Muhammad Hadi Malik,Shahid Iqbal,Muhammad Noman,Zouina Sarfraz,Azza Sarfraz,Shabbir Mustafa
Mental Health Disparities Among Homosexual Men and Minorities: A Systematic Review
gay and bisexual,men,sexual minority,mental health,psychiatric care
Mental health disparities in sexual minorities, particularly homosexual and bisexual men, are a significant public health concern. This study examines six key themes: general psychiatric issues, health services, minority stress, trauma and PTSD, substance and drug misuse, and suicidal ideation. The aim is to provide a comprehensive synthesis of the evidence, identify potential intervention and prevention strategies, and address knowledge gaps in understanding the unique experiences of homosexual and bisexual men. Reported as per the PRISMA Statement 2020 guidelines, PubMed, PsycINFO, Web of Science, and Scopus were searched until February 15, 2023, with no language restrictions. A combination of the following keywords and MeSH terms was used: homosexual, bisexual, gay, men who have sex with men, mental health, psychiatric disorders, health disparities, sexual minorities, anxiety, depression, minority, stress, trauma, substance, drug misuse, and/or suicidality. Out of 1,971 studies located through database searching, 28 were included in this study pooling a total of 199,082 participants from the United States, the United Kingdom, Australia, China, Canada, Germany, the Netherlands, Israel, Switzerland, and Russia. Thematic findings of all the studies were tabulated and thereby synthesized. Addressing mental health disparities in gay, bisexual men, and sexual minorities requires evidence-based, comprehensive approaches, culturally competent care, accessible services, targeted prevention strategies, community-based support, public awareness, routine screenings, and research collaboration. This inclusive, research-informed approach can effectively reduce mental health issues and enable optimal well-being in these populations.
Mental Health Disparities Among Homosexual Men and Minorities: A Systematic Review

Mental health disparities in sexual minorities, particularly homosexual and bisexual men, are a significant public health concern. This study examines six key themes: general psychiatric issues, health services, minority stress, trauma and PTSD, substance and drug misuse, and suicidal ideation. The aim is to provide a comprehensive synthesis of the evidence, identify potential intervention and prevention strategies, and address knowledge gaps in understanding the unique experiences of homosexual and bisexual men. Reported as per the PRISMA Statement 2020 guidelines, PubMed, PsycINFO, Web of Science, and Scopus were searched until February 15, 2023, with no language restrictions. A combination of the following keywords and MeSH terms was used: homosexual, bisexual, gay, men who have sex with men, mental health, psychiatric disorders, health disparities, sexual minorities, anxiety, depression, minority, stress, trauma, substance, drug misuse, and/or suicidality. Out of 1,971 studies located through database searching, 28 were included in this study pooling a total of 199,082 participants from the United States, the United Kingdom, Australia, China, Canada, Germany, the Netherlands, Israel, Switzerland, and Russia. Thematic findings of all the studies were tabulated and thereby synthesized. Addressing mental health disparities in gay, bisexual men, and sexual minorities requires evidence-based, comprehensive approaches, culturally competent care, accessible services, targeted prevention strategies, community-based support, public awareness, routine screenings, and research collaboration. This inclusive, research-informed approach can effectively reduce mental health issues and enable optimal well-being in these populations.

Mental health disparities among sexual minorities, specifically homosexual and bisexual men, represent a significant public health concern. Despite the growing body of research on this subject, sexual minority (SM) individuals continue to experience higher rates of mental health issues when compared with their heterosexual counterparts (Reczek, 2020). This phenomenon is likely multifaceted, stemming from various psychosocial and environmental factors, including discrimination, stigma, and minority stress (Correro & Nielson, 2020). To address knowledge gaps, the present systematic review aims to provide a comprehensive synthesis and evaluation of the available evidence on mental health disparities among homosexual, bisexual men, and sexual minorities. This systematic review will focus on six key themes: general psychiatric issues, health services, “minority stress,” trauma and PTSD, substance and drug misuse, and suicidal ideation. The first theme in this systematic review will explore general psychiatric issues prevalent among homosexual and bisexual men and other sexual minorities. Research has indicated that these populations experience higher rates of mood disorders, anxiety, and other mental health conditions compared with their heterosexual counterparts. The second theme will focus on access to and utilization of health services by homosexual and bisexual men and less advantaged peers than their heterosexual counterparts. Given the unique mental health challenges faced by these individuals, understanding the barriers and facilitators to access appropriate mental health care is crucial. This theme will consider the role of culturally competent and affirmative mental health services in addressing these disparities. The third theme will delve into the concept of “minority stress” as a key factor contributing to mental health disparities among homosexual and bisexual men and sexual minorities. Minority stress refers to the unique stressors experienced by individuals belonging to marginalized groups, which can have a significant impact on their mental health. The fourth theme of this systematic review will address the prevalence and impact of trauma and post-traumatic stress disorder (PTSD) among homosexual and bisexual men and sexual minorities. This population may be at an increased risk of experiencing trauma due to factors such as hate crimes, harassment, and intimate partner violence. The fifth theme will examine the issue of substance and drug misuse among homosexual and bisexual men and sexual minorities. Research has suggested that this population is more likely to engage in substance and drug use because of increased minority stress/increased psychosocial risk factors, which can have significant implications for their mental health (Abreu et al., 2023; Flenar et al., 2017). The sixth and final theme of this systematic review will focus on suicidal ideation among homosexual and bisexual men and sexual minorities. Studies have consistently reported higher rates of suicidal ideation and suicide attempts in this population. The relationship between sexual orientation and mental health has been the subject of increasing research efforts over the past few decades. However, most of the literature up until now (February 15, 2023) has focused primarily on the experiences of lesbian, gay, and bisexual (LGB) individuals as a single, homogeneous group (Russell & Fish, 2016). This approach fails to account for the unique experiences of homosexual and bisexual men, whose mental health outcomes may differ from other SM populations. The existing literature predominantly concentrates on negative mental health outcomes, neglecting the potential for resilience and protective factors within this population (Ramirez & Paz Galupo, 2019). This systematic review investigates the underlying mechanisms contributing to mental health disparities among homosexual and bisexual men, with an emphasis on identifying potential avenues for intervention and prevention strategies.

