C 2006) Sex Roles, Vol. 54, Nos. 1/2, January 2006 (
DOI: 10.1007/s11199-006-8870-0

Mental Health Stereotypes About Gay Men Guy A. Boysen,1,3 David L. Vogel,1 Stephanie Madon,1 and Stephen R. Wester2

Three studies were conducted to examine the mental health stereotypes about gay men among college student and therapist trainee samples. Results from Study 1 indicated that (a) college students and therapist trainees endorsed a stereotype of the mental health of gay men that was similar in terms of its content and strength, and (b) the stereotype was consistent with five DSM-IV-TR disorder categories: mood, anxiety, sexual and gender identity, eating, and personality disorders. In Study 2 and 3 we investigated whether homophobia or a tendency to report cultural beliefs could account for the lack of difference between college students and therapist trainees. Results did not support either explanation. KEY WORDS: mental health; stereotypes; psychotherapy; gay men.

A few decades ago, homosexuality was considered a pathological and deviant variant of human sexuality. In fact, it was only in 1973 that homosexuality per se was removed from the Diagnostic and Statistical Manual of Mental Disorders (DSM), and not until 1987 that it was completely removed from the diagnostic system. During the late 1960s and early 1970s, when homosexuality was still officially considered a mental illness, researchers began to study what stereotypes the public endorsed about gay men. These studies converged on the finding that the stereotype of gay men was unfavorable, including the beliefs that gay men were deviant, mentally ill (Simmons, 1965), and suffering from a sickness (Levitt & Klassen, 1974). Although 30 years have passed since homosexuality was removed from the DSM, there has not been a subsequent assessment of how public conceptions of gay men’s mental health may have changed nor how these perceptions are similar to or different from those of professionals who provide therapeutic services to gay clients. To address this gap in the literature, we assessed mental

health stereotypes about gay men among the public as well as among individuals being trained to provide mental health services. The Stereotype of Gay Men A survey of the relevant literature revealed a wide variety of attributes that are perceived as stereotypic of gay men. For example, in two early studies, Simmons (1965) found that gay men were perceived as perverted and lonely, and Levitt and Klassen (1974) found that gay men were seen as having strong sex drives and as being dangerous to youth. Staats (1978) examined college students’ attitudes and found a large number of both favorable and unfavorable stereotypic attributes, such as cowardly, shy, kind, and individualistic. There has also been a clear and consistent pattern of gay men being perceived as feminine (Kite & Deaux, 1987; Levitt & Klassen, 1974; Madon, 1997; Simmons, 1965; Taylor, 1983). For example, Madon (1997) performed a factor analysis of college students’ stereotypes about gay men and found that gay men were seen as having feminine qualities and as rejecting the masculine gender role. In addition, some researchers have found that feminine behaviors are part of the stereotype as well (Kite & Deaux, 1987; Madon, 1997).

1 Iowa

State University, Ames, Iowa. of Wisconsin-Milwaukee, Milwaukee, Wisconsin. 3 To whom correspondence should be addressed at Department of Psychology, Iowa State University, W112 Lagomarcino Hall, Ames, IA 50011-3180; e-mail: [email protected]. 2 University

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70 Although past work on the stereotype of gay men has provided important information about the personality traits and behaviors that are perceived as characterizing gay men, little attention has been paid directly to people’s beliefs about gay men’s mental health. An assessment of these beliefs is important, however, as the stereotypes people have about the mental health of a group can lead to public discrimination and prejudice, which, in turn, can then lead to self-stigma and increased psychological distress and psychiatric symptoms (Corrigan, 2004). As such, there is need to examine directly the mental health stereotype that currently exists about potentially stigmatized groups such as gay men. There is also a need to assess these beliefs among different populations. Although the general public’s stereotype of gay men’s mental health may be important for understanding the potential effects of stigma, it is also important to assess the stereotypes of those who are in training to provide mental health services. Endorsement of a stereotype about gay men by future therapists, for example, could have an impact on therapist trainees’ expectations about clients’ mental health, which could influence their assessment, diagnosis, and treatment of those clients (Vogel, Epting, & Wester, 2003; Wester, Vogel, Pressley, & Heesacker, 2002) and create self-fulfilling prophecies (Berman, 1979). Indeed, other minorities have been adversely affected when those responsible for diagnosing and treating their mental health problems relied on stereotypes (Adebimpe, 1981; Neighbors, Jackson, Campell, & Williams, 1989). Therefore, although we hope that therapists possess a greater understanding of these issues and, therefore, possess less prevalent stereotypes than the public does, this notion ought to be tested.

Mental Health Stereotypes There is considerable difficulty in predicting what the current mental health beliefs about gay men will be. On one hand, considering that general attitudes about homosexuality have become more positive in recent years (Yang, 1997) and that people probably now know that homosexuality is not a mental disorder, gay men and straight men may be perceived as similar with regard to mental health. On the other hand, although homosexuality has been eliminated as a diagnosable mental disorder, stereotypes may still be influenced by past and cur-

Boysen, Vogel, Madon, and Wester rent negative perceptions of gay men as well as by knowledge about the mental health of gay men. For example, gay men seek out counseling disproportionately more than their straight counterparts do (Barret & Logan, 2002; Liddle, 1999). In addition, large-scale, representative, epidemiological studies have shown that gay men tend to suffer more frequently than straight men from certain mental health symptoms such as depression (Cochran & Mays, 2000a; Sandfort, de Graaf, Bijl, & Schnabel, 2001), suicide (Cochran & Mays, 2000a), anxiety (Sandfort et al., 2001), substance abuse (Gilman et al., 2001), and panic (Cochran & Mays, 2000a). Because stereotypes can be based on a “kernel of truth” (Campbell, 1967) people’s beliefs may echo these trends.

