Postpartum depression studied in ‘invisible sexual minority’ women

The average rate of postpartum depression in women in this country is around 13 percent. But, while studies have shown how postpartum depression or PPD, affects women from a variety of socio-economic, racial and cultural backgrounds, there have been remarkably few looking at PPD rates among gay and bisexual women. A recent grant from the National Institute of Mental Health will help rectify that and take it a step further by looking at a group the researchers refer to as ‘invisible sexual minority women,’ those who do not identify as gay or bisexual but have a history of relationships with other women.

New England Psychologist’s Catherine Robertson Souter spoke with Abbie E. Goldberg, Ph.D., associate professor in the department of psychology at Clark University, who, along with Lori E. Ross, Ph.D., associate professor in the department of psychiatry at the University of Toronto, will work on a three-and-a-half year, longitudinal and qualitative study funded with a $718,770 grant from the National Institute of Mental Health. The study will cross borders, not only physically between the U.S. and Canada, but also in terms of social theory in looking at how the countries’ very different health care systems affect the outcomes for these women.

Q: What is the goal of the project?

A: The big goal is to understand the risk factors of postpartum depression with an emphasis on understanding these risk factors for sexual minority women, lesbian and bisexual women and for invisible sexual minority women.

We are looking to recruit 20 invisible, 20 visible sexual minority women and 20 heterosexual women. These are currently pregnant women in their third trimester who we plan to recruit through obstetricians and midwives.

Q: How do you define invisible sexual minority women?’

A: You can conceptualize sexual orientation in several ways: attraction, identification and behavior. What we found in the pilot data was that the women most at risk for PPD are women who are partnered with a man at the time but who have a history of relationships with women in the past five years. So behaviorally, they are bisexual but they do not identify as bisexual.

The pilot study did show an elevated risk for these women. We are not sure why. Maybe these women are lacking a support system.

Q: If the study confirms your preliminary findings, how would you recommend this group be identified and treated?

A: It may be that we will recommend providers ask women about their sexual histories with other women, especially if that can have unique implications in postpartum. We ask about their sexual histories to see if there are STDs that could be passed on to a child. Why steer away from that if we can help health care providers identify a group who may need social support? I am not sure we will recommend this but depending on the findings, it may be reasonable.

 Q: Is this problem a large one?

A: Depending on how you slice the pie, you find different rates of depression within the different groups. If you categorize everyone based on how they identify, you get a different result than if you ask who they had relationships with in the last past five years. We did find higher rates in women who identify as heterosexual but had relationships with women in the past five years.

We are interested in what we call visible sexual minority women, too. What is the PPD rate for those women? Are there unique protector or risk factors? Lesbian or bisexual women may have lower rates than straight identifying women so we call them “protector” factors, not just “risk” factors. In the pilot study, there was no difference between lesbian and straight women in consistent relationships with men or women. The invisible sexual minority women had statistically significantly higher rates of depression than anyone else, controlling for prenatal depression.

Q: Why is this study important and why now?

A: Essentially because we are really not sure whether there are particular, unique risk factors in this group. There are very few studies looking at postpartum mental health in lesbian or bisexual women – and those are generally with women who self-identify as such.

What is it about a woman partnered with a man but who has had relationships with women in her immediate past that puts her at risk for PPD?

For instance, if someone was a member of a gay community for 15 years and then partnered with a man to get pregnant, who is their primary source of community and support now? How open are these women with their male partners and their families about their past relationships?

We are trying to reach beyond the stereotypical, straight identified woman married to a man. We want to look at the transition to parenthood for those women who don’t fit the stereotype.

Q: How do you find these women?

A: We found them through consecutive admissions to midwives and obstetricians. If you ask everyone who comes in, some small proportion of these people, not a huge number of people, will fall into this group. In our pilot study, nine out of 147 women we surveyed fell into this group. It’s less than 7 percent.

Q: That sounds like a larger number than one might expect, actually.

A: Well, it’s still not so much a crisis but more a lesson of how we define groups and the consequences of that. If we divide groups based on how people identify versus behavior we are missing some part of the story. A big part of this current study is going to be qualitative as well, doing in-depth interviews asking what their lives are like and the ways in which sexual identities affect mental health.

Q: In doing an international study, what do you hope to find?

A: We are working in two sites, in Boston and in Toronto, and so we are also looking at the international, cultural or contextual difficulties in regard to what problems women are having in general and with talking to health care providers. We argue that the Canadian context is different because there is more support and less divisiveness. Of course, within the U.S., Massachusetts by-and-large is open and affirming. We are not comparing Toronto with rural Tennessee, but even within Massachusetts, there is quite a lot of variability depending on where you live. These are similar areas, Boston and Toronto, but there still might be differences.

Q: Do you project that the two countries’ different medical systems will affect the outcome?

A: From what we’ve seen in comparing notes, in some ways, Canada is better. You get six months off for parental leave. On the other hand, in the U.S., the mental health parity law means that most health insurances offer some mental health counseling whereas there is no coverage for counseling in Canada. So in this area the U.S. looks better. But will that have consequences, whether people have access to treatment?

Q: What will be your follow-up to this study?

A: When we are finished with this study, the big question will be, ‘have we replicated the earlier study, have we found the same patterns?’ Then come the questions of, “What are the implications for health care providers? What kinds of recommendations are we going to come up with?”

This is also a longitudinal study and we will be following three groups of women, heterosexual and invisible and visible sexual minority women. One consequence of the study could be to follow these women for a longer period of time.