5
Early/Middle Adulthood

Those belonging to the current cohort of adults would have witnessed the genesis of the gay rights movement during their childhood. They would have experienced the explosion of the HIV/AIDS epidemic as they transitioned into adulthood, and as adults they would have seen the U.S. Supreme Court strike down all sodomy laws in Lawrence v. Texas in 2003 and, in 2004, Massachusetts become the first state to legalize marriage between same-sex couples.

Early/middle adulthood, defined roughly in this report as the period of life from the 20s to the 60s, is ushered in by a transition from adolescence generally thought to involve a number of physiological, work, family, and social life milestones. These include the physical changes associated with puberty and growth in adulthood, as well as the completion of formal education, issues of career choice and efforts to establish financial independence, the selection of a mate (often with the introduction of children into the relationship), the launching of friendships and other interpersonal relationships, and community involvement. During the adult years, these physiological, work, family, and social life domains continue to evolve. The journey through adulthood is often characterized by the physical manifestations of midlife, career achievements and transitions, relationship and family development and changes, and changes in interpersonal ties and community participation. These same domains and issues characterize the experiences of LGBT adults, albeit often in different forms. People who are LGBT engage in educational and career pursuits in ways that are similar to those of their heterosexual peers (even if levels and outcomes may differ). Other domains, however, particularly marriage and parenthood, may be



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5 Early/Middle Adulthood T hose belonging to the current cohort of adults would have witnessed the genesis of the gay rights movement during their childhood. They would have experienced the explosion of the HIV/AIDS epidemic as they transitioned into adulthood, and as adults they would have seen the U.S. Supreme Court strike down all sodomy laws in Lawrence v. Texas in 2003 and, in 2004, Massachusetts become the first state to legalize marriage between same-sex couples. Early/middle adulthood, defined roughly in this report as the period of life from the 20s to the 60s, is ushered in by a transition from adolescence generally thought to involve a number of physiological, work, family, and social life milestones. These include the physical changes associated with puberty and growth in adulthood, as well as the completion of formal education, issues of career choice and efforts to establish financial inde- pendence, the selection of a mate (often with the introduction of children into the relationship), the launching of friendships and other interpersonal relationships, and community involvement. During the adult years, these physiological, work, family, and social life domains continue to evolve. The journey through adulthood is often characterized by the physical manifes- tations of midlife, career achievements and transitions, relationship and family development and changes, and changes in interpersonal ties and community participation. These same domains and issues characterize the experiences of LGBT adults, albeit often in different forms. People who are LGBT engage in educational and career pursuits in ways that are similar to those of their heterosexual peers (even if levels and outcomes may differ). Other domains, however, particularly marriage and parenthood, may be 185

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186 THE HEALTH OF LGBT PEOPLE affected by larger cultural and legal forces. Personal relationships, social support, and community involvement may also assume different forms, similarly affected by cultural influences. The last two decades have seen a growing recognition of the unique health needs of LGBT individuals. Research, however, is still sparse on the developmental life stage of adulthood with regard to the specific health issues confronted by the LGBT community broken down by race/ethnicity and socioeconomic status, with the largest body of work focusing on HIV/ AIDS. The following sections describe research on LGBT adults in the areas of the development of sexual orientation and gender identity; mental health status; physical health status; risk and protective factors; health services; and contextual influences, including demographic characteristics and the role of the family. The final section presents a summary of key findings and research opportunities. It is important to note that some of the literature presented in this chapter may also appear in the following chapter on later adulthood because studies do not always delineate their findings according to the age ranges used in this report, and certain studies may present find- ings that are relevant to both early/middle and later adulthood. DEVELOPMENT OF SEXUAL ORIENTATION AND GENDER IDENTITY The process of sexual orientation development and of “coming out” is different for each LGBT individual. As individuals come out, they reach various milestones in the process: they experience their first awareness of same-sex attraction, they have their first same-sex sexual experience, they self-identify as LGB, and they choose to disclose their sexual orientation identity to others. Depending on contextual factors in their lives, LGB individuals may choose to come out at many different times throughout the life course, and the stage at which they come out will influence their experiences. Moreover, the association between sexual orientation identity, or coming out, and mental health is not invariant across LGBT populations in the United States. Multiple social, cultural, and psychological influences affect the extent to which members of homosexually active populations ex- perience favorable consequences from self-identity as lesbian or gay. Thus, the assumption of a universal positive link between coming out and mental health appears unwarranted. Gates (2010) examined the relationship between demographic factors and coming out among different age cohorts using data from the 2008 General Social Survey, a nationally representative sample of 2,023 adults aged 18 and older. Of the 1,773 respondents providing information about sexual orientation and behavior, 58 self-identified as LGB, and 104 reported