Issues in Stereotype Research Three important issues need to be addressed before considering stereotypes any further. First, the term stereotype is used so often colloquially that it needs to be operationally defined. Since Campbell’s (1967) work on stereotypes and the perceptions of group differences, researchers have explicitly or implicitly defined stereotypes as consisting of attributes that are perceived to distinguish between groups. Thus, although stereotypes can be thought of as consisting of attributes that are typical or common among members of a social group (e.g., “Most gay men are depressed,” Ashmore & Del Boca, 1986), researchers usually either implicitly or explicitly define a stereotype as consisting of attributes that differentiate between social groups (e.g., “Gay men are depressed more often than straight men,” see Lee, Jussim, & McCauley, 1995). For example, McCauley and Stitt (1978) defined stereotypes as “predictions that distinguish the stereotyped group from others” (p. 929), and Ottati and Lee (1995) defined stereotypes as “characteristics of a social group [that] are implicitly comparative” (p. 31). As such, stereotypes do not need to be representative of most group members but do need to be useful in distinguishing groups from each other (Ryan, 2002). The comparative definition of a stereotype is useful in understanding mental health stereotypes because most disorders occur at relatively low base rates, that is, few disorders will be typical or common among any particular group. Thus, there is a potential for individuals to believe that a particular disorder is more characteristic among one group (e.g., gay men) than another (e.g., straight men), even if the disorder is generally

Mental Health Stereotypes uncommon within the social group (see McCauley & Stitt, 1978). A second point for consideration is that stereotype content can be distinguished from its strength (see Madon, 1997). A stereotype’s content refers to the specific attributes that people believe distinguish between social groups (McCauley & Stitt, 1978), whereas the strength of a stereotype is the degree to which people believe the attributes in a stereotype distinguish between social groups. That is, a stereotype’s strength is how strongly people associate a stereotype with a particular social category (Madon, 1997; Stangor & Lange, 1994). Measures of stereotype content allow researchers to determine which attributes are thought to differentiate between groups. Once the content has been determined, measures of strength then add knowledge regarding the depth to which stereotypes are actually endorsed, such that deeply held stereotypes have higher strength. Therefore, both content and strength give insight into the nature of stereotypes. Finally, it is also useful to distinguish a stereotype’s content from its accuracy. Whereas a stereotype’s content refers to the specific attributes that people believe distinguish between social groups (McCauley & Stitt, 1978), a stereotype’s accuracy is the extent to which these perceived group differences correspond to actual group differences (Madon et al., 1998). Therefore, it is reasonable to assume that the stereotype about gay men’s mental health will include some attributes that are accurate (i.e., perceived differences between gay and straight men that correspond to real group differences) and other attributes that are inaccurate (i.e., perceived differences between gay and straight men that do not correspond to real group differences). Although classic research has emphasized that stereotypes are inaccurate (Alport, 1956), there is no clear empirical evidence to demonstrate that stereotypes are inherently inaccurate, and defining them as such raises conceptual and methodological difficulties (Jussim, McCauley, & Lee, 1995). Therefore, most contemporary research pertaining to stereotype accuracy acknowledges that stereotypes may be accurate or inaccurate (Ashmore & Del Boca, 1986; Judd & Park, 1993; see Ryan, 2002, for a review).

STUDY 1 This investigation was designed to measure the content of the stereotypes that college students and

71 therapist trainees possess about the mental heath of gay men, the strength of that stereotype, and how the content and the strength of the stereotype endorsed by college students differ in comparison to that of therapist trainees. Stereotypes were assessed using the established procedure for studying stereotypes through group comparison (e.g., gay men as compared to straight men; see Jackson & Sullivan, 1989; Levitt & Klassen, 1974; Madon, 1997; Page & Yee, 1986). Once the content and strength of the stereotype were separately examined for the college student and therapist trainee groups, the two groups were then compared.

Method Participants The college student sample included 293 undergraduates enrolled at a large midwestern university. Participants were recruited from psychology courses and received extra credit in exchange for participation. Both psychology majors and nonmajors participated, and psychology majors made up approximately 10% of the sample. The sample was 43% men and 57% women. The average age was 19.3 years, with a range of 18–25 years. The reported racial/ethnic makeup of the sample was 73.7% European American, 11.1% Asian American, 9.1% African American, and 2% did not specify their race. Although sexual orientation was not assessed in this sample, similarly recruited samples have consisted of less than 1% gay, lesbian, or bisexual students (see Study 2). The therapist trainee sample included 49 graduate students in a Master’s degree program in counseling in the Department of Education at a small, urban, midwestern university. The program allows three areas of concentration: school counseling, community counseling, and rehabilitation counseling, and has both full-time and part-time students. Institutional review policies disallow the collection of demographic information to ensure anonymity; however, what follows are the characteristics of the general counseling program students. At the time of this study, the mean age of the students in the program was 29 years (SD = 8.4). Eighty-one percent of them were female; 19% were male. Students were not required to disclose racial or ethnic background upon registration, but of those that disclosed, 48% were European American, 41% were African American,

72 and 11% were Asian American. Mean years in the program at the time of this study was 2.2 (SD = 1.8), which means that they would have completed classes such as Theories of Counseling, Multicultural Counseling, Assessment and Diagnoses, and Counseling Techniques. The mean years of counseling experience was 2.4 years (SD = 4).