This systematic review is reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement 2020 guidelines to ensure a rigorous and transparent methodology. This study, focused on analyzing existing literature, does not involve primary data collection or interaction with human participants, and therefore, is exempt from obtaining ethical approval. The research poses no potential risks or harm to any subjects, adhering to the relevant institutional guidelines. The protocol for this systematic review is registered in the Open Science Framework (OSF): osf.io/3n6q9.

The study selection process involved a comprehensive search of electronic databases, including PubMed, PsycINFO, Web of Science, and Scopus. The search strategy employed a combination of keywords and MeSH terms related to mental health, disparities, and sexual minorities. The Boolean logic was applied (and/or), with the following keywords: Homosexual, Bisexual, Gay, Men who have sex with men, Mental health, Psychiatric disorders, Health disparities, Sexual minorities, Anxiety, Depression, Minority, Stress, Trauma, Substance, Drug misuse, and/or Suicidality. The search string is appended in Supplementary Table 1. Reference lists of relevant articles and previous systematic reviews were screened to identify additional studies (umbrella methodology). Only publications in the previous 10 years (January 2012 to February 15, 2023) were included with no restrictions on the language (i.e., non-English studies were translated to English). Two independent reviewers screened titles and abstracts of the identified articles for potential eligibility. Full-text articles were obtained for further assessment, with any disagreements between the reviewers resolved through discussion or consultation with a third reviewer. The bibliographic management tool utilized in this study was EndNote X9 (Clarivate Analytics).

Original empirical research, including observational, cross-sectional, and longitudinal studies. Studies focusing on mental health disparities among homosexual, bisexual men, and sexual minorities. Studies providing quantitative or qualitative data on the key themes of the review (General Psychiatric issues, Health Services, “Minority Stress,” Trauma and PTSD, Substance and Drug Misuse, and Suicidal Ideation).

Non-empirical articles, such as editorials, commentaries, and narrative reviews. Studies that do not provide sufficient data on mental health disparities among the target population. Studies that solely focus on heterosexual populations or do not differentiate between sexual orientation groups in their analysis.

The data from the included studies were extracted using a standardized data extraction form to maintain consistency and reduce potential bias. The extracted data were thereby organized under the following headings: author and year, title, study type, inclusion/selection criteria, scale/questionnaire used, location, participants, and key findings. All reviewers conducted the data extraction process, with any discrepancies resolved through discussion or consultation with the last reviewer. This approach enhanced the reliability and validity of the extracted data. The extracted data were synthesized through a narrative synthesis approach, which involved organizing and summarizing the findings in a coherent and structured manner. This method allowed for a thorough examination of the included studies, taking into consideration the various factors that may have contributed to the observed mental health disparities among homosexual and bisexual men and sexual minorities. The narrative synthesis was organized according to the key themes identified during the data extraction process. For each theme, a summary of the relevant findings was presented, followed by a summary of the results of the different studies. This synthesis highlighted potential patterns or trends that emerged. The presentation of the synthesized data involved a combination of textual descriptions and tabulation. The textual descriptions provided a detailed summary of the key findings, focusing on the prevalence, risk factors, and underlying mechanisms of mental health disparities among homosexual and bisexual men and disenfranchised groups/minorities. Whereas, the table was used to organize and display the extracted data in a structured and accessible format. This allowed for a clear and concise presentation of the study characteristics, participant demographics, mental health outcomes, and key findings related to the themes.

The methodological quality and risk of bias of the included studies were assessed using appropriate tools based on the study design. The Cochrane Risk of Bias tool for randomized controlled trials (ROB 2) and the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool were utilized for randomized and non-randomized trials. The Newcastle–Ottawa Scale (NOS) checklist was used for observational studies. Risk of bias assessments was conducted independently by two reviewers, with any discrepancies resolved through discussion or consultation with a third reviewer.

