Why do bisexual women experience such high rates of poor health?

Growing up in Lima, Peru, in the 1990s, Valeria Saavedra felt she was different, but it would take her years to figure out why. “My friends and the other children were never aggressive or mean towards me,” she says, still trying to make sense of her earliest memories. “But I used to get the feeling that I was always the one people laughed at behind my back. The little odd one.” By 16, she learned there was a word for what she was—bisexual—but she hadn’t come out yet; she vividly recalls the awkwardness of watching her straight female friends jokingly flirt with one another. “I was scared of participating because maybe they would know,” she says. “For them, it was only a game.”

At 17, Saavedra moved to Buenos Aires, Argentina, with her mother. She tried to integrate into the city’s comparatively large queer community, which she says was very activist, but also had a binary view of sexuality. “When I told them I’m not straight or a lesbian, they were not understanding. As if I was not a ‘pure breed,’ as if I were just exploring, or even just ‘easy.’”

The next year, Saavedra emigrated to Montreal to go to university. “[I was excited to] explore this part of me that I left inside a closet,” she says. But even with its queer scene and gay village, she found exclusion there too. The lesbians and straight men she dated often saw her as untrustworthy because of her bisexuality.

Whether in North or South America, finding a place in the queer community was not easy for Saavedra. Now 26, she says she’s creating community in Montreal as well as a sense of self-acceptance in herself. “I feel like I’m learning to be at peace with it, and happy in who I am.”

But navigating the world as a bisexual woman, along with her interwoven identities as a person of colour and an immigrant, has affected her health. Isolation triggered stress and anxiety, while her feelings of social unease and awkwardness led her to substance use. “I was very stressed as a kid. I was smoking cigarettes, doing drugs—very rebellious,” Saavedra says. “Because I didn’t really know where my place was.”

Many bisexual people report feelings like Saavedra—stuck between worlds, stereotyped and searching for belonging even within the queer community. Even though they reportedly represent 50 percent or more of the LGB community, bisexuals have historically been treated as a footnote in health research. They are often grouped into larger studies that focus on lesbians or gay men, if not ignored altogether.

However, researchers and advocates are starting to paint a fuller picture of bisexual health, and are finding that in many cases, both the physical and mental health of bi individuals lags behind many other LGBTQ2 subgroups. Bisexual women in particular have one of the worst health profiles within the communities. As more people identify as bisexual than ever before—many of them female-identified—why are their health outcomes so bad, and what’s being done to improve them?

The earliest recorded use of the term “bisexual” was in 1824 to describe someone we’d now consider intersex, a pathologizing medical term. At the turn of the 20th century, sexologists described bisexuals as having brains that were part male, part female, possibly an affront to the natural order of things. A little later on, Sigmund Freud claimed bisexuals had immature sex drives and should ideally move beyond that state to become monosexual—either gay or straight.

Many of those beliefs and misconceptions about bisexuality still resonate today. In mainstream media, bisexuality is often represented as a phase (like Buffy the Vampire Slayer’s briefly bisexual Willow, or the infamous Sex and the City claim that bisexuality is just a “layover on the way to Gay Town”) or a threat (Catherine in Basic Instinct as a villainous, murderous bisexual woman). Female-identified bisexual characters have long been characterized as untrustworthy (Empire’s recurring antagonist Camilla Marks-Whiteman), undecided (Orange is the New Black’s protagonist Piper Chapman) or overly sexualized (Glee’s Brittany Pierce). Even the queerest of shows like The L Word have perpetuated some of these myths, a reminder that biphobia comes from both inside and outside the LGBTQ2 community.

But bisexual visibility is having a moment—and may even be creating a movement. More celebrities, including Evan Rachel Wood, Lilly Singh, Halsey and Anna Paquin, have come out as bisexual. TV characters like Rosa Diaz are revolutionizing primetime bisexuality with their totally normal, non-tropey portrayals, while #bitwitter elevates non-monosexual life, love and meme-making in a halo of pink, purple and blue (remember bisexual lighting?). Because after all, #stillbisexual.

Despite more visibility and positivity around bisexual identity, numerous studies have found some dire physical and mental health discrepancies. Bisexual people are at higher risk for depression, anxiety, suicide and suicidal ideation than their lesbian, gay or heterosexual counterparts. The Canadian Community Health Survey, for instance, shows bisexual women are six times more likely than heterosexual women to experience suicidal thoughts and attempts, whereas lesbian women are four times more likely. Other research has found that young bisexual women have the highest suicide rates of all LGB youth. (It’s important to note that a significant number of trans and non-binary people also identify as bisexual; an American survey showed 23 percent of transgender respondents identified as bisexual. These individuals would likely also report poor health outcomes, but the data is hard to come by.)

