Catholic Medical Quarterly Volume 71(1) February 2021

Sexual Orientation Health Disparities: A Critique of the Minority Stress Theory

Christopher H. Rosik, Ph.D. and Andre Van Mol, M.D.

The aim of this critique is to answer two questions:

(a)    To what extent are health disparities between heterosexual and non-heterosexual orientations a function of sexual orientation specific minority stresses (e.g., prejudice, discrimination, harassment, etc.) and

(b)    What other factors may influence such discrepancies in psychological and physical health?

Health Disparities and Minority Stress.

It is well established in the literature that lesbian, gay, and bisexual (LGB) identified persons report poorer health than their heterosexual counterparts across several health dimensions [1, 2].

Minority stress theory postulates that experiencing or even fearing stigma specifically related to one’s LGB identity arouses feelings of distress that can have profound consequences for the well-being of LGB identified persons [3]. Yet it is less clear the extent to which objective orientation-specific forms of minority stress are responsible for health differences.

Meta-analytic research (which summarize results over multiple studies) provides perhaps the most reliable estimates on the association between per­ceived discrimination and health outcomes. These studies indicate the strength of this relationship is significant but small, with minority stresses (orientation specific or not) directly explaining less than 9% of the relationship [4-6]. In terms of the scientific literature, then, it appears the direct impact of minority stressors should neither be dismissed as a factor in health disparities nor offered as the sole or dominant influence. Clearly, sexual orientation stigma and discrimination alone are far from a complete explanation for greater psychiatric and health risks among non-heterosexual orientations.

This suggests that the strict adherence to a minor­ity stress explanatory model within the medical and psychological disciplines may actually be doing a significant disservice to LGBT identified persons. Factors behind health disparities may be overlooked when they do not accord with the assumptions of what has been termed equalitari­anism, a “sacred value” strongly associated with liberalism and positing the only reason groups differ is because of prejudice and discrimination [7]. Consequently, insights and interventions that might derive from other factors may be left undeveloped and thus unable to improve the lives of LGBT identified persons.

Another critical element in understanding sexual orientation health disparities is to remember that the research in this area is almost entirely reliant upon self-reports of perceived discrimination, and the relation of this to objective discrimination is not well understood. Self-report data make it difficult to tell how much of the association between perceived discrimination and well-being or psychological distress reflects the effects of perceptions of discrimination per se and how much is the effect of actual encounters with discrimination and negative treatment[6].

Broadening Minority Stress: Alternative Theories

The relationship of sexual orientation related stigma and discrimination to psychological and physical well-being among LGB identified persons is undoubtedly complex, and no single theory is likely to provide a universal explanation. Important alternative theories have been proposed to challenge or supplement the causal assumptions of the minority stress view.

Mediation theories. Some theories with empirical support suggest that other factors indirectly mediate the pathways linking discrimination and stigma with disparities in LGB psychological health [8]. Specific sexual orientation discrimina­tion or stigma may be minimally related to psychological distress and physical health in the absence of certain intra- or interpersonal processes [9,10]. These processes may include emotion /avoidant-based coping mechanisms, passive coping styles, an inability to regulate one’s negative emotions, rumination (the tendency to passively and repetitively focus on one’s distress and distress-related circumstances), rejection sensitivity, relational loss, and the stress of living with HIV/AIDS or other related physical ailments.

Non-heterosexual lifestyle theory. This perspective posits that LGB lifestyles are inherently riskier than those of heterosexuals because of certain features of LGB social communities [11]. Schumm has suggested that differences in conduct between non-heterosexuals and heterosexual persons rather than sexual orientation identity may lead to or reinforce discrimination [10]. These behaviors may include antisocial behaviors, unsafe sexual practices, and drug use.

Common factors theory.

This theory asserts that the elevated health problems among non-heterosexuals could be directly or indirectly due to genetic or environ­mental “common causes” of both health risks and non-heterosexuality [11]. Gender nonconformity, and divergence in behavior, personality, and perceived identity from those typical of one’s sex are likely influenced by the same genetic and neurodevelopmental factors as non-heterosexual­ity, and therefore may be linked to both victimiza­tion and mental health regardless of sexual orientation. Other personality traits may be implicated as common causes as well. Increased internalizing (e.g., self-harm) and externalizing risk behaviors (e.g., sexual risk taking) may be due to direct or indirect shared genetic effects between non-heterosexuality and neuroticism or sensation seeking, rather than non-heterosexuality per se. Common causes could also be environmental. For example, to the extent the same environments (e.g., large cities, college campuses, night clubs) that provide opportunities for exposure to sexually arousing stimuli also provide opportunities for engagement in various risk behaviors or carry other health risks, this could be a common cause for both health risks and non-heterosexuality.

Stress sensitization theory.

There is substantial evidence that LGB identified persons have much greater prevalence of adverse childhood experiences (ACEs), including emotional, physical, and sexual abuse [12]. The Stress Sensitization Model hypothesizes child­hood adversity and trauma sensitize individuals to subsequent stress and increase reactivity via both psychological and physiological mechanisms that decrease one’s ability to regulate emotions[13], heightening perceptual tendencies that may moderate and amplify the experience of minority stress.Anatomical differences. In addition, some dispro­portionately distributed medical conditions, such as sexually transmitted diseases (including HIV) among men having sex with men (MSM), may be influenced by stigma but are ultimately grounded in biological reality. One comprehensive review found an overall 1.4% per-act probably of HIV transmission for anal sex and a 40.4% per-partner probability [14]. The authors noted, “The 1.4% per-act probability is roughly 18-times greater than that which has been estimated for vaginal in­tercourse” (p. 5). In addition, sexually transmitted infections other than HIV/AIDS have been found in 35.6% of MSM compared to 6.6% of a matched population sample of men having sex with women [15].


