Abstract

This study aimed to analyze the association between internalized homophobia and its domains and depression in homosexual and bisexual individuals and to quantify its results in depression. This is a cross-sectional online and anonymous study based on the LGBT+ health study conducted in Brazil from August to November, 2020, summing 926 respondents. Depression was self-reported. Internalized Homophobia was measured by the Brazilian Internalized Homophobia Scale for Gays and Lesbians, using 80% percentile to classify elevated total and by domain scores. Statistical analysis was based on Poisson Regression models with robust variance. Depression prevalence was 23.7%. The results revealed that internalized homophobia was positively associated with depression only among homosexuals (Prevalence Ratio (RP) = 1.80; 95% confidence interval (95%CI) 1.12-2.90). We found no statistical association for stigma and oppression domains. Population attributable fraction of depression was 2.3% (95%CI 0.1-4.5) in relation to internalized homophobia. Our findings highlight the need of controlling internalized homophobia to decrease the prevalence of depression among homosexuals.

Key words:
Mental health; Depression; Sexual and gender minorities; Sexism; Homophobia

Introduction

Mental health is a public health problem that has gained prominence mainly since the onset of the COVID-19 pandemic in 2020, given that its main prevention measure, before the implementation of vaccination in 2021, was social distancing¹1 Brasil. Portaria no 454, de 20 de março de 2020. Declara, em todo o território nacional, o estado de transmissão comunitária do coronavírus (covid-19). Diário Oficial Da União; 2020.. Despite this, in sexual and gender minorities, which include Lesbians, Gays, Bisexuals, Travesti, Trans, and related identities (LGBT+), mental health had already been the focus of study well before the onset of the pandemic, with emphasis placed on depression, with a prevalence of 35% in cis bisexual women, as compared to a prevalence of 16% in cis heterosexual women²2 Chaudhry AB, Reisner SL. Disparities by Sexual Orientation Persist for Major Depressive Episode and Substance Abuse or Dependence: Findings from a National Probability Study of Adults in the United States. LGBT Health 2019; 6(5):261-266.. Among cis gay men, the lifetime prevalence reaches 20%, almost 2.4 times higher than that of cis heterosexual men²2 Chaudhry AB, Reisner SL. Disparities by Sexual Orientation Persist for Major Depressive Episode and Substance Abuse or Dependence: Findings from a National Probability Study of Adults in the United States. LGBT Health 2019; 6(5):261-266..

In the population of sexual and gender minorities, one of the theories that attempts to explain this excess prevalence of depression is the Minority Stress Theory³3 Meyer IH. Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence. Psychol Bull 2003; 129(5):674-697.. The concept of “minority stress”, proposed by Meyer³3 Meyer IH. Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence. Psychol Bull 2003; 129(5):674-697., can be applied to groups that are considered minorities, not because of their prevalence in the population, but because they do not hold the hegemonic power to control the narrative about themselves: the black population, women, economically vulnerable individuals, and the population of sexual and gender minorities. When the term “stress of sexual and gender minorities” is used, reference is made to this condition, which impacts the formation of subjectivity, the construction of self-perception and self-care, as well as the construction of social relationships by these individuals, considering the external and internal aspects of stress to which they are subjected³3 Meyer IH. Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence. Psychol Bull 2003; 129(5):674-697..

According to the minority stress theory, constant situations of stigma and prejudice can lead to the deterioration of mental health, which, in addition to the diagnosis of depression, can be characterized by psychological stress⁴4 Gonzales G, Loret de Mola E, Gavulic KA, McKay T, Purcell C. Mental Health Needs Among Lesbian, Gay, Bisexual, and Transgender College Students During the COVID-19 Pandemic. J Adolesc Health 2020; 67(5):645-648.^,55 Salerno JP, Devadas J, Pease M, Nketia B, Fish JN. Sexual and Gender Minority Stress Amid the COVID-19 Pandemic: Implications for LGBTQ Young Persons' Mental Health and Well-Being. Public Health Rep 2020; 135(6):721-727., loneliness, social isolation, and/or low emotional support⁶6 Pedrosa AL, Bitencourt L, Fróes ACF, Cazumbá MLB, Campos RGB, de Brito SBCS, Simões E Silva AC. Emotional, Behavioral, and Psychological Impact of the COVID-19 Pandemic. Front Psychol. 2020; 11:566212.

