The Cost of Homophobia

The Cost of Homophobia:

Literature Review on the

Human Impact

Ha of Homophobia In of Homophobia Canada 1

Human Impact Submitted by: Christopher Banks, Rochon Associated Human Resource Management Consulting Inc.

Submitted to: Gay and Lesbian Health Services, Saskatoon, SK

May 2003

Additional copies of this document may be obtained from:

Gay & Lesbian Health Services of Saskatoon Mailing Address: PO Box 8581  Saskatoon, SK  S7K 6K7 Office Address: 203 – 220 – 3rd Avenue South  Saskatoon, SK  S7K 1M1 Telephone: 306.665.1224 Toll-free: 1.800.358.1833 Fax: 306.665.1280 E-mail: [email protected] Internet: www.glhs.ca

Any questions or comments can be directed to GLHS or to the researcher:

Christopher Banks (Rochon Associated Human Resource Management Consulting Inc.) Address: 109 – 15 Innovation Blvd.  Saskatoon, SK  S7N 2X8 Telephone: 306.664.3904 Fax: 306.665.6897 E-mail: [email protected]

Internet: www.rochonassociated.com

This research project was funded through the following agency:

Community-University Institute for Social Research (Community Health Determinants and Health Care Policy Module) Address: John Mitchell Building  Room 289 118 Science Place University of Saskatchewan  Saskatoon, SK  S7N 5E2 Telephone: 306.966.2121 Fax: 306.966.2122 E-mail: [email protected] Internet: www.usask.ca/cuisr

TABLE OF CONTENTS (SUMMARY)

1 TABLE OF CONTENTS (SUMMARY)

2 TABLE OF CONTENTS

5 LIST OF TABLES

6 LIST OF ABBREVIATIONS AND ACRONYMS

6 NOTE ON STATISTICS

7 EXECUTIVE SUMMARY

8 FOREWORD by Gens Hellquist

10 INTRODUCTION

11 HOMOPHOBIA

17 BASE RATE OF HOMOSEXUALITY AND BISEXUALITY

21 HEALTH AND SOCIAL ISSUES OF GAYS, LESBIANS AND BISEXUALS

40 SUMMARY OF HUMAN IMPACT ESTIMATES

41 LIMITATIONS

46 FURTHER RESEARCH NEEDED

47 METHODOLOGICAL IMPROVEMENTS NEEDED

49 ENDNOTES

50 REFERENCES

67 APPENDIX: CALCULATIONS FOR HUMAN IMPACT ESTIMATES

TABLE OF CONTENTS

TABLE OF CONTENTS (SUMMARY) ...... 1

TABLE OF CONTENTS ...... 2

LIST OF TABLES ...... 5

LIST OF ABBREVIATIONS AND ACRONYMS ...... 6

NOTE ON STATISTICS ...... 6

EXECUTIVE SUMMARY ...... 7

FOREWORD by Gens Hellquist ...... 8

INTRODUCTION ...... 10

Ha HOMOPHOBIA ...... 11 Definition ...... 11 Effect of Homophobia on Gay, Lesbian and Bisexual Individuals ...... 13 Reasons for Negative Effects ...... 13 Lack of Support and Helping Resources ...... 13 Internalized Homophobia ...... 14 Self-concealment of Sexual Orientation ...... 14 of Homophobia Alteration of Behaviour ...... 14 Coming Out Stress ...... 15 2 Coming Out and Risk Behaviours ...... 15

Confusion Related to Expressing Sexuality ...... 15 a External Homophobia ...... 15 Coping and Substance Abuse ...... 15 Positive Responses ...... 15 Alternative Explanations for Increased Incidences of Health and Social Problems ...... 16

BASE RATE OF HOMOSEXUALITY AND BISEXUALITY ...... 17

Human Impact HEALTH AND SOCIAL ISSUES OF HOMOSEXUALS AND BISEXUALS ...... 21 Calculation of Human Cost Estimates ...... 22 Calculation of Rates ...... 22 Estimation of Total Human Cost ...... 22 Number of GLB ...... 22 Number of Sufferers ...... 22 Equivalency of Rates ...... 23 Extra Sufferers ...... 23 Total Number of Deaths ...... 23 Suicide ...... 23 General Population Statistics ...... 23 Gay, Lesbian and Bisexual Statistics ...... 23 Human Impact ...... 27 Smoking ...... 27 General Population Statistics ...... 27 Gay, Lesbian and Bisexual Statistics ...... 27 Human Impact ...... 28

TABLE OF CONTENTS (CONTINUED)

HEALTH AND SOCIAL ISSUES OF HOMOSEXUALS AND BISEXUALS (CONTINUED) Alcohol Abuse ...... 29 General Population Statistics ...... 29 Gay, Lesbian and Bisexual Statistics ...... 29 Human Impact ...... 30 Illicit Drug Use ...... 31 General Population Statistics ...... 31 Gay, Lesbian and Bisexual Statistics ...... 31 Human Impact ...... 33 Depression ...... 33 General Population Statistics ...... 33 Gay, Lesbian and Bisexual Statistics ...... 33 Human Impact ...... 34 Unemployment ...... 34 General Population Statistics ...... 34 Gay, Lesbian and Bisexual Statistics ...... 34 t c a p m I n a m u H Human Impact ...... 35 Murder ...... 35 General Population Statistics ...... 35 Gay, Lesbian and Bisexual Statistics ...... 35 Human Impact ...... 36 HIV/AIDS ...... 36 a

General Population Statistics ...... 36 Gay, Lesbian and Bisexual Statistics ...... 36 3 Human Impact ...... 37

Corollary Issue: Access to Quality Health Care and Services ...... 38 a i b o h p o m o H f o

SUMMARY OF HUMAN IMPACT ESTIMATES ...... 40

LIMITATIONS ...... 41 Literature Review ...... 41 Exploratory Nature of the Review ...... 41

Human Costs are Estimations Only ...... 41 Generalizability of Research ...... 41 Synthesizing of Research ...... 41 Non-weighting of Research ...... 42 Overgeneralization of Research ...... 42 Diversity of GLB Populations ...... 42 Variables Unaccounted For ...... 42 Research Reviewed ...... 43 Small Sample Sizes ...... 43 Respondents Declining to Participate ...... 43 Clinical Samples ...... 43 Under-representation of Certain Groups ...... 43 Cross-sectional Designs ...... 43 Self-report Designs ...... 44 Convenience Samples ...... 44 Samples from Specific Geographic Areas ...... 44 Disclosure of Orientation and Health and Social Problems ...... 44

TABLE OF CONTENTS (CONTINUED)

LIMITATIONS (CONTINUED) Research Reviewed (Continued) Response Bias ...... 44 Consistency of Definitions ...... 44 Differences Among Age Groups ...... 44 Cohort Effects ...... 44 Social Desirability ...... 45 Unmeasured, Overlapping, and Confounding Variables, and Temporal and Causal Order of Variables ...... 45 Real Versus Perceived Homophobia ...... 45

FURTHER RESEARCH NEEDED ...... 46

METHODOLOGICAL IMPROVEMENTS NEEDED...... 47

Ha ENDNOTES ...... 49

REFERENCES ...... 50

APPENDIX: CALCULATIONS FOR HUMAN IMPACT ESTIMATES ...... 67 Homophobia and Suicide ...... 67 Homophobia and Smoking ...... 68 of Homophobia Homophobia and Alcohol Abuse ...... 69 Homophobia and Illicit Drug Use ...... 70

a Human Impact

LIST OF TABLES

Table 1. Estimates of the Base Rate of Homosexuality and Bisexuality ...... 18

Table 2. Percentage of Gays, Lesbians and Bisexuals Who Attempt Suicide ...... 24

Table 3. Homophobia and Suicide: Four Estimates of Annual Deaths ...... 27

Table 4. Percentage of Gays, Lesbians and Bisexuals Who Smoke ...... 28

Table 5. Homophobia and Smoking: Four Estimates of Annual Deaths ...... 28

Table 6. Percentage of Gays, Lesbians and Bisexuals Who Abuse Alcohol ...... 30

Table 7. Homophobia and Alcohol Abuse: Four Estimates of Annual Deaths ...... 31

t c a p m I n a m u H Table 8. Percentage of Gays, Lesbians and Bisexuals Who Use Illicit Drugs ...... 32

Table 9. Homophobia and Illicit Drug Use: Two Estimates of Annual Deaths ...... 33

Table 10. Percentage of Gays, Lesbians and Bisexuals Who Suffer From

Depression ...... 35

Table 11. AIDS and HIV Cases in Canada for 1997 ...... 38 5

a i b o h p o m o H f o Table 12. Estimations of the Annual Human Impact of Homophobia on Canada ...... 40

LIST OF ABBREVIATIONS AND ACRONYMS

AIDS: Acquired Immunodeficiency Syndrome

GB: Gay males and Bisexual males and females

GL: Gay males and Lesbian females

GLB: Gay males, Lesbian females, and Bisexual males and females

GLBT: Gay males, Lesbian females, Bisexual persons and Transgendered persons

HIV: Human Immunodeficiency Virus

US: United States of America

of Homophobia NOTE ON STATISTICS

6 everal statistical terms are used throughout this document; below are some

definitions of those terms: a S

Mean: The arithmetic average of a set of data or group of numbers. For example, the mean of this group of numbers (1, 3, 4, 7, 5) is 4 since (1 + 3 + 4 + 7 + 5) / 5 = 4.

Human Impact Median: The middle value in a distribution in terms of the frequency. The median is the value that has fifty percent of all of the values in the distribution both below and above it. For example, the median of this group of numbers (1, 1, 4, 6, 10) is 4 since two numbers are below it (1, 1) and two are above it (6, 10). If a set of data contains an even amount of numbers, then the median is the average of the two middle numbers. For example, the median of this group of number (1, 2, 4, 7) is 3 since the average of 2 and 4 is 3.

Outlier: A number that is far apart from the rest of the data; an extreme value either much lower or much higher than the rest of the values in the data set. Outliers are known to skew means or averages. For example, 85 is an outlier in this group of numbers (1, 1, 3, 4, 1, 3, 85).

EXECUTIVE SUMMARY

esearch was reviewed related to Using the assumption that, the negative results of without the existence of homophobia, R homophobia on gays, lesbians GLB and the heterosexual population and bisexuals (GLB), and the human would have equivalent rates of health impact of such negative effects. Human and social issues, estimates of the impact was defined as the number of annual number of pre-mature deaths “pre-mature” deaths caused by caused by homophobia were developed homophobia; that is, compared to based on five and ten percent base rates mortality rates of non-GLB, human costs of homosexuality: measures how many GLB die before they otherwise would have as a result of • Suicide = 818 to 968 deaths per year homophobia. Homophobia was defined • Smoking = 1232 to 2599 deaths per as the irrational fear of, or aversion to, year homosexuals and homosexuality, while • Alcohol abuse = 236 to 1843 deaths t c a p m I n a m u H the related construct of heterosexism per year was defined as a belief system that • Illicit drug use = 64 to 74 deaths per values heterosexuality as superior to year and/or more natural than homosexuality, and/or the assumption There was insufficient data to calculate

a that all people are heterosexual. The mortality estimates for the issues of research reviewed showed that GLB and depression, unemployment, murder and heterosexuals were equivalent in terms HIV/AIDS; however, the annual human 7 of psychological and psychosocial costs associated with those issues are a i b o h p o m o H f o health and functioning, but that GLB substantial, and evidence exists that had a shorter life expectancy and faced indicates GLB are at increased risks for health risks and social problems at a contracting HIV/AIDS, of being victims greater rate than the heterosexual of murder, and of being unemployed, population. The suspected reason for which ultimately results in pre-mature these increased problems is the chronic mortality. a stress placed on GLB resultant from The present research has several coping with society’s negative responses weaknesses that are reviewed in the and stigmatization. Limitations section. Most of these Eight major health and social limitations can be overcome with issues were examined, which included further research. Additional research suicide, smoking, alcohol abuse, illicit needs to be conducted in the area of drug use, depression, unemployment, homophobia, the consequences of murder, and HIV/AIDS. In addition, homophobia on GLB and the human since homophobia results in impact of those consequences. In substandard health care for GLB, the addition, methodological improvements issue of access and quality of health care need to be implemented in further services was examined, since ineffective research in the area to ensure health services and practices exacerbate conclusions are valid. the health and social issues that were examined.

FOREWORD by Gens Hellquist

If there’s been one constant in time. They were brilliant, witty men my nearly 40 years of participation in who dedicated their lives to educating the gay and lesbian community and my others. If they were still alive they over 30 years as a gay activist, it has would be at that point in their life when been death. Some of my earliest they would be retiring. However, the memories of being a part of this stressors brought about by homophobia community were hearing about the caused them to adopt coping death of someone that I had known mechanisms that killed them before from my involvement in the gay, lesbian their time. and bisexual community. While it was I remember a young man who often difficult to understand what dark grew up in my neighbourhood. Jim was force would lead someone to take their a few years younger than me and after I

life, after listening to people’s stories of moved out of the neighbourhood I had

Ha rejection and verbal and physical no expectation of seeing him again. violence it became easier to understand. However, he was soon back in my life These were people who believed they when he called and asked specifically could no longer survive in an for me on Saskatoon’s first gay/lesbian environment that was so hateful and phone-line. He talked about his feelings intolerant. I’ve watched close and dear of being gay and how frightening it was

of Homophobia friends slowly kill themselves with for him to embrace those feelings. He alcohol and drugs and I have watched a felt being gay would be a major 8 generation of gay men decimated by disappointment to his family.

AIDS. This is not something that simply Like most mothers, mine would a happened in my early days of keep me up-to-date about the lives of involvement in the GLBT community those who grew up in the but something that continues today. neighbourhood and it was no different Gay & Lesbian Health Services with Jim. She kept me informed about commissioned this study because we Jim’s marriage, divorce, remarriage and

work with that pain and intolerance and birth of his first child. Occasionally I Human Impact know first hand the enormous toll that would run into Jim hanging in the homophobia exacts on our community shadows of a gay venue and we would and our lives. We also know the once again talk about the difficulty he importance of being mindful that we are was having in accepting being gay. He talking about real people in this study, was a gentle and kind man, respected not just abstract statistics. Those victims by all who knew him. This went on for of homophobia are someone’s child, a number of years until one morning grandchild, parent, brother, sister, aunt, when I opened the newspaper to learn uncle or best friend. Each death has an that he had driven out to the country, impact far beyond the loss of that one put a pistol to his head and killed life. himself. On my next visit with my Two of the men who were mother she talked about the confusion important mentors to me when I first his family was going through trying to came out have been dead for a number figure out why someone who appeared of years. Both died a slow and painful to have everything going for him would death from alcoholism long before their

kill himself. I, however, knew the The maddening thing about all reason. these deaths is that they are preventable. Jim is only one of countless Our health care systems and our young people I have watched kill education systems are rife with themselves because the stressors of homophobia. Governments are living in a homophobic environment reluctant to take action for fear of hostile were too much for them to bear. reactions from those segments of society Usually the survivors are left wondering who wish to keep homophobia live. why their loved one chose to kill While the research clearly shows that themselves. What was so bad that it the health and social problems endemic drove them to take their life? In most to the GLBT population result from the cases the real story was never told. stressors of living in a climate of In the 1980s AIDS hit my ignorance and hate, those enablers of community hard and a new round of homophobia twist that research to death and dying began. Those who suggest the mere fact of being gay is have worked in the AIDS field are only what causes the problems.

t c a p m I n a m u H too aware of how homophobia causes It’s time we looked at the facts people to devalue their life and take and addressed the issues. A 2001 study risks that make them susceptible to HIV. that looked at the economic cost of Issues of low self-esteem are epidemic in homophobia shows that it could be as my community and cause people to high as 8 billion dollars a year. This devalue their lives. Marginalization has study clearly shows that it is killing a

a negative impact on any community people at an alarming rate. Make no that is denied the full rights of mistake about it, homophobia is clearly 9 citizenship whether it occurs because of killing us. racism, colonialization, sexism or a i b o h p o m o H f o homophobia.

