Background
Sexual minority people include people who are lesbian, gay, bisexual (LGB), pansexual, omnisexual, queer, questioning, fluid, asexual and have other sexual orientations [
1], which we abbreviate as LGB+. LGB+ persons are considered a subgroup of the general population, or a sexual minority as their sexual identity, orientation, or practices differ from the majority of the society in which they live [
2]. Yet, estimates of the proportion of people who belong to this subgroup are generally lacking since questions pertaining to sexual orientation are rarely integrated in representative population studies [
3,
4]. In 2019, the Organisation for Economic Co-operation and Development (OECD) reported that in the 14 OECD countries where LGB+ estimates were available (i.e., Australia, Canada, Chile, France, Germany, Iceland, Ireland, Mexico, New Zealand, Norway, Sweden, United Kingdom, and the U.S.), 2.7% of the adult population identified as LGB [
3]. For Belgium, national representative estimates of LGB+ persons are lacking. Yet, some representative regional estimates suggest that three to 8 % of the Flemish population identifies as LGB+ [
5,
6]. For the Walloon region in Belgium, prevalence estimates are not available to our knowledge.
With this study, we want to contribute to the knowledge about the LGB+ persons in Belgium based on representative population data because the current lack of data regarding sexual orientation in population studies or census data limits our understanding of the size of the LGB+ population and their health outcomes [
4,
7].
Although the available evidence is limited, Belgian studies based on convenience samples almost consistently show an association between identifying as LGB+ and negative mental health outcomes [
8‐
11]. The evidence suggests that LGB+ persons are more at risk of developing certain mental disorders compared to heterosexual persons, such as depression, anxiety, suicide attempts or suicides, and substance-related problems [
12‐
16]. Poorer health among LGB+ persons compared to heterosexual persons is most often explained by lifestyles and associated differences in sociodemographic situations [
17‐
19] resulting in LGB+ persons showing more general risk factors for experiencing mental health problems (i.e., exposure to violence and abuse, sensation seeking, family factors, a lack of social support, financial difficulties etc.) [
18‐
23]. Minority stress has been proposed to explain this observed increased risk [
18,
24‐
27]. As such, studying minority stress is relevant to health outcomes research, particularly in studies regarding LGB+ persons. It refers to stress experienced as a result of one’s stigmatized social position by belonging to a minority. A person’s minority status can be the result of self-identification with a minority group as well as by appointment by others as a member of a minority group [
24].
Minority stress theory describes the ways in which the everyday stress of living as a societal minority has a negative impact on the well-being [
16,
28]. In addition to everyday stressors, distinct sexual minority experiences including victimization, prejudice and discrimination, negatively influence the well-being and health of this population disproportionately [
16,
24]. Minority stress adds to general stressors, requiring an additional effort to cope with the stressful situation and should be considered as a chronic and socially based phenomenon since it is related to underlying social and cultural structures and processes beyond the individual level [
24].
Minority stress emerges from three stress processes [
24]. First, LGB+ persons experience distal objective external stressors which include all forms of structural or institutionalized discrimination and prejudice as well as direct interpersonal victimization experiences. These distal stressors occur independently of personal identification with the minority group. More centrally at play are processes involving anticipated social rejection or victimization which elicit vigilance related to these expectations. The third and most proximal process is the internalization of negative social attitudes, also known as internalized stigma/homophobia [
16,
24,
29]. These processes are the most subjective since they rely on an individual’s perceptions and appraisals, and are related to self-identification as sexual minority. The concealment of one’s sexual identity can be seen as a proximal stressor since the associated stress effects are considered to stem from internal psychological processes. When something is central to one’s identity, being unable to safely express this part of oneself negatively affects a person’s well-being. Shaping and accepting an identity which is different from that of the dominant group and elicits shame and negative attributions, may result in internal conflicts. Accordingly, internalized stigma has repeatedly been linked to mental health problems [
8,
13,
21,
24,
30,
31]. Intrapersonal psychological processes such as coping, emotion regulation and appraisals, mediate the link between experiences of minority stress and mental disorders [
13,
16,
26,
32]. On the other hand, experiencing social support and positive social relations with both LGB+ and non-LGB+ persons has been identified as a potential protective factor [
18,
21,
23,
24,
26,
33,
34].
