Research
Volume 48, Issue 3, March 2019

Bisexual mental health: Findings from the ‘Who I Am’ study

Julia Taylor    Jennifer Power    Elizabeth Smith    Mark Rathbone   
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Background
Despite consistent evidence that bisexual people have poorer mental health than heterosexual people, gay men or lesbians, the reasons for this remain largely unknown. The ‘Who I Am’ study aims to address this current knowledge gap.
Methods
A cross-sectional survey was completed by 2651 adults living in Australia who had bisexual attraction, identity and/or experience. Ordinal regression identified significant (P <0.05) predictors of poor mental health.
Results
Higher levels of internalised biphobia, being in a heterosexual relationship and having a less supportive partner significantly (P <0.05) predicted higher psychological distress in this sample.
Discussion
While there has been an increased focus on lesbian and gay health in recent years, general practitioners may be less familiar with the specific health needs of bisexual people. This is the largest study of bisexual Australians to date and provides detailed information about the relationships between bisexual life experiences and poor mental health.
 

Bisexual people have consistently been found to have poorer mental health than their gay, lesbian or heterosexual counterparts.1–7 They are significantly more likely than those of other sexual orientations to be diagnosed with a mental health disorder,1 have symptoms of depression and anxiety,2 harm themselves3,4 and report suicidal ideation.5–7 Despite more than one in 10 Australians over the age of 16 years reporting attraction to more than one gender,8 the reasons behind poor mental health in bisexual people remain largely unknown.4,9

Bisexuality is associated with unique life experiences that may present as challenges for bisexual people. Biphobia refers to bisexual people’s experiences of poor treatment and discrimination based on their sexuality and can emanate from both the heterosexual and the lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI) communities,10,11 or can emerge internally from a lack of self-acceptance.12,13 Invisibility and erasure are commonly experienced by bisexual people, with their sexuality often invisible because of assumptions that they are either heterosexual or homosexual based on the presumed gender of their partner9,13 and the common belief that bisexuality does not exist, leading to an active erasure of their identity by others.14 Furthermore, literature describes the experience of bisexuals disclosing their sexuality to others, reporting that bisexuals tend to be less ‘out’ regarding their sexuality than their gay or lesbian counterparts,2,11,14 are faced with the unique decision of whether or not to be ‘out’ to intimate partners,10 and often feel they need to repeatedly come ‘out’ in order to maintain a state of disclosure as the perceived gender of their partner does not implicitly infer their orientation.13 Additionally, community and belonging can present significant challenges for bisexual people, who frequently report belonging in neither heterosexual nor gay and lesbian communities,15 while access to bisexual-specific communities is severely limited.13 Finally, maintaining a bisexual identity within a relationship,13 finding a supportive partner11 and negotiating monogamy or non-monogamy in the context of commonly held stereotypes instantiating bisexuals as promiscuous and unable to commit10,11 make navigating intimate relationships complex for bisexual people.11,13

Given the uniqueness of these life experiences, it cannot be assumed that what is known about the mental health of lesbian, gay or heterosexual people adequately explains factors affecting bisexual mental health.16 These life experiences have the potential to detrimentally affect mental health. Despite this, potential relationships between these experiences and mental health have not hitherto been comprehensively explored.

This paper presents findings from the recent ‘Who I Am’ study. This study aimed to address the significant knowledge gap relating to bisexual mental health by improving understanding of the relationship between the social experiences of bisexual people and their mental health by identifying factors that predict poorer mental health in this population.

Methods

‘Who I Am’ was a cross-sectional survey of Australian adults conducted between September 2016 and March 2017. Using Yoshino’s17 inclusive definition of bisexuality, this study was open to people who identified as bisexual and/or those who had attraction to more than one gender and/or those who had sexual experience with more than one gender. Convenience sampling was the necessary sampling method for this study because of the characteristically dispersed and hidden nature of the target population. A range of advertising material with consistent ‘Who I Am’ branding was distributed via relevant online platforms, including social media sites, online news publications and email networks. Additionally, printed advertising material was distributed to sexual health centres and universities across the country. Wording on the advertisements varied, with some including the word ‘bisexual’ and others simply calling for people ‘attracted to more than one gender’.