7 Kneale D, Bécares L. Discrimination as a predictor of poor mental health among LGBTQ+ people during the COVID-19 pandemic: Cross-sectional analysis of the online Queerantine study. BMJ Open 2021; 11:e049405. 8. #Voltelgbt. Diagnóstico LGBT+ Na Pandemia: Desafios Da Comunidade LGBT+ No Contexto de Isolamento Social Em Enfrentamento à Pandemia de Coronavírus [Internet]. São Paulo: #votelgbt; 2020 [acessado 2023 ago 1]. Disponível em https://sinapse.gife.org.br/download/diagnostico-lgbt-na-pandemia.^-88 #Voltelgbt. Diagnóstico LGBT+ Na Pandemia: Desafios Da Comunidade LGBT+ No Contexto de Isolamento Social Em Enfrentamento à Pandemia de Coronavírus [Internet]. São Paulo: #votelgbt; 2020 [acessado 2023 ago 1]. Disponível em https://sinapse.gife.org.br/download/diagnostico-lgbt-na-pandemia.
https://sinapse.gife.org.br/download/dia... . Data indicate that 65% of sexual and gender minorities have suffered discrimination due to their non-heterosexual emotional orientation by family members and neighbors⁹9 Magno L, Silva LAVD, Guimarães MDC, Veras MASM, Deus LFA, Leal AF, Knauth DR, Brito AM, Rocha GM, Lima LNGC, Kendall C, Motta-Castro ARC, Kerr LRFS, Mota RMS, Merchan-Hamann E, Dourado IC; Brazilian HIV/MSM Surveillance Group. Discrimination based on sexual orientation against MSM in Brazil: a latent class analysis. Rev Bras Epiemiol 2019; 22(Supl. 1):e190003., with the home being the main place of occurrence, according to the Notifiable Diseases Information System (SINAN) of 2015-2017¹⁰10 Pinto IV, Andrade SSA, Rodrigues LL, Santos MAS, Marinho MMA, Benício LA, Correia RSB, Polidoro M, Canavese D. Profile of notification of violence against lesbiangay, bisexual, transvestite and transsexual people recorded in the national information system on notifiable diseases, Brazil, 2015-2017. Rev Bras Epidemiol 2020; 23(Supl. 1):e200006.. Furthermore, such situations can affect the perception of these individuals in society, so that they can reject their own identity (proximal minority stress), causing negative and distressing feelings known as internalized homophobia¹¹11 Williamson IR. Internalized homophobia and health issues affecting lesbians and gay men. Health Educ Res 2000; 15(1):97-107..