In the identification phase, 1,971 studies were located of which 183 duplicates were removed. In the screening phase, 1,788 titles and abstracts were screened; of those, 231 studies were sought for retrieval and assessed for full-text eligibility. Twenty-eight studies were included in this systematic review. The total participant count of all populations was 199,082. The PRISMA flowchart is illustrated in Figure 1. The findings are further elucidated below.

Seven studies were collectively presented for general psychiatric characteristics and outcomes (Chen et al., 2012; Gevonden et al., 2014; Gonzales et al., 2016; Hart et al., 2020; Hylton et al., 2017; Lyons et al., 2012; Price-Feeney et al., 2019). The total sample comprised 88,397 participants from Australia, China, the Netherlands, Russia, and the United States. One study was an interventional trial whereas the other six were cross-sectional observational studies. The studies are characterized in Table 1. Hart et al. (2020) reported on sexually transmitted diseases (STDs) and high HIV prevalence among gay and bisexual men globally. Their study provided evidence of a 10-session cognitive behavioral therapy (CBT) intervention to reduce substance use, social anxiety, and sexual risk behaviors in HIV-negative respondents. Post 10 sessions of CBT, the authors reported a 50% reduction in STD/HIV sexual risk behavior during the 6 months; reductions in problematic alcohol use and social anxiety were reported. Overall, CBT emerged as an efficacious approach to reducing HIV/STD risk behavior, social anxiety, and problematic alcohol use in gay and bisexual men (Hart et al., 2020). Price-Feeney et al. (2019) examined whether LGB youth living in a rural community had worse health status compared with heterosexual counterparts living in a nonrural community. The authors pooled a total of 5,100 youths aged 13 to 18 in the United States between 2010 and 2011. The findings underscored that LGB youth underwent more psychological and social challenges including depression, substance use, bullying, and low self-esteem over 1 year as compared with nonrural and rural heterosexual youth. The rural community living status was not a contributor to other challenges for the LGB youth. The study recommended that health care providers ensure an LGB-inclusive environment to promote self-disclosure and provide clinical services to address these psychosocial challenges (Price-Feeney et al., 2019). Hylton et al. (2017) led a cross-sectional survey study in Moscow, Russia between 2010 and 2013 and enrolled 1,367 MSM. The authors studied the relationship between recent stigma, sexual identity, and probable depression by applying logistic regression models. Depression was defined by a score of 23 or more on the Center for Epidemiological Studies Depression scale (CES-D). In total, 36.7% of participants had probable depression with bisexual men’s sexual identity acting as a protective factor against probable depression. Recent stigma led to increased chances of probable depression. An interaction was found between anti-gay laws and stigma. Among those that experienced stigma, there was a 1.67-fold increase in probably depression post the passing of anti-gay laws. The authors highlight the co-occurrence of depression among MSM in Russia, which was exacerbated by laws denying homosexual identity and recent stigma (Hylton et al., 2017). Gonzales et al. (2016) analyzed data from the 2013 and 2014 National Health Interview Survey. This was the first study to question self-identified sexual orientation to ascertain health outcomes from the leading U.S. health survey. An analysis was conducted to compare health risks and health factors between LGB (gay, N = 624 and bisexual, N = 515) and heterosexual adults (N = 67,150). It was determined that LGB adults faced substantial disparities compared with their heterosexual counterparts; causes included stressors such as heavy drinking, severe psychological distress, and smoking. The authors further highlighted the need for sensitivity toward sexual minorities during health screening (Gonzales et al., 2016). Gevonden et al. (2014) investigated whether sexual minorities were at higher risk of developing psychotic symptoms due to overlapping stressors as ethnic minorities such as defeat, social exclusion, and discrimination. The authors conducted a national cross-sectional survey using the Composite International Diagnostic Interview of individuals between the age of 18 and 64 years (NEMESIS 1 and NEMESIS 2). A total of 11,235 LGB individuals were pooled. The participants were more likely to have experienced psychotic symptoms as compared with their heterosexual counterparts. Mediators of this association comprised bullying, childhood trauma, and discrimination. The study concludes that exposure to minority stress is a key mechanism that links psychosis and other mental health problems and minority status (Gevonden et al., 2014). Chen et al. (2012) assessed the social, behavioral, and psychological characteristics of MSM in China to understand the risks associated with HIV transmission. A total of 714 responses were analyzed where a high-risk and a control group were classified. MSM notably had high-risk behaviors including heavy alcohol consumption, intentional attempts of suicide, a history of sexual abuse in childhood, and a mistaken belief that HIV was protected through condom use alone. The authors reported that the two groups did not have significant differences in education levels, sexual orientation, drug use, discrimination, and social stigma experiences. The study concludes that interventions targeted at HIV and AIDS transmission among MSM must account for different psychological and social characteristics of the group with and without high-risk behaviors (Chen et al., 2012). Lyons and colleagues (2012) enrolled 1,135 gay males aged 40 years or older in an online survey. A nationwide study was conducted in Australia to explore the psychological impact of HIV in both HIV-positive and HIV-negative groups. The findings revealed that individuals with HIV were more likely to receive treatment for a psychiatric condition, but were not more likely to obtain treatment for a physical health condition other than HIV. Men with HIV reported higher levels of psychological distress. The underlying factors of poorer mental health included living alone, not working or lower income, experiencing discrimination, receiving treatment for a major health condition, and considering one’s sexual orientation as a key part of self-identity. The reported disparities in HIV-negative and positive gay men were larger for mental not physical health. The authors suggest that more attention is required to address the underlying psychosocial factors among those living with HIV (Lyons et al., 2012).