INTRODUCTION

his literature review is a reasons. First, although a wide-ranging companion report to “The Cost search of medical, psychology, and T of Homophobia: Literature sociology databases was undertaken on Review of the Economic Impact of subjects related to homophobia, the Homophobia on Canada” (Banks, 2001). human impact of various health and While the original report examined the social issues, and the base rate of financial costs of homophobia, the homosexuality, there are large gaps in present report examines the human knowledge for which there was no costs of homophobia. Human cost is research or data available. As Ryan, defined as the annual number of GLB Brotman and Rowe (2000) and Goldfried individuals who die each year “pre- (2001) point out, documentation on GLB maturely” most likely as a result of health is relatively scarce, and

homophobia; that is, without homosexuality issues in general have

Ha homophobia, death rates of GLB and been largely ignored in mainstream non-GLB should be equivalent. research. Especially scarce is The purpose of the present information on the effect homophobia report is similar to the original: to has on GLB health. The present examine and synthesize existing data document does not attempt to fill in and research on the human impact of those knowledge gaps, but rather

of Homophobia homophobia on Canadian society. In summarizes current knowledge and general, the literature search focused on suggests future research. 10 answering these questionsi: Second, research and literature

1. What effect does homophobia have reviews already exist that attempt to a on gays, lesbians and bisexuals answer the first two of the three (GLB)? questions posed above. Therefore, an in 2. As compared to the general depth analysis of those areas and some population, do GLB have increased related areas is not repeated in the rates of health and social problems as present review. For example, the

result of homophobia? present review does not examine in Human Impact 3. What are the number of “premature” detail the health effects and subsequent deaths due to these increased rates of mortality of illicit drug use on humans. health and social problems? Given these limitations on the Some short, informal overviews of the comprehensiveness of this literature issues related to homophobia, GLB review, the present review does health, and related human costs have accomplish several important goals: (1) been attempted (e.g., Hellquist, 1996), synthesizing the research on but none have attempted to integrate homophobia, GLB health and social the three components in a single issues, (2) providing an exploratory document. analysis of the human impact of This literature review is not an homophobia, and (3) an identification of entirely comprehensive review of the gaps in the research and further issue of the human impact of research that needs to be conducted. homophobia in Canada for several

HOMOPHOBIA

efinition avoidance, verbal abuse, and civil discrimination. D Negative attitudes toward homosexuality exist on a continuum In addition, there are other types of from homophobia to heterosexism homophobia/heterosexism: (Berkman & Zinberg, 1997): Institutional Homophobia or Homophobia: Any belief system that Heterosexism: Refers to the many supports negative myths and ways in which government, business, stereotypes about homosexual churches, educational institutions people, or any of the varieties of and other organizations and negative attitudes that arise from fear institutions discriminate against or dislike of homosexuality. The people on the basis of sexual

irrational fear of, or aversion to, orientation. These organizations and t c a p m I n a m u H homosexuals and homosexuality. institutions set policies, allocate Homophobics react to homosexuals resources, and maintain unwritten as enemies to be feared, hated and standards for the behaviour of their actively repressed (Mihalik, 1991). members in ways that discriminate. For example, many religious

Heterosexism: A belief system that organizations have stated policies values heterosexuality as superior to against GLB people holding offices; and/or more natural than most educational institutions fail or 11 homosexuality; that does not refuse to allocate funds and staff for

a i b o h p o m o H f o acknowledge the existence of non- GLB support groups; and most heterosexuals; and that assumes that businesses have norms for social all people are heterosexual. A belief events which prevent GLB that heterosexuality is normative and employees from bringing their same that non-heterosexuality is deviant sex partners while heterosexual and intrinsically less desirable. employees are encouraged to bring

Heterosexists react to homosexuals as their opposite sex partners. unfortunate, devalued individuals (Mihalik, 1991). Cultural Homophobia or Heterosexism: Refers to social standards and norms Homophobia can manifest itself in a which dictate that being heterosexual number of ways: is better or more moral than being GLB, and that everyone is Internal Homophobia: Learned biases heterosexual or should be. While that individuals, including GLB, these standards are not written down incorporate or internalize into their as such, they are spelled out each day belief systemsii. in television shows where the vast majority of characters are External Homophobia: Overtly heterosexual and most relationships observed or experienced expression involve a female and a male; or in the of internal biases such as social assumption made by most adults in social situations that all "normal"

children will eventually be attracted Hankins, Robertson, and Radford (1988) to and marry a person of the opposite found that only thirty-three percent of sex. Often heterosexual people do Canadian grade seven students agreed not realize that these standards exist, with the statement “Homosexuals while GLB people are acutely aware should be allowed to be teachers,” and of the standards. The feeling that only eighteen percent reported that they results is one of being an outsider in “would be comfortable talking with a society. homosexual person.” The reasons for the existence of Heterosexism is more subtle homophobia are varied and numerous. than homophobia and permeates Other authors have reviewed these culture and its social institutions reasons in detail (e.g., Stein, 1999). (Berkman & Zinberg, 1997). Some examples of these are: Homophobia and/or heterosexism have • There is an absence of accurate and

been demonstrated in mental health positive portrayals of GLB in media

practitioners (Rudolph, 1988; Rudolph, (O’Hanlan, 1995). There is also a lack Ha 1989; Garfinkle & Morin, 1978; Glenn & of positive GLB role models in Russell, 1986; Lawrence et al., 1990; society (Morrow, 1993). Trezza, 1994), undergraduates (O’Hare, • There is an absence of accurate Williams & Ezoviski, 1996), nurses information regarding same-sex (Smith, 1993b; Strasser & Damrosch, orientation available to the public

1992), governments (Herek, 1990) and (Dempsey, 1994). of Homophobia social workers (Berkman & Zinberg, • The American Psychiatric 12 1997). Association regarded homosexuality

Homophobia, or more as psychopathology until 1973.

a accurately, sexual prejudice, can be Homosexuality is still a classification directed at homosexual behaviour, category in the International people with homosexual or bisexual Classification of Diseases (World orientation, communities of GLB people Health Organization, 1997). (Herek, 2000) or the children of GLB • Some religious institutions and other (Gershon, Tschann & Jemerin, 1999). groups portray homosexuality as Human Impact Most individuals do not perceive immoral and perpetuate the negative themselves as homophobic, yet stereotypes associated with unfamiliarity with members of the GLB homosexuality (Stokes, Kilman & community can inadvertently result in Wanlass, 1983; O’Brien, 1991; acceptance of misinformation or biased Forstein, 1988). attitudes (O’Hanlan, 1995). Several • The education system does not studies have shown that individuals usually teach school-aged children who know one or more GL personally about sexual diversity or orientation demonstrate less hostility toward all GL (Morrow, 1993; Remafedi, 1993; (Ellis & Vasseur, 1993; Smith, 1993b). Glasgow Women’s Library, 1999). Evidence exists that indicates • There are minimal sanctions against that homophobia and stigmatization of those who harass and discriminate GLB is a serious and prevalent social against GLB (Morrow, 1993). Also, problem in North America (Tremblay & there is tolerance of homophobic and Ramsay, 2000; Herek, 1991). For heterosexist attitudes in society example, King, Beazley, Warren, (Morrison & L’Heureux, 2001).

• National and local governments higher rates of depression, anxiety, often pass laws stating that substance abuse, loneliness and other homosexual behaviour is wrong and psychological distress (Morrow, 1993; criminal (Dempsey, 1994). Rudolph, 1988; Rudolph, 1989; • Most GLB hide their true identity Ungvarski & Grossman, 1999; Ziebold & and so constitute an invisible Mongeon, 1982; Kehoe, 1990). population; therefore, the majority of the heterosexual population does not Reasons for Negative Effects become familiar with GLB, and In general, the chronic stress of biases can flourish. coping with social stigmatization and societal hatred is the primary reason for Effect of Homophobia on Gay, Lesbian the negative effects of homophobia and Bisexual Individuals (Bux, 1996; Greene, 1994; Ross, 1978; Being GLB is not genetically or Cochran & Mays, 1994; Gillow & Davis, biologically hazardous to one’s physical 1987; Savin-Williams, 1994; Ungvarski & Grossman, 1999). Meyer (1995)

or psychological health (O’Hanlan, 1995; t c a p m I n a m u H Remafedi, French, Story, Resnick & conceptualized the homophobia GLB Blum, 1998; Ross, Paulsen & Stalstrom, feel as a component of minority stress, 1988; Wayment & Peplau, 1995). which is the psychosocial stress derived Although few studies have directly from membership in a low status linked particular stressors resulting minority group. Meyer (1995) theorized from homophobia and their health and that GLB are subjected to chronic stress a

social outcomes, most researchers agree related to their stigmatization, their that homophobia increases a multitude internalized homophobia and actual 13 of risk factors associated with events of discrimination and violence. psychological, psychosocial, psychiatric, More specifically, the reasons for the a i b o h p o m o H f o social and health problems (Bagley & deleterious effects of homophobia are D’Augelli, 2000; D’Augelli & listed below: Hershberger, 1993; Frable, Wortman & Joseph, 1997; Schneider, Farberow & Lack of Support and Helping Kruks, 1989; Muehrer, 1995) and that Resources. GLB feel isolation, alienation

a homophobia is a major health hazard to and disenfranchisement from the GLB and society (Wagner, 1997). Ross resources and assistance society (1989) studied homosexually oriented ordinarily provides in the face of life males in four countries (i.e., Sweden, stressors (Waldo, Hesson-McInnis & Finland, Ireland and Australia) and D’Augelli, 1998; Saunders & Valente, found that homosexual adolescents are 1987; Prince, 1995). Well-being and likely to have more problems in the health are negatively affected when GLB more anti-homosexual countries. This do not have social and family support suggests that the level of homophobia and a sense of community (Nesmith, manifested in a particular country or Burton & Cosgrove, 1999; Strommen, culture may be directly linked to the 1989b; Hershberger & D’Augelli, 1995; extent of GLB health and social Turner, Pearlin & Mullan, 1998; problems. Johnston, Stall & Smith, 1995; Watkins, Some examples of the specific 2000). Loss of support is also seen in the problems that GLB suffer that are workplace; GLB who experience greater associated with homophobia include heterosexism demonstrate greater job

withdrawal (Waldo, 1999). Although all which causes unusual stress (Roberts & people experience health and social Sorensen, 1995; D’Augelli, Hershberger problems, GLB are especially vulnerable & Pilkington, 1998; Ungvarski & because of a lack of support, and denial Grossman, 1999; Herek, 1991; Sewell et of information and helping resources. al., 2000; Mays & Cochran, 2001). In addition, stress caused by Concealing homosexuality has been homophobia may be worse than other found to have a negative effect on stressors because of the loss of friend physical health (Larson & Chastain, and family support systems (Bradford, 1990). Cole, Kemeny, Taylor and Ryan & Rothblum, 1994; DiPlacido, Visscher (1996) found that in their 1994; Brooks, 1981; Larson & Chastain, sample of 222 GB males, the incidence of 1990). These support systems are lost cancer and moderately serious because GLB have been rejected or have infectious diseases (e.g., pneumonia, a need to hide their thoughts and bronchitis, sinusitis, tuberculosis)

feelings. increased in direct proportion to the

degree to which participants concealed Ha Internalized Homophobia. GLB their homosexual identity. None of feel distress that is the result of these effects could be accounted for by internalized negative attitudes toward demographic characteristics, health one’s own homosexuality (Protor & relevant behavioural patterns, Groze, 1994; Malyon, 1982; Forstein, depression, anxiety, repressive coping

1988; Meyer & Dean, 1996). Internalized or social desirability response biases. In of Homophobia homophobia in GLB results in lower general, openness to others about sexual levels of community integration and orientation is associated with better

14 social support, lower self-esteem, psychological adjustment, less fear of

a increased feelings of guilt, exposure, increased receiving of mental demoralization, alienation, isolation and health services, and increased choice other problems (Bux, 1996; Meyer & about where to seek help (Bradford, Dean, 1996; McGregor et al., 2001; Ryan & Rothblum, 1994); however, Flowers & Buston, 2001). Meyer and there are also risks associated with such Dean (1996) found that GLB with higher disclosures (see Garnets & Kimmel, Human Impact internalized homophobia had fewer 1991; Gonsiorek & Rudolph, 1991). coping abilities. Alternately, Hershberger & D’Augelli (1995) found Alteration of Behaviour. that self-acceptance (i.e., low Homophobia results in the alteration of internalized homophobia) was the behaviour to avoid anti-GLB largest predictor of mental health in a harassment or violence (e.g., not sample of GLB. speaking about their lives to co-workers, friends or family; altering clothing; Self-concealment of Sexual avoiding physical contact with Orientation. As a result of living in a partner/lover in public; and altering homophobic society, many GLB feel political involvement in community pressure to conform and fear issues) (e.g., Padesky, 1989). Although discrimination and reprisals. This in these behaviours probably do not turn causes many GLB to conceal their directly result in increased health sexual orientation, to be secretive in problems, the further isolation that the their lives, and to repress their feelings, behaviours entail may indirectly lead to

the exacerbation of health and social about how to express it in a hostile problems. social environment (Herrell, Goldberg, True, Ramakrishnan, Lyons, Eisen & Coming Out Stress. The process Tsuang, 1999). Sexuality identity was of coming out of secrecy and disclosing cited as a source of stress in lesbians 3.5 one’s homosexuality to friends and times more frequently than in family is an emotionally stressful heterosexual women (Bernhard & process that often results in social Applegate, 1999). rejection, non-supportiveness, shame, diminished self-concept, intolerance, External Homophobia. Many of lowered self esteem, emotional isolation, the outcomes of homophobia are related severe anxiety, loss of loved ones, to external homophobia such as hostile discrimination, verbal and physical attitudes, verbal and physical assaults abuse, depression, and other stress (Herek, 1986; Larsen, Reed & Hoffman, related patterns (e.g., dissatisfaction 1980; Remafedi, 1987; Hershberger & with sex lives, problems in close D’Augelli, 1995; Herek, 1991), and

t c a p m I n a m u H relationships, feeling overwhelmed) denial of employment, housing, custody (Roberts & Sorensen, 1995; D’Augelli, and legal representation (Wagner, 1997). Hershberger & Pilkington, 1998; For example, victims of GLB hate O’Hanlan, 1995; Schneider, Farberow & violence can suffer psychological and Kruks, 1989; Strommen, 1989a; emotional outcomes such as phobias,

Strommen, 1989b; Garnets, Herek & post-traumatic stress syndromes, a

Levy, 1990; Morrison & L’Heureux, chronic pain syndromes, eating 2001). disorders, headaches, increased 15 agitation, sleep disorders, Coming Out and Risk Behaviours. uncontrollable crying, and depression a i b o h p o m o H f o The results of revealing ones sexual (Barnes & Ephross, 1994; Otis & Skinner, orientation described above place GLB 1996). at risk of engaging in individual risk behaviours and clusters of risk Coping and Substance Abuse. behaviours (e.g., unsupportive health Wells (1999) notes that GLB may use

a habits, self-destructive behaviours). substances as a mechanism for coping or Garofalo, Wolf, Kessel, Palfrey & as a means of escape from painful DuRant (1998) analyzed data from a emotional issues or sexual identity. survey of 4159 Massachusetts’ youth, of which 104 self identified as GLB. Positive Responses. Not all GLB Results indicate that more than 30 exhibit negative effects as a result of health risk behaviours were positively homophobia; many GLB often exhibit associated with self-reported GLB resiliency (Savin-Williams, 2001), even orientation including violence-related in the most extreme situations (Tremble, behaviours, suicidal ideation and 1993). For example, Anderson (1998) attempts, multiple substance abuse, and found that in a sample of gay male sexual risk behaviours. youth, many individuals developed strengths that enabled them to Confusion Related to Expressing successfully cope with the stresses of Sexuality. GLB are not usually confused being gay. Also, Bennett and Thompson about sexuality, but are often confused (1980) found that older gay men had

more stable self-concepts and greater orientation (also discussed by Bux, satisfaction with their heterosocial lives 1996). The three alternative than younger gay men, perhaps explanations given by Fergusson, suggesting that over time, GLB Horwood and Beatrais (1999) have not individuals acquire more successful been accounted for in much of the coping strategies. research conducted in the area. Bux (1996) reviewed several Alternative Explanations for Increased theories to explain health problems in Incidences of Negative Health and GLB, which included: (1) internalized Social Problems homophobia (self-hatred of one’s own Fergusson, Horwood and sexuality); (2) gender-role conflict and Beautrais (1999) conclude that, although gender non-conformity (discomfort or there may be an association between rejection of traditional gender role); (3) sexual orientation and several health social stress and discrimination (due to

and social problems, the cause of such experienced discrimination and

problems cannot be definitively prejudice, GLB experience high levels of Ha interpreted as being a result of stress, tension, and anxiety); (4) aspects homophobic attitudes and social of gay and lesbian subculture (reliance prejudice. The researchers offer three on bars for social outlets); and (5) alternative explanations: (1) associations differences in social roles and adult are artifactual as a result of development. Bux (1996) found that,

measurement and other research design although there was little empirical of Homophobia problems; (2) the possibility of reverse evidence to support any of the theories, causality in which people prone to some the social stress and discrimination