Systematic reviews have consistently shown that at least one component of minority stress theory is related to biological¹²12 Flentje A, Heck NC, Brennan JM, Meyer IH. The relationship between minority stress and biological outcomes: A systematic review. J Behav Med 2020; 43(5):673-694. and mental¹³13 Camp J, Vitoratou S, Rimes KA. LGBQ+ Self-Acceptance and Its Relationship with Minority Stressors and Mental Health: A Systematic Literature Review. Arch Sex Behav 2020; 49(7):2353. outcomes. Regarding internalized homophobia, one study conducted in Cyprus with 110 adults (aged 18 years or older) showed a positive association between internalized homophobia and depression in a univariate analysis¹⁴14 Yolaç E, Meriç M. Internalized homophobia and depression levels in LGBT individuals. Perspect Psychiatr Care 2021; 57(1):304-310.. Data from 543 couples of homosexual men in the United States also confirmed this positive correlation¹⁵15 Curtis MG, Kogan S, Mitchell JW, Stephenson R. Dyadic effects of enacted stigma, internalized homophobia, and communal coping on depressive symptoms among cisgender sexual minority male couples. Fam Process 2022; 61(4):1541-1558.. Similar results were found in 2,178 adults (aged 19 years or older) from South Korea¹⁶16 Lee H, Operario D, Yi H, Choo S, Kim SS. Internalized homophobia, depressive symptoms, and suicidal ideation among lesbian, gay, and bisexual adults in South Korea: An age-stratified analysis. LGBT Health 2019; 6(8):393-399. and in 581 adult women from Taiwan (aged 20 years or older), after the relevant adjustments¹⁷17 Wang YC, Miao NF, Chang SR. Internalized homophobia, self-esteem, social support and depressive symptoms among sexual and gender minority women in Taiwan: An online survey. J Psychiatr Ment Health Nurs 2021; 28(4):601-610..

Despite the international evidence cited above¹²12 Flentje A, Heck NC, Brennan JM, Meyer IH. The relationship between minority stress and biological outcomes: A systematic review. J Behav Med 2020; 43(5):673-694.

13 Camp J, Vitoratou S, Rimes KA. LGBQ+ Self-Acceptance and Its Relationship with Minority Stressors and Mental Health: A Systematic Literature Review. Arch Sex Behav 2020; 49(7):2353.

14 Yolaç E, Meriç M. Internalized homophobia and depression levels in LGBT individuals. Perspect Psychiatr Care 2021; 57(1):304-310.

15 Curtis MG, Kogan S, Mitchell JW, Stephenson R. Dyadic effects of enacted stigma, internalized homophobia, and communal coping on depressive symptoms among cisgender sexual minority male couples. Fam Process 2022; 61(4):1541-1558.

16 Lee H, Operario D, Yi H, Choo S, Kim SS. Internalized homophobia, depressive symptoms, and suicidal ideation among lesbian, gay, and bisexual adults in South Korea: An age-stratified analysis. LGBT Health 2019; 6(8):393-399.^-1717 Wang YC, Miao NF, Chang SR. Internalized homophobia, self-esteem, social support and depressive symptoms among sexual and gender minority women in Taiwan: An online survey. J Psychiatr Ment Health Nurs 2021; 28(4):601-610., not all studies demonstrated independence of the association between internalized homophobia and depression¹⁴14 Yolaç E, Meriç M. Internalized homophobia and depression levels in LGBT individuals. Perspect Psychiatr Care 2021; 57(1):304-310.^,1515 Curtis MG, Kogan S, Mitchell JW, Stephenson R. Dyadic effects of enacted stigma, internalized homophobia, and communal coping on depressive symptoms among cisgender sexual minority male couples. Fam Process 2022; 61(4):1541-1558.. In Brazil, no studies were found on this topic, despite the country having a society marked by high rates of violence against sexual and gender minorities, reaching almost one report of violence perpetrated against these people per hour¹⁰10 Pinto IV, Andrade SSA, Rodrigues LL, Santos MAS, Marinho MMA, Benício LA, Correia RSB, Polidoro M, Canavese D. Profile of notification of violence against lesbiangay, bisexual, transvestite and transsexual people recorded in the national information system on notifiable diseases, Brazil, 2015-2017. Rev Bras Epidemiol 2020; 23(Supl. 1):e200006.. Therefore, the present study sought was to analyze the association between internalized homophobia, its domains, and the diagnosis of depression in homosexual and bisexual men and women living in Brazil, and quantify the result of its decrease in the prevalence of depression.