Three studies addressed health services for homosexual men and sexual minorities (Grov et al., 2013; Rimes et al., 2018; Stanley & Duong, 2015). The total participant count was 16,589 with studies from the United States and the United Kingdom. All three studies were observational and cross-sectional in nature. The characteristics of these studies are listed in Table 1. Rimes et al. (2018) compared clinical, sociodemographic, and treatment characteristics in adult patients who received psychological interventions from Improving Access to Psychological Therapies (IAPT) in London, UK. Data were reported for 3,744 men (N = 75, bisexual; N = 645, gay; and N = 3,024, heterosexual) who were analyzed for pre- and post-treatment changes. The findings suggested that bisexual men had higher chances of having depression caseness as compared with gay men; however, anxiety caseness was higher in the group as compared with heterosexual or gay men. Insignificant differences were reported for treatment outcomes otherwise. The authors highlighted the need to understand the reasons behind differential outcomes in the male groups; these included discrimination, stigma, or traumas about sexual orientation while obtaining therapy services or in daily life (Rimes et al., 2018). Stanley and Duong’s (2015) key objective was to test the correlation between mental health service utilization and sexual orientation among older gay and bisexual adults; they assessed the possible impact of excessive alcohol use, psychological distress, and self-perceived poor general health. The authors utilized data from the 2011 New York City Community Health Survey with a sample of 5,138 adults aged 50 or above. Logistic regression modeling was applied to determine the associations between mental health service use and sexual orientation, where it was revealed that LGB older adults were more likely than heterosexual counterparts to have utilized psychiatric medication and counseling. These trends were computed over 1 year. Alcohol use, distress, and self-perceived health were insignificant mediators of the correlation. Overall, LGB older adults faced difficulties in accessing mental health services, and further research was warranted to make more assertive conclusions (Stanley & Duong, 2015). Grov and colleagues (2013) identified the importance of five health issues, namely body image, drugs and alcohol, HIV and STDs, mental health, and smoking by pooling 660 bisexual and gay men in New York, USA. The authors applied a time-space sampling method in bathhouses and bars/clubs to collect data. Participants were assessed for recent sexual risk behavior, substance use, smart device use, and demographics. As opposed to previous research in the area, the authors identified that STDs and HIV were both received as the most important health issues. Mental health and drugs were rated high, suggesting the importance of HIV prevention in addressing these issues. Most of the respondents owned smart devices, suggestive of the usefulness of online platforms for health prevention and education in the target group (Grov et al., 2013).

Four studies specifically reported psychiatric problems with “minority stress” (Pachankis et al., 2015; Przedworski et al., 2015; Sattler et al., 2017; Wight et al., 2012). In total, 35,520 participants were assessed with origins from Germany and the United States. Three studies were observational in nature; one was a comparative, population-based study, with another being a retrospective cohort, and the third was a cross-sectional student health survey. One study was a randomized controlled trial. The studies are tabulated in Table 1. Sattler and colleagues (2017) aimed to investigate the mental health differences between gay and bisexual men compared with heterosexual males in Germany while assessing for stress in the sample. A total of 931 gay/bisexual male participants were assessed using the SCL-90-S questionnaire. Utilizing linear regression, the authors reported that bisexual and gay men had higher levels of mental health problems with stress being a significant predictor. Further research was suggested to manage and reduce the impact of “minority stress” on mental health outcomes among bisexual and gay men (Sattler et al., 2017). Pachankis et al. (2015) administered transdiagnostic cognitive behavioral therapy (CBT) to 63 adult gay and bisexual men to reduce minority stress, and improve health risks and mental health. A comparison of immediate treatment subjects was made to those on a 3-month waitlist group. The participants submitted self-reports and interviews of past-90-days behaviors. Transdiagnostic CBT significantly reduced alcohol use, depression, sexual compulsivity, and past-90-day condomless sex with casual partners. A moderate improvement in anxiety and heavy drinking was reported. The study intervention was considered potentially helpful in providing evidence-based treatment to LGB-affirmative adults (Pachankis et al., 2015). Przedworski et al. (2015) compared the mental health outcomes of SM and heterosexual college students. They collected data from the 2007 to 2011 College Student Health Survey, which enrolled 34,324 students across 40 institutes in Minnesota, USA. The findings revealed that SM groups including gay and bisexual students were more likely to report any psychiatric diagnosis along with mental distress as compared with heterosexual counterparts. All groups excluding “unsure men” had higher odds of experiencing two or more stressful life events. The study findings support the notion that the group experiences worse mental health outcomes and they may benefit from targeted structural, social, and individual interventions to address disparities (Przedworski et al., 2015). Wight and colleagues (2012) tested the correlation between mental health and stress in midlife and old gay-identified males. The authors did not account for HIV status and aimed to explore the impact of emotional support and mastery on this correlation, as well as the impact of same-sex marriage. Data was obtained within the United States of the Multicenter AIDS Cohort Study. A total of 202 participants aged 44 to 75 years were enrolled between 2009 and 2010. The findings revealed that SM stress including excessive HIV bereavements, gay-related stigma, and aging-related stress including fiscal concerns impacted mental health. A partial mediator correlation was found for the sense of mastery. On the contrary, being legally married was protective against stressors, whereas HIV status, education, and ethnicity/race had no noteworthy impact (Wight et al., 2012).

