarly, compared to heterosexual men, gay and bisexual men had significantly higher proportions for the majority of mental disorder diagnoses, ten and eight, respectively. Unsure individuals had a higher prevalence of FMD, anorexia, and bulimia than heterosexual individuals. Although there was no significant difference among discordant heterosexual individuals for FMD, discordant heterosexual men had higher prevalence of anorexia, bulimia, depression, panic attacks, and post-traumatic stress diagnoses than heterosexual men. The prevalence of each stressful life event across sexual orientation is presented in Appendix Tables 1 (women) and 2 (men). There were significant differences across sexual orientation for all 11 stressful life events among women, whereas significant differences were observed among men for five of 11 events.

Table 3.

Sample Prevalence of Mental Disorders, FMD, and Stressful Life Events Among Females by Sexual Orientation

Heterosexual Discordant heterosexual Gay Bisexual Unsure
n=20,177 n=166 n=258 n=757 n=346 p-valuea
93.0% 0.8% 1.2% 3.5% 1.6%
Mental disorder diagnoses, past year
Anorexia 0.5% 0.0% 0.4% 1.5%* 1.6%* <0.001
Anxiety 10.8% 12.0% 18.4%* 18.1%* 9.3% <0.001
Attention deficit disorder 1.7% 4.5%* 5.7%* 3.7%* 4.3%* <0.001
Bipolar disorder 0.5% 1.9%* 2.9%* 2.8%* 1.6%* <0.001
Bulimia 0.5% 1.3% 1.2% 1.8%* 0.3% <0.001
Depression 9.8% 12.7% 15.6%* 18.0%* 10.2% <0.001
Obsessive-compulsive 0.9% 1.3% 4.1%* 2.8%* 1.3% <0.001
Panic attacks 4.2% 5.1% 6.0% 11.0%* 4.4% <0.001
Post-traumatic stress 1.2% 1.3% 5.7%* 5.3%* 0.6% <0.001
Seasonal affective disorder 2.0% 3.9% 3.7% 5.1%* 2.8% <0.001
Social phobia/performance anxiety 1.7% 3.2% 3.6%* 5.9%* 2.8% <0.001
Any mental disorder diagnosis 17.1% 22.0% 32.4%* 31.9%* 17.9% <0.001
2+ mental disorder diagnoses 9.1% 12.6% 15.0%* 19.5%* 9.2% <0.001
Frequent mental distress (FMD) 15.6% 18.8% 23.6%* 27.5%* 23.4%* <0.001
Any stressful life event 56.6% 63.9%* 67.8%* 75.8%* 59.5% <0.001
2+ stressful life events 29.6% 39.8%* 40.7%* 54.0%* 34.4%* <0.001
Open in a new tab

Note: Data from the Minnesota College Student Health Survey, 2007–2011.

Boldface indicates statistical significance (p<0.05)

a

Wald chi-square test, adjusted for school clustering

*

statistically different from “Heterosexual” at p<0.05, adjusted for school clustering

Table 4.

Sample Prevalence of Mental Disorders, FMD, and Stressful Life Events Among Males by Sexual Orientation

Heterosexual Discordant heterosexual Gay Bisexual Unsure p-valuea
n=11,630 n=106 n=361 n=201 n=200
93.1% 0.9% 2.9% 1.6% 1.6%
Mental disorder diagnoses, past year
Anorexia 0.2% 2.1%* 2.3%* 0.5% 1.0%* <0.001
Anxiety 4.9% 9.4% 10.8%* 15.0%* 4.7% <0.001
Attention deficit disorder 2.0% 2.1% 5.4%* 4.2%* 1.0% <0.001
Bipolar disorder 0.4% 2.1% 1.1%* 2.6%* 0.5% <0.001
Bulimia 0.1% 2.1%* 0.9%* 0.5%* 1.0%* <0.001
Depression 4.8% 10.4%* 11.6%* 16.0%* 5.2% <0.001
Obsessive-compulsive 0.5% 1.0% 2.3%* 2.1%* 0.5% <0.001
Panic attacks 1.7% 5.2%* 4.3%* 5.7%* 1.1% <0.001
Post-traumatic stress 0.7% 4.2%* 1.1% 1.6% 1.6% 0.002
Seasonal affective disorder 1.0% 2.1% 4.3%* 2.6%* 1.6% <0.001
Social phobia/performance anxiety 1.5% 2.1% 4.0%* 2.6% 0.5% <0.001
Any mental disorder diagnosis 9.3% 13.1% 20.1%* 22.7%* 8.3% <0.001
2+ mental disorder diagnoses 4.5% 10.1%* 11.9%* 13.4%* 4.2% <0.001
Frequent mental distress (FMD) 9.4% 7.6% 16.9%* 22.4%* 15.5%* <0.001
Any stressful life event 50.0% 54.7% 62.6%* 63.7%* 53.5% <0.001
2+ stressful life events 24.5% 36.8%* 37.7%* 41.3%* 28.5% <0.001
Open in a new tab

Note: Data from the Minnesota College Student Health Survey, 2007–2011

Boldface indicates statistical significance (p<0.05)

a

Wald chi-square test, adjusted for school clustering

*

statistically different from “Heterosexual” at p<0.05, adjusted for school clustering

Unadjusted models were similar to the adjusted; therefore, only results from adjusted logistic regression analyses are presented in Table 5. Compared to heterosexual counterparts, LGB men and women were more likely to receive a mental health diagnosis, have FMD, and experience stressful life events. Unsure participants also had higher odds of FMD. Inclusion of mental health service utilization attenuated estimates of mental disorder diagnoses slightly; however, results remained statistically significant for all groups, except for the odds of two or more mental disorder diagnoses among gay or lesbian women (data not shown).

