present with stressors related to social environment and health care access. Similarly, Page (2004) explored the experiences with mental health services of self-identified bisexual men and women (n = 217) and found that the bisexual men had experienced greater stress related to their bisexual identity and that bisexual issues had played a more significant role in their decision to seek mental health services. Mathy (2002a,b) compared the mental health status of 73 transgender individuals and nonclinical samples of nontransgender women and men, either homosexual or heterosexual. The transgender individuals were more likely to report suicidal ideation and attempts, to take psychotropic medications, and to have a problem with alcohol relative to the nontransgender men and heterosexual women, but no such differences were found between the transgender and lesbian individuals. For the latter two groups, the author attributed the higher likelihood of mental health and substance use problems to their experiencing both heterosexism and sexism. Bockting and colleagues (Bockting et al., 2005a) compared baseline data from an intervention study of 207 transgender participants, 480 men who have sex with men, and 122 bisexually active women; the transgender individuals were most likely to report depression (52 percent versus 38 percent and 40 percent, respectively) and suicidal ideation (47 percent versus 31 percent and 32 percent, respectively). However, this study did not assess depression with a standardized instrument.

While more research has been conducted on mental health than on physical health conditions among LGBT adults, large gaps still remain in our understanding of mental health issues among LGBT people. There is conflicting evidence on the mental health status of LGB adults, and the existing research examining the mental health of transgender adults has limitations. It is clear, however, that deleterious effects on the mental health of lesbian, gay, and bisexual individuals result overwhelmingly from unique, chronic stressors due to the stigma they experience as a disadvantaged minority in American society (Meyer, 2003). Herek and Garnets (2007) note that sexual stigma leads to stress resulting from multiple types of “enacted stigma” (e.g., personal rejection and ostracism, discrimination, and criminal victimization), which can have serious and enduring psychological consequences. Beyond such direct manifestations of stigma, Herek and Garnets (2007) suggest there are pervasive effects of institutionalized stigma, or “heterosexism,” among gay, lesbian, and bisexual populations, such as denial of the right to marriage in most states, negative economic effects in the workplace, and frequent disenfranchisement from religious and spiritual resources needed to ameliorate the effects of stress.

Herek and Garnets (2007) also identify two other sources of stress experienced by sexual minorities: “felt stigma” and “self-stigma.” They contend that felt stigma—the subjective experience of stigma against one’s group, even without direct experience of enacted stigma—may often occur



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