What does the scholarly research say about the effects of discrimination on the health of LGBT people?

Alessi, E.J., Martin, J.I., Gyamerah, A., & Meyer, I.H. (2013). Prejudice events and traumatic stress among heterosexuals and lesbians, gay men, and bisexuals. Journal of Aggression, Maltreatment and Trauma, 22(5), 510-526.

This mixed-methods study examined associations between prejudice events and post-traumatic stress disorder (PTSD) among 382 lesbians, gays, and bisexuals (LGB) and 126 heterosexuals. Using the Composite International Diagnostic Interview, we assessed PTSD with a relaxed Criterion A1; that is, we allowed events that did not involve threat to life or physical integrity to also qualify as traumatic. We first assessed whether exposure to prejudice-related qualifying events differed with respect to participants’ sexual orientation and race. We found that White LGBs were more likely than White heterosexuals to encounter a prejudice-related qualifying event, and among LGBs, Black and Latino LGBs were no more likely than White LGBs to experience this type of event. We then used qualitative analysis of participants’ brief narratives to examine prejudice events that precipitated Relaxed Criterion A1 PTSD among 8 participants. Two themes emerged: (a) the need to make major changes, and (b) compromised sense of safety and security following exposure to the prejudice event.

Almeida, J., Johnson, R. M., Corliss, H. L., Molnar, B. E., & Azrael, D. (2009). Emotional distress among LGBT youth: The influence of perceived discrimination based on sexual orientation. Journal of Youth and Adolescence, 38(7), 1001-1014.

The authors evaluated emotional distress among 9th-12th grade students, and examined whether the association between being lesbian, gay, bisexual, and/or transgendered (i.e., “LGBT”) and emotional distress was mediated by perceptions of having been treated badly or discriminated against because others thought they were gay or lesbian. Data come from a school-based survey in Boston, Massachusetts (n = 1,032); 10% were LGBT, 58% were female, and ages ranged from 13 to 19 years. About 45% were Black, 31% were Hispanic, and 14% were White. LGBT youth scored significantly higher on the scale of depressive symptomatology. They were also more likely than heterosexual, non-transgendered youth to report suicidal ideation (30% vs. 6%, p < 0.0001) and self-harm (21% vs. 6%, p < 0.0001). Mediation analyses showed that perceived discrimination accounted for increased depressive symptomatology among LGBT males and females, and accounted for an elevated risk of self-harm and suicidal ideation among LGBT males. Perceived discrimination is a likely contributor to emotional distress among LGBT youth.

Andersen, J. P., Zou, C., & Blosnich, J. (2015). Multiple early victimization experiences as a pathway to explain physical health disparities among sexual minority and heterosexual individuals. Social Science & Medicine, 133, 111-119.

Prior research shows that health disparities exist between sexual minority and heterosexual individuals. We extend the literature by testing if the higher prevalence of childhood victimization experienced by sexual minority individuals accounts for lifetime health disparities. Heterosexual (n = 422) and sexual minority (n = 681) participants were recruited on-line in North America. Respondents completed surveys about their childhood victimization experiences (i.e., maltreatment by adults and peer victimization) and lifetime physician-diagnosed physical health conditions. Results showed that sexual minority individuals experienced higher prevalence of childhood victimization and lifetime physical health problems than heterosexuals. Mediation analyses indicated that maltreatment by adults and peer bullying explained the health disparities between sexual minority individuals and heterosexuals. This study is the first to show that multiple childhood victimization experiences may be one pathway to explain lifetime physical health disparities. Intervention programs reducing the perpetration of violence against sexual minority individuals are critical to reduce health care needs related to victimization experiences.

Arayasirikul, S., Wilson, E. C., & Raymond, H. F. (2017). Examining the effects of transphobic discrimination and race on HIV risk among transwomen in San Francisco. AIDS and Behavior, 21(9), 2628-2633.

Transwomen, in particular transwomen of color (TWOC), are among the most vulnerable populations at risk for HIV. This secondary analysis is organized using a gender minority stress framework to examine the effects of transphobic discrimination and race on HIV risk factors. We describe the sample of 149 HIV- adult transwomen in San Francisco and use binary logistic regression to examine the relationship between levels of transphobic discrimination and TWOC status on binge drinking and condomless receptive anal intercourse (CRAI), controlling for potential confounders. Those with high levels of transphobic discrimination had 3.59 fold greater odds of engaging in binge drinking compared to those who reported a low level of transphobic discrimination (95% CI 1.284-10.034; P = 0.015). TWOC had nearly threefold greater odds of CRAI compared to white transwomen (95% CI 1.048-8.464; P = 0.040). We discuss implications for gender minority stress research and future interventions for this population.

Austin, E. L., & Irwin, J. A. (2010). Age differences in the correlates of problematic alcohol use among southern lesbians. Journal of Studies on Alcohol and Drugs, 71(2), 295-298.

OBJECTIVE: Research has demonstrated a high frequency and intensity of alcohol use among lesbian women. This work explores age differences in risk factors for problematic alcohol use among self-identified Southern lesbians. Risk factors of interest include depression, general stress, and three measures of sexual minority stress (i.e., experiences of discrimination, lesbian/gay-related stigma, and internalized homophobia). METHOD: We analyze data from the Lesbian Social Life study, which recruited 1,141 self-identified Southern lesbians for participation in an anonymous Web-based survey. We present results from a series of regression models predicting scores on the CAGE scale, a self-reported measure of problematic alcohol use. Results are reported separately by age group (19-29, 30-49, >/=50). RESULTS: Frequent and intense alcohol use was most common among lesbian women ages 19-29. Depression and stress were the most consistent psychosocial correlates of problematic alcohol use, although these patterns varied by age. Each of the minority stress measures was associated with problematic alcohol use, although no clear age-related pattern appeared. CONCLUSIONS: Our findings suggest that depression and stress are strong predictors of problematic alcohol use among lesbians, which is comparable to previous findings in heterosexual populations. Additional research is needed to understand how the association between sexual minority stress and problematic alcohol use changes across the life course.

Ballard, M.E., Jameson, J.P., & Martz, D.M. (2017). Sexual identity and risk behaviors among adolescents in rural Appalachia. Journal of Rural Mental Health, 41(1), 17-29.

Previous research suggests that rural youth and youth who are lesbian, gay, bisexual, and questioning (LGBQ) have higher risk of multiple psychological and behavioral risk factors compared with their heterosexual counterparts. This study compared risk for bullying victimization, suicide risk, school violence, drug use, and sexual risk behavior between rural LGBQ youth and heterosexual youth. The Youth Risk Behavior Survey (YRBS), developed by the Centers for Disease Control and Prevention (CDC), was administered by the local health department in 2 high schools in rural Appalachia. Findings indicate that rural LGBQ youth are at much higher risk than rural heterosexual youth for suicide risk, bullying victimization, school violence, drug use, and sexual risk behavior. Risk was particularly high for LGBQ youth in regard to bullying victimization and for suicide risks. Further, bullying victimization resulting from the perception of LGBQ status partially mediated drug use, but not suicide risk or school violence. Our results have particular implications for possible interventions targeting LGBQ youth by high school system personnel in rural Appalachia.

Bandermann, K.M., & Szymanski, D.M. (2014). Exploring coping mediators between heterosexist oppression and posttraumatic stress symptoms among lesbian, gay, and bisexual persons. Psychology of Sexual Orientation and Gender Diversity, 1(3), 213-224.

Recently, scholars have begun to advocate that categories of traumatic events be expanded to include experiences that do not meet the traditional diagnostic criteria for posttraumatic stress disorder (PTSD), such as oppression. Our study builds on this work by examining experiences with 2 kinds of heterosexist oppression: 1 that meets the traditional diagnostic criteria for PTSD (i.e., sexual orientation-based hate crime victimization) and 1 that does not (i.e., heterosexist discrimination), as predictors of PTSD symptoms in a sample of 423 lesbian, gay, and bisexual persons who responded to an online survey. In addition, we examined the mediating roles of coping with heterosexism via internalization, detachment, and drug and alcohol use in the heterosexist oppression-PTSD symptoms link. Results indicated that when examined concurrently, both sexual orientation-based hate crime victimization and heterosexist discrimination had direct and unique links to PTSD symptoms. In addition, the results of the mediational analysis using bootstrapping provided support for a theorized model in which coping with oppressive events via internalization, detachment, and drug and alcohol use mediated the link between heterosexist discrimination and PTSD symptoms but not between sexual orientation-based hate crime victimization and PTSD symptoms. Finally, the 5 variables in the model accounted for 42% of the variance in PTSD scores.

Barboza, G.E., Dominguez, S., & Chance, E. (2016). Physical victimization, gender identity and suicide risk among transgender men and women. Preventive Medicine Reports, 4, 385-90.

We investigated whether being attacked physically due to one’s gender identity or expression was associated with suicide risk among trans men and women living in Virginia. The sample consisted of 350 transgender men and women who participated in the Virginia Transgender Health Initiative Survey (THIS). Multivariate multinomial logistic regression was used to explore the competing outcomes associated with suicidal risk. Thirty-seven percent of trans men and women experienced at least one physical attack since the age of 13. On average, individuals experienced 3.97 (SD = 2.86) physical attacks; among these about half were attributed to one’s gender identity or expression (mean = 2.08, SD = 1.96). In the multivariate multinomial regression, compared to those with no risk, being physically attacked increased the odds of both attempting and contemplating suicide regardless of gender attribution. Nevertheless, the relative impact of physical victimization on suicidal behavior was higher among those who were targeted on the basis of their gender identity or expression. Finally, no significant association was found between multiple measures of institutional discrimination and suicide risk once discriminatory and non-discriminatory physical victimization was taken into account. Trans men and women experience high levels of physical abuse and face multiple forms of discrimination. They are also at an increased risk for suicidal tendencies. Interventions that help transindividuals cope with discrimination and physical victimization simultaneously may be more effective in saving lives.

Barnett, A.P., Molock, S.D., Nieves-Lugo, K., & Zea, M.C. (2018). Anti-LGBT victimization, fear of violence at school, and suicide risk among adolescents. Psychology of Sexual Orientation and Gender Diversity, 6(1), 88-95.

We investigated whether strengths of the relationships between anti-lesbian, gay, bisexual, and transgender (LGBT) victimization, fear of violence at school, and suicide risk differ by sexual orientation among a predominantly ethnic minority sample of adolescents. Using the 2012 District of Columbia Youth Risk Behavior Survey high school data set, we performed a 4-stage, stepwise logistic regression for suicide attempts, suicidal ideation, and suicide planning. First, we tested the independent variables, sexual orientation and anti-LGBT victimization. Second, we added an anti-LGBT victimization by sexual orientation interaction term. Third, we tested the independent variable, fear of violence at school, in an additive model. Fourth, we added a fear of violence at school by sexual orientation interaction term. In Model 1, sexual orientation and anti-LGBT victimization were both significantly associated with each suicide risk behavior. In Model 2, the anti-LGBT victimization by sexual orientation interaction term was not significant for any of the dependent variables. In Model 3, fear of violence at school was significantly associated with each suicide risk behavior. In Model 4, the fear of violence at school by sexual orientation interaction term was not significant for suicide attempts or suicidal ideation but was significant for suicide planning in the direction opposite to our hypotheses. Anti-LGBT victimization, sexual orientation, and fear of violence at school were associated with suicidal ideation, suicide planning, and suicide attempts. The strength of the association between fear of violence at school and suicide planning was weaker for sexual minority adolescents than for heterosexual adolescents.

Bauermeister, J.A., Meanley, S., Hickok, A., Pingel, E., Vanhemert, W., & Loveluck J. (2014). Sexuality-related work discrimination and its association with the health of sexual minority emerging and young adult men in the Detroit Metro Area. Sexuality Research and Social Policy, 11(1), 1-10.

Discrimination has been linked to negative health outcomes among minority populations. The increasing evidence regarding health disparities among sexual minorities has underscored the importance of addressing sexuality discrimination as a public health issue. We conducted a web-based survey between May and September of 2012 in order to obtain a diverse sample of young men who have sex with men (ages 18-29; N = 397; 83% gay; 49% Black, 27% White, 15% Latino) living in the Detroit Metro Area (Michigan, USA). Using multivariate regression models, we examined the association between overall health (self-rated health, days in prior month when their physical or mental health was not good, limited functionality) and experiences of sexuality-based work discrimination. Fifteen percent reported at least one experience of sexuality-based work discrimination in the prior year. Recent workplace discrimination was associated with poorer self-rated health, a greater number of days when health was not good, and more functional limitation. We discuss the importance of addressing sexuality-related discrimination as a public health problem and propose multilevel intervention strategies to address these discriminatory practices. Public Significance Statement: The results of this study suggest that being harassed based on actual or perceived lesbian, gay, bisexual, or transgender status is associated with suicide risk behaviors among a predominantly ethnic minority sample of high school students. In addition, we found evidence of a positive association between fear of future violence at school and suicide risk for this population.

Bauermeister, J. A., Connochie, D., Jadwin-Cakmak, L., & Meanley, S. (2017). Gender policing during childhood and the psychological well-being of young adult sexual minority men in the united states. American Journal of Men’s Health, 11(3), 693-701.

Hegemonic masculinities (i.e., sets of socially accepted masculine behaviors and beliefs within a given time and culture) may affect the well-being of sexual minority men, yet quantitative relationships between these masculinities and well-being remain largely unexplored. Using data from a national cross-sectional survey of young sexual minority men (N = 1,484; ages 18-24 years), the current study examined the relationship between parental gender policing during childhood and adolescence and subsequent substance use and psychological distress. Over one third of the sample (37.8%) reported their parent(s) or the person(s) who raised them had policed their gender, including the use of disciplinary actions. Using multivariable regression, this study examined the relationship between parental gender policing and psychological well-being and substance use, after adjusting for age, race/ethnicity, educational attainment, and current student status. Gender policing during childhood and adolescence was associated with recent substance use behaviors and psychological distress in multivariable models. A linear association between substance use behaviors and psychological distress and the number of disciplinary actions experienced during childhood and adolescence was also observed. Parents’ attempts to police their sons’ gender expression were associated with markers of distress among young sexual minority men. The relationship between parental gender policing during childhood and adolescence and distress among young sexual minority men are discussed.

Bazargan, M., & Galvan, F. (2012). Perceived discrimination and depression among low-income Latina male-to-female transgender women. BMC Public Health, 12, 663.

BACKGROUND: This study examines exposure to perceived discrimination and its association with depression among low-income, Latina male-to-female transgender women as well as evaluates the impact of sexual partner violence and mistreatment on depression. METHODS: A total of 220 Latina male-to-female transgender women who resided in Los Angeles, California, were recruited through community based organizations and referrals. Participants completed individual interviews using a structured questionnaire. Depressive symptoms were assessed using the Patient Health Questionnaire (PHQ-9). Perceived discrimination was assessed using a fifteen-item measure that was designed to assess the experiences of maltreatment of transgender individuals. Multinomial logistic regression was used to examine the association between perceived discrimination and depression after controlling for the presence of other variables. RESULTS: Of the sample, 35% reported significant depressive symptoms (PHQ-9 >/= 15). Additionally, one-third of the participants indicated that in the two weeks prior to the interviews they had thought either of hurting themselves or that they would be better off dead. The extent of perceived discrimination in this population was extensive. Many of the participants experienced discrimination on a daily basis (14%) or at least once or twice a week (25%) as demonstrated by a positive response to at least 7 of 15 items in the measure of perceived discrimination. Almost six out of ten participants admitted that they had been victims of sexual partner violence. Those who reported more frequent discrimination were more likely to be identified with severe depression. There was also a notable association between self-reported history of sexual partner violence and depression severity. CONCLUSIONS: A significant association between depression severity and perceived discrimination was identified. How exposure to discrimination leads to increased risk of mental health problems needs additional investigation. Models investigating the association between perceived discrimination and depression among transgender women should include sexual partner violence as a potential confounding variable.

Bergfeld, J.R., & Chiu, E.Y. (2017). Mediators in the relationship between minority stress and depression among young same-sex attracted women. Professional Psychology: Research and Practice, 48(5), 294-300.

Minority stress has been associated with poor mental health outcomes among same-sex attracted young adult women, though there is limited research on the underlying factors that could explain how minority stress affects psychological functioning. The current study investigated such factors (trait mindfulness, coping strategies, and social support) that can potentially mediate the relationship between minority stress and depressive symptoms among same-sex attracted college-aged women. The study was completed online, and participants were 175 women between the ages of 18 and 28 who are mainly attracted to other women. Simple mediation analysis results revealed that 3 of the hypothesized protective factors (trait acceptance, avoidance coping, and perceived lesbian, gay, and bisexual social support) partially mediated the relationship between minority stress and depressive symptoms. A multiple mediation analysis indicated that trait acceptance and avoidance coping completely mediated the relationship between minority stress and depressive symptoms when included in a mediation model together. These results demonstrate that more research is needed to understand how minority stress affects mental health through its impact on one’s personal resources and coping strategies, particularly factors such as mindfulness, acceptance, and social support. Furthermore, clinicians working with this population should use treatments that emphasize mindful acceptance and social support.

Birkett, M., Espelage, D.L., & Koenig, B. (2009). LGB and questioning students in schools: the moderating effects of homophobic bullying and school climate on negative outcomes. Journal of Youth and Adolescence, 38(7), 989-1000.

Lesbian, gay, and bisexual students (LGB) and those questioning their sexual orientation are often at great risk for negative outcomes like depression, suicidality, drug use, and school difficulties (Elliot and Kilpatrick, How to Stop Bullying, A KIDSCAPE Guide to Training, 1994; Mufoz-Plaza et al., High Sch J 85:52-63, 2002; Treadway and Yoakam, J School Health 62(7):352-357, 1992). This study examined how school contextual factors such as homophobic victimization and school climate influence negative outcomes in LGB and questioning middle school students. Participants were 7,376 7th and 8th grade students from a large Midwestern county (50.7% Female, 72.7% White, 7.7% Biracial, 6.9% Black, 5.2% Asian, 3.7% Hispanic, and 2.2% reported “other”). LGB and sexually questioning youth were more likely to report high levels of bullying, homophobic victimization, and various negative outcomes than heterosexual youth. Students who were questioning their sexual orientation reported the most bullying, the most homophobic victimization, the most drug use, the most feelings of depression and suicidality, and more truancy than either heterosexual or LGB students. A positive school climate and a lack of homophobic victimization moderated the differences among sexual orientation status and outcomes. Results indicate that schools have the ability to lessen negative outcomes for LGB and sexually questioning students through creating positive climates and reducing homophobic teasing.

Birkett, M., Newcomb, M.E., & Mustanski, B. (2015). Does it get better? A longitudinal analysis of psychological distress and victimization in lesbian, gay, bisexual, transgender, and questioning youth. Journal of Adolescent Health, 56(3), 280-285.

PURPOSE: The mental health and victimization of lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth have garnered media attention with the “It Gets Better Project.” Despite this popular interest, there is an absence of empirical evidence evaluating a possible developmental trajectory in LGBTQ distress and the factors that might influence distress over time. METHODS: This study used an accelerated longitudinal design and multilevel modeling to examine a racially/ethnically diverse analytic sample of 231 LGBTQ adolescents aged 16-20 years at baseline, across six time points, and over 3.5 years. RESULTS: Results indicated that both psychological distress and victimization decreased across adolescence and into early adulthood. Furthermore, time-lagged analyses and mediation analyses suggested that distress was related to prior experiences of victimization, with greater victimization leading to greater distress. Support received from parents, peers, and significant others was negatively correlated with psychological distress in the cross-sectional model but did not reach significance in the time-lagged model. CONCLUSIONS: Analyses suggest that psychological distress might “get better” when adolescents encounter less victimization and adds to a growing literature indicating that early experiences of stress impact the mental health of LGBTQ youth.

Blosnich, J.R., Cassese, E.C., Friedman, M.R., Coulter, R.W.S., Sang, J.M., Matthews, D.D., et al. (2019). Religious freedom restoration acts and sexual minority population health in the United States. American Journal of Orthopsychiatry, 89(6), 675-681.

Religious freedom restoration acts (RFRAs) in the United States potentially facilitate discrimination against lesbian, gay, and bisexual individuals (i.e., sexual minorities). In the current investigation, we explored whether a population health metric among sexual minority adults changed over time based on the presence, absence, or introduction of a state RFRA. Data are from 21 of the United States that gathered sexual orientation data from population-based samples of noninstitutionalized adults in the 2015 Behavioral Risk Factor Surveillance System (CDC, 2015, 2016). The analytic sample included 4,911 sexual minority individuals. Time was measured in 4 3-month quarters (i.e., Q1, Q2, Q3, Q4). For each state, the prevalence of sexual minority adults reporting >14 unhealthy days/30 days was calculated. Only Indiana (the only state in the sample that passed an RFRA in 2015) exhibited significant increasing proportions over time of sexual minority adults reporting >14 unhealthy days (Q1 = 24.5%, Q2 = 34.8%, Q3 = 41.2%, Q4 = 59.5%; B ≤ = 0.50, SE = 0.23, p = .037). Post hoc analyses revealed that unhealthy days did not increase for heterosexual adults in Indiana. Indiana’s RFRA could have contributed to the increasing prevalence of unhealthy days among sexual minority adults in that state during 2015. Public health surveillance tools are needed to expedite analyses of the impact of laws on minority population health.

Public Policy Relevance Statement: Legal scholars posit that religious freedom restoration acts (RFRAs) create a significant potential for discrimination against sexual minorities, which provides the scaffolding to uphold sexual minority health disparities. Taking advantage of a natural experimental phenomenon, the present results suggest the passage of a religious freedom restoration act in the State of Indiana in March, 2015 may have been associated with increased poor self-reported overall health among sexual minorities in Indiana.

Bockting, W.O., Miner, M.H., Swinburne Romine, R.E., Hamilton, A., & Coleman, E. (2013). Stigma, mental health, and resilience in an online sample of the US transgender population. American Journal of Public Health, 103(5), 943-951.

OBJECTIVES: We assessed the association between minority stress, mental health, and potential ameliorating factors in a large, community-based, geographically diverse sample of the US transgender population. METHODS: In 2003, we recruited through the Internet a sample of 1093 male-to-female and female-to-male transgender persons, stratified by gender. Participants completed an online survey that included standardized measures of mental health. Guided by the minority stress model, we evaluated associations between stigma and mental health and tested whether indicators of resilience (family support, peer support, identity pride) moderated these associations. RESULTS: Respondents had a high prevalence of clinical depression (44.1%), anxiety (33.2%), and somatization (27.5%). Social stigma was positively associated with psychological distress. Peer support (from other transgender people) moderated this relationship. We found few differences by gender identity. CONCLUSIONS: Our findings support the minority stress model. Prevention needs to confront social structures, norms, and attitudes that produce minority stress for gender-variant people; enhance peer support; and improve access to mental health and social services that affirm transgender identity and promote resilience.

Bouris, A., Everett, B.G., Heath, R.D., Elsaesser, C.E., & Neilands T.B. (2016). Effects of victimization and violence on suicidal ideation and behaviors among sexual minority and heterosexual adolescents. LGBT Health, 3(2), 153-161.

PURPOSE: Sexual minority youth (SMY) are at higher risk for victimization and suicide than are heterosexual youth (HY). Relatively little research has examined which types of victimization are most closely linked to suicide, which is necessary to develop targeted prevention interventions. The present study was conducted to address this deficit. METHODS: The data come from the 2011 Chicago Youth Risk Behavior Survey (n = 1,907). Structural equation modeling (SEM) in Mplus evaluated the direct, indirect, and total effects of sexual orientation on a latent indicator of suicidal ideation and behaviors via seven types of victimization. Four indicators of victimization were school-specific (e.g., harassment due to sexual orientation or gender identity (SO/GID), bullying, threatened or injured with a weapon, and skipping school due to safety concerns), and three indicators assessed other types of victimization (e.g., electronic bullying, intimate partner violence, and sexual abuse).

Brennan, S.L., Irwin, J., Drincic, A., Amoura, N.J., Randall, A., & Smith-Sallans, M. (2017). Relationship among gender-related stress, resilience factors, and mental health in a Midwestern US transgender and gender-nonconforming population. International Journal of Transgenderism, 18(4), 433-445.

Background: Transgender and gender-nonconforming individuals experience more discrimination than their cisgender peers, and this discrimination can be associated with poorer mental health. This study used the gender minority stress model as a framework to examine the relationship among gender-related stressors and resilience factors and mental health outcomes. The study particularly aimed to increase knowledge of the gender-nonconforming population. Methods: A community sample of 83 individuals that identify as a gender different than the sex assigned to them at birth completed an online survey. Depression and anxiety were assessed using the Center for Epidemiological Studies Depression Scale (CES-D) and Beck Anxiety Inventory (BAI), respectively. The Gender Minority Stress and Resilience measure was used to assess distal and proximal stressors and resilience factors. Results: The median CES-D and BAI scores were 16 and 13, respectively. Forty percent had a history of non-suicidal self-injury (NSSI), 75% had experienced suicidal ideation, and 45% had attempted suicide. Proximal stress was found to be a positive predictor of depressive symptoms. Resilience was a weak negative predictor of anxiety symptoms. Distal stress was a positive predictor of suicide attempts, and resilience factors and hormone use were marginal negative predictors of suicide attempt. Trans women were significantly less likely to have engaged in NSSI, but had a significantly higher proximal stress score than trans men and gender-nonconforming individuals. Conclusion: Our study found high rates of mental health problems in the trans and gender-nonconforming sample. Our findings in part support the gender minority stress model, with gender-related stress predicting certain mental health problems and resilience being a negative predictor. Overall, gender-nonconforming individuals have had similar experiences and mental health findings as transgender individuals.

Breslow, A.S., Brewster, M.E., Velez, B.L., Wong, S., Geiger, E., & Soderstrom, B. (2015). Resilience and collective action: Exploring buffers against minority stress for transgender individuals. Psychology of Sexual Orientation and Gender Diversity, 2(3), 253-265.

With a national sample of 552 transgender adults, the present study tested hypotheses drawn from minority stress theory and positive psychology research on stress-ameliorating processes. Specifically, the present study examined the relations of minority stressors (i.e., antitransgender discrimination, stigma awareness, and internalized transphobia) and individual- and group-level buffers (i.e., resilience and collective action) of minority stress. As expected, each minority stressor was positively correlated with psychological distress. In terms of buffers, resilience–though not collective action–was negatively correlated with psychological distress. Additionally, stigma awareness–but not internalized transphobia–mediated the relation of antitransgender discrimination with higher psychological distress. Moderation analyses indicated that resilience did not moderate any of the relations of the minority stressors with psychological distress. However, contrary to prediction, collective action strengthened the positive relation of internalized transphobia with psychological distress. Furthermore, at high levels of collective action, internalized transphobia became a significant mediator of the discrimination-distress relation. Strategies for developing individual (e.g., resilience building strategies) and group-level (e.g., engagement in collective action) interventions targeted toward transgender individuals who experience discrimination are discussed.

Brewster, M.E., Velez, B.L., Foster, A., Esposito, J., & Robinson, M.A. (2016). Minority stress and the moderating role of religious coping among religious and spiritual sexual minority individuals. Journal of Counseling Psychology, 63(1), 119-126.

In prior research with primarily heterosexual religious and spiritual individuals, positive and negative forms of religious coping have been posited to moderate the links between minority stressors and psychological outcomes (Kim, Kendall, & Webb, 2015; Szymanski & Obiri, 2011). With a sample of 143 sexual minority people, the present study extended these hypotheses by examining the moderating roles of positive and negative religious coping in the link of 2 sexual minority-specific minority stress variables (heterosexist discrimination, internalized heterosexism) with psychological distress and well-being. In partial support of our hypotheses, we found that positive religious coping moderated the relation of internalized heterosexism and psychological well-being such that greater positive religious coping weakened the deleterious impact of internalized heterosexism on psychological well-being. Negative religious coping did not moderate any links. As the first test of the moderating roles of religious coping styles in the sexual minority stress-psychological distress link, the present study yields important findings for research and practice with religious and spiritual sexual minority individuals.

Bruce, D., Harper, G.W., & Bauermeister, J.A. (2015). Minority stress, positive identity development, and depressive symptoms: Implications for resilience among sexual minority male youth. Psychology of Sexual Orientation and Gender Diversity, 2(3), 287-296.

INTRODUCTION: Minority stress processes have been shown to have significant associations with negative mental health outcomes among sexual minority populations. Given that adversity may be experienced growing up as a sexual minority in heteronormative, if not heterosexist, environments, our research on resilience among sexual minority male youth proposes that positive identity development may buffer the effects of a range of minority stress processes. METHODS: An ethnically diverse sample of 200 sexual minority males ages 16-24 (mean age, 20.9 years) was recruited using mixed recruitment methods. We developed and tested two new measures: concealment stress during adolescence and sexual minority-related positive identity development. We then tested a path model that assessed the effects of minority stressors, positive identity development, and social support on major depressive symptoms. RESULTS: Experience of stigma was associated with internalized homophobia (beta=.138, p<.05) and major depressive symptoms (beta=1.076, OR=2.933, p<.001), and internalized homophobia partially mediated experience’s effects on major depression (beta=.773, OR=2.167, p<.001). Concealment stress was associated with positive identity development (beta=.155, p<.05) and internalized homophobia (beta=.418, p<.001), and positive identity development partially mediated concealment stress’s effects on internalized homophobia (beta=-.527, p<.001). Concealment stress demonstrated a direct effect on major depression (beta=1.400, OR=4.056, p<.001), and indirect paths to social support through positive identity development. CONCLUSIONS: With these results, we offer an exploratory model that empirically identifies significant paths among minority stress dimensions, positive identity development, and major depressive symptoms. This study helps further our understanding of minority stress, identity development, and resources of resilience among sexual minority male youth.

Burks, A.C., Cramer, R.J., Henderson, C.E., Stroud, C.H., Crosby, J.W., & Graham, J. (2018). Frequency, nature, and correlates of hate crime victimization experiences in an urban sample of lesbian, gay, and bisexual community members. Journal of Interpersonal Violence, 33(3), 402-420.

The present study examines two central research questions. First, we sought to add to current knowledge on the frequency and types of hate crime experiences in an urban sample. Also, drawing on existing frameworks for sexual minority specific (SMS) stress, we examined internalized SMS stress (defined by internalized homophobia and acceptance concerns regarding one’s minority status) as a mediator of the association between hate crime victimization (i.e., objective or social SMS stress) and mental health symptoms (i.e., symptoms of depression, anxiety, and general stress). Participants were 336 self-identified lesbian, gay, and bisexual (LGB) community members who elected to participate in research at a community health agency in an urban southwestern United States jurisdiction. Results suggested (a) approximately one third of the sample reported lifetime hate crime victimization, with the most common types characterized by interpersonal, as opposed to property, crimes; (b) approximately half of participants reported their most recent victimization to law enforcement; and (c) internalized SMS stress mediated the relation between hate crime victimization and overall mental health symptoms. Findings are discussed with respect to implications of the unique nature of hate crimes in an urban setting, as well as theoretical and practical implications of SMS stress findings.

Burns, M.N., Kamen, C., Lehman, K.A., & Beach, R.H. (2012). Minority stress and attributions for discriminatory events predict social anxiety in gay men. Cognitive Therapy and Research, 36(1), 25-35.

This study revealed that attributional style can identify gay men at risk for adverse mental health correlates of discrimination, as well as those resilient in the face of frequent discriminatory events. Men identifying as gay (N = 307) completed online self-reports of social anxiety, perceived frequency of discriminatory events, attributions for discriminatory events, and key minority stress constructs: internalized homonegativity and gay identity development. A new measure was constructed to assess different types of attributions regarding discrimination, with factor analyses yielding promising psychometric properties. Global attributions and the importance ascribed to discrimination were associated with increased social anxiety, above and beyond other minority stress constructs related to mental health in gay men. Attribution style also served as a moderator, as perceived discrimination was only associated with increased social anxiety in gay men who attributed high globality/importance to discriminatory events. Attributions may serve as risk or protective factors in the context of discrimination.

Burton, C.M., Marshal, M.P., Chisolm, D.J., Sucato, G.S., & Friedman, M.S. (2013). Sexual minority-related victimization as a mediator of mental health disparities in sexual minority youth: a longitudinal analysis. Journal of Youth and Adolescence, 42(3), 394-402.

Sexual minority youth (youth who are attracted to the same sex or endorse a gay/lesbian/bisexual identity) report significantly higher rates of depression and suicidality than heterosexual youth. The minority stress hypothesis contends that the stigma and discrimination experienced by sexual minority youth create a hostile social environment that can lead to chronic stress and mental health problems. The present study used longitudinal mediation models to directly test sexual minority-specific victimization as a potential explanatory mechanism of the mental health disparities of sexual minority youth. One hundred ninety-seven adolescents (14-19 years old; 70 % female; 29 % sexual minority) completed measures of sexual minority-specific victimization, depressive symptoms, and suicidality at two time points 6 months apart. Compared to heterosexual youth, sexual minority youth reported higher levels of sexual minority-specific victimization, depressive symptoms, and suicidality. Sexual minority-specific victimization significantly mediated the effect of sexual minority status on depressive symptoms and suicidality. The results support the minority stress hypothesis that targeted harassment and victimization are partly responsible for the higher levels of depressive symptoms and suicidality found in sexual minority youth. This research lends support to public policy initiatives that reduce bullying and hate crimes because reducing victimization can have a significant impact on the health and well-being of sexual minority youth.

Calabrese, S.K., Meyer, I.H., Overstreet, N.M., Haile, R. & Hansen, N.B. (2015). Exploring discrimination and mental health disparities faced by black sexual minority women using a minority stress framework. Psychology of Women Quarterly, 39(3), 287-304.

Black sexual minority women are triply marginalized due to their race, gender, and sexual orientation. We compared three dimensions of discrimination-frequency (regularity of occurrences), scope (number of types of discriminatory acts experienced), and number of bases (number of social statuses to which discrimination was attributed)-and self-reported mental health (depressive symptoms, psychological well-being, and social well-being) between 64 Black sexual minority women and each of two groups sharing two of three marginalized statuses: (a) 67 White sexual minority women and (b) 67 Black sexual minority men. Black sexual minority women reported greater discrimination frequency, scope, and number of bases and poorer psychological and social well-being than White sexual minority women and more discrimination bases, a higher level of depressive symptoms, and poorer social well-being than Black sexual minority men. We then tested and contrasted dimensions of discrimination as mediators between social status (race or gender) and mental health outcomes. Discrimination frequency and scope mediated the association between race and mental health, with a stronger effect via frequency among sexual minority women. Number of discrimination bases mediated the association between gender and mental health among Black sexual minorities. Future research and clinical practice would benefit from considering Black sexual minority women’s mental health in a multidimensional minority stress context.

Chae, D.H., Krieger, N., Bennett, G.G., Lindsey, J.C., Stoddard, A.M., & Barbeau, E.M. (2010). Implications of discrimination based on sexuality, gender, and race/ethnicity for psychological distress among working-class sexual minorities: The United for Health Study, 2003-2004. International Journal of Health Services, 40(4), 589-608.

This study investigated the distribution of demographic characteristics, the prevalence of discrimination based on sexuality, gender, and race, and relationships with psychological distress among 178 working-class sexual minorities (i.e., who identified as lesbian, gay, or bisexual (LGB) or had ever engaged in same-sex sexual behaviors) recruited to the United for Health Study (2003-2004). The results indicated considerable heterogeneity in responses to items assessing sexual orientation and sexual behavior, with a majority of sexual minority participants not identifying as LGB (74.2%). The authors found significant demographic differences in LGB identification by gender, race/ethnicity, nativity, and socioeconomic factors. In addition, LGB participants had higher levels of psychological distress than non-LGB-identified sexual minorities. Linear regression analyses revealed that reports of racial/ethnic discrimination and sexuality discrimination were associated with higher levels of psychological distress among sexual minority participants. The results underscore the need to collect multiple measures of sexuality in conducting research on racially diverse working-class communities; to consider demographic factors in collecting sexuality data; and to disaggregate information on sexuality by LGB identification. Findings also highlight the importance of addressing discrimination in ameliorating problematic mental health outcomes among working-class sexual minorities.

Chen, Y.C., & Tryon, G.S. (2012). Dual minority stress and Asian American gay men’s psychological distress. American Journal of Community Psychology, 40(5), 539-554.

The present study investigated the direct and additive effects of racial minority stress and sexual minority stress on the psychological well-being among a community sample of 139 Asian American gay men. Self-esteem was tested to see whether it moderated or mediated the effects of perceived dual minority stress on psychological distress. Results revealed that sexual minority stress predicted self-esteem and both were predictors of psychological distress. Racial minority stress did not predict psychological distress. Contrary to the minority stress model existing in the current literature, the added disadvantages of racial/ethnic minority status did not increase Asian American gay men’s psychological distress. Self-esteem did not mediate or moderate the relationships between minority stresses and psychological distress. These findings highlight the robust effects of stresses related to one’s homosexuality on psychological well-being and suggest that self-esteem may not always protect against multiple discriminations for Asian American gay men.

Clements-Nolle, K., Marx, R., & Katz, M. (2006). Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization. Journal of Homosexuality, 51(3), 53-69.

To determine the independent predictors of attempted suicide among transgender persons we interviewed 392 male-to-female (MTF) and 123 female-to-male (FTM) individuals. Participants were recruited through targeted sampling, respondent-driven sampling, and agency referrals in San Francisco. The prevalence of attempted suicide was 32% (95% CI = 28% to 36%). In multivariate logistic regression analysis younger age (<25 years), depression, a history of substance abuse treatment, a history of forced sex, gender-based discrimination, and gender-based victimization were independently associated with attempted suicide. Suicide prevention interventions for transgender persons are urgently needed, particularly for young people. Medical, mental health, and social service providers should address depression, substance abuse, and forced sex in an attempt to reduce suicidal behaviors among transgender persons. In addition, increasing societal acceptance of the transgender community and decreasing gender-based prejudice may help prevent suicide in this highly stigmatized population.

