Abstract
Purpose: The current study examines differences between lesbian, gay, bisexual, and questioning (LGBQ) students and heterosexual students in terms of counseling and mental health services received (healthcare utilization), from whom students would seek help, and who contributed positively to students' ability to cope during a stressful period.
Methods: An online survey was administered among 25,844 college students, enrolled in 76 schools (mean age = 25.52). The majority of participants was graduate students (42.81%) and reported their race/ethnicity as non-Hispanic White (70.49%).
Results: Compared with their heterosexual counterparts, gay males and lesbian/gay and bisexual females reported receiving more counseling or mental health services, most notably from counselors, therapists, psychologists, and/or social workers. Bisexual males and LGBQ females were less likely to seek help from a parent or family member compared with heterosexual males and females, respectively. Racial/ethnic minority bisexual females were less likely to seek help from a friend or roommate than non-Hispanic White bisexual females. Compared with their heterosexual counterparts, gay and questioning males and LGBQ females were more likely to report that religion reduced their ability to cope.
Conclusion: The current findings illuminate important differences by sexual orientation in terms of seeking and receiving mental health services. Although we found that lesbian/gay and bisexual college students were more likely to receive counseling and mental healthcare, we cannot ascertain whether they were satisfied with the services they received. The findings also suggest that certain groups of LGBQ students do not find support with their clergy and family, which may indicate a lack of understanding or acceptance of LGBQ issues.
Keywords: : college students, healthcare utilization, LGBQ, sexual orientation
Introduction
Lesbian, gay, bisexual, and questioning (LGBQ) or sexual minority individuals experience unique stressors,1,2 including difficulty accessing health services.3,4 For example, a study among New Zealand secondary school students showed that although same- and both sex-attracted adolescents were more likely to see health professionals, they had more difficulty getting the help that they were seeking.4 Limited access to health services may be compounded by practitioners' lack of competence and training in sexual minority healthcare, leading sexual minority individuals not to seek help.3,5 For example, compared with people in different-sex relationships, people in same-sex relationships6 and bisexual and lesbian females7 are less likely to seek regular checkups. People in same-sex relationships are also more likely to report unmet medical needs.6 It has been suggested that this is due to cost8,9 and found to be most common for LGB individuals who do not disclose their sexual orientation to their physician.10,11 In contrast, when it comes to mental health and counseling services, LGB adults are more likely to seek treatment.12,13
There may also be differences in the types of services that people seek. In a study among adolescents and young adults who were seeking mental healthcare, LGBQ adolescents and young adults reported more openness to discussing issues, including health, substance use, and relationships, compared with heterosexuals.14 This may indicate that LGBQ adolescents and young adults are more comfortable talking to mental healthcare providers, whereas heterosexual adolescents and young adults may prefer talking to friends and family about such issues.14
Because LGBQ adolescents and young adults report more openness to seeking mental healthcare from a professional,14 utilization of these health services may be higher.12,13 However, clinicians can be insensitive and may be unaware of the lack of family support or the impact of minority stress on mental health.3,15 Health professionals have also contributed to the harmful treatment of LGBQ individuals by practicing forms of conversion therapy.16,17 Thus, there may be a difference between LGBQ and heterosexual individuals with respect to from whom they seek mental health services and whether they receive these services. Furthermore, in addition to formal healthcare, informal care or counseling may be provided by religious entities.18
There is currently little research on which types of formal and informal health services LGBQ students seek and which types of health services they avoid. Because of this gap in knowledge, it is difficult to improve access to, and quality of, mental healthcare for LGBQ young adults. The current study defines health services in broad terms, as any service that may aid in supporting or improving a person's health, whether that is formal mental healthcare or informal care from clergy and family members.
We hypothesized that LGBQ college students would differ from heterosexual college students in terms of the amount of care they have received and from whom they would seek help. We expect that LGBQ college students will be more likely to receive services from mental healthcare professionals and counselors, and we will explore differences in care received from other sources of formal (e.g., medical provider) and informal systems (e.g., clergy, friends, and family). We will also explore the self-reported effectiveness of students' coping resources.
Methods
Participants and procedure
The current study utilized a sample of 26,429 college students across 76 schools, from the National Research Consortium of Counseling Centers in Higher Education, for whom data were collected in 2011. We excluded data from students who did not report their sexual orientation as this was a main predictor (n = 160; 0.61%). We also excluded data from a small group of students (n = 360; 1.36%) who reported a sexual orientation other than heterosexual or straight, lesbian/gay, bisexual, or questioning and a small group of students who reported a transgender identity (n = 47; 0.18%)* or those who did not report their gender identity (n = 64; 0.24%).† This resulted in an analytic sample of 25,844 students, aged 18–90 years old (M = 25.52, SD = 7.89).
An online survey was e-mailed to a random selection of students at 4-year institutions of higher education that were representative of national higher education institutions in terms of size, whether they were private or public, and location. The response rate for students was 26.3%. Participants who started the survey were entered into a drawing in which they could win one of 100 gift cards worth $50 each. Electronic informed consent was obtained from all participants in the online survey; their participation was voluntary and anonymous, and they could withdraw at any time. Completing the survey took ∼20 minutes, and all participants received contact information for mental health and emergency services on their campus or in their local community. The Institutional Review Board for the Protection of Human Subjects at the University of Texas at Austin approved the original study, and the approval extends to the current study.
