Pages: 01-09
Date of Publication: 30-Nov--0001
Minority Stress and LGBTQ Mental Health in Greece and The Balkans: A Social-Psychiatric Scoping Review
Author: Stergios Kaprinis, Anastasios Charalampakis, Ioannis Sarris, Theodoros Tsirigotis
Category: Medical and Clinical Research
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Abstract:
Background: LGBTQ people in Greece and the Balkans experience elevated rates of depression, anxiety, substance use, and suicidality, which are increasingly understood through minority stress theory as consequences of socially produced stressors rather than intrinsic vulnerabilities. Recent European and Greek data indicate that these disparities persist despite legal reforms and increasing public visibility. Case presentation (context): A theory-guided scoping review was undertaken to synthesize peer-reviewed and institutional evidence on minority stress, mental health, and structural conditions affecting LGBTQ populations in Greece, Croatia, Romania, Bosnia and Herzegovina, North Macedonia, Serbia, and the wider Western Balkans. This review was accompanied by an embedded cross-sectional Greek pilot psychometric study among 108 adults, of whom 67 identified as LGBTQ+, in order to examine the feasibility of structured minority-stress assessment in a regional clinical context. Investigations: Participants completed measures of depressive symptoms, psychological distress, perceived stress, trauma exposure, rejection sensitivity, internalized LGBTQ-phobia, and structural stigma. Psychometric analyses included internal consistency, confirmatory factor analysis, and convergent validity correlations. Recent Greek studies in community and refugee samples provide convergent context for these constructs. Outcome: Across Greece and the reviewed Balkan settings, LGBTQ populations showed elevated psychological distress, depressive symptoms, and suicidality linked to discrimination, violence, family rejection, concealment, internalized stigma, and barriers to affirming care. The Greek pilot demonstrated good-to-excellent internal consistency and theory-consistent associations between minority-stress indicators and mental health outcomes, broadly aligning with recent Greek psychometric work in LGBTQ+ populations. Conclusion: Minority stress theory generalizes well to Greece and the Balkan region and provides a clinically useful social-psychiatric framework for understanding LGBTQ mental health disparities. Structured assessment of minority-stress exposures and related cognitions appears feasible and relevant for clinical care, including for refugees and asylum seekers.
Keywords: LGBTQ, Minority Stress, Greece, Balkans, Depression, Suicidality, Social Psychiatry, Structural Stigma, Psychometrics, Case-Linked Review
Full Text:
Introduction
LGBTQ populations worldwide show disproportionately high rates of depression, anxiety, substance use, self-harm, and suicidality, a pattern consistently documented in psychiatric epidemiology and increasingly recognized in clinical practice (Meyer, 2003; Hatzenbuehler, 2009; Mezza et al., 2024). International research in the field has consistently shown that these disparities are associated with stigma-related stress exposure, including discrimination, violence, family rejection, concealment, and internalized stigma, rather than with sexual or gender identity itself (Meyer, 2003; Hatzenbuehler, 2009). Minority stress theory conceptualizes these inequalities as the product of chronic, socially structured stressors tied to stigmatized identities rather than intrinsic vulnerabilities, distinguishing distal stressors such as discrimination, violence, and institutional exclusion from proximal processes such as concealment, expectations of rejection, and internalized stigma (Meyer, 2003; Hatzenbuehler, 2009).
From a social-psychiatric perspective, minority stress represents a specific configuration of social causation in which structural policies, institutional practices, community norms, and family relationships shape exposure to stigma-related stressors and access to protective resources and care (Meyer, 2003; Mezza et al., 2024). Recent systematic work has reinforced the cross-context relevance of this model for sexual and gender minority mental health (Mezza et al., 2024).
Greece and its Balkan neighbors form a particularly important context because legal reforms have progressed unevenly while familistic norms, religiosity, and politicized backlash continue to shape social climates (European Commission, 2025; Pikrammenou, 2024; World Bank, 2018). In Greece, civil marriage was opened to same-sex couples through Law 5089/2024, yet recent reports and survey data indicate persistent bullying, harassment, concealment, and barriers to affirming care, especially for trans people and LGBT+ refugees and asylum seekers (Hellenic Republic, 2024; European Union Agency for Fundamental Rights, 2024; Aslanis et al., 2025). This coexistence of legal progress and continuing social vulnerability makes the region especially relevant for clinically oriented minority stress research (World Bank, 2018; Council of Europe, 2025).