Conlin, S.E., Douglass, R.P., & Ouch, S. (2019). Discrimination, subjective wellbeing, and the role of gender: A mediation model of LGB minority stress. Journal of Homosexuality, 66(2), 238-259.

The present study examined the link between discrimination and the three components of subjective wellbeing (positive and negative affect and life satisfaction) among a cisgender sample of lesbian, gay, and bisexual (LGB) adults. Specifically, we investigated internalized homonegativity and expectations of rejection as potential mediators of the links between discrimination and subjective wellbeing among a sample of 215 participants. Results from our structural equation model demonstrated a strong, positive direct link between discrimination and negative affect. Discrimination also had small, negative indirect effects on life satisfaction through our two mediators. Interestingly, neither discrimination nor our two mediators were related with positive affect, demonstrating the need for future research to uncover potential buffers of this link. Finally, our model evidenced configural, metric, and scalar invariance, suggesting that our model applies well for both women and men. Practical implications and future directions for research are discussed.

Corliss, H.L., Cochran, S.D., Mays, V.M., Greenland, S., & Seeman, T.E. (2009). Age of minority sexual orientation development and risk of childhood maltreatment and suicide attempts in women. American Journal of Orthopsychiatry, 79(4), 511-521.

Women with minority sexual orientations (e.g., lesbian, bisexual) are more likely than heterosexual women to report histories of childhood maltreatment and attempted suicide; however, the importance of the timing of minority sexual orientation development in contributing to this increased risk is uncertain. This study investigated relationships between self-reported ages of achieving minority sexual orientation development milestones (first awareness of same-gender attractions, disclosure of a minority sexual orientation to another person, and same-gender sexual contact), and childhood maltreatment and suicide attempt experiences in a sample of 2,001 women recruited from multiple-community sources. Younger age of minority sexual orientation development milestones was positively linked to self-reported recall of childhood maltreatment experiences, and to a childhood suicide attempt. After adjusting for differences in maltreatment, the odds of suicide attempt attributable to younger age of sexual orientation development milestones was reduced by 50 to 65%, suggesting that maltreatment may account for about half of the elevated risk for childhood suicide attempts among women with early minority sexual orientation development. Implications for services, interventions, and further research to address maltreatment disparities for sexual minorities are discussed.

Coulter, R.W., Kinsky, S.M., Herrick, A.L., Stall, R.D., & Bauermeister, J.A. (2015). Evidence of syndemics and sexuality-related discrimination among young sexual-minority women. LGBT Health, 2(3), 250-257.

PURPOSE: Syndemics, or the co-occurrence and interaction of health problems, have been examined extensively among young men who have sex with men, but their existence remain unexamined, to our knowledge, among sexual-minority (i.e., lesbian, gay, and bisexual) women. Thus, we investigated if syndemics were present among young sexual-minority women, and if sexual-orientation discrimination was an independent variable of syndemic production. METHODS: A total of 467 sexual-minority women between the ages of 18 and 24 completed a cross-sectional online survey regarding their substance use, mental health, sexual behaviors, height, weight, and experiences of discrimination. We used structural equation modeling to investigate the presence of syndemics and their relationship to sexual-orientation discrimination. RESULTS: Heavy episodic drinking, marijuana use, ecstasy use, hallucinogen use, depressive symptoms, multiple sexual partners, and history of sexually transmitted infections (STIs) comprised syndemics in this population (chi-square=24.989, P=.201; comparative fit index [CFI]=0.946; root mean square error of approximation [RMSEA]=0.023). Sexual-orientation discrimination is significantly and positively associated with the latent syndemic variable (unstandardized coefficient=0.095, P<.05), and this model fit the data well (chi-square=33.558, P=.059; CFI=0.914; RMSEA=0.029). The reverse causal model showed syndemics is not an independent variable of sexual-orientation discrimination (unstandardized coefficient=0.602, P>.05). CONCLUSIONS: Syndemics appear to be present and associated with sexual-orientation discrimination among young sexual-minority women. Interventions aimed at reducing discrimination or increasing healthy coping may help reduce substance use, depressive symptoms, and sexual risk behaviors in this population.

Coulter, R.W.S., Bersamin, M., Russell, S.T., & Mair, C. (2018). The effects of gender- and sexuality-based harassment on lesbian, gay, bisexual, and transgender substance use disparities. Journal of Adolescent Health, 62(6), 688-700.

PURPOSE: We tested three competing models about whether gender- and sexuality-based harassment at school have nonindependent, additive, or interactive effects on adolescents’ electronic cigarette use (i.e., vaping), cigarette smoking, alcohol use, and heavy episodic drinking (HED). We also tested whether harassment mediated substance use disparities between lesbian, gay, bisexual, transgender (LGBT) adolescents and their cisgender heterosexual peers. METHODS: We analyzed cross-sectional data from the 2013-2014 California Healthy Kids Survey, including 316,766 students in grades 7, 9, and 11 from more than 1,500 middle and high schools. We used logistic regression models and interaction terms to estimate associations of past-year gender- and sexuality-based harassment at school on past-month substance use, and the Karlson-Holm-Breen method to test whether harassment mediated LGBT disparities in substance use. RESULTS: Vaping, smoking, drinking, HED, and gender- and sexuality-based harassment were higher for transgender adolescents than for cisgender males and females, and for adolescents who were lesbian, gay, or bisexual only versus heterosexual only. Gender- and sexuality-based harassments were independently associated with greater odds of using each substance in every grade. These two types of harassment had positive interactions with each other for vaping in grade 11, smoking in grade 11, and HED in grades 9 and 11. Gender- and sexuality-based harassment significantly mediated many of the LGBT disparities in substance use. CONCLUSIONS: Gender- and sexuality-based harassment at school independently or interactively produced LGBT disparities in substance use. Reducing these types of discrimination in schools will likely mitigate these disparities.

Cramer, R.J., Wright, S., Long, M.M., Kapusta, N.D., Nobles, M.R., Gemberling, T.M., et al. (2018). On hate crime victimization: Rates, types, and links with suicide risk among sexual orientation minority special interest group members. Journal of Trauma & Dissociation, 19(4), 476-489.

Hate crimes remain pressing traumatic events for sexual orientation minority adults. Previous literature documents patterns in which hate crime victimization is associated with elevated risk for poor mental health. The present paper held 2 aims to advance literature. First, we investigated the rates and types of hate crime victimization among sexual orientation minority adults. Second, adopting a mental health amplification risk model, we evaluated whether symptoms of depression, impulsivity, or post-traumatic stress exacerbated the hate crime victimization-suicide risk link. Participants were 521 adult sexual orientation minority-identifying members of the National Coalition for Sexual Freedom (i.e., a bondage and discipline, and sadomasochism-identifying sexuality special interest group). Participants completed demographic and mental health inventories via online administration. Results showed: (1) low rates of total lifetime hate crime victimization and (2) higher rates of interpersonal violence compared to property crime victimization within the sample. Regression results showed: (1) independent positive main effects of all 3 mental health symptom categories with suicide risk; (2) an interaction pattern in which impulsivity was positively associated with suicide risk for non-victims; and (3) an interaction pattern in which post-traumatic stress was positively associated with suicide risk for hate crime victims and non-victims. Results are discussed concerning implications for trauma-informed mental healthcare, mental health amplification models, and hate crime and suicide prevention policies.

Craney, R.S., Watson, L.B., Brownfield, J., & Flores, M.J. (2018). Bisexual women’s discriminatory experiences and psychological distress: Exploring the roles of coping and LGBTQ community connectedness. Psychology of Sexual Orientation and Gender Diversity, 5(3), 324-337.

The present study examined the relations among antibisexual discrimination, coping mechanisms, psychological distress, and lesbian, gay, bisexual, transgender, and queer (LGBTQ) community connectedness among bisexual women. It was hypothesized that both adaptive (i.e., resistance, education/advocacy) and maladaptive (i.e., internalization, drug and alcohol use, detachment) coping mechanisms would significantly mediate the positive link between antibisexual discrimination and psychological distress. More specifically, we expected that antibisexual discrimination would predict more adaptive and maladaptive coping mechanisms, although adaptive coping would relate to less distress and maladaptive coping would relate to more distress. In addition, LGBTQ community connectedness was explored as a moderating variable in each of these links (i.e., moderated mediation). Antibisexual discrimination was significantly positively correlated with all coping mechanisms. Moreover, antibisexual discrimination, education/advocacy, internalization, resistance, and detachment significantly positively predicted psychological distress. In addition, education/advocacy, internalization, resistance, and detachment partially mediated the positive relation between antibisexual discrimination and psychological distress, whereas alcohol and drug use did not. LGBTQ community connectedness moderated the link between antibisexual discrimination and psychological distress, such that the relation was nonsignificant among higher levels of community connectedness. Practice implications and suggestions for future research are discussed.

Public Significance Statement: The present study examined the mediating role of coping mechanisms in the link between anti-bisexual discrimination and psychological distress among bisexual women. Results suggested that internalization, detachment, resistance, and education/advocacy significantly mediated the positive link between anti-bisexual discrimination and psychological distress, although drug and alcohol use did not. In addition, LGBT community connectedness buffered the relation between anti-bisexual discrimination and psychological distress.

D’Augelli, A.R., Hershberger, S.L., & Pilkington, N.W. (1998). Lesbian, gay, and bisexual youth and their families: disclosure of sexual orientation and its consequences. American Journal of Orthopsychiatry, 68(3), 361-371; discussion 372-375.

Lesbian, gay, and bisexual youngsters, aged 14-21 and living at home, were studied for patterns of disclosure of sexual orientation to families. Three-quarters had told at least one parent, more often the mother than the father. Those who had disclosed were generally more open about their sexual orientation than those who had not, and few of the nondisclosed expected parental acceptance. Those who had disclosed reported verbal and physical abuse by family members, and acknowledged more suicidality than those who had not “come out” to their families.

D’Augelli, A.R., Grossman, A.H., Salter, N.P., Vasey, J.J., Starks, M.T., & Sinclair, K.O. (2005). Predicting the suicide attempts of lesbian, gay, and bisexual youth. Suicide and Life-Threatening Behavior, 35(6), 646-660.

In this study predictors of serious suicide attempts among lesbian, gay, and bisexual (LGB) youth were examined. Three groups were compared: youth who reported no attempts, youth who reported attempts unrelated to their sexual orientation, and youth whose attempts were considered related to their sexual orientation. About one third of respondents reported at least one suicide attempt; however, only half of the attempts were judged serious based on potential lethality. About half of all attempts were related to youths’ sexual orientation. Factors that differentiated youth reporting suicide attempts and those not reporting attempts were greater childhood parental psychological abuse and more childhood gender-atypical behavior. Gay-related suicide attempts were associated with identifiability as LGB, especially by parents. Early openness about sexual orientation, being considered gender atypical in childhood by parents, and parental efforts to discourage gender atypical behavior were associated with gay-related suicide attempts, especially for males. Assessment of past parental psychological abuse, parental reactions to childhood gender atypical behavior, youths’ openness about sexual orientation with family members, and lifetime gay-related verbal abuse can assist in the prediction of suicide attempts in this population.

D’Augelli, A.R., Grossman, A.H., & Starks, M.T. (2006). Childhood gender atypicality, victimization, and PTSD among lesbian, gay, and bisexual youth. Journal of Interpersonal Violence, 21(11), 1462-1482.

This study examined childhood gender atypicality, lifetime victimization based on sexual orientation, and current mental health, including trauma symptoms and posttraumatic stress disorder (PTSD), among 528 lesbian, gay, and bisexual youth. Nearly 80% reported verbal victimization, 11% physical, and 9% sexual, with males reporting significantly more victimization. Victimization began, on average, at age 13. Verbal attacks occurred as early as age 6, physical attacks at 8, and sexual attacks at 9. Youth who were considered gender atypical in childhood reported more victimization and more current mental health symptoms. PTSD was found in 9% of youth and was associated with past physical victimization.

Davis, B., Royne Stafford, M.B., & Pullig, C. (2014). How gay-straight alliance groups mitigate the relationship between gay-bias victimization and adolescent suicide attempts. Journal of the American Academy of Child and Adolescent Psychiatry, 53(12), 1271-1278.e1.

OBJECTIVE: We examined the relationships between victimization from being bullied, suicide, hopelessness, and the presence of a Gay-Straight Alliance (GSA) on a school campus. METHOD: We analyzed data from the California Healthy Kids Survey from 2005 to 2007 using hierarchical modeling. RESULTS: We found that gay-bias (versus non-gay-bias) victimization is meaningfully connected with the inwardly destructive behavior of attempted suicide among adolescents. We also found that hopelessness helps explain associations between gay-bias victimization and suicide attempts and that the presence of a GSA club on a school’s campus attenuates significant connections between gay-bias victimization and suicide attempts by reducing hopelessness. CONCLUSION: Gay-bias victims are more likely than other victims to attempt suicide while also feeling more hopeless. The presence of a GSA on campus may help to reduce the attempted suicide and hopelessness associated with gay-bias victimization.

DeBlaere, C., Brewster, M.E., Bertsch, K.N., DeCarlo, A.L., Kegel, K.A., & Presseau, C.D. (2014). The protective power of collective action for sexual minority women of color: An investigation of multiple discrimination experiences and psychological distress. Psychology of Women Quarterly, 38(1), 20-32.

We utilize an additive intersectionality framework in the present study to examine the relations among perceived racism, sexism, and heterosexism and the psychological distress of self-identified sexual minority women of color. Participants (N = 134) aged 19 to 75 recruited through electronic mailing lists, discussion groups, and virtual communities aimed toward sexual minority women of color completed online surveys. When each form of discrimination was examined in a single multiple regression analysis, only perceived heterosexism explained significant and positive variance in psychological distress. In addition, collective action was tested as a moderator of the effects of racism, sexism, and heterosexism on psychological distress; specifically, the potential attenuating roles of three forms of collective action (race and ethnicity, feminist, and sexual minority) in the respective racism –> distress, sexism –> distress, and heterosexism –> distress links were investigated. Sexual minority collective action buffered the heterosexist experiences –> psychological distress link. More specifically, in the context of lower collective action, perceived heterosexism positively predicted distress; however, perceived heterosexism did not predict psychological distress at higher levels of collective action. No other significant interaction effects were found. Our results suggest that discrimination experiences continue to be important to assess in research and practice with marginalized individuals. Also, encouraging clients to engage in collective action could represent a useful intervention tool for counselors.

Denton, F.N., Rostosky, S.S., & Danner, F. (2014). Stigma-related stressors, coping self-efficacy, and physical health in lesbian, gay, and bisexual individuals. Journal of Counseling Psychology, 61(3), 383-391.

Understanding and intervening to address health disparities is part of the expanding role of psychologists (Johnson, 2013). We drew on Hatzenbuehler’s (2009) psychological mediation framework and Lick, Durso, and Johnson’s (2013) conceptual pathways to lesbian, gay, and bisexual (LGB) physical health disparities to test a serial mediation model in which 2 types of cognitive appraisals (proximal minority stressors and coping self-efficacy) partially account for the association between perceived discrimination and prejudice (distal minority stressor) and self-reported physical health symptoms in a nationally recruited sample of 564 LGB individuals (270 women, 294 men) who participated in a web-based survey. Results indicated that perceived experiences of discrimination and prejudice were associated with expectations of rejection and internalized homonegativity. These 2 proximal stressors were associated with lower coping self-efficacy, and the combined cognitive appraisal pathways were associated with higher levels of self-reported physical symptom severity. The pathway through emotion-focused coping self-efficacy was particularly salient in accounting for the overall mediation. Interventions to address distal and proximal minority stressors and improve emotion-focused coping self-efficacy may be particularly helpful in reducing the negative effects of stigma on physical health.

Dermody, S.S., Marshal, M.P., Burton, C.M., & Chisolm, D.J. (2016). Risk of heavy drinking among sexual minority adolescents: indirect pathways through sexual orientation-related victimization and affiliation with substance-using peers. Addiction, 111(9), 1599-1606.

AIMS: To test two indirect pathways through which sexual minority adolescents (SMAs) may be at risk for heavy episodic drinking (HED) including a socialization pathway via substance-using peer affiliations and social marginalization pathway via sexual minority-specific victimization and subsequent substance-using peer affiliations. DESIGN: Analysis of the first three waves (6 months apart) of a longitudinal adolescent health risk study (2011-14). Participants were referred by medical providers or a screening system in providers’ waiting rooms. SETTING: Two large urban adolescent health clinics in Pennsylvania and Ohio, USA. PARTICIPANTS: A total of 290 adolescents (ages 14-19 years, mean: 17.08) who were 71.0% female, 33.4% non-Hispanic white and 34.5% SMAs. MEASUREMENTS: Self-reported sexual minority status (wave 1) and affiliation with substance-using peers (waves 1 and 2), and latent sexual-minority specific victimization (waves 1 and 2) and HED (waves 1 and 3) variables. FINDINGS: Using mediation analyses in a structural equation modeling framework, there was a significant indirect effect of sexual minority status (wave 1) on HED (wave 3) via affiliation with substance-using peers [wave 2; indirect effect = 0.03, 95% confidence interval (CI) = 0.01, 0.07], after accounting for the indirect effect of sexual-orientation related victimization (wave 2; indirect effect = 0.10, 95% CI = 0.02-0.19). The social marginalization pathway was not supported, as victimization (wave 1) was not associated with affiliation with substance-using peers (wave 2; beta = – 0.04, P = 0.66). Sex differences in the indirect effects were not detected (Ps > 0.10). CONCLUSIONS: Sexual minority adolescents in the United States appear to exhibit increased heavy episodic drinking via an indirect socialization pathway, including affiliations with substance-using peers and a concurrent indirect pathway involving sexual minority-related victimization. The pathways appear to operate similarly for boys and girls.

Donnelly, R., Robinson, B. A., & Umberson, D. (2019). Can spouses buffer the impact of discrimination on depressive symptoms? An examination of same-sex and different-sex marriages. Society and Mental Health, 19(2), 192-210.

Discrimination due to personal characteristics (e.g., gender, sexuality, appearance) is a common yet stressful experience that is detrimental to mental health. Prior work has not considered how spouses in same- and different-sex marriages help each other cope with discrimination despite the importance of marriage for managing stress and adversity. We analyze survey data collected from both spouses in same-sex and different-sex marriages within the United States (N=836 individuals) to examine whether support from spouses weakens the impact of discrimination on depressive symptoms. Results suggest that discrimination contributes to depressive symptoms, but greater support from spouses buffers the mental health consequences of discrimination. Individuals in same-sex marriages report more spousal support than do individuals in different-sex marriages, even after accounting for experiences of discrimination. Same-sex couples may get needed spousal support, whereas women married to men receive the least spousal support and may be vulnerable to stressors that challenge mental health.

Drazdowski, T.K., Perrin, P.B., Trujillo, M., Sutter, M., Benotsch, E.G., & Snipes, D.J. (2016). Structural equation modeling of the effects of racism, LGBTQ discrimination, and internalized oppression on illicit drug use in LGBTQ people of color. Drug and Alcohol Dependence, 159, 255-262.

BACKGROUND: Experiences with lesbian, gay, bisexual, transgender, or queer (LGBTQ) discrimination and racism have both been associated with mental health problems and illicit drug use. However, the cumulative effects of both forms of discrimination–and resulting internalized oppression–on illicit drug use in LGBTQ people of color (POC) has not been examined in the research literature. METHODS: Using online questionnaires, this study collected self-report data from 200 LGBTQ POC about their experiences with racism, LGBTQ discrimination, internalized racism, internalized LGBTQ discrimination, and illicit drug use. RESULTS: Two structural equation models yielded adequate fit indices in which experiences with racism and LGBTQ discrimination led to more internalized oppression, which then led to greater illicit drug use magnitude. LGBTQ discrimination was directly related to increased internalized oppression, which was positively associated with illicit drug use magnitude; the relationship between LGBTQ discrimination and illicit drug use magnitude was mediated by internalized oppression in both models. However, racism and the interaction between racism and LGBTQ discrimination did not show valid direct effects on internalized oppression or indirect effects on illicit drug use magnitude. CONCLUSIONS: LGBTQ POC can be the targets of both racism and LGBTQ discrimination, although the current study found that the most psychologically damaging effects may come from LGBTQ discrimination. Interventions meant to decrease or prevent illicit drug use in LGBTQ POC may benefit from helping participants examine the links among LGBTQ discrimination, internalized oppression, and illicit drug use as a coping strategy, focusing on substituting more adaptive coping.

DuBois, L.Z., Powers, S., Everett, B.G., & Juster, R.P. (2017). Stigma and diurnal cortisol among transitioning transgender men. Psychoneuroendocrinology, 82, 59-66.

This study assessed diurnal cortisol functioning in relation to stigma-based transition-specific stressors experienced by transgender men during their transition from female to male. Sixty-five healthy transgender men undergoing testosterone therapy participated in in-person interviews through which transition-specific stressors were identified. Interviews were coded according to participant reported (1) Transitioning-identity stress; (2) Coming Out stress; (3) Gender-specific Public Bathroom stress; and (4) levels of general Perceived Stress. Participants provided fifteen salivary samples assessing cortisol diurnal rhythm over three days. Hierarchical linear models, adjusted for duration of time on testosterone therapy, body mass index, steroid-related medication use, mean awakening time, and CAR, confirmed that elevated diurnal cortisol levels at awakening were associated with transition-specific social stressors including experiencing Transitioning-identity stress, frequent Coming Out stress, and Gender-specific Public Bathroom stress. Transitioning-identity stress and Gender-specific Public Bathroom stress also predicted a steeper negative slope at awakening. General Perceived Stress was not associated with elevated cortisol or slope. These results clarify the relation of increased cortisol at awakening with a negative linear slope to perceived stigma and transition-related stress experience among transgender men.

Dunbar, E. (2006). Race, gender, and sexual orientation in hate crime victimization: Identity politics or identity risk? Violence & Victims, 21(3), 323-337

This study examined the impact of hate crimes upon gay and lesbian victims, reviewing 1538 hate crimes committed in Los Angeles County. Differences between sexual orientation and other hate crime categories were considered for offense severity, reportage to law enforcement, and victim impact. The type of offense varied between crimes classified for sexual orientation (n=551) and other bias-motivated crimes (n=987). Assault, sexual assault, sexual harassment, and stalking were predictive of sexual orientation hate crimes. Sexual orientation bias crimes evidenced greater severity of violence to the person and impact upon victim level of functioning. More violent forms of aggression were predictive of gay and lesbian victim’s underreportage to law enforcement. For sexual orientation offenses, victim gender and race/ethnicity differences were predictive of the base rates of crime reportage as well. These findings are considered in terms of a group-risk hypothesis, encountered by multiple outgroup persons, that influences help-seeking behavior and ingroup identity.

Duncan, D.T., & Hatzenbuehler, M.L. (2014). Lesbian, gay, bisexual, and transgender hate crimes and suicidality among a population-based sample of sexual-minority adolescents in Boston. American Journal of Public Health, 104(2), 272-278.

OBJECTIVES: We examined whether past-year suicidality among sexual-minority adolescents was more common in neighborhoods with a higher prevalence of hate crimes targeting lesbian, gay, bisexual, and transgender (LGBT) individuals. METHODS: Participants’ data came from a racially/ethnically diverse population-based sample of 9th- through 12th-grade public school students in Boston, Massachusetts (n = 1292). Of these, 108 (8.36%) reported a minority sexual orientation. We obtained data on LGBT hate crimes involving assaults or assaults with battery between 2005 and 2008 from the Boston Police Department and linked the data to the adolescent’s residential address. RESULTS: Sexual-minority youths residing in neighborhoods with higher rates of LGBT assault hate crimes were significantly more likely to report suicidal ideation (P = .013) and suicide attempts (P = .006), than were those residing in neighborhoods with lower LGBT assault hate crime rates. We observed no relationships between overall neighborhood-level violent and property crimes and suicidality among sexual-minority adolescents (P > .05), providing evidence for specificity of the results to LGBT assault hate crimes. CONCLUSIONS: Neighborhood context (i.e., LGBT hate crimes) may contribute to sexual-orientation disparities in adolescent suicidality, highlighting potential targets for community-level suicide-prevention programs.

Dworkin, E.R., Gilmore, A.K., Bedard-Gilligan, M., Lehavot, K., Guttmannova, K. & Kaysen D. (2018). Predicting PTSD severity from experiences of trauma and heterosexism in lesbian and bisexual women: A longitudinal study of cognitive mediators. Journal of Counseling Psychology, 65(3), 324-333.

Sexual minority women (SMW) are at high risk of trauma exposure and, subsequently, the development of posttraumatic stress disorder (PTSD). The authors extended a theoretical model explaining the higher risk of mental disorders in minority populations to the maintenance and exacerbation of PTSD symptoms among young adult SMW specifically. This study used observational longitudinal data from a sample of 348 trauma-exposed 18- to 25-year-old individuals assigned female sex at birth who identified as either bisexual (60.1%) or lesbian (39.9%) and met screening criteria for PTSD. Participants identified as White (82.8%), Hispanic/Latina (12.4%), American Indian/Alaska Native (13.5%), Black/African American (13.8%), and/or Asian/Asian American (4.9%). The authors investigated whether distal stressors (i.e., criterion A traumatic events, daily experiences of heterosexism) produced proximal stressors (i.e., trauma-related cognitions, internalized heterosexism) that maintained or exacerbated PTSD symptoms. Findings indicated that daily heterosexism longitudinally predicted trauma-related cognitions (i.e., cognitions related to the self, world, and self-blame). Internalized heterosexism and cognitions about the self longitudinally predicted PTSD symptom severity. In addition, a significant indirect effect was identified between daily heterosexism and PTSD symptoms via self-related posttraumatic cognitions. These findings suggest that exposure to minority-specific distal stressors appears to promote nonminority-specific cognitive processes that, in turn, may maintain or exacerbate PTSD among young adult SMW exposed to trauma. Clinicians should consider addressing daily heterosexism in young adult SMW presenting with PTSD and evaluate how these experiences might promote clients’ global, negative views regarding themselves.

Public Significance Statement: This study suggests that trauma-exposed sexual minority women’s day-to-day experiences of discrimination may lead them to develop negative beliefs about themselves which, in turn, could maintain or worsen symptoms of posttraumatic stress disorder. These findings highlight potential areas for clinicians to explore with sexual minority women seeking treatment for posttraumatic stress disorder.

Dyar, C., & London, B. (2018). Longitudinal examination of a bisexual-specific minority stress process among bisexual cisgender women. Psychology of Women Quarterly, 42(3), 342-360.

Bisexual individuals experience increased risk of mental health disorders compared to lesbian, gay, and heterosexual populations. This increased risk is theorized to arise from the stigmatization of bisexuality (i.e., anti-bisexual stigma). Research has linked anti-bisexual experiences with higher internalized binegativity (i.e., internalized anti-bisexual stigma), sexual identity uncertainty, and anxiety and depression. However, researchers have almost exclusively used cross-sectional designs, limiting our ability to draw conclusions about processes through which anti-bisexual stigma affects mental health. In the current study, we longitudinally examined a proposed bisexual-specific minority stress process in a sample of predominately White (92.2%), self-identified bisexual, cisgender women. Results provide support for the proposed process, indicating that experiencing more frequent anti-bisexual stigma predicted subsequent increases in internalized binegativity and sexual identity uncertainty. In turn, these increases in internalized binegativity were associated with concurrent decreases in strength of identification as bisexual, increases in strength of identification with monosexual identity labels (i.e., heterosexual, lesbian), and changes in visibility management strategies. These changes in identification were associated with concurrent increases in symptoms of anxiety and depression, and changes in visibility management were associated with increases in anxiety. Clinicians should consider this process when treating bisexual clients who present with psychological distress arising from anti-bisexual stigma.

Espelage, D.L., Aragon, S.R., Birkett, M., & Koenig, B. (2008). Homophobic teasing, psychological outcomes, and sexual orientation among high school students: What influence do parents and schools have? School Psychology Review, 37(2), 202-216.

Homophobic teasing is often long-term, systematic, and perpetrated by groups of students (Rivers, 2001); it places targets at risk for greater suicidal ideation, depression, and isolation (Elliot & Kilpatrick, 1994). This study fills a gap in the literature by examining buffering influences of positive parental relations and positive school climate on mental health outcomes for high school students who are questioning their sexual orientation. Participants were 13,921 high school students from a Midwestern U.S. public school district. Students completed a survey consisting of a wide range of questions related to their school experiences (bullying, homophobia, school climate), parental support, mood, and drug-alcohol use. Students were categorized into three groups: (a) youth who identified as heterosexual, (b) youth who questioned their sexual orientation, and (c) youth who identified as lesbian, gay, or bisexual (LGB). As hypothesized, sexual minority youth were more likely to report high levels of depression-suicide feelings and alcohol-marijuana use; students who were questioning their sexual orientation reported more teasing, greater drug use, and more feelings of depression and suicide than either heterosexual or LGB students. Sexually questioning students who experienced homophobic teasing were also more likely than LGB students to use drugs-alcohol and rate their school climate as negative. Finally, positive school climate and parental support protected LGB and questioning students against depression and drug use.

Feinstein, B.A., Goldfried, M.R., & Davila, J. (2012). The relationship between experiences of discrimination and mental health among lesbians and gay men: An examination of internalized homonegativity and rejection sensitivity as potential mechanisms. Journal of Consulting and Clinical Psychology, 80(5), 917-927.

OBJECTIVE: The current study used path analysis to examine potential mechanisms through which experiences of discrimination influence depressive and social anxiety symptoms. METHOD: The sample included 218 lesbians and 249 gay men (total N = 467) who participated in an online survey about minority stress and mental health. The proposed model included 2 potential mediators-internalized homonegativity and rejection sensitivity-as well as a culturally relevant antecedent to experiences of discrimination-childhood gender nonconformity. RESULTS: Results indicated that the data fit the model well, supporting the mediating roles of internalized homonegativity and rejection sensitivity in the associations between experiences of discrimination and symptoms of depression and social anxiety. Results also supported the role of childhood gender nonconformity as an antecedent to experiences of discrimination. Although there were not significant gender differences in the overall model fit, some of the associations within the model were significantly stronger for gay men than lesbians. CONCLUSIONS: These findings suggest potential mechanisms through which experiences of discrimination influence well-being among sexual minorities, which has important implications for research and clinical practice with these populations.

Feinstein, B.A., Wadsworth, L.P., Davila, J., & Goldfried, M.R. (2014). Do parental acceptance and family support moderate associations between dimensions of minority stress and depressive symptoms among lesbians and gay men? Professional Psychology: Research and Practice, 45(4), 239-246.

This study examined the extent to which parental acceptance of one’s sexual orientation and more general family support moderated the associations between 3 dimensions of minority stress (internalized homonegativity, rejection sensitivity, and discrimination) and depressive symptoms in a sample of 414 self-identified lesbians and gay men who participated in an online survey. Results indicated that internalized homonegativity and rejection sensitivity were positively associated with depressive symptoms for those reporting less accepting parental attitudes, but they were not associated for those reporting more accepting parental attitudes. In contrast, parental acceptance did not moderate the association between discrimination and depressive symptoms, and general family support did not moderate any associations. Findings suggest that more accepting parental attitudes toward one’s sexual orientation may protect individuals from distress in the face of their own negative thoughts and feelings related to their sexual orientation, but not overt discrimination. Further, parents’ attitudes toward their child’s sexual orientation may be more important than the extent to which they provide more general support. Interventions for parents struggling with their child’s sexual orientation are encouraged to focus on the importance of parents expressing acceptance and support, which may directly impact well-being and act as a buffer in the face of minority stress.

Figueroa, W.S., & Zoccola, P.M. (2015). Individual differences of risk and resiliency in sexual minority health: The roles of stigma consciousness and psychological hardiness. Psychology of Sexual Orientation and Gender Diversity, 2(3), 329-338.

Individual differences that confer risk and resiliency should be considered when examining lesbian, gay, and bisexual (LGB) health. Stigma consciousness in LGB has been directly associated with poorer self-reported mental health and, to a much lesser extent, physical health. Psychological hardiness, a personality trait characterized by control, commitment, and challenge, has been shown to be directly associated with better health in non-LGB populations. The current study tested the direct effects of psychological hardiness and stigma consciousness on self-reported health in LGB. As exploratory aims, the interaction between stigma consciousness and hardiness and the interrelationship between stigma consciousness and perceived discrimination from family and friends was examined. A sample of 277 LGB adults completed a 1-time online questionnaire assessing stigma consciousness, perceived discrimination from family and friends, and self-reported health. Results from hierarchical regression analyses showed that stigma consciousness was directly associated with greater psychological distress, as well as poorer self-reported physical health. The relationship between greater stigma consciousness and more physical symptoms depended on the level of hardiness. Individuals with low hardiness and high stigma consciousness reported being bothered the most by physical symptoms. Furthermore, the associations between stigma consciousness and self-reported health were fully mediated by perceived discrimination from family and friends. The current study corroborates and extends past work on the association between stigma consciousness and self-reported mental health. Finally, the current study indicates that hardiness may be important to examine both directly and as a moderator in future minority stress-health research in LGB populations.

Figueroa, W.S., & Zoccola, P.M. (2016). Sources of discrimination and their associations with health in sexual minority adults. Journal of Homosexuality, 63(6), 743-763.

Health disparities exist between sexual minorities and heterosexuals. These health disparities may be due to stressful social situations and environments that are created by discrimination. The current study recruited 277 sexual minorities to complete an online survey to examine the effects of discrimination on health. Discrimination from family and friends, compared to non-family and friends, was found to be more strongly associated with poorer health. This effect was partially statistically mediated by perceived stress reactivity. Findings from this study highlight the importance of distinguishing between different sources of discrimination when examining the effect of discrimination on health in sexual minority adults.

Fish, J.N., Rice, C.E., Lanza, S.T., & Russell, S.T. (2018). Is young adulthood a critical period for suicidal behavior among sexual minorities? Results from a US national sample. Prevention Science, 20(3), 353-365.

The developmental timing of suicide-related disparities between heterosexuals and sexual minorities (i.e., lesbian/gay and bisexual (LGB) people) is an understudied area that has critical prevention implications. In addition to developmentally situated experiences that shape risk for suicidality in the general population, sexual minorities also experience unique social stressors (e.g., anti-LGB stigma) that may alter their risk for suicidal behavior at different ages. Using a nationally representative US sample of adults, we assessed age-varying rates of suicidal behavior among heterosexuals and sexual minorities ages 18 to 60 and the age-varying association between anti-LGB discrimination and suicidal behavior. We also tested whether these age-varying prevalences and associations differed for men and women and for sexual minorities who did and did not endorse a sexual minority identity. Results indicate a critical period for suicide behavior risk for sexual minorities during young adulthood, with the highest rates of risk at age 18 followed by a steady decline until the early 40s. Disparities were particularly robust for sexual minorities who identified as lesbian, gay, or bisexual. This pattern was present for both men and women, though sexual minority women in their 30s were more likely to report suicidal behavior than heterosexuals and sexual minority men. Sexual minorities who experienced anti-LGB discrimination were more likely to report suicidal behavior, but the significance of this association was limited to those under 30. The effect of discrimination on suicidal behavior was stronger among young adult sexual minority men, relative to sexual minority women, but was present for a wider age range for sexual minority women (until age 30) relative to sexual minority men (until age 25).

Flenar, D.J., Tucker, C.M., & Williams, J.L. (2017). Sexual minority stress, coping, and physical health indicators. Journal of Clinical Psychology in Medical Settings, 24(3-4), 223-233.

Sexual minorities experience higher rates of several physical health problems compared to their heterosexual counterparts. The present study uses Meyer’s Minority Stress Model (Psychological Bulletin, 129(5): 674-697, 2003) to examine physical health indicators among 250 adults who identified as sexual minorities. Study hypotheses include that sexual minority stress is predictive of two physical health indicators (i.e., engagement in a health-promoting lifestyle and number of physical health problems) and that planning (i.e., problem-focused) and social support coping will partially mediate the relationship between sexual minority stress and each physical health indicator. Results showed that as level of sexual minority stress increased, engagement in a health-promoting lifestyle decreased and the number of physical health problems increased. Planning and social support coping did not mediate these relationships; however, as levels of coping increased, engagement in a health-promoting lifestyle increased. These findings have implications for researchers and healthcare professionals in their efforts to promote the physical health of sexual minorities.

Fredriksen-Goldsen, K.I., Emlet, C.A., Kim, H.J., Muraco, A., Erosheva, E.A., Goldsen, J., et al. (2013). The physical and mental health of lesbian, gay male, and bisexual (LGB) older adults: the role of key health indicators and risk and protective factors. Gerontologist, 53(4), 664-675.

PURPOSE: Based on resilience theory, this paper investigates the influence of key health indicators and risk and protective factors on health outcomes (including general health, disability, and depression) among lesbian, gay male, and bisexual (LGB) older adults. DESIGN AND METHODS: A cross-sectional survey was conducted with LGB older adults, aged 50 and older (N = 2,439). Logistic regressions were conducted to examine the contributions of key health indicators (access to health care and health behaviors), risk factors (lifetime victimization, internalized stigma, and sexual identity concealment), and protective factors (social support and social network size) to health outcomes, when controlling for background characteristics. RESULTS: The findings revealed that lifetime victimization, financial barriers to health care, obesity, and limited physical activity independently and significantly accounted for poor general health, disability, and depression among LGB older adults. Internalized stigma was also a significant predictor of disability and depression. Social support and social network size served as protective factors, decreasing the odds of poor general health, disability, and depression. Some distinct differences by gender and sexual orientation were also observed. IMPLICATIONS: High levels of poor general health, disability, and depression among LGB older adults are of major concern. These findings highlight the important role of key risk and protective factors, which significantly influences health outcomes among LGB older adults. Tailored interventions must be developed to address the distinct health issues facing this historically disadvantaged population.