The main outcome measure used in this study was the Kessler Psychological Distress Scale (K10).18 The K10 is widely used in Australian population health research, including national surveys administered by the Australian Bureau of Statistics (ABS).19 K10 scores range from 10 to 50. For this analysis, K10 scores were grouped into categories with parameters taken from the ABS: low distress (10–15), moderate (16–21), high (22–29) and very high (30–50).19

The survey instrument included standard demographic questions relating to age, sex at birth, gender identity, sexual identity, local area description, income and educational attainment. In addition, respondents were asked to report on their past and present mental health. Survey questions related to bisexual life experiences were devised by the researchers in consultation with key mental health, LGBTQI and bisexual-specific organisations and were further refined following piloting of the instrument with a small sample of potential respondents.

Data were analysed using IBM SPSS Version 25 software. As a result of gender diversity presenting an added layer of complexity when examining mental health,20 the analyses for this paper were conducted on a subset of data containing only cases where gender had been selected as either man or woman and ‘sex at birth’ was identified as being in congruence with this (cisgender). Analyses included basic frequencies, partial Spearman’s rank order correlations, linear-by-linear association chi-square tests and ordinal logistic regression. Independent variables were included in the regression model if they were found to have a significant relationship (set at P <0.05) with K10 categories from the previous Spearman’s rho and chi-square tests. Twelve variables met this criterion. In addition, the question ‘Do people ever assume you are gay or lesbian?’ was included as its relationship with K10 categories was close to significant.

Ethics approval was granted by La Trobe University’s Human Ethics Committee (approval number: HEC16-067) and the ACON (formerly the AIDS Council of New South Wales) Research Ethics Review Committee.

Results

The survey was completed by 2651 Australian adults who identified as bisexual or who had sexual attraction to, or experiences with, more than one gender. The total number of cisgender respondents was 2010. The majority of these respondents were female (80%). The sample included respondents from all Australian states and territories. Almost 80% lived in inner-metropolitan or outer-metropolitan areas. Ages ranged from 18 to 77 years, with a mean of 29 years. Slightly fewer than 90% of respondents were aged less than 45 years (Table 1). The majority of respondents were in a relationship (60%, n = 1033) with 69.6% (n = 991) reporting their current or most recent relationship was heterosexual.

Table 1. Sample characteristics
Characteristic n Frequency Percentage (%)
Gender 2,010
Male 410 20.4
Female 1,600 79.6
Age group (in years) 2,010
18–24 915 45.5
25–44 889 44.2
≥45 206 10.2
Aboriginal and/or Torres Strait Islander origin 1,983
Yes 52 2.6
No                        1,931 97.4
Ethnicity 1,984
Anglo–Australian 1,694 85.4
Other 290 14.6
State or territory currently residing 2,010
Vic 686 34.1
NSW 471 23.4
Qld 221 11.0
WA 196 9.8
Tas 162 8.1
ACT 145 7.2
SA 111 5.5
NT 18 0.9
Local area description 2,010
Capital city/inner suburban 1,086 54.0
Outer suburban 515 25.6
Regional centre 256 12.7
Rural or remote 153 7.6
Highest level of education achieved 1,959
Year 10 or below 33 1.7
Year 11 44 2.2
Year 12 544 27.8
Apprenticeship/trade certificate/TAFE certificate/Tertiary diploma 380 19.4
Undergraduate university degree 603 30.8
Postgraduate university degree 355 18.1
Total pre-tax income per year 2,002
$0 63 3.1
$1–$29,999 767 38.3
$30,000–$49,999 335 16.7
$50,000–$79,999 371 18.5
$80,000–$99,999 127 6.3
$100,000–$124,999 94 4.7
$125,000–$149,999 40 2.0
$150,000–$199,999 27 1.3
≥$200,000 21 1.0
Prefer not to answer 157 7.8

The mean K10 score was 24.34 (standard deviation [SD] = 8.89). The majority of the sample (58.5%, n = 941) reported high or very high current psychological distress (Table 2). The most commonly reported mental disorders were depression, anxiety, eating disorders and post-traumatic stress disorder (PTSD). Close to half of respondents had considered self-harm and/or thought about committing suicide within the past two years. More than one in four had attempted suicide at some point in their lives (Table 2).