16 problems (e.g., psychiatric disorders) theory enjoyed the most support.

a are more prone to experience Therefore, although several alternate homosexual attraction or contact; and theories exist to explain health problems (3) the possibility that lifestyle choices in GLB, Bux’s (1996) results seem to made by GLB place them at greater risk indicate that it is homophobia that is the of adverse life events and stresses that most likely cause. include risks of health and social

Human Impact problems, independent of sexual

BASE RATE OF HOMOSEXUALITY AND BISEXUALITY

he present literature review related to the cause of homosexuality contains a review of the studies (e.g., biological or genetic, T estimating the base rate of psychological, social, character homosexuality in the general preference), different research settings population. This is required because, in and different sampling methods based order to estimate the human impact of on those different definitions. This increased health and social issues of makes comparing base rate studies very gays and lesbians, it must first be difficult. determined the base rate of The second major difficulty is homosexuality (i.e., percentage of the that sexual orientation cuts across all population who are GLB). There are social categories, which makes any many difficulties in estimating this base generalizations from research difficult. rate. The first difficulty is that there are Another difficulty is that GLB are a multitude of conceptual and relatively hidden in society, and so it is t c a p m I n a m u H operational definitions of the terms difficult to ascertain the base rate “gay,” “lesbian,” “bisexuality” and accurately using self-report methods. “homosexuality.” For example, As long as discrimination exists, the homosexuality can be defined exact prevalence will be impossible to behaviourally (e.g., sexual practices ascertain (Ryan, Brotman & Rowe,

a include homosexual sex) or by identity 2000). Also, “estimating a single constructs (e.g., participation in GLB number for the prevalence of socio-cultural network). Homosexuality homosexuality is a futile exercise 17 can also be defined as a dichotomous because it presupposes assumptions

a i b o h p o m o H f o construct, or as a continuum (Kinsey, that are patently false: that Pomeroy & Martin, 1948 and 1953). homosexuality is a uniform attribute Although some good definitions exist across individuals, that it is stable over (e.g., “a man [woman] who has affection time, and that it can be uniformly and attraction, both emotional and measured” (Laumann, Gagnon, Michael

physical, for other men [women]” & Michales, 1994). Stein (1999) therefore a (Government of Canada, 1998)), a suggests that studies should use various detailed review of the various estimates of the base rate of definitions is not given here (see Stein homosexuality. (1999) for a useful overview of sexual The present literature review orientation). employed this method of using a low A related problem is that studies and high estimate of the base rate of that use different definitions of homosexuality. Table 1 lists some homosexuality use different survey estimates from the research literature. instruments, different assumptions

Table 1. Estimates of the Base Rate of Homosexuality and Bisexuality Estimate of Percentage of Population Definition of Homosexuality (Sample Description) Research Study that is Homo- sexual Men admitting to at least some overt homosexual experience between Kinsey, Pomeroy, and 37.0 adolescence and old age (5300 white males in the United States). Martin (1948) Adult males having had a homosexual experience to orgasm (data from Fay, Turner, Klasser and 20.3 National Opinion Research Center survey of 1450 males in the United States). Gagnon (1989) Males reporting same-sex attraction to or sexual behaviour since age 15 (3381 18.6 Sell, Wells and Wypij (1995) participants in the United States, France and the United Kingdom). Females reporting same-sex attraction to or sexual behaviour since age 15 18.6 Sell, Wells and Wypij (1995) (1874 participants in the United States, France and the United Kingdom). High estimate of predominant same sex orientation (review of Kinsey, Gonsiorek, Sell and Weinrich 17.0 Pomeroy and Martin (1948) and Laumann, Gagnon, Michael and Michales (1995) (1994) studies adjusting for possible risks involved in self-disclosure). Males reporting being homosexual to some degree (stratified random sample 15.3 Bagley and Tremblay (1997a) of 750 males in Calgary). Women admitting to at least some overt homosexual experience between Kinsey, Pomeroy, and 13.0 adolescence and old age (5940 white females in the United States). Martin (1948) Men who were more or less exclusively homosexual for at least three years Kinsey, Pomeroy, and 10.0

Ha (5300 white males in the United States). Martin (1948) 9.2 High estimate from a male twin study (161 males in the United States). Bailey and Pillard (1991) Men reporting having had frequent or on going homosexual experiences 9.0 Janus and Janus (1993) (cross sectional nationwide survey of American adults aged 18 and over). Males reporting same-sex sexual partner in last five years (3685 participants 7.5 Sell, Wells and Wypij (1995) in the United States, France and the United Kingdom). High estimate of males having experienced some same sex sexual contact in 7.0 adulthood (review of five probability surveys from 1970 to 1990 in the United Rogers and Turner (1991) States involving 8,857 participants). of Homophobia Males having a homosexual experience during more than three years of their 7.0 Hunt (1974) lives (volunteer survey of 2036 people). Preferential, experimental and situational homosexuals (review of 12 large 7.0 Hewitt (1998) 18 surveys)

High estimate of females reporting homosexual behaviour (review of studies

a 6.9 conducted in Japan, Thailand, Denmark, France, Palau, Great Britain, and Diamond (1993) Australia from 1948 to 1991). High estimate of individuals reporting to be homosexual or bisexual since age 6.0 18 (probability sample of approximately 1500 people; nationally Smith (1991) representative in the United States). Males reporting homosexual behaviour (review of studies on homosexual 5.5 Diamond (1993) behaviour from 1948 to 1991). Men reporting sexual activity with a same sex partner since age 18 (national Binson, Michaels, Stall,

Human Impact 5.3 probability surveys with 3941 respondents in the United States between 1989 Coates, Gagnon and Catania and 1994). (1995) Male respondents who reported having same sex sexual activity (stratified Safe Schools Coalition of 5.3 random sample of ~4,300 Grade 8 to 12 students in Vermont). Washington (1999) Low estimate of males having experienced some same sex sexual contact in 5.0 adulthood (review of five probability surveys from 1970 to 1990 in the United Rogers and Turner (1991) States involving 8,857 participants). Low estimate of individuals reporting to be homosexual or bisexual since age 5.0 18 (probability sample of approximately 1500 people; nationally Smith (1991) representative in the United States). Women reporting having had frequent or ongoing homosexual experiences 5.0 Janus and Janus (1993) (cross sectional nationwide survey of American adults aged 18 and over). Respondents who described themselves as GLB (Census study of 8,406 Grade Safe Schools Coalition of 4.5 9 to 12 students in Seattle). Washington (1999) Low estimate of predominant same sex orientation (review of Kinsey, Gonsiorek, Sell and Weinrich 4.0 Pomeroy and Martin (1948) and Laumann, Gagnon, Michael and Michales (1995) (1994) studies adjusting for possible risks involved in self-disclosure). Men who were exclusively homosexual throughout their lives from Kinsey, Pomeroy, and 4.0 adolescence on (5300 white males in the United States). Martin (1948) Males predominately or exclusively homosexual (white college-educated 4.0 Gebhard (1972) males). Men reporting a same sex sexual partner in the previous five years (aged 16 to 4.0 Taylor (1993) 50 years).

Table 1 (Continued). Estimates of the Base Rate of Homosexuality and Bisexuality Estimate of Percentage of Population Definition of Homosexuality (Sample Description) Research Study that is Homo- sexual Respondents who described themselves as GLB and/or had same-gender Safe Schools Coalition of 4.0 experience (stratified random sample of 3,982 Grade 9 to 12 students in Washington (1999) Massachusetts). Orientation given as bisexual or homosexual (telephone survey of 663 males 3.7 Harry (1990) using a national probability sample in the United States). Average estimate of females reporting homosexual behaviour (review of 3.6 Diamond (1993) studies conducted in the United States from 1948 to 1991). Female respondents who reported having same-gender sexual activity Safe Schools Coalition of 3.4 (stratified random sample of ~4,300 Grade 8 to 12 students in Vermont). Washington (1999) Adult males reporting having had homosexual sex occasionally or fairly often Fay, Turner, Klasser and 3.3 at some point in their adult lives (data from National Opinion Research Gagnon (1989) Center survey of 1450 males in the United States). High estimate of women who were exclusively homosexual throughout their Kinsey, Pomeroy and Martin 3.0 lives from adolescence on (5940 white females in the United States). (1948) Females having a homosexual experience during more than three years of 3.0 Hunt (1974) their lives (volunteer survey of 2036 people).

Women reporting a same sex sexual partner in the previous five years (aged t c a p m I n a m u H 3.0 Taylor (1993) 16 to 50 years). Females reporting same-sex sexual partner in the last five years (2027 2.8 Sell, Wells and Wypij (1995) participants in the United States, France and the United Kingdom). Men reporting some level of homosexual (or bisexual) identity (random Laumann, Gagnon, Michael 2.8 probability sample of 3432 men and women in the United States between the and Michaels (1994) ages of 18 and 59). Average estimate of females reporting homosexual behaviour (review of

2.5 studies conducted in Japan, Thailand, Denmark, France, Palau, Great Britain, Diamond (1993) a

and Australia from 1948 to 1991). Males admitting to a same sex experience in the last ten years (3300 men aged Billy, Tanfer, Grady and 2.3 20 to 39 in the United States). Klepinger (1993) Self identified homosexual and bisexual Danish survey respondents (2460 19 2.1 Ventegodt (1998) Danish adults)

a i b o h p o m o H f o Hamer, Hu, Magnuson, Hu 2.0 Self identified gay men (40 Twin adult males in Washington, D.C.). and Parratucci (1993) Females predominately or exclusively homosexual (white college-educated 1.5 Gebhard (1972) females). Women reporting some level of homosexual (or bisexual) identity (random Laumann, Gagnon, Michael 1.4 probability sample of 3432 men and women in the United States between the and Michaels (1994) ages of 18 and 59). Pietropinto and Simenauer 1.3 Men reporting same-sex partner (4066 males). (1977) a Males admitting they were exclusively gay (national probability sample of Billy, Tanfer, Grady and 1.1 3321 men aged 20 to 39 in the United States). Klepinger (1993) Respondents describing themselves as bisexual, mostly homosexual or 100% Safe Schools Coalition of 1.1 homosexual (stratified random samples of 36,254 Grade 7 to 12 students in Washington (1999) Minnesota). Low estimate of women who were exclusively homosexual throughout their Kinsey, Pomeroy, and 1.0 lives from adolescence on (5,940 white females in the United States). Martin (1948) Low estimate of females reporting homosexual behaviour (review of studies 0.2 conducted in Japan, Thailand, Denmark, France, Palau, Great Britain, and Diamond (1993) Australia from 1948 to 1991). Note: Studies differ in conceptual and operational definitions, methodology and response rates. Divergent estimates of the base rate of homosexuality probably result from whether research focused on sexual experience or sexual identity. In addition, studies estimating base rates assume: (1) everyone is conscious of his or her true sexual desires, (2) everyone’s self reports can be trusted, (3) everyone is comfortable admitting them, and (4) everyone is able to fit himself or herself into researchers’ commonsense categories of sexual orientation. Most GLB individuals will find it difficult to speak about their sexual behaviours and fantasies because of homophobia and repression (Stein, 1999). Because of these factors, the above studies most likely underreport the base rate of homosexuality.

For the purposes of the present research. It is entirely possible that literature review, two estimates of the the base rate of homosexuality is base rate of homosexuality in the greater than ten percent; however, Canadian population were used. The present research methodologies have low estimate was five percent, and the not allowed the “hidden population” high estimate was ten percent. The of GLB to be accurately counted. rationales for choosing these three estimates are as follows: Consistent with the five and ten • Five percent. This estimate is based percent estimates used in the present on the median (n = 48 results; research, Bagley and Tremblay (1997b) maximum = 37%; minimum = 0.2%) also used the five and ten percent of the studies reviewed above. estimates for the base rate of Homophobia results in an homosexuality in the male population underreporting of homosexuality, (“wholly or predominately

and therefore five percent most likely homosexual” category). In addition,

represents a low estimate, but one Hogg, Strathdee, Craib, O’Shaughnessy, Ha that is based on existing research. Montaner and Schechter (1997) used • Ten percent. This is the most three scenarios, based on extensive commonly cited base rate for empirical evidence, for the base rate of homosexuality and is originally homosexuality: three, six and nine based on Kinsey, Pomeroy and percent of the population. Again, these

Martin’s (1948 and 1953) research. estimates are similar to the ones used in of Homophobia Although Kinsey, Pomeroy and the present research, and encompass 20 Martin’s (1948 and 1953) studies were both conservative and liberal estimates.

flawed, re-examinations of the data For a detailed review of the

a reveal that ten percent is still a likely measurement of sexual orientation see base rate for homosexuality, Gonsiorek, Sell and Weinrich (1995). especially given people’s reticence to

be honest about their sexuality in Human Impact

HEALTH AND SOCIAL ISSUES OF GAYS, LESBIANS AND BISEXUALS

ays, lesbians and bisexuals face Therefore, GLB life expectancy is health risks and social significantly lower than the G problems that are not inherent heterosexual population. There is in sexual orientation itself, but rather are evidence that this decreased life due to society’s negative responses expectancy is due to increased levels of (O’Hanlan, Lock, Robertson, Cabaj, health and social problems faced by Schatz & Nemrow, 1996; Coyle, 1993; GLB. Savin-Williams, 2001). Extensive Research and data in eight major research reveals that there are no health and social areas have been differences between GLB and examined in this literature review: (1) heterosexual people in levels of suicide, (2) smoking, (3) alcohol abuse, maturity, neuroticism, psychological (4) illicit drug use, (5) depression (6) adjustment, goal orientation, or self unemployment, (7) murder, and (8)

actualization (Bersoff & Ogden, 1991; HIV/AIDS. The additional issue of t c a p m I n a m u H Dancey, 1990; Freedman, 1971; Gartrell, access to health care and services was 1981; Hart, Roback, Tittler, Weitz, also examined even though no mortality Walston & McKee, 1978; Herek, 1990; analysis is presented. This is because Hooker, 1969; Kurdek & Schmitt, 1986; homophobia often results in Pagelow, 1980; Peters & Cantrell, 1991; substandard services from health care

Ross, Paulsen & Stalstrom, 1988; providers (e.g., discrimination, Siegelman, 1979; Stokes, Kilman & misdiagnosis), which exacerbates the Wanlass, 1983; Thompson, McCandless severity of health and social problems in 21 & Strickland, 1971). Yet there is a large GLB.

a i b o h p o m o H f o discrepancy between the life expectancy As described above, although of GLB and that of heterosexuals. there are many potential negative Statistics Canada (2001f) reports that outcomes resultant from homophobia, average life expectancy in 1990-1992 for the present literature review examined Canadian males was 75 years and for only eight of the major health and social Canadian females was 81 years. In a issues. The issues under consideration

a flawed study, Cameron, Cameron and were limited to issues where there was Playfair (1998) found that the median research or data available, and where a age of death for homosexuals was less human impact could be estimated in than 50 years; similar follow-up studies some way. For example, there is found median age of death of 42 years evidence that GLB suffer higher (Cameron, Playfair and Wellum, 1994) incidences of eating disorders (Lee, and 46 years (Cameron, 2002) for 2000; Yager, Kurtzman, Landsverk & homosexual men. A more rigorous Wiesmeier, 1988) and cancer (Ungvarski study by Hogg, Strathdee, Craib, & Grossman, 1999); however, there is O’Shaughnessy, Montaner and insufficient data at the present time to Schechter (1997) found that the life make any useful mortality estimates. expectancy of 20 year old GB men in Related to this, there are many issues Vancouver was 34 to 46.3 years, as that related in some way to the issues compared to 54.3 years for non-GLB 20 discussed in the present review. For year old men (this equates to an overall example, low self-esteem, shame, life expectancy of 54 to 66.3 years). anxiety, mood disturbance,

demoralization and guilt are all likely impact of all of the issues can not be outcomes of homophobia in GLB; presented. Instead, a rough estimate of however, they were not examined in each individual issue was presented. detail in the present literature review Given these caveats, the general because data did not exist on the human method of calculating deaths was as impact of those issues. follows:

Calculation of Human Costs Estimates Calculation of Rates. The relative The purpose of this literature GLB and heterosexual rates for review was to review the existing particular health and social issues from literature on homophobia, existing literature were estimated (e.g., homophobia’s effect on GLB, and 25% of all Canadians smoke compared estimate the human impact this effect to 40% of GLB). Most commonly, two has on Canada. Although approximate rates were used for GLB. The first rate

numbers are given for several health was the percentage of the GLB

and social issues, it should be population suffering from the particular Ha remembered that these estimates are problem. This was estimated using the very preliminary since there are many median of several research studies. The gaps in the research. second rate was the number of times Also, many of the health and greater the GLB rate was as compared to social issues discussed most likely have a heterosexual control sample. Not all

reciprocal relationships. To separate the studies reported this information, but of Homophobia number of premature deaths of each for the studies that did the median was issue independent of all other issues is used. The Appendix shows the detailed