Measure Stereotypes were measured with a 58-item questionnaire modeled after measures commonly used in previous research on the stereotype of gay men (e.g., Jackson & Sullivan, 1989; Levitt & Klassen, 1974; Madon, 1997; Page & Yee, 1986). Specifically, it measured the extent to which mental health symptoms are perceived to characterize gay men in comparison to straight men. The mental health symptoms included in the questionnaire were developed on the basis of the DSM-IV-TR (American Psychiatric Association [APA], 2000) criteria for Axis I and II mental disorders. Due to the commonality and overlap in symptoms of various diagnoses, we did not include every possible symptom. In addition, the 58 symptom descriptions were shortened into common terminology. For example, symptom #3 from Gender Identity Disorder, i.e., “strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex” (APA, p. 581), was shortened to “feels like a woman,” and symptom #4 from Narcissistic Personality Disorder, i.e., “requires excessive admiration” (APA, p. 717), was shortened to “needs admiration.” Participants responded to each DSM-IV-TR symptom on the following comparative scale: 1 (Much less characteristic of gay men than of heterosexual men), 2 (Somewhat less characteristic of gay men than heterosexual men), 3 (Equally as characteristic of gay men as of heterosexual men), 4 (Somewhat more characteristic of gay men than heterosexual men), and 5 (Much more characteristic of gay men than of heterosexual men). To establish that the symptoms included in the questionnaire were indeed perceived as pathological, we performed a preliminary study. Eighty-two college students were sampled separately from the 293 primary study participants. The sample was 64% female and 30% male students, with a mean age of 20 years. The reported racial/ethnic background of the sample was 83% European American, 4% Asian American, 2% African American, 2% Latino/a, 1% Native American, and 2% “other.” Participants re-

Boysen, Vogel, Madon, and Wester sponded to the following question for each of the symptoms included in the mental health stereotype questionnaire: “How much do you believe that a person who possess the following attributes is also distressed, functioning in an unhealthy way, and deviating from normal behavior?” Participants rated each symptom on a 5-point scale that ranged from 1 (Not distressed, Not dysfunctional, Healthy) to 5 (Extremely distressed, Extremely dysfunctional, Extremely unhealthy). The average score of the symptoms was 3.13, which indicates a moderate level of distress, dysfunction, and unhealthy functioning for the collection of symptoms. In addition, a one-sample t’s-test was conducted for each symptom to determine whether its mean rating differed significantly from a rating of no pathology, which corresponded to 1 on the rating scale. Significant differences were found for every symptom (all t’s ≥ 7.19, all p’s < .001), which suggest that the symptoms included in the mental health stereotype questionnaire were understood as representative of pathology. Procedure Both samples completed the survey in groups. After providing their informed consent, participants received verbal instructions that informed them that they would complete a questionnaire designed to assess their personal opinions about gay men’s mental health. Participants were also informed that there were no right or wrong answers and that all of their responses would be anonymous. Upon completion of the questionnaire, participants were debriefed and dismissed. Results Stereotype Content Analyses addressed two questions related to the content of the stereotype regarding gay men’s mental health: (a) What is the content of the stereotype?; (b) Do college students and therapist trainees endorse different stereotypes? To assess the content of the stereotype, we used the procedure set forth by Ashmore and Del Boca (1986) and Madon (1997; also see Madon et al., 2001). Frequency distributions were used to identify the symptoms that participants perceived as stereotypic of gay men. A symptom was considered stereotypic if at least 33% of participants judged the

Mental Health Stereotypes

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symptom as much more or somewhat more characteristic of gay men than straight men and less than 10% of participants rated the symptom as much less or somewhat less characteristic of gay men than straight men. Ashmore and Del Boca (1986) characterized frequencies between 33 and 50% as a sizable minority, frequencies between 51 and 67% as a simple majority, and frequencies between 68 and 100% as a strong majority. Analyses were performed separately for the college student and the therapist trainee samples. In the college student sample, the analysis yielded 19 symptoms with percentages that ranged from 35 to 85%. Table I presents the stereotypic symptoms and their corresponding percentages separately for the college student and the therapist Table I. Mental Health Stereotypes of Gay Men

Traits Cross-dresses Feels like a woman Is overly dramatic Cries easily Excessively emotional and attention seeking Unsatisfied with appearance Overly talkative Needs attention Touches strangers Eats too little Feels anxious Paranoid Panicky Moody Often feels sad Relives past trauma Was abused as a child Binges/Purges Feels worthless Becomes aroused by strange objects Distressed Nervous Tense Feels helpless Unable to control impulses Feels empty Has recurrent inappropriate thoughts Sexually enjoys suffering Sexually attracted to children

Therapist College Therapist trainees students trainees who rated (%) (%) society (%) 85 80 73 72 68

78 76 78 63 74

90 92 94 88 86

— 65 48 53 43 42 41 41 46 39 40 36 36 35 35

67 61 55 — 33 55 54 43 37 — 41 37 41 43 —

— 79 74 67 59 72 61 66 66 57 59 69 51 61 57

— — — — — — —

41 39 35 — — — —

63 55 — 69 54 51 51

— —

— —

47 46

Note. Frequencies between 33 and 50% reflect a sizable minority, frequencies between 51 and 67% a simple majority, and frequencies between 68 and 100% a strong majority.

