Reacción a "A comprehensive scientific review confirms inequalities in mental health amongst LGBTQIA+ people"

The study by Oliva et al. in World Psychiatry is an important contribution to our understanding of the differences in mental health between LGBTQIA+ populations and the general population. The authors have carried out a thorough statistical analysis of a considerable body of previous research, which allows for a more precise assessment of the strength of the observed associations, particularly in relation to depressive disorders and suicidal behaviour.

Its main strength is also its main limitation: it provides a highly rigorous quantitative description of the existing differences, but does little to explain the mechanisms underlying them. The authors highlight the role of stigma and discrimination – factors that are undoubtedly relevant – although the design of the studies analysed does not allow for the specific contribution of these factors to be determined, nor for causal relationships to be established.

From a clinical perspective, it would have been interesting to explore certain variables in greater depth, particularly sex and exposure to hormone treatments in transgender populations. Sex should have been considered as a cross-cutting factor across the various analyses, as there are well-known differences between cisgender women and men in the prevalence of mental disorders, particularly depression, which is more common in women. These differences may influence the associations observed when comparing populations with different sex compositions. It is therefore important to distinguish between effects related to sex and those associated with sexual orientation and gender identity – dimensions that are not equivalent and which may interact with one another.

Another aspect worthy of attention is the role of stigma. In the scientific literature, there is a problem regarding its definition and how it is measured, as a distinction should be made between structural stigma—related to social norms and institutional policies—interpersonal stigma, which encompasses experiences of discrimination, harassment or rejection; and internalised stigma, referring to the internalisation of negative judgements about one’s own identity. Although the authors recognise these dimensions, it is not possible to determine from their analyses the specific contribution of each to the observed differences in mental health.

The findings relating to body image also merit special attention, as they reveal differences between women and men according to their sexual orientation. These differences could reflect both biological and sociocultural factors, including ideals of beauty, social pressures regarding physical appearance, and expectations associated with gender and sexual orientation. These are likely to be interacting processes, and it would be interesting to investigate their relative contributions.

Overall, I consider this to be a valuable piece of work, both for the considerable effort put into synthesising the literature and for the questions it leaves open for future research.