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There is limited understanding of which dimensions of sexual orientation are most meaningfully related to suicidal behavior. One recent adolescent study that incorporated multiple measures of sexual orientation found suicidal behavior to be significantly higher in youth who identified as gay, lesbian or bisexual, compared to those who identified as heterosexual (Zhao, Montoro, Igartua, & Thombs, 2010). Those who indicated same-sex attraction or behavior but identified as heterosexual, however, did not report a higher rate of suicide attempt than heterosexual youth without same-sex behavior or attraction. Data from a large national survey of U.S. adults that included multiple questions related to sexual orientation (Bostwick, Boyd, Hughes, & McCabe, 2010) showed that rates of mood and anxiety disorders, key risk factors for suicidal behavior, were more strongly linked to gay, lesbian or bisexual identity than to sexual behavior or attraction, particularly in women.

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Sexual orientation varies among transgender individuals, just as it does among people who perceive their gender identity to be aligned with their biological sex. Although precise numbers are lacking, one survey of 515 self-identified transgender persons found that 31% of male-to-female respondents and 65% of female-to-male respondents identified as gay, lesbian, or bisexual (Clements-Nolle, Marx, Guzman, & Katz, 2001).

A recent meta-analysis of 25 international population-based studies that measured suicidal behavior in LGB adolescents and/or adults (variously defined) concluded that the lifetime prevalence of suicide attempt in gay/bisexual males was about four times that of comparable heterosexual males (King et al., 2008). Based on the relatively small number of studies in this meta-analysis that included substantial numbers of women, lesbian/bisexual women were found to have lifetime suicide attempt rates almost twice those of heterosexual women. Overall, LGB adolescents and adults were also more than twice as likely as comparable heterosexual persons to report a suicide attempt in the past 12 months.

Studies have generally found lifetime suicide attempt rates to be higher in gay/bisexual men than in lesbian/bisexual women (King et al., 2008). This represents a clear departure from the population overall, in which women are three times more likely than men to make a lifetime suicide attempt (Kessler, Borges, & Walters, 1999). The Danish registry data (Mathy, Cochran, et al., 2009), which showed an increased risk of completed suicide among same-sex-partnered men but not same-sex-partnered women, suggests that LGB suicide deaths may occur disproportionately among men, similar to the gender pattern found in the general population.

Elevated rates of mental disorders, including substance use disorders, have also been reported in one-quarter to one-third of LGB adult respondents in large-scale health surveys that have defined sexual orientation based on self-identity (Bostwick et al., 2010; Cochran, Mays, & Sullivan, 2003; Cochran, Mays, Alegria, et al., 2007; Conron, Mimiaga, & Landers, 2010; Hughes, Szalacha, & McNair, 2010; Jorm, Korten, Rodgers, Jacomb, & Christensen, 2002; McCabe, Hughes, Bostwick, West, & Boyd, 2009) or gender of sexual partners (Cochran, Ackerman, Mays & Ross, 2004; Gilman et al., 2001). Combining results from 25 international adolescent and adult studies, researchers found depression, anxiety disorders, and substance use disorders to be 1.5 times more common in LGB people than in comparable heterosexual individuals (King et al., 2008). Although findings for most disorders were similar for males and females, lesbian/bisexual women had especially high rates of substance dependence, more than three times the rate for heterosexual women. The findings of higher rates of depression and panic disorder in gay/bisexual men, and higher rates of substance use disorders in lesbian/bisexual women point to different gender patterns among LGB people, compared to the population as a whole.

A recent analysis of these data (Bostwick et al., 2010) confirmed a higher prevalence of lifetime mood and anxiety disorders among participants who identified as LGB, compared to those who identified as heterosexual. Men who reported same-sex sexual behavior or attraction reported a higher prevalence of most mood and anxiety disorders. Among women, however, those who reported only female sexual partners had a lower prevalence of every disorder examined compared to women who reported only male or both male and female sexual partners, or who were not sexually active. Similarly, women who reported sexual attraction to only females had the lowest rates of most mood and anxiety disorders compared with other attraction-defined groups (only male, mostly male, both male and female, and mostly female). Confirming findings of an earlier large-scale Australian survey (Jorm et al., 2002), this analysis found that bisexual behavior and identity were strongly associated with elevated risk of mood and anxiety disorders in both men and women. Similar to men who identified as gay or bisexual, men who reported being unsure about their sexual identity were significantly more likely to have mood or anxiety disorders than heterosexual men. In women with unsure sexual identity, however, rates of these disorders were generally not significantly higher than among heterosexual women. The findings of this study point to the complexity of defining sexual orientation, especially in women, and illuminate differences among female subgroups that past surveys have subsumed within a single female category.

Prohibiting same-sex marriage has also been found to result in significant disparities in health insurance coverage between heterosexual and same-sex couples (Buchmueller & Carpenter, 2010; Carpenter & Gates, 2008; Heck, Sell, & Gorin, 2006; Ponce, Cochran, Pizer, & Mays, 2010). One recent study in California found that partnered lesbians and gay males were more than twice as likely to be uninsured as married heterosexuals, primarily because of lower rates of employer-provided coverage of dependent partners (Ponce et al., 2010). Using data from the California Health Interview Survey in 2001, 2003, and 2005, the study found that partnered gay men were less than half (42%) as likely to have dependent health insurance coverage as married heterosexual men, and partnered lesbians were only 28% as likely to have coverage as married heterosexual women. Even when insurance coverage is offered to domestic partners, this study noted that the benefit is not financially equivalent to that provided to heterosexual married spouses because federal law requires unmarried partners to pay income tax on the value of employer-sponsored health insurance. Because of the Defense of Marriage Act (DOMA), same-sex couples who have been legally married in a U.S. state or other jurisdiction are treated as unmarried for this and all other federal tax provisions.

Associated factors identified in these surveys include high rates of depression, anxiety and substance abuse (Clements-Nolle, Noelle, Guzman, et al., 2001; Mathy, 2002b; Xavier et al., 2007). Transgender youth have reported parental rejection to be a particular stressor (Grossman & D'Augelli, 2008), and frequent experiences of discrimination have been reported by transgender adults (Clements-Nolle, Marx, & Katz, 2006). Preliminary findings from a 2009 U.S. National Transgender Discrimination Survey (National Center for Transgender Equality & the National Gay and Lesbian Task Force, 2009), which included almost 6,500 transgender and gender-variant people identified through a network of 800 trans-related service and advocacy organizations, support groups, list-servs and online social networks, showed that 47% reported an adverse job action because of transgender status. This included not getting a job (44%), being denied a promotion (23%), or being fired (26%); Black and multiracial respondents were especially likely to report these events. Overall, respondents reported being unemployed at twice the rate of the population as a whole, and only 40% reported having employer-based insurance coverage, which directly impacts access to health and mental health care. Almost all (97%) reported having experienced mistreatment or harassment on the job, including invasion of privacy, verbal abuse and being purposefully referred to as the wrong gender.

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