Fredriksen-Goldsen, K.I., Cook-Daniels, L., Kim, H.J., Erosheva, E.A., Emlet, C.A., Hoy-Ellis, C.P., et al. (2014). Physical and mental health of transgender older adults: an at-risk and underserved population. Gerontologist, 54(3), 488-500.

PURPOSE: This study is one of the first to examine the physical and mental health of transgender older adults and to identify modifiable factors that account for health risks in this underserved population. DESIGN AND METHODS: Utilizing data from a cross-sectional survey of lesbian, gay, bisexual, and transgender older adults aged 50 and older (N = 2,560), we assessed direct and indirect effects of gender identity on 4 health outcomes (physical health, disability, depressive symptomatology, and perceived stress) based on a resilience conceptual framework. RESULTS: Transgender older adults were at significantly higher risk of poor physical health, disability, depressive symptomatology, and perceived stress compared with nontransgender participants. We found significant indirect effects of gender identity on the health outcomes via fear of accessing health services, lack of physical activity, internalized stigma, victimization, and lack of social support; other mediators included obesity for physical health and disability, identity concealment for perceived stress, and community belonging for depressive symptomatology and perceived stress. Further analyses revealed that risk factors (victimization and stigma) explained the highest proportion of the total effect of gender identity on health outcomes. IMPLICATIONS: The study identifies important modifiable factors (stigma, victimization, health-related behaviors, and social support) associated with health among transgender older adults. Reducing stigma and victimization and including gender identity in nondiscrimination and hate crime statutes are important steps to reduce health risks. Attention to bolstering individual and community-level social support must be considered when developing tailored interventions to address transgender older adults’ distinct health and aging needs.

Fredriksen-Goldsen, K.I., Kim, H.J., Bryan, A.E., Shiu, C., & Emlet, C.A. (2017). The cascading effects of marginalization and pathways of resilience in attaining good health among LGBT older adults. Gerontologist, 57(suppl 1), S72-S83.

PURPOSE OF THE STUDY: Lesbian, gay, bisexual, and transgender (LGBT) older adults comprise a diverse and growing health disparate population. In the present study, using the Health Equity Promotion Model, we investigated pathways by which LGBT older adults experience resilience, risk, and marginalization and their relationship to attaining positive health outcomes. DESIGN AND METHODS: Aging with Pride: National Health, Aging, and Sexuality/Gender Study (NHAS) is the first longitudinal research project designed to examine the health, aging, and well-being of LGBT adults aged 50 and older. Using data from 2014 (N = 2,415), we tested a structural equation model linking lifetime marginalization, identity affirmation and management, social and psychological resources, and health behaviors to positive health outcomes. RESULTS: Identity affirmation positively predicted social resources and mental health, and social resources positively predicted mental health. Marginalization was associated with fewer social resources for LGBT older adults with an open identity management style, lower identity affirmation for LGBT older adults who strategically concealed their sexual identity, and poorer mental health. Mental health was associated with better health behaviors, which in turn predicted positive physical health outcomes. IMPLICATIONS: Although a health disparate population, good health among LGBT older adults appears to be attained via multiple resilience and risk pathways. Providers must remain aware of the historical contexts in which LGBT older adults lived and the strengths they developed in order to understand their health and to develop tailored and targeted prevention and intervention services.

Friedman, M.S., Koeske, G.F., Silvestre, A.J., Korr, W.S., & Sites, E.W. (2006). The impact of gender-role nonconforming behavior, bullying, and social support on suicidality among gay male youth. Journal of Adolescent Health, 38(5), 621-623.

This study hypothesized that gender-role nonconformity is associated with suicidality, and bullying mediates this relationship. Gay males retrospectively answered questions pertaining to elementary, middle, and high school. Support for the hypotheses was found. Results can help screen gay youth for suicidality and support the need for policies prohibiting harassment based on sexual orientation.

Frost, D.M., & Fingerhut, A.W. (2016). Daily exposure to negative campaign messages decreases same-sex couples’ psychological and relational well-being. Group Processes & Intergroup Relations, 19(4), 477-492.

Throughout history, the rights of stigmatized minority group members have been subject to popular debate and voter referenda. The impact of the resulting devaluing social discourse on the well-being of minority group members remains unknown. For example, exposure to the discourse leading up to decisions on same-sex marriage may have negative consequences for sexual minority individuals and same-sex couples. We examined the impact of exposure to same-sex marriage campaign messages (e.g., commercials, billboards, yard signs) on the psychological and relational well-being of couples living in the four states that had same-sex marriage voter initiatives in the 2012 general election. Sixty-two same-sex couples (N = 124) completed a baseline survey and 10 daily diary reports during the month before the election. Daily exposure to negative campaign messages was associated with increased negative affect and decreased positive affect and relationship satisfaction. These associations persisted controlling for baseline levels of depression and daily fluctuations in general stress among both members of the couple. Exposure to a devaluing social discourse regarding the rights of same-sex couples represents a unique form of social stress resulting in negative consequences for the psychological and relational well-being of same-sex couples. Thus, the health of same-sex couples may be of particular concern in contexts where marriage policy decisions are pending and the subject of popular debate.

Gamarel, K.E., Mereish, E.H., Manning, D., Iwamoto, M., Operario, D., & Nemoto, T. (2016). Minority stress, smoking patterns, and cessation attempts: Findings from a community-sample of transgender women in the San Francisco Bay Area. Nicotine & Tobacco Research, 18(3), 306-313.

INTRODUCTION: Research has demonstrated associations between reports of minority stressors and smoking behaviors among lesbian, gay, and bisexual populations; however, little is known about how minority stressors are related to smoking behaviors and cessation attempts among transgender women. The purpose of this study was twofold: (1) to examine the associations between transgender-based discrimination and smoking patterns among a sample of transgender women; and (2) to identify barriers to smoking cessation in a sample of transgender women with a history of smoking. METHODS: A community sample of 241 transgender women completed a one-time survey. Binary and multinomial logistic regression models examined associations between minority stressors and (1) smoking behaviors and (2) cessation attempts. Both models adjusted for income, education, race/ethnicity, recent sex work, HIV status, depression, alcohol use, and current hormone use. RESULTS: Overall, 83% of participants indicated that they had smoked a cigarette in the last month. Of these women, 62.3% reported daily smoking and 51.7% reported an unsuccessful quit attempt. Discrimination was positively associated with currently smoking (adjusted odds ratio [AOR] = 1.04, 95% confidence interval [CI]: 1.01, 1.08). Discrimination was positively associated with unsuccessful cessation (AOR = 1.03, 95% CI: 1.01, 1.18) and never attempting (AOR = 1.04, 95% CI: 1.01, 1.11) compared to successful cessation. Discrimination was also positively associated with never attempting compared to unsuccessful cessation (AOR = 1.01, 95% CI: 1.00, 1.03). CONCLUSIONS: Smoking cessation may be driven by unique transgender-related minority stressors, such as discrimination. Future research is warranted to address unique stigmatizing contexts when understanding and providing tailored intervention addressing smoking among transgender women.

Garnett, B.R., Masyn, K.E., Austin, S.B., Miller, M., Williams, D.R., & Viswanath, K. (2014). The intersectionality of discrimination attributes and bullying among youth: An applied latent class analysis. Journal of Youth and Adolescence, 43(8), 1225-1239.

Discrimination is commonly experienced among adolescents. However, little is known about the intersection of multiple attributes of discrimination and bullying. We used a latent class analysis (LCA) to illustrate the intersections of discrimination attributes and bullying, and to assess the associations of LCA membership to depressive symptoms, deliberate self harm and suicidal ideation among a sample of ethnically diverse adolescents. The data come from the 2006 Boston Youth Survey where students were asked whether they had experienced discrimination based on four attributes: race/ethnicity, immigration status, perceived sexual orientation and weight. They were also asked whether they had been bullied or assaulted for these attributes. A total of 965 (78%) students contributed to the LCA analytic sample (45% Non-Hispanic Black, 29% Hispanic, 58% Female). The LCA revealed that a 4-class solution had adequate relative and absolute fit. The 4-classes were characterized as: low discrimination (51%); racial discrimination (33%); sexual orientation discrimination (7%); racial and weight discrimination with high bullying (intersectional class) (7%). In multivariate models, compared to the low discrimination class, individuals in the sexual orientation discrimination class and the intersectional class had higher odds of engaging in deliberate self-harm. Students in the intersectional class also had higher odds of suicidal ideation. All three discrimination latent classes had significantly higher depressive symptoms compared to the low discrimination class. Multiple attributes of discrimination and bullying co-occur among adolescents. Research should consider the co-occurrence of bullying and discrimination.

Gibbs, J.J., & Rice, E. (2016). The social context of depression symptomology in sexual minority male youth: Determinants of depression in a sample of Grindr users. Journal of Homosexuality, 63(2), 278-299.

The purpose of this study was to understand which social context factors most influence depression symptomology among sexual minority male youth (SMMY). In 2011, 195 SMMY who use Grindr were recruited to complete an online survey in Los Angeles, California. Items focused on social context variables and depression symptomology. Hierarchical multiple regressions were conducted using an ecological framework. The best fitting model accounted for 29.5% of the variance in depression. Experiences of homophobia, gay community connection, presence of an objecting network member, and emotional support were found to be significant predictors. Past experiences of homophobia continuing to affect youth indicates the need for intervention to reduction of homophobia in youths’ social contexts. Interventions that teach youth skills to manage objecting viewpoints or help youth to reorganize their social networks may help to reduce the impact of an objecting network alter.

Goldbach, J.T., Schrager, S.M., Dunlap, S.L., & Holloway, I.W. (2015). The application of minority stress theory to marijuana use among sexual minority adolescents. Substance Use & Misuse, 50(3), 366-375.

Previous research indicates that lesbian, gay, and bisexual (LGB) adolescents are at increased risk for substance use, including heightened rates of marijuana use. Minority stress theory suggests that difficult social situations create a state of chronic stress that leads to poor health outcomes for LGB adults; however, the applicability of this model has not been well explored in relation to substance use among LGB adolescents. The current study is a secondary analysis of the OutProud survey, conducted in 2000. The original study used purposive sampling to collect data from 1,911 LGB adolescents (age 12-17) across the United States, and represents the largest known study to explore experiences specific to identifying as LGB, such as homophobia and gay-related victimization. We used structural equation modeling (SEM) to explore the feasibility of applying a minority stress framework to understand marijuana use in this population. The final structural model for marijuana use in the LGB adolescent sample displayed excellent fit and modest explanatory power for marijuana use. Two of the five factors, community connectedness and internalized homophobia, were significantly (p < .05) associated with marijuana use. Findings suggest that minority stress theory may be appropriately applied to marijuana use in this population; however, better measurement of minority stress concepts for LGB adolescents is needed.

Goldblum, P., Testa, R.J., Pflum, S., Hendricks, M.L., Bradford, J., & Bongar, B. (2012). The relationship between gender-based victimization and suicide attempts in transgender people. Professional Psychology: Research and Practice, 43(5), 468-475.

This article presents empirical research findings from a subsample of 290 transgender participants in the Virginia Transgender Health Initiative Survey (THIS) who reported whether or not they had experienced hostility or insensitivity related to their gender identity or expression during high school, termed in-school gender-based victimization (GBV). The purpose of this study was to assess the impact of in-school GBV on rates of suicide attempts among transgender people. Of the 290 respondents, 44.8% reported they had experienced in-school GBV, and 28.5% reported a history of suicide attempt. Among those who had attempted, 32.5% reported having made one attempt, 28.6% reported a history of two attempts, and 39.0% reported having made three or more attempts. Participants who reported experiencing GBV were approximately four times more likely to have attempted suicide than those who did not. Among the subgroups of 147 trans women and 81 trans men, GBV was associated both with history of suicide attempt, and with a higher number of suicide attempts over the life span. Implications for policy and clinical interventions are discussed.

Gonzales, G., & Ehrenfeld, J.M. (2018). The association between state policy environments and self-rated health disparities for sexual minorities in the United States. International Journal of Environmental Research and Public Health, 15(6), 1136.

A large body of research has documented disparities in health and access to care for lesbian, gay, and bisexual (LGB) people in the United States. Less research has examined how the level of legal protection afforded to LGB people (the state policy environment) affects health disparities for sexual minorities. This study used data on 14,687 sexual minority adults and 490,071 heterosexual adults from the 2014-2016 Behavioral Risk Factor Surveillance System to document differences in health. Unadjusted state-specific prevalence estimates and multivariable logistic regression models were used to compare poor/fair self-rated health by gender, sexual minority status, and state policy environments (comprehensive versus limited protections for LGB people). We found disparities in self-rated health between sexual minority adults and heterosexual adults in most states. On average, sexual minority men in states with limited protections and sexual minority women in states with either comprehensive or limited protections were more likely to report poor/fair self-rated health compared to their heterosexual counterparts. This study adds new findings on the association between state policy environments and self-rated health for sexual minorities and suggests differences in this relationship by gender. The associations and impacts of state-specific policies affecting LGB populations may vary by gender, as well as other intersectional identities.

Griffin, J.A., Drescher, C.F., Eldridge, E.D., Rossi, A.L., Loew, M.M., & Stepleman, L.M. (2018). Predictors of anxiety among sexual minority individuals in the Southern US. American Journal of Orthopsychiatry, 88(6), 723-731.

Sexual minority individuals experience a disproportionate burden of mental health issues, particularly in less populous cities of the southern United States. Unique identity-related stressors may explain these disparities. The current study examines relationships between sexual minority stress, identity, and anxiety in sexual minority individuals from a small metropolitan area of the South. Sexual minority individuals (N = 249) from the Central Savannah River Area completed a survey assessing minority stress (i.e., identity-based discrimination, internalized homophobia), identity (i.e., outness comfort, community connectedness) and history of anxiety as part of a larger lesbian, gay, bisexual, transsexual, queer community health needs assessment. All minority stress variables were significantly, positively associated with an anxiety history whereas community connectedness was significantly, negatively associated with anxiety history at the bivariate level. A multiple logistic regression model revealed that assault history was significantly associated with increased odds of anxiety history, whereas community connectedness was associated with decreased odds of anxiety history. These results demonstrate an influence of discriminatory experiences on anxiety in sexual minority individuals of the South and the protective value of community connectedness. Providers and advocates should work at the individual, community, and systemic levels to eliminate lesbian, gay, bisexual discrimination and facilitate community involvement, thereby reducing mental health disparities.

Hamblin, R., & Gross, A.M. (2013). Role of religious attendance and identity conflict in psychological well-being. Journal of Religion & Health, 52(3), 817-827.

A sample of individuals who identified as gay or lesbian were administered measures of church attendance, their religious organization’s view of homosexuality, perceived conflict between religious faith identity and sexual orientation identity, social support, depression, and generalized anxiety. Among participants who rated their church as rejecting of homosexuality, greater frequency of attendance was related to a higher incidence of GAD symptoms, but not depression. No correlation was found for those attending accepting faith communities. Those who attend rejecting faith communities attended services less often, experienced greater identity conflict, and reported significantly less social support than those of the Accepted group. Regression analyses indicated that identity conflict and social support did not fully account for the relationship between attendance and GAD symptoms. Overall, findings from the current study support previous suggestions that participation in conservative or rejecting religious communities may adversely affect the emotional well-being of GL individuals.

Hatchel, T., Valido, A., De Pedro, K.T., Huang, Y., & Espelage, D.L. (2018). Minority stress among transgender adolescents: The role of peer victimization, school belonging, and ethnicity. Journal of Child and Family Studies, 28(9), 2467–2476.

Transgender youth peer relations is understudied when compared to lesbian, gay, and bisexual youth (LGB). Likewise, transgender youth of color (YOC) are also understudied given the difficulties associated with accessing the sample. This study examines the relations among peer victimization, school belonging, and mental health with an ethnically diverse sample of transgender adolescents (N = 4778). Invariance testing and structural equation modeling were employed to explore these relations as well as the potential moderating role of ethnic minority status. Findings demonstrate that an alarming number of transgender youth were exposed to victimization and that victimization predicted mental health issues like suicidal ideation. Furthermore, analyses showed that peer victimization was associated with diminished school belonging. School belonging was associated with better mental health and appeared to mediate the relation between victimization and mental health issues. Ethnic minority status did not moderate these associations. Implications for research are discussed.

Hatzenbuehler, M.L., Keyes, K.M., & Hasin, D.S. (2009). State-level policies and psychiatric morbidity in lesbian, gay, and bisexual populations. American Journal of Public Health, 99(12), 2275-2281.

OBJECTIVES: We investigated the modifying effect of state-level policies on the association between lesbian, gay, or bisexual status and the prevalence of psychiatric disorders. METHODS: Data were from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative study of noninstitutionalized US adults (N=34,653). States were coded for policies extending protections against hate crimes and employment discrimination based on sexual orientation. RESULTS: Compared with living in states with policies extending protections, living in states without these policies predicted a significantly stronger association between lesbian, gay, or bisexual status and psychiatric disorders in the past 12 months, including generalized anxiety disorder (F=3.87; df=2; P=.02), post-traumatic stress disorder (F=3.42; df=2; P=.04), and dysthymia (F=5.20; df=2; P=.02). Living in states with policies that did not extend protections also predicted a stronger relation between lesbian, gay, or bisexual status and psychiatric comorbidity (F=2.47; df=2; P=.04). CONCLUSIONS: State-level protective policies modify the effect of lesbian, gay, or bisexual status on psychiatric disorders. Policies that reduce discrimination against gays and lesbians are urgently needed to protect the health and well-being of this population.

Hatzenbuehler, M.L., Nolen-Hoeksema, S., & Dovidio, J. (2009). How does stigma “get under the skin”?: The mediating role of emotion regulation. Psychological Science, 20(10), 1282-1289.

Stigma is a risk factor for mental health problems, but few studies have considered how stigma leads to psychological distress. The present research examined whether specific emotion-regulation strategies account for the stigma-distress association. In an experience-sampling study, rumination and suppression occurred more on days when stigma-related stressors were reported than on days when these stressors were not reported, and rumination mediated the relationship between stigma-related stress and psychological distress. The effect of social support on distress was moderated by the concealability of the stigma: Lesbian, gay, and bisexual (LGB) respondents reported more isolation and less social support than African American respondents subsequent to experiencing stigma-related stressors, whereas African Americans reported greater social support than LGB participants. Social isolation mediated the stigma-distress association among LGB respondents. In a second experimental study, participants who ruminated following the recall of an autobiographical discrimination event exhibited prolonged distress on both implicit and explicit measures relative to participants who distracted themselves; this finding provides support for a causal role of rumination in the stigma-distress relationship.

Hatzenbuehler, M.L., McLaughlin, K.A., Keyes, K.M., & Hasin, D.S. (2010). The impact of institutional discrimination on psychiatric disorders in lesbian, gay, and bisexual populations: A prospective study. American Journal of Public Health, 100(3), 452-459.

OBJECTIVES: We examined the relation between living in states that instituted bans on same-sex marriage during the 2004 and 2005 elections and the prevalence of psychiatric morbidity among lesbian, gay, and bisexual (LGB) populations. METHODS: We used data from wave 1 (2001-2002) and wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (N = 34,653), a longitudinal, nationally representative study of noninstitutionalized US adults. RESULTS: Psychiatric disorders defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, increased significantly between waves 1 and 2 among LGB respondents living in states that banned gay marriage for the following outcomes: any mood disorder (36.6% increase), generalized anxiety disorder (248.2% increase), any alcohol use disorder (41.9% increase), and psychiatric comorbidity (36.3% increase). These psychiatric disorders did not increase significantly among LGB respondents living in states without constitutional amendments. Additionally, we found no evidence for increases of the same magnitude among heterosexuals living in states with constitutional amendments. CONCLUSIONS: Living in states with discriminatory policies may have pernicious consequences for the mental health of LGB populations. These findings lend scientific support to recent efforts to overturn these policies.

Hatzenbuehler, M.L. (2011). The social environment and suicide attempts in lesbian, gay, and bisexual youth. Pediatrics, 127(5), 896-903.

OBJECTIVE: To determine whether the social environment surrounding lesbian, gay, and bisexual youth may contribute to their higher rates of suicide attempts, controlling for individual-level risk factors. METHODS: A total of 31 852 11th grade students (1413 [4.4%] lesbian, gay, and bisexual individuals) in Oregon completed the Oregon Healthy Teens survey in 2006-2008. We created a composite index of the social environment in 34 counties, including (1) the proportion of same-sex couples, (2) the proportion of registered Democrats, (3) the presence of gay-straight alliances in schools, and (4) school policies (nondiscrimination and antibullying) that specifically protected lesbian, gay, and bisexual students. RESULTS: Lesbian, gay, and bisexual youth were significantly more likely to attempt suicide in the previous 12 months, compared with heterosexuals (21.5% vs 4.2%). Among lesbian, gay, and bisexual youth, the risk of attempting suicide was 20% greater in unsupportive environments compared to supportive environments. A more supportive social environment was significantly associated with fewer suicide attempts, controlling for sociodemographic variables and multiple risk factors for suicide attempts, including depressive symptoms, binge drinking, peer victimization, and physical abuse by an adult (odds ratio: 0.97 [95% confidence interval: 0.96-0.99]). CONCLUSIONS: This study documents an association between an objective measure of the social environment and suicide attempts among lesbian, gay, and bisexual youth. The social environment appears to confer risk for suicide attempts over and above individual-level risk factors. These results have important implications for the development of policies and interventions to reduce sexual orientation-related disparities in suicide attempts.

Hatzenbuehler, M.L., Jun, H.J., Corliss, H.L., & Austin, S.B. (2014). Structural stigma and cigarette smoking in a prospective cohort study of sexual minority and heterosexual youth. Annals of Behavioral Medicine, 47(1), 48-56.

BACKGROUND: Sexual minority youth are more likely to smoke cigarettes than heterosexuals, but research into the determinants of these disparities is lacking. PURPOSE: This study aimed to examine whether exposure to structural stigma predicts cigarette smoking in sexual minority youth. METHODS: Prospective data from adolescents participating in the Growing Up Today Study (2000-2005) were utilized. RESULTS: Among sexual minority youth, living in low structural stigma states (e.g., states with non-discrimination policies inclusive of sexual orientation) was associated with a lower risk of cigarette smoking after adjustment for individual-level risk factors (relative risk [RR] = 0.97; 95 % confidence interval [CI], 0.96, 0.99; p = 0.02). This association was marginally significant after additional controls for potential state-level confounders (RR = 0.97; 95 % CI, 0.93, 1.00; p = 0.06). In contrast, among heterosexual youth, structural stigma was not associated with past-year smoking rates, documenting specificity of these effects to sexual minority youth. CONCLUSIONS: Structural stigma represents a potential risk factor for cigarette smoking among sexual minority adolescents.

Hatzenbuehler, M.L., & McLaughlin, K.A. (2014). Structural stigma and hypothalamic-pituitary-adrenocortical axis reactivity in lesbian, gay, and bisexual young adults. Annals of Behavioral Medicine, 47(1), 39-47.

BACKGROUND: Youth exposed to extreme adverse life conditions have blunted cortisol responses to stress. PURPOSE: This study aims to examine whether growing up in highly stigmatizing environments similarly shapes stigmatized individuals’ physiological responses to identity-related stress. METHODS: We recruited 74 lesbian, gay, and bisexual young adults (mean age = 23.68) from 24 states with varying levels of structural stigma surrounding homosexuality. State-level structural stigma was coded based on several dimensions, including policies that exclude sexual minorities from social institutions (e.g., same-sex marriage). Participants were exposed to a laboratory stressor, the Trier Social Stress Test (TSST), and neuroendocrine measures were collected. RESULTS: Lesbian, gay, and bisexual young adults who were raised in highly stigmatizing environments as adolescents evidenced a blunted cortisol response following the TSST compared to those from low-stigma environments. CONCLUSIONS: The stress of growing up in environments that target gays and lesbians for social exclusion may exert biological effects that are similar to traumatic life experiences.

Hatzenbuehler, M.L., Jun, H.J., Corliss, H.L., & Bryn Austin, S. (2015). Structural stigma and sexual orientation disparities in adolescent drug use. Addictive Behaviors, 46, 14-18.

Although epidemiologic studies have established the existence of large sexual orientation disparities in illicit drug use among adolescents and young adults, the determinants of these disparities remain understudied. This study sought to determine whether sexual orientation disparities in illicit drug use are potentiated in states that are characterized by high levels of stigma surrounding sexual minorities. State-level structural stigma was coded using a previously established measure based on a 4-item composite index: (1) density of same-sex couples; (2) proportion of Gay-Straight Alliances per public high school; (3) 5 policies related to sexual orientation discrimination (e.g., same-sex marriage, employment non-discrimination); and (4) public opinion toward homosexuality (aggregated responses from 41 national polls). The index was linked to individual-level data from the Growing Up Today Study, a prospective community-based study of adolescents (2001-2010). Sexual minorities report greater illicit drug use than their heterosexual peers. However, for both men and women, there were statistically significant interactions between sexual orientation status and structural stigma, such that sexual orientation disparities in marijuana and illicit drug use were more pronounced in high-structural stigma states than in low-structural stigma states, controlling for individual- and state-level confounders. For instance, among men, the risk ratio indicating the association between sexual orientation and marijuana use was 24% greater in high- versus low-structural stigma states, and for women it was 28% greater in high- versus low-structural stigma states. Stigma in the form of social policies and attitudes may contribute to sexual orientation disparities in illicit drug use.

Hendy, H.M., Joseph, L.J., & Can, S.H. (2016). Repressed anger mediates associations between sexual minority stressors and negative psychological outcomes in gay men and lesbian women. Journal of Gay & Lesbian Mental Health, 20(3), 280-296.

Sexual minority individuals may be exposed to unique social stressors that include anticipation of harassment and concealment of their sexual identity, with increased risk for psychological problems as a result of such stressors. The present study identified coping behaviors of gay men and lesbian women that mediate these associations between sexual minority stressors and negative psychological outcomes. Participants included 128 gay men and 123 lesbian women who completed online surveys to report two social stressors (harassment, concealment), three psychological outcomes (health concerns, self-esteem, posttraumatic stress disorder [PTSD] symptoms), and seven possible coping behaviors (exercise, sleep, alcohol use, tobacco use, religiosity, expressed anger, repressed anger). For both gay men and lesbian women, repressed anger was the only coping behavior that mediated associations between sexual minority stressors (harassment and concealment for men, concealment for women) and negative psychological outcomes of health concerns, poor self-esteem, and PTSD. Results from the study suggest that responding to sexual minority stressors with repressed anger may be a ‘maladaptive’ coping behavior that increases the risk of poor psychological outcomes. Counselors could guide sexual minority individuals to develop more ’emotional openness’ while taking action to reduce the prevalence of sexual minority stressors.

Herek, G.M., Gillis, J.R., Cogan, J.C., & Glunt, E.K. (1997). Hate crime victimization among lesbian, gay, and bisexual adults: Prevalence, psychological correlates, and methodological issues. Journal of Interpersonal Violence, 12(2), 195-215.

Questionnaire data about victimization experiences were collected from 147 lesbians, gay men, and bisexuals (74 females, 73 males; aged 16-68 yrs) in the Sacramento, California area. In addition, 45 of the respondents participated in a follow-up interview. 41% reported experiencing a bias-related criminal victimization since age 16, with another 9.5% reporting an attempted bias crime against them. Nearly all of the perpetrators described by Ss were males, both for male and female victims. A plurality of perpetrators were White, with most of the remainder either Hispanic or Black. The distribution of bias-related victimization and harassment experiences in the sample resembled patterns reported in other US surveys with similar samples. Compared to other respondents, bias-crime survivors manifested higher levels of depression, anxiety, anger, and symptoms of posttraumatic stress. Methodological and substantive issues in empirical research on hate crimes against lesbians and gay men are discussed.

Herek, G.M., Gillis, J.R., & Cogan, J.C. (1999). Psychological sequelae of hate-crime victimization among lesbian, gay, and bisexual adults. Journal of Consulting and Clinical Psychology, 67(6), 945-951.

Questionnaire data about criminal victimization experiences were collected from 2,259 Sacramento-area lesbians, gay men, and bisexuals (N = 1,170 women, 1,089 men). Approximately 1/5 of the women and 1/4 of the men had experienced victimization because of their adult sexual orientation. Hate crimes were less likely than nonbias crimes to have been reported to police. Compared with other recent crime victims, lesbian and gay hate-crime survivors manifested significantly more symptoms of depression, anger, anxiety, and posttraumatic stress. They also displayed significantly more crime-related fears and beliefs, lower sense of mastery, and more attributions of their personal setbacks to sexual prejudice than did nonbias crime victims and nonvictims. Comparable differences were not observed among bisexuals. The findings highlight the importance of recognizing hate-crime survivors’ special needs in clinical settings and in public policy.

Hershberger, S.L., Pilkington, N.W., & D’Augelli, A.R. (1997). Predictors of suicide attempts among gay, lesbian, and bisexual youth. Journal of Adolescent Research, 12(4), 477-497.

Identified predictors of past suicide attempts in 194 lesbian, gay, and bisexual 15-21 yr olds who attended social and recreational groups in urban community settings. In comparison to youth who made no suicide attempts, attempters reported that they had disclosed more completely their sexual orientation to others, had lost more friends because of their disclosures, and had experienced more victimization due to their sexual orientation. Suicide attempters had lower self-esteem and acknowledged more mental health problems. The loss of friends due to youth’s sexual orientation, and current suicidal ideation were among the strongest predictors of suicide attempts. Youth who reported early awareness of their sexual orientation, disclosure to family and friends, peer rejection, and victimization based on their sexual orientation may be at risk for mental health problems.

House, A.S., Van Horn, E., Coppeans, C., & Stepleman, L.M. (2011). Interpersonal trauma and discriminatory events as predictors of suicidal and nonsuicidal self-injury in gay, lesbian, bisexual, and transgender persons. Traumatology, 17(2), 75-85.

Recent research suggests that gay, lesbian, bisexual, and transgender (GLBT) persons are at greater risk for mental health problems, including suicidal and nonsuicidal self-injury, than heterosexuals. However, few studies have investigated factors that may be linked to this increased risk. This study investigated interpersonal violence, victimization, and discriminatory events as possible predictors of suicidal and nonsuicidal self-injury in a sample of sexual minorities (i.e., a GLBT sample). Participants were 1,126 self-identified gay, lesbian, bisexual, and/or transgender (GLBT) individuals who responded to an Internet-based survey. Results indicated that both experiences of interpersonal trauma and sexual discrimination were associated with increased likelihoods of engaging in suicidal and nonsuicidal self-injury. In addition, participants at the greatest risk were those experiencing high levels of both interpersonal trauma and sexual discrimination. Clinical implications of these results are discussed.

Huebner, D.M., Rebchook, G.M., & Kegeles, S.M. (2004). Experiences of harassment, discrimination, and physical violence among young gay and bisexual men. American Journal of Public Health, 94(7), 1200-1203.

OBJECTIVES: We examined the 6-month cumulative incidence of anti-gay harassment, discrimination, and violence among young gay/bisexual men and documented their associations with mental health. METHODS: Gay/bisexual men from 3 cities in the southwestern United States completed self-administered questionnaires. RESULTS: Thirty-seven percent of men reported experiencing anti-gay verbal harassment in the previous 6 months; 11.2% reported discrimination, and 4.8% reported physical violence. Men were more likely to report these experiences if they were younger, were more open in disclosing their sexual orientation to others, and were HIV positive. Reports of mistreatment were associated with lower self-esteem and increased suicidal ideation. CONCLUSIONS: Absent policies preventing anti-gay mistreatment, empowerment and community-building programs are needed for young gay/bisexual men to both create safe social settings and help them cope with the psychological effects of these events.

Huebner, D.M., Nemeroff, C.J., & Davis, M. (2005). Do hostility and neuroticism confound associations between perceived discrimination and depressive symptoms? Journal of Social and Clinical Psychology, 24(5), 723-740.

A growing body of research links perceived discrimination to psychological distress, yet recent reviews of this literature suggest that the subjectivity inherent in reports of discrimination is an important methodological consideration. Specifically, personality characteristics may predispose individuals to psychological distress and also affect whether discrimination is perceived, thereby spuriously inflating associations between discrimination and mental health. The present study examined this possibility. Gay and bisexual men (N = 250) completed self-report measures of perceived discrimination, depressive symptoms, hostility, and neuroticism. Perceived discrimination was positively associated with depressive symptoms. Hostility and neuroticism were both significant confounders of this relation, together accounting for 42% of the observed association between discrimination and depression. Discrimination remained a significant predictor of depressive symptoms even after controlling for hostility and neuroticism.

Huebner, D.M., Thoma, B.C., & Neilands, T.B. (2015). School victimization and substance use among lesbian, gay, bisexual, and transgender adolescents. Prevention Science, 16(5), 734-743.

Lesbian, gay, bisexual, and transgender (LGBT) adolescents are at increased risk for substance use, relative to their heterosexual counterparts. Although previous research has demonstrated that experiences of anti-LGBT harassment, discrimination, and victimization may explain some of this disparity, little is known about the mechanisms whereby such mistreatment leads to substance abuse. This study aimed to examine whether mechanisms suggested by the Social Development Model might explain the links between school-based victimization and substance use in this population. Five hundred and four ethnically diverse LGBT adolescents ages 14-19 reported their experiences with school victimization, substance abuse, school bonding, and deviant peer group affiliation. Anti-LGBT victimization in school was associated with substance abuse, and although causality cannot be established, structural equation modeling confirmed that the data are consistent with a theoretical model in which this association was mediated by increased affiliation with deviant peers. Preventive interventions for LGBT adolescents must not only attempt to make schools safer for these youth, but also help keep them engaged in healthy peer groups when they are confronted with mistreatment in school.

Irwin, J.A., & Austin, E.L. (2013). Suicide ideation and suicide attempts among White Southern lesbians. Journal of Gay & Lesbian Mental Health, 17(1), 4-20.

Several studies find suicide behaviors to be more prevalent among lesbian, gay, and bisexual (LGB) populations than their heterosexual counterparts. Studies of non-LGB populations reveal 13% prevalence of lifetime ideation and 4% prevalence of lifetime attempts. This study analyzed data from the Lesbian Social Life (LSL) study, a primarily online, survey-based research project focusing on lesbians living in the southern United States, and found that more than 40% of participants had seriously considered suicide and more than 15% had attempted suicide. We estimated the likelihood of suicide ideation and attempts by utilizing known general risk factors and lesbian-specific indicators within hierarchical logistic regression. Predictors of suicide ideation and attempts included depressive symptoms, discrimination, social support, self-esteem, and stigma. Results highlight the magnitude of suicide behaviors in southern lesbians and important predictor variables. Analysis shows support for the minority stress theory, and policy and clinical recommendations are provided.

Irwin, J.A., Coleman, J.D., Fisher, C.M., & Marasco, V.M. (2014). Correlates of suicide ideation among LGBT Nebraskans. Journal of Homosexuality, 61(8), 1172-1191.

The aim of this investigation is to outline correlates of suicide ideation among LGBT individuals living in Nebraska. A community-based participatory research approach was utilized to develop a 30-minute, online anonymous survey. Almost half of the sample had seriously considered suicide at some point in their lives. Significant correlates of increased likelihood of suicide ideation are age, gender, transgender identity, income, depression, and discrimination. Suicide ideation is a serious concern for the health of LGBT Nebraskans. Steps should be taken to incorporate individuals who fall into these high-risk categories in suicide outreach programs.

Jackman, K.B., Dolezal, C., & Bockting, W.O. (2018). Generational differences in internalized transnegativity and psychological distress among feminine spectrum transgender people. LGBT Health, 5(1), 54-60.

PURPOSE: This study examined internalized transnegativity and psychological distress in two age groups of transgender individuals who identified their gender identity on the feminine spectrum (rather than congruent with their male sex assigned at birth). Due to greater visibility and acceptance of gender diversity in the United States, we hypothesized that internalized transnegativity would be lower in the younger compared with the older group, and that the younger generation would, therefore, report lower levels of psychological distress than the older generation. METHODS: The study sample consisted of trans-feminine individuals (N = 440) who completed a online survey of the U.S. transgender population and comprised a younger group aged 18-24 years (n = 133) and an older group aged 40 years and older (n = 307). Internalized transnegativity was assessed using the Transgender Identity Survey, and psychological distress was assessed with the Brief Symptom Inventory 18. We used regression and mediation analysis to examine differences between the two groups. RESULTS: Contrary to our expectations, the older group reported significantly lower levels of both internalized transnegativity and psychological distress compared with the younger group. Internalized transnegativity partially mediated the relationship between age group and psychological distress. CONCLUSION: Despite greater visibility of transgender people and increasing acceptance of gender diversity in the United States, the younger trans-feminine individuals reported more psychological distress than the older transfeminine individuals, which was, in part, related to internalized transnegativity. Trans-feminine individuals may benefit from culturally sensitive and clinically competent mental health services to alleviate internalized transnegativity and psychological distress.

Jefferson, K., Neilands, T.B., & Sevelius, J. (2013). Transgender women of color: discrimination and depression symptoms. Ethnicity and Inequalities in Health and Social Care, 6(4), 121-136.