Methods

Design and sampling

This work is a cross-sectional study based on data from the LGBT+ health survey, carried out in Brazil from August to November 2020, through a self-completed online and anonymous link, with individual questions and standardized questionnaires about sociodemographic and health-related characteristics. Although not representative of the entire population, as it is a non-probabilistic sample, the survey was disseminated nationally on social networks, such as Facebook, Instagram, and WhatsApp, via a link, through snowball dissemination. More information about the study and research team can be found in another publication¹⁸18 Torres JL, Goncalves GP, Pinho AA, Souza MHN. The Brazilian LGBT+ Health Survey: methodology and descriptive results. Cad Saude Publica 2021; 37(9):e00069521.. The inclusion criteria were: being 18 years old or over, living in one of the five Brazilian regions, self-declared as an individual from the sexual and gender minority population, having access to the Internet to fill out the questionnaire, and agreeing to participate in the research. For the present analysis, individuals who reported an affective orientation other than homosexual or bisexual (n=39) were excluded due to the characteristic of the independent variable, totaling 937 participants.

The LGBT+ health survey was approved by the Ethics and Research Committee of the Federal University of Minas Gerais (CAAE 34123920.9.0000.5149) and followed all recommendations from the National Health Council.

Dependent variable

The dependent variable of this study was self-reported medical diagnosis of depression (yes, no), assessed through the question “Has a doctor or health professional ever told you that you have depression?”.

Independent variable

The independent variable was internalized homophobia, measured using the validated scale of Internalized Homophobia for Brazilian Gays and Lesbians¹⁹19 Lira AN, Morais NA. Validity evidences of the Internalized Homophobia Scale for Brazilian gays and Lesbians. Psico USF 2019; 24(2):361-372., consisting of 19 items with a score of up to 57 points. Each item ranges from 0-3 points (from “totally agree” to “totally disagree”), with higher scores representing higher levels of internalized homophobia. The scale is divided into two domains, with 15 items related to the internal perception of stigma (maximum score of 45 points), such as the items “homosexuality is morally acceptable” and “I feel comfortable talking about homosexuality/bisexuality in a public place” and 4 items related to the social perception of oppression (maximum score of 12 points), such as the items “most people have negative reactions to homosexuality/bisexuality” and “discrimination against gays and lesbians is still common”. The 80% percentiles were used as a cutoff point to classify the total score and the scores per domain as high or not high.

Potential confounding variables

Potential confounding variables in this study were divided into blocks of variables, named according to minority stress theory, as follows: (1) Socioeconomic circumstances and type of minority: affective orientation (homosexual or bisexual); gender identity (cisgender woman, cisgender man, or other gender minorities); age group (18-29 years, 30-49 years, ≥50 years); education (high school or less, incomplete or complete undergraduate degree, incomplete or complete postgraduate degree); race/color (black/brown/other, white); (2) General and minority stressors: loneliness, classified according to the score obtained by the 3-item UCLA Loneliness Scale²⁰20 Kuznier TP, Oliveira F, Mata LRF, Chianca TCM. Translation and Cross-Cultural Adaptation of Ucla Loneliness Scale - (Version 3) for the Elderly in Brazil. REME 2016; 20:e950., which varies from 3 to 9, with the higher the score, the higher the level of loneliness (none (score 3/ 4), mild (score 5/7), severe (score 8/9)); Discrimination related to emotional orientation by close family members, assessed by the frequency of perception of discriminatory attitudes (never/sometimes, frequent); (3) Coping strategies and social support from professionals: alcohol consumption, assessed through the weekly frequency of consumption and doses on each occasion (does not consume, up to 2x/week in low doses, up to 2x/week in high doses (above 3 doses on one occasion), 3x/week or more; smoking, considering current cigarette consumption (yes, no); health professionals in the quality of care (yes, no).

Statistical analysis

For data analysis, first, a descriptive analysis of the sample was carried out, considering Pearson’s chi-square test to evaluate differences between frequencies in each category of depression. Poisson regression with robust variance was used to estimate crude and adjusted Prevalence Ratios (PR) and their 95% confidence intervals (95%CI) to investigate the association between a high internalized homophobia score and its domains and depression in sexual and gender minorities. All study variables were maintained in the adjusted models, regardless of statistical significance, adopting adequacy to the proposed theoretical model as a criterion.

