January 2020 Mental Health Facts on Bisexual Populations

Bisexuality is defined as: “The capacity for (e.g., mental health, substance use, and sexual emotional, romantic, and/or physical attraction to health problems) compared with monosexual more than one sex or gender” noting, “that capacity (heterosexual and gay/lesbian) individuals. Though for attraction may or may not manifest itself in there are several reasons for these disparities, a terms of sexual interaction.”1 significant contributor is a stress that is related to stigma and discrimination.1 Research shows that bisexual individuals are at increased risk of adverse health outcomes

Bisexual Behaviors and Identity • The largest self-identified group within the LGBTQ and opposite-sex partners (bisexual behavior) in a community is bisexual (B) individuals. In contrast, lifetime.3 (Note that behavior and identity often do the proportion of research on LGBTQ mental not correlate identically)3 health focusing on bisexual people is small. 2 • People who report bisexual attractions or • Research studies estimate that 3.9% of the US behavior may self-identify as bisexual, but may adult population self-identify as bisexual (5.5% of also use alternative labels (e.g., queer, pansexual) female, 2.0% of male);3 and 6.0% of US high school or identify as lesbian, gay, or heterosexuals.1 students from 9th to 12th grade self-identify as • There are several variations within the subgroup bisexual (9.8% female, 2.4% male).4 of bisexuals in terms of both sexual attraction and • Although 5.5% of women and 2.0% of men identify sexual behavior with same-sex and opposite-sex as bisexual, research shows that 17.4% of women partners. (Figure 1) and 6.2% of men report having had both same-sex

Kinsey Scale of Sexual Behavior 0 1 2 3 4 5 6

Heterosexual Mainly Mainly Equal amount Mainly Mainly Homosexual relationships heterosexual: heterosexual: of hetero- and homosexual: homosexual: relationships only rarely has sometimes has homo- sexual sometimes has rarely has only homosexual homosexual relationships heterosexual heterosexual relationships relationships relationships relationships

Figure 1: The Kinsey Scale is used in research to describe a person's sexual orientation based on one’s desires or experiences at a given time. The scale ranges from 0 to 6, with "0" representing people who exclusively desire sexual experiences with the opposite-sex and "6" representing those who exclusively desire sexual experiences with the same sex. Those whose sexual desires range from 1 to 5 are considered to have varying levels of desire or experiences with both sexes, including "incidental" or "occasional" desire for sexual activity with the same sex. The scale does not reference whether they "identified" as heterosexual, bisexual, or homosexual.

2020 | psychiatry.org 1 Stressors associated with Bisexuality Stigma and Discrimination which someone integrates their identity and finds a community that will positively impact their • Bisexuals can experience homophobia or mental health. biphobia—a dislike of or prejudice against bisexual people – similarly to discrimination experienced by • Bisexual individuals ‘regularly’ experience hostility their lesbian and gay peers.5 from members of the LGBTQ community. These experiences are described as bi-negativity - • Bisexuals also experience monosexism—the belief antagonism of bisexual individuals by heterosexual, 5 that people are only heterosexual, lesbian, or gay. gay, lesbian, or transgender individuals - which • Stigma and discrimination can result in social often makes it difficult for bisexual individuals to isolation of bisexuals from both heterosexual and find a safe and supportive community. (Feinstein). lesbian and gay communities, called bi-erasure— As a result of such hostile and negative attitudes, the dismissal of the existence of bisexuality.5 significant numbers of bisexual individuals experience microaggressions.1 Minority Stress Theory: • Research shows that bisexual individuals are • The minority stress model6 developed by Ilan more likely to hide their identity compared with H. Meyer in 1995 creates a cohesive model to gay men and lesbians which leads to stress and understand how gender, sexual orientation, race anxiety.1 and environmental stressors conspire to affect the mental health of the LGBTQ community. An essential aspect of the model is the degree to

H. Coping and Social Support (community and individual)

A. Circumstances in C. General Stressors the Environment

I. Mental Health D. Minority Stress Processes Outcomes (distal) • Negative B. Minority Status: • Prejudice events • Positive • Sexual (discrimination, violence) Orientation • Race/ethnicity • Gender

F. Minority Stress Processes (proximal) G. Characteristics of Minority Identity • Expectations of rejection • Concealment E. Minority Identity (gay, • Prominence • Internalized homophobia lesbian, bisexual) • Valence • Integration