PURPOSE: Trans women of color contend with multiple marginalizations; the purpose of this study is to examine associations between experiencing discriminatory (racist/transphobic) events and depression symptoms. It uses a categorical measure of combined discrimination, and examines a protective association of transgender identity on depression symptoms. DESIGN/METHODOLOGY/APPROACH: Data from a subset of trans women of color participants in the Sheroes study were analyzed with linear and logistic regression. Associations of depression symptoms with racist and transphobic events, combined discrimination, coping self-efficacy, and transgender identity were assessed with odds ratios. FINDINGS: Exposure to discriminatory events and combined discrimination positively associated with depression symptom odds. Increased transgender identity associated with increased coping self-efficacy, which negatively associated with depression symptom odds. RESEARCH LIMITATIONS/IMPLICATIONS: Cross-sectional study data prohibits inferring causality; results support conducting longitudinal research on discrimination’s health effects, and research on transgender identity. Results also support operationalizing intersectionality in health research. The study’s categorical approach to combined discrimination may be replicable in studies with hard to reach populations and small sample sizes. PRACTICAL IMPLICATIONS: Health programs could pursue psychosocial interventions and anti-discrimination campaigns. Interventions might advocate increasing participants’ coping self-efficacy while providing space to explore and develop social identity. SOCIAL IMPLICATIONS: There is a need for policy and health programs to center trans women of color concerns. ORIGINALITY/VALUE: This study examines combined discrimination and identity in relation to depression symptoms among trans women of color, an underserved population.

Johns, M.M., Pingel, E.S., Youatt, E.J., Soler, J.H., McClelland, S.I., & Bauermeister, J.A. (2013). LGBT community, social network characteristics, and smoking behaviors in young sexual minority women. American Journal of Community Psychology, 52(1-2), 141-154.

Smoking rates among young sexual minority women (YSMW) are disproportionately high as compared to heterosexual populations. While this disparity has commonly been attributed to the sexual minority stress process, little empirical work has explored what may protect YSMW from high rates of smoking. Using data (N = 471) from a cross-sectional study designed to investigate YSMW’s (age 18-24) smoking behaviors and correlates; we explore the relationship of LGBT community connections, YSMW’s social network characteristics, and stress to smoking behaviors (i.e., status, frequency, amount). Through this analysis, we find support for LGBT community connection as well as friendships with other sexual minorities as protective in relation to YSMW’s smoking behaviors. We discuss the implications of our results, highlighting the need for future longitudinal research and interventions designed to bolster YSMW’s connections to the LGBT community and their social networks.

Kamen, C., Jabson, J.M., Mustian, K.M., & Boehmer, U. (2017). Minority stress, psychosocial resources, and psychological distress among sexual minority breast cancer survivors. Health Psychology, 36(6), 529-537.

OBJECTIVE: Few studies have examined unique factors predicting psychological distress among sexual minority (i.e., lesbian and bisexual) women postbreast cancer diagnosis. The present study assessed the association of minority stress and psychosocial resource factors with depression and anxiety symptoms among sexual minority breast cancer survivors. METHOD: Two hundred one sexual minority women who had ductal carcinoma in situ or Stage I-IV breast cancer participated in this study through the Love/Avon Army of Women. Self-report questionnaires were used to assess demographic and clinical factors, minority stress factors (discrimination, minority identity development, outness), psychosocial resources (resilience, social support), and psychological distress (anxiety and depression). These factors were included in a structural equation model, testing psychosocial resources as mediators between minority stress and psychological distress. RESULTS: There were no significant differences noted between lesbian and bisexual women. The final structural equation model demonstrated acceptable fit across all sexual minority women, chi2 = 27.83, p > .05; confirmatory fit index = 0.97, root-mean-square error of approximation = 0.04, Tucker-Lewis index = 0.93. The model accounted for significant variance in psychological distress (56%). Examination of indirect effects confirmed that exposure to discrimination was associated with distress via association with resilience. CONCLUSIONS: Factors unique to sexual minority populations, such as minority stress, may be associated with higher rates of psychological distress among sexual minority breast cancer survivors. However, presence of psychosocial resources may mediate relationships with distress in this population; enhancement of resilience, in particular, could be an aim of psychological intervention.

Katz-Wise, S.L., Mereish, E.H., & Woulfe, J. (2017). Associations of bisexual-specific minority stress and health among cisgender and transgender adults with bisexual orientation. Journal of Sex Research, 54(7), 899-910.

Among sexual minorities, bisexuals are at the greatest risk for poor health due in part to prejudice and stigma. This research examined associations of bisexual-specific minority stress and health among cisgender (non-transgender) and transgender adults with bisexual orientation. Participants were 488 adults (378 cisgender women, 49 cisgender men, 61 transgender individuals), age 18 to 66 years, with bisexual orientation based on identity and/or attractions to multiple genders. Participants completed an online survey. Hierarchical linear regression analyses were conducted with sexual minority stress and bisexual-specific minority stress as the predictors and physical health, measured by the 36-Item Short Form Survey (SF-36), as the outcome. Models controlled for demographic variables. Moderation analyses were conducted to test for gender differences. Greater bisexual-specific minority stress significantly predicted poorer overall physical health (beta = -0.16), greater pain (beta = -0.16), and poorer general health (beta = -0.25) above and beyond the effects of sexual minority stress. Gender moderated the association between bisexual-specific minority stress and health, such that bisexual-specific minority stress predicted overall physical health and role limitations for transgender individuals but not for cisgender women. Addressing bisexual-specific minority stress is necessary to improve the health and well-being of bisexual individuals.

Kecojevic, A., Wong, C.F., Corliss, H.L., & Lankenau, S.E. (2015). Risk factors for high levels of prescription drug misuse and illicit drug use among substance-using young men who have sex with men (YMSM). Drug and Alcohol Dependence, 150, 156-163.

BACKGROUND: Limited research has focused on prescription drug misuse among young men who have sex with men (YMSM), or investigated risk factors contributing to misuse. This study aims to investigate the relationship between multiple psychosocial risk factors (i.e., childhood abuse, discrimination, mental health distress) and prescription drug misuse among YMSM who are current substance users. METHODS: YMSM (N=191) who reported prescription drug misuse in the past 6 months were recruited in Philadelphia between 2012 and 2013 to complete an anonymous survey assessing demographic information, substance use, and psychosocial factors. RESULTS: High levels of childhood physical abuse and perceived stress were associated with higher opioid misuse, while high levels of depression were associated with lower misuse of opioids. Those with higher levels of perceived stress were more likely to report higher tranquilizer misuse, while those with more experiences of social homophobia/racism and higher levels of depression and somatization reported higher stimulant misuse. Regarding demographic correlates, older participants were more likely than younger participants to report higher opioid misuse, while racial minorities were less likely than White participants to report higher misuse of tranquilizers, stimulants, and illicit drug use. Bisexual/heterosexual/other identified participants were more likely than gay identified participants to report higher misuse of all three classes of prescription drugs. CONCLUSIONS: Associations of risk factors with substance use among YMSM are complex and offer opportunities for additional research. Our findings show that prevention efforts must address substance use among YMSM in sync with psychosocial stressors.

Kim, H.J., & Fredriksen-Goldsen, K.I. (2017). Disparities in mental health quality of life between Hispanic and non-Hispanic White LGB midlife and older adults and the influence of lifetime discrimination, social connectedness, socioeconomic status, and perceived stress. Research on Aging, 39(9), 991-1012.

We assessed factors contributing to ethnic and racial disparities in mental health quality of life (MHQOL) among lesbian, gay, and bisexual (LGB) midlife and older adults. We utilized cross-sectional survey data from a sample of non-Hispanic White and Hispanic LGB adults aged 50 and older. Structural equation modeling was used to test the indirect effect of ethnicity/race on MHQOL via explanatory factors including social connectedness, lifetime discrimination, socioeconomic status (SES), and perceived stress. Hispanics reported significantly lower levels of MHQOL, compared to non-Hispanic Whites. In the final model, the association between ethnicity/race and MHQOL was explained by higher levels of perceived stress related to lower SES, higher frequency of lifetime discrimination, and lack of social connectedness among Hispanic LGB adults. This study suggests that perceived stress related to social disadvantage and marginalization plays an important role in MHQOL disparities among Hispanic LGB midlife and older adults.

Kim, H.J., Jen, S., & Fredriksen-Goldsen, K.I. (2017). Race/ethnicity and health-related quality of life among LGBT older adults. Gerontologist, 57(Suppl.), S30-S39.

PURPOSE OF THE STUDY: Few existing studies have addressed racial/ethnic differences in the health and quality of life of lesbian, gay, bisexual, and transgender (LGBT) older adults. Guided by the Health Equity Promotion Model, this study examines health-promoting and health risk factors that contribute to racial/ethnic health disparities among LGBT adults aged 50 and older. DESIGN AND METHODS: We utilized weighted survey data from Aging with Pride: National Health, Aging, and Sexuality/Gender Study. By applying multiple mediator models, we analyzed the indirect effects of race/ethnicity on health-related quality of life (HRQOL) via demographics, lifetime LGBT-related discrimination, and victimization, and socioeconomic, identity-related, spiritual, and social resources. RESULTS: Although African Americans and Hispanics, compared with non-Hispanic Whites, reported lower physical HRQOL and comparable psychological HRQOL, indirect pathways between race/ethnicity and HRQOL were observed. African Americans and Hispanics had lower income, educational attainment, identity affirmation, and social support, which were associated with a decrease in physical and psychological HRQOL. African Americans had higher lifetime LGBT-related discrimination, which was linked to a decrease in their physical and psychological HRQOL. African Americans and Hispanics had higher spirituality, which was associated with an increase in psychological HRQOL. IMPLICATIONS: Findings illustrate the importance of identifying both health-promoting and health risk factors to understand ways to maximize the health potential of racially and ethnically diverse LGBT older adults. Interventions aimed at health equity should be tailored to bolster identity affirmation and social networks of LGBT older adults of color and to support strengths, including spiritual resources.

King, S.D., & Richardson, V.E. (2016). Influence of income, being partnered/married, resilience, and discrimination on mental health distress for midlife and older gay men. Journal of Gay & Lesbian Mental Health, 20(2), 127-151.

Predictors of mental health distress were examined in 316 older gay men in a cross-sectional analysis using resilience and minority stress theories. Stigma, discrimination, internalized homophobia, health locus of control, social supports, income, and age cohort were included in a stepwise regression that explained 46% of variance. Discrimination, resilience, income and being partnered emerged as significant main effects while interaction effects between internalized homophobia and age cohort and resiliency and being partnered/married were found. The importance of examining within group variability, resilience, and moderating factors, such as resilience and cohort effects, when examining mental distress among LGBT individuals are discussed.

Klein, A., & Golub, S.A. (2016). Family rejection as a predictor of suicide attempts and substance misuse among transgender and gender nonconforming adults. LGBT Health, 3(3), 193-199.

PURPOSE: We examined associations between family rejection and risk of suicide attempts and substance misuse among a national sample of transgender and gender nonconforming adults. METHODS: Data were drawn from the National Transgender Discrimination Survey (N = 6456). This secondary analysis was restricted to 3458 individuals who self-identified as transgender or gender nonconforming and provided complete data on study variables. We used multivariable logistic regression to examine health risks by level of reported family rejection (low/moderate/high), controlling for relevant sociodemographic characteristics. RESULTS: Overall, 42.3% of the sample reported a suicide attempt and 26.3% reported misusing drugs or alcohol to cope with transgender-related discrimination. After controlling for age, race/ethnicity, sex assigned at birth, binary gender identity, income, education, and employment status, family rejection was associated with increased odds of both behaviors. Odds increased significantly with increasing levels of family rejection. CONCLUSIONS: Family rejection related to gender identity is an understudied interpersonal stressor that may negatively affect health outcomes for transgender and gender nonconforming individuals. A better understanding of the role of close relationships in both risk and resilience for transgender individuals is critical in the development of effective public health interventions for this community.

Klemmer, C.L., Arayasirikul, S., & Raymond, H.F. (2018). Transphobia-based violence, depression, and anxiety in transgender women: The role of body satisfaction. Journal of Interpersonal Violence. Advanced online publication.

Psychological processes may mediate the relationship between minority stress and mental health though limited data exist showing this pathway among trans women. Trans women’s degree of satisfaction with their body is associated with mental health outcomes. This study used a model of minority stress to explore for indirect effects on the association between transphobia-based victimization and anxiety and depression through one’s degree of body satisfaction. Analysis also explored for racial differences. Transgender women ( N = 233) were recruited in 2013 using respondent-driven sampling. Sociodemographics, transphobia-based victimization experiences such as having been physically abused, body satisfaction, and mental health were measured. Analyses assessed for direct and indirect associations while controlling for gender confirmation therapies (i.e., cross-sex hormone therapy and gender confirmation surgeries) and racial identity; 57% reported depression and 42.1% reported anxiety diagnoses. Participants averaged nearly three of six assessed violence experiences. More than 20% reported low body satisfaction. Contrary to authors’ expectations, those reporting African American and Other racial identity experienced less transphobia-based violence than whites. Transphobia-based violence was significantly associated with anxiety, depression, and body satisfaction. Body satisfaction was associated with mental health diagnoses. Bootstrapping revealed significant indirect and total effects. Body satisfaction mediated the relationship between transphobia-based violence and mental health. Clinical intervention that promotes body satisfaction including access to gender confirmation therapies, especially hormone therapy, may prevent negative mental health outcomes among trans women. Individual intervention, however, is not a panacea for structural discrimination. Attention to structural interventions that reduce gender minority stressors including transphobia-based violence is necessary.

Kosciw, J.G., Palmer, N.A., & Kull, R.M. (2015). Reflecting resiliency: openness about sexual orientation and/or gender identity and its relationship to well-being and educational outcomes for LGBT students. American Journal of Community Psychology, 55(1-2), 167-178.

For lesbian, gay, bisexual, and transgender (LGBT) youth, coming out (i.e., disclosure of LGBT identity to others) can be a key developmental milestone, one that is associated with better psychological well-being. However, this greater visibility may come with increased risk of peer victimization. Being out, therefore, may reflect resilience and may unfold differently depending on ecological context as some spaces may be more or less supportive of LGBT youth than others. This article explores a model of risk and resilience for outness among LGBT youth, including whether it varies by community context. We tested our hypothesized model with a national dataset of 7,816 LGBT secondary school students using multi-group structural equation modeling. Consistent with our hypotheses, outness was related to higher victimization but also to higher self-esteem and lower depression. Greater victimization was related to negative academic outcomes directly and indirectly via diminished well-being. The increases in victimization associated with outness were larger for rural youth, and benefits to well-being partly compensated for their lower well-being overall. This article suggests that being out reflects resilience in the face of higher risk of victimization, in addition to promoting well-being in other ways. Nonetheless, contextual factors influence how this model operates among LGBT youth.

Kulick, A., Wernick, L.J., Woodford, M.R., & Renn, K. (2017). Heterosexism, depression, and campus engagement among LGBTQ college students: Intersectional differences and opportunities for healing. Journal of Homosexuality, 64(8), 1125-1141.

LGBTQ people experience health disparities related to multilevel processes of sexual and gender marginalization, and intersections with racism can compound these challenges for LGBTQ people of color. Although community engagement may be protective for mental health broadly and for LGBTQ communities in buffering against heterosexism, little research has been conducted on the racialized dynamics of these processes among LGBTQ communities. This study analyzes cross-sectional survey data collected among a diverse sample of LGBTQ college students (n = 460), which was split by racial status. Linear regression models were used to test main effects of interpersonal heterosexism and engagement with campus organizations on depression, as well as moderating effects of campus engagement. For White LGBTQ students, engaging in student leadership appears to weaken the heterosexism-depression link-specifically, the experience of interpersonal microaggressions. For LGBTQ students of color, engaging in LGBTQ-specific spaces can strengthen the association between sexual orientation victimization and depression.

Kuper, L.E., Adams, N., & Mustanski, B.S. (2018). Exploring cross-sectional predictors of suicide ideation, attempt, and risk in a large online sample of transgender and gender nonconforming youth and young adults. LGBT Health, 5(7), 391-400.

PURPOSE: Rates of suicide ideation and attempt appear to be particularly high in the transgender and gender nonconforming (TGNC) population, yet little is known about which factors are the most salient contributors for TGNC young people and how these contributors vary across suicide-related outcomes. METHODS: Within the largest sample of TGNC young people to date (N = 1896; ages 14-30), we examined the contribution of demographics (age, assigned sex, gender identity, sexual orientation identity, race/ethnicity, and socioeconomic status), minority stress (gender-related affirmation, gender-related self-concept, victimization, and gender-affirming medical treatment desire/access), social support (from family and friends), and depressive symptoms in the cross-sectional prediction of three suicide-related outcomes: past-year attempt, past-year ideation, and a composite measure of suicide risk. RESULTS: Each set of factors explained significant variance in each outcome; however, only several predictors remained significant in each of the full models. Gender-related victimization and depressive symptoms were independent predictors for all three outcomes. Additional predictors varied across outcome. Age, male identity, sexual orientation-based victimization, and friend support were associated with suicide attempt. Age, queer identity, gender-related self-concept negativity, and family support were associated with suicide ideation, and pansexual identity and gender-related self-concept negativity were associated with positive suicide risk screen. CONCLUSION: Prevention and intervention efforts aimed at building support and positive self-concept, decreasing victimization, and treating depression are likely to partially reduce suicide ideation and attempt in TGNC adolescents and young adults. Comprehensive interventions with younger adolescents are particularly critical.

Lambe, J., Cerezo, A., & O’Shaughnessy, T.O. (2017). Minority stress, community involvement, and mental health among bisexual women. Psychology of Sexual Orientation and Gender Diversity, 4(2), 218-226.

Although the larger lesbian, gay, bisexual, transgender, and queer (LGBTQ) community has experienced increased visibility and acceptance in many areas of the United States, research shows that bisexual individuals continue to face negative messages about the legitimacy of their sexual orientation (Alarie & Gaudet, 2013). Using a national sample of 203 bisexual women, we ran a series of correlation, regression, and moderation models to examine (a) whether perceived binegative discrimination and internalized binegativity were correlated with self-esteem and depression and (b) whether perceived binegative discrimination and internalized bisexuality predicted self-esteem and depression. Based on findings from the regression models, we then examined whether involvement in the bisexual community reduced the impact of internalized binegativity on self-esteem and depression. A unique contribution of this study is that participants reported experiences of perceived binegative discrimination from heterosexual individuals as well as lesbians and gay men. Findings revealed that perceived binegative discrimination and internalized binegativity were statistically significantly correlated with self-esteem and depression but that only internalized binegativity predicted self-esteem and depression. Furthermore, we also found that participation in a bisexual-specific community at high levels (i.e., daily to 2 to 3 times per week) reduced the impact of internalized binegativity on depression but not self-esteem. Recommendations for future research, clinical practice, and advocacy are provided.

LeBlanc, A.J., Frost, D.M., & Bowen, K. (2018). Legal marriage, unequal recognition, and mental health among same-sex couples. Journal of Marriage and Family, 80(2), 397-408.

The authors examined whether the perception of unequal relationship recognition, a novel, couple-level minority stressor, has negative consequences for mental health among same-sex couples. Data came from a dyadic study of 100 (N = 200) same-sex couples in the U.S. Being in a legal marriage was associated with lower perceived unequal recognition and better mental health; being in a registered domestic partnership or civil union – not also legally married – was associated with greater perceived unequal recognition and worse mental health. Actor Partner Interdependence Models tested associations between legal relationship status, unequal relationship recognition, and mental health (nonspecific psychological distress, depressive symptomatology, and problematic drinking), net controls (age, gender, race/ethnicity, education, and income). Unequal recognition was consistently associated with worse mental health, independent of legal relationship status. Legal changes affecting relationship recognition should not be seen as simple remedies for addressing the mental health effects of institutionalized discrimination.

Lee, J.H., Gamarel, K.E., Bryant, K.J., Zaller, N.D., & Operario, D. (2016). Discrimination, mental health, and substance use disorders among sexual minority populations. LGBT Health, 3(4), 258-265.

PURPOSE: Sexual minority (lesbian, gay, bisexual) populations have a higher prevalence of mental health and substance use disorders compared to their heterosexual counterparts. Such disparities have been attributed, in part, to minority stressors, including distal stressors such as discrimination. However, few studies have examined associations between discrimination, mental health, and substance use disorders by gender among sexual minority populations. METHODS: We analyzed data from 577 adult men and women who self-identified as lesbian, gay, or bisexual and participated in Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Six questions assessed discrimination due to sexual orientation. Weighted multivariable logistic regression examined associations between experiences of sexual orientation discrimination and both mental health and substance use disorders. Analyses were conducted separately for sexual minority men and women, adjusting for sociodemographic covariates. RESULTS: Sexual minority men who ever experienced discrimination (57.4%) reported higher odds of any lifetime drug use disorder and cannabis use disorder compared to sexual minority men who never experienced discrimination. Sexual minority women who ever experienced discrimination (42.9%) reported higher odds of any lifetime mood disorder and any lifetime anxiety disorder compared to sexual minority women who never experienced discrimination. CONCLUSION: The findings suggest that discrimination is differentially associated with internalizing (mental health) and externalizing (substance use) disorders for sexual minority men and women. These findings indicate a need to consider how homophobia and heteronormative discrimination may contribute to distinct health outcomes for lesbian and bisexual women compared with gay and bisexual men.

Lehavot, K., & Simoni, J.M. (2011). The impact of minority stress on mental health and substance use among sexual minority women. Journal of Consulting and Clinical Psychology, 79(2), 159-170.

OBJECTIVE: We examined the direct and indirect impact of minority stress on mental health and substance use among sexual minority women. METHOD: A combination of snowball and targeted sampling strategies was used to recruit lesbian and bisexual women (N = 1,381) for a cross-sectional, online survey. Participants (M age = 33.54 years; 74% White) completed a questionnaire assessing gender expression, minority stressors (i.e., victimization, internalized homophobia, and concealment), social-psychological resources (i.e., social support, spirituality), and health-related outcomes. We used structural equation modeling to test associations among these factors, with gender expression as an antecedent and social-psychological resources as a mediator between minority stress and health. RESULTS: The final model demonstrated acceptable fit, chi(2)(79) = 414.00, p < .05, confirmatory fit index = .93, Tucker-Lewis index = .91, standardized root-mean-square residual = .05, root-mean-square error of approximation = .06, accounting for significant portions of the variance in mental health problems (56%) and substance use (14%), as well as the mediator social-psychological resources (24%). Beyond indirect effects of minority stress on health outcomes, direct links emerged between victimization and substance use and between internalized homophobia and substance use. CONCLUSIONS: Findings indicate a significant impact of minority stressors and social-psychological resources on mental health and substance use among sexual minority women. The results improve understanding of the distinct role of various minority stressors and their mechanisms on health outcomes. Health care professionals should assess for minority stress and coping resources and refer for evidence-based psychosocial treatments.

Lewis, R.J., Derlega, V.J., Berndt, A., Morris, L.M., & Rose, S. (2001). An empirical analysis of stressors for gay men and lesbians. Journal of Homosexuality, 42(1), 63-88.

This research describes the empirical classification of stressors for gay men and lesbians. Volunteer respondents were recruited through a free local gay and lesbian newspaper, through gay and lesbian student organizations nationwide, through gay and lesbian bookstores nationwide, and at a gay festival in St. Louis. Nine hundred seventy-nine (979) participants completed a 70-item measure with stressors that had been identified in previous qualitative research. Participants were asked to indicate the degree to which they had experienced stress associated with a variety of experiences. Participants also completed a measure of dysphoria (CES-D), responded about their degree of openness regarding sexual orientation, and provided information about their relationship status and involvement with gay groups and activities. Using confirmatory factor analysis, a six-factor model was predicted to account for the data. One-factor, six-factor, and ten-factor models were tested. The ten-factor model yielded the best fit with the data and accounted for 63.5% of the variance. The factor structure remained stable when gay men were compared to lesbians, when those endorsing a predominantly gay versus exclusively gay orientation were compared, and when those in a relationship were compared to those who were not in a relationship. Increased gay stress was associated with more dysphoria. Implications of these findings are discussed and directions for future research are considered.

Lewis, R.J., Derlega, V.J., Griffin, J.L., & Krowinski, A.C. (2003). Stressors for gay men and lesbians: Life stress, gay-related stress, stigma consciousness, and depressive symptoms. Journal of Social and Clinical Psychology, 22(6), 716-729.

Gay-related stress occurs when gay men and lesbians must deal with stressors that are unique to their sexual orientation. This research examined the relationship of gay-related stress and life events to depressive symptoms. Other potential predictors of depressive symptoms were also considered (internalized homophobia, stigma consciousness, and openness about sexual orientation). A sample of 204 (110 men, and 91 women, three sex-unspecified) gay/lesbian/bisexual individuals completed a packet of self-report measures. The importance of the construct of gay-related stress was demonstrated by explaining independent variance in depressive symptoms compared to variance explained by life stress. Those who reported more severe life stress and more severe gay-related stress also reported more depressive symptoms. Also, gay-related stress and stigma consciousness were independent predictors of depressive symptoms. Those with more severe gay-related stress and more stigma consciousness reported more depressive symptoms. Our results suggest that the construct of gay-related stress is important to understanding the experiences of gay/lesbian/bisexual individuals.

Lewis, R.J., Derlega, V.J., Brown, D., & Rose, S.M. (2009). Sexual minority stress, depressive symptoms, and sexual orientation conflict: Focus on the experiences of bisexuals. Journal of Social and Clinical Psychology, 28(8), 971-992.

The current study answers a need to provide information about bisexual as differentiated from gay/lesbian individuals and to increase understanding of the sexual minority stress experienced by bisexual individuals. Men and women who identified themselves as either bisexual or exclusively Lesbian/Gay (LG) were recruited nationwide and completed questionnaire measures of stressors associated with sexual orientation, openness about sexual orientation, conflict about sexual orientation, and depressive symptoms. Bisexual participants were younger and more likely to be female compared to LG participants. Bisexuals reported more conflict regarding their sexual orientation, were less open about their sexual orientation, and reported less minority stress associated with violence and discrimination. There were no differences in depressive symptoms for bisexual vs. LG participants. Bisexuals who were more open reported more conflict about their sexual orientation. Bisexuals who reported more stress associated with violence, harassment, and discrimination also reported more distress. Given the differences that emerged between LG vs. bisexual participants, future research should consider the importance of differentiating bisexual from LG individuals. Furthermore, this research provides evidence that sexual minority stress and openness about sexual orientation are important considerations in understanding the psychological functioning of bisexual individuals.

Lewis, R.J., Mason, T.B., Winstead, B.A., Gaskins, M., & Irons, L.B. (2016). Pathways to hazardous drinking among racially and socioeconomically diverse lesbian women: Sexual minority stress, rumination, social isolation, and drinking to cope. Psychology of Women Quarterly, 40(4), 564-581.

Lesbian women engage in more hazardous drinking than heterosexual women yet we know relatively little about what explains this disparity. In the present study, race, socioeconomic status, minority stress, general psychological processes and distress were examined as pathways to hazardous drinking among young (18-35 years) Black and non-Hispanic White lesbian women. We used the psychological mediation framework adaptation of minority stress theory and the reserve capacity model as theoretical underpinnings of the conceptual model in the current study. Self-identified lesbian participants (N= 867) completed a one-time online survey that assessed race, socioeconomic status, perceived sexual minority discrimination, proximal minority stress (concealment, internalized homophobia, lack of connection to lesbian community), rumination, social isolation, psychological distress, drinking to cope, and hazardous drinking. Cross-sectional results demonstrated that being Black was associated with hazardous drinking via sequential mediators of rumination, psychological distress, and drinking to cope. Socioeconomic status was associated with hazardous drinking via sequential mediators of sexual minority discrimination, proximal minority stress, rumination, social isolation, psychological distress, and drinking to cope. Understanding these pathways can aid researchers and clinicians studying and working with lesbians who are at risk for hazardous drinking.

Lewis, R.J., Winstead, B.A., Mason, T.B., & Lau-Barraco, C. (2017). Social factors linking stigma-related stress with alcohol use among lesbians. Journal of Social Issues, 73(3), 545-562.

A conceptual model linking stigma-related stress and lesbian women’s alcohol use and related problems via social factors (i.e., social constraints and social isolation), depressive symptoms, and negative reinforcement drinking motives (i.e., coping and conformity) was tested. Self-identified lesbian women (N = 1,048), age 18-35 years in the United States completed an online survey of discrimination, stigma consciousness, social isolation, social constraints, depressive symptoms, drinking motives, alcohol use, and related problems. The hypothesized path model showed excellent model fit. The predicted pathway of stigma-related stressors to alcohol outcomes via social factors, depressive symptoms, and coping/conformity motives was largely supported. Results highlight the importance of social factors in linking stigma-related stress to alcohol use and related problems among lesbians. Understanding the underlying social mechanisms connecting stigma to negative health outcomes may help inform intervention efforts to reduce alcohol use and related problems among lesbians and associated health disparities.

Liao, K.Y., Kashubeck-West, S., Weng, C.Y., & Deitz, C. (2015). Testing a mediation framework for the link between perceived discrimination and psychological distress among sexual minority individuals. Journal of Counseling Psychology, 62(2), 226-241.

Perceived discrimination is a risk factor for mental health problems among sexual minority individuals. An increasing number of research studies have investigated the mechanisms through which stigma-related stressors such as perceived discrimination are linked with adverse mental health outcomes for sexual minority populations. The integrative mediation framework proposed by Hatzenbuehler (2009) underscores the importance of identifying mediators in the association between stigma-related stressors and mental health outcomes. This study tested 3 mediators–expectations of rejection, anger rumination, and self-compassion–in the perceived discrimination-distress link. Moreover, it examined associations among these mediators. A nationwide sample of 265 sexual minorities responded to an online survey. Structural equation modeling results supported the mediator roles of expectations of rejection, anger rumination, and self-compassion. More specifically, perceived discrimination was associated with expectations of rejection, which, in turn, was associated with increased anger rumination and less self-compassion, resulting in greater psychological distress. The findings suggest several avenues for prevention and intervention with sexual minority individuals.

Liu, R.T., & Mustanski, B. (2012). Suicidal ideation and self-harm in lesbian, gay, bisexual, and transgender youth. American Journal of Preventive Medicine, 42(3), 221-8.

BACKGROUND: Suicide is the third-leading cause of death among adolescents and nonsuicidal self-harm occurs in 13%-45% of individuals within this age group, making these phenomena major public health concerns. Lesbian, gay, bisexual, and transgender (LGBT) youth particularly are at risk for engaging in these behaviors. Nevertheless, relatively little is known about the specific risk factors associated with suicidal ideation and self-harm behaviors in the population. PURPOSE: This study provides a longitudinal evaluation of the relative contributions of general and LGBT-specific risk factors as well as protective factors to the occurrence of suicidal ideation and self-harm in an ethnically diverse sample of LGBT youth. METHODS: A community sample of 246 LGBT youth (aged 16-20 years) was followed prospectively over five time points at regular 6-month intervals. Participants completed a baseline structured interview assessing suicide attempt history and questionnaires measuring gender nonconformity, impulsivity, and sensation-seeking. At follow-up assessments, participants completed a structured interview assessing self-harm and questionnaires for suicidal ideation, hopelessness, social support, and LGBT victimization. Data were collected from 2007 to 2011, and HLM analyses were conducted in 2011. RESULTS: A history of attempted suicide (p=0.05); impulsivity (p=0.01); and prospective LGBT victimization (p=0.03) and low social support (p=0.02) were associated with increased risk for suicidal ideation. Suicide attempt history (p<0.01); sensation-seeking (p=0.04); female gender (p<0.01); childhood gender nonconformity (p<0.01); and prospective hopelessness (p<0.01) and victimization (p<0.01) were associated with greater self-harm. CONCLUSIONS: General and LGBT-specific risk factors both uniquely contribute to likelihood of suicidal ideation and self-harm in LGBT youth, which may, in part, account for the higher risk of these phenomena observed in this population.

Livingston, N.A., Heck, N.C., Flentje, A., Gleason, H., Oost, K.M., & Cochran, B.N. (2015). Sexual minority stress and suicide risk: Identifying resilience through personality profile analysis. Psychology of Sexual Orientation and Gender Diversity, 2(3), 321-328.

BACKGROUND: Sexual minority-based victimization, which includes threats or enacted interpersonal violence, predicts elevated suicide risk among sexual minority individuals. However, research on personality factors that contribute to resilience among sexual minority populations is lacking. Using the Five-Factor Model, we hypothesized that individuals classified as adaptive (versus at-risk) would be at decreased risk for a suicide attempt in the context of reported lifetime victimization. METHOD: Sexual minority-identified young adults between the ages of 18 and 25 (N=412) were recruited nationally and asked to complete an online survey containing measures of personality, sexual minority stress, and lifetime suicide attempts. RESULTS: A two-stage cluster analytic method was used to empirically derive latent personality profiles and to classify respondents as adaptive (lower neuroticism and higher extroversion, agreeableness, conscientiousness, and openness) or at-risk (higher neuroticism, lower extroversion, agreeableness, conscientiousness, and openness) on the basis of their Five Factor Personality trait scores. Adaptive individuals were slightly older and less likely to conceal their sexual orientation, but reported similar rates of victimization, discrimination, and internalized heterosexism as their at-risk counterparts. Logistic regression results indicate that despite reporting similar rates of victimization, which was a significant predictor of lifetime suicide attempt, adaptive individuals evidenced decreased risk for attempted suicide in the context of victimization, relative to at-risk individuals. DISCUSSION: These findings suggest that an adaptive personality profile may confer resilience in the face of sexual minority-based victimization. This study adds to our knowledge of sexual minority mental health and highlights new directions for future research.

Livingston, N.A., Flentje, A., Heck, N.C., Szalda-Petree, A., & Cochran, B.N. (2017). Ecological momentary assessment of daily discrimination experiences and nicotine, alcohol, and drug use among sexual and gender minority individuals. Journal of Consulting and Clinical Psychology, 85(12), 1131-1143.

OBJECTIVE: Sexual and gender minority (SGM) individuals experience elevated rates of minority stress, which has been linked to higher rates of nicotine and substance use. Research on this disparity to date is largely predicated on methodology that is insensitive to within day SGM-based discrimination experiences, or their relation to momentary nicotine and substance use risk. We address this knowledge gap in the current study using ecological momentary assessment (EMA). METHOD: Fifty SGM individuals, between 18 and 45 years of age, were recruited from an inland northwestern university, regardless of their nicotine or substance use history, and invited to participate in an EMA study. Each were prompted to provide data, six times daily (between 10:00 a.m. and 10:00 p.m.) for 14 days, regarding SGM-based discrimination, other forms of mistreatment, and nicotine, drug, and alcohol use since their last prompt. RESULTS: Discrimination experiences that occurred since individuals’ last measurement prompt were associated with greater odds of nicotine and substance use during the same measurement window. Substance use was also more likely to occur in relation to discrimination reported two measurements prior in lagged models. Relative to other forms of mistreatment, discrimination effects were consistently larger in magnitude and became stronger throughout the day/evening. CONCLUSION: This study adds to existing minority stress research by highlighting the both immediate and delayed correlates of daily SGM-based discrimination experiences. These results also contribute to our understanding of daily stress processes and provide insight into ways we might mitigate these effects using real-time monitoring and intervention technology.

Marsack, J., & Stephenson, R. (2017). Sexuality-based stigma and depression among sexual minority individuals in rural United States. Journal of Gay & Lesbian Mental Health, 21(1), 51-63.

Sexuality-based stigma is associated with increased rates of depression for urban sexual minority persons. However, this relationship has not been explored specifically for rural sexual minority populations. This study examined the association between self-reported external and internal sexuality-based stigma and depression among an online sample of 771 rural sexual minority persons. Two regression outcomes were modeled, representing continuous depression scores and clinically significant depression. Anticipated, enacted, and internalized sexuality-based stigma were all significantly associated with increased depression scores and clinically significant depression. Interventions sensitive to the unique stigmas experienced by sexual minority populations in rural areas are needed.

Marshal, M.P., Burton, C.M., Chisolm, D.J., Sucato, G.S., & Friedman, M.S. (2013). Cross-sectional evidence for a stress-negative affect pathway to substance use among sexual minority girls. Clinical and Translational Science, 6(4), 321-322.

Sexual minority girls (SMGs) are four times more likely to engage in substance use than are heterosexual girls. A better understanding of the explanatory mechanisms of this disparity is needed to inform prevention and intervention programs. The goal of this study was to conduct a preliminary test of a “stress-negative affect” pathway by examining gay-related victimization and depression as mediators of substance use among SMGs. Adolescent girls (N = 156, 41% SMGs) were recruited from two urban adolescent medicine clinics to participate in an NIH-funded study of adolescent substance use. The average age was 17.0 years old and 57% were nonwhite. Mediation analyses were conducted in a multiple regression framework using SPSS and a mediation macro utilizing bias-corrected bootstrapping. Four models were estimated to test mediated pathways from sexual orientation to gay-related victimization (Mediator 1), to depression symptoms (Mediator 2), and then to each of four substance use variables: cigarettes, marijuana, alcohol, and heavy alcohol use. Significant mediated pathways (mediation tests with 95% CIs) were found for cigarette, alcohol and heavy alcohol use outcome variables. Results provide preliminary support for the minority stress hypothesis and the stress-negative affect pathway, and may inform the development of future prevention and intervention programs.

Martin-Storey, A.M., & Crosnoe, R. (2012). Sexual minority status, peer harassment, and adolescent depression. Journal of Adolescent Health, 35(4), 1001-1011.

The well-documented higher rates of depression among sexual minority youth are increasingly viewed by developmentalists as a byproduct of the stigmatization of sexual minority status in American society and of the negative impact this stigma has on the processes associated with depression. This study attempted to spur future research by testing Hatzenbuehler’s (2009) psychological mediation framework to investigate the ways in which peer harassment related to sexuality puts young people at risk by influencing the cognitive, social, and regulatory factors associated with depression. Analyses of 15 year olds in the NICHD Study of Early Child Care and Youth Development revealed that sexual minority status was largely associated with depressive outcomes via harassment, which was subsequently associated with depression via cognitive and social factors. Results point to various avenues for exploring the importance of the social world and self-concept for the outcomes of sexual minority adolescents in the future.