The aims of this article are to map evidence on minority stress exposures and LGBTQ mental health outcomes in Greece, compare Greek patterns with selected Balkan and Southeastern European contexts, and present embedded Greek pilot psychometric findings that illustrate the feasibility and potential clinical value of structured minority-stress assessment.
Case-Linked Context
Rather than presenting a single patient, this manuscript addresses a population-level clinical context in which mental health professionals in Greece and the Balkans frequently encounter LGBTQ individuals reporting discrimination, family rejection, concealment, fear of stigma within services, and distress associated with structurally hostile environments (Stojanovski et al., 2022; World Bank, 2018; Council of Europe, 2025). This framing is clinically relevant because these experiences shape assessment, formulation, engagement, and treatment planning.
Recent Greek findings support this formulation. A 2026 Greek study reported that minority stressors, including structural stigma and rejection sensitivity, were associated with mental health outcomes in a community sample, while a 2025 study of LGBT+ refugees and asylum seekers in Greece documented substantial mental health burden linked to trauma and social adversity (Charalampakis et al., 2026; Aslanis et al., 2025).
Methods
Scoping Review
A theory-guided scoping review was conducted following JBI methodology and PRISMA-ScR reporting principles, appropriate for mapping heterogeneous evidence rather than estimating pooled effects (Tricco et al., 2018; Peters et al., 2021). Eligible sources included peer-reviewed quantitative and qualitative studies and high-quality institutional or NGO reports addressing minority stress exposures, mental health outcomes, or structural and policy contexts affecting LGBTQ populations in Greece, Croatia, Romania, Bosnia and Herzegovina, North Macedonia, Serbia, and the wider Western Balkans (World Bank, 2018; Council of Europe, 2025).
Databases and platforms included PubMed/MEDLINE, PsycINFO, and Google Scholar, as well as institutional repositories and reports from the European Commission, World Bank, Council of Europe, FRA, and related regional organizations (European Commission, 2025; World Bank, 2018; Council of Europe, 2025). Search concepts combined population, setting, and mechanism terms, and reference lists of key papers and reports were checked for additional sources (Mezza et al., 2024; World Bank, 2018).
Two reviewers independently screened titles, abstracts, or executive summaries, resolving disagreements by consensus (Tricco et al., 2018). A standardized data-charting form captured setting, sample characteristics, minority stress indicators, mental health outcomes, measurement instruments, and directional findings. Formal risk-of-bias appraisal was not used as an exclusion criterion because the objective was evidence mapping rather than effect synthesis.
Embedded Greek Pilot Psychometric Study
The pilot study included 108 adults residing in Greece, of whom 67 self-identified as LGBTQ+, recruited through convenience sampling with mixed-mode administration between 1 October and 11 December 2024 (Charalampakis et al., 2026). Written or electronic informed consent was obtained before participation.
Measures assessed depressive symptoms (BDI-21), psychological distress (K-10 and K-6), suicidality, perceived stress (PSS), rejection sensitivity (RSS), internalized LGBTQ-phobia (IHS), structural stigma, and stressful or traumatic life events exposure (SLESQ-13) (Kaprinis and Charalampakis, 2022; Charalampakis et al., 2026). These constructs were selected to align with emergent Greek and regional research on minority stress and mental health in both community and refugee samples (Aslanis et al., 2025; European Commission, 2025).
Analyses included Cronbach__ampersandsignrsquo;s alpha and McDonald__ampersandsignrsquo;s omega for internal consistency, confirmatory factor analysis using CFI, TLI, SRMR, and RMSEA, and Pearson correlations for convergent validity (Charalampakis et al., 2026). For future work, measurement invariance testing and item-response approaches would strengthen cross-group comparison and scale refinement (Mezza et al., 2024).
Results
Regional Evidence Synthesis
Across Greece and the reviewed Balkan contexts, LGBTQ populations consistently showed elevated psychological distress, depressive symptoms, and suicidality compared with majority populations or with expected population baselines (World Bank, 2018; European Union Agency for Fundamental Rights, 2024; Stojanovski et al., 2022). These disparities were linked to discrimination, victimization, family rejection, concealment pressures, internalized stigma, and barriers to affirming healthcare rather than to identity itself (Meyer, 2003; Hatzenbuehler, 2009; Mezza et al., 2024).