Evidence regarding sexual minority mental health predominantly stems from data collected in student populations in the United States of America (USA). The Western-European cultural climate differs in terms of tolerance towards sexual and gender diversity [
35,
36] and as such, the minority stress theory may potentially be less or differently applicable. First, because levels of minority stress experienced by Western-European LGB+ persons may be lower than experienced by American LGB+ persons as a result of more tolerant attitudes towards LGB+ persons in Western-Europe than in the USA, and secondly, because the pathways linking minority stress to mental health may be different. Yet, a national protective legal framework does not necessarily imply full social acceptance by civilians [
37]. Although Belgium placed second on the Rainbow Index for the second time in a row in 2021 [
36], LGB+ persons still experience ‘othering’ - a set of dynamics, processes, and structures which define and label some individuals or groups as not fitting in within the norms of a social group - and face stigma, prejudice and discrimination [
38,
39]. Thus they may also experience minority stress and associated negative mental health outcomes.
The current study
This study aimed to estimate the proportion of inhabitants of Belgium who self-identify as LGB+. In addition, we wanted to explore whether LGB+ individuals in our sample also identify as belonging to a sexual minority group in Belgium. Although LGB+ persons are often referred to as sexual minority people, this does not necessarily imply that LGB+ persons consider themselves to be part of a minority group in Belgium. Further, we wanted to study whether they experienced minority stress, and if their mental health outcomes vary depending on their self-identification as LGB+, as minority, and the importance for their identity they ascribe to their sexual orientation.
Our study had five specific objectives. First, we wanted to identify the proportion of persons who self-identify as LGB+ and as heterosexual in the Belgian population based on representative data (1). Second, we wanted to compare the observed mental health in LGB+ persons to that of heterosexual persons in our sample (2). We hypothesized that LGB+ identifying persons will report poorer mental health than heterosexual-identifying persons (Hypothesis 1).
Next, we focused on the proportion of LGB+ persons who also identify as belonging to a minority group in Belgium because of their sexual orientation (further referred to as ‘sexual minority’) (3) and examined whether they considered this minority status to be an important element for their identity (4). This resulted in three comparison groups: (a) those LGB+ participants who do not identify with a minority group related to their sexual orientation; (b) those LGB+ participants who do identify with a minority group related to their sexual orientation (sexual minority), but who do not consider this to be key for their identity; and (c) those LGB+ participants who do identify as sexual minority and who do consider this to be important for their identity. Based on this classification, we compared the observed mental health outcomes in these three groups (5) to test the hypothesis that LGB+ participants who identify as sexual minority and consider this characteristic as central to their identity, would show worse mental health outcomes than the other two LGB+ groups (Hypothesis 2).
Results
Sample
The total sample consisted of 2300 male participants and 2332 female participants. The mean age of the sample was 39.07 years (SD = 17.02). In this sample, 4108 participants were born in Belgium. Out of those who were not born in Belgium, 231 persons held the Belgian nationality at the time of the survey. Further, 1020 persons had at least one parent who was not born in Belgium and 1316 persons had at least one grandparent who was not born in Belgium.
Table
1 summarizes the sociodemographic characteristics of the sample. In comparison to publicly available information on the level of education in the entire population, our sample appears to overrepresent higher educated people. Almost half of all respondents (i.e., 49.89%) completed a level of higher education, while - on the population level - 37.6% of Belgian residents between 15 and 64 years completed a higher educational level [
53].