22 likely impossible. For example, it is not calculations for each estimate presented.

a clear at this time whether unemployment causes, pre-determines Estimation of Total Human Cost. or has any role in substance abuse, or The total human lives lost in Canada as alternately whether substance abuse a result of each issue was estimated. causes, predetermines or has any role in unemployment. Another example is Number of GLB. The total Human Impact that alcoholism is a risk factor for number of GLB people in Canada was suicide. Determining how many GLB estimated and subtracted from the total suicides are due to alcoholism alone, Canadian population. This resulted in a how many are due to homophobia total GLB population and a total alone, and how many are due to a heterosexual Canadian population. combination may never be known. As Two estimates of the base rate of stated earlier, these two issues are likely homosexuality were used throughout interrelated and an exact cause-effect (i.e., five percent and ten percent). relationship cannot be determined; however, each issue can be separately Number of Sufferers. Given the examined. Because of the rates of the health and social problems interrelationships among all of the estimated, the total number of GLB and issues, and because homophobia is heterosexuals suffering from the likely not the sole cause of increased particular problem was estimated (e.g., health and social problems in GLB, a 461,700 GLB smoke). grand total estimate of the human

Equivalency of Rates. An Therefore, all estimates in this literature assumption was made that, without the review are simply that: estimates. existence of homophobia and its deleterious effects, equivalent Suicide proportions of GLB and heterosexuals General Population Statistics. would be susceptible to the health and Statistics Canada (2001i) data on social issues reviewed. suicides and suicide rates indicates that there were 3681 reported suicides in Extra Sufferers. The total number Canada in 1997; which means that of “extra” GLB sufferers of the suicide was the 11th leading cause of particular health or social problem was death (Statistics Canada, 2001e and estimated. This figure was calculated by 2001b). This represents a rate of multiplying the total number of GLB by 0.0123% or 12.3 per 100,000. Suicides the heterosexual rate of the health or accounted for 1.7% of all deaths in 1997. social issue and subtracting this number There were 8,626 deaths by from the actual number of GLB who unintentional injuries in 1997 and 1,163

t c a p m I n a m u H suffer from the health or social issue. deaths due to neurotic disorders, personality disorders and other non- Total Number of Deaths. The total psychotic mental disorders; many of number of premature deaths was these deaths could plausibly be estimated. This total number of deaths unreported suicides, and therefore the due to homophobia was obtained by 0.0123% rate is probably an a

multiplying the “extra” GLB sufferers underestimate. by the overall death rate for each health 23 and social issue. Gay, Lesbian and Bisexual Statistics. Romero (1999) found a strong a i b o h p o m o H f o It is important to note that the association between instances of present literature review probably used homophobia experienced by gay men conservative estimates of the human and thoughts of suicide. Psychological cost of homophobia, since limited distress experienced by lesbians predicts information was available. For example, suicidality (Morris, Waldo & Rothblum,

a many suicides go unreported and the 2001). Being GB in a hostile sexual orientation of many Canadians environment was found to be a risk remains hidden. Although the current factor for suicide in another study (Paul literature review focused on the number et al., 2002). Additionally, there is of deaths, the “human cost” of extensive research on rates of suicide homophobia could also include the attempts in GLB (see Tremblay (2000) suffering of GLB and their friends and for a review). Remafedi (1999a) families (Rice, 1993). reviewed six controlled, population- Please keep in mind that some based surveys in the United States and health and social issues lead to death Canada and found that in all six, only after long-term exposure. For attempted suicide rates were higher in example, recent smoking rates were GLB compared to their heterosexual used to calculate current deaths; peers. Table 2 summarizes the results however, current deaths would most from individual studies examining likely be determined by smoking rates attempted suicide rates for GLB. several years or even decades ago.

Table 2. Percentage of Gays, Lesbians and Bisexuals Who Attempt Suicide X Times Number of Percentage of Hetero- Partic- GLB who sexual ipants Sample Description Research Study Attempted Control Involved Suicide Sample in Study Gay, lesbian and bisexual youth; mean age = 18.5 years; Proctor and Groze 66.1 n/a 221 youth group attendees in United States and Canada. (1994) Uribe and 50.0 n/a 37 Mean age = ~ 17.0 years; United States. Harbeck (1992) Gay and bisexual males; mean age = 19.2 years; United D’Augelli and 42.0 n/a 142 States youth groups. Hersberger (1993) Gay and bisexual males; mean age ~ 19 years; United Proctor and Groze 40.3 n/a 159 States and Canada youth groups. (1994) Jay and Young 40.0 n/a 5,000 Homosexual men and women. (1979) Rotheram-Borus, Gay and bisexual males; mean age = 16.8 years; New 39.0 n/a 138 Hunter and York. Rosario (1994) Homosexual and bisexual males and females; Garofalo et al., 35.5 3.3 times 104 Massachusetts. (1998) Jordan, Vaughan

35.3 n/a 34 Gay, lesbian and bisexual school students; United States. and Woodworth

(1997) Ha Gay and bisexual males; mean age = 18.3 years; United 34.0 n/a 29 Remafedi (1987) States. Fergusson, 32.1 4.5 times 28 Birth cohort study; age = 21 years; New Zealand. Horwood and Beautrais (1999) Waldo, Hesson- Gay, lesbian and bisexual youth; mean age ~ 18.5 years; 32.0 n/a 54 McInnis and United States. D’Augelli. (1998)

of Homophobia Males with male sex partner in lifetime; age range = 17 to Cochran and 31.3 8.7 times 80 39 years; United States. Mays (2000a) Males with male sex partner in lifetime; are range = 17 to Cochran and 31.3 9.2 times 80 24 39 years; United States. Mays (2000a) Gay and bisexual males; mean age = 20.0 years; United Roesler and 31.0 n/a 60

a States. Deisher (1972) Homosexual, bisexual and unsure males and females; Garofalo et al., 31.0 3.4 times 129 mean age = 16.1 years; Massachusetts. (1999) Remafedi, Farrow Gay and bisexual males; mean age = 19.6 years; United 30.0 n/a 137 and Deisher States. (1991) Gay, lesbian and bisexual youth; mean age ~ 18 years; Grossman and 30.0 n/a 90 United States. Kerner (1998) Gay and bisexual males; mean age = 19.9 years; United Human Impact 30.0 n/a 239 Remafedi (1994) States. Remafedi, Farrow 30.0 n/a 137 Homosexual respondents. and Deisher (1991) 30.0 n/a n/a High estimate of gay and lesbian youth. Whitcock (1988) Gay and bisexual males; age range = 18 to 25 years; Nicholas and 28.8 4 times 53 Australia. Howard (1998) Remafedi, French, 28.1 7 times ~360 Gay and bisexual males; Minnesota. Story, Resnick and Blum (1998) Homosexual and bisexual sexually active males and Faulkner and 27.5 2 times 113 females; Massachusetts. Cranston (1998) 26.0 n/a 77 Gay and bisexual males; mean age ~ 23.5 years; Canada. Magnuson (1992) 25.7 n/a 52 Gay, lesbian and bisexual youth; United States. Hecht (1998) Gays, lesbians and bisexuals; mean age ~ 23.0 years; Hammelman 25.0 n/a 28 United States. (1993) Note: n/a = not available or not reported. ‘X Times Heterosexual Control Sample’ refers to the number of times higher the GLB sample suicide rate was compared to a control sample of heterosexuals used in the study. Heterosexual control group sample characteristics are not described due to the paucity of information given in the original studies.

Table 2 (Continued). Percentage of Gays, Lesbians and Bisexuals Who Attempt Suicide X Times Number of Percentage of Hetero- Partic- GLB who sexual ipants Sample Description Research Study Attempted Control Involved Suicide Sample in Study Saewyc, 3 to 4 Gay and bisexual males and females; mean age = 14.9 Bearinger, Heinz, 24.4 394 times years; Minnesota. Blum and Resnick (1998) Kelly, Rapheal, Judd, Perdices, 23.6 n/a 229 Gay and bisexual males; mean age = 33.0 years; Australia. Kernutt, Burnett, Dunne and Burrows (1998) Gay and bisexual males; mean age = 36.4 years; Cochand and 22.8 n/a 139 Switzerland. Bovet (1998) Gay, lesbian and bisexual youth; mean age ~ 17.0 years; Martin and 21.0 n/a 500 New York. Hetrick (1988) Bell and 21.0 10.5 times n/a Black homosexual men. Weinberg (1978) Schneider, Gay and bisexual males; mean age = 20.6 years; United

20.0 n/a 108 Farberow and t c a p m I n a m u H States. Kruks (1989) Gay and bisexual males; mean age = ~ 17.0 years; Herdt and Boxer 20.0 n/a 141 Chicago. (1993)

20.0 n/a 20 Gay, lesbian and bisexual youth; United States. Dohaney (1995)

Schneider, 20.0 n/a 108 Gay males. Farberow and

Kruks (1989) a

20.0 n/a n/a Low estimate of gay and lesbian youth. Whitcock (1988)

Males with male sex partner in lifetime; are range = 17 to Cochran and 19.3 5.4 times 3648 25 39 years; United States. Mays (2000a)

White and black gay and bisexual males; mean age = 36.0 a i b o h p o m o H f o 18.4 6 times 683 Harry (1983) years; United States. Bradford, Ryan Lesbians; age range = 17 to 80 years; all 50 American 18.0 n/a 1,898 and Rothblum states. (1994) Gay and bisexual, celibate males; mean age = 22.7 years; Bagley and 15.5 3 times 82 Canada. Tremblay (1997a) White, gay and bisexual males; mean age = 36.0 years; Bell and 14.4 5.8 times 575 United States. Weinberg (1978)

Vinke and van 12.4 2 times 137 Gay and bisexual males; mean age = 20.4 years; Belgium. Heeringen (1998) White, gay and bisexual males; mean age = 36.0 years; Bell and 9.5 13.6 times 575 United States. Weinberg (1978) Gay and bisexual sexually active males; mean age = 22.7 Bagley and 6.1 13.9 times 82 years; Canada. Tremblay (1997a) Note: n/a = not available or not reported. Note: ‘X Times Heterosexual Control Sample’ refers to the number of times higher the GLB sample suicide rate was compared to a control sample of heterosexuals used in the study. Heterosexual control group sample characteristics are not described due to the paucity of information given in the original studies.

In addition to the above data, twins reporting same-gender sexual one particularly rigorous and orientation as compared to the twins methodologically sound study is of reporting no same-gender sexual special note. In a study of 103 adult orientation. The higher rate was not male twin pairs, Herrell, Goldberg, explained by mental health, substance True, Ramakrishnan, Lyons, Eisen and abuse, or the numerous unmeasured Tsuang (1999) found the rate of suicide genetic and non-genetic familial factors attempts was 6.5 times higher in the

accounted for in the co-twin control family members suppress that design. information; therefore, sexual In addition to increased levels of orientation is not reflected in death suicide attempts, Kourany (1987), and certificates. Remafedi, Farrow and Deisher (1991) • Some GLB people suffering from the report that self-injurious acts of fear of homophobic attitudes may homosexual adolescents and adults not have told anyone about their were more serious and lethal, were of sexual orientation or about their limited rescuability, and more often intention to commit suicide due to a resulted in hospitalization than those of crisis related to sexual orientation. their heterosexual peers. Bagley and Many incidents, such as single Tremblay (1997a) report that vehicle automobile accidents, may homosexually oriented males form the be suicides incorrectly interpreted as majority of hospitalizations, and accidents.

probably deaths, resulting from suicide • Sexual orientation of suicide victims

attempts. is difficult to obtain posthumously. Ha Data on GLB completed suicides • Openly GLB individuals are only a is less extensive than attempted suicide subset of the GLB population, and so rates. Kroll and Warneke (1995), Gibson suicide rate results may not (1994) and Remafedi (1994) report that generalize to the entire GLB GLB youth account for 30% of population. completed youth suicides. Remafedi • of Homophobia Attempted suicide behaviours and (1987), Schneider, Farberow and Kruks completed suicides represent 26 (1989), and Remafedi, Farrow and somewhat different phenomena.

Deisher (1991) estimate that GLB • The clustering of variables such as

a teenagers account for 20% to 40% of all substance abuse, depression, and completed suicides. Bagley and family dysfunction limits the ability Tremblay (1997a) reviewed twelve to conclude that homophobia was North American studies on suicide rates the root cause of the suicideiii. of gay and bisexual males and found that the suicide rate was approximately Bagley and Tremblay (1997a) Human Impact 31.3% in 1990. Preliminary research by conclude that most researchers have not Tremblay (1994, 1996) indicates that yet acquired the skills needed to more than half of male youth suicide discover the homosexual orientation of victims were homosexually oriented. GLB individuals after their suicide Tremblay (1995) suggested that up to death; however, Garland and Ziegler 50% of male youth suicide deaths might (1993), Lewinsohn, Rohde and Seeley involve homosexually oriented males. (1993), and Shafii, Carrigan, Whittinghill There are several problems and Derick (1985) report that the best associated with estimating the number predictor of a completed suicide is a of GLB who commit suicide (Halpert, previous suicide attempt. Therefore, the 2002; Remafedi, 1999b; Remafedi, rate of suicide attempts of GLB can be French, Story, Resnick & Blum, 1998; used as a validation of estimates of GLB Remafedi, Farrow & Deisher, 1991): suicide deaths. • Coroners and medical examiners There are three types of research may not be told about the sexual upon which to estimate the suicide rate orientation of the victim because of GLB in Canada. The first is the direct

evidence, which indicates that Table 3. Homophobia and Suicide: Four approximately 30% of all suicides are Estimates of Annual Deaths GLB. The second is the attempted Estimated Annual suicide rate. Of the 44 research studies Method Used Number of reviewed, the median attempted suicide Deaths (1997) rate for GLB was approximately 28% 5% base rate; 30% of (the mean was also 28%). The third is 968 completed suicides are the number of times higher the GLB GLB. attempted suicide rate was from a 5% base rate; GLB suicide 957 rate is 6 times the non-GLB heterosexual control sample. Of the 17 rate. studies with such data, the median was 10% base rate; 30% of 5.8 times and the mean was 6.5 times. 818 completed suicides are Assuming that attempted suicides GLB. predict completed suicides, the 10% base rate; GLB suicide 859 rate is 6 times the non-GLB attempted suicide rate of 28% can be rate. used as an estimate of the suicide rate Range of Estimates = 818 to 968 t c a p m I n a m u H for GLB. Even if this number over estimates the number of completed Note: Base rate = percentage of the population that is GLB. suicides, the under-reporting of suicides, and especially GLB suicides, indicates that 25% (6.07 million out of a would tend to make this estimate more total of 24.3 million) of the 1999 reasonable. Additionally, the estimate Canadian population over 15 years of a

of 28% is congruent with the direct age were smokersiv. Ellison, Mao and evidence suggesting 30% of completed Gibbons (1995) estimated the number of 27 suicides are GLB. In sum, two deaths attributable to smoking for estimates, one relative to the Canada in 2000 to be 46,910. a i b o h p o m o H f o heterosexual population (approximately six times the heterosexual rate) and one Gay, Lesbian and Bisexual independent of the heterosexual Statistics. Table 4 is a summary of some population (30% of suicides are GLB) of the research related to GLB smoking were used for suicide rates of GLB. rates. Of the twelve studies reviewed, the median and mean GLB smoking rate a

Human Impact. Table 3 is a was 38%. Based on the median of the summary of the four estimates of the five studies where that information was total number of suicides in Canada available, it was estimated that 1.6 times related to homophobia (see the as many GLB smoked compared to v Appendix for detailed calculations). As heterosexuals . The Roberts and can be seen, the estimates range from Sorensen (1999) study was excluded 818 to 968 deaths per year. since it was a clear outlier in terms of GLB and heterosexual comparisons. Smoking General Population Statistics. Health Canada’s (2000a) Canadian Tobacco Use Monitoring Survey

Table 4. Percentage of Gays, Lesbians and Bisexuals Who Smoke X Times Number of Percentage of Hetero- Partic- GLB Who sexual ipants Sample Description Research Study Smoke Control Involved Sample in Study Garofalo et al. 59.3 1.7 times 104 GLB youth reporting smoking cigarettes in last 30 days. (1998) Stall, Greenwood, Gay men reporting current smoking in Tucson, Arizona 47.8 n/a 2,593 Acree, Pau and and Portland, Oregon. Coates (1999) Turner et al. 45.3 n/a 548 HIV infected GB men in the United States. (2001) High estimate for lesbians reporting smoking cigarettes 43.0 2.0 times n/a Lee (2000) in the past month. Skinner and Otis 42.7 n/a 489 Lesbians in the Southern United States. (1996) Stall, Greenwood, 40.0 n/a n/a Average of six studies in gay adult men. Acree, Paul and Coates (1999) Low estimate for lesbians reporting smoking cigarettes in

38.0 1.7 times n/a Lee (2000) the past month.