Measures
Received counseling or mental health services
Students were asked “From which of the following have you ever received counseling or mental health services?” (select all that apply): (1) Counselor, therapist, psychologist, and/or social worker, (2) Psychiatrist, (3) Clergy, (4) Other medical provider (e.g., physician and nurse practitioner), (5) Alternative medical provider (e.g., acupuncturist and massage therapist), (6) Other, and (7) I have never received counseling or mental health services. Health services were assessed separately (0 = No, 1 = Yes), and the scores were summed to represent a total score of services received (minimum = 0; maximum is 6).
Resources to which students would turn
To assess to which resources students would turn when faced with problems, students were first provided with a list of problems as follows: (1) Academic problems, (2) Emotional problems (e.g., feeling sad or anxious), (3) Financial problems, (4) Health problems (e.g., illness, nutrition, and fitness), (5) Life issues (e.g., identity struggles, career choices, and life purpose), and (6) Relationship problems (e.g., romantic, friend, and family) and were asked to rate whether or not they would seek help for these problems. Students were then asked to whom they would turn in response to these problems: (1) Advisor (e.g., academic or resident), (2) Friend/roommate, (3) Instructor (e.g., professor, teaching assistant, or coach), (4) Parent/family member, (5) Romantic partner, (6) Professional (e.g., physician, counselor, or clergy), and (7) I would not seek help from these sources for this problem. Answer options were No (0) and Yes (1) and averaged for each source of help (minimum = 0; maximum = 1).
Ability to cope during a stressful period
Students were asked how the following affected their ability to cope during a stressful period: (1) Friend connections, (2) Family connections, (3) Religion, spirituality, or a higher power connection, (4) College or university connections, (5) Mental health professional connections, (6) Experienced a similar situation before, (7) Extracurricular groups, activities, or community involvement, and (8) Campus resources (e.g., student services, health/counseling center, and career center). Answer options ranged from 1 = considerably reduced my ability to cope to 5 = considerably improved my ability to cope.
Gender identity and sexual orientation
Students were asked about their gender identity with the following item “How do you identify?” Response options were as follows: (1) Female, (2) Male, or (3) Transgender. Students were also asked “How would you describe your sexual orientation?” with response options as follows: (1) Bisexual, (2) Gay or lesbian, (3) Heterosexual, (4) Questioning, or (5) Other, please specify.
Control variables
Several control variables were included in the analyses. Students were asked if they had ideated suicide in their lifetime (0 = No, 1 = Yes). They were also asked “Please characterize your lifetime mental health history (e.g., depression, anxiety)” ranging from 1 = no mental health concerns to 5 = substantial mental health concerns. Students were asked about their current relationship status with the following options: (1) single/not currently dating, (2) casually dating, (3) in a steady dating relationship, (4) partnered/married, (5) separated/divorced, and (6) widowed. Answers 1 and 5 were recoded as “currently not involved in a relationship” (0); answers 2 through 4 were recoded as “currently involved in a relationship” (1).
Statistical analyses
The data were analyzed using Stata version 14 (StataCorp LP, College Station, TX). Using survey adjusted regression analyses accounting for the nested structure of the data and adjusting standard error estimates, we assessed differences between three groups of sexual minority (LGBQ) and heterosexual students' use of healthcare services in gender-stratified models and assessed moderation by race/ethnicity. We also assessed interactions by sexual orientation and race/ethnicity. In all analyses, we controlled for demographics (age and race/ethnicity), lifetime mental health concerns, and suicidal ideation. For the models including romantic partner as a potential resource, we also controlled for relationship status.
Results
In terms of sexual orientation, 93.15% self-identified as heterosexual, 2.49% as lesbian/gay, 3.37% as bisexual, and 0.99% as questioning. Similar to other studies among large U.S. campus samples, the majority of participants reported their race/ethnicity as White (74.78%), followed by Asian (11.38%), Hispanic (7.75%), Black (5.17%), Middle Eastern or East Indian (2.74%), Other (2.20%), Native American (1.43%), and Native Hawaiian or other Pacific Islander (0.44%). Students were able to select more than one option; due to small sample sizes of different racial/ethnic groups, we stratified students by non-Hispanic White (70.49%) and Racial/Ethnic Minority (29.51%) for the analyses. The majority of participants were graduate students (42.81%), followed by junior (15.11%), senior (14.70%), sophomore (12.72%), freshman (10.98%), medical (1.74%), law (1.25%), and nondegree students (0.69%).
In Table 1, descriptive statistics are presented by sexual orientation. Overall, LGBQ students reported more lifetime mental health concerns and were more likely to report suicidal ideation than heterosexual students. LGBQ students were less likely to report being involved in a romantic relationship than heterosexual students.
Table 1.