trainee samples. Of these, 12 reflected a sizable minority (needs attention, eats too little, feels anxious, paranoid, panicky, moody, often feels sad, relives past trauma, was abused as a child, binges/purges, feels worthless, becomes aroused by strange objects), 2 reflected a simple majority (overly talkative, touches strangers), and 5 reflected a strong majority (crossdresses, feels like a woman, is overly dramatic, cries easily, excessively emotional and attention seeking). In the therapist trainee sample, the frequency analysis yielded 20 stereotypic symptoms with percentages that ranged from 33 to 78%. Of these symptoms, 10 reflected a sizable minority (panicky, feels worthless, relives past trauma, binges/purges, distressed, nervous, moody, was abused as a child, tense, eats too little), 6 reflected a simple majority (unsatisfied with appearance, cries easily, overly talkative, needs attention, feels anxious, paranoid), and 4 reflected a strong majority (cross-dresses, is overly dramatic, feels like a woman, excessively emotional and attention seeking). Counter-stereotypic symptoms of gay men were also assessed. A symptom was considered counterstereotypic if at least 33% of participants judged the symptom as much less or somewhat less characteristic of gay men than straight men and less than 10% of participants rated the symptom as much more or somewhat more characteristic of gay men than straight men. In the college student sample, only two symptoms were perceived as counter-stereotypic: abuses alcohol (M = 35%) and eats too much, (M = 35%). In the therapist trainee sample, three symptoms were perceived as counter-stereotypic: quick to anger (M = 43), eats too much (M = 33), and has no remorse (M = 33). Chi-square tests were used to assess the extent to which college students and therapist trainees endorsed different stereotypes about gay men’s mental health. Comparisons included each symptom endorsed as stereotypic by either the college student or the therapist trainee samples (see Table I). Chi-square tests enabled us to determine if the frequency with which the college student sample endorsed a particular symptom was significantly different from the frequency with which the therapist trainees endorsed the symptom. Analyses indicated that a significant difference existed between the college student and the therapist trainee samples on only two symptoms: unsatisfied with appearance, χ2 (1, 341) = 9.29, p = .002 (college students: M = 43%; therapist trainees: M = 67%), and touches strangers, χ2 (1, 342) = 6.65, p = .007 (college students: M = 53%; therapist trainees: M = 33%). No

74 other significant differences were found (all p’s > .06). These findings suggest that the college student and the therapist trainee samples endorsed highly similar stereotypes of gay men’s mental health. Stereotype Strength Despite the similarity between the stereotypes endorsed by the two samples, it was still possible that their stereotypes might differ in strength, that is, the extent to which each sample associated the stereotypic symptoms with gay men. To examine this issue, we addressed two questions related to the strength of the stereotype: (a) How strongly held is the stereotype about gay men’s mental health? and (b) Do the stereotypes endorsed by the college student and therapist trainee samples differ in terms of stereotype strength? The strength of each sample’s stereotype was assessed with a two-step procedure. First, we averaged each participant’s ratings of the 22 symptoms listed in Table I. This created one value per participant, such that higher values indicate a more strongly endorsed stereotype. Second, we averaged these values across participants separately by sample. This yielded one grand mean for each sample, such that higher values indicate that a sample endorsed a stronger stereotype on average. The grand means were 3.53 for the college students and 3.55 for the therapist trainees. We used an independent sample’s t-test to examine whether the college student and the therapist trainee samples differed in terms of how strongly they endorsed the stereotype of gay men’s mental health. The dependent variable was participants’ average rating of the symptoms listed in Table I. Results were not significant, t(336) = .37, p > .05, which suggests that the degree to which the stereotypic symptoms were perceived to characterize gay men’s mental health was similar across samples. DSM-IV-TR Categories and the Stereotype about Gay Men’s Mental Health In order to determine if there were trends in the stereotypes reported by the two samples, individual traits were separated into their DSM-IV-TR diagnostic categories and disorders. Once organized, the traits were consistent with five DSM-IV-TR disorder categories and 13 individual disorders (see Table II). Within the diagnostic categories, anxiety included seven traits. The categories of personality and sexual

Boysen, Vogel, Madon, and Wester Table II.

DSM-IV-TR Catagorization of Mental Health Stereotypes of Gay Men Traits

Cries easily Feels worthless Often feels sad Overly talkative Feels anxious Panicky Nervous Tense Distressed Relives past trauma Was abused as a child

DSM diagnostic category Mood Disorders Depression Depression Depression Bipolar Anxiety Disorders Generalized anxiety disorder Generalized anxiety disorder Generalized anxiety disorder Generalized anxiety disorder Generalized anxiety disorder Post-traumatic stress disorder Post-traumatic stress disorder

Sexual and Gender Identity Disorders Cross-dresses Transvestitism Touches strangers Frotteurism Becomes sexually aroused Fetishism by strange objects Feels like a woman Gender identity disorder Eating Disorders Unsatisfied with appearance Anorexia Nervosa Eats too little Anorexia Nervosa Binges/Purges Bulimia Nervosa Personality Disorders Moody Borderline personality disorder Is overly dramatic Histrionic personality disorder Excessively emotional and Histrionic personality disorder attention seeking Needs attention Histrionic personality disorder Paranoid Paranoid personality disorder

and gender identity included five traits each. Mood and eating disorders included four and three traits, respectively. Among the individual disorders, Generalized Anxiety Disorder included five traits. Depression and Histrionic Personality Disorder each included three traits, Post Traumatic Stress Disorder and Anorexia Nervosa included two traits each, and Bipolar Mood Disorder, Transvestitism, Frotteurism, Fetishism, Gender Identity Disorder, Bulimia Nervosa, Borderline Personality Disorder, and Paranoid Personality Disorder each included one trait. Examination of the categories represented by the individual traits does appear to indicate that the DSM-IV-TR categories of anxiety, mood, sexual and gender identity, eating, and personality disorders are part of the mental health stereotype of gay men. Discussion Study 1 yielded two main findings. First, it indicated that there is indeed a stereotype about the

Mental Health Stereotypes mental health of gay men that includes symptoms of anxiety, personality, mood, eating, and sexual and gender identity disorders. Second, Study 1 indicated that college students and therapist trainees similarly endorsed the stereotypical attributes about gay men’s mental health in terms of both content and strength. It is interesting that the stereotype of college students and therapist trainees contained almost no statistically reliable differences despite their different levels of education and career specialization. A likely explanation is that the college students and therapist trainees were both using the same cultural stereotype. Before this statement can be made however, other possible explanations for the similarity between the two groups need to be ruled out. In the next two studies, we examined two alternative hypotheses for the similarity between the two groups.