Ha 35.0 1.3 times n/a Gay men. Lee (2000)

Skinner and Otis 34.9 n/a 556 Gay men in the Southern United States. (1996) Bradford, Ryan National American sample of lesbians indicating they 30.0 n/a 1,791 and Rothblum smoked cigarettes daily. (1994) Faulkner and 22.9 1.3 times 105 Sexually active GL, Massachusetts high school students.

Cranston (1998) of Homophobia -0.77 Roberts and 20.1 1633 American lesbians. times Sorensen (1999) Note: n/a = not available or not reported. Note: ‘X Times Heterosexual Control Sample’ refers to the number of times higher the 28 GLB sample smoking rate was compared to a control sample of heterosexuals used in the study. Heterosexual control group

sample characteristics are not described due to the paucity of information given in the original studies. a Human Impact. Single, Robson, Table 5. Homophobia and Smoking: Xie and Rehm (1996) estimated that Four Estimates of Annual Deaths there were 33,498 tobacco-related deaths Estimated Annual in 1992. Health Canada (1999, January) Method Used Number of

Human Impact estimated that there were 45,214 deaths Deaths (1999) attributable to smoking in 1996 (an 5% base rate; GLB smoking estimate of 45,000 deaths per year due to 1232 rate is 38%; non-GLB smoking was used for 1999). Smoking smoking rate is 24%. deaths accounted for 17% of total 5% base rate; GLB smoking 1314 rate is 1.6 times the non- mortality and 16% of the total years of GLB smoking rate of 24%. life lost due to any cause. Table 5 10% base rate; GLB summarizes the four estimates of the 2599 smoking rate is 38%; non- number of deaths attributable to GLB smoking rate is 24%. homophobia as related to smoking. 10% base rate; GLB smoking rate is 1.6 times 2548 the non-GLB smoking rate of 24%.

Range of Estimates = 1232 to 2599

Note: Base rate = percentage of the population that is GLB. See Appendix for calculations of GLB and non-GLB smoking rates.

Alcohol Abuse & Williams, 1974). Researchers also General Population Statistics. contend that alcohol related problems WebMD Canada (1999) reports that 7% lose their intensity when the of the U.S. population suffers from environment of GLB is not homophobic. alcoholism. While approximately 55% Alderson (2001) cites evidence that not of Canadians consume one or more accepting one’s homosexuality, which drinks per month (Statistics Canada, may be related to homophobia, may be 2001a), the 1996-97 National Population causally related to the high incidence of Health Survey (Statistics Canada, 1998) alcohol abuse in the gay community. found that 2.5% of Canadians reported Williamson (2000) contends that drinking at levels associated with internalized homophobia in GLB results clinical dependence on alcohol. Single, in less effective coping strategies such as Brewster, MacNeil, Hatcher and Trainor alcohol abuse. Johnson and Palermo (1995) reported that 9.2% of adult (1985) believe the minority status of Canadians reported having problems homosexuals itself is not the primary with their drinking. The Addiction cause of alcoholism, but rather that the

t c a p m I n a m u H Research Foundation (2001) estimated homophobia of individuals in treatment that 5% of the adult population was programs is the primary causal factor. alcoholic, which was based on liver This homophobia is manifested through cirrhosis mortality and per capita behaviours such as refusal of services, alcohol consumption data. Adlaf, Ivis non-helpful attitudes of treatment and Smart (1994) found that in a survey workers, and isolation of lesbianism as a

of Ontario adults, 5.3% met the alcohol the problem with little attention dependence criteria. In a large survey, directed toward alcoholism and results 29 Grant, Harford, Dawson, Chou, Dufour, in effective treatment. and Pickering (1994) found that 3% of Table 6 summarizes the a i b o h p o m o H f o American adults abused alcohol. Given estimated incidence of alcohol abuse in the results described above, an estimate GLB. Of the seventeen studies with that 5% of the population suffers from such information, but not including the alcoholism, alcohol abuse or problem Gillow and Davis (1987) research that drinking was used. was not measuring alcohol abuse per se,

the median incidence of alcohol abuse in Gay, Lesbian and Bisexual GLB was 16% while the mean incidence Statistics. No studies have found a was 18% (17% was used for the relationship between homosexuality estimation calculations). In terms of the itself and alcoholism (Small & Leach, GLB rate relative to the heterosexual 1977), yet several studies have found rate, the median of the seven studies higher incidences of alcoholism in GLB. with such data was 1.7 times. As stated Some researchers contend that the previously, inconsistencies in sampling alienation and isolation GLB experience methods and criteria for alcoholism, and as a result of society’s rejection and the invisibility of the GLB population oppression of homosexuality is the greatly limits the generalizability of the reason for this high incidence of research summarized above. alcoholism (Small & Leach, 1977; Ungvarski & Grossman, 1999; Weinberg

Table 6. Percentage of Gays, Lesbians and Bisexuals Who Abuse Alcohol X Times Number of Percentage of Hetero- Partic- GLB Who sexual ipants Sample Description Research Study Abuse Alcohol Control Involved Sample in Study Lesbians reporting use of alcoholic beverages to cope Gillow and Davis 59.0 n/a 142 with stress. (1987) Low estimate of incidence of alcoholism in lesbians from Johnson and 35.0 7 times n/a a review of four studies. Palermo (1985) Barr, Greenberg 30.0 1.5 times n/a Problem drinking in homosexual population. and Dalton (1974) Male homosexuals in the United States, the Netherlands Weinberg and 29.4 n/a 2,497 and Denmark reporting drinking problems. Williams (1974) High estimate of incidence of alcoholism in lesbians from Johnson and 25.0 5 times n/a a review of four studies. Palermo (1985) Bradford, Ryan 25.0 n/a 1,852 National American sample of lesbians. and Rothblum (1994) McKirnan and Peterson (1989a)

Lesbians classified as having an alcohol problem in a 23.0 2.9 times 748 and McKirnan Chicago sample.

Ha and Peterson (1989b) McKirnan and Gay men classified as having an alcohol problem in a 23.0 1.4 times 2652 Peterson (1989a Chicago sample. and 1989b) Male homosexuals aged 25 to 54 who exhibited Stall and Wiley 18.7 1.7 times 748 frequent/heavy-drinking patterns. (1988) Gay male problem drinkers in the Southern United Skinner and Otis 13.2 0.94 times 553 States. (1996) of Homophobia Faulkner and 10.9 9.1 times 105 Sexually active GL, Massachusetts’s high school students. Cranston (1998) Cochran and 10.6 1.4 times 98 Male homosexuals dependent on alcohol. 30 Mays (2000b) Male and female homosexuals classified as problem Skinner and Otis 10.0 1.4 times 1055 a drinkers in the Southern United States. (1996) Welch, Howden- Lesbians in New Zealand reporting alcohol use 5 to 7 9.0 n/a 561 Chapman and times per week Collings (1998) Urban, American men who have sex with men reporting 8.0 n/a 2172 Stall et al. (2001) frequent/heavy alcohol use Skinner and Otis 7.5 3.2 times 491 Lesbian problem drinkers in the Southern United States. (1996)

Human Impact Cochran and 7.0 3.2 times 96 Lesbians dependent on alcohol. Mays (2000b) 1.0 times Homosexual and bisexual women reporting heavy n/a 55 Bloomfield (1993) (equal) alcohol consumption. Note: Operational definitions of alcohol abuse and homosexuality vary across the studies reviewed. n/a = not available or not reported. n/a = not available or not reported. ‘X Times Heterosexual Control Sample’ refers to the number of times higher the GLB sample alcohol abuse rate was compared to a control sample of heterosexuals used in the study. Heterosexual control group sample characteristics are not described due to the paucity of information given in the original studies.

Human Impact. Single, Robson, etc.). Single, Rehm, Robson and Truong Xie and Rehm (1996) examined the (2000) estimated that there were 6507 human costs of substance abuse in alcohol related deaths in 1995 and that Canada, and found that there were 6701 the use and misuse of alcohol, tobacco deaths due to alcohol consumption in and illicit drugs accounted for 20% of 1992. Gorsky, Schwartz and Dennis deaths, and 22.2% of years of potential (1988) estimate that alcohol abuse is a life lost in Canada in 1995. factor in more than 10% of all deaths Since alcohol consumption rates (e.g., traffic accidents, homicide, suicide, remained stable from 1995 to 2000

Table 7. Homophobia and Alcohol estimate the percentage of the Canadian Abuse: Four Estimates of Annual population who use illicit drugs, since Deaths there are numerous types of illicit drugs, Estimated and individuals use different drugs in Annual Method Used different combinations in different Number of Deaths (2000) quantities over different amounts of 5% base rate; GLB alcohol time. Although combining the relative 875 abuse rate is 17%; non-GLB rates of marijuana, cocaine, heroin and alcohol abuse rate is 4.4%. other drug use is not ideal, for the 5% base rate; GLB alcohol present exploratory literature review a abuse rate is 1.7 times the 236 non-GLB alcohol abuse figure of 3.5% was used for the rate of rate of 4.8%. illicit drug use in Canada. This 10% base rate; GLB alcohol represents the mean of the research 1843 abuse rate is 17%; non-GLB results listed above; it also represents a alcohol abuse rate is 3.7%. conservative estimate, since it is known 10% base rate; GLB alcohol that more than this percentage of the abuse rate is 1.7 times the t c a p m I n a m u H 457 non-GLB alcohol abuse population uses marijuana. However, rate of 4.7%. as mentioned previously, drug use Range of Estimates = 236 to 1843 overlaps in individuals, and marijuana is most likely the least costly on society. Note: Base rate = percentage of the population that is GLB. See Appendix for calculations of GLB and non-GLB alcohol abuse rates. Gay, Lesbian and Bisexual a

Statistics. Research indicates that GLB (Brewers Association of Canada, 2002), have increased levels of illicit drug use 31 an estimate of 6930 deaths per year was compared to heterosexuals (Skinner, used (adjusted for population change 1994), most likely as a result of minority a i b o h p o m o H f o since 1995). Table 7 shows the estimates stress (Ostrown, 2000). Table 8 is a of annual alcohol related deaths most summary of the individual studies of likely attributable to homophobia. GLB illicit drug use rates. Studies on the use of illicit drugs Illicit Drug Use vary widely in terms of GLB rates. This General Population Statistics. The a most likely is a result of the differences Canadian Health Network (1999) in drugs used and the age of the study reported that 7.4% of Canadians used participants. Since the percentage of marijuana, 0.7% used cocaine, and 1.1% GLB who use illicit drugs varies so used LSD, speed or heroin. Citing data considerably, the only estimation used from the Centre for Addiction and was the number of times higher the GLB Mental Health’s monitoring studies, the rate was compared to the heterosexual City of Toronto Drug Prevention Centre rate. Of the sixteen studies with such (2000) reported that less than one data, the median was 2.6 times and the percent of adult Canadians had used mean was 4.2 times. Since there were crack cocaine or heroin in the past year, several outliers that unduly influenced ten percent had used marijuana in 1999, the mean, the median rate of 2.6 times and one percent had used cocaine in was used. This is most likely a 1998. No satisfactory method exists to

Table 8. Percentage of Gays, Lesbians and Bisexuals Who Use Illicit Drugs Percentage of X Times Number of Gays, Lesbians Hetero- Partic- or Bisexuals sexual ipants Sample Description Research Study who use Illicit Control Involved Drugs Sample in Study Gay and bisexual male youths meeting criteria for 58.0 n/a 29 Remafedi (1987) substance abuse. Garofalo et al. 53.7 1.7 times 104 GLB reporting use of marijuana in last 30 days (1998) Gay men reporting marijuana use in the Southern United Skinner and Otis 36.5 2.5 times 558 States. (1996) Lesbians reporting marijuana use in the Southern United Skinner and Otis 36.1 4.4 times 492 States. (1996) Safe Schools GLB high school youth reporting heavy or high-risk drug Coalition of 35.8 1.6 times 324 use in the United States. Washington (1999) Council on High estimate of non-parenteral (ingested) substance 35.0 3.2 times n/a Scientific Affairs abuse in GL (1996) Council on Low estimate of non-parenteral (ingested) substance

Ha 28.0 2.5 times n/a Scientific Affairs abuse in GL (1996) Garofalo et al. 25.3 9.4 times 104 GLB reporting use of cocaine in last 30 days (1998) Sexually active GL Massachusetts high school students Faulkner and 20.8 6.7 times 105 reporting using injection drugs at least once. Cranston (1998) Urban, American men who have sex with men reporting 18.9 n/a 2172 Stall et al. (2001) frequent drug use Bradford, Ryan

of Homophobia Lesbians reporting using marijuana daily or more than 14.0 n/a 1,917 and Rothblum once a week (1994) Sexually active GL Massachusetts high school students Faulkner and 13.3 19 times 105 32 reporting using cocaine 10 or more times. Cranston (1998) Sexually active GL Massachusetts high school students Faulkner and 12.4 3.8 times 105 a reporting using marijuana 40 or more times. Cranston (1998) McKirnan and 11.0 1.2 times 748 GLB in Chicago reporting frequent use of marijuana. Peterson (1989a and 1989b) Gay men reporting cocaine use in the Southern United Skinner and Otis 9.7 1.5 times 558 States. (1996) Lesbians in New Zealand reporting more than weekly Welch et al. 8.0 n/a 561 use of marijuana (1998).

Human Impact Lesbians reporting cocaine use in the Southern United Skinner and Otis 7.1 2.6 times 492 States. (1996) Cochran and 5.7 2.0 times 98 Homosexual men dependent on illicit drugs Mays (2000b) Cochran and 5.0 3.8 times 96 Homosexual women dependent on illicit drugs Mays (2000b) Bradford, Ryan Lesbians reporting using cocaine more than once a week 3.0 n/a 1,917 and Rothblum or more than once a month (1994) McKirnan and 2.3 3.3 times 2652 GLB in Chicago reporting frequent use of cocaine. Peterson (1989a and 1989b) Homosexual men (HIV positive and negative) indicating Williams et al. 2.3 n/a 208 drug abuse / dependence (1991) Cochran, Stewart, n/a 2.5 times 168 GLBT and heterosexual youth in Seattle Ginzler and Cauce (2002) Note: Studies differ in operational definitions of illicit drug use and in the types of illicit drugs used. Also, youth and adult rates most likely differ in the GLB and heterosexual populations. n/a = not available or not reported. ‘X Times Heterosexual Control Sample’ refers to the number of times higher the GLB sample illicit drug abuse rate was compared to a control sample of heterosexuals used in the study. Heterosexual control group sample characteristics are not described due to the paucity of information given in the original studies.

conservative estimate; however, given women and 11% of all men in Canada at the inability to accurately estimate the some point in their lives. Patten (2000) GLB or heterosexual rate, it was the analyzed data from the Canadian most reasonable. National Population Health Survey in 1994-1995 and 1996-1997 and found the Human Impact. Single, Robson, following prevalence rates for major Xie and Rehm (1996) estimated that depression: 5.2% (males 12 to 24 years there were 732 illicit drug-related deaths old), 3.5% (males 25 to 44 years old), in Canada in 1992. Single, Rehm, 3.5% (males 45 to 64 years old), 9.6% Robson and Truong (2000) estimated (females 12 to 24 years old), 8.6% that there were 805 deaths in 1995 due (females 25 to 44 years old), 6.3% to illicit drugs. Adjusting for (females 45 to 64 years old), and 3.1% population changes, an estimate of 857 (females over 65 years old). Feightner deaths was used for estimating the (1994) estimates the prevalence of number of annual deaths in Table 9. depression in the general population to

t c a p m I n a m u H be between 3.5% and 27% depending on Table 9. Homophobia and Illicit Drug the definition used and the population Use: Two Estimates of Annual Deaths studied. Given these findings, an Estimated estimate of five percent was used as the Annual Method Used percentage of the population suffering Number of from depression. The Statistics Canada a

