BONUS: Bye-sexual: Mental health correlates of biphobia, bi-erasure, and bi-invisibility (A research paper from grad school)

I wrote this paper in grad school and thought I could share it here.

Bye-sexual: Mental health correlates of biphobia, bi-erasure, and bi-invisibility

Abstract

This paper examines the particular mental health issues that bisexual people encounter, emphasizing the ways that biphobia, bisexual-erasure, and bisexual-invisibility intensify negative mental health outcomes. Compared to heterosexuals, lesbians, and gay men, bisexuals frequently have higher rates of internalized homophobia, self-stigmatization, and a lack of belonging which contribute to attitudes and behaviors that harm mental health. Research findings suggest that bisexuals would benefit from sexuality-specific treatment interventions, advocacy, and bisexual health-informed clinicians. Limitations to this paper include a shortage of research on bisexual populations. This writing emphasizes the need for greater exploration into the unique needs of bisexuals and development of inclusive care from mental health counselors.

Introduction

Over the past several decades in the United States, individuals that identify as lesbian, gay, or bisexual (LGB) have seen varying levels of increased public support. In 1996, the US Supreme court ruled that states may not alter their constitutions to prevent homosexuals from receiving the basic protections afforded to heterosexuals. Then, in 2003, the Court heard a Texas case and struck down anti-sodomy laws as a violation of the fourteenth amendment. Just 12 years later, the landmark Obergefell v Hodges case extended federal legal marriage protections to same-sex couples. The Pew Research Center reports that, in 2022, 61% of Americans supported same-sex marriage (Borelli, 2022). This is starkly more optimistic than the 65% opposition rate reported in 1996, and 60% rate in 2004 (Liu, 2012). Over time, similar attitude changes are reported on surveys measuring Americans’ views on same-sex attraction and adoption by same- sex couples.

This progress, however, has not been dispersed equally to all members under the sexual minority umbrella. Although more US Americans identify as bisexual than gay or lesbian, 2019 data collected by Stanford University reveals bisexuals are significantly less likely to be out to their close friends and family (Brown, 2023). Literature comparing LGB and heterosexuals suggests bisexuals experience increased rates of depression and anxiety and poorer mental health outcomes when compared to heterosexuals, gays, and lesbians (Ross, et al., 2018). Multiple factors contribute to the mental health disparities of bisexuals. The most frequently discussed include biphobia, bi-erasure, and bi-invisibility.

Biphobia, Erasure, and Invisibility

Biphobia is the avoidance, discrimination, or negative bias of individuals perceived to be attracted to multiple genders. While biphobia is attributed to be experienced largely from cisgender heterosexuals, it is important to note that many bisexuals also report discrimination from lesbians and gay men (Barker, et al., 2012). Many lesbians and gay men perpetuate bisexual invalidity through monosexual stereotypes that mimic homophobic beliefs.

Bi-erasure occurs when one dismisses or disputes the validity of bisexuality as an identity, implying that one cannot be attracted to both genders (Murphy, 2024). Many times, bisexual erasure may appear as microaggressions that imply the sexuality as a “phase” or steppingstone to same-sex attraction.

Bi-invisibility is the doubt that bisexuality exists, leading one to ignore or overlook it as a legitimate sexuality (2024). Bisexual invisibility may appear as an overrepresentation of other sexual identities or the assumption that everyone in a same-sex relationship is homosexual and everyone in an opposite-sex relationship is heterosexual. Bisexual erasure and invisibility both consider the propensity to ignore and invalidate the existence of bisexuals.

Bisexuals’ Perception of Biphobia

Bisexuals experience biphobia in many different ways. In a study conducted by Brewster, & Moradi (2010), bisexual participants consistently reported that they felt their orientation was viewed as unstable and illegitimate. Bisexuals also reported experiencing interpersonal hostility from both heterosexuals, lesbians, and gay men (Brewster, & Moradi, 2010). These feelings, however, are not limited to peers. Among family members, many bisexuals report their sexuality is viewed as erratic and they are seen as sexually irresponsible (Todd, Oravecz, & Vejar, 2016).

Survey research by McKinnis, et al., (2022), examined bisexuals’ experiences with biphobia, and their feelings around self-stigmatization and belonging. While there are differences in reports between respondents based on gender, the general research suggests that greater self- stigma is related to a lower sense of belonging, and higher reports of anti-bisexual experiences

(McKinnis, et al., 2022). In other words, internalized biphobia significantly impacts the experiences of bisexual people by diminishing their sense of community and heightening feelings of marginalization.

