Journal of Psychosocial Nursing and Mental Health Services

Original Article 

Experiences of Bisexual Identity, Attraction, and Behavior and Their Relationship With Mental Health: Findings From the Who I Am Study

Julia Taylor, PhD, MHlthSc, BN, RN; Jennifer Power, PhD; Elizabeth Smith, PhD

Abstract

Approximately one in 10 Australian individuals report bisexual attraction, and this group has repeatedly been found to experience high rates of poor mental health. Despite this finding, our understanding of who is most at risk within this group remains limited. The current article presents findings of an online survey conducted in Australia with one of the largest samples of bisexual adults to date (N = 2,651). Chi-square and regression analyses identified significant associations between the three dimensions of bisexuality (i.e., identity, behavior, and attraction) and mental health. Participants who reported identifying as bisexual were found to be especially vulnerable to poor mental health compared to those who reported bisexual attraction and/or sexual experiences without a bisexual identity. These findings provide a significant contribution to the lacking literature on the complexities of bisexual orientation and mental health. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx–xx.]

Abstract

Approximately one in 10 Australian individuals report bisexual attraction, and this group has repeatedly been found to experience high rates of poor mental health. Despite this finding, our understanding of who is most at risk within this group remains limited. The current article presents findings of an online survey conducted in Australia with one of the largest samples of bisexual adults to date (N = 2,651). Chi-square and regression analyses identified significant associations between the three dimensions of bisexuality (i.e., identity, behavior, and attraction) and mental health. Participants who reported identifying as bisexual were found to be especially vulnerable to poor mental health compared to those who reported bisexual attraction and/or sexual experiences without a bisexual identity. These findings provide a significant contribution to the lacking literature on the complexities of bisexual orientation and mental health. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx–xx.]

Bisexual people are often defined as those who are sexually attracted to or have sex with people of more than one gender; but what it means to be bisexual is more complex. There are people who identify as bisexual who have not had sexual experiences with people of more than one gender. There are also people who have sex with people of the same gender, but who identify as heterosexual. Yoshino (2000) defines bisexuality as a diverse experience that can incorporate bisexual identity, bisexual attraction, and/or bisexual behavior. Although this may seem semantic, there is an increasing body of evidence that suggests this more nuanced approach to defining bisexuality may be significant in understanding well-being among bisexual people (Bostwick, Boyd, Hughes, & McCabe, 2010; Geary et al., 2018; Mathy, Lehmann, & Kerr, 2003; McNair, Kavanagh, Agius, & Tong, 2005).

Despite recent research suggesting that the prevalence of those with bisexual attraction is approximately one in 10 of the broader population (Richters et al., 2014), research examining the lives and experiences of bisexual people has been limited, often overshadowed by the examination of gay and lesbian populations (Angelides, 2001; Klein, 1993). Currently, it is well established that bisexual people experience poorer mental health than their heterosexual, gay, or lesbian counterparts (Bostwick et al., 2010; Bostwick et al., 2007; Conron, Mimiaga, & Landers, 2010; Eisner, 2013; Hughes, Szalacha, & McNair, 2010; Jorm, Korten, Rodgers, Jacomb, & Christensen, 2002; Koh & Ross, 2006; Leonard et al., 2012; Li, Dobinson, Scheim, & Ross, 2013; Persson, Pfaus, & Ryder, 2015; Pompili et al., 2014; Steele, Ross, Dobinson, Veldhuizen, & Tinmouth, 2009). However, little is known about why bisexuality correlates with poor mental health and whether variations in experiences of bisexual identity, attraction, and/or behavior are associated with differences in mental health outcomes. Examinations of experiences of mental health across these three dimensions have rarely been conducted, and in research that explores these dimensions, findings have been restricted to comparing bisexual people to other sexual orientation groups (Bostwick et al., 2010) as opposed to comparing bisexual people to one another. With the increasing acknowledgement that bisexual people have high rates of poor mental health, there has never been more urgency to understand which bisexual people are most at risk to provide a starting point for intervention and ultimately improvement in outcomes.

Bisexual Identity, Attraction, and Behavior

Bisexual is a relatively new self-identity label only emerging in the latter half of the 20th century, and despite the cross-cultural existence of bisexual attraction and behavior, bisexual identification appears to be largely confined to Western culture (Carrier, 1999; Esterberg, 2011; George, 1999; Sittitrai, Brown, & Virulrak, 1999; Udis-Kessler, 2013). In recent years, identity labels for those attracted to more than one gender have broadened beyond the term bisexual (often in an effort to accurately describe specific attractions and experiences of those individuals under Eisner's [2013] bisexual umbrella) to include pansexual, queer, biromantic, bi-curious, heteroflexible, and homoflexible among others (Eisner, 2013; Sunfrog, 2013). The labels pan-sexual and queer have increased in usage in recent years and are viewed as more inclusive of gender diversity as they move away from the dichotomous inference of the term bisexual (Callis, 2014).

