Mental Health Disparities Across Sexual Role Identities (Top, Bottom, Versatile, Side) in Gay and Bisexual Men: A Three-Level Meta-Analysis.

Abstract

Sexual role identity (SRI; e.g. Top, Bottom, Versatile, Side/Others) is a central feature of gay and bisexual men's sexual self-definition and a potential source of intra-minority stress such as bottom-shaming, yet its mental health correlates remain unclear and empirical findings are mixed. This preregistered three-level meta-analysis synthesized 393 effect sizes from 41 studies (N = 27,819) on men with a history of same-sex behavior, published in Chinese and English databases up to January 2025. All effect sizes were converted to Cohen's d and modeled using three-level random-effects models. Across studies, Tops showed the most favorable mental health profile, followed by Versatiles and then Bottoms; the Top-Bottom contrast was small-to-moderate for negative indicators (d =  -0.27), indicating higher depression, anxiety, and related distress among Bottoms, and the difference between Tops and Others was marginal. Available sexual-role categories significantly moderated the Top-Bottom association, suggesting that traditional binary classifications (Top vs. Bottom) may exaggerate role-related disparities when Versatile and Side/Others identities are not distinguished. Overall, the findings identify SRI as a small but statistically reliable correlate of mental health disparities among sexual minority men and underscore the need for role-sensitive assessment and interventions that target sexual-role-specific stressors within gay and bisexual communities.