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187 EARLY/MIDDLE ADULTHOOD same-sex partners. The authors found that relative to individuals younger than 30, adults aged 30−54 were 16 times more likely to be closeted. In their analysis of a nonprobability sample of 2,001 women (mean age 5 40) who self-identified as lesbian or bisexual or reported sexual activity with or attraction to other women, Corliss and colleagues (2009) found that on average, the women reported first awareness of same-sex sexual attractions at age 16, first coming out to another person at age 23, and first sexual encounter with another woman at age 21. They also found that women who were aware of their same-sex attractions before age 12 were more likely to be Latina or black, more likely to come from families with less parental education, and more likely to self-identify as a lesbian than as a bisexual woman. Those who reported coming out and having a sexual experience with another female before age 18 were more likely to be younger and less educated than other women in the sample. Factors such as race, ethnicity, and education may affect the coming- out process differently for nonwhite and white members of sexual minori- ties in the United States. In a review of the effects of social context on black homosexual males, Peterson and Jones (2009) note that studies reveal that, relative to men of other racial groups, black men experience higher levels of internalized homophobia, are less likely to disclose their homosexual orientation, and are more likely to perceive that their friends and neigh- bors disapprove of homosexuality. While the effects of race, ethnicity, and education may be widespread, they are likely even more salient among low-income than middle-class nonwhite LGB individuals. Moreover, the resources and social support typically received by nonwhite LGBT individu- als from their racial/ethnic communities before they come out may often be jeopardized if they come out, and this may create significant barriers to the coming out process for these individuals. In addition, black LGBT individu- als may experience racism in mainstream gay and lesbian communities. In a survey of 2,645 LGBT individuals at “black gay pride” festivals across the United States, nearly half of the participants believed that racism was a problem within primarily white LGBT communities. Such experiences pose further obstacles to coming out for these individuals (Battle et al., 2002). For LGB individuals who come out during adulthood, factors such as marital status and parenthood may also influence the coming out process. For example, Morris and colleagues (2002) compared developmental mile- stones among 2,431 self-identified lesbians and bisexual women who had children before coming out (n 5 313, mean age 5 44.8) or after coming out (n 5 187, mean age 5 39.7) or did not have children (n 5 1,919, mean age 5 34.6). They found that mothers who had children before coming out reached developmental milestones at older ages than both other groups. Mothers who had children before coming out reached each milestone in the coming out process approximately 7 to 12 years later than mothers

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188 THE HEALTH OF LGBT PEOPLE who had children after coming out and approximately 6 to 8 years later than nonmothers. As society continues to change, the timing of coming out and achiev- ing developmental milestones also changes. In 1994 Drasin and colleagues (2008) published a survey in The Advocate and examined data from 2,402 self-identified gay men aged 18−83 (mean age 5 38.3) to determine whether trends in developmental, psychological, and sexual developmental mile- stones differed by age cohort and whether those trends had changed over time. Recognizing that this sample may have omitted younger men who identify as gay later in life and that readers of The Advocate may be more likely to identify as gay, the authors performed conservative sensitivity tests on the data and made conservative corrections accordingly. They found that of those who were aged 50 or older at the time of the survey (16 percent of the sample), 57 percent had realized they were gay by age 18, 22 percent had done so by age 22, and 9 percent had not done so by age 30. In exam- ining the social, sexual, and psychological milestones for their sample, the authors found that the milestones occurred at an earlier age in younger co- horts, but the changes in age at occurrence by cohort are occurring at differ- ent rates. For instance, while sexual behavior milestones (age at first sexual contact with another male) are changing slowly, individual psychological milestones (age at first awareness of same-sex attraction, self-identification as gay) are changing more rapidly, and social milestones (age at first coming out, frequenting a gay bar) are changing even more rapidly. Even with the corrections performed by the authors, results showed that coming out to a family member has changed from occurring at age 40 among those who reached age 18 before 1953, to the mid-30s for those who reached age 18 between 1953 and 1962, to the mid- to late 20s in the 1963 to 1982 cohort, to around age 21 for those who reached 18 after 1982. The existing literature examines some of the factors that influence the timing of the coming out process among LGB adults. Further research is needed to elucidate the ways in which the timing of the coming out process influences the health status of LGB people and their specific health needs. Transgender individuals are coming out to affirm their gender identity at younger and younger ages (Makadon et al., 2007). Transgender men tend to come out at earlier ages than transgender women (Zucker and Lawrence, 2009). Transgender women can generally be divided into two groups: those who have been gender nonconforming since childhood in both role and identity and those who have been gender conforming in role, but may or may not have been aware of feelings of cross-gender identity in childhood or adolescence (Bockting and Coleman, 2007; Lawrence, 2010). The latter individuals typically report cross-dressing in private, which ini- tially is often accompanied by sexual arousal; their feelings of cross-gender identity may be expressed in sexual fantasy (Bockting and Coleman, 2007),