Based on the adjusted models, the decrease in the prevalence of depression was estimated in scenarios with internalized homophobia scores below 80% and each of its domains, through the population attributable fraction, which considers, in addition to the strength of association between the variables, the prevalence of the independent variable in the studied population. All analyses included the post-stratification procedure with weights by geographic region, according to the population estimate from the National Health Survey (NHS 2019)²¹21 Macedo Neto AO, Silva SAG, Gonçalves GP, Torres JL. COVID-19 vulnerability among Brazilian sexual and gender minorities: a cross-sectional study. Cad Saude Publica 2022; 38(8):e00234421.. Additionally, the categories of homosexual and bisexual emotional orientation were analyzed separately, as they may differ in relation to homophobia. All statistical analyses were performed using Stata 17.0 SE software (Stata-Corp., College Station, Texas, USA).

Results

Of the 937 participants included in this work, 11 had no information about depression, making a final sample of 926 participants. Of these, 219 (23.7%; 95%CI 19.0-29.1) reported having a medical diagnosis of depression. Participants were mainly homosexual (75%) and cisgender men (57.2%). All sociodemographic characteristics of the respondents can be seen in Table 1. The sociodemographic characteristics that varied according to living with children were age group, race/color, and presence of a partner, which was more common in the age group of 30-49 years, among blacks, browns, or races other than white, and among those who have a partner.

Table 2 shows the results of the raw and adjusted models of the association between internalized homophobia and its domains and the diagnosis of depression in Brazilian sexual and gender minorities. Considering the final models, only a high total internalized homophobia score was positively associated with depression (PR=1.70; 95%CI 1.09-2.65).

Although not presented in Table 2, there was a significant difference between the prevalence of depression in homosexual and bisexual individuals (PR=0.54; 95%CI 0.33-0.90, data not shown), which was lower when comparing bisexual individuals to homosexuals. Considering this and the fact that internalized homophobia can impact homosexual individuals more frequently than bisexual individuals, the same sequential models were carried out separately for each category of affective orientation (homosexuals and bisexuals). As shown by the final models presented in Table 3, total internalized homophobia was positively associated with depression only among homosexual individuals (PR=1.80; 95%CI 1.12-2.90). None of the domains of internalized homophobia were independently associated with depression.

To quantify the change in the prevalence of depression due to a decrease in the total internalized homophobia score and its domains, the difference in the prevalence of depression, considering the observed scenario and scenarios with internalized homophobia scores below 80%, was plotted in Figure 1. In a scenario with internalized homophobia scores below 80%, the prevalence of depression in homosexuals has a potential reduction of 2.30% (95%CI 0.14-4.46), falling from 23.37% to 21.07%. Lower prevalences of depression were not observed in scenarios with scores for each of the internalized homophobia domains below 80%.

Discussion

This study found a high prevalence of the diagnosis of depression in the studied population, regardless of the level of internalized homophobia, and similar to the prevalence reported in the United States²2 Chaudhry AB, Reisner SL. Disparities by Sexual Orientation Persist for Major Depressive Episode and Substance Abuse or Dependence: Findings from a National Probability Study of Adults in the United States. LGBT Health 2019; 6(5):261-266.. Furthermore, those individuals with high internalized homophobia were more likely to present depression, showing that internalized homophobia scores above 80% are associated with a higher prevalence of depression in homosexual individuals.

The main findings of this study corroborate previous studies, which showed a positive association between internalized homophobia and depression¹⁴14 Yolaç E, Meriç M. Internalized homophobia and depression levels in LGBT individuals. Perspect Psychiatr Care 2021; 57(1):304-310.

15 Curtis MG, Kogan S, Mitchell JW, Stephenson R. Dyadic effects of enacted stigma, internalized homophobia, and communal coping on depressive symptoms among cisgender sexual minority male couples. Fam Process 2022; 61(4):1541-1558.