Demographic Characteristics and Key Variables by Sexual Orientation (N = 25,844)
| Sexual orientation | ||||
|---|---|---|---|---|
| Heterosexual | Bisexual | Lesbian/gay | Questioning | |
| Age, M (SD) | 25.52 (7.91) | 25.26 (6.91) | 27.16 (8.84) | 22.71 (5.53) |
| Non-Hispanic White, % | 70.89 | 64.29 | 67.74 | 60.78 |
| Female, % | 63.09 | 73.74 | 38.89 | 67.06 |
| Lifetime mental health concernsa, M (SD) | 1.80 (1.01) | 2.39 (1.23) | 2.30 (1.15) | 2.43 (1.30) |
| Lifetime suicidal ideationb, % | 18.50 | 44.00 | 42.22 | 49.61 |
| Currently involved in a relationshipc, % | 56.27 | 51.21 | 45.79 | 25.59 |
| Help receivedd | ||||
| Sum of total services received, M (SD) | 0.75 (0.98) | 1.16 (1.16) | 1.22 (1.13) | 1.10 (1.16) |
| Counselor, therapist, psychologist, and/or social worker, % | 39.23 | 58.94 | 64.07 | 53.73 |
| Psychiatrist, % | 11.98 | 25.46 | 25.51 | 23.53 |
| Clergy, % | 8.21 | 6.54 | 8.40 | 5.88 |
| Other medical provider, % | 9.73 | 15.02 | 16.33 | 14.12 |
| Alternative medical provider, % | 4.24 | 9.41 | 6.22 | 10.20 |
| Other, % | 1.52 | 1.38 | 1.09 | 2.35 |
| Would seek help frome, M (SD) | ||||
| Adviser | 0.11 (0.14) | 0.12 (0.15) | 0.12 (0.14) | 0.10 (0.13) |
| Friend or roommate | 0.47 (0.31) | 0.48 (0.32) | 0.53 (0.30) | 0.45 (0.30) |
| Instructor | 0.11 (0.12) | 0.12 (0.14) | 0.12 (0.13) | 0.11 (0.13) |
| Parent or family member | 0.58 (0.34) | 0.50 (0.33) | 0.46 (0.34) | 0.49 (0.32) |
| Romantic partner | 0.42 (0.40) | 0.40 (0.40) | 0.40 (0.41) | 0.19 (0.32) |
| Professional | 0.14 (0.19) | 0.20 (0.24) | 0.21 (0.25) | 0.19 (0.26) |
| Improved ability to copef, M (SD) | ||||
| Friends | 4.11 (0.97) | 4.02 (1.02) | 4.13 (0.96) | 3.75 (1.09) |
| Family | 4.12 (1.03) | 3.78 (1.14) | 3.72 (1.17) | 3.69 (1.13) |
| Religion | 3.50 (1.07) | 3.17 (1.06) | 3.11 (1.01) | 3.14 (0.93) |
| College or university | 2.94 (0.91) | 2.90 (0.98) | 2.92 (0.97) | 2.83 (0.97) |
| Mental health professional | 2.89 (0.89) | 3.01 (1.00) | 3.08 (0.98) | 3.10 (0.94) |
| Experienced a similar situation | 3.49 (1.00) | 3.51 (1.02) | 3.43 (1.08) | 3.47 (0.98) |
| Extracurricular activities | 3.19 (0.96) | 3.14 (1.00) | 3.16 (0.98) | 3.10 (0.95) |
| Campus resources | 2.88 (0.86) | 2.97 (0.96) | 2.96 (0.93) | 3.05 (0.86) |
LGBQ students reported higher lifetime mental health concerns compared to heterosexual students (t(25788) = −22.2, p < 0.001).
LGBQ students were more likely to report lifetime suicidal ideation (χ2 = 674.43, p < 0.001).
LGBQ students were less likely to report being involved in a romantic relationship (χ2 = 128.76, p < 0.001).
Response options were 0 = No, 1 = Yes.
Response options were 0 = No, 1 = Yes and averaged for each source of help.
Response options ranged from 1 = considerably reduced my ability to cope to 5 = considerably improved my ability to cope.
LGBQ, lesbian, gay, bisexual, and questioning.
Differences in healthcare services received during their lifetime
We assessed whether LGBQ students differed from heterosexual students in terms of total reported counseling or mental health services received and specific services received (Table 2). Gay male students (B = 0.17, SE = 0.05, p = 0.002) had a higher sum score of counseling or mental health services received than heterosexual male students. Bisexual females (B = 0.11, SE = 0.04, p = 0.006) and lesbian/gay females (B = 0.22, SE = 0.06, p < 0.001) had a higher sum score of counseling or mental health services received than heterosexual female students.
Table 2.