Table 2. Mental health past and present
Characteristic Number of responders (n) Frequency of ‘yes’ responses Percentage (%)
K10 category 1,609
Low (10–15) 309 19.2
Moderate (16–21) 359 22.3
High (22–29) 475 29.5
Very high (30–50) 466 29.0
In the past I think I have had …                  1,667
Anxiety disorder 523 31.4
Depression 671 40.3
Bipolar disorder 75 4.5
Schizophrenia 15 0.9
Borderline personality disorder 79 4.7
Eating disorder 349 20.9
Dissociative identity disorder 21 1.3
Post-traumatic stress disorder 196 11.8
Obsessive compulsive disorder 10 0.6
Attention deficit hyperactivity disorder 6 0.4
Other 18 1.1
I currently think I have … 1,667
Anxiety disorder 528 31.7
Depression 372 22.3
Bipolar disorder 75 4.5
Schizophrenia 21 1.3
Borderline personality disorder 66 4.0
Eating disorder 126 7.6
Dissociative identity disorder 26 1.6
Post-traumatic stress disorder 151 9.1
Obsessive compulsive disorder 13 0.8
Attention deficit hyperactivity disorder 10 0.6
Other 25 1.5
A health professional has said I have one of the above mental health disorders 1,667 1,120 67.2
In the past two years have you …      
Thought about self-harming 1,633 814 49.8
Harmed yourself 1,622 417 25.5
Thought about committing suicide 1,633 739 45.3
Attempted suicide 1,617 110 6.8
Have you ever …      
Thought about self-harming 1,633 1,268 77.6
Harmed yourself 1,622 952 58.7
Thought about committing suicide 1,633 1,268 77.6
Attempted suicide 1,617 450 27.8

For all ordinal bisexual life experience variables, partial Spearman’s rank order tests were conducted to assess potential correlations with K10 categories while controlling for gender, age, local area description, education and income (Table 3). Significant associations were found for all four measures of biphobia, three of the four measures of invisibility and erasure, with ‘Do people ever assume you are gay or lesbian?’ close to the set significance (P = 0.10), three of the four measures of being ‘out’ with being ‘out’ to closest friends not significantly associated (P = 0.52) and partner’s support and understanding (Table 3). No measure of community and belonging was found to have a significant relationship with K10 categories; participation in LGBTQI community events (P = 0.74), bisexual community events (P = 0.39), contact with LGBTQI (P = 0.82) or bisexual (P = 0.85) friends or acquaintances.

Table 3. Significant associations between K10 categories and bisexual life experiences
Bisexual life experiences associated with K10 categories Chi-square statistic (2) Correlation coefficient Significance
(2-tailed)
Biphobia      
Have you ever been treated badly because of your sexuality? 0.17  P <0.001
Have you ever been treated badly by your family because of your sexuality? 0.16 P <0.001
Have you ever been treated badly by your friends because of your sexuality? 0.17 P <0.001
Do you ever feel that your sexuality is bad or wrong? 0.15 P <0.001
Invisibility and erasure      
Do people ever assume you are heterosexual/straight? 0.07 P = 0.01
Do you ever wish that your sexuality was more visible to those around you? 0.10 P <0.001
Do you ever feel that those around you refuse to accept your sexuality and/or believe that your sexuality does not exist? 0.18 P <0.001
Being ‘out’      
Who in your life is aware of your sexuality – immediate family? –0.06 P = 0.03
Who in your life is aware of your sexuality – extended family? –0.10 P <0.001
Who in your life is aware of your sexuality – broader friendship group? –0.05 P = 0.04
Intimate relationships      
Is your partner/partners understanding and supportive of your sexuality that incorporates people of your own gender and at least one other gender? –0.10 P = 0.01
What is the gender of your primary partner/s? 6.30 P = 0.01

Linear-by-linear chi-square association tests were conducted to assess associations between K10 categories and the three categorical life experience variables. Just one was found to be significantly associated with K10 categories: revealing being in a heterosexual relationship was associated with poorer mental health (Table 3). No association was found for ‘Is your partner aware of your sexuality?’ (P = 0.56) or ‘How many partners do you have?’ (P = 0.28).