Internal and identity-related stressors and their negative impacts on mental health are well documented in research, particularly among intersectional identities (Bey, Ulbricht, & Person, 2019). Experiencing stressors such as biphobia, erasure, or invisibility can exacerbate the invalidation of bisexual individuals' marginalized identities, leading to outcomes that extend beyond the individual and affect the broader community.

Bisexuals and Mental Health Outcomes

While there is limited research performed solely on bisexuals, current data tells us that, in relation to heterosexual, lesbian, and gay male populations, bisexuals experience higher rates of childhood sexual victimization, report greater involvement in risky sexual behaviors, express increased levels of substance use issues, increased suicidality, and feel less connected and engaged to both heterosexual and LGBTQ+ communities (Feinstein, Dyar, & Pachankis, 2019; Persson & Pfaus, 2015).

Drug and alcohol use during sexual activity contributes to increased negative health consequences including STI/HIV transmission, sexual assault, and unplanned pregnancy. Data analyzed by Taggart, et al. (2019), supports that the use of substances in sexual contexts varies based on sexual orientation. Among sexual orientations, bisexuals reported the highest rates of alcohol and substance use during sex. Despite having a higher risk of STI transmission, many public health campaigns do not target bisexuals, but heterosexuals, lesbians, and gay men (Taggart, et al. 2019). Sexual wellness is an important component of the overall health of an individual.

Bisexual women show an increased risk of alcohol and substance use when compared to other sexual minority women (Schulz, Glatt, & Stamates, 2022). Importantly, bisexual women have also reported higher rates of alcohol use disorder, opioid misuse, and illicit drug and marijuana use (Schuler, & Collins, 2020). Research suggests higher substance usage and dependence rates among men that report sexual activity with both men and women than gay or heterosexual men (Batchelder, et al., 2021). Substance use disorder is a chronic, and oftentimes fatal disease. It can have devastating effects on one’s mental and physical health.

Suicide is a leading cause of death in the United States, responsible for the deaths of over 48,00 people in 2021 (2024). Bisexuals experience higher levels of suicidal ideation and attempt than heterosexuals, lesbians and gay men (Nystedt, Rosvall, & Lindström, 2019). Further, bisexual women report higher rates of suicidal ideation than any other group (Salway, et al., 2019). Additionally, bisexuals are at higher risk of non-suicidal self-injury (NSSI) with about six times the prevalence of other sexualities (Dunlop, et al., 2020). Because suicide and NSSI are so important to mental health, the increased rates among bisexuals are huge concerns for mental health professionals.

Many bisexuals report feeling sexuality-specific stressors that contribute to a lack of connectedness to the broader LGBTQ+ community. Bisexuals report feeling disconnected from other Queer individuals on college campuses, in Queer bars and spaces, and in other, nonspecific settings (Lambe, Cerezo, & O'Shaughnessy, 2017; Taverez, 2022). These stressors include feelings of compartmentalization and separation from heterosexual and other LGBTQ+ people (Gonzalez, et al., 2021; McClaren, & Castillo, 2021). Without a sense of connection to other, similar marginalized groups, bisexuals could feel isolated and disconnected from others.

Bisexuals demonstrate mental health outcomes that differ from other sexual minorities. Research supports that bisexuals experience distinct stressors that increase their likelihood of adversity and negative mental health outcomes. Depression, anxiety, suicidality, and substance use disorders, among others, impact this population at rates necessitating sexuality-specific training and intervention by mental health professionals.

Implications & Strategies for the Mental Health Counselor

Knowing that bisexuals are facing negative mental health outcomes at equal or higher rates than other sexual minorities, it is important for clinicians to consider what this means for treatment. Because bisexuals are underrepresented amongst LGB communities and in clinical research, one may infer that LGB-inclusive practices may not provide adequate support for bisexuals. Additionally, LGBTQ+ trainings may not provide enough insight on what it means to be bisexual. Clinicians should be vigilant in ensuring that their post-educational trainings give sufficient information related not only to lesbians and gay men, but also to bisexuals. A key component to this may be treating issues related to lesbians, gay men, and bisexuals as three separate groups, instead of a ‘one size fits all’ approach.