Sexual Orientation Predicting Total Services Received and Types of Services Received
| Total services receiveda | Counselor, therapist, psychologist, and/or social worker | Psychiatrist | Clergy | Other medical providerb | Alternative medical providerc | Other | |
|---|---|---|---|---|---|---|---|
| Male students (N = 9288) | |||||||
| Age | 0.02 (0.00)*** | 1.04 (1.03–1.04)*** | 1.03 (1.02–1.03)*** | 1.05 (1.04–1.06)*** | 1.02 (1.01–1.03)*** | 1.03 (1.02–1.04)*** | 1.03 (1.01–1.04)** |
| Non-Hispanic White (REM is ref) | 0.14 (0.02)*** | 1.45 (1.30–1.62)*** | 1.60 (1.34–1.92)*** | 1.54 (1.25–1.91)*** | 1.33 (1.09–1.62)** | 1.03 (0.76–1.40) | 1.09 (0.72–1.64) |
| Sexual orientation (heterosexual is ref) | |||||||
| Bisexual | 0.08 (0.05) | 1.43 (1.03–1.98)* | 1.29 (0.82–2.02) | 0.69 (0.41–1.16) | 0.90 (0.51–1.58) | 2.11 (1.18–3.80)* | 0.52 (0.12–2.23) |
| Gay | 0.17 (0.05)** | 2.20 (1.71–2.84)*** | 1.22 (0.92–1.63) | 0.66 (0.44–0.99)* | 1.30 (0.89–1.89) | 1.58 (0.95–2.63) | 0.64 (0.27–1.53) |
| Questioning | 0.05 (0.10) | 1.33 (0.79–2.23) | 0.77 (0.33–1.77) | 0.62 (0.24–1.64) | 1.34 (0.64–2.81) | 1.24 (0.40–3.88) | 2.80 (0.92–8.49) |
| Lifetime mental health concerns | 0.43 (0.01)*** | 2.51 (2.34–2.68)*** | 2.94 (2.75–3.15)*** | 1.30 (1.20–1.76)*** | 2.04 (1.89–2.19)*** | 1.78 (1.61–1.98)*** | 1.28 (1.06–1.55)* |
| Lifetime suicidal ideation | 0.21 (0.03)*** | 1.69 (1.48–1.93)*** | 1.21 (0.99–1.48) | 1.45 (1.19–1.76)*** | 1.24 (1.02–1.51)* | 1.39 (1.01–1.92)* | 1.65 (1.05–2.61)* |
| Female students (N = 15,828) | |||||||
| Age | 0.02 (0.00)*** | 1.04 (1.04–1.05)*** | 1.03 (1.02–1.03)*** | 1.06 (1.06–1.07)*** | 1.02 (1.02–1.03)*** | 1.04 (1.03–1.05)*** | 1.02 (1.00–1.03)* |
| Non-Hispanic White (REM is ref) | 0.14 (0.02)*** | 1.36 (1.24–1.50)*** | 1.25 (1.07–1.46)* | 1.27 (1.09–1.48)** | 1.57 (1.40–1.75)*** | 1.40 (1.20–1.65)*** | 0.87 (0.64–1.19) |
| Sexual orientation (heterosexual is ref) | |||||||
| Bisexual | 0.11 (0.04)* | 1.43 (1.19–1.72)*** | 1.44 (1.12–1.84)** | 0.66 (0.46–0.92)* | 1.02 (0.82–1.28) | 1.37 (1.02–1.83)* | 0.84 (0.45–1.57) |
| Lesbian/Gay | 0.22 (0.06)*** | 2.37 (1.72–3.25)*** | 1.93 (1.45–2.57)*** | 0.76 (0.43–1.32) | 1.22 (0.91–1.62) | 0.84 (0.49–1.43) | 0.22 (0.03–1.69) |
| Questioning | 0.09 (0.07) | 1.11 (0.75–1.64) | 1.36 (0.86–2.15) | 0.70 (0.39–1.27) | 0.85 (0.54–1.34) | 2.23 (1.42–3.50)** | 0.35 (0.05–2.42) |
| Lifetime mental health concerns | 0.46 (0.01)*** | 2.56 (2.45–2.67)*** | 3.13 (2.94–3.33)*** | 1.31 (1.24–1.39)*** | 2.09 (1.96–2.23)*** | 1.65 (1.54–1.77)*** | 1.20 (1.05–1.37)* |
| Lifetime suicidal ideation | 0.21 (0.02)*** | 1.63 (1.47–1.80)*** | 1.53 (1.37–1.71)*** | 1.48 (1.28–1.72)*** | 1.10 (0.95–1.27) | 1.05 (0.87–1.28) | 1.07 (0.73–1.57) |
Students were asked “From which of the following have you ever received counseling or mental health services?” (select all that apply). Response options were 0 = No, 1 = Yes, and the scores were summed to represent a total score of services received (ranging from 0 to 6).
Unstandardized regression coefficients (standard errors) are presented for total services received; odds ratios (95% confidence intervals) are presented for specific services received.
Other medical provider (e.g., physician and nurse practitioner).
Alternative medical provider (e.g., acupuncturist and massage therapist).
p < 0.05, **p < 0.005, ***p < 0.001.
REM, racial/ethnic minority.
Bisexual males (OR = 1.43, 95% CI 1.03–1.98) and gay males (OR = 2.20, 95% CI 1.71–2.84) were more likely to have seen a counselor, therapist, psychologist, and/or social worker compared with heterosexual males. Bisexual females (OR = 1.43, 95% CI 1.19–1.72) and lesbian/gay females (OR = 2.37, 95% CI 1.72–3.25) were more likely to have seen a counselor, therapist, psychologist, and/or social worker compared with heterosexual females. Similarly, bisexual females (OR = 1.44, 95% CI 1.12–1.84) and lesbian/gay females (OR = 1.93, 95% CI 1.45–2.57) were more likely to have seen a psychiatrist than heterosexual females.