Martin-Storey, A.M., & Crosnoe, R. (2014). Peer harassment and risky behavior among sexual minority girls and boys. American Journal of Orthopsychiatry, 84(1), 54-65.

The role of peer harassment in the association between sexual minority status and adolescent risky behavior was examined for 15-year-olds in the NICHD Study of Early Child Care and Youth Development (n = 957). The findings, although exploratory, suggest the importance of gender. For girls, peer harassment was best viewed as a moderator of the link between sexual minority status and increased risky behavior. It intensified an existing association, reflecting the gendered nature of the impact of sexual minority status on the adolescent social context. For boys, peer harassment was primarily a mediator, such that sexual minority status was associated with more risky behavior via elevated harassment, although sexual minority status itself was associated with lower risky behavior overall.

Martin-Storey, A.M., & August, E.G. (2015). Harassment due to gender nonconformity mediates the association between sexual minority identity and depressive symptoms. Journal of Sex Research, 53(1), 85-97.

The visibility of a stigmatized identity is central in determining how individuals experience that identity. Sexual minority status (e.g., identifying as gay, lesbian, or bisexual) has traditionally been identified as a concealable stigma, compared with race/ethnicity or physical disability status. This conceptualization fails to recognize, however, the strong link between sexual minority status and a visible stigma: gender nonconformity. Gender nonconformity, or the perception that an individual fails to conform to gendered norms of behavior and appearance, is strongly stigmatized, and is popularly associated with sexual minority status. The hypothesis that harassment due to gender nonconformity mediates the association between sexual minority status and depressive symptoms was tested. Heterosexual and sexual minority-identified college and university students (N = 251) completed questionnaires regarding their sexual minority identity, experiences of harassment due to gender nonconformity, harassment due to sexual minority status, and depressive symptoms. A mediational model was supported, in which the association between sexual minority identity and depressive symptoms occurred via harassment due to gender nonconformity. Findings highlight harassment due to gender nonconformity as a possible mechanism for exploring variability in depressive symptoms among sexual minorities.

Mason, T.B., & Lewis, R.J. (2015). Minority stress and binge eating among lesbian and bisexual women. Journal of Homosexuality, 62(7), 971-992.

Previous research demonstrates that lesbian and bisexual (LB) women report more binge eating behaviors compared to heterosexual women although the explanations for this disparity are not well understood. LB women also experience distal (e.g., discrimination) and proximal (e.g., expectations of rejection) minority stressors that are related to negative mental and physical health outcomes. The present study investigated the association between minority stressors and binge eating behaviors in LB women. A sample of 164 LB women completed an online survey that included measures of distal and proximal sexual minority stressors, emotional-focused coping, social isolation, negative affect, and binge eating. The resultant model partially supported both the psychological mediation framework and the affect regulation model. The principal finding was that among LB women, proximal stressors were associated with social isolation and emotion-focused coping, which in turn were associated with negative affect and ultimately binge eating. Overall, the study provides evidence that minority stress is associated with binge eating and may partially explain the disparity in binge eating between LB and heterosexual women.

Mason, T.B., & Lewis, R.J. (2016). Minority stress, body shame, and binge eating among lesbian women: Social anxiety as a linking mechanism. Psychology of Women Quarterly, 40(3), 428-440.

Minority stress, which includes discrimination as well as internalized negative attitudes, is an important factor associated with maladaptive health behaviors such as binge eating among sexual minority individuals. In addition, body shame and social anxiety are robust predictors of binge eating. We examined social anxiety and body shame as sequential mediators of the association between minority stress and binge eating among young adult lesbian women. We hypothesized that social anxiety would be a key factor linking minority stress to body shame and binge eating. Self-identified lesbian women (N = 496) completed online measures of minority stress, social anxiety, body shame, and binge eating. Structural equation modeling supported the hypothesized model. Discrimination and proximal sexual minority stress were associated with increased social anxiety. In turn, social anxiety was associated with more body shame, and body shame was related to binge eating. Results suggest the oppressive social environments created by the experience of minority stress may have adverse consequences for lesbian women’s body satisfaction and eating behaviors. Interventions that bolster coping with sexual minority stress and focus on reducing social anxiety, in addition to targeting eating behavior directly, may be particularly useful for lesbian women with eating disorders or binge eating.

Mason, T.B., & Lewis, R.J., & Heron, K.E. (2017). Indirect pathways connecting sexual orientation and weight discrimination to disordered eating among young adult lesbians. Psychology of Sexual Orientation and Gender Diversity, 4(2), 193-204.

Lesbians engage in similar or more disordered eating than heterosexual women. Yet, models of disordered eating have not been researched adequately among lesbians. Theories contend that experiencing discrimination is associated with increased risk for poorer mental and physical health. To increase our understanding of disordered eating among lesbians, we developed a model in which discrimination and disordered eating were connected via mediators of social support, affect (i.e., general negative affect and social anxiety), and weight discrepancy. We recruited a sample of 436 lesbians in the United States (18-30 years old) to participate in an online study. The majority of participants were White (77.3%), with some postsecondary education (84% had at least some college), and were fairly open about their sexual orientation (85% were mostly or completely ‘out’). Sexual orientation discrimination and weight discrimination were each indirectly associated with disordered eating through a network of mediators. Sexual orientation discrimination was indirectly related to disordered eating via 2 paths: (a) less social support from family and more general negative affect and (b) less social support from family and more social anxiety. Weight discrimination was indirectly associated with more disordered eating via 3 paths: (a) less social support from friends and increased social anxiety, (b) increased social anxiety alone, and (c) higher weight discrepancy alone. The results underscore the need for researchers and clinical providers to understand and assess both sexual orientation discrimination and weight discrimination among lesbians.

Matthews, A., Li, C.C., Aranda, F., Torres, L., Vargas, M., & Conrad, M. (2014). The influence of acculturation on substance use behaviors among Latina sexual minority women: The mediating role of discrimination. Substance Use & Misuse, 49(14), 1888-1898.

BACKGROUND: A large body of work has demonstrated that sexual minority women have elevated rates of substance use morbidity, as compared with heterosexual women, and that this might be especially true for women of color. OBJECTIVES: This study examines the influence of acculturation and discrimination on substance use among Latina sexual minority women. METHODS: Data were collected from 2007 to 2008 as part of a larger community-based survey in the greater Chicago area. Scales measured discrimination, acculturation, and substance use. Structural equation modeling validated scales and examined their relationships, which were further described via mediation analysis. RESULTS: Increased acculturation leads to substance use and this relationship is partially mediated by discrimination (Sobel test = 2.10; p < .05). CONCLUSIONS/IMPORTANCE: Implications of these findings and directions for future research are discussed. Funding was provided by several women’s and public health organizations.

Mays, V.M., & Cochran, S.D. (2001). Mental health correlates of perceived discrimination among lesbian, gay, and bisexual adults in the United States. American Journal of Public Health, 91(11), 1869-1876.

OBJECTIVES: Recent studies suggest that lesbians and gay men are at higher risk for stress-sensitive psychiatric disorders than are heterosexual persons. We examined the possible role of perceived discrimination in generating that risk. METHODS: The National Survey of Midlife Development in the United States, a nationally representative sample of adults aged 25 to 74 years, surveyed individuals self-identifying as homosexual or bisexual (n = 73) or heterosexual (n = 2844) about their lifetime and day-to-day experiences with discrimination. Also assessed were 1-year prevalence of depressive, anxiety, and substance dependence disorders; current psychologic distress; and self-rated mental health. RESULTS: Homosexual and bisexual individuals more frequently than heterosexual persons reported both lifetime and day-to-day experiences with discrimination. Approximately 42% attributed this to their sexual orientation, in whole or part. Perceived discrimination was positively associated with both harmful effects on quality of life and indicators of psychiatric morbidity in the total sample. Controlling for differences in discrimination experiences attenuated observed associations between psychiatric morbidity and sexual orientation. CONCLUSIONS: Higher levels of discrimination may underlie recent observations of greater psychiatric morbidity risk among lesbian, gay, and bisexual individuals.

McCabe, S.E., Hughes, T.L., Matthews, A.K., Lee, J.G.L., West, B.T., & Boyd, C.J. (2017). Sexual orientation discrimination and tobacco use disparities in the United States. Nicotine & Tobacco Research, 21(4), 523–531.

Introduction: Differences in tobacco/nicotine use by sexual orientation are well documented. Development of interventions requires attention to the etiology of these differences. This study examined associations among sexual orientation discrimination, cigarette smoking, any tobacco/nicotine use, and DSM-5 tobacco use disorder (TUD) in the U.S. Methods: We used data from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions based on in-person interviews with a nationally representative sample of non-institutionalized U.S. adults. Approximately 8.3% of the population reported same-sex sexual attraction, 3.1% reported at least one same-sex sexual partner in the past-year, and 2.8% self-identified as lesbian, gay or bisexual. Results: Sexual attraction, sexual behavior, and sexual identity were significantly associated with cigarette smoking, any tobacco/nicotine use, and DSM-5 TUD. Risk of all tobacco/nicotine outcomes was most pronounced for bisexual adults across all three sexual orientation dimensions. Approximately half of sexual minorities who identified as lesbian or gay and one-fourth of those who identified as bisexual reported past-year sexual orientation discrimination. Sexual minorities who experienced high levels of past-year sexual orientation discrimination had significantly greater probability of past-year cigarette smoking, any tobacco/nicotine use, and TUD relative to sexual minorities who experienced lower levels of sexual orientation discrimination or no discrimination. Conclusions: Sexual minorities, especially bisexual adults, are at heightened risk of cigarette smoking, any tobacco/nicotine use, and DSM-5 TUD across all three major sexual orientation dimensions. Tobacco prevention and cessation efforts should target bisexual adults and consider the role sexual orientation discrimination plays in cigarette smoking and treatment of TUD. Implications: Differences in tobacco/nicotine use by sexual orientation are well documented, but little is known about differences across all three sexual orientation dimensions (attraction, behavior, and identity) or the origins of these differences. This study is the first to show that differences in tobacco/nicotine use across the three sexual orientation dimensions for respondents who were exclusively heterosexually-oriented were minimal, but varied more substantially among sexual minority women and men across the three sexual orientation dimensions. Sexual minorities who experienced high levels of past-year sexual orientation discrimination had significantly greater probability of cigarette smoking, any tobacco/nicotine use and DSM-5 tobacco use disorder.

McCarthy, M.A., Fisher, C.M., Irwin, J.A., Coleman, J.D., & Kneip Pelster, A.D. (2014). Using the minority stress model to understand depression in lesbian, gay, bisexual, and transgender individuals in Nebraska. Journal of Gay & Lesbian Mental Health, 18(4), 346-360.

Previous studies demonstrated the utility of the minority stress model in understanding health disparities for lesbian, gay, bisexual, and transgender (LGBT) populations. Since most research has considered large metropolitan areas, predominantly in coastal regions of the United States, this research focuses on a midwestern state, Nebraska. This study sought to assess the relationships between depressive symptoms experienced by participants (N = 770) and minority stress variables, including experiences with violence, perceptions of discrimination, and respondents’ degree of self-acceptance of their LGBT identity. Regression analysis revealed that after controlling for demographic variables, self-acceptance, and perceived discrimination were correlated with depressive symptoms. These findings have implications for policy makers, public health planners, and health care providers.

McConnell, E.A., Birkett, M., & Mustanski, B. (2016). Families matter: Social support and mental health trajectories among lesbian, gay, bisexual, and transgender youth. Journal of Adolescent Health, 59(6), 674-680.

PURPOSE: Lesbian, gay, bisexual, and transgender (LGBT) adolescents are at greater risk for mental health problems than their heterosexual peers, in part due to victimization. Social support, particularly from families, has been identified as an important promotive factor. However, little is known about how LGBT youth experience multiple forms of support or how early support predicts mental health across adolescence and into young adulthood. METHODS: In an analytic sample of 232 LGBT youth aged 16-20 years at baseline across 5.5 years, we compared developmental trajectories of psychological distress between three empirically derived social support cluster types at baseline: those who reported uniformly low support, those who reported uniformly high support, and those who reported nonfamily support (i.e., high peer and significant other but low family support). RESULTS: Longitudinal multilevel modeling, controlling for age, victimization, and social support at each wave, indicated key differences between cluster types. Youth in the low and nonfamily support clusters reported greater distress across all time points relative to youth in the high support cluster; however, they also showed a sharper decline in distress. Youth in the nonfamily cluster gained family support across adolescence, such that they resembled youth in the high support cluster by early adulthood. CONCLUSIONS: Findings underscore the importance of family support for LGBT youth. Youth who lack family support, but who have other forms of support, report a decrease in psychological distress and an increase in family support across adolescence. Youth who are low in all forms of support continue to exhibit high distress.

McConnell, E.A., Clifford, A., Korpak, A.K., Phillips, G., Birkett, M. (2017). Identity, victimization, and support: Facebook experiences and mental health among LGBTQ youth. Computers in Human Behavior, 76, 237-244.

The rise of social networking sites (SNSs) has created new contexts within which lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth and young adults manage their social identities and relationships. On one hand, SNSs provide important social support; on the other, they comprise another realm for victimization and discrimination. Context collapse refers to the ways diverse subgroups (e.g., family, co-workers) are often united in Facebook networks, which presents unique challenges related to outness. In this study, we examine the Facebook contexts of a cohort of LGBTQ youth and young adults with regard to outness, victimization, social support, and psychological distress by first examining descriptive statistics and correlations, and then testing a series of multiple regressions in an analytic sample of 175 (M age = 24.02 years) LGBTQ youth. Participants reported levels of daily Facebook use comparable to other samples of non-LGBTQ youth; however, they reported greater use of security controls, which may function as a tool for managing outness. Participants reported slightly lower outness across relational subgroups on Facebook, and associations between outness to relational subgroups were slightly stronger on Facebook, illustrating the potential impact of context collapse. Regression results showed that great victimization, cyberbullying, and the offering of support online were positively associated with psychological distress. Study findings illuminate how LGBTQ youth use and manage their identities on Facebook and highlight the importance of online contexts in shaping wellbeing for LGBtQ outh and young adults.

McGarrity, L.A., Huebner, D.M., & McKinnon, R.K. (2013). Putting stigma in context: Do perceptions of group stigma interact with personally experienced discrimination to predict mental health? Group Processes & Intergroup Relations, 16(6), 684-698.

Research has linked experiences of personal discrimination with negative mental health consequences, but less is known about the role of group stigma (perceived stigma against one’s group as a whole). The theoretical literature has offered mixed predictions. The present study examined the independent and interactive effects of group stigma and personal discrimination on depressive symptoms and suicidal ideation in a sample of gay and bisexual men (N = 986). Experiences of personal discrimination predicted depressive symptoms and suicidal ideation regardless of group stigma. However, group stigma was associated with depressive symptoms contextually–only when level of perceived personal discrimination was low. Personal discrimination may be a relatively more powerful force in the lives of stigmatized group members that overwhelms the influence of group stigma in harming mental health.

McKirnan, D.J., & Peterson, P.L. (1988). Stress, expectancies, and vulnerability to substance abuse: a test of a model among homosexual men. Journal of Abnormal Psychology, 97(4), 461-466.

We hypothesize that specific attitudes or expectancies make people vulnerable to responding to stress via alcohol or drugs. This “stress-vulnerability” model was tested among homosexual men, who show elevated rates of substance abuse and have culturally specific stressors and vulnerability. Tension reduction expectancies of alcohol effects had a substantial effect on alcohol and marijuana/drug abuse, as did the use of bars as a social resource. Two stress variables—negative affectivity and discrimination attributable to sexual orientation—also had significant, though more moderate effects. Interactions of the vulnerability measures with the stress variables had significant effects on substance abuse beyond the main effects, supporting the central hypothesis. In a second analysis both simple consumption levels and “high-risk” styles of alcohol or drug use predicted alcohol or drug problems better among vulnerable than among nonvulnerable respondents. These findings strongly supported a general stress-vulnerability model of substance abuse and illustrated several important risk factors in homosexual culture. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

McLemore, K.A. (2018). A minority stress perspective on transgender individuals’ experiences with misgendering. Stigma and Health, 3(1), 53-64.

This research investigates transgender individuals’ experiences with misgendering–the misclassification of gender identity–from a minority stress perspective. Four hundred and ten transgender individuals (M = 30.27 years, 83.9% European American) participated in a survey in which they reported how frequently they are misgendered and how stigmatized they feel when it occurs in addition to protective factors (gender identity importance, social support) and psychological distress (anxiety, depression, stress, transgender felt stigma). On average, participants reported being misgendered sometimes (M = 3.05, SD = 1.18) and feeling somewhat stigmatized by these experiences (M = 3.64, SD = 1.30). Perceived frequency of misgendering and feeling stigmatized by these experiences were positively associated with identity importance, but only perceived frequency was negatively associated with social support. Both perceived frequency and feeling stigmatized were positively associated with psychological distress. In turn, identity importance and social support were positively associated with psychological distress. There was a significant interaction between felt stigma and identity importance in predicting depression and stress. There was a positive association between felt stigma and stress and depression at low and high levels of identity importance, but this association was stronger at low levels of identity importance. In addition, there was a significant interaction between perceived frequency of misgendering and social support such that the association between perceived frequency and felt stigma was positive at low levels of social support but not at high levels of social support. In conclusion, misgendering is likely a novel minority stressor for transgender people.

Mereish, E.H., O’Cleirigh, C., & Bradford, J.B. (2015). Interrelationships between LGBT-based victimization, suicide, and substance use problems in a diverse sample of sexual and gender minorities. Psychology, Health & Medicine, 19(1), 1-13.

Research has documented significant relationships between sexual and gender minority stress and higher rates of suicidality (i.e. suicidal ideation and attempts) and substance use problems. We examined the potential mediating role of substance use problems on the relationship between sexual and gender minority stress (i.e. victimization based on lesbian, gay, bisexual, or transgender identity [LGBT]) and suicidality. A nonprobability sample of LGBT patients from a community health center (N = 1457) ranged in age from 19-70 years. Participants reported history of lifetime suicidal ideation and attempts, substance use problems, as well as experiences of LGBT-based verbal and physical attacks. Substance use problems were a significant partial mediator between LGBT-based victimization and suicidal ideation and between LGBT-based victimization and suicide attempts for sexual and gender minorities. Nuanced gender differences revealed that substance use problems did not significantly mediate the relationship between victimization and suicide attempts for sexual minority men. Substance use problems may be one insidious pathway that partially mediates the risk effects of sexual and gender minority stress on suicidality. Substances might be a temporary and deleterious coping resource in response to LGBT-based victimization, which have serious effects on suicidal ideation and behaviors.

Mereish, E.H. (2014). The weight of discrimination: The relationship between heterosexist discrimination and obesity among lesbian women. Psychology of Sexual Orientation and Gender Diversity, 1(4), 356-360.

Lesbian women are at higher risk for obesity than heterosexual women. Yet, there is a dearth in research examining mechanisms that predict obesity among lesbian women. As one form of sexual minority stress, this study examined heterosexist discrimination as a mechanism in predicting risk for being overweight or obese, while accounting for factors usually associated with obesity. An online sample of adult lesbian women (N = 155) was recruited. Participants reported their demographics and health behaviors; they also completed measures assessing depression and heterosexist discrimination. Multinomial logistic regression analyses were used to examine risk for being overweight or obese. While accounting for age, race, education, income, health background and behaviors (i.e., having high blood cholesterol, exercising, and eating fatty foods), and depression, lesbian women who experienced heterosexist discrimination were at 2.55 higher odds of being overweight and at 2.49 higher odds of being obese when compared to normal-weight lesbian women. The findings indicate that experiencing heterosexist discrimination is related to higher risk for being overweight or obese. These results provide support for the effects of sexual minority stress on health and expand the minority stress model to include physical health. Understanding risk factors for obesity among lesbian women is critical for culturally sensitive and affirmative interventions, clinical practice, research, and policy.

Mereish, E.H., & Poteat, V.P. (2015). A relational model of sexual minority mental and physical health: The negative effects of shame on relationships, loneliness, and health. Journal of Counseling Psychology, 62(3), 425-437.

Sexual minorities (e.g., lesbians, gay men, bisexual individuals) are at an increased risk for poorer mental and physical health outcomes than heterosexuals, and some of these health disparities relate to minority stressors such as discrimination. Yet, there is little research elucidating pathways that predict health or that promote resiliency among sexual minorities. Building on the minority stress model, the present study utilized relational cultural theory to situate sexual minority health within a relational framework. Specifically, the study tested mediators of the relationships between distal (i.e., discrimination, rejection, victimization) and proximal stressors (i.e., internalized homophobia, sexual orientation concealment) and psychological and physical distress for sexual minorities. Among 719 sexual minority adults, structural equation modeling analyses were used to test 4 models reflecting the mediating effects of shame, poorer relationships with a close peer and the lesbian/gay/bisexual/transgender (LGBT) community, and loneliness on the associations between minority stressors and psychological distress (i.e., depression and anxiety) and physical distress (i.e., distressing physical symptoms). As hypothesized, the associations between distal and proximal minority stressors and distress were mediated by shame, poorer relationships with a close peer and the LGBT community, and loneliness. Findings underscore the possible relational and interpersonal mechanisms by which sexual minority stressors lead to psychological and physical distress.

Mereish, E.H., Katz-Wise, S.L., & Woulfe, J. (2017). Bisexual-specific minority stressors, psychological distress, and suicidality in bisexual individuals: The mediating role of loneliness. Prevention Science, 18(6), 716-725.

Bisexual individuals are at higher risk for poor mental health outcomes compared to heterosexual as well as lesbian and gay individuals and experience minority stressors, such as discrimination, from both heterosexual and sexual minority communities. However, there is little research examining the negative effects of bisexual-specific minority stressors on bisexual individuals’ mental health as well as psychological factors that might help explain minority stressors’ deleterious effects. This research examined the effects of distal minority stressors (i.e., anti-bisexual experiences from both heterosexual as well as lesbian and gay people) and proximal stressors (i.e., internalized heterosexism and sexual orientation concealment) on psychological distress and suicidality among bisexual adults (N = 503). Building on the relational framing of the minority stress model, we also tested one relational factor (i.e., loneliness) as a mediator of the associations between distal and proximal minority stressors and poor mental health (i.e., psychological distress and suicidality). Structural equation modeling analyses were used to test the mediating effects of loneliness on the associations between minority stressors and psychological distress and suicidality. Although distal and proximal minority stressors were not associated with each other, loneliness mediated the effects of distal and proximal minority stressors on psychological distress and suicidality. The results of this study underscore the importance of targeting bisexual-specific minority stressors as well as loneliness in preventive interventions to improve the mental health of bisexual individuals.

Mereish, E.H., Peters, J.R., & Yen, S. (2018). Minority stress and relational mechanisms of suicide among sexual minorities: Subgroup differences in the associations between heterosexist victimization, shame, rejection sensitivity, and suicide risk. Suicide and Life-Threatening Behavior, 49(2), 547-560.

Despite sexual orientation disparities in suicide, there is limited research examining factors associated with suicide risk among sexual minorities while considering subgroup differences within this group. This study identified differences between sexual minorities at risk for suicide and those not at risk. The study also examined heterosexist victimization, as one form of minority stress, and two relational mechanisms (i.e., shame and rejection sensitivity) as risk factors for suicidality. We examined a moderated-mediation model, in which we tested gender and sexual orientation differences in the mediating effects of the relational mechanisms on the association between heterosexist victimization and suicide risk. Participants were recruited online and completed an online survey. The sample included 719 sexual minority adults. Of the sample, 27.7% were at risk for suicide. Suicide risk varied by age, gender, sexual orientation, income, education, and relationship status. Heterosexist victimization, shame, and rejection sensitivity were significant risk factors for suicide. Shame and rejection sensitivity were mediators of the association between heterosexist victimization and suicide risk for subgroups of sexual minorities, mostly lesbian and gay individuals and to some extent bisexual individuals. The findings underscore minority stress, shame, and rejection sensitivity as key intervention points.

Meyer, I.H. (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36(1), 38-56.

This study describes stress as derived from minority status and explores its effect on psychological distress in gay men. The concept of minority stress is based on the premise that gay people in a heterosexist society are subjected to chronic stress related to their stigmatization. Minority stressors were conceptualized as: internalized homophobia, which relates to gay men’s direction of societal negative attitudes toward the self; stigma, which relates to expectations of rejection and discrimination; and actual experiences of discrimination and violence. The mental health effects of the three minority stressors were tested in a community sample of 741 New York City gay men. The results supported minority stress hypotheses: each of the stressors had a significant independent association with a variety of mental health measures. Odds ratios suggested that men who had high levels of minority stress were twice to three times as likely to suffer also from high levels of distress.

Michaels, M.S., Parent, M.C., & Torrey, C.L. (2016). A minority stress model for suicidal ideation in gay men. Suicide and Life-Threatening Behavior, 46(1), 23-34.

There is a dearth of research on mechanisms underlying higher rates of suicidal ideation among gay men compared to heterosexual men. The purpose of this study was to establish the link between social/psychological predictor variables and suicidal ideation by testing a hypothesized minority stress model. Structural equation modeling was used to assess the relationships posited in the model using data from a community sample of 167 gay men. Model fit was adequate and hypothesized relationships were partially supported. Also, depressive symptoms partially mediated the relationship between (less) outness predicting suicidal ideation. These findings imply that therapeutic approaches targeting the coming out process may be more effective than approaches targeting internalized homophobia when suicidal ideation is indicated in the clinical presentation of gay and bisexual men.

Miller, L.R., & Grollman, E.A. (2015). The social costs of gender nonconformity for transgender adults: Implications for discrimination and health. Sociological Forum, 30(3), 809-831.

Research suggests that transgender people face high levels of discrimination in society, which may contribute to their disproportionate risk for poor health. However, little is known about whether gender nonconformity, as a visible marker of one’s stigmatized status as a transgender individual, heightens trans people’s experiences with discrimination and, in turn, their health. Using data from the largest survey of transgender adults in the United States, the National Transgender Discrimination Survey (N = 4,115), we examine the associations among gender nonconformity, transphobic discrimination, and health-harming behaviors (i.e., attempted suicide, drug/alcohol abuse, and smoking). The results suggest that gender nonconforming trans people face more discrimination and, in turn, are more likely to engage in health-harming behaviors than trans people who are gender conforming. Our findings highlight the important role of gender nonconformity in the social experiences and well-being of transgender people.

Miner, K.N., & Costa, P.L. (2018). Ambient workplace heterosexism: Implications for sexual minority and heterosexual employees. Stress Health, 34(4), 563-572.

This study examined the relationship between ambient workplace heterosexism, emotional reactions (i.e., fear and anger), and outcomes for sexual minority and heterosexual employees. Five hundred thirty-six restaurant employees (68% female, 77% White) completed an online survey assessing the variables of interest. Results showed that greater experiences of ambient workplace heterosexism were associated with heightened fear and anger and, in turn, with heightened psychological distress (for fear) and greater physical health complaints, turnover intentions, and lowered job satisfaction (for anger). Fear also mediated the relationship between ambient workplace heterosexism and psychological distress. In addition, sexual orientation moderated the relationship between ambient workplace heterosexism and fear such that sexual minority employees reported more fear than heterosexuals with greater ambient heterosexism. These effects occurred after controlling for personal experiences of interpersonal discrimination. Our findings suggest that ambient workplace heterosexism can be harmful to all employees, not only sexual minorities or targeted individuals.

Mohr, J.J., & Sarno, E.L. (2016). The ups and downs of being lesbian, gay, and bisexual: A daily experience perspective on minority stress and support processes. Journal of Counseling Psychology, 63(1), 106-118.

Daily diary methods were used to explore identity-related stress and support processes as they occurred from day-to-day in a sample of 61 lesbian, gay, and bisexual (LGB) young adults. At the end of each day for 7-10 consecutive days, participants reported on daily identity-salient experiences (ISEs), proximal minority stressors (internalized stigma, expectations of rejection), and affect (positive, negative). A multilevel latent covariate model was used to examine within- and between-person interrelations among these variables. Participants described a variety of positive and negative ISEs with both heterosexual and LGB people. These ISEs accounted for change in affect from 1 day to the next, even controlling for positive and negative experiences unrelated to identity. For example, relative to the previous day, participants experienced increases in positive affect on days featuring positive ISEs with both heterosexual people and LGB people. ISEs also predicted daily proximal stress variables, and findings differed at the 2 levels of analysis. For example, at the within-person level, participants experienced decreases in internalized stigma on days featuring positive ISEs with heterosexuals. At the between-person level, however, findings indicated that participants who generally had the highest levels of internalized stigma were more likely than others to report negative ISEs with LGB people and less likely to report positive ISEs with LGB people. Finally, proximal stress variables predicted affect at the within-person level: Affect improved on days when levels of internalized stigma and expected rejection were lower than usual.

Molina, Y., Marquez, J.H., Logan, D.E., Leeson, C.J., Balsam, K.F., & Kaysen, D.L. (2015). Current intimate relationship status, depression, and alcohol use among bisexual women: The mediating roles of bisexual-specific minority stressors. Sex Roles, 73(1), 43-57.

Current intimate relationship characteristics, including gender and number of partner(s), may affect one’s visibility as a bisexual individual and the minority stressors they experience, which may in turn influence their health. The current study tested four hypotheses: 1) minority stressors vary by current intimate relationship status; 2) higher minority stressors are associated with higher depressive symptoms and alcohol-related outcomes; 3) depressive symptoms and alcohol-related outcomes vary by current intimate relationship status; and 4) minority stressors will mediate differences in these outcomes. Participants included 470 self-identified bisexual women (65% Caucasian, mean age: 21) from a sample of sexual minority women recruited from different geographic regions in the United States through advertisements on social networking sites and Craigslist. Participants completed a 45 minute survey. Respondents with single partners were first grouped by partner gender (male partner: n=282; female partner: n=56). Second, women were grouped by partner gender/number (single female/male partner: n = 338; women with multiple female and male partners: n=132). Women with single male partners and women with multiple male and female partners exhibited elevated experienced bi-negativity and differences in outness (H1). Experienced and internalized bi-negativity were associated with health outcomes, but not outness (H2). Differences in outcomes emerged by partner number and partner number/gender (H3); these differences were mediated by experienced bi-negativity (H4). These results suggest that experiences of discrimination may underlie differences in health related to bisexual women’s relationship structure and highlight the importance of evaluating women’s relational context as well as sexual identification in understanding health risk behaviors.

Mosovsky, S., Nolan, B.A.D., Markovic, N., & Stall, R. (2016). RADICLE Moms study: Minority stress and implications for lesbian mothers. Women Health, 56(8), 859-870.

Little is known about depressive symptoms among mothers who identify as lesbian. The aim of the researchers in the Relationships And Depression In Childbearing LEsbian (RADICLE) Moms study was to investigate the minority stress model to determine if higher levels of social support altered the relationship between gay-specific minority stress and depressive symptoms in a sample of self-identified lesbian women who had one or more children less than 18 years of age living in the household. The authors hypothesized that social support would influence the relationship between depressive symptoms and minority stress. Participants (n = 131) completed an anonymous Internet survey between May and December, 2011. Controlling for demographic factors and utilizing independent hierarchical multiple regression analyses the authors examined the relationships between depressive symptoms and social support, minority stress, and general stress. While each of these factors had a significantly positive relationship to depressive symptoms, using stepwise regression analyses the authors identified general stress as the most significant factor. Mediation analysis revealed that social support fully mediated the relationship between minority stress and depressive symptoms. This pilot study provides support for development of intervention strategies to decrease general stress and or increase social support among lesbian mothers.

Muehlenkamp, J.J., Hilt, L.M., Ehlinger, P.P., & McMillan, T. (2015). Nonsuicidal self-injury in sexual minority college students: A test of theoretical integration. Child and Adolescent Psychiatry and Mental Health, 9, 16.

BACKGROUND: Individuals identifying as a sexual minority report engaging in nonsuicidal self-injury (NSSI) at substantially higher rates compared to their heterosexual peers. Given that NSSI is a known risk factor for suicide, it is important to understand the processes unique to being a sexual minority that increases risk for NSSI so that adequate prevention efforts can be established. The current study integrated Minority Stress Theory and the Interpersonal Theory of Suicide to test a model of NSSI and suicide risk. METHODS: A total of 137 college students who identified as a sexual minority completed an anonymous on-line study assessing NSSI, suicidal thoughts/behaviors, and constructs of the minority stress and interpersonal theories. Two linear regressions using bootstrapping analyses were conducted to test our hypotheses. RESULTS: Minority stress was directly associated with NSSI and via perceived burdensomeness, explaining 27 % of the variance. NSSI was associated with increased risk for suicide thoughts/behaviors directly, and through acquired capability, explaining 45 % of the variance. CONCLUSIONS: These findings provide evidence that unique stressors individuals face as a result of their sexual minority status increases risk for self-harm by influencing cognitive and emotional processes such as burdensomeness and acquired capability. Implications for prevention, intervention, and future research are briefly discussed.

Mustanski, B., Newcomb, M., & Garofalo, R. (2011). Mental health of lesbian, gay, and bisexual youth: A developmental resiliency perspective. Journal of Gay and Lesbian Social Services, 23(2), 204-225.

Research suggests that lesbian, gay, and bisexual (LGB) youth are at increased risk for both victimization and internalizing mental health problems, but limited research has studied their association or factors that increase resilience. The sample included 425 LGBs between the ages of 16 and 24 year. The majority had disclosed their sexual orientation to family or friends (98%) and 97% had someone in their lives who was accepting. Racial/ethnic minority and female participants in general reported lower levels of disclosure and acceptance. Most participants reported some form of sexual orientation-related victimization (94%). Victimization was associated with psychological distress, but a compensatory model indicated that in the context of this victimization both peer and family support had significant promotive effects. A test of a protective model found social support did not ameliorate negative effects of victimization. The positive effects of family support decreased with age. Peer and family support were particularly important, but they did not significantly dampen the negative effects of victimization. Our findings suggest that mental health professionals working with LGB youth should address social support and that public health approaches are needed to reduce levels of victimization.

Mustanski, B., & Liu, R.T. (2013). A longitudinal study of predictors of suicide attempts among lesbian, gay, bisexual, and transgender youth. Archives of Sexual Behavior, 42(3), 437-448.

This short-term prospective study examined general and lesbian, gay, bisexual, and transgender (LGBT)-specific risk and protective factors for suicide attempts in an ethnically diverse sample of LGBT youth (N = 237, 47.7 % male). A structured psychiatric interview assessed clinical depression and conduct disorder symptoms, as well as past and prospective suicide attempts over a 1-year follow-up period (91 % retention). Participants completed questionnaires measuring general risk factors for suicide attempts, including hopelessness, impulsiveness, and perceived social support. They also completed measures of LGBT-specific suicide risk factors, including gender nonconformity, age of first same-sex attraction, and LGBT victimization. Correlation and multivariate regression analyses were conducted to examine the relations between predictors and suicide attempt, and to identify mediators. Of nine variables examined, seven were related to lifetime history of attempted suicide: hopelessness, depression symptoms, conduct disorder symptoms, impulsivity, victimization, age of first same-sex attraction, and low family support. Depressive symptoms and hopelessness mediated the relation between multiple risk and resilience factors and suicide attempts. Suicide attempt history was the strongest predictor of prospective suicide attempts. Participants who previously attempted suicide (31.6 % of the sample) had more than 10 times greater odds of making another attempt in the 1-year follow-up period than were those who had made no previous attempt. These results highlight the need for suicide prevention programs for LGBT youth and suggest the importance of addressing depression and hopelessness as proximal determinants and family support and victimization, which have more distal effects.

Mustanski, B., Andrews, R., & Puckett, J.A. (2016). The effects of cumulative victimization on mental health among lesbian, gay, bisexual, and transgender adolescents and young adults. American Journal of Public Health, 106(3), 527-533.

OBJECTIVES: To examine the effects of the cumulative victimization experienced by lesbian, gay, bisexual, and transgender youths on mental disorders. METHODS: We recruited 248 participants from the Chicago, Illinois, area in 7 waves of data collected over 4 years, beginning in 2007 (83.1% retention rate). Mean age at enrollment was 18.7 years, and 54.7% were Black. We measured depression and posttraumatic stress disorder using structured psychiatric interviews. RESULTS: Latent class analyses of victimization over time identified a 4-class solution. Class 1 (65.4%) had low, decreasing victimization. Class 2 (10.3%) had moderate, increasing victimization. Class 3 (5.1%) had high, steady victimization. Class 4 (19.2%) had high, decreasing victimization. Controlling for baseline diagnoses and birth sex, lesbian, gay, bisexual, and transgender youths in classes 2 and 3 were at higher risk for depression than were those in class 1; youths in classes 2, 3, and 4 were at elevated risk for posttraumatic stress disorder. CONCLUSIONS: Lesbian, gay, bisexual, and transgender youths with steadily high or increasing levels of victimization from adolescence to early adulthood are at higher risk for depression and posttraumatic stress disorder.

Nemoto, T., Bodeker, B., & Iwamoto, M. (2011). Social support, exposure to violence and transphobia, and correlates of depression among male-to-female transgender women with a history of sex work. American Journal of Public Health, 101(10), 1980-1988.

