In this article the author reviews research evidence on the prevalence of mental disorders in lesbians, gay men, and bisexuals (LGBs) and shows, using meta-analyses, that LGBs have a higher prevalence of mental disorders than heterosexuals. The author offers a conceptual framework for understanding this excess in prevalence of disorder in terms of minority stress— explaining that stigma, prejudice, and discrimination create a hostile and stressful social environment that causes mental health problems. The model describes stress processes, including the experience of prejudice events, expectations of rejection, hiding and concealing, internalized homophobia, and ameliorative coping processes. This conceptual framework is the basis for the review of research evidence, suggestions for future research directions, and exploration of public policy implications. The study of mental health of lesbian, gay, and bisexual (LGB) populations has been complicated by the debate on the classification of homosexuality as a mental disorder during the 1960s and early 1970s. That debate posited a gay-affirmative perspective, which sought to declassify homosexuality, against a conservative perspective, which sought to retain the classification of homosexuality as a mental disorder (Bayer, 1981). Although the debate on classification ended in 1973 with the removal of homosexuality from the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 1973), its heritage has lasted. This heritage has tainted discussion on mental health of lesbians and gay men by associating— even equating— claims that LGB people have higher prevalences of mental disorders than heterosexual people with the historical antigay stance and the stigmatization of LGB persons (Bailey, 1999). However, a fresh look at the issues should make it clear that whether LGB populations have higher prevalences of mental disorders is unrelated to the classification of homosexuality as a mental disorder. A retrospective analysis would suggest that the attempt to find a scientific answer in that debate rested on flawed logic. The debated scientific question was, Is homosexuality a mental disorder? The operationalized research question that pervaded the debate was, Do homosexuals have high prevalences of mental disorders? But the research did not accurately operationalize the scientific question. The question of whether homosexuality should be considered a mental disorder is a question about classification. It can be answered by debating which behaviors, cognitions, or emotions should be considered indicators of a mental

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Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence

The factor structure, reliability, and validity of the Depression Anxiety Stress Scales (DASS; S. H. Lovibond & P. F. Lovibond, 1995) and the 21-item short form of these measures (DASS-21) were examined in nonclinical volunteers (n = 49) and patients with Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) diagnoses of panic disorder (n = 67), obsessive-compulsive disorder (n = 54), social phobia (n = 74), specific phobia (n = 17), and major depressive disorder (n = 46). This study replicates previous findings indicating that the DASS distinguishes well between features of depression, physical arousal, and psychological tension and agitation and extends these observations to the DASS-21. In addition, the internal consistency and concurrent validity of the DASS and DASS-21 were in the acceptable to excellent ranges. Mean scores for the various groups were similar to those in previous research, and in the expected direction. The implications of these findings are discussed.

Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample.

For the past decade, an increasing number of studies have demonstrated that when individuals write about emotional experiences, significant physical and mental health improvements follow The basic paradigm and findings are summarized along with some boundary conditions Although a reduction in inhibition may contribute to the disclosure phenomenon changes in basic cognitive and linguistic processes during writing predict better health Implications for theory and treatment are discussed

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Writing About Emotional Experiences as a Therapeutic Process

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The Development and Psychometric Properties of LIWC2015

Writing about important personal experiences in an emotional way for as little as 15 minutes over the course of three days brings about improvements in mental and physical health. This finding has been replicated across age, gender, culture, social class, and personality type. Using a text-analysis computer program, it was discovered that those who benefit maximally from writing tend to use a high number of positive-emotion words, a moderate amount of negative-emotion words, and increase their use of cognitive words over the days of writing. These findings suggest that the formation of a narrative is critical and is an indicator of good mental and physical health. Ongoing studies suggest that writing serves the function of organizing complex emotional experiences. Implications for these findings for psychotherapy are briefly discussed. © 1999 John Wiley & Sons, Inc. J Clin Psychol 55: 1243–1254, 1999.

Forming a story: The health benefits of narrative

More Americans try to change their health behaviors through self-help than through all other forms of professionally designed programs. Mutual support groups, involving little or no cost to participants, have a powerful effect on mental and physical health, yet little is known about patterns of support group participation in health care. What kinds of illness experiences prompt patients to seek each other's company? In an effort to observe social comparison processes with real-world relevance, support group participation was measured for 20 disease categories in 4 metropolitan areas (New York, Chicago, Los Angeles, and Dallas) and on 2 on-line forums. Support seeking was highest for diseases viewed as stigmatizing (e.g., AIDS, alcoholism, breast and prostate cancer) and was lowest for less embarrassing but equally devastating disorders, such as heart disease. The authors discuss implications for social comparison theory and its applications in health care.

Who talks? The social psychology of illness support groups.

This study investigated whether emotional expression of traumatic experiences influenced the immune response to a hepatitis B vaccination program. Forty medical students who tested negative for hepatitis B antibodies were randomly assigned to write about personal traumatic events or control topics during 4 consecutive daily sessions. The day after completion of the writing, participants were given their first hepatitis B vaccination, with booster injections at 1 and 4 months after the writing. Blood was collected before each vaccination and at a 6-month follow-up. Compared with the control group, participants in the emotional expression group showed significantly higher antibody levels against hepatitis B at the 4 and 6-month follow-up periods. Other immune changes evident immediately after writing were significantly lower numbers of circulating T helper lymphocytes and basophils in the treatment group. The finding that a writing intervention influences immune response provides further support for a link between emotional disclosure and health.

Disclosure of trauma and immune response to a hepatitis B vaccination program.

Inhibition or disclosure of traumatic or stressful experiences may affect psychological and physical well-being. Although a diagnosis of cancer can be a source of considerable stress, the extent to which cancer patients disclose their cancer has not been previously documented. In the present study, 299 women with breast cancer reported how much and with whom they discussed their cancer in the month following their diagnosis, reported disclosure attitudes, and completed psychological measures. Seven percent reported little or no disclosure to anyone besides their spouse or doctor, while 20-30% reported little or no disclosure to entire subgroups of their social network (family, friends, and health professionals). Degree of disclosure was consistent across social targets. Greater disease disclosure was predicted by younger participant age, greater disease severity, optimism, stress-related growth, and disclosure-oriented attitudes.

Kathryn P. Davison

Papers

Who talks? The social psychology of illness support groups.

Disclosure of trauma and immune response to a hepatitis B vaccination program.

Disease disclosure patterns among breast cancer patients.

Repression, disclosure, and immune function: Recent findings and methodological issues.

Emotions, thoughts and healing: After Dafter.