There is a clear consensus in the literature that finding, applying, and maintaining a bisexual identity is complex and often problematic (Balsam & Mohr, 2007; Bradford, 2004; Clausen, 1999; Dodge et al., 2012; Ross, Dobinson, & Eady, 2010; Weinberg, Williams, & Pryor, 1994). Finding an identity that adequately reflects the diversity of attraction and experience of bisexual people can be a difficult task (Bradford, 2004; Dodge et al., 2012; Weinberg et al., 1994). In addition, maintaining an identity that exists outside of the accepted societal dichotomy of heterosexual or homosexual in the face of negative stereotypes, biphobic discrimination, persistent assumptions of sexual orientation based on perceived partner's gender, and the invisibility and erasure of bisexuality in broader society, often presents a significant challenge for bisexual people (Balsam & Mohr, 2007; Bradford, 2004; Clausen, 1999; Dodge et al., 2012; Ross et al., 2010; Weinberg et al., 1994). Given these challenges, it is not surprising that theorists frequently describe bisexual identification as an ongoing process of confusion and uncertainty (Bradford, 2004; Clausen, 1999; Weinberg et al., 1994).

Several notable sex theorists of the 20th century sought to describe and quantify bisexual attraction (Ellis, 1915; Freud, 1920; Kinsey, Pomeroy, & Martin, 1948; Stekel, 1999). In the 1940s, Kinsey et al. (1948) provided a groundbreaking new theory of sexual attraction as existing on a continuum, with exclusive heterosexual attraction at one end and exclusive homosexual attraction at the other. For the first time the existence of, and diversity within, bisexual attraction was able to be clearly conceptualized and the growing discourse around bisexuality that began at this time has paved the way for contemporary understanding of non-monosexual attraction.

In the 21st century, bisexual attraction can be used inclusively to describe sexual and/or romantic attraction to more than one gender (Eisner, 2013). Although several population-based studies have examined bisexual identity, the prevalence of bisexual attraction is rarely reported. One recent large representative study of Australian adults posited a significant addition to the lacking literature on this topic, finding 5.8% of men and 14.2% of women reported attraction to more than one gender (Richters et al., 2014).

Bisexual behavior refers to a person's intimate and sexual experiences with people of more than one gender. In 1951, a landmark study exploring human sexual behavior in 191 countries revealed that bisexual behavior was a common feature of humans cross-culturally (Ford & Beach, 1951). In addition, bisexual behavior has been found to be far more prevalent than bisexual identity and those with heterosexual, gay, or lesbian identities can/do have sexual experiences with people of more than one gender (Geary et al., 2018; Richters et al., 2014; Smith, Rissel, Richters, Grulich, & de Visser, 2003). In contrast, bisexual behavior in the absence of bisexual attraction is rare (Geary et al., 2018).

Mental Health

Despite differences in study design, geographic location, sample sizes, and sample characteristics, research examining the mental health of bisexual people offers one clear consensus: bisexual people have higher rates of poor mental health than other sexual orientation groups (Bostwick et al., 2010; Bostwick et al., 2007; Conron et al., 2010; Eisner, 2013; Hughes et al., 2010; Jorm et al., 2002; Koh & Ross, 2006; Leonard et al., 2012; Li et al., 2013; Persson et al., 2015; Pompili et al., 2014; Steele et al., 2009). Bisexual people report a significantly higher incidence of mental disorders (Hughes et al., 2010; Koh & Ross, 2006; McNair et al., 2005; Persson et al., 2015; Steele et al., 2009), self-harm (Hughes et al., 2010), suicidality (Bostwick et al., 2007; Brennan, Ross, Dobinson, Veldhuizen, & Steele, 2010; Conron et al., 2010; Jorm et al., 2002; Koh & Ross, 2006; McNair et al., 2005; Steele et al., 2009), and psychological distress (Leonard, Lyons, & Bariola, 2015) than heterosexual individuals, lesbian women, or gay men.

Despite these now well established findings and the growing understanding of bisexuality as a characteristically diverse orientation existing across the three dimensions of identity, attraction, and behavior (Bostwick et al., 2010; Drucker, 2010; Yoshino, 2000), few researchers have delved deeper to examine how differences in experiences of these dimensions might relate to mental health.

One valuable contribution to this field of research is Bostwick et al.'s (2010) examination of data from a population-based study in the United States. Although this study does not focus exclusively on the bisexual population, it provides a rare, nuanced analysis of mental health across the three dimensions comparing sexual identity groups, sexual attraction groups, and sexual behavior groups (Bostwick et al., 2010). This study indicated that women who identify as bisexual were more likely to report poorer mental health than those who identified as lesbian or heterosexual (Bostwick et al., 2010). Similarly, women with bisexual attraction had higher rates of poor mental health than those with only mono-sexual attraction and those who had a history of bisexual behavior as opposed to those who had only had sexual experiences with one gender (Bostwick et al., 2010).

These findings were slightly different for men, with bisexually behaving and attracted men still reporting poorer mental health than their monosexually attracted and behaving counterparts. However, although heterosexual identification was associated with the lowest rates of mood disorders, men who identified as gay had higher rates of mood disorders than men who identified as bisexual (Bostwick et al., 2010). Although Bostwick et al. (2010) have identified that varying dimensions of sexual orientation have a relationship with mental health, their study does not provide any information on how bisexual groups compare to one another.

Current Study

The Who I Am Study aims to address a significant gap in the literature by providing new information about bisexuality and bisexual life experiences and shedding light on how these may be associated with poor mental health in bisexual people. The current study is one of the largest studies to date to focus specifically on people who fall under the bisexual umbrella and was guided by one research question: “Why do bisexual people experience poor mental health?” The current article focuses on bisexual peoples' diverse experiences of bisexual orientation by examining the bisexual identity, attraction, and behavior of Who I Am respondents and exploring whether participants' varying experiences of these three dimensions are related to poor mental health.

Method

Who I Am was a cross-sectional study involving an online survey conducted between September 2016 and March 2017.

Sample

The total sample comprised 2,651 adults living in Australia. Participants were recruited if they identified as bisexual and/or were attracted to more than one gender or had sexual experiences with more than one gender. Recruitment involved online advertising through social media sites (e.g., Facebook®), print advertising (i.e., posters), post cards displayed at sexual health centers and universities across Australia, e-mail, and word of mouth advertising through the researchers' professional networks. A range of advertising material was developed using different images, colors, and texts while maintaining consistent Who I Am branding. Some advertisements asked for bisexual or pansexual people, whereas others simply sought people who were attracted to more than one gender.

Survey Instrument

The Who I Am survey included the Kessler Psychological Distress Scale (K10) (Kessler et al., 2002), a standardized measure frequently used in Australian population-based surveys as well as other international research (Australian Bureau of Statistics [ABS], 2012). For the Who I Am Study, K10 scores were computed into four categories to represent participants' levels of current psychological distress as low (10 to 15), moderate (16 to 21), high (22 to 29), and very high (30 to 50) (ABS, 2012). The survey instrument also included basic demographic questions. All other Who I Am survey questions reported were devised by the current researchers after a process of literature review, survey drafting, consultation with key stakeholders, revision of the survey, piloting with a small sample of potential participants, and further refinement of the instrument in response to feedback from the pilot. These questions are listed in Table 1. Key stake-holders that were consulted in the development of the instrument included bisexual specific; lesbian, gay, bisexual, transgender, intersex; and mental health organizations in Australia. Mental health helpline phone numbers were provided at the beginning and end of the survey and alongside questions determined by the researchers to be of a sensitive nature.

Survey Questions Devised by Researchers

Table 1:

Survey Questions Devised by Researchers

Data Analysis

Data were analyzed using IBM® SPSS version 25 software. Frequency counts were conducted on all demographic questions and questions relating to experiences of bisexual identity, attraction, and behavior. An analysis of experiences of same sex versus different sex attraction and behavior was conducted for cisgender respondents (i.e., respondents whose biological sex was in-line with their gender identity) only, as the interpretation of same sex or different sex has added complexity for transgender and gender diverse people and this could not be meaningfully determined using the available data. Thus, transgender/gender diverse participants' sexual attraction and behavior were analyzed by examining whether their experiences incorporated men, women, transgender/gender diverse people, multiple genders, or no one. Participants were included in the transgender/gender diverse group for analysis if they identified their gender to be trans man, trans woman, non-binary/gender diverse, or identified their gender to be man or woman but indicated a different assigned sex at birth.

Answers to the questions “Do you identify as bisexual or pansexual?”; “Are you attracted to people of your own gender and at least one other gender?”; and “Have you had sexual experiences with people of your own gender and at least one other gender?” were then used to compute a new variable categorizing participants into one of seven groups based on their experiences across the three dimensions: identity only (n = 1, <1%); attraction only (n = 128, 4.8%); behavior only (n = 95, 3.6%); identity + attraction (n = 419, 15.8%); identity + behavior (n = 6, <1%); attraction + behavior (n = 358, 13.5%), and identity + attraction + behavior (n = 1,644, 62%). The categories identity only and identity + behavior were excluded from analyses due to their small frequency counts. The remaining five categories of bisexual orientation were then used in a series of Pearson chi-square tests with post-hoc analyses to examine potential relationships with mental health variables. Significance was set at p < 0.05 and adjusted residuals from post-hoc analyses >2.0 were considered to significantly deviate from expected counts.

These categories of bisexual orientation were included as an independent variable in a cumulative odds ordinal logistic regression model with proportional odds using K10 categories as the dependent variable and controlling for gender, age, local area description, education, and income. Collinearity diagnostics were run, and with the variance inflation factor (VIF) allowance set at <2.0, the assumption of multicollinearity was found not to have been violated. The assumption of proportional odds was met, as assessed by a full likelihood ratio test comparing the fit of the proportional odds model to a model with varying location parameters (χ2[18] = 27.039, p = 0.078). Results were considered significant at p < 0.05.

Due to survey questions being able to be skipped at the discretion of each participant, the total number of participants (N = 2,651) does not always correspond precisely with the total number of participants answering each question. The total number of participants answering each question has been included in tables to ensure accuracy of interpretation.

Ethics

Ethics approval for the current study was granted by the La Trobe University Human Ethics Committee and the community based acon (formerly the AIDS Council of New South Wales) Research Ethics Review Committee.

Results

Sample Characteristics

Who I Am respondents ranged in age from 18 to 77 years. Mean respondent age was 28.8 years (SD = 10.66 years). The majority of the sample was cisgender women (64.4%). There were respondents from every state and territory in Australia with the majority from inner or outer suburbia (79.5%). All education levels and income brackets were represented. Detailed sample characteristics are presented in Table 2.

Sample CharacteristicsSample Characteristics

Table 2:

Sample Characteristics

Bisexual Identity, Attraction, and Behavior

Approximately 78% of respondents identified as bisexual or pansexual, whereas 96.2% reported attraction to people of their own gender and at least one other gender (Table 3) and 79.3% reported having had sexual experiences with more than one gender (Table 4).

Experiences of Bisexual Identity and AttractionExperiences of Bisexual Identity and Attraction

Table 3:

Experiences of Bisexual Identity and Attraction

Experiences of Bisexual BehaviorExperiences of Bisexual Behavior

Table 4:

Experiences of Bisexual Behavior

Bisexual (42.9%) and pansexual (18.9%) were the most common sexual identities reported. Other identities included queer (13%), heterosexual/straight (7.5%), lesbian (5.7%), and gay (3.9%). Most participants (52.7%) reported that it was difficult or somewhat difficult to find an identity that fit with their attraction and/or experience. In addition, 45.4% of respondents indicated they always or often felt pressure to identify as heterosexual (Table 3).

Having equal attraction to all genders was reported by a similar percentage of cisgender participants (38.7%) and transgender/gender diverse participants (37%). However, most cisgender participants reported attraction to mostly same sex or mostly different sex people. Meanwhile, 29.8% of transgender/gender diverse respondents reported being mostly attracted to women and 15.8% revealed other attractions, which mostly included reporting attraction to traits (i.e., femininity, masculinity) as opposed to gender or not having sexual attraction to anyone (Table 3).

Sexual activity with different sex partners only was the most commonly reported form of sexual intimacy in the past year for cisgender participants (30.1%), whereas transgender/gender diverse participants were equally most likely to report having been sexually intimate with multiple genders (31.2%) or no one (31.2%). Approximately three quarters of the sample, regardless of their gender, reported having had sexual experiences with multiple genders at some point in their lives (Table 4).

Bisexual Identity, Attraction, Behavior, and Mental Health

Approximately 61% of respondents reported high or very high psychological distress (Table 2). A series of Pearson chi-square tests revealed significant associations between bisexual orientation categories and all mental health variables (Table 5). Post-hoc analyses identified that respondents in the identity + attraction + behavior category had significantly poorer mental health than expected based on the null hypothesis that no association exists. Meanwhile, respondents in the attraction only and the attraction + behavior categories were found to have significantly fewer experiences of poor mental health (Table 5).

Cross-Tabulation and Pearson Chi-Square Associations of Bisexual Orientation Categories and Mental Health

Table 5:

Cross-Tabulation and Pearson Chi-Square Associations of Bisexual Orientation Categories and Mental Health

The cumulative odds ordinal logistic regression model significantly predicted the dependent variable (K10 categories) over and above the intercept-only model (χ2[9] = 282.909, p ≤ 0.001). Respondents in the bisexual identity + attraction + behavior category (odds ratio [OR] = 1.455, 95% confidence interval [CI] [1.129, 1.873], p = 0.004) and those in the identity + attraction category (OR = 1.490, 95% CI [1.096, 2.045], p = 0.014) had significantly higher odds of reporting high levels of psychological distress than those in the attraction only and behavior only categories (Table 6). Participants who did not identify as bisexual, but reported bisexual attraction, bisexual behavior, or bisexual attraction + behavior, did not differ significantly from each other in their levels of psychological distress (Table 6). People who identified as bisexual reported significantly higher levels of psychological distress than those who did not, irrespective of their sexual attraction or behaviors.

Bisexual Orientation Categories as Predictors of High Levels of Psychological Distress (K10)

Table 6:

Bisexual Orientation Categories as Predictors of High Levels of Psychological Distress (K10)

Discussion

There is a large volume of research showing poorer mental health outcomes among people who identify as bisexual. However, the definition of bisexuality is complex, and people's experience of bisexual identity may not always align with their sexual experiences and attractions (Blumstein & Schwartz, 1999; Klein, 1993). Similarly, many people who have sexual experience with and attractions to people of more than one gender do not always identify as bisexual (Richters et al., 2014). The current article is unique in that it examines indicators of mental health according to expressions of bisexual identity, behavior, and attraction. The aim of the current article is to better understand the nature of bisexuality and its relationship to mental health.

Although approximately 80% of Who I Am respondents answered yes to the question “Do you identify as bisexual or pansexual?”, when asked what sexual identity they most identified with, approximately 62% selected one of these two identities. This finding fits with previous research revealing that bisexual people often use multiple identity labels simultaneously and can move fluidly between labels (Diamond, 2008; Dodge et al., 2012; McLean, 2007). This multiplicity and fluidity in labeling is despite their patterns of attraction and behavior usually remaining consistent over time (Diamond, 2008). In addition, these findings reveal that although all respondents to the Who I Am study fit the inclusion criteria of experiencing at least one of the three dimensions of bisexual identity, attraction, or behavior, approximately 20% of respondents did not identify as bisexual or pansexual and approximately 40% did not identify either of these as their most fitting identity label. This inconsistency in bisexual identification, despite the majority of participants reporting bisexual attraction and behavior, may be reflective of the difficulty and complexity of finding, applying, and maintaining an identity label that fits with their bisexual experience, a challenge that has been reported by numerous researchers (Balsam & Mohr, 2007; Bradford, 2004; Dodge et al., 2012; Ross et al., 2010; Weinberg et al., 1994).

Participants' responses supported this finding with more than one half of the sample reporting it had been very difficult or somewhat difficult to find an identity that fit with their attraction and/or experience. Scholars have suggested that this difficulty likely arises from bisexuality being outside of the accepted social norms of dichotomous homosexual or heterosexual identities (Clausen, 1999; Weinberg et al., 1994). This difficulty is reflected in the responses of Who I Am participants, many of whom reported feeling pressure to identify as heterosexual, gay, or lesbian.

The majority (96%) of Who I Am respondents reported attraction to more than one gender. It is well documented that bisexual attraction is diverse, with bisexual people reporting varying degrees of homosexual and heterosexual attraction (Kinsey, Pomeroy, & Martin, 1999; Richters et al., 2014; Smith et al., 2003; Weinberg et al., 1994; Zinik, 2000). Using the Kinsey scale as a means to conceptualize bisexual attraction as existing along a continuum between exclusively heterosexual and exclusively homosexual, it has been suggested that bisexually attracted people may center around the midpoint of this scale with equal attraction to both men and women (Kinsey et al., 1948). However, previous research has debunked this theory, finding that bisexual people with equal attraction to men and women are rare (Weinberg et al., 1994; Zinik, 2000). Recent studies have reported that when bisexual attraction is split into three groups (i.e., mostly same sex attracted, equal attraction to both sexes, mostly opposite sex attracted) an overwhelming majority of respondents who fall into one of these three categories indicate attraction to mostly the opposite sex (Richters et al., 2014; Smith et al., 2003). In contrast, cisgender respondents in the current study were most likely to report equal attraction to all genders, with approximately 25% reporting mostly different sex attraction. Similarly, although comparative data are lacking about transgender or gender diverse people's experiences of bisexual attraction, equal attraction to all genders was most commonly reported by transgender or gender diverse people in the current study.

Previous scholarly endeavors have revealed that bisexual behavior is not necessarily synonymous with either bisexual identity (Blumstein & Schwartz, 1999) or bisexual attraction (Klein, 1993). This revelation is reflected in the current study in which a much larger proportion of respondents reported bisexual attraction (96%) or behavior (79%) than identity (62%). Sexual intimacy with multiple genders was common for cisgender participants, with 76% reporting this in their lifetime and approximately 30% in the past 1 year, a finding consistent with previous research (Badcock et al., 2014; Li et al., 2013; McLean, 2004; Weinberg et al., 1994). Transgender and gender diverse participants in the current study reported similar rates of sex with multiple genders as cisgender participants; however, they were more likely to engage in sexual activity exclusively with other transgender and gender diverse people or no one. As with bisexual attraction, experiences of transgender and gender diverse bisexual individuals' sexual behavior has received limited scholarly attention; thus, comparative data are unavailable, and the current study presents a significant contribution to this field.

With the growing awareness of bisexuality's association with deleterious mental health outcomes (Bostwick et al., 2010; Bostwick et al., 2007; Conron et al., 2010; Hughes et al., 2010; Jorm et al., 2002; Koh & Ross, 2006; Leonard et al., 2012; Li et al., 2013; Persson et al., 2015; Pompili et al., 2014; Steele et al., 2009), there has never been a more pressing time to gain greater insight into how variations in bisexual people's experiences might relate to mental health. In the current study, the authors found that people who reported all three dimensions of bisexual orientation (i.e., identity, attraction, behavior) had poorer mental health than those who did not indicate bisexual identity (those who reported bisexual attraction and/or behavior only). In addition, participants in the identity + attraction + behavior category were also found to report higher levels of psychological distress than those who reported bisexual identity and attraction but not behavior. These findings may point to bisexual identity as being associated with poor mental health, a finding that fits with the writings of numerous theorists and researchers who have highlighted the challenge of maintaining a bisexual identity in a society that reinforces bisexual invisibility, erasure, and discrimination (Balsam & Mohr, 2007; Bradford, 2004; Clausen, 1999; Dodge et al., 2012; Ross et al., 2010; Weinberg et al., 1994).

Even though the authors found differences between these sub-groups of identity, attraction, and behavior within the current study, the whole sample reported significantly higher levels of psychological distress and poorer mental health than seen in the general population (Bostwick et al., 2010; Slade et al., 2009). For example, 20% of respondents in the current study who reported bisexual attraction only, 33% of those who reported bisexual behavior only, and 28% of those reporting bisexual attraction and behavior had attempted suicide, figures that are substantially higher than the 3.3% of the broader Australian population (Slade, 2009). Thus, although the implications of this research suggest that people who identify as bisexual are particularly vulnerable with regard to mental health, it is of paramount importance that there is an understanding that people under the bisexual umbrella who do not identify as bisexual but may be bisexually attracted and/or behaving, still experience far poorer mental health than the general population (Bostwick et al., 2010; Slade, 2009) and that translating these findings into practice should be done with this in mind.

Limitations

The current study was only available online and although a broad recruitment strategy was employed, most participants who took part in this study were alerted via online platforms. Thus, potential respondents who did not have access to the internet were unlikely to find out about the study, and if they did, would not have been able to participate. In addition, the survey's reliance on self-reporting and respondents being given the freedom to skip questions they did not wish to answer resulted in reporting bias and missing data. Similarly, the self-administering format of the questionnaire has inherent limitations. The necessary use of convenience sampling means that findings from the current study may not be representative of the broader bisexual population.

Conclusion

The current article presented findings from the Who I Am Study, one of the largest studies of bisexual people to date, which supports previous studies that show that bisexual people experience significantly poorer mental health than people of other sexualities. The current study also revealed the complexity of bisexual identity. Most participants did not identify as bisexual but reported attraction to people of more than one gender, and/or sexual experiences with people of more than one gender. This finding affirms that self-identity is not always the best way to make sense of an individual's sexuality or sexual history. Holding a self-identity as bisexual may be complex and challenging for people. This may explain a key finding in the current study that people who identified as bisexual reported poorer mental health than those who did not identify as bisexual. Along with these insights into the complexity of bisexual identity and the mental health associations that accompany it, the current study also found that it is not only bisexual people who self-identify as bisexual that experience high rates of poor mental health, but also those reporting bisexual attraction and/or behavior without the identity label. These findings provide much needed new insights that advance the understanding of the diversity of the bisexual experience and will work to better inform future research and mental health service provision.

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Survey Questions Devised by Researchers

QuestionResponse Options
Bisexual Identity
  Do you identify as bisexual or pansexual?

Yes

No

  What sexual identity do you most identify with?

Bisexual/pansexual

Heterosexual/straight

Gay/lesbian

Queer

Asexual

I do not identify with any sexual identity

Other

  Has it been difficult or easy for you to find an identity that fits with your attraction and/or experience?

Very difficult/somewhat difficult

Neither difficult nor easy

Somewhat easy/very easy

  Do you feel pressure to identify as heterosexual, gay, or lesbian?

Never/rarely

Sometimes/often

Always

Bisexual Attraction
  Are you attracted to people of your own gender and at least one other gender?

Yes

No

  How would you describe your sexual attraction?

Free text response

Bisexual Behavior
  Have you had sexual experiences with people of your own gender and at least one other gender?

Yes

No

  Who have you been sexually intimate with in the past year, in the past 5 years, or in your lifetime?

A man/men

A woman/women

A transgender or gender diverse person/people

Other (please specify)

Mental Health
  Has a health professional ever said you have…

Anxiety disorder (e.g., panic attacks, social anxiety)

Depression

Bipolar disorder

Schizophrenia

Borderline personality disorder

Eating disorder

Dissociative identity disorder (e.g., multiple personality disorder)

Posttraumatic stress disorder

  Have you ever…

Thought about self-harming or harmed yourself?

Thought about committing suicide or attempted suicide?

Sample Characteristics

Characteristicn (%)
Gender (n = 2,484)
  Cisgender woman1,600 (64.4)
  Cisgender man410 (16.5)
  Non-binary or gender diverse285 (11.5)
  Trans man63 (2.5)
  Trans woman60 (2.4)
  Other66 (2.7)
Age group (years) (N = 2,651)
  18 to 241,236 (46.6)
  25 to 441,144 (43.2)
  ≥45271 (10.2)
Aboriginal and/or Torres Strait Islander origin (n = 2,581)
  No2,511 (97.3)
  Yes70 (2.7)
Ethnicity (n = 2,585)
  Anglo/Australian2,178 (84.3)
  Other407 (15.7)
State or territory currently residing (n = 2,620)
  Victoria891 (34)
  North South Wales612 (23.4)
  Western Australia260 (9.9)
  Queensland280 (10.7)
  Tasmania216 (8.2)
  Australian Capital Territory189 (7.2)
  South Australia150 (5.7)
  Northern Territory22 (0.8)
Local area description (n = 2,619)
  Capital city/inner suburban1,395 (53.3)
  Outer suburban685 (26.2)
  Regional center340 (13)
  Rural or remote199 (7.6)
Highest level of education achieved (n = 2,499)
  Year 10 or below61 (2.4)
  Year 1165 (2.6)
  Year 12711 (28.5)
  Apprenticeship/trade certificate/TAFE certificate/tertiary diploma498 (19.9)
  Undergraduate university degree745 (29.8)
  Postgraduate university degree419 (16.8)
Total pre-tax income per year (n = 2,569)
  $091 (3.5)
  $1 to $29,9991,062 (41.3)
  $30,000 to $49,999413 (16.1)
  $50,000 to $79,999440 (17.1)
  $80,000 to $99,999147 (5.7)
  $100,000 to $124,999111 (4.3)
  $125,000 to $149,99943 (1.7)
  $150,000 to $199,99928 (1.1)
  ≥$200,00025 (1)
  Prefer not to answer209 (8.1)
K10 categories (n = 2,034)
  Low psychological distress (10 to 15)366 (18)
  Moderate psychological distress (16 to 21)428 (21)
  High psychological distress (22 to 29)606 (29.8)
  Very high psychological distress (30 to 50)634 (31.2)

Experiences of Bisexual Identity and Attraction

Characteristicn (%)
Do you identify as bisexual or pansexual? (N = 2,651)
  Yes2,070 (78.1)
  No581 (21.9)
What sexual identity do you most identify with? (n = 2,520)
  Bisexual1,080 (42.9)
  Pansexual476 (18.9)
  Heterosexual/straight189 (7.5)
  Gay99 (3.9)
  Lesbian143 (5.7)
  Queer328 (13)
  Asexual60 (2.4)
  I do not identify with any sexual identity93 (3.7)
  Other52 (2.1)
Has it been difficult or easy for you to find an identity that fits with your attraction and/or experience? (n = 2,255)
  Very difficult343 (15.2)
  Somewhat difficult846 (37.5)
  Neither difficult nor easy467 (20.7)
  Somewhat easy373 (16.5)
  Very easy226 (10)
Do you feel pressure to identify as heterosexual? (n = 2,262)
  Never331 (18)
  Rarely407 (12.9)
  Sometimes292 (23.7)
  Often535 (30.8)
  Always697 (14.6)
Do you feel pressure to identify as gay or lesbian? (n = 2,247)
  Never731 (32.5)
  Rarely470 (20.9)
  Sometimes559 (24.9)
  Often396 (17.6)
  Always91 (4)
Are you attracted to people of your own gender and at least one other gender? (N = 2,651)
  Yes2,549 (96.2)
  No102 (3.8)
How would you describe your sexual attraction? (cisgender only) (n = 1,884)
  Same sex attracted only44 (2.3)
  Mostly same sex attracted491 (26.1)
  Equally attracted to all genders730 (38.7)
  Mostly different sex attracted467 (24.8)
  Only different sex attracted13 (0.7)
  Fluid/changeable87 (4.6)
  Other52 (2.8)
How would you describe your sexual attraction? (transgender or gender diverse only) (n = 449)
  Only attracted to men1 (0.2)
  Mostly attracted to men47 (10.5)
  Equally attracted to all genders166 (37)
  Mostly attracted to women134 (29.8)
  Only attracted to women3 (0.7)
  Fluid/changeable27 (6)
  Other71 (15.8)

Experiences of Bisexual Behavior

Characteristicn (%)
Have you had sexual experiences with people of your own gender and at least one other gender? (N = 2,651)
  Yes2,103 (79.3)
  No548 (20.7)
Who have you been sexually intimate with in the past year? (cisgender only) (n = 1,654)
  Same sex only281 (17)
  Different sex only498 (30.1)
  Transgender or gender diverse only7 (0.4)
  Multiple genders467 (28.2)
  No one401 (24.2)
Who have you been sexually intimate with in the past 5 years? (cisgender only) (n = 1,654)
  Same sex only201 (12.2)
  Different sex only365 (22.1)
  Transgender or gender diverse only2 (0.1)
  Multiple genders882 (53.3)
  No one204 (12.3)
Who have you been sexually intimate with in your lifetime? (cisgender only) (n = 1,654)
  Same sex only97 (5.9)
  Different sex only203 (12.3)
  Transgender or gender diverse only2 (0.1)
  Multiple genders1,257 (76)
  No one95 (5.7)
Who have you been sexually intimate with in the past year? (transgender or gender diverse only) (n = 407)
  Men only78 (19.2)
  Women only56 (13.8)
  Transgender or gender diverse only19 (4.7)
  Multiple genders127 (31.2)
  No one127 (31.2)
Who have you been sexually intimate with in the past 5 years? (transgender or gender diverse only) (n = 407)
  Men only54 (13.3)
  Women only41 (10.1)
  Transgender or gender diverse only13 (3.2)
  Multiple genders218 (53.6)
  No one81 (19.9)
Who have you been sexually intimate with in your lifetime? (transgender or gender diverse only) (n = 407)
  Men only33 (8.1)
  Women only21 (5.2)
  Transgender or gender diverse only7 (1.7)
  Multiple genders303 (74.4)
  No one43 (10.6)

Cross-Tabulation and Pearson Chi-Square Associations of Bisexual Orientation Categories and Mental Health

Bisexual Orientation CategoriesMental Health Variables
Diagnosed With a Mental DisorderaThought About Self-HarmingSelf-HarmedThought About Committing SuicideAttempted Suicide
Attraction only53.2% (−3.2)64.9% (−3.3)46.8% (−2.8)72.4% (−1.8)19.7% (−2.4)
Behavior only72.3% (0.5)80.3% (0.1)56.7% (−0.9)77% (−0.6)32.8% (0.1)
Identity + attraction67.4% (−0.8)80.2% (0.2)57.6% (−1.8)76.6% (−1.8)22.5% (−4.1)
Attraction + behavior59.4% (−3.7)73.8% (−2.6)54.6% (−2.6)74% (−2.7)27.5% (−1.7)
Identity + attraction + behavior72.4% (4.2)81.8% (2.9)65.7% (4.6)83% (4.2)36% (5.2)
Chi-square statistic χ2 (df)28.648 (4)19.673 (4)24.375 (4)18.656 (4)30.877 (4)
p Value<0.0010.001<0.0010.001<0.001
Cramer's V (фc)0.1170.0980.1090.0950.123

Bisexual Orientation Categories as Predictors of High Levels of Psychological Distress (K10)

Bisexual Orientation CategoriesOR [95% CI]p Value
Attraction only1.344 [0.829, 2.181]0.231
Behavior only1.314 [0.771, 2.239]0.316
Identity + attraction1.490 [1.085, 2.045]0.014
Identity + attraction + behavior1.455 [1.129, 1.873]0.004
Attraction + behavior1.00 [reference]
Authors

Dr. Taylor is Research Officer, Dr. Power is Senior Research Fellow, and Dr. Smith is Research Fellow, La Trobe University, College of Science, Health, and Engineering, Australian Research Centre in Sex, Health, and Society, Bundoora, Victoria, Australia.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Julia Taylor, PhD, MHlthSc, BN, RN, Research Officer, La Trobe University, College of Science, Health, and Engineering, Australian Research Centre in Sex, Health, and Society, Building NR6, La Trobe University, Bundoora, Victoria, Australia 3086; e-mail: j.taylor@latrobe.edu.au.

Received: July 02, 2019
Accepted: September 24, 2019
Posted Online: December 16, 2019

10.3928/02793695-20191211-01

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