STUDY 2 We designed Study 2 to examine whether our particular sample of therapist trainees exhibited attitudes toward homosexuality that are atypical of their profession. Although therapists and therapist trainees typically possess positive attitudes toward homosexuality (Bieschke & Mathews, 1996; Gelso, Fassinger, Gomez, & Latts, 1995; Hayes & Erkis, 2000; Liddle, 1995), it is possible that the group of therapist trainees that we sampled was nonnormative. If the therapist trainees possessed general attitudes toward homosexuality that are similar to those of non-trainees, it might explain why their stereotype did not differ from those endorsed by the college student sample. In Study 2, we directly explored this possibility by examining the attitude toward homosexuality of the previous set of therapist trainees in comparison to a new sample of college students. Even if the two samples differ, stereotypes could still be related to attitudes toward homosexuality. Therefore, in Study 2 we also examined the correlation between attitudes toward homosexuality and stereotype strength.

75 in Study 1. Participants were recruited from psychology courses and received extra credit in exchange for participation. Both psychology majors and nonmajors participated, and psychology majors made up 9% of the sample. They reported a mean age of 20 years with a range of 18–26 years. The reported racial/ethnic makeup of the sample was 84% European American, 8% Asian American, 3% African American, and 3% did not specify their race. Less than 1% of students in the sample reported that they were lesbian, gay, or bisexual. The same 49 therapist trainees used in Study 1 were used in this study.

Measure Participants’ attitudes toward homosexuality were measured using Park and Bieschke’s (2002) Heterosexism Scale (HS). The HS is a subtle measure of bias against homosexuality. This subtlety made it the most appropriate measure for the present study because other measures of attitudes toward homosexuality are too blatant to use with a therapist population (Bieschke & Mathews, 1996). The HS is a 17item instrument designed to measure subtle biases against homosexuality by assessing participants’ preference for heterosexuality. Statements are rated on a 6-point scale that ranges from 1 (Strongly agree) to 6 (Strongly disagree). Higher scores on the HS scale indicate a greater rejection of homosexuality and a greater affirmation of heterosexuality. The internal consistency of this scale has been shown to exceed .90 in other samples (Boysen, Vogel, Madon, in press; Park & Bieshcke, 2002). The current study demonstrated comparable alpha coefficients in both the college student sample (α = .96) and the therapist trainee sample (α = .91). The validity of the HS has also been demonstrated by past researchers, who showed that HS correlates significantly with attitudes toward ethnic minorities, r = .47, p < .001, attitudes toward women, r = .45, p < .001, authoritarian attitudes, r = .59, p < .001, and homophobia, r = .90, p < .001, and that it does not significantly correlate with social desirability (Park & Bieschke, 2002).

Method Procedure Participants A new sample of 77 college students (64% women and 34% men) were recruited from psychology classes at the same large midwestern university as

Both samples completed the survey materials in groups. After they provided their informed consent, participants received verbal instructions to inform them that they would complete a questionnaire

76 designed to assess their personal attitudes toward heterosexuality and homosexuality. Upon completion of the questionnaire, participants were debriefed and dismissed.

Results and Discussion Comparison of Attitudes Toward Homosexuality An independent sample’s t-test was used to examine whether the college student and the therapist trainee samples differed with respect to their attitudes toward homosexuality. Results indicated that therapist trainees had significantly lower HS scores (M = 41.96, SD = 15.56) than did the college student sample (M = 50.53, SD = 15.41), t(124) = 3.03, p < .003. This result indicates that our sample of therapist trainees held more positive attitudes toward homosexuality than did our sample of college students. This suggests that attitude toward homosexuality was not a likely reason why we did not find a difference between the stereotypes endorsed by the college student and the therapist trainee samples in Study 1.

Relation of Attitudes Toward Homosexuality and Stereotype Strength among Therapist Trainees Despite the difference in attitudes toward homosexuality that we found between the college student and the therapist trainee samples, a relationship between general attitudes and stereotypes may still exist. Therefore, the correlation between HS scores and stereotype strength was computed in the therapist trainee sample. A significant relation was found between HS scores and stereotype strength, r = .42, p < .01. The positive correlation indicates that higher levels of heterosexism were related to a stronger stereotype. Therefore, although a similar level of bias does not seem to explain the congruence of stereotypes between the two groups, attitudes toward homosexuality are indeed related to stereotypes.