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189 EARLY/MIDDLE ADULTHOOD particularly among older-generation white transgender women (Nuttbrock et al., 2009a). Transgender women who did not conform to gender roles in childhood tend to come out at an early age, either before or during early adulthood, and if so desired, change gender roles and feminize their body through hormone therapy and/or surgery (Bockting and Coleman, 2007; Lawrence, 2010). By contrast, transgender women who were gender role conforming in childhood tend to come out during mid- or later life (Bockting and Coleman, 2007; Lawrence, 2010), and their developmental challenges may vary as a result. Whereas gender role–nonconforming in- dividuals must develop resilience in the face of enacted stigma early in life (Nuttbrock et al., 2010), gender role–conforming individuals may protect themselves against enacted stigma by keeping their transgender feelings private, yet are likely to experience felt stigma and, in isolation, may not benefit from the support a community of similar others can provide (Meyer, 2007). Several authors have attempted to describe the process of transgender identity development or to adapt stage models of gay and lesbian coming out (Minton and McDonald, 1983) to the coming out process of transgen- der individuals. Bockting and Coleman (2007) describe five stages (pre- coming out, coming out, exploration, intimacy, and identity integration) based on Erikson’s (1950) model of social development and their extensive clinical experience in working with transgender individuals. Devor (2004) defines 14 possible stages of transgender identity development based on sociological field research and in-depth interviews with transgender men. Gagne and colleagues (1997) define four stages (early transgender experi- ences, coming out to one’s self, coming out to others, and resolution of identity) based on a qualitative study of transgender women. Lewins (1995) describes six stages of becoming a (transgender) woman (abiding anxiety, discovery, purging and delay, acceptance, surgical reassignment, and invis- ibility) based on interviews with transsexual women. Finally, based on her clinical experience and a review of the scientific literature, Lev (2004) describes six stages of transgender emergence: awareness; seeking informa- tion/reaching out; disclosure to significant others; exploration, identity, and self-labeling; exploration, transition issues, and possible body modification; and integration, acceptance, and posttransition issues. Although informed by formative research, these stage models have not been tested empirically and systematically. MENTAL HEALTH STATUS LGBT adults are typically well adjusted and mentally healthy. Studies based on probability samples of LGB populations indicate that the majority of LGB adults do not report mental health problems (Cochran and Mays,

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190 THE HEALTH OF LGBT PEOPLE 2006; Herek and Garnets, 2007). While national probability samples of transgender adults are not available, data from convenience samples simi- larly show that many, if not most, transgender adults do not report mental health problems (Clements-Nolle et al., 2001; Nuttbrock et al., 2010). Nonetheless, disparities in mental health do exist among some sexual- minority groups. In a meta-analysis of research on mental health among LGB people published between 1966 and 2005, King and colleagues (2008) examined the prevalence of a number of mental health outcomes. They found that LGB individuals had a 1.5 times higher risk for depression and anxiety disorders over a period of 12 months or a lifetime than heterosexual individuals. Other findings revealed that the risk for suicide attempts over a lifetime among lesbian, gay, and bisexual individuals was more than twice as great as that among heterosexual individuals. The evidence is not conclusive, however. A study comparing lesbians and their heterosexual sisters as a control group found no difference in the prevalence of mental health problems between the lesbian−heterosexual sister pairs (n 5 184 pairs), but found that the lesbians had significantly higher self-esteem than their heterosexual sisters (Rothblum and Factor, 2001). Horowitz and colleagues (2003) examined specific quality-of-life indicators by behaviorally defined sexual orientation categories (hetero- sexual, homosexual, bisexual since age 18 and within the last 12 months) (n 5 11,536). They found that there were no significant differences among heterosexual, homosexual, and bisexual men and women with respect to general happiness, perceived health, or job satisfaction since age 18 or within the last 12 months. For transgender people, the available studies generally suggest high rates of negative mental health outcomes. Most of these studies, however, are limited by the use of nonprobability samples, and few compare the mental health of transgender people and nontransgender controls. A clini- cal sample of 31 male-to-females reported significantly more symptoms on the General Severity Index (GSI) of the Brief Symptom Inventory relative to nontransgender men (n 5 57). Further analyses of the data indicated clinically significant levels of anxiety and depression, along with increased feelings of self-consciousness and distrust of other people (Derogatis et al., 1978). A clinical sample of 20 female-to-males showed no clinically sig- nificant differences on the GSI in comparison with nontransgender females (n 5 143); however, scores on subscales of anxiety and interpersonal sensi- tivity were elevated (Derogatis et al., 1981). There also appear to be mental health differences among lesbian, gay, bisexual, and transgender popula- tions. For instance, in a chart review of 223 lesbians and bisexual women presenting to a mental health clinic, Rogers and colleagues (2003) found that the lesbians were more likely than the bisexual women to present at intake with suicidal ideation, while the bisexual women were more likely to