Table 1
Sample composition (n = 4632) & sociodemographic information
Sex assigned at birth | | | 2.27; 1; .132; .022 | | | .539; 1; .463; .034 |
Female | 2083 (49.98) | 249 (53.66) | | 127 (52.05) | 122 (55.45) | |
Male | 2085 (50.02) | 215 (46.34) | | 117 (47.95) | 98 (44.55) | |
Age groups[mean (SD)] | 39.68 (17.12) | 33.63 (15.11) | 8.07; 603; <.001; .357* | 29.60 (13.07) | 38.10 (15.96) | 6.30; 415; <.001; .585* |
16–24 years old | 1254 (30.09) | 198 (42.67) | | 133 (54.50) | 65 (29.55) | |
25–49 years old | 1374 (32.96) | 174 (37.50) | | 86 (35.25) | 88 (40.00) | |
50–69 years old | 1540 (36.95) | 92 (19.83) | | 25 (10.25) | 67 (30.45) | |
Educational level | | | 10.44; 2; .005; .047 | | | 5.37; 2; .068; .108 |
Primary education or none | 255 (6.12) | 26 (5.60) | | 17 (6.97) | 9 (4.09) | |
Secondary education | 1803 (43.26) | 237 (51.08) | | 113 (46.31) | 124 (56.36) | |
Higher education | 2110 (50.62) | 201 (43.32) | | 114 (46.72) | 87 (39.55) | |
Occupational status | | | 25.39; 2; <.001; .074 | | | 31.84; 2; <.001; .262 |
Remunerated workforce | 2151 (51.61) | 196 (42.24) | | 99 (40.57) | 97 (44.09) | |
Student | 1034 (24.81) | 164 (35.34) | | 111 (45.50) | 53 (24.09) | |
Other | 983 (23.58) | 104 (22.41) | | 34 (13.93) | 70 (31.82) | |
Financial situation | | | 20.32; 1; <.001; .066 | | | 8.78; 1; .003; .138 |
Perceived as difficult | 3101 (74.40) | 300 (64.66) | | 173 (70.90) | 127 (57.73) | |
Perceived as easy | 1067 (25.60) | 164 (35.34) | | 71 (29.10) | 93 (42.27) | |
Gender | | | <.001° | | | .026° |
Man | 2076 (49.81) | 206 (44.40) | | 112 (45.90) | 94 (42.73) | |
Woman | 2083 (49.98) | 233 (50.21) | | 112 (46.90) | 121 (55.00) | |
Transman | 0 | 5 (1.08) | | 4 (1.64) | 1 (.45) | |
Transwoman | 0 | 1 (0.22) | | 1 (.41) | 0 | |
Other | 9 (.22) | 19 (4.09) | | 15 (6.15) | 4 (1.82) | |
The comparison of the distribution of men and women across different age groups in the entire population aged 16 to 69 and those in our sample is presented in Table
2.
Table 2
Sample weights. A comparison in distribution between the Belgian population and the study’s sample
16–24 years old | Female | 576,098 | 0.07 | 699 | 0.15 | 0.47 |
Male | 601,426 | 0.08 | 753 | 0.16 | 0.50 |
25–49 years old | Female | 1,864,081 | 0.24 | 815 | 0.18 | 1.33 |
Male | 1,883,527 | 0.24 | 733 | 0.15 | 1.60 |
50–69 years old | Female | 1,475,820 | 0.19 | 818 | 0.18 | 1.05 |
Male | 1,458,421 | 0.19 | 814 | 0.18 | 1.05 |
Total | 7,859,373 | 1.00 | 4632 | 1.00 | |
Sexual orientation
Table
3 shows an overview of the proportion of the self-identified sexual orientations in the total sample and per sex at birth. In total, 10.01% (
n = 464) identified with a sexual orientation label other than ‘heterosexual’ and were thus classified as LGB+. Male and female participants were equally likely to self-identify as LGB+ (χ
2 = 2.29; df = 1;
p = 0.131; V = 0.022), but male participants identified more often as gay and female participants as bisexual or pan−/omnisexual (χ
2 = 28.28; df = 1;
p < 0.001; V = 0.267).
Table 3
The proportion of participants per sexual orientation, presented in total and per sex at birth
Sexual orientation |
Heterosexual | 4168 (89.92) | 2085 (90.65) | 2083 (89.32) |
Bisexual | 179 (3.86) | 70 (3.04) | 109 (4.67) |
Gay/Lesbian | 129 (2.78) | 87 (3.78) | 42 (1.80) |
Pan−/Omnisexual | 88 (1.90) | 34 (1.48) | 54 (2.32) |
Asexual | 28 (0.60) | 8 (0.35) | 20 (0.86) |
Other | 40 (0.86) | 16 (0.70) | 24 (1.03) |
Minority identity
Among the LGB+ participants (n = 464), 67.03% (n = 311) indicated possessing at least one characteristic that made them member of a minority group in Belgium. In this group, 17.89% (n = 83) considered themselves to be a member of a cultural minority because of their skin color, ethnicity and/or religion/life philosophy, 53.45% (n = 248) indicated to belong to the group of sexual and gender minority people; 19.18% (n = 89) to a minority group because of another characteristic, and 19.61% (n = 91) indicated to belong to more than one of these three minority group.
From the total sample, 5.48% (n = 254) indicated belonging to a minority group because of their sexual orientation. Just over half of the LGB+ participants identified as belonging to a minority group because of their sexual orientation (52.59%, n = 244). When we select the LGB+ participants who indicated to belong to a minority group because of their sexual orientation, 63.31% (n = 157) said that this was important for their identity.