OBJECTIVES: We determined racial/ethnic differences in social support and exposure to violence and transphobia, and explored correlates of depression among male-to-female transgender women with a history of sex work (THSW). METHODS: A total of 573 THSW who worked or resided in San Francisco or Oakland, California, were recruited through street outreach and referrals and completed individual interviews using a structured questionnaire. RESULTS: More than half of Latina and White participants were depressed on the basis of Center For Epidemiologic Studies Depression Scale scores. About three quarters of White participants reported ever having suicidal ideation, of whom 64% reported suicide attempts. Half of the participants reported being physically assaulted, and 38% reported being raped or sexually assaulted before age 18 years. White and African American participants reported transphobia experiences more frequently than did others. Social support, transphobia, suicidal ideation, and levels of income and education were significantly and independently correlated with depression. CONCLUSIONS: For THSW, psychological vulnerability must be addressed in counseling, support groups, and health promotion programs specifically tailored to race/ethnicity.

Newcomb, M.E., Heinz, A.J., Birkett, M., & Mustanski, B. (2014). A longitudinal examination of risk and protective factors for cigarette smoking among lesbian, gay, bisexual, and transgender youth. Journal of Adolescent Health, 54(5), 558-564.

PURPOSE: To investigate change across development in two smoking outcomes (smoking status and rate), describe demographic differences in smoking, and longitudinally examine the effects of psychosocial variables on smoking (psychological distress, victimization, and social support) in lesbian, gay, bisexual, and transgender (LGBT) youth. METHODS: Participants were 248 ethnically diverse LGBT youth (ages 16-20 years at baseline) from a longitudinal cohort study with six waves over 3.5 years. Baseline questionnaires included demographic variables and a measure of impulsivity, and longitudinal questionnaires included measures of cigarette smoking (status and average number of cigarettes smoked daily), LGBT-based victimization, psychological distress, and perceived social support. Analyses were conducted with hierarchical linear modeling. RESULTS: Males had higher odds of smoking and smoking rate than females, but females’ smoking rate increased more rapidly over time. Psychological distress was associated with higher odds of smoking and smoking rate at the same wave, and it predicted smoking rate at the subsequent wave. LGBT victimization was associated with higher odds of smoking at the same wave and predicted smoking rate at the subsequent wave. Finally, significant other support predicted higher odds of smoking and smoking rate at the subsequent wave, but family support was negatively correlated with smoking rate at the same wave. CONCLUSIONS: There are several viable avenues for the development of smoking prevention interventions for LGBT youth. To optimize the efficacy of prevention strategies, we must consider experiences with victimization, the impact of psychological distress, and optimizing support from families and romantic partners.

Ngamake, S.T., Walch, S.E., & Raveepatarakul, J. (2016). Discrimination and sexual minority mental health: Mediation and moderation effects of coping. Psychology of Sexual Orientation and Gender Diversity, 3(2), 213-226.

Stigma and discrimination related to sexual minority status are unique stressors associated with mental and physical health concerns among sexual minority individuals. Although some theoretical models propose that the strategies sexual minorities apply to cope with these particular stressors can mediate and/or moderate their impact on mental health outcomes, only a few studies have examined this proposition empirically, typically using measures of broad coping strategies that are not discrimination-specific. A nonprobability sample of 354 self-identified lesbian, gay, and bisexual (LGB) individuals completed self-report measures of perceived discrimination experiences, psychological distress, and discrimination-specific coping strategies used, including education/advocacy, internalization, drug and alcohol use, resistance, and detachment strategies. Perceived discrimination explained levels of depression, anxiety, and stress after controlling for income, education, and race. Drug and alcohol use mediated the relationship between discrimination and depression, anxiety, and stress symptoms. Internalization mediated the relationship between discrimination and anxiety symptoms and moderated the relationship between discrimination and depression and anxiety. The education/advocacy, resistance, and detachment strategies played no clear mediator or moderator roles in the relationship between discrimination and psychological distress. Psychological interventions that assist sexual minority clients in the development of effective coping skills, such as avoidance of drug and alcohol use for coping and internalization may reduce the harm associated with the experience of stigma and discrimination.

Nuttbrock, L., Hwahng, S., Bockting, W., Rosenblum, A., Mason, M., Macri, M., et al. (2010). Psychiatric impact of gender-related abuse across the life course of male-to-female transgender persons. Journal of Sex Research, 47(1), 12-23.

The psychiatric impact of interpersonal abuse associated with an atypical presentation of gender was examined across the life course of 571 male-to-female (MTF) transgender persons from the New York City Metropolitan Area. Gender-related abuse (psychological and physical), suicidality, and Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision) major depression were retrospectively measured across five stages of the life course using the Life Chart Interview. Among younger respondents (current age of 19-39), the impact of both types of abuse on major depression was extremely strong during adolescence and then markedly declined during later stages of life. Among older respondents (current age of 40-59), the impact of both types of abuse on major depression was strong during adolescence and then marginally declined during later stages of life. The effects of both types of abuse on suicidality were weaker but more consistently observed across the life course among both the younger and older respondents. Gender-related abuse is a major mental health problem among MTF transgender persons, particularly during adolescence. As these individuals mature, however, the consequences of this abuse appear less severe, which may represent the development of moderately effective mechanisms for coping with this abuse.

Nuttbrock, L., Bockting, W., Rosenblum, A., Hwahng, S., Mason, M., Macri, M, et al. (2014). Gender abuse and major depression among transgender women: A prospective study of vulnerability and resilience. American Journal of Public Health, 104(11), 2191-2198.

OBJECTIVES: We examined the social and interpersonal context of gender abuse and its effects on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition major depression among transgender women. METHODS: We conducted a 3-year prospective study (2004-2007) among 230 transgender women aged 19 to 59 years from the New York City Metropolitan Area. Statistical techniques included generalized estimating equations (logistic regression). RESULTS: We observed significant associations of psychological and physical gender abuse with major depression during follow-up. New or persistent experiences of both types of abuse were associated with 4- to 7-fold increases in the likelihood of incident major depression. Employment, transgender presentation, sex work, and hormone therapy correlated across time with psychological abuse; the latter 2 variables correlated with physical abuse. The association of psychological abuse with depression was stronger among younger than among older transgender women. CONCLUSIONS: Psychological and physical gender abuse is endemic in this population and may result from occupational success and attempts to affirm gender identity. Both types of abuse have serious mental health consequences in the form of major depression. Older transgender women have apparently developed some degree of resilience to psychological gender abuse.

Nuttbrock, L., Bockting, W., Rosenblum, A., Hwahng, S., Mason, M., Macri, M. et al. (2014). Gender abuse, depressive symptoms, and substance use among transgender women: a 3-year prospective study. American Journal of Public Health, 104(11), 2199-2206.

OBJECTIVES: We examined the effects of gender abuse (enacted stigma), depressive symptoms, and demographic, economic, and lifestyle factors on substance use among transgender women. METHODS: We conducted a 3-year prospective study (December 2004 to September 2007) of 230 transgender women aged 19 to 59 years from the New York Metropolitan Area. Statistical techniques included generalized estimating equations with logistic and linear regression links. RESULTS: Six-month prevalence of any substance use at baseline was 76.2%. Across assessment points, gender abuse was associated with alcohol, cannabis, cocaine, or any substance use during the previous 6 months, the number of days these substances were used during the previous month, and the number of substances used. Additional modeling associated changes in gender abuse with changes in substance use across time. Associations of gender abuse and substance use were mediated 55% by depressive symptoms. Positive associations of employment income, sex work, transgender identity, and hormone therapy with substance use were mediated 19% to 42% by gender abuse. CONCLUSIONS: Gender abuse, in conjunction with depressive symptoms, is a pervasive and moderately strong risk factor for substance use among transgender women. Improved substance abuse treatment is sorely needed for this population.

Nuttbrock, L., Bockting, W., Rosenblum, A., Hwahng, S., Mason, M. Macri, M., et al. (2015). Transgender community involvement and the psychological impact of abuse among transgender women. Psychology of Sexual Orientation and Gender Diversity, 2(4), 386-390.

Researchers have recently begun to examine resiliency among transgender persons with a few studies suggesting that the effects of stigma on psychological distress may be moderated by aspects of involvement with transgender peers. We extended this line of inquiry with a longitudinal study of transgender community involvement as a moderator of a previously observed association between gender abuse (enacted stigma) and major depression among 230 transgender women from the New York City Area. Statistical techniques including generalized estimating equations. With potential confounders controlled, the longitudinal association between gender abuse and depression was significantly moderated by community involvement. Abuse was strongly associated with depression among those with no community involvement; abuse was only marginally associated with depression among those with high levels of involvement. Involvement in a community of peers with shared experiences of gender abuse appears to protect transgender women from the depressogenic effect of this abuse. The implications and limitations of the study are discussed.

O’Cleirigh, C., Dale, S.K., Elsesser, S., Pantalone, D.W., Mayer, K.H., Bradford, J.B., et al., (2015). Sexual minority specific and related traumatic experiences are associated with increased risk for smoking among gay and bisexual men. Journal of Psychosomatic Research, 78(5), 472-477.

OBJECTIVE: This study examined the hypothesis that sexual minority specific stress and trauma histories may explain some of the risk for smoking among gay/bisexual men. METHODS: Patients at a Boston community health center were invited to complete a 25-item questionnaire assessing demographics, general health, trauma history, and substance use. Of the 3103 who responded, 1309 identified as male and gay or bisexual (82.8% White and mean age of 38.55 [sd = 9.76]). RESULTS: A multinomial logistic regression with never smoked as referent group and covariates of age, education, employment, HIV status, and race, showed that the number of sexual minority stressors/traumas were significantly related to the odds of both current and former smoking. In comparison to participants with no trauma history, those who reported 1, 2, 3, and 4 traumas had respectively 1.70 (OR = 1.70: 95% CI: 1.24-2.34), 2.19 (OR = 2.19: 95% CI: 1.48-3.23), 2.88 (OR = 2.88: 95% CI: 1.71-4.85), and 6.94 (OR = 6.94: 95% CI: 2.62-18.38) the odds of identifying as a current smoker. Adjusted logistic regression analysis revealed a significant dose effect of number of sexual minority stressors/traumas with odds of ever smoking. Experiencing intimate partner violence, anti-gay verbal attack, anti-gay physical attack, and childhood sexual abuse were each independently associated with increased odds of the smoking outcomes. CONCLUSION: A sexual minority specific trauma history may represent a vulnerability for smoking among gay/bisexual men. Interventions that address trauma may enhance the efficacy of smoking cessation programs and improve the mental health of gay/bisexual men.

Owen-Smith, A.A., Sineath, C., Sanchez, T., Dea, R., Giammattei, S., Gillespie, T., et al. (2017). Perception of community tolerance and prevalence of depression among transgender persons. Journal of Gay & Lesbian Mental Health, 21(1), 64-76.

Purpose: The goal of the study was to examine the association between depression and perceived community tolerance after controlling for various demographic and personal characteristics, treatment receipt, and past experiences with abuse or discrimination. Methods: An on-line survey assessed depressive symptoms among transgender and gender non-conforming individuals. Depression was assessed using the 7-item Beck Depression Inventory for Primary Care (BDI-PC) and the 10-item Center for Epidemiologic Studies Depression (CESD-10) scale. Results: The prevalence ratios (95% confidence intervals) comparing depression in persons who did and did not perceive their area as tolerant were 0.33 (0.20-0.54) for BD-PC and 0.66 (0.49-0.89) for CESD-10. Other factors associated with depression were experience with abuse or discrimination, lower education, and unfulfilled desire to receive hormonal therapy. Conclusion: Depression was common in this sample of transgender and gender non-conforming individuals and was strongly and consistently associated with participants’ perceptions of community tolerance, even after adjusting for possible confounding. The association between desire to receive hormonal therapy and depression is a finding that warrants further exploration. Future research should also assess depression and changes in perception of community tolerance in transgender individuals before and after initiation of gender confirmation treatment.

Page, M.J., Lindahl, K.M., & Malik, N.M. (2013). The role of religion and stress in sexual identity and mental health among lesbian, gay, and bisexual youth. Journal of Research on Adolescence, 23(4), 665-677.

This study investigated religious stress, gay-related stress, sexual identity, and mental health outcomes in lesbian, gay, and bisexual (LGB) adolescents and emerging adults. The model examined negative LGB identity as a mediator of the relationships between (1) religious stress and mental health, and (2) gay-related stress and mental health. The data indicated that negative LGB identity fully accounted for both relationships. Findings suggest that a negative sense of sexual identity for LGB youth helps explain the links between religious and gay-related stressors and mental health. As LGB youth may have limited control over these stressors, the importance of helping LGB youth maintain a positive LGB identity, despite homonegative messages from others, is discussed.

Patrick, D.L., Bell, J.F., Huang, J.Y., Lazarakis, N.C., & Edwards, T.C. (2013). Bullying and quality of life in youths perceived as gay, lesbian, or bisexual in Washington State, 2010. American Journal of Public Health, 103(7), 1255-1261.

OBJECTIVES: We examined the association between perceived sexual orientation (PSO), bullying, and quality of life (QOL) among US adolescents. METHODS: We analyzed data from the 2010 Washington State Healthy Youth Survey collected in public school grades 8, 10, and 12 (n = 27,752). Bullying status was characterized as never bullied, bullied because of PSO, or bullied for other reasons. Survey-weighted regression examined differences in QOL, depressed mood, and consideration of suicide by bullying status. RESULTS: Among male students, 14%, 11%, and 9% reported being bullied because of PSO in 8th, 10th, and 12th grades, respectively; and among female students, 11%, 10%, and 6%. In all gender and grade strata, being bullied because of PSO was associated with lower QOL scores and increased the odds of depressed mood or consideration of suicide. Moreover, the magnitudes of these associations were greater than for being bullied for other reasons. CONCLUSIONS: Bullying because of PSO is widely prevalent and significantly affects several facets of youth QOL. Bully-prevention or harm-reduction programs must address bullying because of PSO.

Paul, J.P., Catania, J., Pollack, L., Moskowitz, J., Canchola, J., Mills T., et al. (2002). Suicide attempts among gay and bisexual men: Lifetime prevalence and antecedents. American Journal of Public Health, 92(8), 1338-1345.

OBJECTIVES: We examined lifetime prevalence of suicide attempts and psychosocial correlates in a large population-based sample of men who have sex with men (MSM). METHODS: A telephone probability sample of US urban MSM (n = 2881) were interviewed between November 1996 and February 1998. RESULTS: Twenty-one percent had made a suicide plan; 12% had attempted suicide (almost half of those 12% were multiple attempters). Most who attempted suicide made their first attempt before age 25. Although prevalence of parasuicide (i.e., attempted suicide) has remained constant across birth cohorts, mean age at initial attempts has declined. CONCLUSIONS: MSM are at elevated risk for suicide attempts, with such risk clustered earlier in life. Some risk factors were specific to being gay or bisexual in a hostile environment.

Puckett, J.A, Woodward, E.N., Mereish, E.H., & Pantalone, D.W. (2015). Parental rejection following sexual orientation disclosure: Impact on internalized homophobia, social support, and mental health. LGBT Health, 2(3), 265-269.

Sexual minority individuals face unique stressors because of their sexual identity. We explored associations between parental reactions to children’s coming out, internalized homophobia (IH), social support, and mental health in a sample of 257 sexual minority adults. Path analyses revealed that higher IH and lower social support mediated the association between past parental rejection and current psychological distress. Mental health providers may benefit clients by utilizing interventions that challenge internalized stereotypes about homosexuality, increase social support, and process parental rejection, as well as focusing on how certain crucial experiences of rejection may impact clients’ IH and mental health.

Raifman, J., Moscoe, E., Austin, S. B., McConnell, M. (2017). Difference-in-differences analysis of the association between state same-sex marriage policies and adolescent suicide attempts. JAMA Pediatrics, 171(4), 350-356.

IMPORTANCE: Suicide is the second leading cause of death among adolescents between the ages of 15 and 24 years. Adolescents who are sexual minorities experience elevated rates of suicide attempts. OBJECTIVE: To evaluate the association between state same-sex marriage policies and adolescent suicide attempts. DESIGN, SETTING, AND PARTICIPANTS: This study used state-level Youth Risk Behavior Surveillance System (YRBSS) data from January 1, 1999, to December 31, 2015, which are weighted to be representative of each state that has participation in the survey greater than 60%. A difference-in-differences analysis compared changes in suicide attempts among all public high school students before and after implementation of state policies in 32 states permitting same-sex marriage with year-to-year changes in suicide attempts among high school students in 15 states without policies permitting same-sex marriage. Linear regression was used to control for state, age, sex, race/ethnicity, and year, with Taylor series linearized standard errors clustered by state and classroom. In a secondary analysis among students who are sexual minorities, we included an interaction between sexual minority identity and living in a state that had implemented same-sex marriage policies. INTERVENTIONS: Implementation of state policies permitting same-sex marriage during the full period of YRBSS data collection. MAIN OUTCOMES AND MEASURES: Self-report of 1 or more suicide attempts within the past 12 months. RESULTS: Among the 762‚678 students (mean [SD] age, 16.0 [1.2] years; 366‚063 males and 396‚615 females) who participated in the YRBSS between 1999 and 2015, a weighted 8.6% of all high school students and 28.5% of students who identified as sexual minorities reported suicide attempts before implementation of same-sex marriage policies. Same-sex marriage policies were associated with a 0.6-percentage point (95% CI, -1.2 to -0.01 percentage points) reduction in suicide attempts, representing a 7% relative reduction in the proportion of high school students attempting suicide owing to same-sex marriage implementation. The association was concentrated among students who were sexual minorities. CONCLUSIONS AND RELEVANCE: State same-sex marriage policies were associated with a reduction in the proportion of high school students reporting suicide attempts, providing empirical evidence for an association between same-sex marriage policies and mental health outcomes.

Raifman, J., Moscoe, E., Austin, S. B., Hatzenbuehler, M. L., & Galea, S. (2018). Association of state laws permitting denial of services to same-sex couples with mental distress in sexual minority adults: a difference-in-difference-in-differences analysis. JAMA Psychiatry, 75(7), 671-677.

IMPORTANCE: Recent evidence suggests that state policies affecting sexual minorities are associated with health disparities. Twelve states have laws permitting the denial of services to same-sex couples, and the US Supreme Court is considering whether states can prohibit the denial of services to same-sex couples. OBJECTIVE: We investigated whether state laws permitting individuals to refuse services to sexual minorities were associated with changes in the proportion of sexual minority adults reporting mental distress. DESIGN, SETTING, AND PARTICIPANTS: This difference-in-difference-in-differences linear regression analysis with state fixed effects used Behavioral Risk Factor Surveillance System (BRFSS) data from 2014 through 2016 from adults aged 18 to 64 years in 3 states that implemented laws permitting the denial of services to same-sex couples (Utah, Michigan, and North Carolina) and 6 nearby control states (Idaho and Nevada, Ohio and Indiana, and Virginia and Delaware, respectively). Sexual minority adults were defined as those who identified as gay, lesbian, bisexual, or not sure of their sexual orientation under a module on sexual orientation that BRFSS implemented in 2014 and each state could opt to include. Analysis controlled for year and individual-level sex, race, ethnicity, age group, educational attainment, income, employment, and marital status. A permutation test was conducted to precisely estimate statistical significance. EXPOSURES: An interaction term indicating whether individuals identified as a sexual minority and lived in a state with a law permitting denial of services to same-sex couples in 2015. MAIN OUTCOMES AND MEASURES: Mental distress, defined as poor mental health on 14 or more of the past 30 days. RESULTS: Of 109,089 participants, 4656 (4.8%; all percentages incorporate survey weights) identified as sexual minorities, 86141 (72.1%) were non-Hispanic white, and ages were uniformly distributed between 18 and 64 years. In 2014, 2038 of 16637 heterosexual adults (12.6%) and 156 of 815 sexual minority adults (21.9%) in the 3 same-sex denial states reported mental distress. The proportion of sexual minority adults reporting mental distress increased by 10.1 percentage points (95% CI, 1.8 to 18.5 percentage points, permutation-adjusted P value = 0.046) between 2014 and 2016 in states that passed laws permitting denial of services to same-sex couples compared with control states, a 46% relative increase in sexual minority adults experiencing mental distress. Laws permitting denial of services to same-sex couples were not associated with significant changes in heterosexual adults experiencing mental distress (-0.36 percentage points, 95% CI, -1.73 to 1.01 percentage points). CONCLUSIONS AND RELEVANCE: Laws permitting denial of services to same-sex couples, which exist in 12 states and are under consideration by the US Supreme Court, are associated with a 46% increase in sexual minority adults experiencing mental distress.

Reisner, S.L., Gamarel, K.E., Dunham, E., Hopwood, R., & Hwahng, S. (2013). Female-to-male transmasculine adult health: A mixed-methods community-based needs assessment. Journal of the American Psychiatric Nurses Association, 19(5), 293-303.

BACKGROUND: There is a dearth of health research about transgender people. OBJECTIVES: This mixed-methods study sought to formatively investigate the health and perceived health needs of female-to-male transmasculine adults. DESIGN: A cross-sectional quantitative needs assessment (n = 73) and qualitative open-ended input (n = 19) were conducted in June 2011. A latent class analysis modeled six binary health indicators (depression, alcohol use, current smoking, asthma, physical inactivity, overweight status) to identify clusters of presenting health issues. RESULTS: Four clusters of health indicators emerged: (a) depression; (b) syndemic (all indicators); (c) alcohol use, overweight status; and (d) smoking, physical inactivity, overweight status. Transphobic discrimination in health care and avoiding care were each associated with membership in the syndemic class. Qualitative themes included personal health care needs, community needs, and resilience and protective factors. CONCLUSIONS: Findings fill an important gap about the health of transmasculine communities, including the need for public health efforts that holistically address concomitant health concerns.

Reisner, S.L., Gamarel, K.E., Nemoto, T., Operario, D. (2014). Dyadic effects of gender minority stressors in substance use behaviors among transgender women and their non-transgender male partners. Psychology of Sexual Orientation and Gender Diversity, 1(1), 63-71.

BACKGROUND: Despite evidence that interpersonal processes shape health behaviors, research concerning the dyadic effects of gender minority stressors on substance use behaviors of transgender people is scarce. The objective of this study was to use dyadic analysis to examine whether transgender discrimination was associated with substance use among transgender women and their male partners. METHODS: Transgender women and their male partners (N=191 couples; N=382 individuals) completed questionnaires. Participants’ mean age was 37.1; 79.1% were racial/ethnic minority; 61.3% earned <$500 per-month. The mean relationship duration was 37.9 months. Actor-Partner Interdependence Models were used to examine the associations between transgender-related discrimination and past 30-day non-marijuana illicit drug use adjusting for age, relationship length, financial hardship, and depressive distress among partners in these dyads. RESULTS: Illicit drug use was reported by 31.4% of transgender women and 25.1% of their male partners. Perceived transgender discrimination was independently associated with increased odds of illicit drug use for transgender women (actor effect) but not for their male partners. Financial hardship statistically predicted drug use for both partners (actor effects). There were no partner effects for financial hardship on drug use. Overall, 34.5% of dyads had discrepant substance use. Discrimination scores of male partners differentiated dyads who reported discrepant substance use. DISCUSSION: Gender minority stressors are critical to understanding substance use among transgender women and their male partners. Integrating socioeconomic status into gender minority stress frameworks is essential. Results have implications for substance use prevention and treatment, including the need to incorporate gender minority stressors into interventions.

Reisner, S.L., Hughto, J.M., Dunham, E.E., Heflin, K.J., Begenyi. J.B., & Coffey-Esquivel, J. (2015). Legal protections in public accommodations settings: A critical public health issue for transgender and gender-nonconforming people. Milbank Quarterly, 93(3), 484-515.

POLICY POINTS: Since 2012, Massachusetts law has provided legal protections against discrimination on the basis of gender identity in employment, housing, credit, public education, and hate crimes. The law does not protect against discrimination based on gender identity in public accommodations settings such as transportation, retail stores, restaurants, health care facilities, and bathrooms. A 2013 survey of Massachusetts transgender and other gender minority adults found that in the past 12 months, 65% had experienced public accommodations discrimination since the law was passed. This discrimination was associated with a greater risk of adverse emotional and physical symptoms in the past 30 days. Nondiscrimination laws inclusive of gender identity should protect against discrimination in public accommodations settings to support transgender people’s health and their ability to access health care. CONTEXT: Gender minority people who are transgender or gender nonconforming experience widespread discrimination and health inequities. Since 2012, Massachusetts law has provided protections against discrimination on the basis of gender identity in employment, housing, credit, public education, and hate crimes. The law does not, however, protect against discrimination in public accommodations (eg, hospitals, health centers, transportation, nursing homes, supermarkets, retail establishments). For this article, we examined the frequency and health correlates of public accommodations discrimination among gender minority adults in Massachusetts, with attention to discrimination in health care settings. METHODS: In 2013, we recruited a community-based sample (n = 452) both online and in person. The respondents completed a 1-time, electronic survey assessing demographics, health, health care utilization, and discrimination in public accommodations venues in the past 12 months. Using adjusted multivariable logistic regression models, we examined whether experiencing public accommodations discrimination in health care was independently associated with adverse self-reported health, adjusting for discrimination in other public accommodations settings. FINDINGS: Overall, 65% of respondents reported public accommodations discrimination in the past 12 months. The 5 most prevalent discrimination settings were transportation (36%), retail (28%), restaurants (26%), public gatherings (25%), and health care (24%). Public accommodations discrimination in the past 12 months in health care settings was independently associated with a 31% to 81% increased risk of adverse emotional and physical symptoms and a 2-fold to 3-fold increased risk of postponement of needed care when sick or injured and of preventive or routine health care, adjusting for discrimination in other public accommodations settings (which also conferred an additional 20% to 77% risk per discrimination setting endorsed). CONCLUSIONS: Discrimination in public accommodations is common and is associated with adverse health outcomes among transgender and gender-nonconforming adults in Massachusetts. Discrimination in health care settings creates a unique health risk for gender minority people. The passage and enforcement of transgender rights laws that include protections against discrimination in public accommodations-inclusive of health care-are a public health policy approach critically needed to address transgender health inequities.

Reisner, S.L., Pardo, S.T., Gamarel, K.E., White Hughto, J.M., Pardee, D.J., & Keo-Meier, C.L. (2015). Substance use to cope with stigma in healthcare among U.S. female-to-male trans masculine adults. LGBT Health, 2(4), 324-332.

PURPOSE: Enacted and anticipated stigma exist within healthcare settings for transgender people, but research has yet to examine the effects of these forms of stigma on the substance use behaviors of female-to-male (FTM) trans masculine people. METHODS: Data were analyzed from the cross-sectional U.S. National Transgender Discrimination Survey, a convenience sample of transgender adults purposively sampled in 2008. Trans masculine respondents (n=2,578) were identified using a two-step method: Step 1, Assigned birth sex; Step 2, Current gender identity. A gender minority stress model of substance use was tested to examine the relation of enacted and anticipated stigma with substance use to cope with mistreatment. RESULTS: Overall, 14.1% of the sample reported having been refused care by a provider (enacted stigma), 32.8% reported delaying needed medical care when sick/injured, and 39.1% delayed routine preventive care (anticipated stigma). Having been refused care was significantly associated with avoidance of healthcare, including delaying needed medical care when sick/injured and delaying routine preventive medical care. Substance use to cope with mistreatment was self-reported by 27.6% of the sample. Enacted stigma by providers was associated with self-reported substance use to cope. Delays in both needed and preventive care (anticipated stigma) were highly associated with substance use, and attenuated the effect of enacted stigma. CONCLUSION: Gender minority-related stressors, particularly enacted and anticipated stigma in healthcare, should be integrated into substance use and abuse prevention and intervention efforts with this underserved population.

Reisner, S.L., White Hughto, J.M., Gamarel, K.E., Keuroghlian, A.S., Mizock, L. & Pachankis, J.E. (2016). Discriminatory experiences associated with posttraumatic stress disorder symptoms among transgender adults. Journal of Counseling Psychology, 63(5), 509-519.

Discrimination has been shown to disproportionately burden transgender people; however, there has been a lack of clinical attention to the mental health sequelae of discrimination, including posttraumatic stress disorder (PTSD) symptoms. Additionally, few studies contextualize discrimination alongside other traumatic stressors in predicting PTSD symptomatology. The current study sought to fill these gaps. A community-based sample of 412 transgender adults (mean age 33, SD = 13; 63% female-to-male spectrum; 19% people of color; 88% sampled online) completed a cross-sectional self-report survey of everyday discrimination experiences and PTSD symptoms. Multivariable linear regression models examined the association between self-reported everyday discrimination experiences, number of attributed domains of discrimination, and PTSD symptoms, adjusting for prior trauma, sociodemographics, and psychosocial comorbidity. The mean number of discrimination attributions endorsed was 4.8 (SD = 2.4) and the 5 most frequently reported reasons for discrimination were: gender identity and/or expression (83%), masculine and feminine appearance (79%), sexual orientation (68%), sex (57%), and age (44%). Higher everyday discrimination scores (beta = 0.25; 95% CL [0.21, 0.30]) and greater number of attributed reasons for discrimination experiences (beta = 0.05; 95% CL [0.01, 0.10]) were independently associated with PTSD symptoms, even after adjusting for prior trauma experiences. Everyday discrimination experiences from multiple sources necessitate clinical consideration in treatment for PTSD symptoms in transgender people.

Reitzel, L.R., Smith, N.G., Obasi, E.M., Forney, M. & Leventhal, A.M. (2017). Perceived distress tolerance accounts for the covariance between discrimination experiences and anxiety symptoms among sexual minority adults. Journal of Anxiety Disorders, 48, 22-27.

Sexual orientation-related discrimination experiences have been implicated in elevated rates of anxiety symptoms within sexual minority groups. Theory suggests that chronic discrimination experiences may dampen the ability to tolerate distress, increasing vulnerability for anxiety. This study examined the role of distress tolerance, or the capacity to withstand negative emotions, as a construct underlying associations between discriminatory experiences and anxiety among sexual minority adults. Participants (N=119; M age=36.4+/-14.8; 50% cisgender male, 31% cisgender female, 19% transgender; 37% non-Latino white) were recruited from Houston, Texas. Measures administered included the Heterosexist Harassment, Rejection, and Discrimination Scale (discrimination experiences), Distress Tolerance Scale (distress tolerance), and the State-Trait Inventory for Cognitive and Somatic Anxiety (anxiety). The association of discrimination experiences and anxiety through distress tolerance was assessed using covariate-adjusted mediation modeling. Results indicated that sexual orientation-related discrimination experiences were significantly and positively associated with anxiety and that this association was mediated through lower distress tolerance. Significant indirect effects were specific to cognitive (versus somatic) anxiety symptoms. Results suggest that distress tolerance may be an explanatory mechanism in the association between discriminatory experiences and cognitive symptoms of anxiety and a potentially relevant target within clinical interventions to address anxiety-related health disparities among sexual minority adults. However, more sophisticated designs are needed to delineate causal associations.

Rogers, A.H., Seager, I., Haines, N., Hahn, H., Aldao, A. & Woo-Young, A. (2017). The indirect effect of emotion regulation on minority stress and problematic substance use in lesbian, gay, and bisexual individuals. Frontiers in Psychology, 8, 1881.

Lesbian, gay, and bisexual (LGB) individuals report higher levels of problematic alcohol and substance use than their heterosexual peers. This disparity is linked to the experience of LGB-specific stressors, termed minority stress. Additionally, bisexual individuals show increased rates of psychopathology, including problematic alcohol and substance use, above and beyond lesbian and gay individuals. However, not everyone experiencing minority stress reports increased rates of alcohol and substance misuse. Emotion regulation (ER), which plays a critical role in psychopathology in general, is theorized to modulate the link between minority stress and psychopathology. However, it remains largely unknown whether ER plays a role in linking instances of minority stress with substance and alcohol use outcomes. To address the gap, the current study assessed 305 LGB individuals’ instances of minority stress, ER, and substance and alcohol use outcomes. We assessed the role of ER in problematic alcohol and substance use among LGB individuals using moderated mediation, where sexual minority status was entered as the moderator, and ER difficulties was entered as the mediator. The results indicated significant indirect effects of minority stress, through ER difficulties, on both problematic alcohol and substance use. However, there was no significant interaction with sexual orientation status, suggesting that ER may be important for all LGB individuals in predicting problematic alcohol and substance use. These results highlight the important role that ER plays between instances of minority stress and substance and alcohol use in LGB individuals, suggesting that ER skills may serve as a novel target for intervention.

Rood, B.A., Puckett, J.A., Pantalone, D.W., & Bradford, J.B. (2015). Predictors of suicidal ideation in a statewide sample of transgender individuals. LGBT Health, 2(3), 270-275.

Transgender individuals experience violence and discrimination, which, in addition to gender transitioning, are established correlates of psychological distress. In a statewide sample of 350 transgender adults, we investigated whether a history of violence and discrimination increased the odds of reporting lifetime suicidal ideation (SI) and whether differences in SI were predicted by gender transition status. Violence, discrimination, and transition status significantly predicted SI. Compared with individuals with no plans to transition, individuals with plans or who were living as their identified gender reported greater odds of lifetime SI. We discuss implications for SI disparities using Meyer’s minority stress model.

Rosario, M., Rotheram-Borus, M.J., & Reid, H. (1996). Gay-related stress and its correlates among gay and bisexual male adolescents of predominantly Black and Hispanic background. Journal of Community Psychology, 24(2), 136-159.

Examined the relationships among gay- and non-gay-related stressful life events, emotional distress, self-esteem, and multiple behavior problems (conduct problems, substance use and sexual risk acts) in 136 gay and bisexual male youths (aged 14-19 yrs); Ss were predominantly Hispanic or Black. Measures of anxiety, depression, phobic anxiety, conduct problems, substance use, sexual behaviors, stressful life events and self-esteem were completed by the Ss. Results indicate that increasing gay-related stressful life events were moderately related to emotional distress and multiple behavior problems. High self-esteem was related to low levels of emotional distress, but did not buffer the relationships between gay-related stressful life events and emotional distress or between these life events and the multiple problem behaviors.

Rose, S.M., & Mechanic, M.B. (2002). Psychological distress, crime features, and help-seeking behaviors related to homophobic bias incidents. American Behavioral Scientist, 46(1), 14-26.

Examined psychological distress, crime features, and help-seeking behaviors related to homophobic bias incidents. 290 lesbian, gay, and bisexual individuals (aged 17-58 yrs) provided detailed accounts of their most serious incident of homophobic victimization and were assessed regarding: (1) bias crime type; (2) psychological distress; (3) crime features; and (4) help-seeking behaviors. Results show that 73% of subjects had been the target of at least 1 homophobic incident. Victims of homophobic sexual assaults reported significantly more posttraumatic stress symptoms than did victims of bias threats, victims of other bias acts, and nonvictims. Bias sexual assaults were more likely to involve a known perpetrator, multiple perpetrators, and previous bias incidents. Bias physical assault victims more often had a history of at least 1 incident of nonbias violence. Sexual and physical assault victims were more likely to report the incident and seek other types of help. It is concluded that certain crime types and features result in more psychological distress for bias victims.

Rostosky, S.S., Riggle, E.D.B., Horne, S.G., & Miller, A.D. (2009). Marriage amendments and psychological distress in lesbian, gay, and bisexual (LGB) adults. Journal of Counseling Psychology, 56(1), 56-66.

An online survey of lesbian, gay, and bisexual (LGB) adults (N = 1,552) examined minority stress (I. H. Meyer, 2003) and psychological distress following the 2006 general election in which constitutional amendments to limit marriage to 1 man and 1 woman were on the ballot in 9 states. Following the November election, participants living in states that passed a marriage amendment reported significantly more minority stress (i.e., exposure to negative media messages and negative conversations, negative amendment-related affect, and LGB activism) and higher levels of psychological distress (negative affect, stress, and depressive symptoms) than participants living in the other states. Multiple hierarchical regression analyses revealed significant positive main effects of minority stress factors and state ballot status on psychological distress. In addition, the association between amendment-related affect and psychological distress was significantly higher in states that had passed a marriage amendment compared with other states. Discussion of these findings emphasizes that marriage amendments create an environment associated with negative psychological outcomes for LGB individuals.

Rotheram-Borus, M.J., Hunter, J., & Rosario, M. (1994). Suicidal behavior and gay-related stress among gay and bisexual male adolescents. Journal of Adolescent Research, 9(4), 498-508.

Examined the relationship between stress and attempted suicide in a consecutive series of 138 self-identified gay and bisexual males (aged 14-19 yrs), presenting at a social service agency for lesbian and gay adolescents in New York City. Ss were interviewed and completed the Adolescent Life Events Scale. 39% of the Ss had attempted suicide, and of those who had attempted, more than one-half had tried to kill themselves more than once. Suicide attempters were more likely to have dropped out of school, to live outside their homes, and to have friends or relatives who attempted suicide. Gay-related stressors were significantly more common among suicide attempters compared with nonattempters, but general life stress was not higher.

Rowe, C., Santos, G.M., McFarland, W., & Wilson, E.C. (2015). Prevalence and correlates of substance use among trans*female youth ages 16-24 years in the San Francisco Bay Area. Drug and Alcohol Dependence, 147, 160-166.

Background: Substance use is highly prevalent among transgender (trans) females and has been associated with negative health outcomes, including HIV infection. Little is known about psychosocial risk factors that may influence the onset of substance use among transfemale youth, which can contribute to health disparities during adulthood. Methods: We conducted a secondary data analysis of a study on HIV risk and resilience among transfemale youth (N =292). Prevalence of substance use was assessed and multivariable logistic regression models were used to examine the relationship between posttraumatic stress disorder (PTSD), psychological distress, gender-related discrimination, parental drug or alcohol problems (PDAP) and multiple substance use outcomes. Results: Most (69%) of the transfemale youth reported recent drug use. In multivariable analyses, those with PTSD had increased odds of drug use [AOR = 1.94 (95% CI = 1.09-3.44)]. Those who experienced gender-related discrimination had increased odds of drug use [AOR = 2.28 (95% CI =1.17-4.44)], drug use concurrent with sex [AOR = 2.35 (95% CI = 1.11-4.98)] and use of multiple drugs [AOR = 3.24 (95% CI = 1.52-6.88)]. Those with psychological distress had increased odds of using multiple heavy drugs [AOR = 2.27 (95% CI = 1.01-5.12)]. Those with PDAP had increased odds of drugs use [AOR=2.62 (95% CI = 1.43-4.82)], drug use concurrent with sex [AOR = 2.01 (95% CI, 1.15-3.51)] and use of multiple drugs [AOR = 2.10 (95% CI = 1.22-3.62)]. Conclusions: Substance use is highly prevalent among transfemale youth and was significantly associated with psychosocial risk factors. In order to effectively address substance use among transfemale youth, efforts must address coping related to gender-based discrimination and trauma. Furthermore, structural level interventions aiming to reduce stigma and gender-identity discrimination might also be effective.