Table 5.

Mental Health Diagnoses, FMD, and Stressful Life Events: Adjusted Odds by Gender and Sexual Orientation

Female
Discordant heterosexual Gay Bisexual Unsure
Any mental disorder diagnosis 1.2 (0.7–2.1) 2.5 (1.8–3.4) 2.3 (1.9–2.8) 1.1 (0.8–1.6)
≥2 mental disorder diagnoses 1.2 (0.8–1.8) 1.8 (1.2–2.5) 2.4 (1.9–3.0) 1.1 (0.7–1.5)
Frequent mental distress (FMD) 1.2 (0.8–1.7) 1.9 (1.3–2.7) 1.9 (1.6–2.3) 1.6 (1.2–2.0)
Any stressful life event 1.3 (0.9–1.8) 1.9 (1.4–2.5) 2.3 (2.0–2.6) 1.1 (0.9–1.3)
≥2 stressful life events 1.6 (1.2–2.1) 1.9 (1.5–2.2) 2.7 (2.4–3.1) 1.3 (1.0–1.6)
Male
Discordant heterosexual Gay Bisexual Unsure
Any mental disorder diagnosis 1.5 (0.8–2.6) 2.4 (1.8–3.2) 2.8 (2.1–3.8) 1.0 (0.6–1.7)
≥2 mental disorder diagnoses 2.4 (1.3–4.6) 2.8 (1.9–4.2) 3.1 (2.2–4.4) 1.0 (0.5–2.0)
Frequent mental distress (FMD) 0.8 (0.4–1.7) 1.9 (1.5–2.3) 2.6 (2.0–3.5) 1.6 (1.1–2.3)
Any stressful life event 1.2 (0.9–1.6) 1.6 (1.2–1.9) 1.7 (1.3–2.2) 1.3 (0.9–1.8)
≥2 stressful life events 1.7 (1.2–2.5) 1.7 (1.4–2.1) 2.1 (1.6–2.6) 1.3 (0.9–1.9)
Open in a new tab

Notes: Data from the Minnesota College Student Health Survey, 2007–2011

Boldface indicates statistical significance (p<0.05)

Reference group: heterosexual

CIs adjusted for school clustering

Adjusted for school type, insurance status, age, relationship status, student status, race, ethnicity, children, international student status, living arrangement, SES measures

Discussion

LGB college students in this study were more likely than heterosexual students to experience mental health problems, reflected in higher levels of both mental health diagnosis and FMD. The prevalence of mental disorder diagnoses was high—almost one third of LGB female students and one fifth of LGB male students reported a diagnosis in the past year. Because diagnosed mental illness underestimates the true prevalence of disorder,52 the burden of mental illness is likely higher. These disparities persisted after controlling for mental health service utilization, suggesting that observed differences in diagnoses were not attributable to higher utilization among sexual minority students. Further, unsure students were more likely to report FMD than their heterosexual counterparts. All groups, except for unsure men, were more likely to experience stressful life events than heterosexual students.

Consistent with existing literature, LGB individuals were more likely to be diagnosed with depression and anxiety than heterosexuals.53,54 Additionally, there was evidence of disparities across a number of mental disorders that have been underexamined in this population, including attention deficit, bipolar, and obsessive compulsive disorders. Moreover, there was a higher prevalence of post-traumatic stress and social phobia among LGB college women and of bulimia and panic attacks among LGB college men compared with their heterosexual counterparts. These findings highlight the need for research on a range of mental health problems among sexual minority populations.

Findings also suggest differences in mental health between gay/lesbian and bisexual students. Compared to heterosexual women, bisexual women had a greater prevalence of all 11 diagnoses (lesbian women had a greater prevalence of seven diagnoses), and were the only group more likely to be diagnosed with panic attacks and bulimia. These results are consistent with research indicating worse mental health status among bisexual women than both heterosexual and lesbian women.5,25,55,56 Bisexual individuals must contend with discrimination based on sexual minority status and also may face stigmatization from lesbian and gay communities.57 Combined with the relative lack of bisexual-specific organizations, bisexual individuals have fewer opportunities for affiliation with “similar others”—a protective factor against negative stigma.57,58 Given these and other findings,5,32,59 bisexual individuals should be considered a distinct group in mental health research and intervention design.