Mental health, quality of life and well-being
Table
4 presents the comparison between the observed mental health, quality of life, and well-being in heterosexual and LGB+ participants as well as the comparison of these variables between those LGB+ participants who identify as sexual minority and those who do not. Because each set of comparisons involved 12 independent tests, we adopted a Bonferroni-corrected significance level of .05/12 = .004 for these analyses.
Table 4
Observed mental health, quality of life, and well-being
Quality of lifea | 4.08 (0.72) | 3.79 (0.85) | 7.19; 540; <.001*; .395 | 3.84 (0.84) | 3.72 (0.85) | −1.53; 462; .127; .044 |
Resilienceb | 3.29 (0.74) | 3.02 (0.78) | 7.60; 4630; <.001; .433 | 2.96 (0.80) | 3.08 (0.76) | 1.57; 462; .117; .146 |
Depressionc | 4.83 (4.81) | 7.97 (6.68) | −9.85; 518; <.001*; .751 | 8.41 (6.68) | 7.48 (6.66) | −1.51; 462; .132; .140 |
Anxietyd | 4.85 (4.46) | 7.07 (5.47) | −8.42; 534; <.001*; .622 | 7.43 (5.36) | 6.67 (5.57) | −1.49; 462; .136; .139 |
PTSDe | 0.58 (1.22) | 1.28 (1.73) | −8.41; 516; <.001*; .585 | 1.26 (1.78) | 1.30 (1.68) | .23; 462; .817; .022 |
| n (%) | n (%) | X2; df; p-value; V | n (%) | n (%) | X2; df; p-value; V |
Number of trusted persons | | | 1.47; 1; .225; .018 | | | 17.00; 1; <.001; .191 |
0 to 3 | 2374 (57.19) | 279 (60.13) | | 125 (51.23) | 154 (70.00) | |
4 and more | 1777 (42.81) | 185 (39.87) | | 119 (48.77) | 66 (30.00) | |
Hazardous alcohol usef | | | .03; 1; .871; .029 | | | 2.66; 1; .103; .076 |
Yes | 1279 (37.88) | 174 (37.50) | | 100 (40.98) | 74 (33.64) | |
No | 2589 (62.12) | 290 (62.50) | | 144 (59.02) | 146 (66.36) | |
Sedative use | | | 19.41; 2; <.001; .065 | | | .03; 2; .986; .008 |
No | 2830 (67.90) | 268 (57.76) | | 141 (57.79) | 127 (57.73) | |
Lifetime | 561 (13.46) | 81 (17.46) | | 42 (17.21) | 39 (17.73) | |
Past 12-months | 777 (18.64) | 115 (24.78) | | 61 (25.00) | 54 (24.55) | |
Cannabis use | | | 37.79; 2; <.001; .090 | | | 3.87; 2; .145; .091 |
No | 3149 (75.55) | 301 (64.87) | | 152 (62.30) | 149 (67.73) | |
Lifetime | 607 (14.56) | 76 (16.38) | | 38 (15.57) | 38 (17.27) | |
Past 12-months | 412 (9.88) | 87 (18.75) | | 54 (22.13) | 33 (15.00) | |
Illegal drug use | | | 41.73; 2; <.001; .095 | | | 8.64; 2; .013; .136 |
No | 3923 (94.12) | 402 (86.64) | | 206 (84.43) | 196 (89.09) | |
Lifetime | 148 (3.55) | 31 (6.68) | | 14 (5.74) | 17 (7.73) | |
Past 12-months | 97 (2.33) | 31 (6.68) | | 24 (9.84) | 7 (3.18) | |
Suicide attempt | | | 113.12; 2; <.001; .156 | | | 5.05; 2; .080; .104 |
No | 3948 (94.72) | 380 (81.90) | | 194 (79.51) | 186 (84.55) | |
Lifetime | 188 (4.51) | 69 (14.87) | | 38 (15.57) | 31 (14.09) | |
Past 12-months | 32 (.77) | 15 (3.23) | | 12 (4.92) | 3 (1.36) | |
Self-harm | | | 227.13; 2; <.001; .221 | | | 6.77; 2; .034; .121 |
No | 3790 (90.93) | 319 (68.75) | | 155 (63.52) | 164 (74.55) | |
Lifetime | 280 (6.72) | 87 (18.75) | | 52 (21.31) | 35 (15.91) | |
Past 12-months | 98 (2.35) | 58 (12.50) | | 37 (15.16) | 21 (9.55) | |
From these findings, we derive that LGB+ participants reported poorer mental health, poorer quality of life, and poorer well-being than heterosexual participants. LGB+ persons reported significantly less resilience, more symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD), and more (illegal) drug use, self-harming behavior and suicide attempts. Yet, the only difference between these two groups with a medium effect size, concerns self-harming behavior. No significant difference between these two groups was found for hazardous alcohol use or reported number of trusted persons.