While there is less research on the physical health of bi women, studies show they are overrepresented when it comes to diabetes and hypertension diagnoses relative to their lesbian counterparts. Bisexual women are also more likely to smoke cigarettes, abuse alcohol and engage in substance abuse than lesbians. A recent study found bisexual women are seven times more likely to use cannabis on a daily basis than heterosexual women—double the rate of lesbians.

In terms of relationships and sexual health, bi women experience higher risks of sexual assault and intimate partner violence than lesbians and heterosexual women. They also have a higher risk of contracting sexually transmitted infections (STIs), and bisexual teens face higher rates of pregnancy.

Yasmin Owis, a research assistant and PhD student at the University of Toronto (UofT), identifies as a bisexual woman of colour. Growing up, her foster parents were white and she had few friends who looked like her—but she also suspected she was different in less visible ways. Her childhood experiences of trauma led to years of struggle with clinical depression and anxiety. She had learned skills to manage her mental health while in first year university, but by her third year she had a new source of stress: acknowledging her bisexuality.

“I’m brown — a Middle Eastern-Caribbean mix,” Owis says. Now 26 and completing her PhD, she emphasizes how the homophobia and transphobia of her cultural backgrounds created feelings of “shame and secrecy” about her sexuality. “Growing up, I didn’t really see myself reflected in anything…That was one of the reasons I didn’t come to terms with being bisexual as a brown queer person [until my 20s]. Honestly, I didn’t think it was a possibility for me. I was just like, brown people aren’t queer, and brown people definitely aren’t bi.”

Growing up, neither Saavedra or Owis saw much around them to validate a sexual orientation that wasn’t either straight or gay. Lori Ross, associate professor at the Dalla Lana School of Public Health at UofT, explains that ”as a society we have structured our world around the idea that people are either straight or lesbian.” Ross says that many biphobic beliefs are caused by monosexism, the belief that people can only be attracted to one gender. It exists in both queer and straight communities, further stigmatizing bisexual people.

Margaret Robinson, a Mi’kmaw scholar, member of the Lennox Island First Nation and assistant professor at Dalhousie University, is Two-Spirit and bisexual, an identity she has had difficulty navigating in society. “Like bisexuals, we also experience erasure, although unlike bisexuals it is our cultural identity as well as our gender and/or sexual identity that is being erased,” she said in a 2017 paper.

In an interview with Xtra, Robinson also describes being stigmatized as a bisexual person in the queer community. “When bisexuals are acknowledged, we’re often treated as newcomers, or as if we’re less queer than other people,” Robinson says, “I’ve learned to tolerate a certain level of insult. People are woefully unaware of how much biphobia there is in queer spaces.”

This past June, the federal government released an expansive study on LGBTQ2 health inequities in Canada in order to look at social determinants of health like income, gender, discrimination and race. (Similar studies have long been conducted, but a systematic, governmental review of how these determinants affect sexual and gender minority Canadian is new.)

The study found that, overall, bisexuals reported higher rates of poor mental and physical health, chronic diseases, smoking and alcohol use than gay, lesbian and heterosexual people, with bisexual women surpassing nearly all female-identified participants.

Leading Canadian voices, like Lori Ross, who’s done substantial work on health and bisexuality, were included in the study. In her testimony, Ross emphasized that over 25 percent of bisexual people were defined as low-income, and that they reported much higher levels of depression and post-traumatic stress disorder than those living above the low-income cut-off.

Ross tells Xtra that more research is needed to figure out why bisexual people are more likely to live in poverty, but does assert that low-income bisexual people, particularly women, are among the highest-risk sexual minorities. For instance, many are unlikely to have a job with health benefits, but if they do gain access to mental health support, “finding a provider who is competent in bisexuality issues is going to be slim pickings.”

Access to health care can be a major obstacle to bisexual people, especially when it comes to women’s sexual health. Yasmin Owis says going to the doctor, even for a routine medical check-up, is stressful and invalidating. “They’ll assume I’m straight, because I’m so straight passing, and ask if I’m on birth control.” She often has to educate practitioners on what bisexuality means, and inform them of what that means for her sexual health. Owis believes that the higher rate of STIs bisexual women experience “comes from [medical] misinformation” about the sexual health of bi people.

Carmen Logie, associate professor and the Canada Research Chair in global health equity and social justice with marginalized populations at UofT, tells Xtra that based on her research, bisexual women are more likely to report sexual abuse and transactional sex and less likely to receive appropriate sexual health advice in comparison to other women and sexual minorities. Other studies have confirmed that bisexual and lesbian women have a hard time getting a doctor to agree to pap and STI tests because of the myth that women can’t transmit STIs to each other—causing an increase risk of undiagnosed STIs, abnormal paps and cervical cancer.