This brief overview of sexual orientation health disparities has established science-based answers to our initial questions. First, although the direct effects of sexual orientation specific minority stress should not be dismissed as a potential influence in health-related differences, these effects do not appear to be predominant. There­fore, it is scientifically and ethically irresponsible to neglect consideration of other possible intrap­ersonal, relational, and behavioral influences on these health disparities. Second, among the more theoretically plausible additive or alternative theories to minority stress deserving greater con­sideration are those focusing on mediational, lifestyle, common factors, stress sensitization, and anatomical contributions. Unfortunately, the expansion of our understanding of the factors responsible for sexual orientation health disparities may be hampered by an ideological homogeneity among social scientists in this field of study [16].


  1. Kiekens WJ, La Roi C, Dijkstra, JK. Sexual identity dis­parities in mental health among U.K. adults, U.S. adults, and U.S. adolescents: Examining heterogeneity by race/ethnicity. Psychology of Sexual Orientation and Gender Diversity. 2020. Advance online publication.
  2. Semlyen J, King M, Varney J, Hagger-Johnson G. Sexual orientation and symptoms of common mental disorder or low wellbeing: Combined meta-analysis of 12 UK popu­lation health surveys. BMC Psychiatry. 2016 March 24; 16, 1-9.
  3. Meyer, IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin. 2003 Sept; 129(5), 674-697.
  4. Jones KP, Peddie CI, Gilrane VL, King EB, Gray AL. Not so subtle: A meta-analysitc investigation of the correlates of subtle and overt discrimination. Journal of Man­agement. 2016 June; 42(6): 1588-1613.
  5. Pascoe EA, Richman LS. Perceived discrimination and health: A meta-analytic review. Psychological Bulletin. 2009. 135(4): 531–554.
  6. Schmitt MT, Branscombe NR, Postmes T, Garcia A. The consequences of perceived discrimination for psychological well-being: A meta-analytic review. Psychological Bulletin. 2014. 140(4); 921-948.
  7. Clark CJ, Winegard BM. Tribalism in War and Peace: The Nature and Evolution of Ideological Epistemology and Its Significance for Modern Social Science. Psychological Inquiry. 2020, Jan-Mar; 31(1);1-22.
  8. Hatzenbeuhler ML. How Does Sexual Minority Stigma “Get Under the Skin”? A Psychological Mediation Frame­work. Psychological Bulletin. 2019; 135(5): 707–730.
  9. Sandfort TG, Bakker F, Schellevis F, Vanwesenbeeck I. Coping styles as mediator of sexual orientation-related health differences. Archives of Sexual Behavior. 2009 Apr; 38(2): 253–263.
  10. Schumm WR. Intergenerational transfer of parental sexual orientation and other myths.
    International Journal of the Jurisprudence of the Family. 2013; 4: 267-433.
  11. Williams RC, Vrangalova Z. Mostly heterosexual as a distinct sexualorientation group: A systemic review of the empirical evidence. Developmental Review, 2013 March; 33(1): 55-88.
  12. Blosnich, JR, Anderson JP. Thursday’s child: the role of adverse childhood experiences in explaining mental health disparities among lesbian, gay, and bisexual US adults. Social Psychiatry and Psychiatric Epidemiology. 2015 Feb; 50(2): 335-338.
  13. Hammen C, Henry R, Daley SE. Depression and sen­sitization to stressors among young women as a function of childhood adversity. Journal of Consulting and Clinical Psychology. 2000 Oct; 68(5): 782-787.
  14. Beyer C, Baral SD, van Griensven F, Goodreau SM, Chariyalertsak S, Wirtz A, Brookmeyer R. Global epidemiology of HIV infection in men who have sex with men. The Lancet. (2012, July 28); 380: 366-377.
  15. Swartz JA. (2015). The relative odds of lifetime health conditions and infectious diseases among men who have sex with men compared with a matched general population sample.American Journal of Men’s Health. 2015 Mar; 9(2):150-62.
  16. Duarte JL, Crawford JT, Stern S, Haidt J, Jussim L, Tetlock PE. (2015). Political diversity will improve psy­chological science. Behavioral and Brain Sciences. 2015; 38:e130.>

Christopher H. Rosik, Ph.D.,

is currently a psychologist and director of research at Link Care Center in Fresno, California, as well as a clinical faculty member of Fresno Pacific University. He has published more than 50 articles in peer reviewed journals on topics including sexual orientation and lectured across the U.S. and in Europe. Dr. Rosik has served as President of the Western Region of the Christian Association for Psychological Studies (CAPS) and the Alliance for Therapeutic Choice and Scientific Integrity. He is a member of the American Psycholog­ical Association, International Society for the Study of Trauma and Disociation, and the National Association of Social Workers.

For more on the mental and physical health correlates of Homosexuality and Trans-sexuality please see Treloar A (2019) Transgender, from a medical and a Christian perspective. Catholic Medical Quarterly Volume 70(4) November 2020.