Deaths (2000) 5% base rate; GLB illicit (2001h) and Patten (2000) studies were drug use rate is 2.6 times given more credence because they used 64 33 the non-GLB illicit drug Canadian population data and were use rate of 3.2%. based on methodologically sound a i b o h p o m o H f o 10% base rate; GLB illicit drug use rate is 2.6 times research methods. 74 the non-GLB illicit drug use rate of 3.0%. Gay, Lesbian and Bisexual Range of Estimates = 64 to 74 Statistics. There is no evidence that GLB are any different to heterosexuals in

Note: Base rate = percentage of the population that is GLB. a

See Appendix for calculations of GLB and non-GLB illicit their psychological stability and mental drug rates. functioning (Ross, 1985). Vincke, De Rycke and Bolton (1999) found that Depressionvi chronic stress experienced by gay men General Population Statistics. lead to greater levels of depression. Naiman (2000) reported that 10% of the Most psychological problems Canadian workforce suffers from experienced by GL are due to coping mental illness, including depression. with the negative reaction if he/she is Statistics Canada (2001h) reported that openly homosexual and coping with the in 1996-1997, approximately 1.32 million anxieties of keeping sexual orientation people or 4.4% of the population hidden and fear of disclosure if he/she reported feeling depressed. The Mood is not openly homosexual. Dempsey Disorders Association of Manitoba (1994) found that GL adolescents were (2001) found that depression and/or likely to experience greater manic-depression (bipolar disorder) psychological dysfunction than non-GL occurs in approximately 25% of all peers. D’Augelli (1998) reported on the

negative mental health consequences of from depression was 2.3 times higher growing up in a climate of homophobic than the average rate (although 29% of intolerance. Bell and Weinberg’s (1978) these deaths were attributed to suicide). study of 1500 men and women in San Wulsin (2000) cites a robust study that Francisco found that 56% of gay men found that depression increased (compared to 27% of heterosexual mortality by 24% six years after a males) and 66% of lesbians (compared baseline measure was taken. to 41% of a heterosexual female control Although it is clear that group) reported having consulted a depression increases mortality, even professional about emotional problems when controlling for factors like at some time in their lives. Morgan smoking, physical illness and alcohol (1992) found that 78% of 100 sampled consumption, there was insufficient lesbians and 29% of 309 sampled data to reliably calculate human cost heterosexual women reported having figures for the present literature review.

been in psychotherapy at some time in

their lives. Matthews et al. (2002) found Unemployment Ha that 58% of their sample of 550 lesbians General Population Statistics. had been treated for depression Statistics Canada (2001c and 2001g) data (compared to 52% of heterosexual on the Labour Force indicate that in the women). Simonsen, Blazina & Watkins year 2000, out of the total labour force of (2000) found that gender role conflict 15,999,200 people, 6.81% or 1,089,600

was correlated with depression in a were unemployed. of Homophobia sample of 117 gay men. Table 10 (next page) reviews the research on Gay, Lesbian and Bisexual

34 depression in GLB. Statistics. There is some evidence that

a The median percentage of GLB GLB have a higher unemployment rate suffering from depression from the than heterosexuals (Fastfax, 2000). research summarized above was 15.3%. Pagelow (1980) describes the problems Based on the studies that had such incurred by GLB in attaining and information, GLB are 2.15 times more maintaining employment (e.g., subject likely to suffer from depression than to coercion and blackballing, paranoia, Human Impact heterosexuals. constant anxiety). Bradford, Ryan and Rothblum (1994) found that thirteen Human Impact. There is percent of their national American substantial evidence that major sample of 1,917 lesbians had lost their depression is a risk factor for non- jobs because of anti-gay discrimination. suicide mortality even when controlling The Glasgow Women’s Library (1999) for other factors (Schulz et al., 2000; reported that forty-two percent of Penninx et al., 1999; Schulz et al., 2002; unemployed GL survey respondents Pulska, Pahkala, Laippala & Kivela, perceived that their unemployment was 1997, 1998a, 1998b, 1999, 2000; related to their sexuality, and twenty Ziegelstein, 2001). Penninx et al. (2001) percent of respondents stated that they found that major depression increased had had to leave employment or had the risk for cardiac mortality by almost 3 been refused work due to their sexuality times. Newman (2003) found that the or the homophobia of others. mortality rate of individuals suffering

Table 10. Percentage of Gays, Lesbians and Bisexuals Who Suffer From Depression X Times Number of Percentage of Hetero- Partic- GLB Suffering sexual ipants Sample Description Research Study from Control Involved Depression Sample in Study Gay, lesbians and bisexual New Zealanders (aged 14 to Ferguson, 71.4 1.9 times 28 21 years) in a 21-year longitudinal study suffering from Horwood and major depression. Beautrais (1999) Bradford, Ryan National American survey of lesbians reporting having 37.0 n/a 1,925 and Rothblum suffered from depression sometime in the past. (1994) National American sample of lesbians reporting having Sorensen and 30.0 n/a n/a been in therapy for depression. Roberts (1993) Men reporting same-sex sexual partners meeting the Cochran and 15.3 2.4 times 78 criteria for major depression. Mays (2000a) Cochran and 15.0 1.8 times 96 Homosexual women suffering from major depression. Mays (2000b) Cochran and 13.3 3.0 times 98 Homosexual men suffering from major depression. Mays (2000b) Bradford, Ryan National American survey of lesbians currently suffering 11.0 n/a 1,925 and Rothblum from major depression. (1994) t c a p m I n a m u H Note: The disparity in the Fergusson, Horwood and Beatrais (1999) study was not associated with any significant differences in social, family, or childhood backgrounds. n/a = not available or not reported. ‘X Times Heterosexual Control Sample’ refers to the number of times higher the GLB sample depression rate was compared to a control sample of heterosexuals used in the study. Heterosexual control group sample characteristics are not described due to the paucity of information given in the original studies.

Skinner and Otis (1996) found that 3.5% of his sample of 29 GB male teenagers of their sample of 1067 GLB were had dropped out of high school.

a unemployed, although no comparison There was minimal data on the data was reported. Based on data from unemployment rate of GLB in Canada; the 1996 New Zealand census, Byrne therefore, no estimation was calculated 35

(1997) reported that the unemployment based on GLB unemployment rates. a i b o h p o m o H f o rate was 1.32 times higher for lesbians as compared to heterosexual women (6.2% Human Impact. There is evidence versus 4.7%) and 1.38 times higher for that mortality rates among the gay men as compared to heterosexual unemployed are higher than among the men (5.5% versus 4.0%). Mutchler and employed (Iverson, Andersen,

Freeman (1999) found that 25.4% of their Andersen, Christoffersen & Keiding, a

sample of GLB in Los Angeles were 1987; Martikainen, 1990; Morris, Cook & unemployed. Shaper, 1994; Moser, Fox & Jones, 1984). High school dropout exacerbates However, since little information exists employment problems of GLB because to estimate the unemployment rate of education is related to employability. GLB in Canada, no valid estimate of the Remafedi (1994) cited an American number of premature deaths most likely study that found the high-school caused by homophobia could be dropout rate for GLB youth was 28% calculated. compared to 9% for their heterosexual counterparts. This is primarily due to Murder discrimination (e.g., verbal and physical General Population Statistics. In harassment) of GLB young people by Canada, there were 554 homicides in peers (Roberts & Sorensen, 1995) and 2001 and 546 in 2000 (Statistics Canada, the isolation many GLB feel (Rivers, 2002). 2000). Remafedi (1987) found that 28%

Gay, Lesbian and Bisexual estimations of the human cost of Statistics. Otis and Skinner (1996) homicides caused by homophobia. reported several studies that show hate crimes against gay men and lesbians HIV/AIDS increased substantially from the early General Population Statistics. 1980s to the early 1990s. Roberts (1995) Health Canada (1999a) reported the HIV reported that eleven percent of all hate and AIDS cases and exposure categories crimes are directed against gays and shown in Table 11. In terms of risky lesbians. Evidence of physical and sexual behaviour, Health Canada verbal assaults against GLB is well (1999b) reported in 1994 that 26% of documented (Herek, Gillis & Cogan, men and 19% of women always used 1999; Telljohann & Price, 1993; Savin- condoms with non-regular partners. In Williams, 1994; Herek, 1993; Berrill, addition, in 1997, 27.7% of men and 1990; Barnes & Ephross, 1994; Glasgow 28.1% of women did not use a condom

Women’s Library, 1999; Lee, 2000; the last time they had sexual intercourse

Hunter, 1990; Bradford, Ryan & with a non-regular partner. Ha Rothblum, 1994; Samis, 1995; Faulkner Health Canada (2000b) reported & Cranston, 1998; Faulkner, 1997; Smith, that there were 107 AIDS-related deaths 1993a; New Brunswick Coalition for in 1999, which is down substantially Human Right Reform, 1990; Warwick, from the 1,422 reported in 1995. Aggleton & Douglas, 2001; Morrow, However, due to reporting delays and

2001; Balsam, 2001; D’Augelli & under-reporting for both AIDS cases of Homophobia Grossman, 2001). Murder motivated by and deaths among AIDS cases, this homophobia in Canada is less well estimation may be lower than the actual

36 documented. However, anti-gay number of AIDS-related deaths.

a murder statistics have been reported for Brazil (169 murders in 1999); Minnesota Gay, Lesbian and Bisexual (between 120 and 180 murders between Statistics. Health Canada (1996) 1969 and 2002); and New South Wales, reported that GLB youth have a higher Australia (37 murders between 1989 and risk of HIV infection than the general 1999) (Wockner, 2000; Minnesota Gay youth population. As can be seen in Human Impact Homicide Study, 2000; Mouzos & Table 11, homosexual contact (men who Thompson, 2000). Cameron, Playfair have sex with men) accounted for 52.2 and Wellum (1994) found that percent of AIDS cases and 25.0 percent homosexual men were more frequently of HIV cases in 1997. Although GLB murdered than men in general based on could have constituted a proportion of US obituaries. There was insufficient the HIV and AIDS cases in other scientifically based data to estimate the exposure categories (e.g., occupational number of anti-GLB murders in Canada. exposure), this proportion would be small. Human Impact. It is clear that There are several reasons for the GLB are subject to hate crimes, increased rates of HIV and AIDS in including substantial physical violence. GLB. First, as was demonstrated It can be assumed that there are anti-gay previously, GLB use illicit drugs and murders in Canada; however, there was abuse alcohol at higher rates than the insignificant evidence to warrant any heterosexual population. Research shows that heavy alcohol and drug

users more often engage in unsafe sex Human Impactvii. HIV infection and therefore contract HIV/AIDS was the 15th leading cause of death in (Ostrow, 2000; Rosenberg et al., 2001). Canada in 1997 (Statistics Canada, Second, Meyer and Dean (1996) 2001e). However, it would not be valid and O’Hanlan, Lock, Robertson, Cabaj, to estimate the human impact of Schatz and Nemrow (1996) reported homophobia as it relates to HIV/AIDS that GLB with higher internalized because there is no way to equate GLB homophobia engaged in risky sexual and heterosexuals. This is because risky behaviours at a greater rate than GLB sexual behaviour cannot be conclusively with lower internalized homophobia. linked to homophobia. Unsafe sexual Additionally, Williamson (2000) practices were prevalent in both the reported that GLB with higher GLB and the heterosexual populations internalized homophobia were less when the HIV/AIDS epidemic first affiliated with the gay community and appeared. Although homophobia therefore had less access to safer sex probably contributes to risky sexual information and resources. behaviour and thus increased incidences

t c a p m I n a m u H Third, Peersman, Sogolow and of HIV/AIDS in the GLB population, Harden (2000) reported that people who any human cost estimates would be live at the margins of mainstream futile at this time. Interestingly, non- society, including GLB, are more GLB individuals with a negative vulnerable to HIV/AIDS infection. In attitude toward GLB are more likely to particular, men who have sex with men exhibit risky sexual behaviours because a

are at an exceedingly high risk for HIV they believe HIV/AIDS is a “gay infection (Johnson & Peersman, 2000), disease;” indicating that homophobia 37 and HIV has disproportionately affected may be costing lives in the non-GLB the gay community, which has lead to population also (Burkholder, Harlow & a i b o h p o m o H f o even greater stigmatization (Ostrow, Washkwich, 1999). Fear of homosexual 2000). Graham, Kirscht, Kessler and association also prevents some Graham (1998) found that negative life individuals from pursuing sources of events, depression and anxiety were information about AIDS or practicing predictors of risky sexual behaviours. safe sex (Edgar, Freimuth & Hammond,

Finally, Leserman, Petitto, 1988). Golden, Gaynes, Gu, Perkins, Silva, Although homophobia may not Folds and Evans (2000) found that be directly linked to the acquisition of stressful life events, depression, and HIV/AIDS, Nott and Vedhara (1999) dissatisfaction with social support were found that stresses faced by homosexual associated with an increased risk of men might play a role in the progression contracting AIDS and the progression of of HIV. In addition, internalized HIV. Kelly (2002) found that reducing homophobia has predicted distress risky sexual behaviour in GB men levels in HIV-positive men (Wagner, hinged partly on positive self-esteem Brondolo & Rabkin, 1996). and pride, which can be negatively effected by homophobic attitudes and behaviours.

Table 11. AIDS and HIV Cases in Canada for 1997 1,966 Total HIV 632 Total AIDS Exposure Category Cases (%) Cases (%)

No identified risk factor 33.5 3.6

Men who have sex with men 25.0 52.2

Injecting drug use 22.1 15.3

Heterosexual contact 14.5 17.7

Men who have sex with men and injecting drug use 1.6 4.1

Perinatal 1.4 --

Other 1.2 --

Recipient of blood or clotting factor 0.8 2.2

Occupational exposure -- 0.2

No identified risk – heterosexual -- 4.6

Total 100.0 100.0

Ha Note: The category “Men who have sex with men” may include individuals who do not label themselves as GB.

Corollary Issue: Access to Quality all of the client’s problems, and Health Care and Services generally reduces the success of An additional issue faced by substance abuse treatment programs GLB is the effect of prejudice, (Berkman & Zinberg, 1997; Hall,

of Homophobia discrimination and inadvertent or 1990). purposeful alienation by the social and • Gentry (1992), Lee (2000), Jones and 38 health care communities (O’Hanlan, Gabriel (1999), Baker (1993),

1995). This result of homophobia in the McGarry, Clarke and Cyr (2000), a health care sector worsens the effect of Kroll and Warneke (1995), Roberts homophobia because increased rates of and Sorensen (1995), Savin-Williams health and social problems in GLB are (1994), and Shelby (1999) report that not treated properly or effectively, health care providers rarely ask which can often lead to premature about sexual orientation (i.e.,

Human Impact mortality. GLB have special health heterosexuality is assumed). needs (Waugh, 1996); listed below are • Many health care professionals are some examples of the additional unaware of the unique health care burdens and issues faced by GLB issues related to GLB health care because of homophobia in health care (Ungvarski & Grossman, 1999; Lee, servicesviii: 2000; Mitchell, 2000). • The existence of homophobia in • GLB often delay or decline seeking counselors can interfere with medical assistance, including counseling, lead to inappropriate routine preventative health care, choices of treatment modality and because of fear of ridicule, abuse, treatment goals, result in doctor prejudice, discrimination, minimizing the importance of the disclosing of sexual orientation to client’s sexual orientation and the friends and family, exploitation, negative effects of heterosexism, rejection, neglect, and unconcern viewing homosexual orientation as (Godin, Naccache & Pelletier, 2000; the pathological underlying cause of Stevens, 1994; Gentry, 1992; Wagner,

1997; Sussman-Skalka, 2001; Stevens health provider in the last 12 months & Hall, 1988). said that they had at some time in • The fears described above are their lives received “poor or demonstrated in research by inappropriate mental health services Dardick and Grady (1980) who because of [their] sexual orientation. found that less than 50% of openly • Carter et al. (1996) found that more homosexual men had told their homophobic medical students were primary health care provider that less willing to treat HIV-positive they were gay, while Johnson and patients than less homophobic Palermo (1985) found that only 18% students. of women studied had revealed their • Stevens and Hall (1991) cite several sexual orientation to a physician. examples of lesbians’ negative • Roberts and Sorensen (1995) and experiences in health care settings Ryan, Brotman and Rowe (2000) and subsequent delay in seeking reviewed several studies and found treatment. Stigmatization results in

that health care providers GLB reluctance to seek health care or t c a p m I n a m u H consistently demonstrated negative communicate openly in health care attitudes and behaviours (e.g., encounters. Stevens (1994) found embarrassment, anxiety, pity, that 44% of the 45 lesbians disgust, revulsion, hostility, interviewed did not feel safe enough rejection, condescension) and or respected enough to continue

discomfort treating GLB. Also, contact with health care providers. a

lesbians consistently reported fear • Evans, Ferrando, Rabkin & Fishman that their quality of health care (2000) report that attitudes towards 39 would be affected if they disclosed physicians and other health care their sexuality. It was also found professionals is associated with a i b o h p o m o H f o that the discomfort of both health critical treatment decisions in HIV- care providers and patients could positive men. lead to a lack of sharing information, • Brogan, Frank, Elon and Sivanesan delay in care for illnesses and (1999) described the harassment of reluctance to have routine health lesbians during medical education

promotion visits. and medical practice, which may • Schatz and O’Hanlan (1994) report discourage many lesbians from that two-thirds of 700 physicians becoming physicians and providing knew patients who were denied or the empathetic care needed by many given substandard care by lesbian patients. The absence of physicians because of their sexual GLB in the health care system also orientation. Trezza (1994) also allows prejudice and misinformation reports homophobia was the largest to flourish (Shelby, 1999). predictor of stigmatization of • Siminoff et al., (1998) found that persons infected with AIDS in greater homophobia in a sample of counseling psychologists (although nurses was negatively related to Lawrence et al. (1990) did not quality of psychosocial care. replicate these findings). • The quality of relationship with a • Nystrom (1997) reported that 25% of physician is highly related to overall 1500 GLB and trans-gendered quality of life and treatment respondents who had seen a mental adherence (Heckman et al., 1998).