16 Lee H, Operario D, Yi H, Choo S, Kim SS. Internalized homophobia, depressive symptoms, and suicidal ideation among lesbian, gay, and bisexual adults in South Korea: An age-stratified analysis. LGBT Health 2019; 6(8):393-399.^-1717 Wang YC, Miao NF, Chang SR. Internalized homophobia, self-esteem, social support and depressive symptoms among sexual and gender minority women in Taiwan: An online survey. J Psychiatr Ment Health Nurs 2021; 28(4):601-610.. The biological explanation for this association is based on the fact that experiences of stigma and prejudice generate negative and distressing feelings (stress)³3 Meyer IH. Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence. Psychol Bull 2003; 129(5):674-697., which are moderated by adaptive psychological and behavioral responses, regulated by the nervous system²²22 Mcewen BS. Protection and Damage from Acute and Chronic Stress: Allostasis and Allostatic Overload and Relevance to the Pathophysiology of Psychiatric Disorders. Ann N Y Acad Sci 2004; 1032:1-7.. The regulation of the nervous system is compromised when there is depression, causing hormonal dysregulation²²22 Mcewen BS. Protection and Damage from Acute and Chronic Stress: Allostasis and Allostatic Overload and Relevance to the Pathophysiology of Psychiatric Disorders. Ann N Y Acad Sci 2004; 1032:1-7., and generating a cycle between hormonal dysregulation, chronic stress, and the onset and development of depression²³23 Tafet G, Smolovic J. Psychoneuroendocrinological Studies on Chronic Stress and Depression. Ann N Y Acad Sci 2004; 1032:276-278.. This cycle generates a worsening of physical¹²12 Flentje A, Heck NC, Brennan JM, Meyer IH. The relationship between minority stress and biological outcomes: A systematic review. J Behav Med 2020; 43(5):673-694. and mental¹³13 Camp J, Vitoratou S, Rimes KA. LGBQ+ Self-Acceptance and Its Relationship with Minority Stressors and Mental Health: A Systematic Literature Review. Arch Sex Behav 2020; 49(7):2353. health if there is no control of the stress mechanism or control of the damage caused by depression.

Based on this explanation, medical science, still heavily influenced by the biomedical paradigm, sometimes offers solutions for depression in a non-integrated way, using medications from different classes²⁴24 Cipriani A, Furukawa T, Salanti G, Chaimani A, Atkinson LZ, Ogawa Y, Leucht S, Ruhe HG, Turner EH, Higgins JPT, Egger M, Takeshima N, Hayasaka Y, Imai H, Shinohara K, Tajika A, Ioannidis JPA, Geddes JR. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet 2018; 391(10128):1357-1366. and/or psychotherapy (psychoanalysis, cognitive behavioral therapy, among several other lines). However, based on advances in the understanding of human beings through the paradigm of biopsychosocial-spiritual complexity²⁵25 Anderson MIP, Rodrigues RD. O paradigma da complexidade e os conceitos da medicina integral: saúde, adoecimento e integralidade. Rev Hosp Univ Pedro Ernesto 2017; 15(3):242-252., in which the processes of illness are understood as the result of an interaction of factors (biological, spiritual, sociocultural, psychological, existential, and environmental), it is understood that the mechanisms to diminish depression must be multiple.

In this sense, considering sociocultural and environmental factors, this study demonstrates that collective health actions need to focus on combating internalized homophobia in general. These actions should not only be at an individual level, treating biological consequences of internalized homophobia, but also expand their scope to social organisms. After all, homophobia is internalized from homophobic experiences lived in family and society.