2020 | psychiatry.org 2 Lifetime Rates of Mood/Anxiety Disorders in Women Lifetime Rates of Mood/Anxiety 60 Disorders in WomenMood Disorders 58.7% 57.8%

e AnxietyDisorders Health Disparities Among 50

anc Lifetime Rates of Mood/Anxiety Bisexual Individuals 60 44.4% Mood Disorders cur Disorders in Women 40 58.7% 57.8% 40.8%

e AnxietyDisorders Mental Health 50 anc 30 30.3% 31.3% 60 44.4% Mood Disorders cur 40 58.7% 57.8% 40.8% • Bisexual people are underrepresented in e 20 AnxietyDisorders 50 research on mental health, although bisexuals are entage of Oc anc 30 31.3%

rc 30.3% considered the largest segment of the LGBTQ 10 44.4% cur

Pe 40 2 20 40.8% community. 0 entage of Oc 30 Bisexual- Lesbian Heterose31.3%xual rc 30.3% • Among research that is available on bisexual 10 identified Women populations, data shows that bisexual individuals Pe 20 Women 0 in comparison with heterosexual, gay or lesbian entage of Oc Bisexual- Lesbian Heterosexual rc 10 identified Women

individuals report increased experience of Pe Women depression and suicide.7, 8 0 Bisexual- Lesbian Heterosexual • Lifetime rates of mood/anxiety disorders are identified Women Women higher among bisexual-identified women (58.7% Lifetime Rates of Mood/Anxiety for mood disorders, 57.8% for anxiety disorders) Disorders in Men compared with lesbians (44.4% for mood disorders, 40.8% for anxiety disorders) and Lifetime Rates of Mood/Anxiety heterosexual women (30.5% for mood disorders, 50 Disorders in MenMood Disorders 31.3% for anxiety disorders).1 e AnxietyDisorders 42.3% anc Lifetime40 Rates of Mood/41.2% Anxiety 38.7% • Lifetime rates of mood/anxiety disorders are also 50 36.9% Mood Disorders cur Disorders in Men

e AnxietyDisorders higher among bisexual-identified men (36.9% 30 42.3% for mood disorders, 38.7% for anxiety disorders) anc 40 41.2% 38.7% 50 36.9% Mood Disorders cur 20 compared with heterosexual men (19.8% for 19.8% e AnxietyDisor18.6%ders mood disorders, 18.6% for anxiety disorders), but 30 entage of Oc 42.3% anc 4010 41.2% rates were similar to gay men (42.3% for mood rc 38.7% 36.9% cur 20 1 Pe disorders, 41.2% for anxiety disorders). 19.8% 18.6% 300 entage of Oc Bisexual- Gay Men Heterosexual

• Risk of suicide in bisexual populations is higher rc 10 identified Men

Pe 20 than that of heterosexuals, gay, and lesbian Men 19.8% 18.6% 5 0

individuals. entage of Oc 10 Bisexual- Gay Men Heterosexual rc identified Men • Bisexual males are more likely than heterosexual Pe Men males to have experienced physical abuse and or 0 9 Bisexual- Gay Men Heterosexual non-consensual sex in their childhood. They have identified Men 143-204% the odds of being threatened or injured Men with a weapon compared with heterosexual Risk of Suicide males. They are also 24-57% more likely to suffer these forms of bullying compared to exclusively 9 Risk of Suicide homosexual males. 50 Men

e Women • Bisexual women similarly report worse 45.4% mental health and suicidality than lesbians anc 40 Risk of Suicide 50 Men cur 34.8%

and heterosexual women. In comparison with e Women 30 45.4% heterosexual and lesbian women, bisexual women 29.5% anc 40 25.2% are more likely to report feeling overwhelmingly 50 Men cur 20 34.8%

10 e Women anxiety, exhaustion, and hopelessness. 30 45.4% 29.5% entage of Oc Furthermore, they are almost 21 times more anc 40

rc 10 9.6% 25.2%

cur 20 7.4% likely to have considered prior-year suicide in Pe 34.8% 30 comparison with heterosexual women.11 Bisexual 0 29.5% entage of Oc Heterosexual Homosexual/ Bisexual

rc 10 women are more than twice as likely to have had 9.6% 25.2% 7.4% Lesbian

Pe 20 an eating disorder compared with lesbians.12 0 entage of Oc Heterosexual Homosexual/ Bisexual

rc 10 9.6% 7.4% Lesbian Pe 0 2020 | psychiatry.org Heterosexual Homosexual/ Bisexual 3 Lesbian Substance Use: consumption, marijuana use, and other drugs compared to lesbians and heterosexual women.1 • Data on sexual orientation disparities in substance use shows that bisexual individuals are generally • The same study reported that the rates of alcohol at increased risk for substance use/disorders dependence and other drug use/dependence compared to monosexual individuals.1 were higher among bisexual-identified men compared with heterosexual men. Although • The prevalence of problem drinking patterns is rates were similar for bisexual-identified men 31.2% and 30.5% of illicit substance use among compared with gay-identified, rates were higher 5 bisexual individuals. for behaviorally bisexual men compared with • In a 2016 study, bisexual-identified women were behaviorally gay men.1 found more vulnerable to heavy drinking, alcohol

