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. Author manuscript; available in PMC: 2022 Jul 24.
Published in final edited form as: Arch Sex Behav. 2021 Nov 1;50(8):3563–3574. doi: 10.1007/s10508-021-01997-8

Psychological Distress, Suicidal Ideation, and Suicide Attempt Among Lesbian, Gay, and Bisexual Immigrants: Population-Based Findings from the Stockholm Public Health Cohort

Kirsty A Clark 1, Charlotte Björkenstam 2, Kyriaki Kosidou 3,4, Emma Björkenstam 2,5,6
PMCID: PMC9308978  NIHMSID: NIHMS1823190  PMID: 34725752

Abstract

In a large, population-based sample in Sweden, we sought to examine mental health disparities between lesbian, gay and bisexual (LGB) and heterosexual individuals with different immigration statuses. We conducted a population-based study including 1799 LGB and 69,324 heterosexual individuals, recruited in 2010 and 2014 as part of the Stockholm Public Health Cohort. Data were obtained from self-administered surveys that were linked to nationwide registers. We examined associations between mental health outcomes (i.e., psychological distress, suicidal ideation, and suicide attempt) and sexual orientation (LGB versus heterosexual), immigration status (immigrant versus Nordic-born), and their interaction. Sex-stratified weighted multivariable logistic regression analyses were used to calculate adjusted odds ratios with 95% confidence intervals. LGB individuals demonstrated substantially elevated odds of all mental health outcomes compared to heterosexuals; immigrants reported moderately elevated odds of psychological distress and suicide attempt, but not suicidal ideation, compared to Nordic-born individuals. Interaction terms between sexual orientation and immigration status were significant at p < 0.05 for psychological distress for both sexes and for suicidal ideation and attempt among women. Unexpectedly, models probing interactions generally demonstrated that Nordic-born LGB individuals demonstrated greater risk of psychological distress, suicidal ideation, and suicide attempt than did immigrant LGB individuals, especially among women. Supplemental analyses showed that Nordic-born bisexual women demonstrated the highest risk of all studied outcomes. Being LGB in Sweden is generally a stronger risk factor for poor mental health among Nordic-born than immigrant populations. These findings call for future intersectionality-focused research to delineate the unique cultural, social, and psychological factors associated with mental health and resilience among LGB immigrants.

Keywords: Sexual orientation, Immigration, Stigma, Minority stress, Suicide

Introduction

Clear evidence now demonstrates that lesbian, gay, and bisexual (LGB) individuals in Sweden and across the globe are at greater risk of psychiatric morbidity, including psychological distress, anxiety, depression, self-harm, and suicidal thoughts and behavior, as compared to their heterosexual counterparts (Almeida et al., 2009; Balsam et al., 2005; Bostwick et al., 2014a, 2014b; Cochran & Mays, 2009; Cochran et al., 2003; Gevonden et al., 2014; Gustafsson et al., 2017; Jorm et al., 2002; Lian et al., 2015; Meyer et al., 2008; Plöderl et al., 2013). Additionally, it is well-established across population-based samples in Sweden that immigrants and refugees to Sweden from regions of origin including Eastern European, Latin American, and other non-Western regions including the Middle East and North Africa experience an elevated risk of mental health problems, including depression, anxiety, post-traumatic stress disorder, and suicidality than Swedish natives (Dunlavy & Rostila, 2013; Hollander et al., 2013; Rostila, 2010; Sundquist, 1995; Wiking et al., 2004). However, less is known about the relationship between minority sexual orientation and immigration status on mental health problems in Sweden or elsewhere.

Excess psychiatric morbidity among LGB people has generally been attributed to the adverse effects of anti-LGB discrimination and stigma, including experiences of prejudice events, expectations of rejection, identity concealment, internalized anti-LGB stigma, and maladaptive coping processes, such as alcohol misuse and substance use (Cochran, 2001; Hatzenbuehler, 2009; Meyer, 2003). The cumulative toll of stigma-related stressors in turn produces general emotion dysregulation, social and interpersonal problems, and cognitive processes conferring risk for psychopathology and psychological distress (Hatzenbuehler, 2009).

In Sweden and other Nordic countries, several laws protecting LGB individuals against discrimination based on sexual orientation were enacted in the beginning of the twenty-first century, focusing on discrimination in the workplace, and in 2003, a new legislation against hate speech toward LGB people was introduced. In 2009, a gender-neutral marriage legislation was enacted, accompanied by an increase in accepting attitudes toward LGB people by the general population (Hooghe & Meeusen, 2013; The Swedish Federation for LGBT Rights, 2015). For instance, the European Social Survey asks respondents if they agree with the statement, “Gay men and lesbians should be free to live their own life as they wish.” The proportion of respondents who agreed with this statement in Sweden increased from 82% in 2002 to 92% in 2014. While Sweden is one of the world’s most socially liberal countries, our prior work has documented that Swedish LGB persons still demonstrate higher risk for psychological distress, suicide attempts, and suicide than Swedish heterosexual persons, suggesting that LGB people in Sweden still experience enacted and anticipated stigma-related stressors, such as anti-LGB discrimination, leading to poorer mental health (Björkenstam et al., 2016a, 2017).