SUMMARY OF HUMAN IMPACT ESTIMATES

able 12 is a summary of the calculate the GLB unemployment rate in estimates of the human impact Canada. T of homophobia on Canada. There was clear evidence that GLB are victims of physical violence at a Table 12. Estimations of the Annual much higher rate than the heterosexual Human Impact of Homophobia on population; however, there were limited Canada estimations of the number of anti- Number of Deaths Health or Year homosexual homicides that occur in Low High Social Issue Estimated Estimate Estimate Canada.

Suicide 1997 818 968 The GB male population has been hit especially hard by the Smoking 1999 1232 2599 HIV/AIDS epidemic; however, it cannot

be assumed that GLB and heterosexual Alcohol 2000 236 1843 Ha Abuse populations would have equivalent rates of infection without the presence Illicit Drug 2000 64 74 of homophobia. This is because of the Use transmission routes of the disease, the concentration of the epidemic in the GB There were five issues for which male community in the early stages of a human impact analysis was not of Homophobia the epidemic, and the inability to feasible: depression, unemployment, separate GLB from the injectable drug murder, HIV/AIDS and access to user exposure category. 40 quality health care and services. There

Research clearly demonstrates

a was evidence that GLB suffer higher that homophobia results in substandard rates of depression and that depression health care for GLB, and that GLB do leads to increased mortality rates; not properly access and use the health however, there was insufficient data to care system because of homophobia. make any valid estimations of the This problem intensifies the problems human cost of homophobia. faced by GLB and undoubtedly adds Human Impact Although there was some substantially to the number of research indicating that a greater homophobia related deaths in Canada; percentage of GLB are unemployed however, no human cost estimates were compared to heterosexuals, and that made since insufficient data existed. unemployment leads to premature

mortality, there was insufficient data to

LIMITATIONS

iterature Review were meant to raise awareness of the relevant issues, point to future research L The present literature that is needed, and to give a general review has several limitations, which sense of the human cost of homophobia are discussed below: on Canadian society.

Exploratory Nature of the Review. A Generalizability of Research. Some of review connecting homophobia, the data and research reviewed in the homophobia’s impact on GLB health present review has been culled from and the resultant human impact has not American and European sources from been attempted before. As with any the past 30 years. The results from these exploratory attempt that is not firmly studies are not directly generalizable to established in the research, there is little Canada in the present time period. precedent and little opportunity to learn However, these studies are very similar t c a p m I n a m u H from previous work. to the results of Canadian studies, and, in addition, since most of the results Human Costs are Estimations Only. were fairly consistent across time and The appraisal of the economic costs of throughout different geographic areas, certain health and social issues has they supported the Canadian results.

a increased in the last few years (Goeree, More generally, Canada, the United O’Brien, Blackhouse, Agro & Goering, States and European countries have 1999). In addition, estimations of the much in common, including similar 41 number of deaths attributable to certain standards of living, GLB-related laws,

a i b o h p o m o H f o health and social issues also exist. Both economic conditions, and health care types of appraisals are simply practices and standards that make estimations, since the exact economic generalizing research among these and human costs cannot be known. countries relatively sound from a These cost estimates are not research perspective. scientifically determinable because there a is a considerable amount of unknown Synthesizing of Research. The present information in the area of homophobia, literature review combines studies that homosexuality, and the impact of health vary considerably in their definitions, and social issues on GLB. Also, many methodologies, results and conclusions. health and social issues lead to death For example, dozens of articles related only after long-term exposure. For to attempted suicide rates in GLB were example, recent alcohol abuse rates reviewed. A median or mean rate was were used to calculate current deaths; calculated from those studies; however, however, current deaths would most each study differed in terms of how an likely be determined by alcohol abuse “attempted suicide” was defined, how rates several years before deaths “homosexuality” was defined, and the occurred, since alcohol abuse has long- sample from which the data was term negative consequences. Several collected. Combining the results across mortality estimates were offered in the these studies is problematic; however, present literature review. The since the median or mean rate from approximations and estimates given among those studies was used, the

research that tended to underestimate research and applied to specific sub- rates and the research that tended to populations is problematic. overestimate rates would have balanced each other. Although “true” rates can Diversity of GLB Populations. probably never be known for the Obtaining research examining various health and social issues homosexual males, homosexual females, reviewed in this document, the bisexual males and bisexual females methodology used is the best available separately was very difficult. Although alternative. these groups represent distinct and diverse populations with unique issues, Non-Weighting of Research. A the present review treated research median or mean estimate for the exploring these different groups as different rates of health and social homogenous. The reason for examining problems experienced by GLB was used the communities collectively was for

to calculate the human cost of brevity and, for the sake of presenting

homophobia. No extra weighting was an initial exploratory review of the area, Ha given to studies of higher quality (e.g., no attempt was made to uncover any methodologically sound, using samples differences between those groups at this representative of the population) or time. This limits the degree of specific studies with larger sample sizes, which conclusions that can be made about the could be considered a weakness of the relative impact of homophobia on those

present review. A decision was made to different groups. of Homophobia equally weight all the individual studies; therefore, using the median or Variables Unaccounted For. Related

42 mean was the appropriate methodology. to the generalization problem is that the

a A benefit of this approach is that the GLB population (or more accurately the median would tend to eliminate results GLB sample used to generalize to the that represented outliers in the research. GLB population) studied in much of the research reviewed could have been Overgeneralization of Research. Since different than the heterosexual there are large gaps in the literature, Canadian population in ways that could Human Impact overgeneralization is another difficulty account for the increased health and with the present review. For example, social issue rates in GLB. For example, few studies have directly linked the GLB samples studied could have homophobia with increased health and been different in terms of socio- social problems in GLB. The major economic status than the heterosexual assumption of the present literature control samples in many studies. This review is that homophobia is the itself could account for increased health primary cause of increased incidences of problems in GLB. Whether health and social problems in GLB. homophobia is partly or wholly Also, mortality estimates of various responsible for pre-mature deaths of health and social issues were usually GLB is not known at this timeix. meant to be applied to the Canadian population as a whole, and not Even given these real and specifically to the GLB population. potential limitations with the present Generalizations based on limited review, there are several beneficial outcomes. First, even if skeptics do not

accept that homophobia is the principal Respondents Declining to determinant of increased rates of health Participate. Research in which potential and social problems in GLB, the fact that participants declined to respond could these increased health and social have biased the results. That is, low problems are strongly evident in the response rates to surveys could result in literature is an important finding itself. a selection bias, which could result in an Second, this review may be an impetus under or over reporting of the to conduct further research in the area. phenomena under study. Third, efforts aimed at the elimination of homophobia, including better access to Clinical Samples. GLB samples health care and more appropriate and drawn from clinical samples probably sensitive health care services for the do not represent the total GLB GLB population, may be taken as a population. Also, studies using greater priority given its human impact psychiatric histories as a data source on all of Canada. may under-report certain self- destructive behaviours such as suicide

t c a p m I n a m u H Research Reviewed attempts. This is because older Conclusions based on literature individuals may not recall or interpret reviews are only as good as the early self-destructive behaviours as availability of quality research in the suicide attempts during a psychiatric area. Put another way, the information interview focusing on lifetime summarized in this review suffers from symptoms. a

the same limitations of the research reviewed. Instead of discussing the Under-representation of Certain 43 weaknesses of the individual research Groups. Research conducted on white studies that were studied, general males, which constituted a large portion a i b o h p o m o H f o limitations are discussed below for the of the research reviewed, under sake of brevity. In general, the represented ethnic GLB, and white following limitations were observed in lesbians and bisexuals. This under- some or most of the research reviewed: representation could have biased the results. For example, research has

Small Sample Sizes. Research that shown that males and females have collected data from a relatively small different timelines for “coming out” number of GLB subjects reduced the (D’Augelli & Hershberger, 1993) and ability to generalize to broader that there is a greater condemnatory populations and reduced the ability to orientation toward homosexuality in the detect any differences with heterosexual black community compared to the white populations (e.g., Remafedi, 1987). community (Ernst, Francis, Nevels & Also, studies that compared Lemeh, 1991). homosexual and heterosexual samples but did not match participants Cross-sectional Designs. Research according to race, age, income, location that was cross-sectional in design could or education decreased the ability to only examine the association between conclude that unmeasured, systematic homophobia, sexual orientation and differences between the two groups increased rates of health and social were not the reason for the observed issues; however, no definitive differences. conclusions about causality can be made

from cross-sectional designs. Also, cross-sectional data does not allow Response Bias. Research has not information to be gleaned about been able to uncover whether elevated changes over time. levels of health and social problems in GLB are due to stigmatization and Self-report Designs. Data psychosocial stress related to gathered using self-report techniques homophobia, or whether they are due to does not allow the researchers to know differences in response bias in which whether respondents under-reported or there is possibly a lower threshold over-reported the existence or frequency among GLB for reporting such of health and social issues. More problems. specifically, sexual orientation data gathered using self-report instruments Consistency of Definitions. In is problematic. Even when anonymous general, GLB and health and social

techniques are employed, social stigma research lacks consistent conceptual and

probably prevents many respondents operational definitions and Ha from self-identifying as GLB. It is likely standardized measures. This is that self-report techniques under-report especially true for the definition of GLB orientation. sexual orientation (e.g., definitions of homosexuality can be based on Convenience Samples. Samples behaviour, desire or identity).

drawn from convenience and of Homophobia opportunistic (e.g., snow-ball) samples Differences Among Age Groups. and non-randomized samples reduces Different studies focusing on particular

44 the ability to generalize the results. For age groups (e.g., youth between 12 and

a example, some researchers that reported 16) had inconsistent definitions of the elevated rates of alcohol abuse drew age groups (e.g., one study defined their samples from bar-patrons. youth as persons under age 24). An additional problem is that different age Samples from Specific Geographic groups may face varying levels of Areas. Data gathered from specific homophobia, stress, and health and Human Impact geographic areas reduces the social problems. This precludes any generalizability of the results to other strong synthesizing conclusions being geographic areas. One reason for this is made about the results of those studies. because communities vary in their In suicide research, it is unknown acceptance of GLB. whether the risk of suicide peaks at adolescence or remains constant Disclosure of Orientation and through out the life cycle, which makes Health and Social Problems. It is any generalizations from youth suicide unknown whether a willingness to studies to the adult population, or vice- disclose sexual orientation (socially versa, problematic. stigmatizing information) is positively associated with a similar willingness to Cohort Effects. Most studies did disclose health and social problems. If not attempt to account for any cohort this relationship exists, it would tend to effects that may have been operating. over-estimate health and social That is, there may be greater acceptance problems in GLB. of GLB over time, which may encourage

more openness, at earlier ages, about result from the stress of coping with sexual orientation. homophobia? Or do higher rates of alcohol abuse in GLB result from the Social Desirability. Social fact that many GLB feel bars are the desirability could have resulted in only safe place to meet and gather, with participants under-reporting their alcohol abuse being an outcome of the sexual orientation, homophobia, or amount of time spent in bars? In illegal / stigmatized behaviours. addition, increased rates of health Researchers can only make conclusions problems in GLB could be the result of about GLB who have already self- an unmeasured factor, unrelated to identified as GLB in their studies. homophobia, such as childhood abuse. Another example is that internalized Unmeasured, Overlapping and homophobia overlaps with several other Confounding Variables, and Temporal and relevant concepts such as self-esteem Causal Order of Variables. The (Williamson, 2000). Many studies do interpretation of the causal and not account for the possibility that

t c a p m I n a m u H temporal role of psychological and variables overlap with each other. social stress related to homosexuality and health and social issues (e.g., illicit Real Versus Perceived Homophobia. drug use, depression) is unclear due to Negative effects of homophobia could possible confounds. For example, does be primarily caused by inaccurate homophobia cause stress that results in perceptions by GLB, and not as a result a

substance abuse and ultimately suicide? of actual behaviours by others (Frable, Or does substance abuse confound the Wortman & Joseph, 1997). 45 relationship between stress and suicide? Other unanswered questions include: a i b o h p o m o H f o Do higher rates of alcohol abuse in GLB

FURTHER RESEARCH NEEDED

here are numerous indicators smoking, guilt, shame, depression). that the increased incidence of Policy makers are slowly beginning to T health and social problems incorporate research on the impact of found in the GLB population are related stigmatization and prejudice on GLB to the stigma and shame associated with health and mortality (Saunders, 2000), living in a homophobic society (Ryan, but research needs to be conducted on Brotman & Rowe, 2000), yet there is a the motivations of homophobia, the shortage of rigorous research exploring specific cognitive processes associated this problem directly. with homophobia, the specific adverse HIV/AIDS is often the focus of effects of homophobia on GLB, the the health of GLB individualsx; causal direction of these effects, the however, there is a myriad of other differential effects on different

health and social issues affecting the subpopulations of GLB, and which

Ha GLB population that receive far less prevention efforts are effective in attention (Rofes, 2000; Ryan, Brotman & reducing homophobiaxi and its effects Rowe, 2000). Many of these health and on GLB. social issues are related to the effect of homophobia (e.g., alcohol abuse,

of Homophobia

a Human Impact

METHODOLOGICAL IMPROVEMENTS NEEDED

oncomitant with the research • Consider indirect in addition to suggested above, several direct theories in deciding how to C researchers have recommended interpret the data (Stein, 1999). methodological improvements to • Be less reliant on self-report data research in the area of homophobia and (Stein, 1999). GLB health and social issues. Some • Use longitudinal designs that can suggestions include: track changes in health and social • Use statistical probability sampling issues, behaviours, desires and methods (Stein, 1999; Ryan, Brotman identity and the reliability of & Rowe, 2000; Sell & Petrulio, 1996) responses over a period of time or multiple sampling methods and/or across the life span (Stein, (Skinner & Otis, 1996). 1999; Remafedi, French, Story, • Obtain samples from multiple Resnick & Blum, 1998).

recruitment sites if convenience • Use standardized and detailed t c a p m I n a m u H samples are used (Ryan, Brotman & conceptual and operational Rowe, 2000; Sell & Petrulio, 1996). definitions of homosexuality. • Draw subjects from various cultures Operational definitions should be and sub-cultural groups where developed from conceptual sexual desires may be organized definitions (Roberts & Sorensen,

differently (Stein, 1999; Coyle & 1999; Ryan, Brotman & Rowe, 2000; Rafalin, 2000). Sell & Petrulio, 1996). • Include separate analyses of • Use appropriate heterosexual 47 homosexual males, homosexual comparison groups matched on

a i b o h p o m o H f o females, bisexual males and bisexual relevant variables such as income, females since those groups constitute education and location (Roberts & distinct communities. Also, Sorensen, 1999). categorizing sexual-minority • Attempt to uncover more of the individuals into the clear-cut groups hidden population of GLB in order to may be an oversimplification of the find more representative samples a complex and dynamic nature of (e.g., snowball sampling technique) sexuality (Savin-Williams, 2001; (Roberts & Sorensen, 1999). Mallon, 1999; Williams Collins, 1998; • Create contexts in which GLB feel Ault, 1996) comfortable sharing their sexual • Evaluate subjects’ sexual orientations histories and health related through detailed, longitudinal, behaviours (e.g., interviewing sexual histories (Stein, 1999). techniques that build rapport) (Stein, • Take greater care not to allow 1999). cultural assumptions about sexual • Use techniques that involve desires and how they are organized collaboration with community to influence the classification of organizations and establish projects subjects and the interpretation of the that are meaningful to GLB (Skinner results of studies (Stein, 1999). & Otis, 1996). • Employ community members as stewards of personal information for

obtaining large samples (Skinner & • Include questions about sexual Otis, 1996). orientation in large-scale population • Take into account different attributes surveys, since large samples are of suburban, rural and urban GLB needed for meaningful sub- (Bagley & Tremblay, 1997a). population analyses (i.e., GLB sub-

population) (Remafedi, 1999a).