Two studies reported outcomes on trauma and PTSD (Blosnich et al., 2022; Lucas et al., 2018). A total of 19,306 participants were pooled from the United States. The studies were observational in nature. The studies are enlisted in Table 1. Blosnich et al. (2022) compared and investigated the differences in potentially traumatic events (PTEs) and probably posttraumatic stress disorder (PTSD) in a sample of 18,866 Vietnam veterans who self-identified as gay or bisexual (139 males at birth), compared with heterosexual respondents. Data were obtained from the 2016 to 2017 Vietnam Era Health Retrospective Observational study survey. A multivariable regression analysis was conducted where gay and bisexual veterans were reportedly more likely to have current probably PTSD and had experienced PTEs compared with heterosexual veterans. The differences in PTSD outcomes of LGB and heterosexual veteran groups were partially due to differential PTEs exposure. The authors conclude that sexual orientation is an imperative factor when accounting for mental health outcomes of LGB veterans (Blosnich et al., 2022). Lucas and colleagues (2018) compared the rates of military sexual assault (MSA), PTSD, and depression in non-LGB and LGB veterans. A total of 2583 participants were enrolled from the United States of which 110 were LGB and 330 were non-LGB veterans. The veterans were matched by gender and age. The findings indicated that LGB veterans were more likely to have experienced MSA and have higher rates of depression and probably PTSD. Overall, the authors find that MSA mediates associations with depression and PTSD in LGB veterans. The authors recommend that health care workers assess for MSA when caring for LGB veterans, particularly groups that meet psychiatric thresholds for depression and PTSD (Lucas et al., 2018).

Six studies focused on substance and drug misuse in gay, bisexual men, either alone or compared with heterosexual counterparts (Fallin-Bennett et al., 2017; Heffner et al., 2020; Ip et al., 2017; Jordan et al., 2014; Roth et al., 2018; Starks et al., 2019). Two of the studies were randomized trials; one was controlled and the second was a pilot, interventional trial. Four were cross-sectional surveys. A total of 10,944 participants were included from the United States and Canada. The studies are characterized in Table 1. Heffner and colleagues (2020) compared baseline characteristics and treatment outcomes in SM and non-SM smokers in bisexual versus gay smokers. The authors conducted a randomized controlled trial of two web-based cessation treatments. At enrollment, SM smokers screened positive for all the mental health conditions assessed and were more exposed to passive smoking at home. The differences in baseline traits did not translate into differential treatment outcomes. Cessation outcomes did not significantly differ in SM and non-SM smokers or within SM subgroups. Regardless, the SM smoking group’s willingness/ability to quit smoking could be further understood by taking into account their psychosocial profile for targeted interventions. While there were similar quitting rates in SM and non-SM smokers, the former group must be considered for a younger age, racial/ethnic minority status, lower socioeconomic status, and higher prevalence of mental health symptoms (Heffner et al., 2020). Starks et al. (2019) assessed the efficacy of a substance use module (SUM) and communication training (CT) training videos to reduce sexual HIV transmission and drug use in male couples. In total, 70 male couples, with a total of 140 MSM were randomized to four groups: (a) couples HIV testing and counseling (CHTC); (b) CT videos and CHTC; (c) SUM and CHTC; and (d) CT videos, SUM, and CHTC. The study substantiated that completing SUM without CT videos significantly reduced drug use with related problems. However, those that viewed CT videos retained a reduction during the 3- and 6-month follow-up period. The authors reported CHTC to be an effective method for delivering substance use interventions to MSM couples. No differences in sexual behaviors were observed among the groups (Starks et al., 2019). Roth et al. (2018) conducted bivariate and multivariate analysis by comparing bisexual and gay men for substance use patterns in the Momentum Study; participants were classified based on sexual attraction, self-identity, and sexual behavior while controlling for sociodemographic, sexual behaviors, and psychosocial factors. Bivariate analysis revealed that bisexual men had higher multiple substance use in all samples (p < .05). Heroin and nonprescription stimulants were significant in all multivariate regression models. The authors reported that bisexual men have higher substance use levels, lower education and income, and higher anxiety and depression scores compared with gay men. These findings suggest that tailored health programs are required for gay and bisexual men (Roth et al., 2018). Fallin-Bennett et al. (2017) examined the use of other tobacco products (OTP) among young adult LGB bar patrons; they assessed the relationship between intention to quit, past quit attempts, and binge drinking with OTP use. A cross-sectional survey of adults aged 18 to 26 years in nightclubs/bars in seven US cities between 2012 and 2014 was conducted. The findings revealed that the GB men were more likely to smoke electronic cigarettes, and hookah and use chew and snus. The authors highlighted the need for bar-based interventions to address the use of all forms of tobacco in SM, high-risk groups (Fallin-Bennett et al., 2017). Ip et al. (2017) assessed the misuse of anabolic-androgenic steroids (AAS) in homosexual men. AAS has notably been used to enhance body image based on studies from Australia and the United Kingdom, however, the trend has been reported minimally in the United States. Ip and colleagues compared heterosexual (N = 73) and homosexual (N = 220) male gym members in various districts in San Francisco. A 114-item survey was administered, where it was determined that 10% of homosexual men reported lifetime use of AAS. The respondents regularly engaged in high-risk injection practices and sexual behaviors, placing them at a greater risk of spreading and contracting HIV/other infectious diseases. In sum, the authors find that AAS and other enhancing drugs serve as a potential vector in spreading infectious diseases; therefore, it is necessary to be mindful of psychological health and sexual behavior characteristics in SM groups (Ip et al., 2017). Jordan et al. (2014) examined the differences in tobacco use between SM (LGBQ) and heterosexual youths in the United States. The Out, Proud, and Healthy survey for LGBQ youth and the Missouri Youth Tobacco Survey for general population youth were utilized for data. The results highlighted that while LGBQ youth-initiated smoking at a later age, they were more likely to be poly-tobacco users, current smokers, use cigarillos/cigars, and be exposed to secondhand smoke in vehicles. Increased odds of being a current smoker were associated with older age, LGBQ, female gender, using OTP, and being exposed to secondhand smoke in vehicles. The authors suggest the need for sexual orientation data to be collected in tobacco consumption surveys to address health disparities in LGBQ youth. Overall, LGBQ groups are at a high risk of secondhand smoke and tobacco use as compared with their heterosexual counterparts (Jordan et al., 2014).