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191 EARLY/MIDDLE ADULTHOOD present with stressors related to social environment and health care access. Similarly, Page (2004) explored the experiences with mental health ser- vices of self-identified bisexual men and women (n 5 217) and found that the bisexual men had experienced greater stress related to their bisexual identity and that bisexual issues had played a more significant role in their decision to seek mental health services. Mathy (2002a,b) compared the mental health status of 73 transgender individuals and nonclinical samples of nontransgender women and men, either homosexual or heterosexual. The transgender individuals were more likely to report suicidal ideation and attempts, to take psychotropic medications, and to have a problem with al- cohol relative to the nontransgender men and heterosexual women, but no such differences were found between the transgender and lesbian individu- als. For the latter two groups, the author attributed the higher likelihood of mental health and substance use problems to their experiencing both heterosexism and sexism. Bockting and colleagues (Bockting et al., 2005a) compared baseline data from an intervention study of 207 transgender participants, 480 men who have sex with men, and 122 bisexually active women; the transgender individuals were most likely to report depression (52 percent versus 38 percent and 40 percent, respectively) and suicidal ideation (47 percent versus 31 percent and 32 percent, respectively). How- ever, this study did not assess depression with a standardized instrument. While more research has been conducted on mental health than on physical health conditions among LGBT adults, large gaps still remain in our understanding of mental health issues among LGBT people. There is conflicting evidence on the mental health status of LGB adults, and the ex- isting research examining the mental health of transgender adults has limi- tations. It is clear, however, that deleterious effects on the mental health of lesbian, gay, and bisexual individuals result overwhelmingly from unique, chronic stressors due to the stigma they experience as a disadvantaged mi- nority in American society (Meyer, 2003). Herek and Garnets (2007) note that sexual stigma leads to stress resulting from multiple types of “enacted stigma” (e.g., personal rejection and ostracism, discrimination, and criminal victimization), which can have serious and enduring psychological conse- quences. Beyond such direct manifestations of stigma, Herek and Garnets (2007) suggest there are pervasive effects of institutionalized stigma, or “heterosexism,” among gay, lesbian, and bisexual populations, such as denial of the right to marriage in most states, negative economic effects in the workplace, and frequent disenfranchisement from religious and spiritual resources needed to ameliorate the effects of stress. Herek and Garnets (2007) also identify two other sources of stress experienced by sexual minorities: “felt stigma” and “self-stigma.” They contend that felt stigma—the subjective experience of stigma against one’s group, even without direct experience of enacted stigma—may often occur