Although differences were small, gay males (OR = 0.66, 95% CI 0.44–0.99), and bisexual females (OR = 0.66, 95% CI 0.46–0.92) were less likely to have received services from clergy compared with heterosexual males and females, respectively. Bisexual males (OR = 2.11, 95% CI 1.18–3.80) were more likely to have received services from alternative medical providers than heterosexual males. Bisexual females (OR = 1.37, 95% CI 1.02–1.83) and questioning females (OR = 2.23, 95% CI 1.42–3.50) were more likely to have received services from alternative medical providers than heterosexual females. There were no significant interactions of sexual orientation × race/ethnicity (p > 0.05).
Differences in from whom students would seek help
When students were asked from whom they would seek help when faced with a combination of problems (e.g., academic and emotional), there were several differences between LGBQ and heterosexual students (Table 3). Bisexual males were more likely to seek help from an advisor (B = 0.03, SE = 0.01, p = 0.020), but less likely to seek help from a parent or family member (B = −0.04, SE = 0.02, p = 0.021), compared with heterosexual males. Bisexual females were more likely to seek help from an instructor (B = 0.01, SE = 0.01, p = 0.028) and a professional (i.e., physician, counselor, or clergy) (B = 0.04, SE = 0.01, p < 0.001), but less likely to seek help from a parent or family member (B = −0.06, SE = 0.01, p < 0.001), compared with heterosexual females.
Table 3.
Sexual Orientation Predicting from Whom Students Would Seek Help
| Would seek help from | Advisera | Friend or roommate | Instructorb | Parent or family member | Romantic partner | Professionalc |
|---|---|---|---|---|---|---|
| Male students (N = 9268) | ||||||
| Age | 0.00 (0.00) | −0.01 (0.00)*** | −0.00 (0.00) | −0.01 (0.00)*** | 0.00 (0.00)* | 0.00 (0.00)*** |
| Non-Hispanic White (REM is ref) | −0.02 (0.00)*** | 0.00 (0.01) | 0.00 (0.00) | 0.06 (0.01)*** | 0.07 (0.01)*** | 0.02 (0.00)*** |
| Sexual orientation (heterosexual is ref) | ||||||
| Bisexual | 0.03 (0.01)* | 0.03 (0.02) | 0.01 (0.01) | −0.04 (0.02)* | −0.03 (0.02) | 0.00 (0.01) |
| Gay | 0.02 (0.01)* | 0.16 (0.01)*** | 0.01 (0.01) | 0.00 (0.02) | 0.03 (0.02) | 0.03 (0.01)* |
| Questioning | 0.00 (0.02) | −0.03 (0.04) | 0.01 (0.01) | −0.06 (0.03) | −0.05 (0.02)* | −0.01 (0.02) |
| Lifetime mental health concerns | 0.00 (0.00)* | −0.00 (0.00) | 0.00 (0.00) | −0.01 (0.00)* | 0.00 (0.00) | 0.04 (0.00)*** |
| Lifetime suicidal ideation | −0.02 (0.00)*** | −0.02 (0.01) | −0.00 (0.00) | −0.08 (0.01)*** | −0.02 (0.01) | 0.01 (0.01) |
| Romantic relationship | −0.01 (0.00)* | −0.08 (0.01)*** | −0.00 (0.00) | −0.02 (0.01) | 0.49 (0.01)*** | −0.01 (0.00)** |
| Female students (N = 15,793) | ||||||
| Age | −0.00 (0.00)*** | −0.01 (0.00)*** | 0.00 (0.00) | −0.01 (0.00)*** | −0.00 (0.00) | 0.00 (0.00)*** |
| Non-Hispanic White (REM is ref) | −0.01 (0.00)* | 0.05 (0.01)*** | 0.01 (0.00)*** | 0.09 (0.01)*** | 0.05 (0.01)*** | 0.02 (0.00)*** |
| Sexual orientation (heterosexual is ref) | ||||||
| Bisexual | 0.01 (0.01) | −0.01 (0.01)d | 0.01 (0.01)* | −0.06 (0.01)*** | 0.01 (0.01) | 0.04 (0.01)*** |
| Lesbian/Gay | 0.01 (0.01) | −0.01 (0.02) | 0.01 (0.01) | −0.13 (0.03)*** | 0.05 (0.02)** | 0.06 (0.02)** |
| Questioning | −0.01 (0.01) | −0.05 (0.02)* | 0.00 (0.01) | −0.11 (0.03)*** | −0.05 (0.02)* | 0.04 (0.02)* |
| Lifetime mental health concerns | 0.00 (0.00)* | −0.00 (0.00) | 0.00 (0.00)* | −0.01 (0.00)*** | 0.00 (0.00) | 0.05 (0.00)*** |
| Lifetime suicidal ideation | −0.01 (0.00)*** | −0.04 (0.01)*** | −0.01 (0.00)*** | −0.10 (0.01)*** | −0.02 (0.01)*** | −0.01 (0.00) |
| Romantic relationship | −0.01 (0.00)** | −0.08 (0.01)*** | −0.01 (0.00)*** | −0.04 (0.00)*** | 0.59 (0.00)*** | −0.02 (0.00)*** |
Unstandardized regression coefficients (standard errors) are presented. To assess which resources students would turn to when faced with problems, students were first provided with a list of problems and asked to rate whether or not they would seek help for these problems. Then students were asked to whom they turned in response to these problems. Answer options were No (0) and Yes (1) and averaged together by each source of help (ranging from 0 to 1).