Boysen, Vogel, Madon, and Wester finding did not occur because the two samples held similar attitudes toward homosexuality. In Study 3, we examined whether the lack of significant differences observed in Study 1 might have occurred because the therapist trainees provided their perceptions of the stereotype that society-at-large endorses about gay men rather than their own personal beliefs. If this had occurred, their responses might reflect their knowledge of the cultural stereotype rather than their personal beliefs. This issue was addressed by assessing the symptoms that a new sample of therapist trainees believe society-at-large holds about gay men. If the therapist trainees from Study 1 had reported their perceptions of the cultural stereotype of gay men, then the stereotype content and strength they reported should be very similar to the stereotype content and strength reported by this new sample of therapist trainees. Method Participants Participants included a new group of 83 therapist trainees enrolled in the same graduate program described in Study 1. Institutional review policies disallow the collection of demographic information to ensure anonymity; however, what follows are the characteristics of the general counseling program students. At the time of this study, the mean age of the students in the program was 29 years (SD = 8.4). Eighty-one percent of them were female; 19% were male. Students are not required to disclose racial or ethnic background upon registration, but of those that disclosed 48% were European American, 41% were African American, and 11% were Asian American. Mean years in the program at the time of this study was 2.2 (SD = 1.8), which means that they would have completed classes such as Theories of Counseling, Multicultural Counseling, Assessment and Diagnoses, and Counseling Techniques. The mean years of counseling experience was 2.4 years (SD = 4).

STUDY 3

Measure

The results of Study 1 indicate that the stereotype that college students endorsed about gay men’s mental health did not differ from that endorsed by a therapist trainee sample in terms of either content or strength. The results of Study 2 suggest that this

The same mental health stereotype questionnaire used in Study 1 was used here. The only alteration was in the directions given to participants. Instead of instructing participants to indicate their own beliefs, the questionnaire instructed them to indicate

Mental Health Stereotypes the traits and attributes that society believes characterize gay men in comparison to straight men. Procedure The questionnaire was completed in groups. After they provided their informed consent, participants received verbal instructions to inform them that they would complete a questionnaire designed to assess society’s opinions about gay men’s mental health. Upon completion of the questionnaire, participants were debriefed and dismissed. Results and Discussion Analyses were conducted to address three questions related to the cultural stereotype of gay men’s mental health: (a) What do therapist trainees believe is the content of the cultural stereotype?, (b) Does the content of the stereotype endorsed by the therapist trainees from Study 1 (who indicated their personal beliefs) differ from the content of the stereotype endorsed by the therapist trainees from Study 3 (who indicated society’s beliefs)?, and (c) Does the strength of the stereotype endorsed by therapist trainees from Study 1 differ from the strength of the cultural stereotype endorsed by therapist trainees from Study 3? Content of the Stereotype To assess the symptoms that therapist trainees believe society endorses about gay men’s mental health, we used the same procedures as in Study 1. Specifically, we used frequency distributions to identify those symptoms that at least 33% of participants rated as much more or somewhat more characteristic of gay men than of straight men in society’s view and that less than 10% of participants rated as somewhat less or much less characteristic of gay men than of straight men in society’s view. Of the 58 symptoms included in the mental health stereotype questionnaire, 27 fit these criteria. Of these stereotypic symptoms, 2 reflected a sizable minority (sexually enjoys suffering, sexually attracted to children), 15 reflected a simple majority (touches strangers, panicky, moody, distressed, paranoid, feels worthless, eats too little, relives past trauma, often feels sad, becomes aroused by strange objects, nervous, unable to control impulses, binges/purges, feels empty, has recurrent inappropri-

77 ate thoughts), and 10 reflected a strong majority (is overly dramatic, feels like a woman, cross-dresses, cries easily, excessively emotional and attention seeking, overly talkative, needs attention, feels anxious, was abused as a child, feels helpless). As reported in Table I, the therapist trainees believed that society endorsed almost all the symptoms that the previous sample of therapist trainees had endorsed (i.e., 19 of 20 symptoms were the same) plus 8 additional symptoms not endorsed by the previous sample (i.e., sexually attracted to children, sexually enjoys suffering, feels empty, becomes aroused by strange objects, unable to control impulses, feels helpless, often feels sad, and has inappropriate thoughts). Chi Square tests were used to examine the extent to which the stereotype endorsed by therapist trainees in Study 1 differed from the stereotype endorsed by therapist trainees in Study 3. Comparisons included the 20 symptoms endorsed by the therapist trainees from Study 1 and the 8 additional symptoms endorsed by the therapist trainees from Study 3. Chi-square tests enabled us to determine if the frequency with which the sample from Study 1 endorsed a symptom was significantly different from the frequency with which the therapist trainee sample from Study 3 endorsed the same symptom. The analyses indicated that a significant difference existed between the samples for 21 of 28 symptoms (p’s < .05), which constituted over two-thirds of the symptoms that were compared. These attributes were: overly dramatic, feels helpless, needs attention, moody, overly talkative, distressed, has recurrent inappropriate thoughts, panicky, touches strangers, sexually attracted to children, becomes aroused by strange objects, feels worthless, nervous, often feels sad, abused as a child, eats too little, feels like a woman, sexually enjoys suffering, relives past trauma, feels anxious, and cries easily. In each case, significant differences occurred because a larger frequency of the therapist trainees who rated society’s beliefs endorsed the symptom as stereotypic. These results strongly suggest that the therapist trainees reported their own attitudes in Study 1 and that trainees believe that society is likely to endorse a larger number of symptoms as stereotypic of gay men than they themselves hold.

Strength of the Stereotype In order to test if there were stereotype strength differences between the samples, the 28 symptoms

78 that were rated as stereotypic by either therapist trainee sample were averaged into a stereotype strength score for each participant. Then, an independent samples t-test compared the strength of the personal stereotype endorsed by the therapist trainees from Study 1 to the strength of society’s stereotype as endorsed by the sample of therapist trainees in Study 3. The analysis indicated that there was a significant difference between the strength of the samples’ reported stereotypes of gay men’s mental health, t(124) = 4.78, p < .001. Specifically, the personal stereotype endorsed by therapist trainees from Study 1 (M = 3.46, SD = .31) was weaker than the cultural stereotype reported by the sample in Study 3 (M = 3.78, SD = .41). These findings suggest that therapist trainees reported their own attitudes in Study 1. This also suggests that they believed that society holds a significantly stronger stereotype about gay men’s mental health than they personally endorse.