Because of its international reputation as a liberal country, in addition to being a high-income country with broad social and economic safety-net programs, immigration to Sweden has boomed in the past three decades, especially among asylum seekers and refugees (Migrationsverket, 2021). Indeed, Sweden is one of the largest European recipients of refugees, with more than 160,000 individuals seeking asylum in 2015 alone (Migration Agency, 2018). That same year, 22.2% of the population in Sweden was either foreign-born or a first-generation immigrant (i.e., both parents were born abroad). Prior research from Sweden has shown that immigrants, compared to non-immigrants, are at increased risk for mental health problems, including low overall well-being and elevated rates of several mental disorders such as depression, anxiety, and psychotic disorders including schizophrenia (Gilliver et al., 2014; Tinghög et al., 2010). Such mental health disparities are thought to be produced by interlocking socio-economic disadvantages facing immigrants including higher rates of unemployment and financial strain, lower social support, and the stress associated with the refugee resettlement process including feelings of alienation and refugee-related discrimination (Gilliver et al., 2014; Hollander, 2013; Kosidou et al., 2012; Lindencrona et al., 2008; Tinghög et al., 2010).

To our knowledge, no peer-reviewed studies have investigated the mental health impacts of identifying as an LGB person and as an immigrant in Sweden. Intersectionality theory posits that interlocking forces of oppression—including racism, sexism, ethnicism, and anti-LGB stigma—can uniquely and harmfully corrode the health of multiply marginalized populations (Abrams et al., 2020; Crenshaw, 1990; Ghavami et al., 2016). Intersectionality-informed research from North America has documented that LGB immigrants often report negative and unique experiences resultant from being a “minority within a minority” (Gray et al., 2015). Such experiences include facing both anti-LGB and anti-immigrant discrimination, experiences of sexual violence, persecution by family members, and social and legal discrimination based on LGB or immigrant status leading to reduced healthcare access and limited employment opportunities (Chávez, 2011; Gray et al., 2015; Hopkinson et al., 2017; Lee & Brotman, 2011). Despite providing insight into the dual-stigma potentially facing LGB immigrants, such studies from North America primarily draw from samples of Latinx LGB immigrants (i.e., from Central and South America) that are unlikely to generalize to the immigrant population in Sweden, which is primarily composed of Europeans with a growing refugee population from the Middle East. Further, existing studies generally report results from smaller, qualitative samples precluding the ability to investigate population-level sexual orientation and immigration status differences in mental health. Thus, in the current study, we capitalized on information from the Stockholm Public Health Cohort (SPHC) (Svensson et al., 2013), a sample of approximately 70,000 people aged 16 years and older surveyed in 2010 and 2014, to investigate the intersecting relationship between sexual orientation, immigration status, and mental health problems at the population-level. Drawing upon existing evidence, we hypothesized, first, that immigrants and LGB people would report greater mental health problems than non-immigrants and heterosexuals, respectively, and second, that the magnitude of the association—the greatest psychiatric risk—would be demonstrated among immigrant LGB people.

Method

Participants

We used data from the SPHC, a population-based longitudinal cohort study of nearly 100,000 residents in Stockholm, Sweden (Svensson et al., 2013). The SPHC sampling frame consisted of all adults residing in Stockholm who were listed in the Swedish Total Population Register (Ludvigsson et al., 2016). Respondents were recruited into the cohort in four successive waves (2002, 2006, 2010, and 2014). For each wave, an area-stratified random sample of approximately 50,000 adults was invited to complete self-administered questionnaires assessing health, lifestyle, and social characteristics. Upper age limits varied across the waves; in 2002 and 2006 adults 18–84 years were recruited, but in 2010, the upper age limit was removed and in 2014 the lower age limit was lowered to 16. Across surveys, response rates averaged 59.7%. In 2010 and 2014, all SPHC participants were assessed for sexual orientation. In the current study, only participants who reported their sexual orientation were included.

All Swedish residents receive a unique personal identity number at birth or on obtaining a residency permit (Ludvigsson et al., 2009). Using this identifier, we obtained the SPHC respondent’s demographic information, including immigrant status, from the Longitudinal Integration Database for Health Insurance and Labor Market Studies (LISA) (Statistics Sweden, 2014).

Using the SPHC 2010 and 2014, the final analytical sample for this study included 69,324 heterosexuals and 1799 LGB individuals. Sensitivity analyses (described below) included an additional 880 people who endorsed an “uncertain” sexual orientation.

Measures

Demographic Characteristics

Demographic characteristics from the SPHC questionnaires included: sex, age (16–29, 30–49, 50 +), and marital status (currently married, divorced, never married, and widow/widower). We also supplemented the dataset with information from LISA, including country of birth (coded as Sweden or other Nordic countries, other European Union countries, and other), and level of educational attainment in 2010 and 2014, respectively (9 years or less, 10–12 years, and 13 years or more).