Adviser (e.g., academic or resident).
Instructor (e.g., professor, teaching assistant, or coach).
Professional (e.g., physician, counselor, or clergy).
For females, there was a significant interaction between race/ethnicity and a bisexual orientation in terms of seeking help from a friend or roommate, (B = 0.06, SE = 0.03, p = 0.027). Among racial/ethnic minority females, having a bisexual orientation was related to less help-seeking from a friend or roommate, compared with having a heterosexual orientation (B = −0.06, SE = 0.02, p = 0.018), whereas among non-Hispanic White bisexual females, having a bisexual orientation was not related to seeking help from a friend or roommate, compared with having a heterosexual orientation (B = 0.01, SE = 0.01, p = 0.613).
p < 0.05, **p < 0.005, ***p < 0.001.
Gay males were more likely to seek help from an advisor (B = 0.02, SE = 0.01, p = 0.013), a friend or roommate (B = 0.16, SE = 0.01, p < 0.001), and a professional (B = 0.03, SE = 0.01, p = 0.005), compared with heterosexual males. Lesbian/gay females were more likely to seek help from a romantic partner (B = 0.05, SE = 0.02, p = 0.002) or a professional (B = 0.06, SE = 0.02, p = 0.001), but less likely to seek help from a parent or family member (B = −0.13, SE = 0.03, p < 0.001), compared with heterosexual females. Questioning males and females were less likely to seek help from a romantic partner, compared with heterosexual males and females (B = −0.05, SE = 0.02, p = 0.045; B = −0.05, SE = 0.02, p = 0.005), respectively. Questioning females were less likely to seek help from a friend or roommate (B = −0.05, SE = 0.02, p = 0.017) or parent or family member (B = −0.11, SE = 0.03, p < 0.001), but more likely to seek help from a professional (B = 0.04, SE = 0.02, p = 0.024), compared with heterosexual females. For females, there was a significant interaction between race/ethnicity and a bisexual orientation in terms of seeking help from a friend or roommate, (B = 0.06, SE = 0.03, p = 0.027). Among racial/ethnic minority females, having a bisexual orientation was related to less help-seeking from a friend or roommate, compared with having a heterosexual orientation (B = −0.06, SE = 0.02, p = 0.018), whereas among non-Hispanic White bisexual females, having a bisexual orientation was not related to seeking help from a friend or roommate, compared with having a heterosexual orientation (B = 0.01, SE = 0.01, p = 0.613).
Differences in what improved student's ability to cope
When asked what improved students' ability to cope during a stressful period, LGBQ students differed from heterosexual students (Table 4). Compared with heterosexual females, bisexual females were more likely to report that their family (B = −0.23, SE = 0.04, p < 0.001) and religion (B = −0.38, SE = 0.04, p < 0.001) reduced their ability to cope during a stressful period, but were more likely to report that having experienced a similar situation before (B = 0.10, SE = 0.04, p = 0.018) improved their ability to cope. Compared with heterosexual males, bisexual males were more likely to report that having experienced a similar situation before (B = −0.15, SE = 0.07, p = 0.033) and extracurricular activities (B = −0.18, SE = 0.08, p = 0.032) reduced their ability to cope. Compared with heterosexual males, gay males were more likely to report that friends improved their ability to cope (B = 0.27, SE = 0.05, p < 0.001), whereas they were more likely to report that religion reduced their ability to cope (B = −0.22, SE = 0.06, p = 0.001). Compared with heterosexual females, lesbian/gay females were more likely to report that family (B = −0.40, SE = 0.08, p < 0.001) and religion (B = −0.42, SE = 0.06, p < 0.001) reduced their ability to cope, but they were more likely to report that mental health professionals (B = 0.13, SE = 0.06, p = 0.017) and campus resources (B = 0.12, SE = 0.06, p = 0.034) improved their ability to cope.
Table 4.