GENERAL DISCUSSION We have presented three studies in which we examined the stereotype of gay men’s mental health among college student and therapist trainee groups. Results indicate three main findings. First, college students and therapist trainees both endorsed a stereotype that contains traits of five DSM-IV-TR disorder categories: anxiety, mood, sexual and gender identity, eating, and personality. Second, the stereotypes endorsed by college students and therapist trainees showed few significant differences in terms of either content or strength. Third, neither general attitudes toward homosexuality nor the tendency for participants to report cultural stereotypes rather than their own personal beliefs could fully account for the lack of differences between the samples’ stereotypes. These results represent the first attempt to identify specific mental health stereotypes about gay men. Nonetheless, past research does provide some perspective on why certain symptoms emerged as stereotypical. Epidemiological studies have shown that gay men do appear to report certain mental health problems more frequently than heterosexual men. For example, depression (Cochran & Mays, 2000b; Sandfort et al., 2001), suicide (Cochran & Mays, 2000a), anxiety (Gilman et al., 2001; Sandfort et al., 2001), and panic (Cochran & Mays, 2000b) have higher prevalence rates among gay men than

Boysen, Vogel, Madon, and Wester straight men. Given that the stereotypes endorsed by both samples included acknowledgement of depression and anxiety as more characteristic of gay men than straight men; society-at-large may be at least partially aware of the mental health problems of gay men today. Despite the potential awareness of some mental health concerns in the gay male population, other stereotypic attributes endorsed by the participants do not seem to reflect accurate perceptions. Substance abuse, for example, is another mental health problem gay men may be more likely than straight men to have (Gilman et al., 2001). Yet, this stereotypic attribute did not emerge as part of the stereotype endorsed by either group, and alcohol abuse was actually thought by college students to be counter-stereotypic of gay men. In addition, several mental health attributes that pertain to sexual and personality disorders that emerged as stereotypic in our research are not supported by epidemiological research. The use of general cultural stereotypes about gay men provides a possible explanation for the similarity of the mental health stereotypes in the college student and the therapist trainee samples. Their stereotypes were generally consistent with past research on cultural stereotypes of gay men. Social psychological researchers have found that gay men are consistently stereotyped as feminine (Kite & Deaux, 1987; Levitt & Klassen, 1974; Madon, 1997; Simmons, 1965; Staats, 1978; Taylor, 1983), and some of the symptoms that were endorsed by our participants seem to reflect that belief. For example, gay men were thought to feel like women. They also were thought to have traits of disorders more common in women than men such as eating disorders and histrionic and borderline personality disorders (APA, 2000). This also may be evidence that college students and therapist trainees share common gender role stereotypes. The view of gay men as fulfilling the feminine gender role may have led participants to endorse all characteristics that were seen as typical of women. Unfortunately, teasing apart whether the beliefs result from the stereotype gay of men or gender role stereotypes is impossible at this juncture. Bias is another possible explanation for the results of Study 1. Individuals with a generally unfavorable view of gay men may be more inclined to endorse what they perceive as negative attributes, such as characteristics of mental illness, as more common in that population. Our findings provide some support for this interpretation. Participants had the

Mental Health Stereotypes opportunity to rate any and all traits as characteristic of straight men, but overwhelmingly choose to rate them as characteristic of gay men. Only two traits related to mental disorders were rated as more characteristic of straight men (counterstereotypes), whereas 28 traits were rated as more characteristic of gay men. Furthermore, the correlation between stereotype strength and heterosexism was significant. In essence, participants may simply have been associating the stigmatized concepts of homosexuality and mental illness together. Bias cannot fully explain the results, however, because the therapist trainees had significantly lower levels of bias than college students did but the nonetheless endorsed a similar stereotype. It is unclear how different levels of bias would lead to the similar stereotype found in the two samples if it were fully mediating the results. The topic of eating disorders and gay men is worthy of extended discussion because the topic illustrates the possible influence of stereotypes on mental health care and research. Eating disorder traits were seen as stereotypic of gay men, but it is not clear how to interpret these beliefs, especially among the therapist trainees. Although studies with small, non-random samples commonly show higher rates of eating disorders or body image dissatisfaction among gay men than among straight men (Russell & Keel, 2002; Siever, 1994), there have been contrary studies (Hausmann, Mangweth, Walch, Rupp, & Pope, 2004). More important, although differences in eating behavior and attitudes have been found in a large-sample study of gay adolescents (Austin et al., 2004), no epidemiological research has emerged to indicate a higher prevalence of eating disorders among gay men. Even though higher rates of eating disorders among gay men are widely accepted as true, the evidence is still being amassed and caution must be used because of the low base rates of eating disorders and the relatively low number of gay men. To illustrate this point, in one epidemiological study researchers did try to assess for eating disorders among gay men but chose not to present their data due to low prevalence rates (Sandfort et al., 2001). The very stereotypes found in the present study are an interesting explanation for the relative ease with which high prevalence rates of eating disorders among gay men have made it to clinical lore despite only emerging evidence and small base rates. Individuals may be more likely to believe gay men than straight men have eating disorders because it is consistent with their stereotype of gay men as feminine.

79 In addition to the feminine stereotype about gay men, society has also traditionally seen gay men as sexually deviant (Levitt & Klassen, 1974; Simmons, 1965). Attributes of transvestitism, frotteurism, and fetishism seem to be indicative of this perceived sexual deviancy. However, in the case of these disorders, the traits indicated as more characteristic of gay men may have been interpreted in nondisordered ways. For example, cross-dresses could have been interpreted in the drag culture rather than the transvestitism context. Also, touching strangers may or may not have been unilaterally construed in a sexual context. Despite these questions, there is some limited evidence that gay men are still seen as sexually deviant.