Exposure

Sexual Orientation

Sexual orientation was measured by a single item (“What is your sexual orientation?”) with four response options (“Heterosexual,” “Homosexual,” “Bisexual,” and “Uncertain”). From this, we dichotomized individuals into one of two groups: LGB for those who answered “Homosexual” or “Bisexual” and heterosexual for those who responded “Heterosexual.” In two sets of sensitivity analyses (described below), we, first, examined associations separating sexual orientation into three categories (heterosexual, lesbian/gay, and bisexual), and, second, we included participants who endorsed an “uncertain” sexual orientation with the LGB participants to create an overall “minority sexual orientation” category.

Immigration Status

We obtained information on country of birth from LISA and parents’ country of birth from the Multi-Generation Register. From this, we created two immigration status categories; one for Nordic-born individuals including people born in Sweden and the other Nordic countries (Denmark, Norway, Finland, and Iceland), and one for immigrants from all other countries. Individuals from all Nordic countries were categorized with Swedish-born individuals because of the similar social, economic, and cultural structures in all Nordic countries, including being among the most progressive countries in the world regarding sexual and gender equality (Kjaran, 2017; Pachankis & Bränström, 2018).

Outcomes

Recent Self-Reported Psychological Distress

The 12-item General Health Questionnaire (GHQ-12), included in the SPHC survey, was used to identify recent levels of psychological distress. The GHQ-12 is a widely used self-reported questionnaire that has been validated for use in Swedish populations measuring psychological distress in the last few weeks (Goldberg, 1970; Sconfienza, 1998). The GHQ-12 has been utilized as a valid measure of psychological distress among immigrant populations (Löfvander et al., 2014; Pernice et al., 2000). We dichotomized scale scores to denote a cutoff score of 3 or more denoting significant psychological distress (= 1) versus a score of less than 3 denoting less psychological distress (= 0) (Wadman et al., 2009).

Lifetime Self-Reported Suicidal Ideation and Suicide Attempt

The SPHC survey assessed lifetime suicidal ideation (“Have you ever been in the situation that you seriously considered taking your own life, maybe even planned how you would do that?”) and attempt (“Have you ever made an attempt to take your life?”). We dichotomized responses to both questions as yes (= 1) versus no (= 0).

Statistical Analysis

Analyses were conducted in SAS v.9.4 and Stata v.15, incorporating design information and sample weights. We first examined differences in demographic characteristics associated with sexual orientation and immigration status. Next, in weighted crude and multi-adjusted logistic regression models, we examined associations between each outcome (i.e., psychological distress, suicidal ideation, and suicide attempt) and sexual orientation, immigration status, and their interaction (i.e., sexual orientation × immigration status). For outcomes where interaction terms reached statistical significance at p < 0.05, we then conducted multi-adjusted logistic regression models including a categorical interaction variable to denote sexual orientation × immigration status. Such an approach probes the intersection of sexual orientation and immigration status by delineating whether the odds of experiencing the outcome may differ by whether participants hold one stigmatized status (e.g., immigrant, heterosexual), the other stigmatized statuses (e.g., Nordic-born, LGB), or both stigmatized statuses (i.e., immigrant, LGB) compared to the reference group which holds neither stigmatized status (i.e., Nordic-born, heterosexual). Analyses were stratified by sex and were adjusted for age, education, and marital status. We report weighted proportions and adjusted odds ratios (aORs) with 95% confidence intervals (CIs).

Sensitivity Analyses

In a first set of sensitivity analyses, we calculated weighted proportions and conducted the multi-adjusted logistic regression models described earlier including a categorical variable to denote sexual orientation × immigration status where the categorical variable for sexual orientation was separated into heterosexual, lesbian/gay, and bisexual. We assessed this three-level categorical variable for sexual orientation in recognition of the growing body of research showing that bisexual individuals often face elevated psychiatric morbidity compared to both their heterosexual and gay/lesbian counterparts (Bostwick & Harrison, 2020). In a second set of sensitivity analyses, we conducted the multi-adjusted logistic regression models including a categorical variable to denote sexual orientation × immigration status where individuals who reported an “uncertain” sexual orientation were included with the LGB group.

Results

Demographic Characteristics

Table 1 provides weighted descriptive characteristics, stratified by sexual orientation, immigration status, and sex. Sexual orientation and immigration status were associated with several individual characteristics (p < 0.001 for all comparisons; Table 1). Among both sexes, regardless of immigration status, a higher proportion of LGB individuals were younger, had a higher educational attainment, and were never married.

Table 1.