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192 THE HEALTH OF LGBT PEOPLE as a consequence of societal events in which antigay hostility is demon- strated (e.g., antigay violence, antigay political campaigns). Likewise, these authors suggest that self-stigma may occur among some sexual minorities as a result of accepting society’s negative attitudes toward them (e.g., inter- nalized homophobia, internalized heterosexism, and internalized homon- egativity). These negative feelings about one’s own homosexual desires can have negative impacts on mental and physical health and heighten the stress experienced by sexual minorities. Mood/Anxiety Disorders Some population studies have compared rates of anxiety disorders in homosexually and heterosexually active men and women. Using data from the 1996 National Household Survey of Drug Abuse, Cochran and Mays (2000b) examined differences in the prevalence of psychiatric syndromes among sexually active individuals. Behavioral sexual orientation was com- pared between respondents who reported exclusively other-sex sex partners (n 5 9,714) and those who reported any same-sex sex partners (n 5 194) in the prior year. While most homosexually active individuals did not meet criteria for any of the syndromes assessed, multivariate logistic regression analyses revealed that homosexually active men were more likely than other men to evidence a panic attack syndrome. Cochran and Mays (2000a) also examined possible associations be- tween homosexual/bisexual behavior patterns and lifetime prevalence of affective disorders, including mania, major depression, and dysthymia, among men (aged 17−39) using data from the National Health and Nutri- tion Examination Survey (NHANES) III. Sexual orientation was defined be- haviorally based on self-reports of sexual partners and classified into three groups: any male sex partners (n 5 108), only female partners (n 5 3,208), and no sexual partners (n 5 187). The results revealed that homosexually/ bisexually experienced men were no more likely than exclusively hetero- sexual men to meet criteria for lifetime diagnoses of affective disorders. Similarly, Gilman and colleagues (2001) examined the risk of psychi- atric disorders among individuals with same-sex and different-sex sexual partners based on data from the National Comorbidity Survey. Respon- dents were asked two sexual behavior questions: the number of women and, separately, men with whom they had engaged in sexual intercourse in the prior 5 years. Based on these responses, the respondents were classified into three groups: any same-sex partners (n 5 125), exclusively hetero- sexual partners (n 5 4,785), and no sexual partners (n 5 967). Respon- dents with same-sex sexual partners had a higher 12-month prevalence of anxiety and mood disorders than respondents with different-sex partners only. The authors note the limitation that using a behavioral definition of

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193 EARLY/MIDDLE ADULTHOOD sexual orientation excludes those respondents not sexually active in the 5 years prior to the interview. Cochran and colleagues (2003) later analyzed data from the MacArthur Foundation National Survey of Midlife Development in the United States (MIDUS) to examine possible sexual orientation−related differences in mor- bidity, distress, and use of mental health services. The sexual orientation of 2,917 adults (aged 25−74) was based on self-report as heterosexual (n 5 2,844), homosexual (n 5 41), or bisexual (n 5 32). The samples of indi- viduals who identified as homosexual and those who identified as bisexual were combined for analysis. The results revealed that gay/bisexual men had a higher prevalence of panic attacks than heterosexual men, while lesbian/ bisexual women had a higher prevalence of generalized anxiety disorder than heterosexual women. However, the authors note the limited number of participants who reported a homosexual or bisexual orientation. More recently, Bostwick and colleagues (2010) used data from the 2004−2005 National Epidemiologic Survey on Alcohol and Related Con- ditions (n 5 34,653) to examine lifetime and past-year mood and anxiety disorders among different sexual orientation groups. Identity, attraction, and behavior measures were used to assess sexual orientation. The authors found mental health disparities among some sexual-minority groups. Self- identified lesbian, gay, or bisexual individuals had higher rates of mood and anxiety disorders than self-identified heterosexual individuals. Women who reported exclusively same-sex sexual behavior and women who reported exclusively same-sex attraction were found to have some of the lowest rates of mood and anxiety disorders. With the exception of these women, how- ever, individuals reporting any same-sex sexual behavior or same-sex attrac- tion were found to have higher rates of most mood and anxiety disorders than those reporting exclusively different-sex sexual behavior or exclusively different-sex attraction. Bisexual behavior was found to be associated with the highest incidence of mood or anxiety disorders. There have been relatively few studies on the prevalence of mood and anxiety disorders among transgender adults. In a study previously men- tioned, Derogatis and colleagues (1978) found significantly higher levels of anxiety and depression among a sample of male-to-female transsexuals in comparison with nontransgender men. More recent literature on depression among transgender adults is presented in the next section. Depression Some evidence is available from population studies on differences in rates of major depression between homosexually and heterosexually active men and women. Cochran and Mays (2000b) examined possible differences in psychiatric syndromes between homosexually active and heterosexually