Russell, S.T., Toomey, R.B., Ryan, C. & Diaz, R.M. (2014). Being out at school: The implications for school victimization and young adult adjustment. American Journal of Orthopsychiatry, 84(6), 635-643.

Many lesbian, gay, bisexual, and transgender (LGBT) adolescents disclose their sexual and/or gender identities to peers at school. Disclosure of LGBT status is linked with positive psychosocial adjustment for adults; however, for adolescents, “coming out” has been linked to school victimization, which in turn is associated with negative adjustment. This study investigates the associations among adolescent disclosure of LGBT status to others at school, school victimization, and young adult psychosocial adjustment using a sample of 245 LGBT young adults (aged 21-25 years, living in California). After accounting for the association between school victimization and later adjustment, being out at high school was associated with positive psychosocial adjustment in young adulthood. Results have significant implications for training of school-based health and mental health providers, education and guidance for parents and caregivers, fostering positive development of LGBT youth, and developing informed school policies and educational practices.

Ryan, C., Huebner, D., Diaz, R.M., & Sanchez, J. (2009). Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics, 123(1), 346-352.

OBJECTIVE: We examined specific family rejecting reactions to sexual orientation and gender expression during adolescence as predictors of current health problems in a sample of lesbian, gay, and bisexual young adults. METHODS: On the basis of previously collected in-depth interviews, we developed quantitative scales to assess retrospectively in young adults the frequency of parental and caregiver reactions to a lesbian, gay, or bisexual sexual orientation during adolescence. Our survey instrument also included measures of 9 negative health indicators, including mental health, substance abuse, and sexual risk. The survey was administered to a sample of 224 white and Latino self-identified lesbian, gay, and bisexual young adults, aged 21 to 25, recruited through diverse venues and organizations. Participants completed self-report questionnaires by using either computer-assisted or pencil-and-paper surveys. RESULTS: Higher rates of family rejection were significantly associated with poorer health outcomes. On the basis of odds ratios, lesbian, gay, and bisexual young adults who reported higher levels of family rejection during adolescence were 8.4 times more likely to report having attempted suicide, 5.9 times more likely to report high levels of depression, 3.4 times more likely to use illegal drugs, and 3.4 times more likely to report having engaged in unprotected sexual intercourse compared with peers from families that reported no or low levels of family rejection. Latino men reported the highest number of negative family reactions to their sexual orientation in adolescence. CONCLUSIONS: This study establishes a clear link between specific parental and caregiver rejecting behaviors and negative health problems in young lesbian, gay, and bisexual adults. Providers who serve this population should assess and help educate families about the impact of rejecting behaviors. Counseling families, providing anticipatory guidance, and referring families for counseling and support can help make a critical difference in helping decrease risk and increasing well-being for lesbian, gay, and bisexual youth.

Salfas, B., Rendina, H.J., & Parsons, J.T. (2018). What is the role of the community? Examining minority stress processes among gay and bisexual men. Stigma and Health, 4(3), 300-309.

Gay and bisexual men suffer from higher rates of mental health disorders than their heterosexual counterparts. Minority stress theory provides the framework for much research that seeks to explain this discrepancy. Recently, several studies have also examined the role of connection with the gay community, with mixed results. Operationalizing gay community connectedness in terms of two separate constructs–community involvement and community identification–this study sought to examine and compare the role that each of these factors plays in affecting gay and bisexual men’s mental health. We analyzed data from 371 gay and bisexual men in New York City, focusing on measures of minority stress factors, gay community connectedness, and mental health outcomes. As hypothesized, factor analysis showed that the community connectedness scale loaded onto two subfactors corresponding to the theorized constructs of identification and involvement. Linear regression models adjusting for potential confounding factors showed that community involvement was significantly associated with better mental health outcomes. Community involvement also significantly moderated the impact of internalized homonegativity on mental health. This factor was not a significant moderator of the impact of sexual orientation discrimination on mental health, and community identification was not significantly associated with mental health outcomes. It also did not significantly moderate the effect of either minority stress factor. Future research would benefit from developing an updated and highly reliable measure of community involvement.

Sanders, E.K., & Chalk, H.M. (2016). Predictors of psychological outcomes in nonheterosexual individuals. Psi Chi Journal of Psychological Research, 21(2), 100-110.

Gay, lesbian, bisexual, pansexual, and queer (GLBPQ) individuals have higher rates of negative psychological outcomes, but the reasons for these trends are unclear. Gay-related stress including internalized homophobia, perceived stigma, and overt discrimination may contribute to these heightened rates, but gay identity may buffer these consequences. GLBPQ individuals (N = 1,169) completed online surveys of gay-related stress, protective factors, and outcomes including depression, anxiety, stress, nonsuicidal self-injury, and suicidality. Hierarchical regressions were used to examine predictive relationships between gay-related stress, gay identity, and negative outcomes. Among gay/lesbian participants, overt discrimination predicted all outcomes; gay identity predicted Center for Epidemiologic Studies Depression Scale (CES-D) depression, Depression Anxiety Stress Scale (DASS) depression, and DASS stress; and internalized homophobia predicted Perceived Stress Scale (PSS) stress (p < .001). Among bisexual and pansexual participants, perceived stigma predicted CES-D depression, DASS depression, and Pereceived Stress Scale (PSS) stress, and overt discrimination predicted CES-D depression (p < .001). Gay identity predicted reduced negative outcomes among gay and lesbian people, but did not affect bisexual or pansexual people. Gay identity did not interact significantly with overt discrimination, perceived stigma, or internalized homophobia, challenging the hypothesis that it would buffer their effects. These results indicated that the factors may function differently in different populations, highlighting the need for further research on the topic.

Sandfort, T.G., Melendez, R.M., & Diaz, R.M. (2007). Gender nonconformity, homophobia, and mental distress in Latino gay and bisexual men. Journal of Sex Research, 44(2), 181-189.

This study explored whether gender nonconformity in gay and bisexual men is related to mental distress and if so, whether this relationship is mediated by negative experiences that are likely associated with gender nonconformity, including abuse and harassment. To study this question, data were analyzed from face-to face interviews with 912 self-identified gay and bisexual Latino men in three major U.S. cities collected by Diaz and colleagues (2001). Gay and bisexual Latino men who considered themselves to be effeminate had higher levels of mental distress and more frequently reported various negative experiences, compared with gay and bisexual Latino men who did not identify as effeminate. Higher levels of mental distress in effeminate men seemed to primarily result from more experiences of homophobia. Findings suggest the need for more attention to gender in research as well as counseling of sexual minority men.

Sandil, R., Robinson, M., Brewster, M.E., Wong, S., & Geiger, E. (2015). Negotiating multiple marginalizations: Experiences of South Asian LGBQ individuals. Cultural Diversity and Ethnic Minority Psychology, 21(1), 76-88.

Drawing from minority stress (Meyer, 2003) and feminist multicultural (Brown, 1994) theories, the present study investigated the additive and interactive relations between 2 types of external minority stress (heterosexist discrimination and racist events) and 4 internal stress processes related to identifying as a South Asian American lesbian, gay, bisexual, and queer (LGBQ) person (internalized heterosexism, acculturation, enculturation, and outness as LGBQ) with psychological distress. With 142 participants, Pearson’s correlations, multiple regression, and simultaneous multiple moderation analyses were conducted. Experiences of heterosexist discrimination, racist events, and internalized heterosexism were correlated positively with psychological distress and enculturation was correlated negatively. In a test of the additive model, heterosexist discrimination, racist events, and internalized heterosexism accounted for significant and unique variance in psychological distress, but outness, acculturation, and enculturation did not. To test the interactive model, the simultaneous moderating roles of the internal stress processes were examined in the links between the external minority stressors to psychological distress. Only outness as LGBQ emerged as a moderator. The link between racist events and psychological distress was exacerbated in instances of higher outness, such that respondents with high racist events and high outness reported the highest levels of psychological distress. Clinical implications of these findings are discussed and future research directions focused on the needs of South Asian American LGBQ people are suggested.

Schwartz, D.R., Stratton, N., & Hart, T.A. (2016). Minority stress and mental and sexual health: Examining the psychological mediation framework among gay and bisexual men. Psychology of Sexual Orientation and Gender Diversity, 3(3), 313-324.

Objective: Compared to heterosexual men, gay and bisexual men (GBM) are at an increased risk of adverse mental and sexual health outcomes. The psychological mediation framework (PMF; Hatzenbuehler, 2009) posits that minority stress is associated with changes in cognitive, affective, and social psychological processes, thereby leading to negative mental health outcomes among sexual minority individuals. This study examined whether these psychological processes account for the relationship between minority stress and poor mental health among GBM and extended the PMF to examine the effects on sexual health outcomes. Method: HIV-negative GBM (N = 465) completed a battery of self-report questionnaires assessing minority stress; cognitive, affective, and social processes; and mental and sexual health outcomes. Structural equation modeling was used to examine study hypotheses. Results: Findings partially supported the PMF by demonstrating that affective and social factors had a significant indirect effect in the relationship between minority stress and mental health outcomes; however, cognitive factors were nonsignificant. A significant indirect effect was found for cognitive factors in the relationship between minority stress and sexual health outcomes, whereas affective and social factors were nonsignificant. Conclusion: By uncovering the mediators underlying the relationship between minority stress and poor health outcomes, these findings have important clinical implications in the development of future interventions aimed at reducing adverse stigma-related health outcomes among GBM. The differential pattern of findings in the mental and sexual health models suggests that different psychological processes may need to be targeted in the treatment of mental health versus sexual health problems.

Seelman, K.L. (2016). Transgender adults’ access to college bathrooms and housing and the relationship to suicidality. Journal of Homosexuality, 63(10), 1378-99.

Transgender and gender non-conforming people frequently experience discrimination, harassment, and marginalization across college and university campuses (Bilodeau, 2007; Finger, 2010; Rankin et al., 2010; Seelman et al., 2012). The minority stress model (Meyer, 2007) posits that experiences of discrimination often negatively impact the psychological wellbeing of minority groups. However, few scholars have examined whether college institutional climate factors-such as being denied access to bathrooms or gender-appropriate campus housing-are significantly associated with detrimental psychological outcomes for transgender people. Using the National Transgender Discrimination Survey, this study analyzes whether being denied access to these spaces is associated with lifetime suicide attempts, after controlling for interpersonal victimization by students or teachers. Findings from sequential logistic regression (N = 2,316) indicate that denial of access to either space had a significant relationship to suicidality, even after controlling for interpersonal victimization. This article discusses implications for higher education professionals and researchers.

Seelman, K.L., Woodford, M.R., & Nicolazzo, Z. (2017). Victimization and microaggressions targeting LGBTQ college students: Gender identity as a moderator of psychological distress. Journal of Ethnic & Cultural Diversity in Social Work, 26(1-2), 112-125.

Lesbian, gay, bisexual, transgender, and queer and questioning (LGBTQ) discrimination continues to be common on college campuses. While a number of studies have examined blatant victimization among students, little attention has been given to LGBTQ microaggressions. In this study, we examine both blatant victimization and microaggressions and their association with psychological distress among LGBTQ college students (N = 497) and look at whether gender identity moderates these relationships. Both forms of discrimination are associated with lower self-esteem and greater stress and anxiety. Victimization is more negatively associated with self-esteem among trans students. Our findings emphasize the importance of addressing both blatant and subtle forms of discrimination targeting LGBTQ college students.

Shramko, M., Toomey, R.B., & Anhalt, K. (2018). Profiles of minority stressors and identity centrality among sexual minority Latinx youth. American Journal of Orthopsychiatry, 88(4), 471-482.

Few studies have examined how the amalgamation of minority stressors for youth with multiple marginalized identities is associated with well-being. Additionally, among youth with multiple marginalized identities, identity centrality may clarify the associations between specific types of minority stressors (i.e., bias-based peer victimization, perceived discrimination) and adjustment. This study sought to identify intersectional profiles of perceived peer victimization, perceived discrimination, and identity centrality, specific to either Latinx ethnicity or sexual minority identity in the United States. Demographic characteristics associated with each profile (i.e., age, socioeconomic status, gender nonconformity, survey language, gender, rurality) were examined, as well as associations between profiles and grade point average, self-esteem, and depression. In a sample of 219 in-school Latinx sexual minority youth (47% secondary, 53% postsecondary; M age = 19 years, SD = 2.3), four profiles of intersectional minority stress (perceived victimization, discrimination) and identity centrality were identified: (a) low stress, low centrality; (b) low stress, high centrality; (c) moderate stress, moderate centrality, and (d) high stress, moderate centrality. Men, youth who were relatively older, socioeconomically advantaged, gender nonconforming, and those living in urban areas had higher probabilities of membership in profiles with moderate and high stress. Compared to the low stress, low centrality profile, profiles with higher levels of intersectional stress were associated with maladjustment, whereas the profile characterized by low stress, high centrality had higher levels of self-esteem.

Simpson, C.C., Sutter, M., & Perrin, P.B. (2016). Can community consciousness be a bad thing? A moderated mediation analysis of heterosexism, mental health and body appreciation in sexual minority men. Culture, Health & Sexuality, 18(11), 1279-1294.

This study examined the connections between heterosexism, mental health, body appreciation and community consciousness in sexual minority men (SMM). Participants (n = 89) completed a national online survey. Simultaneous multiple regressions found that heterosexism explained 9.4% of the variance in body appreciation and 25.8% of the variance in mental health; mental health accounted for 28.0% of the variance in body appreciation. Within these models, harassment/rejection heterosexism was a unique positive predictor of mental health problems and a unique negative predictor of body appreciation; depression was a unique negative predictor of body appreciation. A moderated mediational model found that depression mediated the relationship between harassment/rejection heterosexism and body appreciation, but only in men who endorsed high community consciousness. Intervention research might benefit from helping SMM explore the ways in which body image is affected by heterosexism and mental health, as well as the ways that contemporary Western gay communities might contribute to these connections.

Slater, M.E., Godette, D., Huang, B., Ruan, W.J., & Kerridge, B.T. (2017). Sexual orientation-based discrimination, excessive alcohol use, and substance use disorders among sexual minority adults. LGBT Health, 4(5), 337-344.

PURPOSE: The purpose of this study was to examine relationships between sexual orientation-based discrimination and excessive alcohol use and substance use disorders and to identify how these relationships differ by sexual identity, sex, race, Hispanic origin, and education among sexual minorities. METHODS: We used logistic regression to analyze associations between discrimination and substance use measures among 1351 gay/lesbian, bisexual, or unsure adults from a nationally representative survey. Differential effects by sexual identity, sex, race, Hispanic origin, and education were assessed using interaction models followed by stratified models. RESULTS: Discrimination was associated with increased odds of the following: exceeding weekly drinking limits [adjusted odds ratio (aOR) = 1.52, 95% confidence interval (CI): 1.12-2.08] among bisexuals, any substance use disorder (aOR = 2.04, 95% CI: 1.41-2.95) and nicotine use disorder (aOR = 1.52, 95% CI: 1.08-2.14) among Hispanic sexual minorities, and exceeding weekly drinking limits (aOR = 1.56, 95% CI: 1.08-2.26) among those with a high school degree or less. CONCLUSION: Sexual orientation-based discrimination was associated with select substance use outcomes, especially among bisexuals, Hispanics, and less educated sexual minority adults, highlighting potential disparities associated with experiencing discrimination.

Smith, N.G., & Ingram, K.M. (2004). Workplace heterosexism and adjustment among lesbian, gay, and bisexual individuals: The role of unsupportive social interactions. Journal of Counseling Psychology, 51(1), 57-67.

This study examined the relationships between workplace heterosexism, unsupportive social interactions (negative responses from others concerning one’s experience of heterosexism), and adjustment among 97 employed lesbian, gay, and bisexual (LGB) individuals. Results revealed that heterosexism and unsupportive social interactions were each related to negative psychological health outcomes. After controlling for outness and involvement in the LGB community, responses characterized by blaming were found to moderate the relationship between heterosexism and both depression and distress. Contrary to predictions, results suggested that at low levels of blaming there was a positive relationship between heterosexism and both depression and distress. It may be possible that at low levels of blaming, the salient stressor was heterosexism, whereas at high levels of blaming, the salient stressor was the blaming itself.

Smith, E.R., & Perrin, P.B. (2017). Structural equation modeling linking perceived heterosexism, mental health, and nonsuicidal self-injury in ethnically diverse sexual minority men and women. Traumatology, 23(3), 258-264.

This study examined associations among experiences of perceived heterosexism, mental health, and nonsuicidal self-injury (NSSI) in an ethnically diverse sample of sexual minority adults (SMA). Participants self-identified as gay, bisexual, queer, or an ‘other’ nonheterosexual sexual orientation (n = 239), and completed a national online survey. In the total sample, 14.2% of participants reported having engaged in NSSI during the past year, and 35.6% at some point in their lifetime. 14.7% of women reported NSSI in the past year, slightly higher than men (13.5%), but this difference was not statistically significant. Women reported a 40.0% lifetime rate of NSSI, while men reported a 28.0% rate (p = .063). Two structural equation models (SEMs) were specified with perceived heterosexism leading to mental health and then to lifetime or past-year NSSI. Both models yielded adequate fit indices and contained statistically significant direct effects from perceived heterosexism to mental health and from mental health to NSSI. A statistically significant, partial mediation occurred from perceived heterosexism to past year NSSI via mental health, and a statistically significant full mediation occurred for the same paths to lifetime NSSI. NSSI-reduction interventions targeting SMA may benefit from incorporating an examination of the effects of perceived heterosexist discrimination on mental health and then on NSSI.

Sowe, B.J., Taylor, A.J., & Brown, J. (2017). Religious anti-gay prejudice as a predictor of mental health, abuse, and substance use. American Journal of Orthopsychiatry, 87(6), 690-703.

Anti-gay, or homonegative, prejudice is generally considered harmful to the wellbeing of sexual minority individuals. However, the origins or nature of such prejudice may vary. Despite a sizable body of literature suggesting homonegative prejudice is frequently religious-based, the psychological impact of exposure to religious anti-gay prejudice remains largely undetermined. Addressing this research gap, the authors examined whether opposition to same-sex sexuality on religious grounds predicted detrimental outcomes among same- and both-sex attracted individuals, as well as their heterosexual counterparts. A nationwide U.S. sample of 1600 individuals-recruited using contemporary online crowd-sourcing techniques designed to limit selection bias-completed a novel inventory assessing interpersonal exposure to religious (as well as nonreligious) homonegative disapproval. Outcome variables assessed included a number of clinically relevant measures spanning general mental health, social support, suicidality, abuse, and substance use. Analyses revealed that greater exposure to religious anti-gay prejudice predicted higher levels of anxiety, stress, and shame; more instances of physical and verbal abuse; and more problematic alcohol use. Furthermore, while sexual minority individuals tended to fare more poorly than their heterosexual counterparts on almost every outcome measure assessed, homonegative prejudice predicted poorer outcomes among all respondents regardless of their sexual orientation or religious identification. Hence, results are among the first to demonstrate that anti-gay religious exposure is associated with substantial threats to wellbeing, and that such effects may be observed beyond religious sexual minorities. Overall, findings imply that homonegative religious social conditions may be of broader health and mental health concern than is conventionally recognized.

Su, D., Irwin, J.A., Fisher, C., Ramos, A., Kelley, M., Mendoza, D.A.R., et al. (2016). Mental health disparities within the LGBT population: A comparison between transgender and nontransgender individuals. Transgender Health, 1(1), 12-20.

Purpose: This study assessed within a Midwestern LGBT population whether, and the extent to which, transgender identity was associated with elevated odds of reported discrimination, depression symptoms, and suicide attempts. Methods: Based on survey data collected online from respondents who self-identified as lesbian, gay, bisexual, and/or transgender persons over the age of 19 in Nebraska in 2010, this study performed bivariate t- or chi-square tests and multivariate logistic regression analysis to examine differences in reported discrimination, depression symptoms, suicide attempts, and self-acceptance of LGBT identity between 91 transgender and 676 nontransgender respondents. Results: After controlling for the effects of selected confounders, transgender identity was associated with higher odds of reported discrimination (OR=2.63, p<0.01), depression symptoms (OR=2.33, p<0.05), and attempted suicides (OR=2.59, p<0.01) when compared with nontransgender individuals. Self-acceptance of LGBT identity was associated with substantially lower odds of reporting depression symptoms (OR=0.46, p<0.001). Conclusion: Relative to nontransgender LGB individuals, transgender individuals were more likely to report discrimination, depression symptoms, and attempted suicides. Lack of self-acceptance of LGBT identity was associated with depression symptoms among transgender individuals.

Sun, C.J., Ma, A., Tanner, A.E., Mann, L., Reboussin, B.A., Garcia, M., et al. (2016). Depressive symptoms among Latino sexual minority men and Latina transgender women in a new settlement state: The role of perceived discrimination. Depression Research and Treatment, 2016, 4972854.

Background. Little is known about the role of discrimination on depression among Latino sexual and gender identity minorities. This manuscript examined the relationship between ethnic/racial discrimination and sexual discrimination on clinically significant depressive symptoms among Latino sexual minority men (i.e., gay and bisexual men and other men who have sex with men) and Latina transgender women. Methods. A community-based participatory research partnership recruited participants (N = 186; 80.6% cisgender men) in North Carolina to a social network-based HIV intervention. Using baseline data, we quantified the amount of perceived discrimination and conducted mixed-effects logistic regression analyses to examine correlates of clinically significant depressive symptoms. Results. A high percentage of participants reported ethnic/racial discrimination (73.7%) and sexual discrimination (53.8%). In the multivariable models, ethnic/racial discrimination, sexual discrimination, masculinity, fatalism, and social support were significantly associated with clinically significant depressive symptoms. Discussion. Improving mental health requires multilevel interventions that address pertinent individual, interpersonal, and system level factors.

Sutter M., & Perrin, P.B. (2016). Discrimination, mental health, and suicidal ideation among LGBTQ people of color. Journal of Counseling Psychology, 63(1), 98-105.

Discrimination based on race/ethnicity, sexual orientation, and gender identity has been linked to many negative psychological and physical health outcomes in previous research, including increased suicidal ideation. Two hundred lesbian, gay, bisexual, transgender, and queer (LGBTQ) people of color (POC) were surveyed on their experiences of LGBTQ-based discrimination, racism, mental health (depression, anxiety, satisfaction with life), and suicidal ideation in a national online study based in the United States. A structural equation model (SEM) was created and found that LGBTQ-based discrimination exerted an indirect effect on suicidal ideation through mental health. Racism exerted a direct effect on mental health but was not associated with suicidal ideation in the SEM. The effects of LGBTQ-based discrimination on mental health may be a key area for interventions to reduce suicidal ideation in LGBTQ POC.

Sutter, M., Perrin, P.B., & Trujillo, M.A. (2018). Understanding the association between discrimination and depression among sexual minority people of color: Evidence for diminishing returns of socioeconomic advantage. Journal of Clinical Psychology, 74(6), 940-952.

OBJECTIVE: To examine the differential association of heterosexism and racism on depression as moderated by socioeconomic status (SES) among sexual minority people of color. METHOD: A cross-sectional sample of sexual minority people of color (n = 170) was surveyed on their experiences of heterosexism, racism, depression, and SES in a national online study based in the United States. RESULTS: Bivariately, SES was inversely associated with depression, racism, and heterosexism. Moderation analyses found that for individuals with less socioeconomic advantage, the associations between heterosexism and depression were not as strong. However, at higher socioeconomic advantage, heterosexism was more strongly positively associated with depression. CONCLUSION: These results suggest that the effects of discrimination on depression in sexual minority individuals of color may be accentuated at higher socioeconomic levels. Implications suggest helping sexual minority clients of color from higher SES backgrounds explore the effects of discrimination on their mental health.

Szymanski, D.M. (2005). Heterosexism and sexism as correlates of psychological distress in lesbians. Journal of Counseling & Development, 83(3), 355-360.

This study examined the effects of external and internalized heterosexism and sexism on lesbians’ mental health. Hierarchical regression analysis, controlling for education and income, identified recent sexual-orientation-based hate crime victimization, recent sexist events, internalized heterosexism, and the interaction of recent sexual-orientation-based hate crime victimization and recent sexist events as significant predictors of psychological distress, accounting for 31% of the variance.

Szymanski, D.M. (2006). Does internalized heterosexism moderate the link between heterosexist events and lesbians’ psychological distress? Sex Roles, 54(3-4), 227-234.

The purpose of this study was to examine the relationship between heterosexist events and various indices of psychological distress in lesbians. In addition, it examined the potential moderating role of internalized heterosexism in the link between heterosexist events and psychological distress. Furthermore, psychometric support for the Heterosexist Harassment, Rejection, and Discrimination Scale (HHRDS) developed for this study is provided. Consistent with feminist theory and previous research, results indicated that recent perceived heterosexist harassment, rejection, and discrimination correlated positively with several indices of psychological distress. Contrary to research on gay men, internalized heterosexism did not moderate the relationship between external heterosexism and lesbians’ psychological distress.

Szymanski, D.M., & Meyer, D. (2008). Racism and heterosexism as correlates of psychological distress in African American sexual minority women. Journal of LGBT Issues in Counseling, 2(2), 94-108.

This study examined the relations between experiences of racism and heterosexism, both external and internalized, and African American sexual minority women’s psychological distress. Results indicated that racist events, heterosexist events, and internalized heterosexism each correlated positively with psychological distress; however, when examined together, only racist events and internalized heterosexism accounted for unique variance. Furthermore, internalized racism, the interaction of racist events and heterosexist events, and the interaction of internalized racism and internalized heterosexism did not predict psychological distress. The findings supported a ‘complex additive’ multicultural-feminist oppression perspective.

Szymanski, D.M., & Owens, G.P. (2009). Group-level coping as a moderator between heterosexism and sexism and psychological distress in sexual minority women. Psychology of Women Quarterly, 33(2), 197-205.

The purpose of this study was: (1) to examine concurrently the relationship between heterosexist events and sexist events and psychological distress and (2) to investigate sexual orientation-based and gender-based group-level coping as potential moderators of the heterosexism-distress and sexism–distress links among 282 lesbian and bisexual women. Findings from the Internet survey revealed that, when examined together, both heterosexism and sexism were unique and additive predictors of psychological distress. Results also supported a moderating role of feminist group-level coping in the link between number of sexist events and psychological distress, with the difference between the high- and low-feminist-activity groups occurring at the lower levels of sexism. Thus, it appears that high involvement in feminist activities may provide a buffer against the negative effects of sexism, but only when sexist events are relatively low in number.

Szymanski, D.M., & Sung, M.R. (2010). Minority stress and psychological distress among Asian American sexual minority persons. The Counseling Psychologist, 38(6), 848-872.

The purpose of this study was to examine multiple minority stressors (i.e., heterosexist events, racist events, heterosexism in communities of color, racism in sexual minority communities, race-related dating and relationship problems, internalized heterosexism or homophobia, outness to family, and outness to world) as they relate to the psychological distress of 144 Asian American lesbian, gay, bisexual, transgender, and questioning (LGBTQ) persons. When examined concomitantly, these minority stress variables accounted for approximately one third of the variance in psychological distress scores. Results indicate that heterosexism in communities of color, race-related dating and relationship problems in the LGBTQ community, internalized heterosexism, and outness to world were the only significant and unique predictors of Asian American LGBTQ persons’ psychological distress. In addition, no support was found for the moderating or mediating roles of outness in the internalized heterosexism-distress link.

Szymanski, D.M., & Balsam, K.F. (2011). Insidious trauma: Examining the relationship between heterosexism and lesbians’ PTSD symptoms. Traumatology, 17(2), 4-13.

Recently, scholars have begun to conceptualize oppressive experiences as traumatic events and have advocated that categories of traumatic events be expanded to include experiences of oppression that do not meet the traditional diagnostic criteria for posttraumatic stress disorder (PTSD). Building on this literature, this study explored the relationship between two kinds of heterosexist experiences, one that meets the traditional diagnostic criteria for PTSD (i.e., heterosexist hate crime victimization) and one that does not (i.e., heterosexist discrimination) and lesbians’ PTSD symptoms. Furthermore, it explored the potential moderating and mediating role of self-esteem in the heterosexism–PTSD symptom link. Results revealed that both heterosexist hate crime victimization and heterosexist discrimination were unique and significant positive predictors of lesbians’ PTSD symptoms. Support was found for a partially mediating but not a moderating role of self-esteem in the relationship between heterosexist discrimination and lesbians’ PTSD symptoms.

Szymanski, D.M., & Ikizler, A.S. (2013). Internalized heterosexism as a mediator in the relationship between gender role conflict, heterosexist discrimination, and depression among sexual minority men. Psychology of Men & Masculinities, 14(2), 211-219.

This study examined the relationships between gender role conflict, heterosexist discrimination, internalized heterosexism, and depression among 203 sexual minority men. Findings revealed that more gender role conflict occurring between work and family relations was uniquely and directly related to greater depression. In addition, internalized heterosexism fully mediated the relationships between both gender role conflicts around restrictive affectionate behavior between men and heterosexist discrimination and depression. That is, the findings are consistent with the notion that sexual minority men who experience more discomfort with expression of caring between men and more heterosexist discrimination may be more likely to experience internalized heterosexism which may lead to higher levels of depression. Gender role conflicts related to success, power, and competition and restrictive emotionality were not uniquely related to depression. Finally, the variables in the model accounted for 24% of the variance in depression scores.

Szymanski, D.M., Dunn, T.L., & Ikizler, A.S. (2014). Multiple minority stressors and psychological distress among sexual minority women: The roles of rumination and maladaptive coping. Psychology of Sexual Orientation and Gender Diversity, 1(4), 412-421.

Using Meyer’s (2003) minority stress and Hatzenbuehler’s (2009) psychological mediation models as theoretical frameworks, this study examined the relationships between external and internalized heterosexism and sexism and psychological distress beyond that which is accounted for by perceived general stress among 761 sexual minority women in the United States. The study also explored the potential mediating roles of rumination and maladaptive coping within these links. Findings suggest that heterosexist events, sexist events, internalized heterosexism, and internalized sexism are all unique predictors of psychological distress. In addition, rumination, coping with multiple minority stressors via detachment, and coping with multiple minority stressors via internalization mediated the external sexism–psychological distress link, the internalized heterosexism–psychological distress link, and the internalized sexism–psychological distress link. Coping with multiple minority stressors via detachment also mediated the external heterosexism–distress link. The variables in this model accounted for 62% of the variance in psychological distress scores. Future research and clinical implications are discussed.

Szymanski, D.M., & Henrichs-Beck, C. (2014). Exploring sexual minority women’s experiences of external and internalized heterosexism and sexism and their links to coping and distress. Sex Roles, 70(1-2), 28-42.

This study examined experiences of external and internalized heterosexism and sexism and their links to coping styles and psychological distress among 473 sexual minority women. Using an online sample of United States lesbian and bisexual women, the findings indicated that many participants experienced heterosexist and sexist events at least once during the past 6 months, and a number of participants indicated some level of internalized oppression. Supporting an additive multiple oppression perspective, the results revealed that when examined concurrently heterosexist events, sexist events, internalized heterosexism, and internalized sexism were unique predictors of psychological distress. In addition, suppressive coping and reactive coping, considered to be maladaptive coping strategies, mediated the external heterosexism-distress, internalized heterosexism-distress, and internalized sexism-distress links but did not mediate the external sexism-distress link. Reflective coping, considered to be an adaptive coping strategy, did not mediate the relations between external and internalized heterosexism and sexism and psychological distress. Finally, the variables in the model accounted for 54 % of the variance in psychological distress scores. These findings suggest that maladaptive but not adaptive coping strategies help explain the relationship between various oppressive experiences and psychological distress.

Szymanski, D.M., & Mikorski, R. (2016). External and internalized heterosexism, meaning in life, and psychological distress. Psychology of Sexual Orientation and Gender Diversity, 3(3), 265-274.

In the current study, we examined the mediating role of internalized heterosexism in the link between heterosexist discrimination and psychological distress among 361 lesbian, gay, and bisexual (LGB) persons who completed an online survey. We also examined the potential moderating role of meaning in life (both search for and presence of) in the links between heterosexist discrimination and psychological distress and between the heterosexist discrimination and internalized heterosexism. As such, we examined a moderated mediation model. We hypothesized that search for meaning would play an exacerbating role and presence of meaning would play a buffering role in these relationships. Results revealed internalized heterosexism mediated the heterosexist discrimination and psychological distress link. In addition, presence of meaning moderated and buffered the heterosexist discrimination-psychological distress link. Findings from the moderation analyses also revealed that the direct effect of heterosexist discrimination on internalized heterosexism and the conditional indirect effect of heterosexist discrimination on psychological distress were contingent on search for meaning such that these relationships were only significant among LGB persons with moderate to high levels of search for meaning. Finally, search for meaning did not moderate the heterosexist discrimination-psychological distress link and presence of meaning did not moderate the heterosexist discrimination-internalized heterosexism link.

Taliaferro, L.A., McMorris, B.J., & Eisenberg, M.E. (2018). Connections that moderate risk of non-suicidal self-injury among transgender and gender non-conforming youth. Psychiatry Research, 268, 65-67.

We examined associations between social connections and non-suicidal self-injury (NSSI) among transgender/gender non-conforming (TGNC) youth. Data came from the 2016 Minnesota Student Survey (N = 2168). Logistic regression analyses determined connectedness factors associated with any past-year NSSI and repetitive NSSI, as well as moderating effects of significant connectedness factors on different risk factors. Almost 55% of TGNC students engaged in NSSI, and 40% of self-injurers reported repetitive self-injury. Parent connectedness, connections to non-parental adults, and school safety emerged as robust protective factors. Strategies to prevent/reduce NSSI should focus on fostering connections with prosocial adults, and ensuring schools represent safe places.

Talley, A.E., & Bettencourt, B.A. (2011). The moderator roles of coping style and identity disclosure in the relationship between perceived sexual stigma and psychological distress. Journal of Applied Social Psychology, 41(12), 2883-2903.

The current study examined whether the association between perceived sexual stigma and psychological distress is influenced by individuals’ level of identity disclosure and their typical coping strategies. Regression analyses were conducted with data from a survey of 79 gay men and lesbians. Results revealed a 3-way interaction between participants’ perceived level of stigma, the extent of their identity disclosure, and their utilization of avoidant coping strategies in predicting their endorsement of depressive symptoms. Findings also revealed an interaction between participants’ perceived level of stigma, the extent of their identity disclosure, and their utilization of problem-solving coping strategies in predicting their endorsement of depressive symptoms. The implications are discussed with regard to various models of minority stress.

Tatum, A.K. (2017). The interaction of same-sex marriage access with sexual minority identity on mental health and subjective wellbeing. Journal of Homosexuality, 64(5), 638-653.

Previous psychological and public health research has highlighted the impact of legal recognition of same-sex relationships on individual identity and mental health. Using a sample of U.S. sexual minority (N = 313) and heterosexual (N = 214) adults, participants completed a battery of mental health inventories prior to the nationwide legalization of same-sex marriage. Analyses of covariance (ANCOVAs) examining identity revealed sexual minority participants living in states where same-sex marriage was banned experienced significantly higher levels of internalized homonegativity than sexual minority participants living in states where same-sex marriage was legal, even after controlling for state-level political climate. Mental health ANCOVAs revealed sexual minority participants residing in states without same-sex marriage experienced greater anxiety and lower subjective wellbeing compared to sexual minority participants residing in states with same-sex marriage and heterosexual participants residing in states with or without same-sex marriage. Implications for public policy and future research directions are discussed.

Tebbe, E.A., & Moradi, B. (2016). Suicide risk in trans populations: An application of minority stress theory. Journal of Counseling Psychology, 63(5), 520-533.

Drawing on minority stress theory, the present study tested the relations of minority stressors (i.e., experiences of prejudice and discrimination, internalized antitrans attitudes, fear of antitrans stigma), social support (i.e., friend, family, and significant other support), and substance use (i.e., drug and alcohol use) with depression and suicide risk in a sample of trans individuals. Depression was examined as a mediator of the relations of minority stressors and social support with suicide risk; drug and alcohol use were examined as direct correlates of suicide risk. Participants were 335 trans-identified individuals, diverse in gender identities (e.g., trans men, trans women, nonbinary gender identities). They were recruited using online social networks and they completed the study survey online via Qualtrics. Structural equation modeling was used to test hypothesized relations. Depression fully mediated the relations of perceived experiences of discrimination, fear of antitrans stigma, and friend support with suicide risk, and partially mediated the relation of internalized antitrans attitudes with suicide. Drug use was positively associated with suicide risk, whereas alcohol use was not linked with suicide risk. Exploratory comparisons across gender subgroups suggested that the pattern of relations among study variables was consistent across trans men, trans women, and individuals with nonbinary gender identities. These findings point to minority stressors, friend support, and drug use as potentially fruitful targets of prevention and intervention efforts to reduce depression and suicide risk in trans populations.