It is important to remember that society encompasses health services. In this way, the use of the National Comprehensive Health Policy for Lesbians, Gays, Bisexuals, Travestis, and Trans, implemented in 2011, is reinforced, whose objectives include the elimination of discrimination and institutional prejudice²⁶26 Brasil. Portaria nº 2.836, de 1° de Dezembro de 2011. Política Nacional de SaúdeIntegral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais (LGBT). Diário Oficial da União; 2011.. In addition to the national level, more regionalized actions that respond to local specificities are also important, such as the State Policy for Comprehensive Health for Lesbians, Gays, Bisexuals, Travestis, and Transsexuals of Minas Gerais²⁷27 Minas Gerais. Deliberação CIB-SUS/MG no 3.202, de 14 de agosto de 2020. Política Estadual de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais (LGBT) [Internet]. 2020 [acessado 2023 ago 1]. Disponível em https://www.saude.mg.gov.br/images/documentos/Del%203202%20-%20SUBPAS_SAPS%20%20-%20Pol%C3%ADtica%20Sa%C3%BAde%20LGBT%20-%20alterada%20-%20revis%C3%A3o%20DPAPS%20-%20alt.%202%20-%20rev%20DPAPS2%20-%20final%20(1).pdf.
https://www.saude.mg.gov.br/images/docum... , which expanded the financing of health actions aimed at this population.

However, sexual and gender minority populations are not always similar in all their characteristics. Conducting a more in-depth exploration of internalized homophobia among homosexuals and bisexuals, it was found that internalized homophobia was only positively associated with depression in homosexual individuals. Unlike these findings, one prior study found no difference between homosexual and bisexual women¹⁷17 Wang YC, Miao NF, Chang SR. Internalized homophobia, self-esteem, social support and depressive symptoms among sexual and gender minority women in Taiwan: An online survey. J Psychiatr Ment Health Nurs 2021; 28(4):601-610., while another study was unable to find different levels of internalized homophobia between homosexual and bisexual men²⁸28 Lin HC, Chang CC, Chang YP, Chen YL, Yen CF. Associations among Perceived Sexual Stigma from Family and Peers, Internalized Homonegativity, Loneliness, Depression, and Anxiety among Gay and Bisexual Men in Taiwan. Int J Environ Res Public Health 2022; 19(10):6225.. Despite this, a study conducted in the Netherlands that evaluated the general mental health levels of heterosexual, bisexual, and homosexual individuals found that the general mental health levels of bisexual individuals were similar to heterosexual individuals, which, in turn, were better than the levels of homosexual individuals²⁹29 Sandfort TGM, Bakker F, Schellevis FG, Vanwesenbeeck I. Sexual orientation and mental and physical health status: Findings from a Dutch population survey. Am J Public Health 2006; 96(6):1119-1125..

Some characteristics may explain the differences found between homosexuals and bisexuals in relation to depression, although they are not always found in the literature, and are sometimes divergent³⁰30 Ross LE, Salway T, Tarasoff LA, MacKay JM, Hawkins BW, Fehr CP. Prevalence of Depression and Anxiety Among Bisexual People Compared to Gay, Lesbian, and Heterosexual Individuals:A Systematic Review and Meta-Analysis. J Sex Res 2018; 55(4-5):435-456.. The main one is the type of social relationship. Because they belong to a cisheteronormative society, bisexual individuals may have heterosexual romantic relationships more regularly and, casually, have homosexual relationships³¹31 Muñoz-Laboy M, Garcia J, Wilson P, Parker R, Severson N. Heteronormativity and Sexual Partnering Among Bisexual Latino Men. Arch Sex Behav 2015; 44(4):895-902.. In this sense, the bisexual affective orientation is partially hidden, causing these individuals to suffer fewer episodes of discrimination than homosexual individuals, partially explaining the lack of association between internalized homophobia and depression in bisexual individuals in the present study.