A cumulative odds ordinal logistic regression with proportional odds was run to determine the effect of 13 bisexual life experience variables on K10 categories while adjusting for gender, age, local area description, education and income (Table 4). The final model significantly predicted the dependent variable (K10 category) over and above the intercept-only model (P <0.001). Three of the 13 independent variables were significant predictors of high or very high levels of psychological distress: 1) participants feeling their sexuality was bad or wrong; 2) being in a heterosexual relationship; and 3) lower perceived levels of support or understanding of sexuality from partner/s (Table 4).

Table 4. Bisexual life experiences as predictors of K10 categories
Bisexual life experiences associated with K10 categories OR (95% CI) P value
Biphobia    
Have you ever been treated badly because of your sexuality? 1.13 (0.92, 1.38) 0.24
Have you ever been treated badly by your family because of your sexuality? 1.12 (0.96, 1.31) 0.15
Have you ever been treated badly by your friends because of your sexuality? 1.05 (0.86, 1.29) 0.64
Do you ever feel that your sexuality is bad or wrong? 1.25 (1.07, 1.45) 0.004
Invisibility and erasure    
Do people ever assume you are heterosexual/straight? 1.15 (0.93, 1.42) 0.19
Do people ever assume you are gay or lesbian? 1.08 (0.93, 1.25) 0.34
Do you ever wish that your sexuality was more visible to those around you? 1.00 (0.88, 1.13) 0.98
Do you ever feel that those around you refuse to accept your sexuality and/or believe that your sexuality does not exist? 1.15 (0.99, 1.33) 0.06
Being ‘out’    
Who in your life is aware of your sexuality – immediate family? 1.04 (0.82, 1.32) 0.76
Who in your life is aware of your sexuality – extended family? 0.85 (0.66, 1.10) 0.21
Who in your life is aware of your sexuality – broader friendship group? 1.01 (0.78, 1.30) 0.97
Intimate relationships    
Is your partner/partners understanding and supportive of your sexuality that incorporates people of your own gender and at least one other gender? 0.84 (0.71, 0.99) 0.04
What is the gender of your primary partner/s?    
Opposite-sex 1.46 (1.03, 2.07) 0.03
Same-sex 1.00 (reference)
CI, confidence interval; OR, odds ratio


Discussion

The results of this study support the findings of previous research reporting that bisexual people have poorer mental health than their heterosexual, gay or lesbian counterparts.1,2,5,7,10,20,21 Levels of psychological distress were considerably higher in this sample than the national average, with 58.5% of participants having high or very high psychological distress, in comparison to 11.7% of the general population.22 Similarly, the K10 mean score of 24.34 for this sample was significantly higher than that found in a recent study of LGBTQI Australians, which reported a mean K10 score of 19.6.20 Suicidality was also substantially more prevalent in this sample than in the broader Australian community, with 77.6% of participants having ever thought about committing suicide, compared with 13.3% of the general population, and 27.8% having attempted suicide, compared with 3.3% of the general population.23

Biphobia, invisibility, erasure, being ‘out’ and some aspects of intimate relationships were significantly related to mental health in this sample. However, while the current literature suggests that managing and maintaining monogamy or non-monogamy within relationships presents a significant challenge for bisexual people,10,11 the present findings suggest that, if these challenges exist, they are not associated with poorer mental health. Additionally, in contrast to the findings of previous research with smaller sample sizes,13,20 this study found that contact with LGBTQI or bisexual people or communities was not related to mental health. In practice, these findings may present useful directions when assessing and supporting the mental health of bisexual people. Asking bisexual patients about the challenges they might face because of their sexual orientation can be a good starting point to identifying potential issues (refer to ‘Suggested questions’ at the end of the article for sample questions).