When bisexuality isn’t seen as a distinct identity with unique health and community needs, there is a decline in overall health. “One thing that’s particular to bisexual people is that you’re facing discrimination not only from the straight communities and straight people in your life, but also from queer communities and queer people in your life,” Ross says.

One of the leading explanations of health outcomes for bisexual people—and other LGBTQ2 folks—is the minority stress model: stressors related to being a marginalized person which build up and affect physical and mental health. For bisexual people, minority stress includes experiencing bi-erasure, feeling that they don’t fit in with any societal group, feeling rejected from the rest of the LGBTQ2 community and dealing with biphobia, which includes the assumption that they face less stigma than other sexual and gender minorities because they have the option to “pass” or disguise their sexual identity.

Research into bisexual women’s poor health have cited minority stress as the possible key factor, but, as Ross points out, bisexual women still have poorer health than lesbian women in most cases, suggesting there are social determinants tied specifically to being bisexual.

But poor outcomes for bi women are also likely related to gender inequality; women are often underemployed and underpaid, have more barriers to healthcare and are much more likely to experience violence than men. These socio-economic and health gaps become even larger for women of colour. At a time when more Black women and non-Black women of colour in the U.S. are identifying as bisexual than ever before, it’s critical to understand the unique health profiles of bisexual women in North America today.

Logie points out that while the minority stress model sounds deterministic and dark, it’s not actually hopeless. “It shows that things such as social support and resilience can moderate or reduce the impact of stigma on mental health outcomes,” she says. “Obviously you can intervene to reduce the stigma. But you can also focus on building support and community and interconnectedness between LGBTQ2 folks, and look at adaptive coping strategies.”

Planned Parenthood Toronto (PPT), for instance, has been creating bi-affirming medical spaces by listening to the needs of the community. Yasmin Owis calls them a “beacon” for providing her with free mental health counselling that also validates her identity. A factsheet co-created by PPT, “Young bisexual women and sexual health: getting the care you need,” says that at the most basic level, bi women need their health providers to know they exist, but they also need informed contraception and STI counselling.

While these resources are critical, the root causes of health inequalities need to be addressed as well. “We experience all these health disparities, and it’s important that any kind of effort around LGBTQ2S health needs to recognize bisexual people,” says Cheryl Dobinson, PPT’s director of community programming and research. Her research focused on young bisexual women has revealed the staying power of stereotypes. “If you’re given messages that are not positive, they can affect your access to social supports, your support for yourself and [thoughts about] whether you’re worthy of care and health,” Dobinson says, citing common beliefs that bisexuals are not trustworthy, relationship-worthy or even real at all.

Lori Ross focuses on institutional-level solutions like biphobia and monosexism, policy and health funding. She would like to see LGBTQ2 health concerns embedded into the mandate of the Canadian Institutes of Health Research (the federal agency agency that funds health research in Canada), and also for the government to collect more and better survey data on sexual and gender minorities. Interventions on issues like homelessness and employment discrimination that disproportionately affect sexual minorities is also important.

That said, Ross acknowledges the importance of solutions that work on interpersonal and personal levels; studies have consistently shown that bisexual people’s wellness is related to feeling seen and understood, and this can be put into action immediately on personal and community levels. But Ross also understands that even though bisexuals are an increasingly visible group, spaces for bisexual people to meet—such as community events and support groups—are still sparse.

While interpersonal supports are lacking, digital communities and campaigns strive to give voice to what has been called the “invisible majority.” For instance, March 2019 marked the fifth year of the U.S.-based Bisexual Resource Centre’s Bisexual Health Awareness Month, which has a significant #BiHealthMonth social media presence. The Bi Arts Festival, one the world’s largest celebrations of bisexual voices, takes place every year in Toronto. Some organizations are even holding bi-specific Pride celebrations to coincide with Bi Visibility Day on September 23.

As the largest sexual minority group, overcoming the stigma affecting bisexuals will be no small feat, especially for bi people of colour, women, trans folks or others who are marginalized in multiple ways. But the strengths of the bisexual community—the resistance to stereotypes, the resilience of self-definition—might also create spaces for radical healing and belonging.

Yasmin Owis, has found her own ways of healing, like attending a queer-friendly yoga program at The 519 community centre in Toronto. She calls UofT a “liberal space,” and gets to work with other queer and bisexual people while she completes her PhD. While she still feels out of place sometimes as a Brown person in mainly-white academic spaces, and would love to feel a greater sense of belonging in the queer community, she says her involvement in research and teaching “feeds what I need.” For Valeria Saavedra, she’s on the path to creating and finding more acceptance in Montreal. “The more people I came to know in the LGBTQ community, the more I understood that I wasn’t something weird and different, or some kind of freak,” she says.

In turn, making relationships in the community has been critical to her mental wellness: “When people show you love, it helps you love yourself and accept yourself.”