Demographic characteristics of participants of the Stockholm Public Health Cohort in 2010 and 2014, by sex, sexual orientation and immigration status

Heterosexual
 LGB*
Weighted proportion (95% CI)
Nordic-born Immigrants Nordic-born Immigrants
Women
Total 80.8 (80.1–81.4) 16.0 (15.5–16.6) 2.5 (2.3–2.8) 0.7 (0.6–0.9)
Age
16–29 years 20.0 (19.2–20.8) 15.5 (13.9–17.3) 45.8 (40.7–51.0) 21.6 (14.6–30.9)
30–49 years 34.5 (33.9–35.2) 48.5 (46.5–50.4) 38.8 (34.3–43.5) 59.9 (50.2–69.0)
50 + years 45.5 (44.8–46.2) 36.0 (34.2–37.8) 15.4 (34.3–43.5) 18.5 (12.6–26.2)
Educational attainment
≤ 9 years 19.9 (19.3–20.5) 17.6 (16.1–19.2) 15.0 (11.8–18.9) 16.4 (9.8–26.1)
10–12 years 40.6 (39.8–41.3) 34.1 (32.3–36.0) 36.5 (31.9–41.4) 37.0 (27.9–47.1)
≥ 13 years 38.8 (38.1–39.6) 42.2 (40.2–44.1) 47.5 (42.5–52.5) 38.9 (29.9–48.7)
Missing 0.7 (0.6–0.9) 6.1 (5.2–7.2) 0.9 (0.4–2.5) 7.7 (4.0–14.4)
Marital status
Currently married 37.1 (36.4–37.8) 50.8 (48.8–52.7) 16.1 (13.3–19.3) 42.4 (33.2–52.2)
Never married 41.6 (40.8,42.4) 23.8 (22.1–25.7) 74.3 (70.4–77.9) 35.8 (27.0–45.6)
Divorced 14.5 (14.0–15.0) 19.7 (18.3–21.3) 8.2 (6.3–10.8) 18.8 (11.2–29.7)
Widowed 6.9 (6.5–7.2) 5.7 (4.9–6.6) 1.4 (0.7–2.8) 3.1 (1.3–7.2)
Men
Total 79.4 (78.7–80.1) 17.0 (16.3–17.7) 2.7 (2.5–3.0) 0.9 (0.7–1.2)
Age
16–29 years 21.8 (20.8–22.9) 15.2 (13.1–17.5) 21.7 (17.0–27.4) 26.2 (15.9–39.8)
30–49 years 37.3 (36.5–38.2) 41.4 (39.2–43.5) 43.7 (38.9–48.5) 50.8 (39.9–61.6)
50 + years 40.9 (40.1–41.7) 43.5 (41.4–45.6) 34.6 (30.5–39.0) 23.1 (16.3–31.6)
Educational attainment
< = 9 years 21.1 (20.4–21.8) 18.2 (16.5–20.1) 17.0 (13.3–21.5) 13.3 (6.7–24.9)
10–12 years 40.4 (39.5–41.3) 36.9 (34.8–39.0) 41.8 (37.0–46.8) 33.6 (24.0–44.8)
> = 13 years 37.7 (36.8–38.6) 39.3 (37.2–41.5) 39.9 (35.3–44.7) 48.0 (37.3–58.9)
Missing 0.8 (0.6–1.0) 5.6 (4.6–6.8) 1.3 (0.5–3.3) 5.1 (2.3–10.6)
Marital status
Currently married 39.2 (38.4–40.0) 54.2 (51.9–56.4) 19.3 (16.2–22.9) 36.4 (26.7–47.3)
Never married 48.2 (47.3–49.1) 27.6 (25.4–29.9) 72.2 (68.1–76.0) 51.6 (40.7–62.3)
Divorced 10.4 (9.9–10.8) 16.7 (15.2–18.2) 7.3 (5.4–9.8) 11.4 (6.7–18.7)
Widowed 2.3 (2.1–2.5) 1.6 (1.2–2.2) 1.2 (0.6–2.2) 0.6 (0.1–3.0)
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*

Lesbian, Gay, Bisexual

Main and Interaction Effects of Sexual Orientation and Immigration Status on Outcomes

Table 2 presents sex-stratified crude and multi-adjusted weighted ORs with 95% CIs for self-reports of recent psychological distress, lifetime suicidal ideation, and lifetime suicide attempt by sexual orientation, immigration status, and their interaction.

Table 2.

Recent psychological distress, lifetime suicidal ideation, and lifetime suicide attempts, by sex, sexual orientation, and immigration status. Weighted odds ratios (ORs) with 95% confidence intervals (CIs)