Substance Use Rates in Women Substance Use Rates in Men

Bisexual identified women Bisexual identified men Lesbian Gay men Heterosexual women Heterosexual men 25 25% 20 19.5% e e 22.2% 17.7% 16.8%16.8% 16.8%

anc 20 20.1% anc 15 cur cur 16.7% 15 16% 14.1% 13.3% 12.6% 10 10

entage of Oc 8.4% entage of Oc

rc rc 5 5.1% 5 4.5% Pe Pe 3.2% 3.1% 2.5% 2.6% 0 0 0.5% Heavy Alcohol Marijuana Other Drug Alcohol Other Drug Other Drug Drinking Dependence Use Use Dependence Use Dependence

Bisexuality and Treatment Planning • Bisexual individuals may seek mental health • When providing mental health services to bisexual services for concerns about their sexual individuals it’s important to: orientation less frequently than their gay and o Avoid expressing judgment, dismissing or lesbian peers; and may rate these services as less pathologizing bisexuality. helpful than their peers.13 o Offer positive practices that may include the • Bisexual people experience minority stress use of open-ended questions and expressing and social isolation as a result of their sexual positive or neutral reactions to disclosure. identities being marginalized, which should be acknowledged in treatment.14 o Abstain from using negative practices such as asking intrusive or excessive questions.

This resource was prepared by the APA Division of Diversity and Health Equity. It was authored by Sarah Noble, MD. and reviewed by Eric Yarbrough, MD, Daena Petersen, MD, and Sejal Patel, MPH.

2020 | psychiatry.org 4 Bibliography

1. Feinstein, B. A., & Dyar, C. (2017). Bisexuality, minority stress, and health. Current sexual health reports, 9(1), 42–49. DOI:10.1007/s11930-017-0096-3 2. Swan DJ, Habibi S. “Bisexuality: Theories, research, and recommendations for the invisible sexuality.” Cham: Springer; 2018. https://ebookcentral. proquest.com/lib/[SITE_ID]/detail.action?docID=5357988. 10.1007/978-3-319-71535-3. 3. Copen, Casey, et al. “Sexual Behavior, Sexual Attraction, and Sexual Orientation Among Adults 18-44 in the United States.” National health statistics reports DHHS publication. 88 (2016) 4. Kann L, Olsen EO, McManus T, et al. “Sexual Identity, Sex of Sexual Contacts, and Health-Related Behaviors Among Students in Grades 9–12.” 5. Lori E Ross, Greta R Bauer, Melissa A MacLeod, Margaret Robinson, Jenna MacKay, Cheryl Dobinson.” Mental health and substance use among bisexual youth and non-youth in Ontario, Canada.” PLoS One. 2014;9(8):e101604. 6. Ilan H. Meyer. “Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence.” Psychol Bull. 2003 Sep; 129(5): 674–697. 7. Pakula B, Shoveller J, Ratner PA, Carpiano R. “Prevalence and co-occurrence of heavy drinking and anxiety and mood disorders among gay, lesbian, bisexual, and heterosexual Canadians.” American journal of public health. 2016;106(6):1042-1048. 8. Bauer GR, Flanders C, MacLeod MA, Ross LE. “Occurrence of multiple mental health or substance use outcomes among bisexuals: A respondent-driven sampling study.” BMC Public Health. 2016;16(1):1-11 9. Friedman MS, Marshal MP, Guadamuz TE, et al. “A meta-analysis of disparities in childhood sexual abuse, parental physical abuse, and peer victimization among sexual minority and sexual nonminority individuals.” American journal of public health. 2011;101(8):1481-1494 10. Kerr DL, Santurri L, Peters P. “A comparison of lesbian, bisexual, and heterosexual college undergraduate women on selected mental health issues.” Journal of American college health: J of ACH. 2013;61(4):185-194 11. Conron KJ, Mimiaga MJ, Landers SJ. “A population-based study of sexual orientation identity and gender differences in adult health. “American journal of public health. 2010;100(10):1953-1960. 12. Audrey S. Koh & Leslie K Ross. “A Comparison of Lesbian, Bisexual and Heterosexual Women” Journal of Homosexuality 51, no. 1 (Sept 2006): pp 33-57. 13. Page EH. “Mental health services experiences of bisexual women and bisexual men.” Journal of Bisexuality. 2004;4(1-2):137-160 14. Eady A, Dobinson C, Ross LE. “Bisexual people's experiences with mental health services: A qualitative investigation.” Community Mental Health Journal. 2011;47(4):378-389.

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