Within the LGB+ group, the difference in observed mental health, quality of life and well-being between those who identify as sexual minority and those who do not, appears less significant. A significant difference in proportions of number of trusted people was only found between identification as belonging to a sexual minority and those that did not identify as sexual minority (p < 0.001).
Within the sexual minority group, the difference in observed mental health, quality of life and well-being between those that find their sexual related characteristics important for their identity and those that do not, were not significant (
p > 0.05). These results were not added to Table
4 as none of the variables came out to be significant.
Respondents who self-identified as belonging to the sexual minority group reported an average of 1.88 (SD = 0.41) on the OBS-S (with scores ranging from 1 to 5 and where higher scores indicate greater minority stress). None of the respondents scored higher than 3.20, which means that no one reported a high level of minority stress (OBS-S value > 4). More than half (56%) of the respondents in the sexual minority group reported a high level of community connectedness (value > 4). The average community connectedness in this group is of 3.76 (SD = 0.84).
Respondents who self-identified as belonging to the sexual minority group and find their sexual orientation characteristics important for their identity scored significantly (t = − 3.23; df = 235; p < 0.001) higher on the OBS-S (mean of 1.95, SD = 0.41) compared to sexual minority respondents that did not find these same characteristics key to their identity (mean of 1.77, SD = 0.40). There was no significant difference between these two groups concerning the level of community connectedness (t = − 0.75; df = 245; p = 0.454).
Discussion
This study was the first to include sexual orientation-related questions in a Belgian national representative population study. Based on this sample, we estimate that 10.01% of the population in Belgium self-identifies as LGB+, which is a higher rate than the estimates from earlier non-representative samples ranging from three to 8 % in Flanders [
5,
6].
The most frequently reported non-heterosexual sexual orientation was bisexual (3.86%) followed by gay or lesbian (2.78%), pan- or omnisexual (1.90%), asexual (0.60%). A small number of 0.86% indicated to identify with a sexual orientation that was not mentioned in our list. Male and female participants were equally likely to identify with an LGB+ sexual orientation, but the distribution over the different LGB+ identity labels varied. LGB+ men were more likely than women to identify as gay, whereas women tended to label themselves more often as bisexual, pan−/omnisexual, asexual, or other compared to men.
Among the LGB+ participants, 67.03% identified with any minority group. Interestingly, only a little over half of the LGB+ participants indicated that they considered themselves as belonging to a minority group because of their sexual orientation (i.e., as sexual minority). This means that about half of this population either did not identify as belong to a minority at all or they did so because of another characteristic (e.g., because of their ethnicity, skin color, disability, age, …). LGB+ participants who did identify as part of a minority group were significantly older than those not identifying as belonging to a minority group. This could be explained by older participants potentially having been more exposed to othering experiences confirming their minority identities, but more research is needed to confirm this. Further, almost one in five LGB+ participants (19.61%) indicated to belong to more than one minority group. Qualitative research is needed to explore the relationship between self-labelling as LGB+ and the specific aspects of their minority identity. Future studies on LGB+ populations and sexual minority groups should thoroughly pilot their questionnaires given that our findings show that depending on the questions about sexual orientation versus sexual minority status, different study samples self-select. Participants who identify as LGB+ (n = 464) appear to be a different subgroup than those who identified as sexual minority (n = 254). Our findings suggest that using ‘LGB+ persons’ and ‘sexual minority people’ as synonyms will yield different prevalence rates and may introduce bias in estimating the proportion of non-heterosexual members of Belgian society.
In line with our expectations and previous international studies, we found mental health outcomes to be significantly worse for LGB+ participants than for heterosexual participants, although effect sizes were mostly small, with the exception of a medium effect size found for self-harming behavior. Contrary to what we expected, we could not detect any difference between these two groups in social support, as indicated by the number of trusted people. Studies on mental health disparities in minority groups often link the reported poorer mental health to sociodemographic variables [
17‐
19]. In our sample, no differences were found in educational level, occupational status, or financial situation between the heterosexual and LGB+ participants. As such, these sociodemographic variables do not explain the observed differences. These two compared groups did however show a difference in mean age: the LGB+ participants were significantly younger than the heterosexual participants. Younger persons tend to apply different defense mechanisms and coping strategies compared to older persons [
54], but more research is needed to study a potential age effect.