Six studies addressed suicidal ideation in gay, bisexual men, either alone or compared with heterosexual counterparts (Diamond et al., 2012; Hill & Pettit, 2012; Lian et al., 2015; Lyons et al., 2019; Swannell et al., 2016; Wang et al., 2012). Five of the studies were cross-sectional studies, with two population-based surveys, two representative sample studies, and one retrospective study; one phase I/II controlled, interventional, clinical trial was included. The total participant count was 28,326 with locations including Australia, China, Israel, Switzerland, and the United States. The characteristics of these studies are enlisted in Table 1. Lyons et al. (2019) aimed to fill gaps in information on suicide epidemiology among gay individuals. Based on the National Violent Death Reporting System data obtained from 18 states in the United States between 2003 and 2014, the sociodemographic characteristics and suicidal circumstances were compared between gay male decedents and nongay male decedents. Logistic regression analysis was conducted to investigate associations between sexual orientation, suicide, and precipitating circumstances. The authors identified differences based on age, mechanism of injury, suicidal intent and planning, and precipitating circumstances. The study highlights the need for culturally sensitive suicide prevention efforts to account for the needs of sexual minorities (Lyons et al., 2019). Swannell et al. (2016) studied the relationship between sexual orientation, suicidality measures, and non-suicidal self-injury in Australian adults. A national, representative sample of 10,531 adults was included where males and females were analyzed separately by applying logistic regression models. The results revealed that SM individuals had a greater risk of self-injury and suicidality as compared with their heterosexual counterparts. Similarly, gay males were more likely to report suicide attempts and suicidal ideation as compared with heterosexual men. The study highlights the need for clinicians to openly discuss suicide and self-harming thoughts/behaviors with clients, particularly those who identify as sexual minorities. Therapeutic strategies are essential in enhancing personal/social resources and reducing internalized stigma (Swannell et al., 2016). Lian et al. (2015) studied the relationship between suicide and sexual orientation in Asian youth. In their cross-sectional study, 17,016 individuals aged 15–24 were included from Hanoi, Shanghai, and Taipei in China. The study identified that the overall prevalence of suicidal ideation and attempts in the past 12 months was higher in LGB youth as compared with heterosexual counterparts (12.8% vs. 8.1% and 4.0% vs. 2.4%, respectively). Suicidal attempts and ideation were reportedly the highest in Taipei, followed by Shanghai and Hanoi. The multivariate logistic regression analysis revealed that youth in Taipei were at higher risk of suicidal ideation. Overall, the findings suggest that suicidality was a common occurrence in Asian youth and urbanized cities (Lian et al., 2015). Diamond and colleagues (2012) aimed to modify attachment-based family therapy (ABFT) to fit suicidal LGB adolescents and gather initial efficacy data in an open trial. The study comprised two phases; the first involved a treatment development team that adapted ABFT to meet the unique need of suicidal LGB youth. The second consisted of enrolling 10 suicidal LGB youth that underwent 3 months of ABFT. The findings suggested that the population was responsive to family-based therapy as documented with significant decreases in depression, suicidal ideation, material attachment-related anxiety, and avoidance and with high treatment retention. The authors conducted the first-ever family-based treatment tested and adapted specifically for suicidal LGB adolescents. Larger samples are required testing to ensure that the results are more generalizable (Diamond et al., 2012). Hill and Pettit (2012) aimed to test a model explaining the relationship between suicidal ideation and sexual orientation in college students. The model proposed that thwarted belongingness and perceived burdensomeness could account for this association. A total of 198 LGB college students were enrolled who reported higher levels of suicidal ideation and perceived burdensomeness compared with their heterosexual counterparts. While perceived burdensomeness partially accounted for the relationship between suicidal ideation and sexual orientation, thwarted belongingness did not. An indirect effect was more pronounced in individuals who anticipated and perceived rejection due to sexual orientation. The authors highlight the importance of addressing perceived burdensomeness in prevention and interventional treatment efforts targeted at suicide reduction in SM groups (Hill & Pettit, 2012). Wang et al. (2012) examined suicidality risks in young men of different sexual orientations in Switzerland. In total, 571 participants whom either self-identified gay/bisexual men or other MSM were included. The findings of three probability surveys revealed that men under the age of 25 reported the highest 12-month suicidal ideation/suicide attempt prevalence. In gay/bisexual men between the age of 16 and 20, the lifetime prevalence of suicide attempts was 5.1% to 22%. The group was significantly more likely to report 12-month suicidal plans, ideation, and attempts. The ratios and prevalence of suicidal behavior varied among men based on age and sexual orientation. Overall, the study highlights the need for targeted suicide prevention strategies for men of diverse sexual orientations (Wang et al., 2012).