In Greece, recent national survey and analytic reports document ongoing harassment, concealment, and implementation gaps despite legal reform, while refugee-focused studies indicate additional burdens associated with trauma exposure, legal precarity, and barriers to services (European Union Agency for Fundamental Rights, 2024; Pikrammenou, 2024; Aslanis et al., 2025). In North Macedonia, stigma shapes both mental health outcomes and experiences with mental health services, illustrating how proximal and structural stressors intersect in service settings (Stojanovski et al., 2022).
The regional pattern is also visible in other Balkan settings. Council of Europe guidance for Bosnia and Herzegovina emphasizes equal access and the need to reduce healthcare discrimination, while recent Serbian evidence reports anxiety and depression burden among men who have sex with men (Council of Europe, 2025; Baro__ampersandsignscaron; et al., 2024). Western Balkan attitude reports indicate sustained negative climates and reform-backlash cycles that likely maintain chronic vigilance and concealment (World Bank, 2018).
Greek Pilot Psychometric Findings
Internal consistency was high across instruments in the Greek pilot, including depressive symptoms, psychological distress, rejection sensitivity, trauma exposure, and structural stigma (Charalampakis et al., 2026). Confirmatory factor analyses generally supported expected structures, and convergent validity patterns were coherent: perceived stress, rejection sensitivity, internalized LGBTQ-phobia, structural stigma, and trauma exposure were associated with distress, depression, and suicidality (Charalampakis et al., 2026; Kaprinis and Charalampakis, 2022).
These patterns are consistent with recent Greek work showing that minority stressors are meaningfully linked to mental health outcomes in both community and refugee samples (Charalampakis et al., 2026; Aslanis et al., 2025). Taken together, the pilot findings support the feasibility of harmonized minority-stress measurement in Greek settings and its potential usefulness for both research and clinically informed assessment.
Discussion
This synthesis supports the applicability of minority stress theory to LGBTQ mental health in Greece and the Balkans and shows that it can be integrated productively into a social-psychiatric framework (Meyer, 2003; Hatzenbuehler, 2009; Mezza et al., 2024). Across contexts, disparities were systematically linked to stigma-related stressors operating at interpersonal, familial, institutional, and structural levels rather than to sexual or gender identity per se (Meyer, 2003; Mezza et al., 2024).
Regional social conditions appear to intensify minority stress exposure. Familism can heighten the salience of family rejection but may also become protective where families are affirming (Pikrammenou, 2024). Religiosity may legitimize condemnation in some settings while supporting community and resilience in others (L__ampersandsign#259;z__ampersandsign#259;rescu et al., 2023; Stojanovski et al., 2022). Political backlash and uneven implementation of reforms can sustain uncertainty and vigilance even after major legal changes, as illustrated by the coexistence of marriage equality and persistent stigma in Greece (Hellenic Republic, 2024; European Commission, 2025).
For clinical practice, these findings support routine assessment of discrimination, family acceptance or rejection, concealment pressures, internalized stigma, trauma exposure, and perceived structural stigma when working with LGBTQ patients (Meyer, 2003; Hatzenbuehler, 2009). This is particularly important for refugees and asylum seekers, whose minority stress burden is compounded by displacement-related trauma and legal precarity (Aslanis et al., 2025; Council of Europe, 2025).
At the service level, training and quality standards for affirming care remain necessary to reduce healthcare discrimination, improve engagement, and limit gatekeeping, especially for trans individuals (Stojanovski et al., 2022). Recent comparative qualitative work involving Greece suggests that non-affirming psychological services remain a source of distress for some trans service users (Stojanovski et al., 2022).
Limitations
This review is scoping in nature and does not provide pooled effect estimates or formal risk-of-bias synthesis suitable for meta-analysis (Tricco et al., 2018; Peters et al., 2021). The underlying evidence base is methodologically heterogeneous and uneven across countries, with stronger recent evidence in some settings than in others (World Bank, 2018; Council of Europe, 2025).
The embedded pilot used a modest convenience sample and cross-sectional design, limiting causal inference and generalizability, particularly for rural populations, economically marginalized groups, refugees, and multiply minoritized subgroups. Future studies should prioritize longitudinal and multi-country designs, harmonized proximal minority-stress measures, measurement invariance testing, and intersectional analyses that incorporate migration status, ethnicity, socioeconomic position, and gender identity (Mezza et al., 2024).
Conclusion
Minority stress provides a coherent and empirically supported framework for understanding LGBTQ mental health disparities in Greece and the Balkans. The combined review and Greek pilot findings indicate that harmonized measurement is feasible and clinically informative, supporting future comparative work and evaluation of minority stress-informed services and policies in Southeastern Europe. Recent evidence from community, trans, and refugee samples strengthens the case for integrating minority-stress assessment into routine social-psychiatric practice.