This research indicates that LGB students were more likely to report experiencing stressful life events than heterosexual students. Additional research is necessary to elucidate the impact of sexual orientation differences in stressful life events on mental health outcomes. Greater exposure to negative life events, such as parental conflict or loss of employment, may likely be a direct or indirect consequence of social, institutional, and interpersonal discrimination LGB individuals experience because of their sexual orientation. As of 2014, a majority of states do not have laws that protect LGB individuals from discrimination in schools, workplaces, housing, or public spaces, nor do many states recognize same-sex marriages and families,60 highlighting existing structural sexual orientation discrimination. Similarly, although social attitudes towards sexual minority individuals have shifted over the past decade, a third of Americans continue to believe that homosexuality should be discouraged, 40% said they would be upset if their child was gay or lesbian, and nearly half believe that same-sex sexual behavior is a sin.61 Experiences of structural and interpersonal discrimination and stigma can have serious deleterious impacts on the mental health and well-being of sexual minority individuals.62,63

Consistent with existing research, students who reported being unsure of their sexual identity had greater risk of psychological distress compared to heterosexual students.5,27 Unsure students, despite not identifying as LGB, may experience structural heterosexism and internalized homophobia.33 They may also experience psychological distress as a result of uncertainty in exploring a new sexual identity, as well as being less integrated into the LGB community.27 Despite the importance of assessing the mental health of these individuals, findings for this group should be interpreted with caution.42 Unsure students in this study were more racially and ethnically diverse and younger than other sexual orientation groups, and were more likely to be international students. The terminology used in the survey (i.e., heterosexual, gay or lesbian, and bisexual) is historically and socioculturally specific, and thus may fail to adequately represent the diversity of sexual orientation identities, particularly among marginalized communities and those from other countries.64

Although there were no significant differences in the odds of mental disorder diagnoses or FMD among heterosexual women based on sexual behavior (i.e., heterosexual versus discordant heterosexual), findings indicate that same-sex sexual behavior may have a significant impact on the mental health of self-identified heterosexual men. One possible explanation is that heterosexuality is policed more punitively among men, and the stress associated with concealing same-sex sexual behavior, along with internalized shame and stigma, may contribute to increased psychopathology for heterosexual men who have sex with men.5,11,65–67

The findings point to a need for targeted interventions to improve the mental health and well-being of sexual minority college students, by providing evidence-based approaches to protecting students’ mental health and creating a welcoming and inclusive campus climate. Given the significant consequences of discrimination and stigma on sexual minority students’ mental health,11,15 colleges should ensure that sexual orientation is included as a protected class in anti-discrimination policies, and have mechanisms to effectively respond to discriminatory events. College campuses can also develop programs promoting visibility and demonstrating institutional support for these students.64 Colleges should also provide training for healthcare professionals to increase their knowledge of sexual minority–specific health concerns, and enhance their ability to provide inclusive and sensitive services to these students.68 Additional research is needed that explores effective college-based interventions to promote the mental health of sexual minority students.

Limitations

This study examined a broad range of mental health–related issues among college students by sexual orientation using a large population-based data set. However, this study was cross-sectional, and we cannot determine causality. The large sample size allowed a nuanced approach examining differences across gender-specific strata of sexual orientation; however, sample sizes may not have been sufficient to detect differences for some subgroups. Further, the generalizability may be limited owing to a lower response rate, and findings may not be generalizable to other geographic areas. A major strength was examining multiple mental health measures, allowing a more comprehensive understanding of mental health. However, mental disorder diagnoses may underestimate the true prevalence of disorders in the population because many disorders are not diagnosed.52 Additionally, there is no research examining the accuracy of self-reported diagnoses for this age group, although in other populations agreement between self-reports of diagnosed depression and medical records has high specificity.69 Finally, the wording of the question did not specify that diagnoses should only be included if from a medical professionals; therefore, respondents may also have included non-clinical diagnoses (e.g., self-diagnosis, online screening tools). Two factors mitigate these measurement limitations. First, the bias should tend toward underestimating disorder and should be similar across groups, giving us confidence about the patterns of prevalence across sexual orientation. Second, the use of FMD, a widely used mental distress measure that is independent of respondent engagement with mental health services, bolsters the study findings of mental health disparities by sexual orientation.

Conclusions

In 2011, the American Psychological Association characterized the mental health problems on college campuses as a crisis.70 Psychological distress and psychopathology can have significant implications for students’ success and retention in college.22–24 Therefore, the findings that sexual minority college students experience more mental disorder diagnoses, stressful life events, and FMD than their heterosexual counterparts are disconcerting. Although sexual minority students are likely to benefit from general interventions to improve student well-being, it is unlikely that these efforts alone will address the sexual orientation disparities in mental health. Instead, sexual minority students may require interventions that target the structural and social causes of these disparities, as well as individual-level interventions that consider the unique life experiences of sexual minority students.15

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Acknowledgments

J.M. Przedworski was supported by the National Cancer Institute (R25CA163184). N.A. VanKim was supported by the National Institute of Diabetes and Digestive and Kidney Diseases (T32DK083250). Additional support was provided by the Eunice Kennedy Shriver National Institute of Child Health & Human Development (R21HD073120; Principal Investigator, M. Laska).

Footnotes

The content is solely the responsibility of the authors and does not necessarily represent the official view of NIH.

No financial disclosures were reported by the authors of this paper.

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References

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