The Social Determinants Of Mental Illness In The LGBT Community

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Introduction

Sexuality differing from the ‘hetero-norm’ has a complicated socio-legal history within the UK, with legal developments key to LGBT acceptance. The first act of equality was the 1967 Sexual Offences Act in which (private) homosexual acts were legalised for those over the age of 21 in England and Wales (Scotland following suit in 1981 and Northern Ireland in 1982). The age of consent in homosexual activity was then reduced to 16 in 2000 and homosexuality was legally made equal to heterosexuality in 2003 (Dryden, 2018). Despite legal equality, there is a well acknowledged prevalence of mental health disorders within the LGBT community, arguably rooted in societal attitudes. These vary from depression, suicidal behaviour and substance abuse. Recent data pooling and meta-analysis has shown such individuals are twice as likely to suffer from mental health illnesses than heterosexual individuals (Semlyen et al., 2016). As such, it appears that despite legal equality, social factors are a key element in governing the mental health of members of the LGBT community. Understanding these causatives will not only progress equality but inform future preventative health measures against mental illness within the LGBT community.

Social Theories of Causality

Homosexuality is historically entangled with mental illness; up to 1973 the influential American Psychiatric Association classed homosexuality as a mental illness and the WHO did so till 1990 (WHO, 2011). Subsequently, until recently many have proposed that the prevalence of various mental health problems within LGBT individuals was a symptom of the overall ‘condition’ of homosexuality, rather than individuals suffering with separate ailments. These attitudes to illness changing demonstrate approaches to illness classification to be a product of social construction and so alter with society (Gergen, 1985).

Separating sexuality from concurrent mental health problems and instead placing emphasis on detrimental social factors was argued by Judd Marmor, a pioneer of homosexual-mental health reform (Hopkins-Tanne, 2004). Marmor stated that in society LGBT individuals are ‘uniformly treated with disparagement or contempt’ and it ‘would be surprising indeed if substantial numbers of them did not suffer’ with mental health problems (Marmor, 1881). Marmor’s argument was a critical development in the understanding of interactions between the social environment and an individual’s health, relating LGBT mental health to the theory of social stress.

Social stress is defined as socio-environmental factors which place pressure on the ordinary adaptive system of an individual (Aneshensel, 1992). Thus, social stress is a product of the environment, social interactions and constructs and the individual’s relative coping ability. Many sociologist and psychologists alike use the Engineering Model to explain the toll of social stress (Scheid and Wright, 2009), in which the stress or force placed on an object will eventually pass its load threshold, causing damage- resulting in poor mental health.

All members of society are exposed to social stress in every day context, however the LGBT community furthers this stress through being a minority community. This status of ‘minority community’ often entails discrimination and stigmatisation from the majority ‘norm’ of the society, thus leading to a higher and chronic presence of stressors in the minorities’ lives (Meyer, 1995). This is coined as minority stress. Examples of LGBT minority stress include; homosexuals who may experience minority stress due to challenging the ‘norms’ of sexuality or transsexual minority stress for challenging both the ‘norms’ of sexuality and gender (i.e. gender as a fixed state).

In his paper, Meyer argues there are three key qualities of minority stress. Namely; determining conditions are external, elevated caution resulting from necessary stress adaptation and result in negative internalisations.

An individual within the LGBT community is often exposed to these social stresses on two levels: proximally (a stressor from the individual themselves) and distally (a stressor which arises from social contexts). These two levels of stress often interact with one another, such as the distal stress of stereotypes and discrimination causing the proximal stress of anxiety and emotional distress- as will be demonstrated in later theories (Fiske, Gilbert and Lindzey, 2010). Both of these minority stresses may be deemed opposite poles of a spectrum by which distal stressors are objective to the society in question such as illegal discrimination. Proximal stressors are extremely subjective and their effect intimately depends of the individual’s character and response to stressors. Conversely whilst distal stressors are objective, it is important to note that they are societally subjective, for example some societies may cause far less distal minority stressors due to an accepting culture or harsher punishments to deter against discrimination.

Social interaction is often seen as a collective way of building ‘the self’. Charles Cooley is an advocate of such a concept. Cooley believed the ‘looking glass self’ was the way in which we perceived ourselves through different members of society; compiling how a mother interacts with their child and how the teacher interacts, allows a ‘reflective’ image to be formed, from which one interprets character and qualities (Cooley, Rieff and Mead, 1902). Logically, it seems that if the ‘looking glass self’ was built upon the discrimination an individual received (i.e. distal stress), then in reaction to this our idea of ‘the self’ will be rife with such negative ideas (such as low self-esteem- a proximal stress) and give rise to mental health problems. Several studies have explored the link between society and the formation of our self-concept. A study of school adolescents found that those who deem themselves high in the ‘social hierarchy’ and thus surrounded by more peers were statistically more likely to suffer with depression and low self-esteem than those of lower social status or no group affiliation (p=

The concept that our social environment builds knowledge of our self is not solely due to Cooley but also the infamous 20th century sociologist Emile Durkheim. In 1897, Durkheim studied suicide in society, arguing suicide to be a result of imbalance between moral dysregulation and social integration (Hilbert, 1986). Durkheim’s theory argued that moral dysregulation (losing control over human nature- a distal stressor) causes a loss of collective identity and shared beliefs. This in-turn prevents social integration of individuals (or minorities) and fulfilling social needs, furthering society from unity, common beliefs and into ‘Normlessness’ where social norms have been eroded. Such a theory seems logical in explaining the causes of mental health problems within the LGBT community, as the differences in sexuality and gender which oppose those reflected by the majority lead to moral dysregulation or in other terms, homophobia and transphobia.