Women Men
Model 1a Model 2b Model 1a Model 2b
Recent psychological distressc
  Sexual orientation
  Heterosexual 1 (REF) 1 (REF) 1 (REF) 1 (REF)
  LGB* 2.13 (1.76–2.58) 3.77 (2.00–7.10) 1.44 (1.16–1.79) 3.11 (1.49–6.50)
  Immigration status
  Nordic-born individuals 1 (REF) 1 (REF) 1 (REF) 1 (REF)
  Immigrants 1.35 (1.23–1.48) 1.45 (1.31–1.61) 1.54 (1.36–1.73) 1.68 (1.48–1.91)
  Sexual orientation by immigration status interaction – P value = 0.0076 – P value = 0.0219
Suicidal ideation (lifetime)d
  Sexual orientation
  Heterosexual 1 (REF) 1 (REF) 1 (REF) 1 (REF)
  LGB* 2.48 (2.01–3.07) 6.26 (2.96–13.26) 2.61 (2.08–3.28) 3.97 (1.78–8.82)
  Immigration status
  Nordic-born individuals 1 (REF) 1 (REF) 1 (REF) 1 (REF)
  Immigrants 0.91 (0.84–1.08) 1.06 (0.92–1.22) 0.83 (0.70–0.97) 0.88 (0.74–1.04)
  Sexual orientation by immigration status interaction – P value = 0.0084 – P value = 0.2298
Suicide attempt (lifetime)e
  Sexual orientation
  Heterosexual 1 (REF) 1 (REF) 1 (REF) 1 (REF)
  LGB* 3.51 (2.58–4.78) 8.76 (3.05–25.12) 4.11 (2.89–5.84) 5.70 (1.78–18.32)
  Immigration status
  Nordic-born individuals 1 (REF) 1 (REF) 1 (REF) 1 (REF)
  Immigrants 1.62 (1.33–1.97) 1.76 (1.42–2.19) 1.44 (1.08–1.93) 1.52 (1.11–2.09)
  Sexual orientation by immigration status interaction – P value = 0.0357 – P value = 0.4968
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*

Lesbian, gay, bisexual

a

Crude models

b

Models adjusted for age, education, and marital status

c

Recent psychological distress measured by a score of 3 or higher on the General Health Questionnaire (GHQ-12)

d

Suicidal ideation measured by an affirmative response to the question: “Have you ever been in the situation that you seriously considered taking your own life, maybe even planned how you would do that?”

e

Suicide attempt measured by an affirmative response to the question: “Have you ever made an attempt to take your life?”

Recent Psychological Distress

LGB individuals reported substantially elevated odds of psychological distress compared to heterosexuals (among women, odds ratio [OR] = 3.77 [95% CI = 2.00–7.10]; among men, OR = 3.11 [95% CI = 1.49–6.50]). Immigrants reported moderately elevated odds of psychological distress compared to Nordic-born individuals (among women, OR = 1.45 [95% CI = 1.31–1.61]; among men, OR = 1.68 [95% CI = 1.48–1.91]). Further, for both sexes, the interaction term of sexual orientation by immigration status was statistically significant at p < 0.05.

Lifetime Suicidal Ideation

LGB individuals reported substantially greater odds of life-time suicidal ideation compared to heterosexuals (among women, OR = 6.26 [95% CI = 2.96–13.26], among men, OR = 3.97 [95% CI = 1.78–8.82]). Immigration status was not associated with lifetime suicidal ideation (for both sexes, 95% confidence intervals included 1). Among women, sexual orientation and immigration status demonstrated a significant interaction effect (p < 0.05); among men, this interaction was not statistically significant.

Lifetime Suicide Attempt

LGB individuals demonstrated substantially elevated odds of lifetime suicide attempt compared to heterosexuals (among women, OR = 8.76 [95% CI = 3.05–25.12]; among men, OR=5.70 [95% CI = 1.78–18.32]). Immigrants reported moderately greater odds of lifetime suicide attempt than Nordic-born individuals (among women, OR = 1.76 [95% CI = 1.42–2.19]); among men, OR = 1.52 [95% CI = 1.11–2.09). The interaction between sexual orientation and immigration status only reached significance at p < 0.05 among women.

Probing Statistically Significant Interaction Effects of Sexual Orientation and Immigration Status

Tables 3 and 4 present weighted proportions and multi-adjusted weighted ORs with 95% CIs for models including a categorical interaction variable denoting the intersection of sexual orientation and immigration status.

Table 3.

Interaction of sex, sexual orientation, and immigration status on self-reported recent psychological distress

N Weighted proportion (95% CI) Weighted odds ratios (ORs) with 95% confidence intervals (CIs)
Women
  Heterosexual
 Nordic-born individuals 7141 23.7 (23.0–24.4) 1 (REF)
 Immigrants   985 29.9 (28.0–31.8) 1.45 (1.30–1.60)
  LGB*
 Nordic-born individuals   299 42.9 (37.9–48.1) 1.84 (1.48–2.28)
 Immigrants  48 25.2 (24.6–25.9) 1.33 (0.84–2.11)
Men
  Heterosexual
 Nordic-born individuals 3840 18.8 (16.1–17.6) 1 (REF)
 Immigrants   692 24.0 (22.1–26.1) 1.68 (1.48–1.91)
  LGB*
 Nordic-born individuals   168 24.7 (20.7–29.2) 1.54 (1.21–1.96)
 Immigrants  31 22.5 (14.9–32.5) 1.25 (0.72–2.17)
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*

Lesbian, gay, and bisexual

a

Models adjusted for age, education, and marital status

Recent psychological distress measured by a score of 3 or higher on the General Health Questionnaire (GHQ-12)

Table 4.

