توضیح نابرابری بهداشت روانی زنان غیر تک جنسی: سابقه سوء و رابطه جنسی پرخطر، یا تحمل عدم افشاگری؟

Research has found that non-monosexual women report worse mental health than their heterosexual and lesbian counterparts. The reasons for these mental health discrepancies are unclear. This study investigated whether higher levels of child abuse and risky sexual behavior, and lower levels of sexual orientation disclosure, may help explain elevated symptoms of depression and anxiety among non-monosexual women. Participants included 388 women living in Canada (Mean age = 24.40, SD = 6.40, 188 heterosexual, 53 mostly heterosexual, 64 bisexual, 32 mostly lesbian, 51 lesbian) who filled out the Beck Depression and Anxiety Inventories as part of an online study running from April 2011 to February 2014. Participants were collapsed into non-monosexual versus monosexual categories. Non-monosexual women reported more child abuse, risky sexual behavior, less sexual orientation disclosure, and more symptoms of depression and anxiety than monosexual women. Statistical mediation analyses, using conditional process modeling, revealed that sexual orientation disclosure and risky sexual behavior uniquely, but not sequentially, mediated the relation between sexual orientation, depression and anxiety. Sexual orientation disclosure and risky sexual behavior were both associated with depression and anxiety. Childhood abuse did not moderate depression, anxiety, or risky sexual behavior. Findings indicate that elevated levels of risky sexual behavior and deflated levels of sexual orientation disclosure may in part explain mental health disparities among non-monosexual women. Results highlight potential targets for preventive interventions aimed at decreasing negative mental health outcomes for non-monosexual women, such as public health campaigns targeting bisexual stigma and the development of sex education programs for vulnerable sexual minority women, such as those defining themselves as bisexual, mostly heterosexual, or mostly lesbian.

