Received Dec 17; Accepted Aug This article has been cited by other articles in PMC. Abstract Background Awareness of health disparities based on sexual orientation has increased in the past decades, and many official public health agencies throughout Europe call for programs addressing the specific needs of lesbian, gay and bisexual LGB individuals.
However, the acceptance of LGB individuals varies significantly in different countries, which potentially influences health and well-being in this population. We explored differences in self-rated health and subjective well-being between individuals living in same-sex and opposite-sex couples. We also examined the effects of discrimination and country-level variations in LGB acceptance on health and well-being and the potential mediating role of social capital in these associations.
We performed structural equation modeling analyses to estimate path coefficients, mediations and interactions. Results LGB acceptance was significantly related to better self-rated health and subjective well-being among all individuals, and these associations were partially mediated by individual social capital.
No differences in these associations were found between individuals living in same-sex and opposite-sex couples.
Sexuality-based discrimination had an additional significantly negative effect on self-related health and subjective well-being. Conclusions The findings of this study suggest a negative association between exposure to discrimination based on sexual orientation and both health and well-being of individuals living in same-sex couples. Members of same-sex couples and opposite-sex couples alike may benefit from living in societies with a high level of LGB acceptance to promote better health and well-being.
Background Eliminating health disparities is a fundamental goal of public health research and practice. Health disparities can be described as differences in the incidence, prevalence, mortality and disease burden between minority and majority population groups [ 1 ].
Disparities based on many factors such as age, ethnicity, gender, socioeconomic status, geography and disability have been identified in public health research [ 1 ]. In the past several years, public health policy and research have begun to address the substantial health disparities that exist between sexual minority i. In particular, recent studies have revealed large differences in mental health between sexual minorities and heterosexual individuals [ 3 ].
A recent review of physical health disparities according to sexual orientation also identified substantial and compelling evidence for physical health problems among LGB individuals compared with heterosexuals [ 4 ]. Poor physical and mental health among LGB individuals has been explained by the concept of minority stress.
According to Meyer , minority stress among LGB individuals can influence physical and mental health through four main processes: In his model of minority stress and mental health, Meyer also describes stress-ameliorating factors such as coping and social support, which can reduce the impact of minority stressors. When looking at the distressing effects of social support and environments in particular, an increasing number of studies have confirmed that structural social environmental discrimination is negatively associated with health among sexual minorities [ 6 — 12 ].
Structural forms of discrimination include unequal marriage legislation, policies extending protections against hate crimes, employment discrimination based on sexual orientation, and the low concentration of same-sex couples. Structural discrimination of LGB individuals varies widely across Europe, as demonstrated in several European-wide surveys [ 13 ].
These surveys have shown that in numerous countries LGB people still live in communities where a majority of the population supports discrimination and inequality for sexual minorities. In many countries, LGB people are also subject to legal discrimination concerning basic civil rights, e.
For example, equal marriage rights for sexual minorities have recently been a topic of heated political debate in the United Kingdom and France [ 14 , 15 ]. However, in other countries such as Belgium, the Netherlands, Spain and most Scandinavian countries, equal marriage rights have been legally in place for many years. These significant differences in LGB acceptance and differences in institutional discrimination make cross-European studies particularly suitable for exploring the consequences of structural discrimination, social support and LGB acceptance on health.
Given the minority stress model, discrimination toward sexual minorities on the socio-cultural level, i. Discrimination may lower the ability of LGB individuals to participate in social activities, which leads to increased social exclusion.
Furthermore, discrimination may hamper the accessibility of stress-ameliorating social support. In the social sciences, the availability and accessibility of social support have been conceptualized in the theory of social capital. Social capital is commonly used in relation to social inclusion, participation and support.
A higher level of social capital, and access to it, has been associated with elevated population health and psychological well-being [ 17 — 19 ]. Two basic elements are often used in most definitions of social capital: The structural component is described as the extent to which societies are formally linked and their members are actively involved in social activities [ 17 ].
This element may serve as a bridge for deviations between groups bridging or within groups bonding , leading potentially to social inclusion [ 17 , 20 , 21 ]. The cognitive component captures common societal perceptions and trust between persons within a community based on shared values, attitudes and beliefs [ 17 , 20 ].
It is common to refer to the cognitive component of social capital as social trust when studying its effects on health. Consistent with the theory of social capital and minority stress, one can hypothesize that low LGB acceptance may lead to the exclusion of LGB individuals from social neighborhood communities and dominant majority groups, lower levels of social trust and support among LGB groups, and lower accessibility of social capital.
These processes cumulatively result in greater minority stress and health disparities when LGB individuals are compared with opposite-sex-attracted individuals. Bonding within the LGB population may serve as a compensation mechanism for the negative impact of social exclusion from majority groups. However, such within-group support is less likely to have as strong a positive effect on LGB individuals as it has on members of ethnic minorities [ 21 ]. First, a strong LGB group identity is lacking because of the large degree of diversity within the LGB population [ 24 , 25 ].