Ha of Homophobia

a Human Impact

ENDNOTES i Several sections, such as the one on x HIV/AIDS and GLB research is extensive, homophobia, are quite similar to the ones in the including, for example, studies on well-being and original report; they were included to maintain quality of life of GLB with HIV/AIDS (Siegel, continuity in the current report. Although most Raveis & Karus, 1994; Ross & Ryan, 1995; Burgess section are similar to the previous report, most et al., 1993; Burgess et al., 2000; Carretero et al., sections contain significant updates and new 1996; Schonnesson, 2002; Bing et al., 2000; research that has become available in the last few Raphael et al., 2001; Cederfjall et al., 2001; Copfer years. et al., 1996; Holmes & Shea, 1998; Igreja et al., 2000; Rabkin et al., 1993a and 1993b), physical ii Ross and Rosser (1996) have developed a scale health implications of HIV/AIDS infection of to measure internalized homophobia. GLB (Keithley et al., 1992; Billings et al., 2000; Antoni et al., 2002; Pakenham & Rinaldis, 2001; iii Remafedi, Farrow and Deisher (1991) found Wagner et al., 2000), risky sexual behaviour among men who have sex with men (Williams, that about one third of the subjects in their study Elwood & Bowen, 2000), disclosure of sexuality reported that their suicide attempts had roots in and relation to HIV/AIDS prevention (Kennamer their personal issues about their homosexual et al., 2000), disclosure of HIV status (Yoshioka & t c a p m I n a m u H identity. Schustack, 2001), religious beliefs among GLB

with variable proximity to AIDS (Bivens et al., iv Statistics Canada (2001d) found that 23% of 1994-95), psychosocial implications of HIV/AIDS Canadians reported smoking daily in 1998-1999. (Rabkin et al., 2000; Kurdek & Siesky, 1990; Evans et al., 1998; Fell et al., 1993; Carstensen & v Exacerbating the situation is evidence that GLB Fredrickson, 1998; Bloom, 1997; Salisbury, 1986; are specifically targeted by tobacco companies a

Kalichman et al., 1997), social support of (Goebel, 1994; Washington, 2002). HIV/AIDS infected GLB (Nott, Vedhara & Power, 1995; Travers & Paoletti, 1999; Waller, vi Although there is some evidence that GLB 2001; Shernoff, 1990; Lichtenstein et al., 2002; 49

have a higher incidence of other mental Bennett, Kelaher & Ross, 1994; Barnes et al., 1993; a i b o h p o m o H f o disorders, such as Generalized Anxiety Disorder Kadushin, 1996), the rift between HIV positive and Conduct Disorder, most evidence has and HIV negative gay men (Botnick, 2000), centered on major depression; therefore, only substance abuse and HIV/AIDS (Shernoff & that specific mental disorder was reviewed in the Springer, 1992), sexual dysfunction (Tindall, present report. Forde, Goldstein, Ross & Cooper, 1994), suicidality of AIDS survivors (Rabkin, Remien, vii Katoff & Williams, 1993b), HIV/AIDS education

Several reviews have found that HIV a prevention interventions for GLB youths are and counseling (Visser & Antoni, 1994), effective at reducing HIV transmission, and are bereavement in gay men whose partners died of cost effective compared to the potential economic AIDS (Folkman, 1997); and HIV/AIDS and and human cost to society of increased sexual abuse of GLB (Batholow et al., 1994). HIV/AIDS cases (Pinkerton, Holtgrave, DiFranceisco, Stevenson & Kelly, 1998; Tao & xi For example, see Serdahely and Ziemba (1985) Remafedi, 1998; Grossman, Arbess, Cavacuiti & or Herek (1991). Urbshott, 2000). viii See Ryan, Brotman and Rowe (2000) for an extensive review of this area. ix Some researchers have argued that it is “gay lifestyle” choice that accounts for increased smoking and alcohol abuse rates.

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APPENDIX: CALCULATIONS FOR HUMAN COST ESTIMATES

Homophobia and Suicide

Basic Statistics (1997) Estimated Number of Suicides (1997) Estimated Annual Costs (1997)

• Only 5% as opposed to 30% of completed suicides should be GLB • Non-GLB suicides constant = 2577 • Completed suicides = 30% GLB • Total suicides if GLB and non-GLB • Total suicides in Canada = 3681 equivalent = 2713 • Non-GLB suicides = 2577 • GLB suicides = 136 (instead of 1104 • GLB suicides = 1104 GLB suicides, there should be 136 so • GLB base rate = 5% difference is 968) • Total population = 29,987,200 • Extra deaths = 968 • Non-GLB population = 28,487,840 • GLB and non-GLB suicides rates • GLB population = 1,499,360 • GLB suicide rate 6 times the non- should be equivalent GLB rate • Non-GLB suicides constant = 2798 • Total suicide rate = 0.00012275 • Total suicides if GLB and non-GLB

t c a p m I n a m u H • Non-GLB suicide rate = 0.00009820 rates equivalent = 2945 • Non-GLB suicides = 2798 • GLB suicides = 147 (instead of 1104 • GLB suicide rate = 0.00058921 GLB suicides, there should be 147, • GLB suicides = 883 so difference is 957) • Extra deaths = 957 • Only 10% as opposed to 30% of completed suicides should be GLB • Non-GLB suicides constant = 2577 • Completed suicides = 30% GLB a

• Total suicides if GLB and non-GLB • Total suicides in Canada = 3681 equivalent = 2863 • Non-GLB suicides = 2577 • GLB suicides = 286 (instead of 1104 • GLB suicides = 1104 GLB suicides, there should be 286 so 67 • GLB base rate = 10% difference is 818) • Total population = 29,987,200 • Extra deaths = 818 a i b o h p o m o H f o • Non-GLB population = 26,988,480 • GLB and non-GLB suicides rates • GLB population = 2,998,720 • GLB suicide rate 6 times the non- should be equivalent GLB rate • Non-GLB suicides constant = 2209 • Total suicide rate = 0.00012275 • Total suicides if GLB and non-GLB • Non-GLB suicide rate = 0.00008183 rates equivalent = 2454 • Non-GLB suicides = 2209 • GLB suicides = 245 (instead of 1104 • GLB suicide rate = 0.00049101 GLB suicides, there should be 245, • so difference is 859) GLB suicides = 1472 a

• Extra deaths = 859

On the surface, it seems that the estimated number of suicides as related to homophobia should be greater when the base rate of homosexuality is higher. However, this is not the case. The reason that the 5% base rate estimates are greater than the 10% base rate estimates has to do with the method of estimating the number of GLB suicides per year and the calculation of how many GLB suicides there should be if GLB and non-GLB suicide rates were equivalent. One estimate of GLB suicide rates stated that 30% of all suicides are GLB. Without homophobia, GLB should account for either 5% or 10% of suicides based on the 5% and 10% base rates of homosexuality estimates. Therefore, when calculating how many GLB suicides there should be, the 5% base rate estimate results in fewer GLB suicides than the 10% base rate estimate (136 for 5% and 245 for 10%). Therefore, the difference between how many GLB suicides there are estimated to be now (1104) compared to how many there should be without homophobia is greater for the 5% base rate estimate than for the 10% base rate (1104 - 136 = 968 for 5% base rate; 1104 - 245 = 859 for 10% with base rate). Put another way, the more GLB people there are, the greater the percentage of suicides they will account for, and so the less “extra” suicides there will be because of homophobia.

Homophobia and Smoking

Basic Statistics (1999) Estimated Smoking Rates (1999) Estimated Annual Costs (1999)

• Smoking rates of GLB should be equivalent to non-GLB • Non-GLB smokers constant = • Total smoking rate = 0.2500 5,613,300 • Total smokers = 6,075,000 • Total smokers if GLB and non-GLB • Non-GLB smoking rate = 0.2431 rates equivalent = 5,908,667 • Non-GLB smokers = 5,613,300 • GLB smokers = 295,367 (instead of • GLB smoking rate = 0.3800 461,700, there should be 295,367, so • GLB base rate = 5% • GLB smokers = 461,700 difference is 166,333) • Total adult Canadian population = • Extra deaths = 1232 (Without the extra 24,300,000 166,333 GLB smokers, the number of • Total non-GLB adult population = annual deaths would be 43,768) 23,085,000 • Smoking rates of GLB should be • Total GLB adult population = equivalent to non-GLB 1,215,000 • GLB smoking rate 1.6 times the non- • Non-GLB smokers constant = • Total smoking related deaths = 45,000 GLB rate 5,602,730

• Total smoking rate = 0.2500 • Total smokers if GLB and non-GLB

• Total smokers = 6,075,000 rates equivalent = 5,898,611 Ha • Non-GLB smoking rate = 0.2427 • GLB smokers = 294,881 (instead of • Non-GLB smokers = 5,602,730 472,270, there should be 294,881, so • GLB smoking rate = 0.3883 difference is 177,389) • GLB smokers = 472,270 • Extra deaths = 1314 (Without the extra 177,389 GLB smokers, the number of annual deaths would be 43,686) • Smoking rates of GLB should be equivalent to non-GLB

of Homophobia • Non-GLB smokers constant = • Total smoking rate = 0.2500 5,151,600 • Total smokers = 6,075,000 • Total smokers if GLB and non-GLB 68 • Non-GLB smoking rate = 0.2356 rates equivalent = 5,724,108 • Non-GLB smokers = 5,151,600 • GLB smokers = 572,508 (instead of

• GLB smoking rate = 0.3800 923,400, there should be 572,508, so a • GLB base rate = 10% • GLB smokers = 923,400 difference is 350,892) • Total adult Canadian population = • Extra deaths = 2599 (Without the extra 24,300,000 350,892 GLB smokers, the number of • Total non-GLB adult population = annual deaths would be 42,401) 21,870,000 • Smoking rates of GLB should be • Total GLB adult population = equivalent to non-GLB 2,430,000 • GLB smoking rate 1.6 times the non- • Non-GLB smokers constant = • Total smoking related deaths = 45,000 GLB rate 5,158,018 Human Impact • Total smoking rate = 0.2500 • Total smokers if GLB and non-GLB • Total smokers = 6,075,000 rates equivalent = 5,731,012 • Non-GLB smoking rate = 0.2358 • GLB smokers = 572,994 (instead of • Non-GLB smokers = 5,158,018 916,982, there should be 572,994, so • GLB smoking rate = 0.3774 difference is 343,988) • GLB smokers = 916,982 • Extra deaths =2548 (Without the extra 343,988 GLB smokers, the number of annual deaths would be 42,452)

Homophobia and Alcohol Abuse

Basic Statistics (2000) Estimated Alcohol Abuse Rates (2000) Estimated Annual Costs (2000)

• Alcohol abuse rates of GLB should be equivalent to non-GLB • Non-GLB alcohol abusers constant = • Total alcohol abuse rate = 0.05 1,032,487 • • Total alcohol abusers = 1,243,960 Total alcohol abusers if GLB and non- GLB rates equivalent = 1,086,848 • Non-GLB alcohol abuse rate = 0.0437 • GLB alcohol abusers = 54,361 (instead • Non-GLB alcohol abusers = 1,032,487 of 211,473, there should be 54,361, so • GLB alcohol abuse rate = 0.1700 difference is 157,112) • GLB alcohol abusers = 211,473 • GLB base rate = 5% • Extra deaths = 875 (Without the extra • Total adult Canadian population = 157,112 GLB alcohol abusers, the 24,879,199 number of annual deaths would be • Total non-GLB adult population = 6055) 23,635,239 • Alcohol abuse rates of GLB should be • Total GLB adult population = equivalent to non-GLB 1,243,960 • • GLB alcohol abuse rate 1.7 times the Non-GLB alcohol abusers constant = • Total alcohol related deaths = 6930 non-GLB rate 1,141,799

t c a p m I n a m u H • Total alcohol abuse rate = 0.05 • Total alcohol abusers if GLB and non- • Total alcohol abusers = 1,243,960 GLB rates equivalent = 1,201,665 • • Non-GLB alcohol abuse rate = 0.0483 GLB alcohol abusers =59,866 (instead of 102,161, there should be 59,866, so • Non-GLB alcohol abusers = 1,141,799 difference is 42,295) • GLB alcohol abuse rate = 0.0821 • Extra deaths = 236 (Without the extra • GLB alcohol abusers = 102,161 42,295 GLB alcohol abusers, the number of annual deaths would be 6694)

• Alcohol abuse rates of GLB should be equivalent to non-GLB • Non-GLB alcohol abusers constant = • Total alcohol abuse rate = 0.05 821,014 69 • • Total alcohol abusers = 1,243,960 Total alcohol abusers if GLB and non- GLB rates equivalent = 913,067 a i b o h p o m o H f o • Non-GLB alcohol abuse rate = 0.0367 • GLB alcohol abusers = 92,053 (instead • Non-GLB alcohol abusers = 821,014 of 422,946, there should be 92,053, so • GLB alcohol abuse rate = 0.1700 difference is 330,893) • GLB alcohol abusers = 422,946 • GLB base rate = 10% • Extra deaths = 1843 (Without the extra • Total adult Canadian population = 330,893 GLB alcohol abusers, the 24,879,199 number of annual deaths would be • Total non-GLB adult population = 5087) 22,391,279 • Alcohol abuse rates of GLB should be

• Total GLB adult population = equivalent to non-GLB 2,487,920 • • GLB alcohol abuse rate 1.7 times the Non-GLB alcohol abusers constant = • Total alcohol related deaths = 6930 non-GLB rate 1,046,321 • • Total alcohol abuse rate = 0.05 Total alcohol abusers if GLB and non- • Total alcohol abusers = 1,243,960 GLB rates equivalent = 1,161,859 • • Non-GLB alcohol abuse rate = 0.0467 GLB alcohol abusers = 115,538 (instead of 197,639 there should be 115,538, so • Non-GLB alcohol abusers = 1,046,321 difference is 82,101) • GLB alcohol abuse rate = 0.0794 • Extra deaths = 457 (Without the extra • GLB alcohol abusers = 197,639 82,101 GLB alcohol abusers, the number of annual deaths would be 6473)

Homophobia and Illicit Drug Use

Basic Statistics (2000) Estimated Alcohol Abuse Rates (2000) Estimated Annual Costs (2000)

• Illicit drug use rates of GLB should be equivalent to non-GLB • GLB illicit drug use rate 2.6 times • • GLB base rate = 5% Non-GLB illicit drug users constant = the non-GLB rate 765,957 • Total adult Canadian population = • Total illicit drug use rate = 0.035 • 24,879,199 Total illicit drug users if GLB and non- • Total illicit drug users = 870,772 GLB rates equivalent = 806,261 • Total non-GLB adult population = • Non-GLB illicit drug use rate = • 23,635,239 GLB illicit drug users = 40,304 (instead 0.0324 of 104,815 there should be 40,304, so • Total GLB adult population = • Non-GLB illicit drug users = 765,957 difference is 64,511) 1,243,960 • GLB illicit drug use rate = 0.0843 • Extra deaths = 64 (Without the extra • Total illicit drug related deaths = 857 • GLB illicit drug users = 104,815 64,511 GLB illicit drug abusers, the number of annual deaths would be 793) • Illicit drug use rates of GLB should be equivalent to non-GLB

• GLB illicit drug use rate 2.6 times • Non-GLB illicit drug users constant = • GLB base rate = 10% the non-GLB rate 675,599 Ha • Total adult Canadian population = • Total illicit drug use rate = 0.035 • 24,879,199 Total illicit drug users if GLB and non- • Total illicit drug users = 870,772 GLB rates equivalent = 750,666 • Total non-GLB adult population = • Non-GLB illicit drug use rate = • 22,391,279 GLB illicit drug users = 75,067 (instead 0.0302 of 195,173 there should be 75,067, so • Total GLB adult population = • Non-GLB illicit drug users = 675,599 difference is 120,106) 2,487,920 • GLB illicit drug use rate = 0.0784 • Extra deaths = 74 (Without the extra • Total illicit drug related deaths = 857 • GLB illicit drug users = 195,173 75,067 GLB illicit drug abusers, the number of annual deaths would be

of Homophobia 783)

a Human Impact