The risk of bias synthesis and quality assessment is presented in the Supplementary Materials summarizing the methodological quality of each study and highlighting potential limitations in the evidence base. Supplementary Figure 1 presents bias assessments of the included trials (non-randomized and randomized) using ROBINS-I and ROB 2 tools (Cochrane). The quality assessment of nonrandomized observational studies is presented in Supplementary Table 2 (NOS).

The results of this systematic review shed light on the mental health disparities among homosexual, bisexual men, and less advantaged peers than their heterosexual counterparts across various mental health dimensions. The studies reviewed in this analysis originate from different countries with the highest representation from the United States (N = 16), followed by Canada/Australia/China (N = 2 each). A wide range of methodologies (i.e., randomized controlled trials, open-label pilot-testing, observational cohorts, population-based studies) were applied involving diverse participant samples (i.e., urban/rural, different social/economic backgrounds). The key findings from these studies emphasize the complex and multifaceted nature of mental health disparities in this population, warranting further investigation and targeted interventions. This systematic review assessed seven studies reporting general psychiatric traits and outcomes in sexual minorities, emphasizing the need for tailored interventions and inclusive health care environments. The studies highlighted that sexual minorities face unique mental health challenges and risk behaviors, with minority stress being a crucial mechanism linking mental health problems to minority status. Factors such as stigma, discrimination, and trauma related to sexual orientation contributed to these disparities. Three cross-sectional, observational studies were examined, focusing on health services for homosexual men and sexual minorities, totaling 16,589 participants from the United States and the United Kingdom. The findings emphasized the complexities in accessing and utilizing mental health services among sexual minorities, suggesting that innovative approaches like online platforms may be beneficial in providing health prevention and education. This review examined four studies on psychiatric problems related to “minority stress,” totaling 35,520 participants from Germany and the United States. The findings highlighted the challenges disenfranchised groups/minorities face regarding mental health and stress, suggesting the need for tailored interventions and support to address disparities. Our review analyzed two studies that reported outcomes on trauma and PTSD among sexual minorities, with a total of 19,306 participants from the United States. The findings emphasized the increased vulnerability of SM veterans to potentially traumatic events (PTEs), posttraumatic stress disorder (PTSD), and depression compared with their heterosexual counterparts. The results underscored the importance of considering sexual orientation when addressing mental health outcomes in LGB veterans and suggested that health care providers should assess for military sexual assault (MSA) when caring for this population. Further research is needed to better understand the factors contributing to these disparities and to develop targeted strategies for supporting SM veterans experiencing trauma and PTSD. This systematic review examines six studies on substance and drug misuse in gay and bisexual men (10,944 participants from the United States and Canada) and six studies on suicidal ideation in gay and bisexual men (28,326 participants from Australia, China, Israel, Switzerland, and the United States). The studies reveal the need for tailored interventions and programs addressing substance misuse and suicide in these populations, as well as further research to understand contributing factors and develop targeted strategies. Key findings include the importance of understanding the psychosocial profile of SM smokers, efficacy of substance use modules and couples HIV testing and counseling for male couples, tailored health programs based on substance use patterns, bar-based interventions for tobacco use, anabolic-androgenic steroid misuse prevalence and associated high-risk behaviors in homosexual men, and higher risks of secondhand smoke and tobacco use in LGBQ youth. Regarding suicidal ideation, the studies emphasize the need for culturally sensitive suicide prevention efforts, open discussion of suicide and self-harming thoughts/behaviors with clients who identify as sexual minorities, the prevalence of suicidal ideation and attempts in LGB youth (particularly in urbanized cities), the potential efficacy of attachment-based family therapy for suicidal LGB adolescents, the role of perceived burdensomeness in suicidal ideation and sexual orientation, and targeted suicide prevention strategies for men of diverse sexual orientations. As of February 15, 2023, the scientific literature contains a limited number of systematic reviews and meta-analytical studies that specifically focus on mental health disorders in lesbian, gay, and bisexual individuals. For instance, King et al. (2008) conducted a systematic review between 1966 and 2005 to locate 25 studies. The authors reported a nearly two-fold rise in suicide attempts in the LGB population (Risk ratio: 2.47); similarly, the risk of anxiety and depression was nearly 1.5 times higher in the LGB population (RR: 1.54–2.58) (King et al., 2008). Escobar-Viera and colleagues (2018) published a systematic review focusing on the use