Javier J. Pérez Flores
Lecturer and researcher in the Department of Clinical Psychology, Psychobiology and Methodology at the University of La Laguna
The study has a clear strength in that it brings together research that was previously scattered across different mental health issues and different population groups. Specifically, it incorporates 22 reviews covering 398 studies and applies common criteria to assess the consistency of their findings. This makes it possible to identify which inequalities emerge most consistently and which are still supported by limited evidence. However, it is important to distinguish between the quality of the procedure used to compile and analyse this information, and the quality of the studies from which it is derived. A well-organised review remains subject to the limitations of the available data on which it is based.
The first important point is that the existence of these inequalities is nothing new. The review by King et al., published in 2008 and included in this study, had already found a higher prevalence of depression and suicidal behaviour among lesbian, gay and bisexual people. The contribution of the new study lies in organising this accumulated knowledge, assessing its consistency and demonstrating that the differences are not distributed uniformly within the group. The latter point is of interest because referring to LGBTQIA+ populations as if they shared the same experiences and needs can obscure significant differences.
Among the most consistent findings is an incidence of depression approximately twice as high, and of suicide attempts approximately two and a half times higher over the past year, among lesbian, gay and bisexual people compared with the comparison groups. There are also more symptoms of anxiety and self-harm without suicidal intent among bisexual people than among lesbians and gay men. These figures describe differences between the populations studied. They do not allow us to predict the situation of a specific individual, nor do they imply that these problems have a direct link to, or stem from, experiences associated with their sexual orientation.
A similar situation applies to the findings on eating behaviour. Among gay adolescent boys, there are more instances of dieting and purging than among heterosexuals. Here, it is important to clarify what has been measured, as behaviour associated with an eating disorder does not, in itself, equate to a diagnosis. For example, knowing the frequency of certain weight-control practices does not allow us to conclude how many people meet the criteria for anorexia or bulimia.
Furthermore, particular caution is required due to the limitations of the original studies. All the included reviews were rated as having low or critically low quality. The authors highlight problems with the search strategies used in the previous studies, the justification for excluding certain studies, and the consideration of potential biases. This does not prove that the disparities are false, but it does necessitate a more nuanced interpretation of the term ‘high-credibility evidence’. In this paper, that phrase refers to compliance with certain statistical criteria. The fact that several studies find similar results lends credibility, but does not rule out possible common errors in participant selection or in the way problems were assessed.
Caution is also required when interpreting the causes. Most of the studies provide a snapshot of a specific point in time (they are cross-sectional). This allows us to observe that two groups differ, but it is insufficient to reconstruct how these differences have arisen. The authors interpret the findings using models that highlight the role of stigma, discrimination and rejection. This interpretation is consistent with previous research, but this review does not determine the extent to which each factor explains the findings. Furthermore, much of the data comes from North America, and the most robust results are concentrated among lesbian, gay and bisexual populations. It would therefore be inappropriate to apply all the figures directly to Spain or to extend them equally to all people falling under the LGBTQIA+ umbrella.
From a care perspective, the study reinforces the need to recognise these inequalities and to address each person’s individual circumstances. For example, it can guide professionals to explore experiences of rejection, available support or difficulties in seeking help, alongside the issues that led to the consultation.
In the field of public policy, the findings support paying attention to both care needs and the social conditions that may undermine well-being. However, the study does not compare interventions nor does it allow us to determine which would be the most effective. Nor did it find any systematic reviews with meta-analyses that met its criteria for assessing access to mental health care. To evaluate the healthcare response, it would be necessary to examine whether people receive help when they need it, whether that care is tailored to their difficulties, and whether they encounter barriers or experiences of discrimination within the system itself. Identifying an inequality is a necessary step; verifying that the measures taken succeed in reducing it requires further evaluation.