Despite this, there is an understatement in overcoming attitudes of a society causing moral dysregulation, for example despite legal racial equality and decades of progress, 26% of the UK’s population state they are ‘very’ or ‘a little’ prejudiced to other races (Kelley, Khan and Sharrock, 2017).

Societal stigmatisation and its effects on health have always been a call for both medico-social research. Gordon E. Moss’ biosocial theory of mental health and society (much alike Cooley’s notional of societal input) argues that each individual internalises information from both the social and non-social environment (Moss, 1974). If the social environment then provides information which is counter to that which the individual has internalised, somatic processes initialise and initiate a reduction in both mental and physical health. Furthermore, if this information is given by a community and the individual chooses to reject the information supplied, alienation of the individual may occur or additionally, spread of the new information across social networks. Such a model seems a plausible way of explaining both why hatred towards LGBT qualities may cause mental health issues but also explain how the prevalence of illness in the LGBT community is not due to the individual’s act but networks across social communities. Not only is the effect of stress on mental health evident to many clinicians but the biosocial link is clearly supported by medical research supporting the phenomenon (Kiecolt-Glaser et al., 1984), where pre-exam medical students had lower T-cell counts than those with no current exams. Furthermore, the biosocial link between stress and disease is supported further by immune suppression contributing to cancer development (Vissoci Reichea, Vargas Nunes and Kaminami Morimoto, 2004).

Gordon Allport stated that the previously discussed laws of social interaction are laws of which no individual in society is immune to, regardless of their position, and so will certainly have some nature of effect on personality (Dovidio, Glick and Rudman, 2006). In ‘The Nature of Prejudice’ Allport famously stated “One’s reputation, whether false or true, cannot be hammered, hammered, hammered, into one’s head without doing something to one’s character”, perfectly summarising that whether one chooses to accept that which is deemed of them by society or not, society will always impact on the individual and thus fault or cause is not within one’s natural constitution but in society’s attitudes (Allport, 2008).

The LGBT Community and Minority Stressor Exposure

As explored by the various factors in the discussed social theories, minority stressors have a key impact on the mental health of the LGBT community. The LGBT community experiences countless minority stressors which are unique due to the specific homosexual-transsexual niche the LGBT community fills- often spanning beyond these labels in recent years. Therefore, it appears logical to study these unique stressors in order to work towards prevention of their effects.

Perhaps the most common form of minority stress to the LGBT community is prejudice, with 40% of a survey reporting LGBT targeted hatred in 2018 (UK Government, 2018). Prejudice may cause the aforementioned negative actualisation of the self and devalue themselves with no reason to explain why they are not accepted by society other than self-blame (Gartner, 1999). Expanding to socioeconomic theories, discrimination in the workplace may cause the individual to leave their position and take on a career with a lower salary or skill set to which they can provide, thus causing economic difficulties and mental strains- leading towards illness. Stonewall found that 20% of LGBT staff have been targeted by colleagues and 12% lost their job for being homosexual or trans- clearly portraying discrimination in the workplace to have social impacts and limitations on individual job prospects (Stonewall, 2018).

Spanning from discrimination is the proximal stressor of internalised homophobia or transphobia. Here, the discrimination of homo/transsexuality is, in the words of Allport, ‘hammered’ into the LGBT individual’s beliefs, often before realising their own sexuality. Thus, upon realising their LGBT sexual desires, they become conflicted between desire and internalised beliefs and result in self-hatred and often suppression of desires (Gonsiorek, 1982). Mental health impacts commonly related to this social phenomenon include self-harm and suicide (Williamson, 2000. Price and Herek, 1999). Cornish found through LGBT surveying, that an average score of 72.6/148 (148 being 100% homophobic) was found across homosexual males and females (Cornish, 2012). This research supports minority stress and its negative impact on mental health through Cooley’s model and highly accurate account of Durkheim’s model of incongruence between environmental knowledge and that from the self.

Conclusion

From Durkheim to Cooley, one common theme in poor mental health seems clear; the role of discrimination and alienation in altering the ‘self’. Whilst this model of social disturbance is likely to be far more complex and comprise many factors, community affiliation and acceptance appear key to lowering the detrimental health outcomes. Although responsibility of this lies with all, it is the duty of higher authorities to intervene in reducing hate crimes and provide LGBT role models for positive identification in order to move towards tackling the issues on mental health in the LGBT community.

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The Social Determinants Of Mental Illness In The LGBT Community

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