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194 THE HEALTH OF LGBT PEOPLE active men and women using data from the National Household Survey of Drug Abuse. Men who have sex with men were more likely than exclusively heterosexual men to be diagnosed with major depression. Homosexually active women were no more likely than exclusively heterosexual women to evidence major depression syndrome. Cochran and colleagues (2003), using data from the MIDUS survey, found that the sample of self-identified gay and bisexual men (combined for analysis) showed a higher prevalence of depression than heterosexual men. Gilman and colleagues (2001), using data from the National Comorbidity Survey, found that women with any same-sex partner had a significantly higher 12-month prevalence of major depression than women with only different-sex partners. Conron and colleagues (2008), using data from the Massachusetts Behavioral Risk Factor Surveillance System survey of adults aged 18–64 (n 5 38,910), found that bisexual adults were significantly more likely to report feeling “sad or blue” than either heterosexual or lesbian and gay adults. Cochran and colleagues (2007c) also looked at differences in mental health disorders using data from the National Latino and Asian American Study (n 5 4,488). Sexual orientation was defined based on self-identity and past-year history of sexual experiences. Those who identified as gay, lesbian, or bisexual and/or reported any same-sex sexual experiences in the past year (n 5 245) were compared with the rest of the sample. Results showed that lesbian/bisexual women were significantly more likely than heterosexual women to meet criteria for depressive disorders, either in the past year or in lifetime histories. Similarly, gay/bisexual men were signifi- cantly more likely than heterosexual men to report a recent suicide attempt. The authors note that the prevalence of mental health disorders found in sexual-minority Latinos and Asian Americans was similar to or lower than that found in population-based studies of lesbian, gay, and bisexual adults in general. Rates of depression among transgender people are far less well studied. In a convenience sample of 392 transgender women and 123 transgender men aged 18−67 in San Francisco, rates of depression ranged from 55 percent among transgender men to 62 percent among transgender women (Clements-Nolle et al., 2001). Among LGBT participants in a sexual health seminar intervention, 52 percent of transgender participants (n 5 207) reported depression. This was a higher percentage than that among men who have sex with men (n 5 480, 38 percent) or bisexually active women (n 5 122, 40 percent) (Bockting et al., 2005a). In their meta-analysis of 29 transgender studies, Herbst and colleagues (2008) found that a large percentage (weighted mean 43.9 percent) of transgender respondents indi- cated a desire for mental health counseling to address transgender-specific issues.

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195 EARLY/MIDDLE ADULTHOOD Suicide/Suicidal Behavior Some studies have found that nonheterosexual adults are more likely than heterosexual adults to report past suicidal ideation and attempts. Cochran and Mays (2000a), using data from a national probability sam- ple of 3,503 participants (NHANES III), found that men who reported same-sex sexual behavior showed greater lifetime prevalence rates of suicidal ideation and suicide attempts than men who reported exclusively different-sex sexual behavior, even after adjustment for possible demo- graphic confounding. Using data from the National Comorbidity Survey in a study previ- ously described, Gilman and colleagues (2001) observed differences in suicide symptoms between men and women participants with same-sex (n 5 125) and different-sex (n 5 4,785) sexual partners. They found no significant differences in the 12-month prevalence of suicidal thoughts, plans, and attempts between those with same-sex and different-sex part- ners overall. Among women, however, they found a higher prevalence of suicidal thoughts and plans in the any same-sex partner group than in the other-sex partner group, and among men, a higher prevalence of suicidal plans and attempts in the any same-sex partner group than in the other-sex partner group. Also, the lifetime risk of suicidal thoughts was significantly greater for both men and women in the same-sex partner group than in the different-sex partner group. Overall, the authors note that the effects of having same-sex versus different-sex partners appear to be stronger for women than for men. Other studies have demonstrated that suicidal ideation and behavior vary by both sexual orientation and gender. Mathy and colleagues (2003) compared suicidal intent, mental health difficulties, and mental health treat- ment among bisexual and transgender individuals. They found that, relative to bisexual males (n 5 1,457), bisexual females (n 5 792) and transgender individuals (n 5 73) had a higher prevalence of all three variables (Mathy et al., 2003). In a study of 1,304 women conducted at 33 health care sites across the United States, Koh and Ross (2006) found that differences in rates of suicidal ideation and attempts varied among bisexual women (n 5 143), lesbians (n 5 524), and heterosexual women (n 5 637) and were also correlated with disclosure of sexual orientation. Bisexual women who had disclosed their sexual orientation to a majority of friends, family, and coworkers were twice as likely to have reported suicidal ideation relative to heterosexual women. Among sexual minorities who had not disclosed their sexual orientation to a majority of friends, family, and coworkers, lesbians were 90 percent more likely to have ever made a suicide attempt, and bisexual women were three times more likely than heterosexual women to have done so (Koh and Ross, 2006).

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