Research analyzed by Sharac, et al., (2010), suggests individuals with mental health diagnoses are more likely to experience stigmatization and discrimination that contributes to negative economic impacts. People that have struggled with negative mental health outcomes may expect to feel disadvantaged in the job market and anticipate lower earning potential (Sharac, et al., 2010). Clinicians that work with bisexual populations, including vocational rehabilitation counselors, should consider the economic impacts not only of mental health diagnoses, but how their clients’ bisexual identification has affected their job prospects.

About 1/5 of all substance use treatment facilities in the United States report having LGBT-specific programs (Williams & Fish, 2020). While these numbers are higher than we’ve seen before, that leaves about 80% of all facilities with no reported program. High-risk populations, including bisexuals, will need clinicians that can understand community and identity-specific stressors that have contributed to increased substance usage.

Bisexual and Sexual Minority Treatment Interventions

Feinstein, Dyar, & Pachankis, (2019) evaluated clinically effective treatment methods that target bisexual groups. Cognitive behavioral therapy (CBT) techniques can be utilized with bisexual patients to address substance use, depressive symptoms, coping, and self-stigma. The digital RainbowSPARX program was created to target adolescents with symptoms of depression that report non-heterosexual attraction (Lucassen, et al., 2015). A key advantage of this treatment is that is can be done virtually and in addition to other treatment. Effective Skills to Empower Effective Men (ESTEEM) is a CBT program that aims to target minority stress among men who experience same-sex attraction (Pachankis, 2014). Other clinically relevant interventions include expressive writing and internalized stigma reduction interventions (Feinstein, Dyar, & Pachankis, 2019). These are, of course, in combination with other evidence-based treatments.

Advocacy as a Strategy

Advocacy must be a consideration for counselors who support and work with bisexual clients. It is essential to have a thorough understanding of bisexuality, bi-erasure, and the particular obstacles bisexual individuals encounter, including self-stigmatization and experiences of biphobia. By sharing this knowledge within their organization or community, counselors can help correct misunderstandings and promote a more supportive, inclusive environment (Wurthermann, & Ortega, 2024).

Counselors can implement and advocate for approaches that affirm bisexuality as a legitimate and distinct sexual orientation, separate from heterosexuality and homosexuality. This involves using language that is inclusive, refraining from making assumptions about a client’s attractions, and actively promoting bisexual visibility in settings like group therapy or community discussions.

Limitations & Future Research

Bisexuality and issues related to bisexuals have been significantly underrepresented in research. In the social sciences, bisexual identity and experience has not been thoroughly explored. This lack of study is contributing to marginalization and furthering the notion of bi- invisibility (Monro, Hines, & Osborne, 2017). A simple exploration of LGBTQ+ health services, websites, and activist forums will reveal the glaringly obvious underrepresentation of bisexuality within sexual and gender minority communities.

More in-depth studies about the impacts of bi-erasure and bi-invisibility should be explored, particularly with individuals that have multiple identities. It is fair to hypothesize that intersectionality would play a part in greater negative mental health outcomes of bisexual individuals, but we don’t have sufficient research to support this. Additionally, bisexuals appear to be at higher sexual risk that heterosexuals, lesbians, and gay men. The research on why these numbers are so inflated is not quite clear (Perrson, & Pfaus, 2015). More studies are needed to investigate the correlation between bisexuals and increased sexual risk.

Studies on the psychological effects of self-stigma and internalized biphobia might bring awareness on the ways in which these interactions damage mental health. Many studies on the mental health of bisexuals include the interaction of self-stigmatization. Because of this, it is important that future research investigate the dimensions of stigma amongst bisexual people. The same could be said for bisexuals and increased instances of substance use. Studies that evaluate bisexuals and their relationship to alcohol and drug usage would be critical in understanding causes and effective treatments to those with a substance use disorder.

This paper is limited in that its information is dependent on the results of previous studies, which are lacking. With more comprehensive and available research, its reports could be more conclusive.

Conclusion

In conclusion, biphobia, bi-erasure, and bi-invisibility present particular mental health issues for bisexual people. Negative mental health outcomes are further aggravated by cultural biases, which not only support external discrimination but also self-stigmatization and internalized biphobia. Bisexual identities must be acknowledged and validated through tailored, sexuality-specific treatment to address these challenges.

Furthermore, to counteract the widespread erasure and stigmatization bisexual people face, there must be more activism and visibility in the heterosexual and LGBTQ+ communities. The lack of previous literature and study, particularly addressing bisexual experiences, is an important limitation of this paper. Closing this gap should be a top priority for future research in order to better understand and treat the mental health needs of bisexual communities and to create more effective and inclusive support networks.

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