Internalised biphobia refers to a lack of self-acceptance experienced by some bisexual people as a result of their own heteronormative views.12,13 Bisexual people have been found to experience a greater lack of self-acceptance with regards to their sexuality than homosexual people.12 Previous qualitative research has indicated a link between participants’ mental wellbeing and their level of internal conflict resulting from their sexual and romantic attractions being outside of the socially accepted dichotomy of homosexual or heterosexual.13 The present study supports this, finding that experiencing ‘feeling your sexuality is bad or wrong’ increases the odds of having higher psychological distress. These findings suggest that self-acceptance of one’s sexuality is an important aspect of mental wellbeing for bisexual people.

Participants in the ‘Who I Am’ study who were in heterosexual relationships reported significantly poorer mental health than those in same-sex relationships. This phenomenon has similarly been observed in previous research, with bisexual women finding those in same-sex relationships fared best emotionally while those with a male partner were particularly vulnerable to depressive symptoms and bi-negativity.24 This finding challenges the long promulgated belief that bisexual people in heterosexual relationships are afforded ‘heterosexual privilege’ because they are less exposed to the stressors associated with being in a same-sex relationship, such as having a more visible sexual minority status.25 The clinical implication of this is that clinicians may see bisexual people in heterosexual relationships as being less vulnerable to social oppression and the stressors associated with it; this finding suggests the reverse.

The mental health benefits afforded to bisexual people whose partners are supportive of their sexual orientation are considerable.10 A recent qualitative study revealed that bisexual people report better mental health if they have a partner who is supportive and understanding following disclosure of their bisexual orientation, while negative reactions to disclosure are associated with internal emotional challenges.10 This study supports this, finding that having a supportive and understanding partner was a significant predictor of better mental health. This is an experience particular to bisexual people as, unlike heterosexual, gay or lesbian people, their sexual orientation is not inferred by the gender of their partner nor is it necessarily obvious to their partners when in a relationship. The ‘Suggested questions’ box at the end of this article offers some practical tips for GPs working with bisexual, or potentially bisexual, patients to assist them to start a conversation regarding bisexual relationships and partner support.

There are some limitations to this study. The survey instrument was only available online and the majority of recruiting occurred through online media, thus people not connected to the internet had limited exposure to advertising and could not access the survey. As a result of the use of convenience sampling, the findings from this survey may not be representative of the bisexual population in Australia. Additionally, as the survey relied on self-reporting and participants had the ability to skip questions, reporting bias and missing data were limitations. People with transgender or gender-diverse experience were not included in these analyses and the experiences of these participants are thus not represented in this paper. The complexity that comes from the intersection of gender diversity and bisexuality warrants specific analysis.

This paper presents the findings of one of the largest studies of bisexual people ever conducted and posits a significant contribution to the severely limited knowledge relating to poor mental health in the bisexual population. The results of this study support the previously reported finding that bisexual people have poorer mental health than other sexual orientation groups. Experiences of biphobia, invisibility, erasure and not being ‘out’ were found to be associated with poorer mental health. Internalised biphobia, being in a heterosexual relationship and having an unsupportive partner significantly increased the odds of having higher psychological distress. The life experiences associated with poorer mental health in this study are specific to bisexual people and, providing mental healthcare on the basis of existing paradigms developed for those of other sexual orientations is thus inappropriate. With 10% of the broader population reporting bisexual attraction and GPs the most commonly reported first point of contact for mental health care in Australia,23 these findings are relevant to all GPs working across the country.

Implications for general practice

This paper draws to our attention some important implications that should not be underappreciated by GPs, including the:

  • frequency of bisexuality (and therefore the potential number in any patient base who are bisexual)
  • mental health statistics applying to this cohort of patients
  • potential psychosocial reasons for these statistics.

This paper shows the importance of identifying bisexuals among patients and provides considerable insight into the factors that predispose them to dramatically worse mental health statistics in comparison to other sexual orientation groups.

Suggested questions for GPs

These questions may be helpful as a starting point for practitioners working with bisexual patients in identifying individuals who might be at risk of poor mental health:

  • Do you have a partner/are you sexually active?

-  If yes – what gender is your partner/s?

-  Is your partner supportive of your sexuality?

  • Does your sexuality present any challenges for you
Competing interests: None.
Provenance and peer review: Not commissioned, externally peer reviewed.
Funding: None.

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