Furthermore, the support of strong family ties may be absent for LGB individuals living in low-acceptance settings due to the high risks of abandonment after they disclose their sexual orientation [ 26 ].
LGB acceptance may therefore not only affect health directly via lowering discrimination and minority stress but also through the influence of social capital and inclusion and the availability and accessibility of social support.
Hence, bonding and bridging social capital may serve as a positive mediator in the hypothesized relation between acceptance and health of sexual minorities. To the best of our knowledge no studies to date have specifically examined the influence of acceptance and social capital on the mental and physical health of LGB individuals.
We explore differences in subjective well-being and self-reported health between sexual minority individuals members of same-sex couples and heterosexuals members of opposite-sex couples using data from the European Social Survey ESS [ 27 ]. We also examined how country-level LGB acceptance, social capital on the individual and country level, and socio-demographic variables affected health and well-being.
The specific research questions of the study include: Do levels of health and well-being differ between individuals in same-sex and opposite-sex couples? Is LGB acceptance on the country level associated with health and well-being, and can social capital mediate this association? Methods Participants and countries Data were obtained from the fifth ESS on the attitudes, beliefs and behavior patterns of diverse populations from over 30 nations from based on validated questionnaires [ 27 ].
The ESS includes variables on a range of social themes such as moral values, security, politics and trust in governments; the results demonstrate significant cross-country variation. The ESS also includes general self-rated health outcomes. In this fifth round, the response rates ranged from The survey employs rigorous methodologies.
The data were collected by means of hour-long, face-to-face interviews incorporating questions on a variety of core topics repeated from previous rounds of the survey.
Lithuania was excluded from this study due to the combination of a low response rate National and European Union data protection guidelines apply to all data collection methodologies. After the data are collected by national institutes, they are handled anonymously and are openly available on the ESS website after registration.
We retrieved anonymous data from the ESS website and used them for this study based on earlier non-study-specific informed consent. Propensity-score matching In total, individuals from same-sex couples and 28, individuals from opposite-sex couples were identified in the ESS dataset. Since the number of individuals living in opposite-sex couples significantly outnumbered the number of individuals living in same-sex couples, we performed propensity-score matching using the R plugin in IBM SPSS Statistics 21 software [ 28 ].
This technique reduces bias by accounting for different covariates, which creates more comparable groups. We used the following covariates in the propensity-score matching: The individuals from same-sex couples were matched with the individuals from opposite-sex couples following a most-similar-case approach based on the calculated individual propensity score using the determined covariates.
This procedure resulted in a sample of individuals living in same-sex couples and individuals in opposite-sex couples. We examined the standardized mean differences before and after matching to test the level of similarity of the propensity score distributions. The standardized differences between the covariates in the two groups reduced to almost zero: Measures In addition to information regarding socio-demographics i.
We constructed country scores by using aggregated mean values from all of the ESS respondents before selecting individuals from same-sex couples and matching them with members of opposite-sex couples.
Single-item assessments of self-rated health of this type have shown by previous studies to be strong predictors of future mortality [ 29 , 30 ].
Subjective well-being We measured subjective well-being using two variables concerning self-rated happiness and satisfaction with life. Social Capital As described in a literature review of studies related to social capital and health by Islam et al. We assessed the level of social capital using a total of four items.
Three questions regarding interpersonal trust were measured on eleven-point scales between two extremes: The fourth item used social participation as a measure of structural social capital [ 31 ]: The responses to all items were standardized and summed to create a score of overall social capital.
The internal consistency of the scale was 0. We constructed a country-level variable on social capital using the mean country scores of individual social capital. We used the mean country-level scores to aggregate the data on LGB acceptance on the country level.
Same-sex partnership Indirect data on sexual orientation were derived from the database by combining data on gender, household composition, gender of household members, and relationships within households.
The latter were measured with the question: Additionally, when the respondent and the second household member had different sexes and were partners, the respondents were coded as being in an opposite-sex couple i. Data-centering principles were applied to diminish potential problems with multicollinearity and to avoid contaminating statistical inferences when performing the additional analyses [ 36 ].
To test our hypotheses, we used multilevel path analyses with the Mplus 7 software package. These analyses can handle estimating parameters using both individual and country-level data synchronically. Since a mediating role of individual social capital mediator was hypothesized between LGB acceptance independent variable and self-rated health and subjective well-being dependent variables , we added specific mediating paths to the model to test for intermediate processes underlying the directly observed relationships.
Thereafter, we tested the separate effects of the mediator and independent variable on the dependent variable using a regression equation. Next, we employed the Sobel test to test the mediation model of the mediator and the dependent and independent variables. We accordingly added the mediator to the multilevel path analysis model.
In the mediation models Fig. We adopted the following recommended levels for the data fit indices as indicators of models: