Perceived Community Belonging as a Moderator of the Association Between Sexual Orientation and Health and Well-Being

Purpose This study examines the moderating role of perceived community belonging in the association between sexual orientation and various health and well-being outcomes. Design A national cross-sectional survey. Setting Confidential microdata from the 2021 Canadian Community Health Survey. Subjects Individuals aged 15 and older, with a sample size ranging from 43,000 to 44,100. Measures Sexual orientation, health and well-being outcomes, and sense of community belonging were all self-reported. Outcomes included self-rated general and mental health, depressive symptoms, and life satisfaction. Analysis A series of multiple linear regression models. Results Compared to heterosexual individuals, bisexual individuals reported poorer self-rated general health (b = .402, P < .001 for men; b = .454, P < .001 for women) and mental health (b = .520, P < .001 for men; b = .643, P < .001 for women), higher depressive symptoms (b = 2.140, P < .001 for men; b = 2.685, P < .001 for women), and lower life satisfaction (b = .383, P < .05 for men; b = .842, P < .001 for women). Few disparities were observed among gay men and lesbians. Contrary to some recent findings, no disparities were observed among individuals uncertain about their sexual orientation or those who chose not to disclose it, even without controlling for covariates. A stronger sense of community belonging mitigated the disadvantages associated with self-rated general health (b = -.276, P < .01) and depressive symptoms (b = -.983, P < .01) for gay men, and life satisfaction (b = -.621, P < .01) for lesbians. Conclusion This study is among the first to highlight the stress-buffering role of community belonging in the association between sexual orientation and health and well-being outcomes.

9][20] Existing research has indicated a societal inclination to treat bisexuality as a 'choice,' primarily because bisexuals express romantic interests in both genders. 19,21einforcing this perspective, a study by Eliason 22 found that only 26% of respondents agreed with the statement that "people are probably born bisexual."In contrast, there is a growing societal consensus acknowledging that gay men and lesbians are likely born with their sexual orientation. 23This differential stance, based on perceived 'choice,' contributes to societal views that often depict bisexuals as selfish, immature, and less competent compared to their heterosexual, gay, and lesbian counterparts. 24This perspective is consistent with the broader observation that stigmatized traits perceived as controllable frequently encounter heightened discrimination. 25If society perceives certain characteristics as controllable, those possessing them may face increased blame for their marginalized status. 19In the context of bisexuality, these perceptions may suggest that society views bisexuals as responsible for their orientation, thereby possibly justifying discrimination against them. 19hile a wealth of research exists on this topic, the present study seeks to advance prior work by addressing three critical limitations.First, much of the existing research has been UScentric, raising questions about the applicability of such findings in other countries.This investigation delves into the association between sexual orientation and health and wellbeing outcomes in Canada.With its comparatively more accepting attitude towards sexual diversity than the US, 26 Canada offers a compelling setting for this exploration.This progressive attitude was evident when Canada legalized samesex marriage in 2005, a full decade before the US. 27Furthermore, Canada's public health care system could potentially mitigate some of the health disparities linked to sexual orientation. 28,29However, as the system primarily focuses on physical health and hospital-related care, 30 significant mental health disparities may still exist among sexual minority individuals. 31xisting Canadian studies that explore the association between sexual orientation and health present varied results.Evidence indicates that both homosexual and bisexual individuals are more likely to report mood and anxiety disorders than heterosexuals. 32Some studies have stratified their analysis by gender, showing that sexual minority men and women are more likely to report mood disorders than their heterosexual counterparts, respectively. 33A few investigations focus exclusively on one gender.Such studies have indicated that gay and bisexual men do not show significant differences in self-rated general and mental health, smoking, and drinking outcomes relative to heterosexual men. 34In contrast, bisexual women are more likely to report worse selfrated general and mental health compared to heterosexual women, while differences between lesbian and heterosexual women are minimal. 35hese varied results emphasize the need for a more indepth examination.This study seeks to build on prior Canadian investigations by distinguishing between homosexual and bisexual individuals and stratifying the analysis by gender.Employing recent data from the 2021 Canadian Community Health Survey (CCHS)-the only national survey incorporating a sexual orientation variable with a range of health and well-being measures-this study considers selfrated mental and general health, life satisfaction, and, following Statistics Canada's 2021 initiative, depressive symptoms.Based on the minority stress model, it is hypothesized that gay, lesbian, and bisexual individuals will report poorer self-rated mental and general health, higher depressive symptoms, and lower life satisfaction compared to heterosexual individuals (Hypothesis 1).Furthermore, it is anticipated that bisexual individuals will report greater disparities compared to homosexual individuals (Hypothesis 2).
Second, while there is significant interest in examining the association between sexual orientation and health and wellbeing outcomes, few studies have specifically addressed individuals who do not respond to questions about sexual orientation.Recent literature reveals a portion of respondents, comparable to those identifying as gay men or lesbians, who report non-responses like "don't know" or "refusal." 36,37otably, this pattern of non-response is not random; older participants or those with a lower educational background are less likely to report their sexual orientation, potentially due to a lack of understanding of the question. 38Furthermore, individuals from certain cultural backgrounds (eg, Chinese, South Asian, Southeast Asian, or Arab) are also less likely to answer a question on sexual orientation, 39 possibly due to stigmas associated with their sexual minority status. 40espite the potential health disadvantages these individuals may face, most research has not viewed them as a distinct sexual orientation subgroup in a multivariate framework.The only Canadian study addressing this issue, conducted by Sivakumaran and Margolis, 40 found that middle-aged and older adults reporting "don't know" in response to the sexual orientation question were more likely to report poor self-rated general and mental health relative to their heterosexual counterparts.However, some of these disparities were fully accounted for by covariates.To the best of the author's knowledge, no study has estimated this association in the broader general population.Nevertheless, the study by Sivakumaran and Margolis 40 provides some evidence to support the hypothesis that individuals reporting "don't know" or "refusal" to the sexual orientation question will experience poorer self-rated mental and general health, higher depressive symptoms, and lower life satisfaction compared to their heterosexual counterparts (Hypothesis 3).
Third, the current understanding of potential coping resources that may alleviate health and well-being disparities among sexual minority individuals is limited.This oversight is significant, particularly considering the disproportionate experiences of chronic stress reported by sexual minority individuals.The stress process model 41 posits that stressors originating from a disadvantaged social status can influence an individual's health and well-being.However, these effects may be buffered or moderated by coping resources, such as social support.3][44] Yet, given the potentially limited access to social support resulting from family and peer rejection, 32 there is a growing call among health scholars for the identification of potential communitylevel coping resources. 453][54][55][56] Applied to the present scenario, a strong sense of community connectedness could provide a less stigmatized living environment for sexual minority individuals, facilitating more positive identity development. 32oreover, a strong sense of community belonging may bolster self-esteem, promote social engagement and participation, and foster health-enhancing behaviors such as a balanced diet and regular physical activity among sexual minority individuals. 45,57nfortunately, few studies have explored its moderating potential in the association between sexual orientation and health and well-being.A notable exception is a study based on the 2007-2012 CCHS by Pakula and colleagues. 32Contrary to expectations, they did not find evidence supporting the stressbuffering role of community belonging.Instead, they discovered that the penalties associated with mood disorders were amplified among homosexual respondents (ie, combining gays and lesbians) with a stronger sense of community belonging.Despite this unexpected finding, drawing from research about social support and community belonging, it is plausible that a stronger sense of community belonging will alleviate disadvantages associated with self-rated mental and general health, depressive symptoms, and life satisfaction among gay, lesbian, and bisexual individuals (Hypothesis 4).

Data
To test the proposed hypotheses, this study utilized data from the confidential microdata file of the 2021 Canadian Community Health Survey (CCHS). 58The CCHS is a nationally representative cross-sectional survey administered by Statistics Canada.It collects information on health status, health determinants, and health care utilization patterns of Canadians aged 12 and older.However, the survey excludes residents of Indian reserves, health care institutions, some remote areas, and full-time members of the Canadian Forces.Data collection was conducted through both telephone and in-person interviews.Participation in the survey was voluntary, and informed consent was obtained from all participants.See Statistics Canada for further details about the CCHS sample design and data collection procedures. 58ince the question concerning sexual orientation was directed only at individuals aged 15 and older, 1,793 respondents between the ages of 12 and 14 were excluded from the analysis.Missing values for the selected variables were minimal, ranging between .14 and 3.74%.This made listwise deletion an appropriate procedure for handling them.The final sample size for analyzing self-rated mental and general health, as well as life satisfaction, was 44,100.However, due to missing data concerning depressive symptoms in 1,100 individuals, the final sample size for analyzing depressive symptoms was reduced to 43,000.

Measures
Self-rated mental health was measured with the question: "In general, would you say your mental health is…?" Responses were coded as "excellent" (1), "very good" (2), "good" (3), "fair" (4), and "poor" (5).This measure was treated as a continuous variable. 59,60elf-rated general health was measured with the question: "In general, would you say your health is…?" Responses included "excellent" (1), "very good" (2), "good" (3), "fair" (4), and "poor" (5).This measure was also treated as a continuous variable. 59,61ife satisfaction was measured with the question: "Using a scale of 0 to 10, where 0 means 'very dissatisfied' and 10 means 'very satisfied,' how do you feel about your life as a whole right now?"This item was then reverse-coded.
Depressive symptoms were measured with nine established items from the Patient Health Questionnaire (PHQ-9). 62Respondents were asked to indicate how often over the previous two weeks they had experienced a range of problems: "little interest or pleasure in doing things," "feeling down, depressed, or hopeless," "trouble falling or staying asleep, or sleeping too much," "feeling tired or having little energy," "poor appetite or overeating," "feeling bad about yourselfor that you are a failure or have let yourself or your family down," "trouble concentrating on things, such as reading the newspaper or watching television," "moving or speaking so slowly that other people could have noticed?Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual," and "thoughts that you would be better off dead, or of hurting yourself in some way."Each item was coded as "not at all," "several days," "more than half the days," and "nearly every day."A scale was created by summing the responses, ranging from 0 to 27, with higher scores indicating increased depressive symptoms (alpha = .81).However, due to high skewness, responses were top-coded at 10. 63,64  Sexual orientation was identified through self-reporting with the question: "What is your sexual orientation?"Responses were coded as "heterosexual," "gay or lesbian," "bisexual or pansexual," "not elsewhere classified," "don't know," "refusal," and "not stated."Respondents who reported "not elsewhere classified" and "not stated" were excluded from the analysis due to small sample sizes.
Gender was coded as "men," "women," and "gender diverse."Respondents identifying as "gender diverse" were excluded from the analysis due to a small sample size.

Analytical Strategy
The present study employed a series of Ordinary Least Squares (OLS) regression models to test the proposed hypotheses.All models included a full set of control variables and weights provided by the survey.The analysis began with Models 1-4 in Table 2, which explored the association between sexual orientation and four outcomes-self-rated mental health, self-rated general health, life satisfaction, and depressive symptoms.These models were conducted separately for men (Panel A) and women (Panel B) to account for potential gender-specific differences. 12Additionally, Table 3 tested the interaction terms.Models 1-4 examined whether the association between sexual orientation and each health and well-being outcome varied across levels of community belonging.These models were also stratified by gender, with men represented in Panel A and women in Panel B. All analyses were performed using Stata/SE 14.2.

Results
Table 2 presents OLS regression models predicting self-rated mental and general health, life satisfaction, and depressive symptoms, stratified by gender.Models 1-4 of Panel A demonstrated that bisexual men reported poorer self-rated mental (b = .520,P < .001)and general (b = .402,P < .001)health, lower life satisfaction (b = .383,P < .05),and higher depressive symptoms (b = 2.140, P < .001)compared to heterosexual men, with few disparities among gay men and those who reported "don't know" or "refusal" to the sexual orientation question.Similar patterns were observed for women: Models 1-4 of Panel B revealed that bisexual women reported poorer self-rated mental (b = .643,P < .001)and general (b = .454,P < .001)health, lower life satisfaction (b = .842,P < .001),and higher depressive symptoms (b = 2.685, P < .001)compared to heterosexual women.However, no disparities were observed among lesbians and those reporting "don't know" or "refusal" to the sexual orientation question.Collectively, these findings partially supported Hypothesis 1 that gay, lesbian, and bisexual individuals would report poorer self-rated mental and general health, higher depressive symptoms, and lower life satisfaction, compared to heterosexual individuals; fully supported Hypothesis 2 that bisexual individuals would report greater disparities compared to homosexual individuals; and failed to support Hypothesis 3 that individuals who reported "don't know" or "refusal" to the sexual orientation question would experience poorer self-rated mental and general health, higher depressive symptoms, and lower life satisfaction compared to their heterosexual counterparts.Table 3 presents OLS regression models predicting the moderating effects of community belonging on the association between sexual orientation and each health and well-being outcome, stratified by gender.While community belonging did not moderate the associations between sexual orientation and self-rated mental health and life satisfaction among men (as shown in Models 1 and 3 of Panel A), there were negative and statistically significant interactions between sexual orientation and community belonging in predicting self-rated general health (b = -.276,P < .01)and depressive symptoms (b = -.983,P < .01)(as shown in Models 2 and 4 of Panel A).To interpret these 2 coefficients, predicted values were calculated (see Figures 1 and 2).These values indicated that a stronger sense of community belonging attenuated the disadvantages in self-rated general health and depressive symptoms among gay men.
Somewhat different patterns were observed among women in Panel B; that is, community belonging did not moderate the associations between sexual orientation and self-rated mental and general health and depressive symptoms (as shown in Models 1, 2, and 4), but there was a negative and statistically significant interaction between sexual orientation and community belonging in predicting life satisfaction (b = -.621,P < .01).To interpret this coefficient, predicted values were calculated once again (see Figure 3).These values indicated that a stronger sense of community belonging attenuated the disadvantages in life satisfaction among lesbians.Collectively, these findings partially supported Hypothesis 4 that a stronger sense of  3. Low and high community belonging represent -1 and +1 standard deviations from the mean, respectively.3. Low and high community belonging represent -1 and +1 standard deviations from the mean, respectively.community belonging would alleviate disadvantages associated with self-rated mental and general health, depressive symptoms, and life satisfaction among gay, lesbian, and bisexual individuals.

Discussion and Conclusion
Drawing from the most recent cycle of the CCHS, this study examined the association between sexual orientation and multiple health and well-being outcomes, considering the moderating influence of perceived community belonging.Several findings emerged from this investigation.First, consistent with prior research in the United States, [10][11][12][13][14] it was observed that bisexual men and women reported poorer selfrated mental and general health, lower life satisfaction, and higher depressive symptoms compared to their heterosexual counterparts.This supports the minority stress perspective, suggesting that due to their stigmatized sexual identity, sexual minority individuals experience more adverse health and wellbeing outcomes. 9Interestingly, few disparities were observed among gay men and lesbians.
1][12][13][14] For instance, Liu and Reczek, 13 utilizing the 2013-2018 National Health Interview Survey, highlighted more significant disparities in self-rated general health among gays and lesbians.The lack of significant disparities observed in this study may be attributed to Canada's more supportive attitudes toward sexual diversity and the protective influence of the publicly funded health care system, 26,28,29 underscoring the importance of taking the social context into account when researching the association between sexual orientation and health and wellbeing.
Some readers may question if the grouping of sexual orientation subgroups could affect the observed patterns.To address this, several additional models were conducted.The patterns from Appendix A showed that when gay men and lesbians were combined, the results were largely consistent with those presented in Table 2.However, according to Appendix B, when homosexual and bisexual individuals were grouped together, sexual minority men and women reported worse health and well-being outcomes, with the exception of life satisfaction among sexual minority men.This suggests that bisexual individuals, a subgroup at high risk of health and well-being disparities, could drive the association for the non-heterosexual category.Future research in Canada should thus avoid lumping homosexual with bisexual respondents into a single group, when documenting health and well-being consequences to ensure more accurate information.
Second, in response to recent appeals for more research to investigate potential health and well-being consequences among respondents who do not disclose their sexual orientation, 40 this study revealed that those who reported "don't know" or "refusal" to the sexual orientation question experienced no disparities across all four outcomes.One plausible explanation could be the relatively small sample size of those who did not report their sexual orientation.To test this claim, the models from Table 2, combining "don't know" with "refusal," were conducted.This approach increased the proportion of nonresponse, making it comparable to that of sexual minority individuals.However, the results remained statistically insignificant (see Appendix C).
Another potential explanation is that the penalties among those who reported nonresponse were fully explained by covariates such as age, race/ethnicity, and education. 40To evaluate this claim, the models from Table 2, without controlling for any covariates, were conducted (see Appendix  3. Low and high community belonging represent -1 and +1 standard deviations from the mean, respectively.D).p1755) It is important to note, though, that in their study, Sivakumaran and Margolis 40 did not identify a consistent pattern since the penalties among those not responding to the sexual orientation question varied across age groups and health outcomes.Consequently, many questions remain unanswered about the health consequences among this group of individuals, highlighting the need for further research given their non-negligible size.
Third and possibly one of the most novel findings of this study, pertains to the moderating effects of community belonging.It was found that a stronger sense of community belonging alleviated the disparities in self-rated general health and depressive symptoms among gay men, and life satisfaction among lesbians.][54][55][56] However, these results also raise questions as to why the moderating effects of community belonging varied based on specific outcomes.Only one Canadian study, to the best of the author's knowledge, has evaluated the moderating potential of community belonging among sexual minority individuals: Pakula and colleagues 32 found that community belonging intensified the disparities in mood disorders but not anxiety disorders, among homosexual individuals.p1189-1190) Future research utilizing a mixedmethod approach could offer more insightful perspectives into the moderating role of community belonging among sexual minority individuals.
This study has its limitations.7][68] Despite using nationally representative data from the 2021 CCHS, the cell sizes were inadequate to estimate the relationship between sexual orientation and health and well-being across various sociodemographic groups.Some researchers have attempted to overcome this limitation by pooling data from multiple waves and combining gay/lesbian individuals with bisexual individuals. 68However, their findings may still be somewhat conservative.Second, sexual orientation is a multidimensional construct that can be measured by sexual identity, sexual attraction, or sexual behavior. 19Unfortunately, measures of sexual attraction and sexual behavior were not available in the CCHS, except for the 2015-2016 cycle.Emerging research has begun to explore how discordance in sexual orientation can shape health and well-being outcomes. 69Thus, future studies should consider multiple dimensions of sexual orientation when estimating health and well-being consequences.
Despite these limitations, the present study offers the most recent and comprehensive analysis of health and well-being disparities by sexual orientation and gender using the 2021 CCHS data.Furthermore, this study is among the first to examine and confirm the stress-buffering role of perceived community belonging.These findings can inform the development of public health interventions aimed at improving the health and well-being of sexual minority individuals.

Figure
FigureThe moderating effects of community belonging on the association between sexual orientation and self-rated general health among men.Note: Results are based on Model 2 of Panel A in Table3.Low and high community belonging represent -1 and +1 standard deviations from the mean, respectively.

Figure 2 .
Figure 2. The moderating effects of community belonging on the association between sexual orientation and depressive symptoms among men.Note: Results are based on Model 4 of Panel A in Table3.Low and high community belonging represent -1 and +1 standard deviations from the mean, respectively.

Figure 3 .
Figure 3.The moderating effects of community belonging on the association between sexual orientation and life satisfaction among women.Note: Results are based on Model 3 of Panel B in Table3.Low and high community belonging represent -1 and +1 standard deviations from the mean, respectively.

Table 1 .
Descriptive Statistics of Selected Variables in the Study.

Table 2 .
Ordinary Least Squares Regression Predicting Self-Rated Mental and General Health, Life Satisfaction, and Depressive Symptoms.
Note: "SR" = self-rated and "ref" = reference.All models include a full set of control variables: Age, race/ethnicity, marital status, household size, education, main activity, household income, and province.All models are weighted.Following the vetting rules of Statistics Canada, the sample sizes are rounded.***P < .001;**P < .01;*P < .05.

Table 3 .
Ordinary Least Squares Regression Predicting Self-Rated Mental and General Health, Life Satisfaction, and Depressive Symptoms, Moderation by Community Belonging.
Note: "SR" = self-rated and "ref" = reference.All models include a full set of control variables: Age, race/ethnicity, marital status, household size, education, main activity, household income, and province.All models are weighted.Following the vetting rules of Statistics Canada, the sample sizes are rounded.***P < .001;**P < .01;*P < .05 : All models included a full set of control variables: age, race/ethnicity, marital status, household size, education, main activity, household income, and province.All models were weighted.Following the vetting rules of Statistics Canada, the sample sizes were rounded.***P < .001;**P < .01. b b Note