Interaction of sexual orientation and immigration status on self-reported lifetime suicidal ideation and suicide attempts among women

Women N Weighted proportion (95% CI) Weighted odds ratios (ORs) with 95% confidence intervals (CIs)a
Suicidal ideation (Lifetime)b
  Heterosexual
 Nordic-born 3800 11.8 (11.3–12.4) 1 (REF)
 Immigrants   440 11.6 (10.4–13.0) 1.06 (0.92–1.21)
  LGB*
 Nordic-born   222 27.7 (23.5–32.5) 2.69 (2.12–3.42)
 Immigrants  23 12.2 (11.8–12.7) 1.19 (0.68–2.09)
Suicide attempt (Lifetime)c
  Heterosexual
 Nordic-born 1009 3.6 (3.3–4.0) 1 (REF)
 Immigrants   185 6.0 (5.0–7.1) 1.75 (1.40–2.17)
  LGB*
 Nordic-born  94 13.5 (10.1–17.9) 3.45 (2.44–4.90)
 Immigrants  13 11.4 (6.3–19.6) 2.65 (1.27–5.53)
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*

Lesbian, gay, and bisexual

a

Models adjusted for age, education, and marital status

b

Suicidal ideation measured by an affirmative response to the question: “Have you ever been in the situation that you seriously considered taking your own life, maybe even planned how you would do that?”

c

Suicide attempt measured by an affirmative response to the question: “Have you ever made an attempt to take your life?”

Recent Psychological Distress: Both Sexes

Among women, weighted proportions show that Nordic-born LGB individuals were at greatest likelihood of reporting recent psychological distress (42.9%) compared to Nordic-born heterosexuals (23.7%), immigrant heterosexuals (29.9%), and immigrant LGB people (25.2%; see Table 3). In the multi-adjusted logistic model among women, compared to Nordic-born heterosexuals, immigrant heterosexuals (OR = 1.45, 95% CI = 1.30–1.60) and Nordic-born LGB individuals (OR = 1.84, 95% CI = 1.48–2.28) demonstrated increased odds of recent psychological distress. LGB immigrants did not significantly differ in their odds of recent psychological distress compared to Nordic-born heterosexuals (95% CI crossed the null; see Table 3). Among men, weighted proportions demonstrated that Nordic-born heterosexuals demonstrated the lowest prevalence of psychological distress (18.8%) compared to heterosexual immigrants (24.0%), Nordic-born LGB individuals (24.7%), and LGB immigrants (22.5%). In the multi-adjusted model among men, compared to Nordic-born heterosexuals, immigrant heterosexuals (OR = 1.68, 95% CI = 1.48–1.91) and Nordic-born LGB individuals (OR = 1.54, 95% CI = 1.21–1.96) demonstrated greater odds of psychological distress; LGB immigrants did not significantly differ in psychological distress from Nordic-born heterosexuals (95% CI crossed the null; see Table 3).

Lifetime Suicidal Ideation: Women Only

These results are presented only among women due to the sexual orientation × immigration status interaction term reaching significance at p < 0.05 among women but not among men. A substantially higher proportion of Nordic-born LGB individuals reported lifetime suicidal ideation (27.7%) compared to Nordic-born heterosexuals (11.8%), immigrant heterosexuals (11.6%), and immigrant LGB people (12.2%; see Table 4). Results from the multi-adjusted model show that compared to Nordic-born heterosexual women, Nordic-born LGB women demonstrated 2.69 times the odds of lifetime suicidal ideation (95% CI = 2.12–3.42); odds of lifetime suicidal ideation did not differ between Nordic-born heterosexual women and immigrant heterosexual women or immigrant LGB women (95% CIs crossed the null; see Table 4).

Lifetime Suicide Attempt: Women Only

Similar to above, these results are presented only among women. Weighted proportions show that Nordic-born heterosexuals had the lowest lifetime prevalence of suicide attempt (3.6%) followed by immigrant heterosexuals (6.0%), immigrant LGB people (11.4%) and then Nordic-born LGB people (13.5%; see Table 4). Multi-adjusted models showed a similar pattern of results: compared to Nordic-born heterosexuals, elevated odds of suicide attempts were evidenced by immigrant heterosexuals (OR = 1.75, 95% CI = 1.40–2.17), immigrant LGB people (OR = 2.65, 95% CI = 1.27–5.53), and Nordic-born LGB people (OR = 3.45, 95% CI = 2.44–4.90).

