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A new study published in JAMA Network Open looked at mental health disparities by sexual orientation and gender identity in the All of Us Research Program.

“Our study examined mental health disparities between sexual and gender minority (SGM) individuals and their cisgender heterosexual peers using data from the All of Us Research Program,” study author Junjie Anderson Lu told us. ”We wanted to understand how mental health conditions like anxiety, depression, PTSD, and others might differ across various sexual orientation and gender identity groups. This is particularly important because previous research has been limited by small sample sizes or lack of detailed data on SGM subgroups.”

The researchers based their research on two key theories. Minority stress theory posits that SGM individuals face chronic stressors, from discriminatory laws and policies (distal stressors) to family rejection and internalized stigma (proximal stressors) which directly impact their mental health outcomes. Ecosocial theory emphasizes how social and environmental factors, including access to healthcare, economic opportunities, and community support systems, interact with these stressors to shape health disparities.

“Given these frameworks, we expected higher rates of mental health conditions in SGM populations, but with important variations,” Lu told us. “For example, we anticipated that transgender individuals might face additional challenges related to gender-affirming care access and documentation barriers, while sexual minority women might experience compounded discrimination based on both gender and sexual orientation. We also expected that gender diverse or nonbinary individuals might face distinct challenges in healthcare settings where binary gender norms are still prevalent.”

While previous research has shown mental health disparities in SGM populations, most studies were limited in that they included small samples and/or relied on study participants remembering and self-reporting their mental health history. The All of Us Research Program offered a unique opportunity to examine these disparities using clinical diagnoses from participants’ electronic health records in a large, diverse national cohort. 

"This allowed us to provide more robust evidence about these health disparities and examine nuanced differences across SGM subgroups such as among gender diverse individuals,” Lu told us.

The researchers analyzed data from 269,947 participants in the All of Us Research Program, including 22,189 who identified as SGM. They used electronic health records to capture diagnosed mental health conditions and compared their prevalence between SGM and non-SGM groups. They also used surveys from participants to account for many socioeconomic and demographic factors like age, race and ethnicity, education, income, and residential location to ensure we were capturing disparities specifically related to SGM status.

“We found significant mental health disparities between SGM and non-SGM groups,” Lu told us. "For example, cisgender sexual minority women had higher odds of all 10 mental health conditions we studied compared to cisgender heterosexual women. Gender diverse people assigned female at birth had particularly high odds of PTSD - about 3.7 times higher than cisgender heterosexual men. These disparities persisted even after accounting for demographic and socioeconomic factors.”

While the researchers expected to find disparities, the magnitude of some differences was striking. For instance, the consistently higher odds of multiple mental health conditions across almost all SGM subgroups, even after controlling for demographic and socioeconomic factors, emphasizes just how significant these disparities are. Further, others have shown that SGM individuals are often less likely to have access to healthcare which drives diagnosis of these conditions. Therefore the true disparities in mental health are likely even more significant than our study suggests. This highlights the urgent need for targeted interventions and support for SGM communities.

“These findings underscore the critical need for systemic changes to support SGM mental health,” Lu told us. “This includes developing tailored mental health interventions, improving healthcare access, and addressing the underlying social stigma and discrimination that contribute to these disparities. It's crucial to note that these associations don’t imply that being SGM causes mental health conditions, but rather reflect the impact of stigma and minority stress on these communities.”

It's important to emphasize that these disparities are not inevitable, Lu explained. As noted in an accompanying commentary, SGM people have demonstrated strong resiliency in the face of persistent bias and discrimination. With appropriate support systems, legal protections, and inclusive healthcare environments, these disparities could be reduced or eliminated. 

“Our findings should serve as a call to action for policymakers, healthcare providers, and society at large to better support the mental health and well-being of SGM individuals,” Lu told us.