Furthermore, the findings indicate that preventive actions related to internalized homophobia have the potential to reduce depression in homosexual women and men by 2.3%. One study carried out in European countries demonstrated that the lack of acceptance of sexuality at a societal level is one of the factors that diminishes the subjective well-being of individuals in same-sex relationships³²32 Van Der Star A, Bränström R. Acceptance of sexual minorities, discrimination, social capital and health and well-being: A cross-European study among members of same-sex and opposite-sex couples. BMC Public Health 2015; 15:812.. Furthermore, family stigma is directly associated with greater internalized homophobia³³33 Lin CY, Griffiths MD, Pakpour AH, Tsai CS, Yen CF. Relationships of familial sexual stigma and family support with internalized homonegativity among lesbian, gay and bisexual individuals: The mediating effect of self-identity disturbance and moderating effect of gender. BMC Public Health 2022; 22(1):1465. and both increase depression in homosexual individuals²⁸28 Lin HC, Chang CC, Chang YP, Chen YL, Yen CF. Associations among Perceived Sexual Stigma from Family and Peers, Internalized Homonegativity, Loneliness, Depression, and Anxiety among Gay and Bisexual Men in Taiwan. Int J Environ Res Public Health 2022; 19(10):6225. and can culminate in suicidal ideation³⁴34 Costa AB, Pasley A, Machado WDL, Alvarado E, Dutra-thomé L, Koller SH. The Experience of Sexual Stigma and the Increased Risk of Attempted Suicide in Young Brazilian People from Low Socioeconomic Group. Front Psychol 2017; 8:192..

Based on these findings, some structural-level interventions have already been proposed to reduce the effects of minority stress. Highlights include the creation of organizations that generate “safe spaces” for homosexuals, the increased visibility of sexual minorities in the media and physical spaces, and teaching about “heterosexual privilege” in schools and universities³⁵35 Chaudoir SR, Wang K, Pachankins J. What reduces sexual minority stress? A review of the intervention "toolkit." J Soc Issues 2017; 73(3):586-617.. Finally, considering that, in Brazil, the home is main place where violence occurs due to affective orientation¹⁰10 Pinto IV, Andrade SSA, Rodrigues LL, Santos MAS, Marinho MMA, Benício LA, Correia RSB, Polidoro M, Canavese D. Profile of notification of violence against lesbiangay, bisexual, transvestite and transsexual people recorded in the national information system on notifiable diseases, Brazil, 2015-2017. Rev Bras Epidemiol 2020; 23(Supl. 1):e200006., enforcing the primary health care attribute of family orientation is essential in the prevention of internalized homophobia and the creation of more effective mechanisms to deal with stigma and oppression.

Strengths and limitations

As strengths, the novelty of the research stands out in evaluating the implications of internalized homophobia in Brazilian sexual and gender minorities, considering a survey carried out with participants from the five Brazilian regions and the use of post-stratification in the statistical analysis.

However, as a limitation of this study, the use of a sample from an online survey stands out, which is limited to the participation of the population with less social vulnerability due to internet access, despite being a recurrent method to reach populations of difficult access. Second, depression was assessed through self-reports; therefore, the possibility of information bias generating erroneous classification in the groups of absent or present depression cannot be ruled out, given that it can decrease the strength of association. Third, the possibility of reverse causality cannot be eliminated due to the study design, despite the explanatory model presupposing a hormonal dysregulation in the cycle, allowing one to infer the bidirectionality of the association found in this study. Finally, as the differences in the proportions of depression in each of the domains of internalized homophobia were small, the absence of associations by domain in the present study may have occurred due to insufficient test power for the sample size (<0,80). Therefore, it is recommended that future studies with larger samples of sexual and gender minorities explore the association between depression and the domains of internalized homophobia.

Conclusions

The findings of the present study reinforce the crucial role of internalized homophobia in the prevalence of depression among homosexual individuals. Therefore, public policies must contain mechanisms that promote societies with reduced levels of homophobia among homosexual individuals in order to promote improvements in the mental health of these individuals.

Acknowledgments

TS Batista and FMP Tavares are scientific initiation scholarships funded by the Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG).

References

Publication Dates

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