Sensitivity Analyses

In the first set of sensitivity analyses, we ran the sexual orientation × immigration status comparisons separating sexual orientation into a three-level heterosexual, lesbian/gay, and bisexual categorical variable (see Supplemental Table 1). Sixty percent of LGB females and 36% of LGB males reported being bisexual. Weighted proportions and multi-adjusted regression analyses showed that Nordic-born bisexuals demonstrated higher odds of all studied outcomes compared to all other sexual orientation × immigration status categories including immigrant bisexuals (see Supplemental Table 1). In the second set of sensitivity analyses, we ran the multi-adjusted categorical interaction models described in the main analyses where we included those individuals with “uncertain” sexual orientation as part of the LGB group (see Supplemental Table 2). Differences from the results described in the main analyses were negligible.

Discussion

Drawing on data from the Stockholm Public Health Cohort (2010 and 2014) linked with Sweden’s extensive and high-quality nationwide registers, the present study examined population-level associations among sexual orientation, immigration status, and mental health problems, including recent psychological distress and lifetime suicidal ideation and attempts. By sex-stratifying analyses, this study offers a nuanced depiction of how identity characteristics including sex, sexual orientation, and immigration status can intersect to impact psychiatric morbidity. In concordance with existing population-based evidence (Björkenstam et al., 2016b; Bränström & Pachankis, 2018; Conron et al., 2010; Erlangsen et al., 2020; Hollander, 2013; Hollander et al., 2013; Johnson et al., 2017; Missinne & Bracke, 2012), study results supported our first hypothesis that LGB individuals would be more likely to report psychological distress, suicidal ideation, and suicide attempt than heterosexuals and partially supported that immigrants would be more likely to report these psychiatric outcomes than Nordic-born individuals. Notably, we did not find an association between immigration status and suicidal ideation. Unexpectedly, the present study’s results did not support our second hypothesis that sexual minority identity and immigrant status would intersect to confer greatest risk of psychological distress and suicidality among immigrant LGB people (i.e., those holding two stigmatized statuses). Instead, we found that Nordic-born LGB individuals demonstrated greater risk of psychological distress, suicidal ideation, and suicide attempt than did immigrant LGB individuals, and these effects were pronounced among women. Supplemental analyses revealed that Nordic-born bisexual women may be driving these elevations in psychiatric morbidity.

Minority stress theory, which posits that anticipated and enacted discrimination, prejudice events, and the internalization of stigmatizing beliefs underlie sexual orientation and other minority group disparities in mental health (Meyer, 2003), might partially explain why immigrants and LGB people generally demonstrated greater psychological distress and suicidal thoughts and behavior than their Nordic-born and heterosexual counterparts, respectively. Regarding immigration status, previous research highlights that immigrant populations in Sweden experience discrimination in access to employment often hinging on anti-immigrant and anti-ethnic minority prejudice (Rydgren, 2004). A stark example of such bias was demonstrated by a population-based study showing that immigrants to Sweden from Asian, African, and Slavic countries who changed their surname to a Swedish-sounding name reported substantially higher earnings after the name change (Arai & Skogman Thoursie, 2009; Eliassi, 2017). Another population-based study of Kurdish immigrant men to Sweden found that over 80% of the sample reported being discriminated against in Sweden (Taloyan et al., 2006). Qualitative research further supports that immigrants, especially ethnic minority immigrants, in the majority-white Swedish population face anti-immigrant bias (Eliassi, 2017; Ortiz & Ekeroth, 2018; Sadikot, 2011). In addition to navigating anti-immigrant and/or anti-ethnic minority stressors, immigrant populations can face compounding social stressors related to economic insecurity, post-traumatic stress, limited social capital, disrupted social networks, and assimilation concerns which are associated with poorer mental health (Behtoui & Neergaard, 2010; Bennet & Lindström, 2018; Johnson et al., 2017; Tinghög et al., 2010). Regarding LGB identity, despite robust social and legal protections and generally accepting social attitudes toward LGB people in Sweden, evidence from prior studies suggests that LGB people in Sweden still report greater exposure to minority stressors including victimization and assault and lower social support than their heterosexual counterparts, with younger gay men and bisexual women reporting greatest exposure to minority stressors and highest levels of psychiatric morbidity (Björkenstam et al., 2017; Bränström, 2017). Such findings from prior studies regarding sexual orientation-related discrimination might help to explain the strong sexual orientation disparity in psychological distress and suicidality that we found even in this socially liberal country.