Several studies have found that bisexual women report higher levels of anxiety, depression, suicidality, and substance abuse than their heterosexual and lesbian counterparts (Bostwick et al., 2010, Cochran et al., 2003, Fredriksen-Goldsen et al., 2010, Hequembourg et al., 2013, Hughes et al., 2010b, Kerr et al., 2013, King et al., 2008, McCabe et al., 2009 and Wilsnack et al., 2008). Research suggests negative stereotypes exist about bisexuality, such as: bisexuality does not exist as a sexual identity or as a sexual orientation; and bisexuals are sexually promiscuous (Herek, 2002, Rust, 2002 and Zivony and Lobel, 2014). While identity confusion and risky sexual behavior might be associated with maladjustment, there is another possibility: that the negative social reality created by these stereotypes helps explain the greater prevalence of psychological distress among bisexuals. In the history of homosexuality as psychopathology in North America, it was argued that it would be surprising if homosexual individuals in the 1970s would not be distressed considering the hostile social climate they were living in Marmor (1980). The importance of social climate to a range of mental health outcomes is still relevant. For instance, studies in the United States (Hatzenbuehler and Keyes, 2013 and Hatzenbuehler et al., 2011) have found that sexual minority individuals who live in states with policies protective of their rights have lower prevalence of suicidality and psychiatric disorders compared to those living in states without such policies. Research has suggested that, currently, bisexual individuals face more stigma than homosexual individuals (Zivony and Lobel, 2014), which may be related to monosexism (preference for single-gender orientations) (Ross et al., 2010). For instance, it has been found that heterosexual women hold more negative attitudes towards bisexual than towards lesbian women (Herek, 2002). Due to these stereotypes, it has been assumed that bisexual individuals are subjected to minority stress, in the form of stigma and discrimination (Meyer, 2003), which is in turn hypothesized to relate to their elevated levels of psychological distress. Several studies indicate that there is an association between minority stress, symptoms of depression, suicidality, and substance use among bisexual women (Bostwick, 2012, Lea et al., 2014, Lehavot and Simoni, 2011 and McCabe et al., 2010). Although minority stress may be a good model for bisexual mental health disparities overall, it is conceivable that factors other than stigma and discrimination may be relevant. Some studies have explored the association between childhood adversity, sexual orientation, and mental health (Alvy et al., 2013, Austin et al., 2007, Austin et al., 2008, Drabble et al., 2013, Hequembourg et al., 2013, Lehavot et al., 2012, Rothman et al., 2011 and Schneeberger et al., 2014). A meta-analysis demonstrated that bisexual females report higher prevalence for both sexual and parental physical abuse compared to lesbian and heterosexual females (Friedman et al., 2011). Further, there is evidence that exposure to victimization and adversity in childhood and adolescence mediates the association between bisexuality, suicidality, depressive symptoms, and substance use (McLaughlin et al., 2012). Research has documented a potential link between childhood sexual abuse and adult sexual victimization (Roodman and Clum, 2001), and between childhood sexual abuse and risky sexual behavior in adulthood (Senn and Carey, 2010 and Walsh et al., 2013). A recent study found that bisexual females reported more sexual risk behaviors (e.g., use of emergency contraception) than their heterosexual and lesbian counterparts (Tornello et al., 2013). Compared to heterosexual females, both lesbian and bisexual females were more likely to report being forced to have sex with a male. The above-mentioned findings fit with other research suggesting bisexual women are more likely to experience adult sexual victimization than other women (Hequembourg et al., 2013, Hughes et al., 2010a, Hughes et al., 2010b, Lehavot et al., 2012 and McLaughlin et al., 2012). A report on bisexual health by the National Gay and Lesbian Task Force (2007) listed sexual health among the top ten health issues relevant to the bisexual community. The report underlined that bisexual women report higher risk sexual behavior than heterosexual women and that they have higher rates of combining substance/alcohol use with sex than both heterosexual and lesbian women (Miller et al., 2007). In short, there has been a call for research to further explore sexual risk among bisexual women. Sexual orientation disclosure may be positively associated with physical and mental health (Durso and Meyer, 2013 and Juster et al., 2013). Research has documented, however, that bisexual women are less likely than lesbian women to disclose their sexual orientation to healthcare providers (Durso and Meyer, 2013). In this study, at one year-follow-up, the researchers found that concealment of sexual orientation was associated with poor psychological wellbeing. As previously discussed, bisexual women may be more stigmatized than lesbian women, which, in turn, could be the reason they are less likely to disclose (Ross et al., 2010). For instance, a qualitative study found that bisexual individuals mainly reported negative experiences with mental health service providers (Eady et al., 2011). Recent research has indicated “mostly heterosexual” and “mostly lesbian” represent distinct sexual orientations, groups distinguished from “heterosexual” and “lesbian” by the presence of some same-sex or other-sex orientation, respectively, and from “bisexual” by less same-sex or other-sex orientation, respectively (Savin-Williams and Vrangalova, 2013). Data have suggested that these women's reported rates of childhood abuse, risky sexual behavior, and substance abuse are similar to bisexual women's (Alvy et al., 2013, Austin et al., 2008, Corliss et al., 2009, Hughes et al., 2010b, Loosier and Dittus, 2010 and McCabe et al., 2012). Although the reasons for these similarities are still unclear, mostly heterosexual and mostly lesbian women, as bisexual women, may experience marginalization and low levels of social support (Corliss et al., 2009 and Hughes et al., 2010b). Sexual orientation, defined as an internal mechanism directing sexuality (Bailey, 2009), typically refers to a combination of cognitive, behavioral, and affective components (Savin-Williams and Vrangalova, 2013). Research has found that outcomes may be sensitive to which dimension of sexual orientation is used to classify individuals (McCabe et al., 2012 and Savin-Williams, 2009). Therefore, the current study included both self-identification and behavior as indices of sexual orientation. The purpose of the current research was three-fold. First, we aimed to explore the association between female sexual orientation, childhood abuse, risky sexual behavior, depression, and anxiety. We expected non-monosexual women to report higher levels of depression and anxiety, childhood abuse, and risky sexual behavior than monosexual women. Further, we expected that childhood abuse would moderate depression, anxiety, and risky sexual behavior, and that risky sexual behavior would mediate the association between sexual orientation, depression and anxiety. Second, we aimed to examine the link between sexual orientation disclosure, depression, and anxiety. We expected higher levels of sexual orientation disclosure among lesbian women than non-monosexual women, and that sexual orientation disclosure would mediate the relationship between sexual orientation, depression, and anxiety. Third, we aimed to determine whether there would be sequential mediation between sexual orientation, sexual orientation disclosure, risky sexual behavior, depression, and anxiety. We expected that lower levels of sexual orientation disclosure would be associated with higher levels of risky sexual behavior, in turn associated with higher levels of anxiety and depression.

Results of this study support a growing body of research documenting mental health disparities, higher reported levels of childhood adversity, sexual health concerns, and greater sexual orientation concealment among non-monosexual women. Findings suggest that higher levels of risky sexual behavior and lower levels of sexual orientation disclosure may in part explain why non-monosexual women report poorer mental health than their monosexual counterparts. Contrary to expectations, childhood abuse did not moderate the relation between sexual orientation and mental health nor between sexual orientation and risky sexual behavior. In general, results were stronger when sexual behavior rather than self-identified sexual orientation was used as a variable, supporting other data suggesting that research findings relevant to sexual orientation may be sensitive to which dimension of sexual orientation is used (McCabe et al., 2012 and Savin-Williams, 2009).