Sexual Orientation Predicting What Improved the Ability to Cope During a Stressful Period
| Friend connections | Family connections | Religion, spirituality, or a higher power connection | College or university connections | Mental health professional connections | Experienced a similar situation before | Extracurricular groups, activities, or community involvement | Campus resourcesa | |
|---|---|---|---|---|---|---|---|---|
| Male students | ||||||||
| Age | −0.01 (0.00)** | 0.01 (0.00)*** | 0.01 (0.00)*** | 0.00 (0.00) | 0.01 (0.00)*** | 0.01 (0.00)*** | −0.01 (0.01)*** | −0.00 (0.00) |
| Non-Hispanic White (REM is ref) | 0.13 (0.03)*** | 0.12 (0.02)*** | 0.06 (0.04) | −0.05 (0.02)* | 0.08 (0.02)*** | 0.07 (0.03)* | 0.02 (0.02) | −0.04 (0.02)* |
| Sexual orientation (heterosexual is ref) | ||||||||
| Bisexual | 0.04 (0.06) | −0.12 (0.07) | −0.05 (0.07) | −0.05 (0.08) | −0.09 (0.08) | −0.15 (0.07)* | −0.18 (0.08)* | −0.01 (0.08) |
| Gay | 0.27 (0.05)*** | −0.10 (0.06) | −0.22 (0.06)** | 0.08 (0.04) | 0.10 (0.05) | −0.08 (0.06) | −0.05 (0.05) | 0.04 (0.05) |
| Questioning | −0.30 (0.12)* | −0.19 (0.13) | −0.22 (0.11)** | −0.18 (0.11) | −0.09 (0.10) | −0.04 (0.10) | −0.13 (0.10) | 0.03 (0.09) |
| Lifetime mental health concerns | −0.09 (0.02)*** | −0.13 (0.01)*** | −0.07 (0.01)*** | −0.03 (0.01)* | 0.15 (0.01)*** | −0.00 (0.01) | −0.05 (0.01)*** | 0.05 (0.01)*** |
| Lifetime suicidal ideation | −0.06 (0.03) | −0.24 (0.04)*** | −0.07 (0.03)* | −0.12 (0.03)*** | −0.00 (0.02) | 0.04 (0.03) | −0.04 (0.03) | −0.04 (0.03) |
| Romantic relationship | −0.03 (0.02) | 0.03 (0.03) | 0.03 (0.02) | −0.03 (0.02) | −0.02 (0.02) | −0.01 (0.02) | −0.10 (0.02)*** | −0.01 (0.02) |
| Female students | ||||||||
| Age | −0.00 (0.00) | 0.00 (0.00)** | 0.02 (0.00)*** | 0.00 (0.00)* | 0.01 (0.00)*** | 0.01 (0.00)*** | −0.01 (0.00)*** | −0.00 (0.00)* |
| Non-Hispanic White (REM is ref) | 0.23 (0.02)*** | 0.23 (0.02)*** | −0.07 (0.03)* | 0.03 (0.02) | 0.06 (0.02)** | 0.04 (0.02) | 0.06 (0.02)** | −0.05 (0.02)** |
| Sexual orientation (heterosexual is ref) | ||||||||
| Bisexual | −0.04 (0.04) | −0.23 (0.04)*** | −0.38 (0.04)*** | 0.01 (0.04) | 0.04 (0.03) | 0.10 (0.04)* | 0.04 (0.04) | 0.07 (0.04) |
| Lesbian/Gay | −0.02 (0.07) | −0.40 (0.08)*** | −0.42 (0.06)*** | −0.04 (0.06) | 0.13 (0.06)* | −0.10 (0.07) | 0.07 (0.06) | 0.12 (0.06)* |
| Questioning | −0.27 (0.07)*** | −0.30 (0.10)** | −0.30 (0.08)*** | −0.01 (0.07) | 0.23 (0.07)** | 0.03 (0.08) | −0.04 (0.07) | 0.20 (0.07)** |
| Lifetime mental health concerns | −0.10 (0.01)*** | −0.13 (0.01)*** | −0.07 (0.01)*** | −0.05 (0.01)*** | 0.20 (0.01)*** | −0.00 (0.01) | −0.06 (0.01)*** | 0.06 (0.01)*** |
| Lifetime suicidal ideation | −0.14 (0.02)*** | −0.27 (0.03)*** | −0.04 (0.03) | −0.09 (0.02)*** | −0.03 (0.02) | −0.01 (0.02) | −0.07 (0.02)** | −0.04 (0.02)* |
| Romantic relationship | −0.06 (0.01)*** | −0.01 (0.02) | −0.08 (0.02)** | −0.10 (0.02)*** | −0.03 (0.02)* | 0.02 (0.02) | −0.09 (0.02)*** | −0.03 (0.01) |
Unstandardized regression coefficients (standard errors) are presented. Students were asked who or what service affected their ability to cope during a stressful period. Answer options ranged from 1 = Considerably reduced my ability to cope to 5 = Considerably improved my ability to cope. Ns for these analyses range from 9000 (males) to 15,687 (females).
Campus resources (e.g., student services, health/counseling center, and career center).
p < 0.05, **p < 0.005, ***p < 0.001.
Compared with heterosexual males and females, questioning males and females were more likely to report that friends (B = −0.30, SE = 0.12, p = 0.017; B = −0.27, SE = 0.07, p < 0.001, respectively) and religion (B = −0.22, SE = 0.11, p = 0.003; B = −0.30, SE = 0.08, p < 0.001, respectively) reduced their ability to cope. Compared with heterosexual females, questioning females were more likely to report that family reduced their ability to cope (B = −0.30, SE = 0.10, p = 0.003), but they were more likely to report that mental health professionals (B = 0.23, SE = 0.07, p = 0.003) and campus resources (B = 0.20, SE = 0.07, p = 0.004) improved their ability to cope. There were no significant interactions of sexual orientation × race/ethnicity (p > 0.05).