Because of the preponderance of evidence documenting that immigrant status and LGB identity are each associated with mental health problems due in part to anti-immigrant and anti-LGB bias, we expected that individuals who identified as both immigrants and LGB would be at greatest risk for both psychological distress and suicidality. Why immigrant LGB people reported less psychological distress and suicidality compared to Nordic-born LGB individuals in the current study represents a conundrum that is not well-supported by the current literature; for example, it is unclear why more than 40% of Nordic-born LGB women reported recent psychological distress compared to just 25% of immigrant LGB women (a proportion nearly the same as that reported by Nordic-born, heterosexual women). We offer two plausible hypotheses that might explain these findings based on our supposition that LGB people who immigrate to Sweden, by virtue of Sweden’s highly liberal social and political landscape, were likely to have faced greater discrimination or even legal persecution related to their sexual identity in their home country (Pachankis & Bränström, 2018). First, we hypothesize that LGB immigrants might be most likely to demonstrate the “healthy immigrant effect,” whereby immigrants are often found to be healthier than native-born populations, with this effect often hinging on selectivity of who immigrates versus who is left behind (e.g., those who immigrate are wealthier and healthier and have more social connections, pass health screenings, etc.) (Kennedy et al., 2015). We postulate that LGB people who immigrate to Sweden might be particularly predisposed to being healthier or have built some psychological resilience from overcoming multiple obstacles (e.g., related to being LGB in their home country, coming out, immigrating in a same-sex partnership, etc.) that might confer some protection against mental health problems. Second, because we expect that LGB immigrants likely faced greater anti-LGB bias or even violence or legal persecution in their home country, we hypothesize that the wide-ranging social and legal protections afforded to LGB people in Sweden might enact a buffering effect against poor mental health among LGB immigrants that may not be fully realized among Nordic-born LGB people who might have not experienced more stigmatizing environments.

Only future research—including qualitative investigations grounded in tenets of intersectionality theory (Crenshaw, 1990; Ghavami et al., 2016)—can clarify the unique characteristics, histories, and lived experiences of being an LGB immigrant person in Sweden that might afford some unforeseen mental health protection compared to Nordic-born LGB people, especially among women. Qualitative research might be a particularly well-suited methodology for investigating the lived experiences of multiply oppressed groups including LGB immigrants in Sweden, with recent guidance stating that intersectionality-informed qualitative research can “…generate new knowledge and more holistic representations of marginalized experiences and the forces that create those experiences to facilitate greater understandings of health as well as more comprehensive solutions (Abrams et al., 2020, p. 2).” Indeed, one recent qualitative study of lesbian, gay, bisexual, transgender, and queer (LGBTQ) refugees who migrated from majority-Islamic societies to either Austria or the Netherlands identified several challenges directly at the intersection of LGBTQ identity and immigration status including: needing to “prove” one’s LGBTQ identity during the asylum process, being alienated by LGBTQ host communities, and feeling shocked by still facing anti-LGBTQ discrimination in their host country (Alessi et al., 2020). In addition to exploring the unique lived experiences of LGB immigrants in Sweden, future research might also seek to investigate whether cultural norms influence whether and how Nordic-born versus immigrant populations respond to mental health questionnaires to determine whether cultural differences influence measurement of key mental health outcomes included in the SPHC.

Limitations

Our findings should be interpreted in the context of the following three limitations. First, while the SPHC is a large cohort and the number of LGB-identified individuals is also quite large, our analyses assessing interactions of sexual orientation and immigration status were limited in power to detect significant differences; further, we were unable to quantify differences by country of origin. Second, the current study’s reliance on lifetime measures of suicidality limit our ability to interpret the temporality of these findings and it is unknown whether any suicide attempt might have occurred before or after immigrating to Sweden. Only future prospective research studies involving populations spanning intersections of immigration status and sexual identity can elucidate whether precursors to suicide attempt differ between LGB and immigrant subgroups. Third, we did not have information on when immigrants moved to Sweden, which precluded analyses to determine whether mental health problems among immigrants varied by the length of time spent in Sweden. Despite these limitations, this study draws upon Sweden’s high-quality survey and registry data to represent one of the first studies assessing the intersection of sexual orientation and immigration status on mental health in a large, population-based sample.

Conclusion

In this large, population-level study in Sweden, LGB people and immigrants were at greater risk of psychological distress and suicidality than heterosexuals and Nordic-born people, respectively. However, an unexpecting finding of this study was that Nordic-born LGB people reported greater psychological distress and suicidality than immigrant LGB people, with these findings being especially pronounced among women. Further, supplemental analyses revealed that Nordic-born bisexual women seemed to be at greatest risk of psychiatric morbidity. While Sweden is generally considered to be one of the world’s most liberal countries and often touted as being a utopia of equality, findings from the current study suggest that anti-LGB and anti-immigrant sentiments might still operate to negatively impact the mental health of individuals who hold one or both of these minority identities. As well, findings from this study call for future research—including prospective cohort studies and theoretically grounded qualitative investigations—to more clearly delineate the unique cultural, social, and psychological factors that can influence mental health and wellbeing especially among individuals holding dual-minority identities including LGB immigrants.

Supplementary Material

Supplementary Material

Acknowledgements

This work was supported by a scholarship from Torsten Amundson Foundation (Grant No. AM2018-0015) and by Region Stockholm. Data linkages were supported by funding from the Swedish Research Council (Grant No. 523-2010-1052).

Footnotes

Conflict of interest The authors declare that they have no conflict of interest.

Ethical approval Informed consent was obtained from all the study participants, and the regional ethical review board in Stockholm, Sweden granted ethical approval for the study (Numbers: 2010/1185–31/1 and 2013/1118–32).

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s10508-021-01997-8.

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