Declarations
Ethics Approval and Consent to Participate: Ethical approval for the pilot study was obtained from the Bioethics and Deontology Committee, Faculty of Medicine, Aristotle University of Thessaloniki (protocol no. 175/2024; approval date 22 April 2024). All participants provided informed consent prior to participation.
Consent for Publication: Not applicable. All data are reported in aggregated and anonymized form.
Availability of Data and Materials: The datasets generated and/or analysed during the current study are not publicly available due to ethical and privacy restrictions, including GDPR considerations, but are available from the corresponding author on reasonable request.
Competing Interests: The authors declare no competing interests.
Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Authors__ampersandsignrsquo; Contributions: SK conceived the study. SK and AC conducted the review. AC led data analysis. All authors contributed to manuscript revision and approved the final version.
Acknowledgements: Not applicable.
References:
Aslanis A, Pavlopoulos V, Vegkos N, Papadaki A, Apostolidou A, Boziaris G, Keratsas G, Levisianos-Lampropoulos I, Papastefanaki K, Moran P, Triantafyllidou S. The mental health burden of LGBT+ refugees and asylum seekers in Greece. Int J Intercult Relat 2025; 108: 102257.
Baroš S, Simić D, Kilibarda B. Prevalence of anxiety and depression among men who have sex with men in Serbia. InBook of Abstracts-International congress Public health–achievements and challenges 2024 (No. Oral presentations, pp. 132-132).
Charalampakis A, Kaprinis S, Agorastos A, Parlapani E. Factors affecting the mental health of the LGBTQ+ population in Greece. Front Psychol 2026; 17: 1811328.
Council of Europe (2025) A guide for the health sector in Bosnia and Herzegovina: equal access of LGBTI people to healthcare services. Strasbourg: Council of Europe.
European Commission (2025) Greece -- country report non-discrimination 2025. Brussels: European Commission.
European Union Agency for Fundamental Rights (2024) LGBTIQ Survey 2024 -- Country factsheet: Greece. Luxembourg: Publications Office of the European Union.
Hatzenbuehler ML. How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychological bulletin 2009; 135: 707.
Hellenic Republic (2024) Law 5089/2024: Equality in civil marriage, amendment to the Civil Code, and other provisions. Government Gazette A' 27/17.02.2024.
Kaprinis S, Charalampakis A. Is Depression and Suicidality a Matter of Sexual Orientation? An Empirical Investigation in Greece. Arch Clin Biomed Res 2022; 6: 826-835.
Lăzărescu G, Karner-Hutuleac A, Maftei A. Modern homophobia among heterosexual Romanian adults: the roles of sexual orientation beliefs, religiosity, perceived social roles, and social media use. Front Psychol 2023; 14: 1219442.
Mezza F, Mezzalira S, Pizzo R, Maldonato NM, Bochicchio V, Scandurra C. Minority stress and mental health in European transgender and gender diverse people: A systematic review of quantitative studies. Clin Psychol Rev 2024; 107: 102358.
Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull 2003; 129: 674-697.
Peters MDJ, Marnie C, Colquhoun H, Garritty CM, Hempel S, Horsley T, Langlois EV, Lillie E, O'Brien KK, Tunçalp Ӧ, Wilson MG, Zarin W, Tricco AC. Scoping reviews: reinforcing and advancing the methodology and application. Syst Rev 2021; 10: 263.
Pikrammenou N. Achievements and challenges for LGBTQ+ people in Greece and their legal status. Athens: diaNEOsis (2024).
Stojanovski K, King EJ, Bondikjova V, Mihajlov A. Stigma shapes lesbian, gay, bisexual, transgender, and queer person's mental health and experiences with mental health services in North Macedonia. Glob Public Health 2022; 17: 857-869.
Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, Moher D, Peters MDJ, Horsley T, Weeks L, Hempel S, Akl EA, Chang C, McGowan J, Stewart L, Hartling L, Aldcroft A, Wilson MG, Garritty C, Lewin S, Godfrey CM, Macdonald MT, Langlois EV, Soares-Weiser K, Moriarty J, Clifford T, Tunçalp Ö, Straus SE. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med 2018; 169: 467-473.
World Bank Group. Life on the margins: Survey results of the experiences of LGBTI people in Southeastern Europe. World Bank; 2018.
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