Implications One major implication of the present work is the potential for stereotypes about gay men’s mental health to lead to discrimination. Gay men are seen as stereotypically different from their straight counterparts; moreover, the perceived differences identified in this study pertain to the sensitive topic of mental illness. Despite the advances that have been made in accepting those with mental disorder in our society, a stigma still exists (Corrigan, 2004). Therefore, there is a potential for discrimination to occur on the basis of perceived differences in the mental health of gay and straight men. Some salient examples of where discrimination might occur are when gay men are in direct competition with straight men for limited occupational or educational resources. Although there is no denying that different groups succumb to mental health problems at different rates, gay men may be especially in danger of being labeled as mentally unstable. If these beliefs are inaccurate, then they have the potential to create a self-fulfilling prophecy whereby an individual gay man may exhibit behaviors indicative of mental instability due to the way that he was treated by others (Merton, 1948). A mental health stereotype also could influence the quality of psychotherapy provided to gay men in several different ways. First, the stereotype could function as an aid to diagnosis in some cases. An accurate stereotype could potentially be of use in detecting and diagnosing disorders that gay men are actually more likely to have. However, with the difficulty of determining the accuracy of stereotypes and the difficulty humans have in using base rate information, extreme care would have to be taken

80 for the stereotypes to be used properly. Furthermore, because stereotypes that are accurate at the level of a group will often be inaccurate when applied to particular individuals in the group, it is questionable how ethical or useful a stereotype could be in the diagnosis process. Indeed, the use of stereotypes in the diagnosis process can be more harmful than helpful. Stereotypes about African Americans, for instance, have led to disproportionate rates of misdiagnoses and more severe diagnoses of African American clients than was warranted (Adebimpe, 1981; Neighbors et al., 1989). For example, the stereotype of African Americans as more jovial than European Americans resulted in the belief that they did not experience the sadness associated with depression (Adebimpe, 1981). Some of the stereotypes found in the current studies could have similar implications. For example, one effect of a belief that gay men are more likely than straight men to experience certain symptoms (i.e., characteristics of borderline and histrionic personality disorders or sexual dysfunctions) is that it could lead to those behaviors being over-pathologized compared to similar behavior in straight men. It must be noted, however, that an opposite effect of under-pathologizing could also occur. Behavior of gay men, such as being anxious, nervous, and panicky, could be ignored because it is seen as typical, and, thus, an anxiety disorder could be overlooked. In general, individuals such as the trainees in these studies who are or will eventually be providing mental health care for gay men should be conscientious about their mental health stereotypes so that problems associated with the misuse of stereotypes in the diagnostic process are avoided.

Limitations There are some limitations to this research that warrant discussion. One limitation regarding the stereotype questionnaire was the translation of DSM symptoms into common language. For some of the symptoms, the conversion may have changed the psychopathological meaning conveyed in the DSM. For example, converting “requires excessive admiration” into “needs admiration” does reduce the level of severity that may be assumed about the trait. Because some form of coding for the symptoms had to be implemented, this limitation was unavoidable. Nonetheless, it is important to keep in mind that at any time a single symptom is separated from its diag-

Boysen, Vogel, Madon, and Wester nostic context information about psychopathology is potentially lost. A second limitation of this research pertains to the potential influence of social desirability on participants’ willingness to endorse symptoms as stereotypic of gay men, especially among the therapist trainees. Centers of training for therapists tend to put more emphasis on egalitarian views about sexuality than other institutions do. Thus, social desirability may have been a larger factor in the therapist trainee group than the college sample group. As such, social desirability, rather than actual lower levels of heterosexism, may have been a factor in their significantly lower scores on the HS. Finally, it must be noted that all the samples were taken in from schools in the Midwest and that only one therapist-training program participated. Thus, replication in other parts of the country and in other training programs is necessary to determine how the results might generalize. Future Directions There are many other useful directions for research on mental health stereotypes. Foremost, future researchers may want to examine stereotypes about lesbians and bisexuals. Lesbians and bisexuals represent understudied groups in the psychological literature (Phillips, Ingram, Smith, & Mindes, 2003). Adding them to the paradigm established by the current research would serve the dual purpose of furthering the limited knowledge about these groups and increasing the awareness of issues that concern lesbians and bisexuals. A missing piece from this study is the lack of input about the mental health of gay men from gay men themselves. Do gay men see themselves as having more or fewer symptoms of mental disorder than straight men? Are the symptoms they believe differentiate them from straight men the same as the ones society sees as stereotypical? To answer these questions, future researchers could also examine the accuracy of gay men’s stereotypes. Gay men’s ratings of their own mental health compared to straight men would provide a measure of stereotype accuracy (Ryan, 2002). Conclusion Despite the decades passed since the removal of homosexuality from the DSM, stereotypes about the mental health of gay men still exist. In the present

Mental Health Stereotypes study, college students and therapist trainees possessed a stereotype about gay men’s mental health that was similar in content and strength despite college students’ more biased attitudes toward homosexuality. Some of those stereotypes represented symptoms that research has shown are actually more common among gay men. However, some of the stereotypes seemed to be similar to more general stereotypes about gay men (e.g., they are feminine). The possibility that these mental health stereotypes could adversely affect the heath care gay men receive is a concern, and those responsible for administering that care should be especially careful not to overuse assumptions about the mental health of gay men.

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