Discussion
The current study identifies differences between heterosexual and LGBQ college students in three domains of health service utilization. First, lesbian/gay students (male and female) and bisexual females reported receiving more counseling or mental health services during their lifetime than heterosexual students. In addition, gay males and bisexual females were less likely to have received services from clergy. Second, LGBQ females were more likely to seek help from professionals, whereas LGBQ females and bisexual males were less likely to seek help from a parent or family member. Third, when asked who contributed to their ability to cope during a stressful period, LGBQ females reported that their family reduced their ability to cope. For gay and questioning males and for LGBQ females, religion reduced their ability to cope. Lesbian/gay and questioning females reported that mental health professionals and campus resources improved their ability to cope. Among females, racial/ethnic minority bisexuals were less likely to seek help from a friend or roommate than non-Hispanic White bisexuals. This may be explained by a perceived lack of acceptance by friends among bisexual females of color,19 leading them not to share during times of distress or not to disclose their sexual orientation to friends.20
As hypothesized, lesbian/gay and bisexual college students reported receiving more counseling and mental health services than heterosexual college students. However, there are clear differences in from whom they seek help and whether these resources improved their ability to cope. Our study cannot infer why LGB college students received more counseling or mental health services. It is possible that LGB individuals' increased rates of depression and suicidality2 make psychological care more urgent; however, when we control for lifetime mental health concerns and suicidal ideation, the differences remain.
The current findings also do not elucidate what are LGBQ students' experiences with counseling and mental health services: whether they disclosed their sexual orientation, whether the help they received was effective, and whether they felt supported and safe. It is possible that LGBQ college students seek more varied providers because they feel unsatisfied with their care providers. Differences in seeking or receiving counseling and mental health services do not confirm that LGBQ college students are more or less satisfied with those services.
We found that gay male and bisexual female college students were less likely to report having received services from clergy and that bisexual males and LGBQ females were less likely to report seeking help from family members. When clergy are nonaffirming, LGB members of the church are found to feel isolated.21,22 Similarly, parents often struggle to support their children when they disclose a nonheterosexual orientation.23,24 The perceived lack of acceptance by clergy and family members may explain why certain groups of LGBQ college students in the current sample were less likely to have sought or received help from these sources and were more likely to report that clergy and family reduced their ability to cope. Perhaps the apparent accessibility of mental healthcare services for college students is a positive characteristic of the college years.
Limitations and future research
The current study has provided empirical data about sexual orientation differences in formal and informal care utilization between LGBQ and heterosexual college students. Despite the additions to the literature, there are several limitations to note. First, the response rate in the current study was relatively low, although comparable to earlier editions of this study and similar higher education studies.25–28 The included sample was not representative of all college students or LGBQ college students, but representative of national higher education institutions. Furthermore, although measures of the included predictors have been used before,25,28 outcomes were not assessed with validated measures.
Despite the sample size and its diversity, we cannot generalize our findings to other college or university students or make comparisons with other samples. Furthermore, college students may be better positioned in terms of insurance coverage and access to healthcare than young adults who are not in college. The current findings should therefore be replicated in representative and noncollege young adult populations. Second, we do not know whether students' sexual orientation was a factor in them seeking mental health services. With a more comprehensive study addressing reasons for seeking care and experiences with healthcare for LGBQ young adults, we might be able to infer the quality of healthcare students receive and better understand why they prefer formal services over clergy or family. Third, due to the small sample of transgender students we were unable to examine differences between transgender and cisgender students in terms of healthcare utilization. Considering that there are large disparities for transgender students in terms of mental and physical health29 and insurance coverage,30 future research should consider the experiences of transgender students with seeking and receiving counseling and mental healthcare services.
Finally, because the majority of participants reported identifying as non-Hispanic White, we were unable to assess differences by sexual orientation and separate racial/ethnic groups in terms of healthcare utilization. Previous work has shown disparities in mental healthcare access and utilization for racial/ethnic minority populations31,32 and LGBQ individuals of color.33,34 For future work it is crucial to consider the intersection of race/ethnicity and sexual orientation in access to and experiences with healthcare.
Conclusion
Our results have direct implications for college campus mental health centers, specifically in terms of increasing students' access to inclusive care. In the current sample, mental healthcare providers and university staff seemed to be accessible to LGBQ college students, especially to female students. The findings from the current study also suggest that family and clergy are not frequent sources of support for certain groups of LGBQ college students. Although the current findings show that LGB college students were more likely to report receiving counseling or mental health services, we need more research to assess whether they find healthcare to be inclusive and helpful.
Acknowledgments
This research was supported by grant, P2CHD042849, Population Research Center, awarded to the Population Research Center at The University of Texas at Austin by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The University of Texas at Austin's Office of the Vice President for Research supported this research as part of the Summer Institute on Discrimination and Population Health Disparities in 2017. Dr. Baams acknowledges generous support from the Communities for Just Schools Fund.
Disclaimer
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Author Disclosure Statement
No competing financial interests exist.
Transgender students had an average age of 27.6 years old (SD = 13.43); 47% identified as a racial/ethnic minority, and the majority was undergraduate students (60%).
There is overlap in missingness as a student could be excluded for more than one reason.
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