From the minority stress literature, we expected that among the LGB+ group, those who indicate to belong to a minority group report more mental health problems than participants without a minority identity. However, our findings did not support this proposition. There was only one exception: LGB+ participants who did not identify as minority reported significantly fewer trusted persons than self-identified minority people. Based on these findings, we cautiously hypothesize that LGB+ persons who do not identify with a minority group may experience less social support.
Moreover, within the LGB+ persons who identified as sexual minority, we found no significant differences in terms of mental health and well-being between those who considered sexual orientation related characteristics central to their identity and those who did not.
Also in contrast with our expectations and the international literature, the sexual minority group did not show high levels of minority stress. They also reported high levels of community connectedness, which may be linked to the more tolerant LGB+ climate in Belgium compared to other countries in the world [
38]. The majority however reported a maximum of three persons that they trusted, but this observation was not significantly different from the general population. Yet, it is important to consider here that we only asked questions related to minority stress to those LGB+ persons who indicated belonging to a minority group and as such, we selected a subgroup of the LGB+ persons in our sample. The outcomes of our study could have been different if we would have included the entire group of LGB+ participants.
Within this group however, we did find a significant difference in reported minority stress related to the importance attached to sexual orientation and gender related characteristics for one’s identity. This leads us to hypothesize that minority characteristics which are considered central to one’s core identity might elicit minority stress.
Our study does not allow to draw causal conclusions, but given the low reported minority stress in our sample, there is no evidence in our findings that it may explain the observed difference in mental health, quality of life, and well-being between heterosexual and LGB+ participants. It may however explain why we did not find a general significant difference within the LGB+ group between those who did and those who did not identify with a minority group.
Limitations
Although we strived for a perfect representative sample of the Belgian population, we recognize that the sample used in this study might differ from the general Belgian population in terms of educational level and language distribution. However, overrepresentation of participants with higher levels of education in research is common [
55‐
57]. Nevertheless, given the potential regional differences in LGB+ accepting climates and their impact on the mental health, quality of life, and well-being of LGB+ persons [
16,
24,
32,
38], future Belgian studies would benefit from balancing the language distribution and if possible the regional distribution over the Flemish, Brussels, and Walloon Region. Further, educational level may also impact our findings regarding experienced minority stress. We expect higher educated people to be more surrounded by other higher educated people. Higher educational status is positively linked to tolerant attitudes towards LGB+ persons [
58,
59].
In this paper, we limited the analysis to exploring findings in the LGB+ population based on one self-identification item. Based on this question, we cannot examine differences among LGB+ individuals who identify with other sexual orientations than those assessed in our survey. Further, sexual orientation can also be measured using multiple dimensions including self-labeling, sexual/romantic attraction and sexual partners and behavior. By applying multiple dimensions to identify LGB+ persons, more individuals with a non-heterosexual identity may have been considered. Large differences emerge when sexual orientation is measured via self-identification versus via sexual behavior or sexual attraction [
3,
4]. Lesbian, gay and bisexual identity estimates increase by 70% when respondents’ sexual behavior is considered (in addition to identity) and they double when sexual attraction is considered as a criterion [
3]. However, another part of the explanation may be linked to what Coffman et al. (2017) observed: LGB people seem less likely to disclose their identification with an LGB+ label in self-identification questions compared to disclosing the sex of their sexual partners or the persons to whom they feel sexually attracted to [
60]. Future studies could thus best measure the multiple dimensions of sexual orientation to get a better understanding of the sociodemographic characteristics, minority statuses, and associated health outcomes inherent to the subgroups defined based on sexual attraction, sexual behavior and sexual orientation labeling.
With regard to minority stress, we cannot examine its occurrence in LGB+ respondents who did not indicate that they are part of a minority group. Further research should present the items measuring minority stress to all LGB+ individuals – and by extension to total samples for comparison - regardless of whether they self-identify as belonging to a minority group or not. People may be exposed to stigma, prejudice and discrimination and potentially experience minority stress without this necessarily being associated with identifying that one has characteristics that may distinguish them from the majority of people in a given context.
Future studies could also benefit from exploring the relationship between internalized stigma, the importance attributed to minority characteristics and mental health. It is possible that internalized homophobia triggers LGB+ persons to devaluate their sexual minority characteristics to reduce internal conflicts.
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