of social media and depression in LGB populations by collating data between 2003 and 2017. The authors included 11 articles where cyberbullying was the most studied experience associated with suicidality and depression (Escobar-Viera et al., 2018). Strongylou and colleagues (2022) conducted a mixed-methods study examining remote mental health-seeking behaviors among GBM in Ireland and the United Kingdom during the COVID-19 lockdown period. Based on 1368 participants’ data, the authors identified that recent anxiety experiences and a previous mental health diagnosis were enabled in accessing resources during the lockdown (Strongylou et al., 2022). There are certain limitations of our study. First, some populations had confounders such as an add-on diagnosis of PTSD, which may have skewed mental health outcomes. Second, the inclusion of LGB populations may pose limitations in generalizability because analytical outcomes were grouped for SM women as well. Finally, an inherent participant bias is that not all SM participants may have reported stress, simply because they did not identify as “minorities.” Therefore, on certain counts, self-reporting bias exists. The recommendations and future directions are as follows: Culturally Competent Care: Health care providers should receive training in culturally competent care, enabling them to understand and address the unique challenges faced by sexual minorities. This will help build trust and rapport with patients, ensuring that they feel comfortable discussing their mental health concerns and substance misuse. Accessible Mental Health Services: Ensure that mental health services are accessible, inclusive, and non-judgmental for disenfranchised groups/minorities. This includes offering specialized support groups, therapy, and counseling services tailored to the needs and experiences of gay, bisexual, and other SM individuals. Targeted Prevention and Intervention Programs: Develop and implement targeted prevention and intervention programs that address the specific risk factors and mental health issues faced by gay, bisexual men, and sexual minorities. This includes substance misuse, trauma, PTSD, and suicidal ideation. These programs should be evidence-based and culturally sensitive. Community-Based Support: Encourage the development and promotion of community-based support networks for disenfranchised groups/minorities. This includes peer support groups, LGBTQ+ community centers, and safe spaces where individuals can share their experiences, access resources, and build resilience against minority stress. Public Awareness Campaigns: Launch public awareness campaigns that promote understanding, acceptance, and support for minorities. These campaigns should challenge stigma, discrimination, and misinformation surrounding LGBTQ+ mental health, and emphasize the importance of mental well-being for all individuals, regardless of their sexual orientation. Routine Screening for Mental Health Issues: Health care providers should routinely screen for mental health issues, trauma, substance misuse, and suicidal ideation in SM patients. Early detection and intervention are crucial for improving mental health outcomes in these populations. Ensuring confidentiality: Mental health care providers must ensure that confidentiality is maintained. This can be achieved by implementing privacy policies and procedures and ensuring that all staff is trained to handle sensitive information appropriately. Offer anonymous hotlines: Anonymous hotlines can provide individuals with a confidential and anonymous way to seek support and information about mental health concerns. These hotlines can be staffed by mental health professionals or trained volunteers. Research and Collaboration: Further research on mental health issues, minority stress, and risk factors specific to gay, bisexual men, and sexual minorities must be encouraged including effective prevention and intervention strategies tailored to these populations. Collaborations must be fostered between the medical scientific community, LGBTQ+ organizations, and policymakers to develop comprehensive solutions to address mental health disparities.

In conclusion, addressing the mental health disparities faced by gay, bisexual men, and sexual minorities necessitates a concerted effort from the health care community, medical professionals, and key stakeholders. A comprehensive approach, grounded in evidence-based practices, is vital to tackle the unique challenges experienced by these individuals. By adopting culturally competent care, ensuring the availability and accessibility of mental health services, devising targeted prevention and intervention strategies, cultivating community-based support systems, raising public awareness, conducting routine screenings for mental health issues, and promoting research and collaborative initiatives, it becomes possible to effectively reduce the burden of mental health issues such as minority stress, trauma, PTSD, substance and drug misuse, and suicidal ideation in these populations. Through a concerted, inclusive, and research-informed approach, society can pave the way for disenfranchised groups/minorities to access the necessary resources, support, and care required to attain and maintain optimal mental well-being.

Click here for additional data file. Supplemental material, sj-docx-1-jmh-10.1177_15579883231176646 for Mental Health Disparities Among Homosexual Men and Minorities: A Systematic Review by Muhammad Hadi Malik, Shahid Iqbal, Muhammad Noman, Zouina Sarfraz, Azza Sarfraz and Shabbir Mustafa in American Journal of Men's Health