Testa, R.J., Sciacca, L.M., Wang, F., Hendricks, M.L., Goldblum, P., Bradford, J., et al. (2012). Effects of violence on transgender people. Professional Psychology: Research and Practice, 43(5), 452-459.

While recent research on transgender populations has demonstrated high rates of experiencing violence, there has been little research attention to the mental health implications of these experiences. This study utilized data collected from the Virginia Transgender Health Initiative Survey (THIS) of transgender people (individuals who described their gender identity as different from their sex assigned at birth) collected from 2005-2006. Current study analyses were limited to two subgroups: trans women (n = 179) and trans men (n = 92). We hypothesized that, as in the general population, exposure to physical and sexual violence would be related to suicidal ideation, suicide attempts, and substance abuse. Both trans women and trans men in this sample were at high risk for physical and sexual violence, as well as suicidal ideation and suicide attempt. Logistic regression analyses indicated that among both trans women and trans men, those who had endured physical and/or sexual violence were significantly more likely than those who had not had such experiences to report a history of suicide attempt and multiple suicide attempts. In addition, among trans men, history of physical and sexual violence were each related to alcohol abuse. Among trans women, history of sexual violence was related to alcohol abuse and illicit substance use. Patterns of violence against transgender people were identified and are discussed, including frequent gender-related motivation for violence, low prevalence of reporting violence to police, and variety of perpetrators of violence. Clinical implications and recommendations are provided.

Testa, R.J., Michaels, M.S., Bliss, W., Rogers, M.L., Balsam, K.F., & Joiner, T. (2017). Suicidal ideation in transgender people: Gender minority stress and interpersonal theory factors. Journal of Abnormal Psychology, 126(1), 125-136.

Research has revealed alarmingly high rates of suicidal ideation (SI) and suicide attempts among transgender and gender nonconforming (TGNC) people. This study aims to analyze the role of factors from the gender minority stress and resilience (GMSR) model (Testa, Habarth, Peta, Balsam, & Bockting, 2015), the interpersonal-psychological theory of suicide (IPTS; Joiner, 2005; Van Orden et al., 2010), and the potential integration of these factors, in explaining SI in this population. A convenience sample of 816 TGNC adults responded to measures of current SI, gender minority stressors, and IPTS factors. Path analysis was utilized to test 2 models. Model 1 evaluated the associations between external minority stressors and SI through internal minority stressors. Model 2 examined the relationships between internal minority stressors and SI through IPTS variables (perceived burdensomeness and thwarted belongingness). All GMSR external stressors (rejection, nonaffirmation, victimization, and discrimination), internal stressors (internalized transphobia, negative expectations, and nondisclosure), and IPTS factors (thwarted belongingness and perceived burdensomeness) were related to SI. Both models demonstrated good fit. Model 1 revealed that rejection, nonaffirmation, and victimization were related to SI through experiences of internalized transphobia and negative expectations. Model 2 indicated that internalized transphobia and negative expectations were associated with SI through IPTS factors. The models demonstrate pathways through which GMSR and IPTS constructs relate to one another and confer risk for SI among TGNC individuals. These pathways and several recently proposed constructs examined here provide promising directions for future research and clinical interventions in this area.

Toomey, R.B., Ryan, C., Diaz, R.M., Card, N.A., & Russell, S.T. (2010). Gender-nonconforming lesbian, gay, bisexual, and transgender youth: School victimization and young adult psychosocial adjustment. Developmental Psychology, 46(6), 1580-1589.

Past research documents that both adolescent gender nonconformity and the experience of school victimization are associated with high rates of negative psychosocial adjustment. Using data from the Family Acceptance Project’s young adult survey, we examined associations among retrospective reports of adolescent gender nonconformity and adolescent school victimization due to perceived or actual lesbian, gay, bisexual, or transgender (LGBT) status, along with current reports of life satisfaction and depression. The participants included 245 LGBT young adults ranging in age from 21 to 25 years. Using structural equation modeling, we found that victimization due to perceived or actual LGBT status fully mediates the association between adolescent gender nonconformity and young adult psychosocial adjustment (i.e., life satisfaction and depression). Implications are addressed, including specific strategies that schools can implement to provide safer environments for gender-nonconforming LGBT students.

Trujillo, M.A., Perrin, P.B., Sutter, M., Tabaac, A., & Benotsch, E.G. (2017). The buffering role of social support on the associations among discrimination, mental health, and suicidality in a transgender sample. International Journal of Transgenderism, 18(1), 39-52.

INTRODUCTION: Per the minority stress framework, trans individuals often experience psychological distress given the unique stress engendered by gender identity-related discrimination. Prior research has identified social support as particularly important for psychological distress and has suggested that social support may moderate this relationship. AIMS: The purpose of the current study was to explore the patterns of connections among discrimination, mental health, and suicidal ideation in trans individuals, and whether social support moderates these relationships. METHODS: Participants (N = 78) completed measures of these constructs as part of a national online survey. RESULTS: A series of simultaneous multiple regressions found that harassment/rejection discrimination was a unique positive predictor of mental health symptoms and suicidal ideation, with depression positively predicting suicidal ideation. A mediational model indicated that the association between harassment/rejection discrimination and suicidal ideation was fully mediated by depression. Three moderated meditational models were run, and one yielded a significant interaction, such that discrimination predicted suicidal ideation most strongly when participants had low social support from a significant other in comparison to moderate or high support. Further, conditional direct effects identified that discrimination led to ideation only for individuals with low support from friends or a significant other but not for those with moderate or high support. CONCLUSIONS: Helping trans individuals cope with harassment and rejection, particularly by drawing on social support, may promote better mental health, which could help reduce suicidality in this population.

Tucker, J.S., Ewing, B.A., Espelage, D.L., Green, H.D., Jr., de la Have, K. & Pollard, M.S. (2016). Longitudinal associations of homophobic name-calling victimization with psychological distress and alcohol use during adolescence. Journal of Adolescent Health, 59(1), 110-115.

PURPOSE: Homophobic victimization, and specifically name-calling, has been associated with greater psychological distress and alcohol use in adolescents. This longitudinal study examines whether sexual orientation moderates these associations and also differentiates between the effects of name-calling from friends and nonfriends. METHODS: Results are based on 1,325 students from three Midwestern high schools who completed in-school surveys in 2012 and 2013. Linear regression analysis was used to examine the associations among homophobic name-calling victimization and changes in anxiety symptoms, depressive symptoms, and alcohol use one year later, controlling for other forms of victimization and demographics. RESULTS: Homophobic name-calling victimization by friends was not associated with changes in psychological distress or alcohol use among either students who self-identified as heterosexual or those who self-identified as lesbian, gay, or bisexual (LGB). In contrast, homophobic name-calling by nonfriends was associated with increased psychological distress over a one-year period among LGB students and increased drinking among heterosexual students. CONCLUSIONS: Homophobic name-calling victimization, specifically from nonfriends, can adversely affect adolescent well-being over time and, thus, is important to address in school-based bullying prevention programs. School staff and parents should be aware that both LGB and heterosexual adolescents are targets of homophobic name-calling but may tend to react to this type of victimization in different ways. Further research is needed to understand the mechanisms through which homophobic victimization increases the risk of psychological distress and alcohol use over time.

Van Sluytman, L., Spikes, P., Nandi, V., Van Tieu, H., Frye, V., Patterson, J., et al., (2015). Ties that bind: Community attachment and the experience of discrimination among Black men who have sex with men. Culture, Health & Sexuality, 17(7), 859-872.

In the USA, the impact of psychological distress may be greater for Black men who have sex with men given that they may experience both racial discrimination in society at large and discrimination due to sexual orientation within Black communities. Attachments to community members may play a role in addressing psychological distress for members of this vulnerable population. This analysis is based on 312 Black men who have sex with men recruited for a behavioural intervention trial in New York City. Analyses were conducted using bivariate and multivariable logistic regression to examine the relationship of discrimination and community attachment to psychological distress. Most participants (63%) reported exposure to both discrimination due to race and sexual orientation. However, a majority of participants (89%) also reported racial and/or sexual orientation community attachment. Psychological distress was significant and negatively associated with older age (40 years and above), being a high school graduate and having racial and/or sexual orientation community attachments. Psychological distress was significantly and positively associated with being HIV-positive and experiencing both racial and sexual orientation discrimination. Similar results were found in the multivariable model. Susceptibility to disparate psychological distress outcomes must be understood in relation to social membership, including its particular norms, structures and ecological milieu.

Velez, B.L., Moradi, B., & Brewster, M.E. (2013). Testing the tenets of minority stress theory in workplace contexts. Journal of Counseling Psychology, 60(4), 532-542.

The links of minority stressors (workplace discrimination, expectations of stigma, internalized heterosexism, and identity management strategies) with psychological distress and job satisfaction were examined in a sample of 326 sexual minority employees. Drawing from minority stress theory and the literature on the vocational experiences of sexual minority people, patterns of mediation and moderation were tested. Minority stressors were associated with greater distress and lower job satisfaction. A mediation model was supported in which the links of discrimination and internalized heterosexism with psychological distress were mediated by a concealment-focused identity management strategy (i.e., avoiding), and the links of discrimination, expectations of stigma, and internalized heterosexism with job satisfaction were mediated by a disclosure-focused identity management strategy (i.e., integrating). Tests of moderation indicated that for sexual minority women (but not men), the positive association of discrimination with distress was stronger at higher levels of internalized heterosexism than at lower levels. In addition, lower levels of internalized heterosexism and concealment strategies (i.e., counterfeiting and avoiding) and higher levels of a disclosure strategy (i.e., integrating) were associated with higher job satisfaction in the context of low discrimination, but this buffering effect disappeared as level of discrimination increased. The implications of these findings for minority stress research are discussed, and clinical recommendations are made.

Velez, B.L., Moradi, B., & DeBlaere, C. (2015). Multiple oppressions and the mental health of sexual minority Latina/o individuals. Journal of Counseling Psychology, 43(1), 7-38.

This study investigated the additive and interactive relations of two forms of external oppression (racist discrimination and heterosexist discrimination) and internalized oppression (internalized racism and internalized heterosexism) with psychological distress, life satisfaction, and self-esteem in a sample of 173 sexual minority Latina/o adults. A combination of external and internalized oppressions was associated uniquely with psychological distress whereas the two internalized oppressions were linked uniquely with life satisfaction and self-esteem. The Racist discrimination x Internalized racism, Racist discrimination x Internalized heterosexism, and Heterosexist discrimination x Internalized racism interactions each accounted for unique variance in self-esteem. Specifically, low internalized racism protected self-esteem at low levels of racist discrimination, low internalized heterosexism protected self-esteem at high levels of racist discrimination, and low internalized racism protected self-esteem at high levels of heterosexist discrimination. Thus, multiple forms of oppression contribute additively and interactively to mental health in this population.

Velez, B.L., & Moradi, B. (2016). A moderated mediation test of minority stress: The role of collective action. Journal of Counseling Psychology, 44(8), 1132-1157.

In the present study, we extended minority stress theory by testing expectations of stigma, internalized heterosexism, and outness as mediators of the relations of heterosexist discrimination with psychological distress and well-being; testing collective action as a mental health promoter by examining its unique relations with distress and well-being; and testing collective action as a moderator of the direct and indirect relations of the minority stressors with mental health among 514 sexual minority adults. Path analyses indicated that heterosexist discrimination, expectations of stigma, internalized heterosexism, and outness were uniquely related to psychological distress, whereas heterosexist discrimination, internalized heterosexism, outness, and collective action were uniquely related to well-being. Expectations of stigma mediated the positive discrimination–distress link. Collective action buffered the direct heterosexist discrimination–internalized heterosexism relation as well as the indirect heterosexist discrimination–well-being relation through internalized heterosexism. Limitations of the study and implications for future research are discussed.

Velez, B.L., Watson, L.B., Cox, R., Jr., & Flores, M.J. (2017). Minority stress and racial or ethnic minority status: A test of the greater risk perspective. Psychology of Sexual Orientation and Gender Diversity, 4(3), 257-271.

Latent variable structural equation modeling (SEM) was used to test expectations of stigma, internalized heterosexism, and identity disclosure as mediators of the associations of heterosexist discrimination with psychological distress and well-being. Multigroup invariance testing was used to evaluate the predictions of the greater risk perspective, which contends that racial or ethnic minority (REM) sexual minorities (a) experience higher levels of minority stressors relative to their White peers and (b) that the associations among these stressors and between the stressors and mental health outcomes are stronger for REM sexual minority people than for White sexual minority people. Participants were 813 sexual minority adults (n = 318 REM; n = 495 White) who completed an online survey. Results of the SEM indicated that heterosexist discrimination, expectations of stigma, and low disclosure were each uniquely related to poorer mental health (i.e., higher distress, lower well-being); internalized heterosexism’s unique associations with both mental health outcomes were nonsignificant. Expectations of stigma and disclosure (but not internalized heterosexism) mediated the relations of heterosexist discrimination with psychological distress and well-being. The invariance tests did not support the predictions of the greater risk perspective. Implications of these findings for clinical work and research with racially and ethnically diverse sexual minority people are discussed.

Public Significance Statement: This study found that various heterosexist stressors were independently associated with poorer mental health among sexual minority people. Furthermore, the levels of these stressors and their associations with mental health did not differ between White and racial/ethnic minority people. Thus, it is important to explore the role of heterosexism in the lives and mental health of diverse sexual minority people.

Vigna, A.J., Poehlmann-Tynan, J., & Koenig, B.W. (2018). Does self-compassion facilitate resilience to stigma? A school-based study of sexual and gender minority youth. Mindfulness, 9(3), 914-924.

Mental health disparities among sexual and gender minority youth likely reflect a maladaptive coping response to contexts rife with stigma messaging and discrimination. Identifying adaptive coping responses to stigma messages is thus a critical step in reducing the disparities that manifest in adolescence. Guided by the minority stress hypothesis, this secondary data analysis (N = 1821) examined self-compassion (SC) as a potential resilience-promoting response to stigma messages received from bias-based bullying. In addition to accounting for more variation in mental health disparities than bias-based bullying, general victimization, and adverse childhood experiences combined, inclusion of SC in the models dramatically attenuated the impact of bias-based bullying, and finally, rates of bias-based bullying moderated the SC’s mediational effect on mental health symptomology. Furthermore, while the average SC scores were on par with those reported in adolescence elsewhere, examination of differences across sexuality and gender status reveals that sexual and gender minority youth report significantly lower rates of self-compassion, with a medium effect size. In sum, while deficits in SC appear to explain a greater degree of variation in mental health disparities than does exposure to adversity, high SC appears to be protective although rates of bias-based bullying erode its protective effects.

Walch, S.E., Ngamake, S.T., Bovornusvakool, W., & Walker, S.V. (2016). Discrimination, internalized homophobia, and concealment in sexual minority physical and mental health. Psychology of Sexual Orientation and Gender Diversity, 3(1), 37-48.

Mental and physical health disparities have been noted for sexual minorities. Minority stress models posit that discrimination plays an important role in these disparities. Evidence supporting the role of proximal and distal minority stressors in LGB mental health has accumulated, but examinations of the role of minority stress processes in LGB physical health remains limited. The role of proximal minority stressors of internalized homophobia and concealment in the relationship between the distal minority stressor of lifetime experiences with discrimination and mental and physical health status was examined among a nonprobability sample of 474 LGB adults. Lifetime reports of perceived discrimination were positively associated with both mental and physical health status. Structural equation modeling revealed a direct path between discrimination and physical health but the relationship between discrimination and mental health was explained by an indirect path through internalized homophobia, suggesting that internalized homophobia may influence the impact of discrimination on mental but not physical health, at least for LGB participants who conceal their sexual orientation. Model comparisons supported the indirect path between discrimination and mental health among LGB participants who conceal their sexual orientation but indicated direct paths between discrimination and both mental and physical health for LGB participants who widely disclose their sexual orientation. Efforts to reduce discrimination may be beneficial for LGB mental and physical health. Special attention to internalized homophobia is warranted for efforts to improve LGB mental health among those who are not able to be fully open about their sexual orientation.

Waldo, C.R., Hesson-McInnis, M.S., & D’Augelli, A.R. (1998). Antecedents and consequences of victimization of lesbian, gay, and bisexual young people: A structural model comparing rural university and urban samples. American Journal of Community Psychology, 26(2), 307-334.

Research indicates that antigay victimization is widespread and that lesbian, gay, and bisexual young people may be very vulnerable to such victimization. The current study builds upon previous work by Hershberger and D’Augelli (1995), who studied the consequences of sexual orientation-based victimization in 194 urban lesbian, gay, and bisexual youths. Using structural equation modeling, the present study models both antecedents and consequences (including psychological distress, self-esteem, and suicidality) of victimization via a secondary analysis of their data set. In addition, a second sample of 54 lesbian, gay, and bisexual youths from a rural university setting was examined to cross-validate and generalize the relationships found in urban settings. Results indicated that a revised model of victimization exhibited sufficient fit to the urban sample data and provided preliminary support for the generalizability of the model beyond the initial sample. Additional similarities were found between the urban and rural university community samples, including a high prevalence of reported suicide attempts: 42% of the urban sample and 32% of the rural university sample had attempted suicide at least once. Results indicated that victimization based on sexual orientation has similar correlates for young people in different community settings.

Walls, N.W., Laser, J., Nickels, S.J., & Wisneski, H. (2010). Correlates of cutting behavior among sexual minority youths and young adults. Social Work Research, 34(4), 213-226.

Using secondary analyses of data from a sample of 265 sexual minority youths, the authors examined correlates of cutting behavior to determine whether patterns are similar to those found in studies of self-injury with community samples of predominately heterosexual youths. The sample consisted of youths who received services at an urban social service agency serving the sexual minority community, youths from the region attending social events, who located the survey through the Internet, or who were referred from other youth-serving agencies; and youths from out of state who found the survey through the Internet or were referred by youth-serving agencies. Prevalence of cutting was higher than that found in community-based samples of similar age groups. However, similar patterns of risk were found with regard to peer victimization, homelessness, suicidality, and depression. Female and transgender respondents were more likely to have engaged in cutting behavior than were male respondents. No significant race-based differences emerged Both age and having knowledge of a supportive adult were associated with decreased likelihood of cutting. Additional findings link higher levels of ‘outness,’ higher occurrence of suicidality among social network, and higher rates of smoking to increased likelihood of cutting Implications for practice and future research are discussed.

Wang, S.B., & Borders, A. (2017). Rumination mediates the associations between sexual minority stressors and disordered eating, particularly for men. Eating and Weight Disorders, 22(4), 699-706.

PURPOSE: Sexual minority individuals experience unique minority stressors leading to negative clinical outcomes, including disordered eating. The psychological mediation framework posits that stress related to discrimination, internalized homonegativity, and concealment makes sexual minority individuals more vulnerable to maladaptive coping processes, such as rumination, known to predict disordered eating. The current study examined the influence of sexual minority stressors and rumination on disordered eating, and whether these associations differed between sexual minority men and women. We hypothesized that perceived discrimination, internalized homonegativity, and concealment would be positively associated with disordered eating, and that rumination about sexual minority stigma would mediate these associations. METHODS: One-hundred and sixteen individuals who identified as sexual minorities completed a survey study assessing perceived discrimination, internalized homonegativity, concealment, rumination about sexual minority stigma, and disordered eating. RESULTS: Discrimination and concealment uniquely predicted disordered eating in both men and women. However, rumination emerged as a significant mediator for concealment and (marginally) for discrimination for men only. Internalized homonegativity was not uniquely associated with rumination or disordered eating for men or women. CONCLUSIONS: Sexual minority men who experience discrimination and conceal their sexual orientation may engage in more disordered eating because they dwell on sexual minority stigma. We propose other potential mechanisms that may be relevant for sexual minority women.

Watson, L.B., Grotewiel, M., Farrell, M., Marshik, J., & Schneider, M. (2015). Experiences of sexual objectification, minority stress, and disordered eating among sexual minority women. Psychology of Women Quarterly, 39(4), 458-470.

Our study extended a modified version of objectification theory to a sample of sexual minority women in order to understand their experiences with body image and disordered eating concerns. Specifically, reported experiences of heterosexist discrimination and internalized heterosexism were integrated into the objectification theory framework. A total of 243 U.S. sexual minority women (primarily White and lesbian) participated in our online study. Results of a path analysis and tests of direct and indirect relations elucidated the important role of heterosexist experiences in sexual minority women’s eating disordered behaviors. Moreover, internalized sociocultural standards of beauty and internalized heterosexism were important predictors of sexual minority women’s body image concerns. Overall, our results supported the applicability of tenets of objectification theory to sexual minority women, with some important modifications. Our study demonstrates the importance of attending to stressors that uniquely affect sexual minority women, which arise from a sexist and heterosexist sociocultural context.

Watson, L.B., Velez, B.L., Brownfield, J. & Flores, M.J. (2016). Minority stress and bisexual women’s disordered eating: The role of maladaptive coping. Journal of Counseling Psychology, 44(8), 1158-1186.

The purpose of this study was to explore the link between bisexual women’s experiences of anti-bisexual discrimination and disordered eating, while examining potential mediating variables underlying this link: outness/identity concealment and maladaptive coping (i.e., coping via internalization, detachment, and drug and alcohol use). A total of 353 bisexual women participated in this study. The relationship between outness and disordered eating was not significant. Higher levels of anti-bisexual discrimination were related to more disordered eating behaviors, and this relationship was mediated by coping via internalization. However, anti-bisexual discrimination was directly related to more coping via detachment and drug and alcohol use. Findings from the study suggest that attending to bisexual women’s experiences of discrimination in counseling is particularly important. Moreover, assisting bisexual women in resisting internalization of discriminatory experiences may be a potential point of intervention for mental health professionals working with bisexual women experiencing disordered eating.

Watson, L.B., Morgan, S.K., & Craney, R. (2018). Bisexual women’s discrimination and mental health outcomes: The roles of resilience and collective action. Psychology of Sexual Orientation and Gender Diversity, 5(2), 182-193.

Using an additive intersectional perspective, this study examined the roles of antibisexual discrimination and sexist experiences in relation to bisexual women’s psychological distress and well-being. In addition, group- (i.e., feminist and lesbian, gay, bisexual, transgender, and queer [LGBTQ] collective action) and individual-level (i.e., resilience) protective factors were examined in these respective links. A total of 304 predominantly White, bisexual women participated in this study. At the bivariate level, results suggested that both antibisexual discrimination and sexist experiences were significantly related to more psychological distress. In addition, resilience and involvement in feminist and LGBTQ activities were related to more psychological well-being. When entered into a hierarchical regression analysis, sexism was uniquely positively related to psychological distress, whereas resilience and collective action were uniquely negatively related to distress. In addition, resilience moderated the sexism–distress link, such that the positive relationship became nonsignificant at high levels of resilience. In addition, resilience and collective action were uniquely positively related to psychological well-being. Results demonstrate the importance of attending to the role of discriminatory (i.e., antibisexual and sexist) experiences in bisexual women’s lives. Moreover, results suggest that resilience may be an important individual-level protective factor that may aid in bisexual women’s psychological health.

Public Significance Statement: Results from this study suggested that both anti-bisexual and sexist discrimination enhance psychological distress among bisexual women. In addition, individual- (i.e., resilience) and group-level (i.e., LGBTQ and feminist collective action) protective factors were related to less psychological distress and more psychological well-being. Last, results suggested that resilience may be an important variable to attend to in bisexual women’s lives, as it also buffered the link between sexism and psychological distress.

Weber, G.N. (2008). Using to numb the pain: Substance use and abuse among lesbian, gay and bisexual individuals. Journal of Mental Health Counseling, 30(1), 31-48.

The purpose of this study was to examine the relationship between heterosexist events, internalized homophobia, and substance use and abuse among 824 lesbian, gay, and bisexual (LGB) individuals. Participants completed the Schedule for Heterosexist Events (SHE), Internalized Homophobia Scale (IHP), Alcohol Use Disorders Identification Test (AUDIT), and the Drug Abuse Screening Test (DAST). A MANCOVA with age as a covariate and sexual orientation as a cofactor indicated there were significant differences in how lesbians, gay males, and bisexuals experienced heterosexism and internalized homophobia. In particular, gay males and lesbians reported experiencing more heterosexism than bisexuals, and gay males and bisexuals reported experiencing more internalized homophobia than lesbians. Participants who were classified as having at least one alcohol or drug use disorder were significantly more likely to have experienced heterosexism and internalized homophobia than those who were not classified as having a substance use disorder. Implications for mental health counselors, counselor educators, and researchers are noted.

White Hughto, J.M., & Reisner, S.L. (2016). Social context of depressive distress in aging transgender adults. Journal of Applied Gerontology, 37(12), 1517-1539.

This study investigates the relationship between discrimination and mental health in aging transgender adults. Survey responses from 61 transgender adults above 50 ( M age = 57.7, SD = 5.8; 77.1% male-to-female; 78.7% White non-Hispanic) were analyzed. Multivariable logistic regression models examined the relationship between gender- and age-related discrimination, number of everyday discrimination experiences, and past-week depressive distress, adjusting for social support, sociodemographics, and other forms of discrimination. The most commonly attributed reasons for experiencing discrimination were related to gender (80.3%) and age (34.4%). More than half of participants (55.5%) met criteria for past-week depressive distress. In an adjusted multivariable model, gender-related discrimination and a greater number of everyday discrimination experiences were associated with increased odds of past-week depressive distress. Additional research is needed to understand the effects of aging and gender identity on depressive symptoms and develop interventions to safeguard the mental health of this vulnerable aging population.

Whitton, S.W., Dyar, C., Newcomb, M.E. & Mustanski, B. (2018). Romantic involvement: A protective factor for psychological health in racially-diverse young sexual minorities. Journal of Abnormal Psychology, 127(3), 265-275.

Sexual minority youth experience elevated rates of internalizing disorders; it is, therefore, important to identify protective factors that decrease risk for psychological distress in this population. In this study, we examined whether involvement in a romantic relationship, a well-established protective factor for mental health among heterosexual adults, is also protective for young sexual minorities. Using eight waves of data provided by a community sample of 248 racially diverse sexual minority youth (ages 16-20 years at baseline), we assessed within-person associations between relationship involvement and psychological distress. Results from multilevel structural equation models indicated that, overall, participants reported less psychological distress at waves when they were in a relationship than when they were not. However, findings differed as a function of race/ethnicity and sexual orientation. Specifically, although relationship involvement predicted lower psychological distress for Black and gay/lesbian participants, the association was not present for White participants and, for bisexuals, relationship involvement predicted higher distress. In addition, relationship involvement reduced the negative association between victimization based on sexual minority status and psychological distress, suggesting a stress-buffering effect that did not differ based on demographic factors. Together, these findings suggest that being in a romantic relationship may promote mental health for many, but not all, young sexual minorities, highlighting the importance of attending to differences among subgroups of sexual minorities in research, theory, and efforts to reduce mental health disparities.

Wight, R.G., LeBlanc, A.J., de Vries, B., & Detels, R. (2012). Stress and mental health among midlife and older gay-identified men. American Journal of Public Health, 102(3), 503-510.

OBJECTIVES: We investigated associations between stress and mental health (positive affect, depressive symptoms) among HIV-negative and HIV-positive midlife and older gay-identified men, along with the mediating and moderating effects of mastery and emotional support. We also studied the mental health effects of same-sex marriage. METHODS: We obtained data from self-administered questionnaires completed in 2009 or 2010 by a subsample (n = 202; average age = 56.91 years; age range = 44-75 years) of participants in the University of California, Los Angeles component of the Multicenter AIDS Cohort Study, one of the largest and longest-running natural-history studies of HIV/AIDS in the United States. RESULTS: Both sexual minority stress (perceived gay-related stigma, excessive HIV bereavements) and aging-related stress (independence and fiscal concerns) appeared to have been detrimental to mental health. Sense of mastery partially mediated these associations. Being legally married was significantly protective net of all covariates, including having a domestic partner but not being married. Education, HIV status, and race/ethnicity had no significant effects. CONCLUSIONS: Sexual minority and aging-related stress significantly affected the emotional lives of these men. Personal sense of mastery may help to sustain them as they age. We observed specific mental health benefits of same-sex legal marriage.

Wight, R. G., Leblanc, A. J., & Badgett, M. V. L. (2013). Same-sex legal marriage and psychological well-being: findings from the California health interview survey. American Journal of Public Health, 103(2), 339-346.

We examined whether same-sex marriage was associated with nonspecific psychological distress among self-identified lesbian, gay, and bisexual adults, and whether it had the potential to offset mental health disparities between lesbian, gay, and bisexual persons and heterosexuals. Population-based data (weighted) were from the 2009 adult (aged 18-70 years) California Health Interview Survey. Within-group analysis of lesbian, gay, and bisexual persons included 1166 individuals (weighted proportion = 3.15%); within-group heterosexual analysis included 35 608 individuals (weighted proportion = 96.58%); and pooled analysis of lesbian, gay, and bisexual persons and heterosexuals included 36 774 individuals. Same-sex married lesbian, gay, and bisexual persons were significantly less distressed than lesbian, gay, and bisexual persons not in a legally recognized relationship; married heterosexuals were significantly less distressed than nonmarried heterosexuals. In adjusted pairwise comparisons, married heterosexuals had the lowest psychological distress, and lesbian, gay, and bisexual persons who were not in legalized relationships had the highest psychological distress (P < .001). Psychological distress was not significantly distinguishable among same-sex married lesbian, gay, and bisexual persons, lesbian, gay, and bisexual persons in registered domestic partnerships, and heterosexuals. Being in a legally recognized same-sex relationship, marriage in particular, appeared to diminish mental health differentials between heterosexuals and lesbian, gay, and bisexual persons. Researchers must continue to examine potential health benefits of same-sex marriage, which is at least in part a public health issue.

Wight, R.G., Harig, F., Aneshensel, C.S. & Detels, R. (2016). Depressive symptom trajectories, aging-related stress, and sexual minority stress among midlife and older gay men: Linking past and present. Research on Aging, 38(4), 427-452.

We concatenate 28 years of historical depressive symptoms data from a longitudinal cohort study of U.S. gay men who are now midlife and older (n = 312), with newly collected survey data to analyze trajectories of depressive symptomatology over time and their impact on associations between current stress and depressive symptoms. Symptoms are high over time, on average, and follow multiple trajectories. Aging-related stress, persistent life-course sexual minority stress, and increasing sexual minority stress are positively associated with depressive symptoms, net of symptom trajectories. Men who had experienced elevated and increasing trajectories of depressive symptoms are less susceptible to the damaging effects of aging-related stress than those who experienced a decrease in symptoms over time. Intervention efforts aimed at assisting gay men as they age should take into account life-course depressive symptom histories to appropriately contextualize the health effects of current social stressors.

Wilson, E.C., Chen, Y.H., Arayasirikul, S., Raymond, H.F., & McFarland, W. (2016). The impact of discrimination on the mental health of transfemale youth and the protective effect of parental support. AIDS and Behavior, 20(10), 2203-2211.

Significant health disparities exist for transgender female (transfemale) youth. We assessed differences in mental health outcomes based on exposure to discrimination among transgender female youth in the San Francisco Bay Area aged 16-24 years. Youth were recruited using a combination of respondent driven sampling with online and social media methods. Logistic regression models were used to estimate odds ratios for the mental health outcomes, comparing levels of discrimination and levels of resiliency promoting protective factors among sexually active youth in the sample (N = 216). High transgender-based discrimination was significantly associated with greater odds of PTSD (AOR, 2.6; 95 % CI 1.4-5.0), depression (AOR, 2.6; 95 % CI 1.2-5.9), and stress related to suicidal thoughts (AOR 7.7, 95 % CI 2.3-35.2). High racial discrimination was significantly associated with greater odds of psychological stress (AOR 3.6; 95 % CI 1.2-10.8), PTSD (AOR 2.1; 95 % CI 1.1-4.2) and stress related to suicidal thoughts (AOR 4.3, 95 % CI 1.5-13.3). Parental closeness was related to significantly lower odds of all four mental health outcomes measured, and intrinsic resiliency positively reduced risk for psychological stress, PTSD, and stress related to suicidal thoughts. Transgender and racial discrimination may have deleterious effects on the mental health of transfemale youth. Interventions that address individual and intersectional discrimination and build resources for resiliency and parental closeness may have success in preventing mental health disorders in this underserved population.

Wiseman, M.C., & Moradi, B. (2010). Body image and eating disorder symptoms in sexual minority men: A test and extension of objectification theory. Journal of Counseling Psychology, 57(2), 154-166.

On the basis of integrating objectification theory research with research on body image and eating problems among sexual minority men, the present study examined relations among sociocultural and psychological correlates of eating disorder symptoms with a sample of 231 sexual minority men. Results of a path analysis supported tenets of objectification theory with the sample. Specifically, findings were consistent with relations posited in objectification theory among sexual objectification experiences, internalization of cultural standards of attractiveness, body surveillance, body shame, and eating disorder symptoms. Within this set of positive relations, internalization of cultural standards of attractiveness partially mediated the link of sexual objectification experiences with body surveillance; body surveillance partially mediated the relation of internalization with body shame; and body shame partially mediated the relation of body surveillance with eating disorder symptoms. In addition to these relations, internalized homophobia was related to greater eating disorder symptoms through body shame, and recalled childhood harassment for gender nonconformity was linked with eating disorder symptoms through a positive series of relations involving internalization of cultural standards of attractiveness, body surveillance, and body shame.

Wong, C.F., Weiss, G., Ayala, G, & Kipke, M.D. (2010). Harassment, discrimination, violence, and illicit drug use among young men who have sex with men. AIDS Education and Prevention, 22(4), 286-298.

We examined the relationship among social discrimination, violence, and illicit drug use among an ethnically diverse cohort of young men who have sex with men (YMSM) residing in Los Angeles. Five Hundred twenty-six YMSM (aged 18-24 years) were recruited using a venue-based, stratified probability sampling design. Surveys assessed childhood financial hardship, violence (physical assault, sexual assault, intimate partner violence), social discrimination (homophobia and racism), and illicit drug use in the past 3 months. Analyses examined main and interaction effects of key variables on drug use. Experiences of financial hardship, physical intimate partner violence and homophobia predicted drug use. Although African American participants were less likely to report drug use than their Caucasian peers, those who experienced greater sexual racism were at significantly greater risk for drug use. Racial/ethnic minority YMSM were at increased risk for experiencing various forms of social discrimination and violence that place them at increased risk for drug use.

Wong, C.F., Schrager, S.M., Holloway, I.W., Meyer, I.H. & Kipke, M.D. (2014). Minority stress experiences and psychological well-being: the impact of support from and connection to social networks within the Los Angeles House and Ball communities. Prevention Science, 15(1), 44-55.

African American young men who have sex with men (AAYMSM) from the House and Ball communities are at high risk for HIV infection. Because these communities are not only sources of risk but also support for AAYMSM, researchers must also consider the resources these communities possess. This knowledge will assist in the formulation of more effective prevention strategies and intervention approaches. Using minority stress theory as a framework, the current study illustrates the impact minority stress has on the psychological well-being of a sample of MSM from the Los Angeles House and Ball communities and investigates how these factors affect the relationship between minority stress and psychological well-being. Surveys were administered to participants over the course of a year. Structural equation modeling was used to estimate a model of the associations between minority stressors, support, connection to social network, and psychological well-being/distress (N = 233). The results indicated significant associations between different sources of minority stress, including distal minority stress (e.g., racism, homophobia), gay identification, and internalized homophobia. Minority stressors were in turn significantly associated with greater distress. However, greater instrumental support significantly reduced the effects of distal minority stress on distress. Greater connection to social network also significantly reduced stress associated with gay identification on distress. The findings captured the diverse sources of minority stress faced by this population and how these stressors are interrelated to impact mental health. The results also illustrate how support from and connection to social networks can reduce the negative impact of minority stress experiences.

Woodford, M.R, Han, Y., Craig, S., Lim, C. & Matney, M.M. (2014). Discrimination and mental health among sexual minority college students: The type and form of discrimination does matter. Journal of Gay & Lesbian Mental Health, 18(2), 142-163.

Research indicates that interpersonal discrimination contributes to mental problems among sexual minorities. However, little attention has been given to subtle discrimination and witnessing discrimination. This study examines the relationship among sexual orientation, experiencing and witnessing hostility (e.g., verbal threats), incivility (e.g., dirty looks), heterosexist harassment (e.g., homophobic names), and moderate/high anxiety and depression symptoms among college students. Results indicated that experiencing hostility, incivility, and heterosexist harassment each partially mediated the relationship between sexual minority status and anxiety. Similar relationships were found for experiencing incivility and heterosexist harassment and depression. Witnessing hostility and heterosexist harassment partially mediated anxiety among sexual minority students.

Woodford, M.R., Kulick, A., & Atteberry, B. (2015). Protective factors, campus climate, and health outcomes among sexual minority college students. Journal of Diversity in Higher Education, 8(2), 73-87.

Heterosexism on campus can create a chilly climate for sexual minority students. Research has documented the negative impacts of campus climate on sexual minority students’ health; however, little research has examined the role of potential protective factors among this population. Drawing on data collected from self-identified sexual minority students as part of a larger campus climate study, we examine the relationship between heterosexism on campus (experiential and psychological) and mental health (depression, anxiety, and alcohol abuse) and negative physical health symptoms. To explore potential protective factors, we investigate the role of individual-level (self-esteem and physical exercise) and interpersonal-level (LGB friends and instructor relations) variables on the climate-mental/physical health relationships. Our findings suggest that experiencing heterosexist harassment, but not perceived attitudes toward sexual minorities, is a risk factor for all 4 outcomes. Further, exercise moderated the impacts of heterosexist harassment on depression and anxiety, self-esteem and LGB friends moderated the impacts of heterosexist harassment on risk for alcohol abuse, and instructor relations moderated the relationship between heterosexist harassment and negative physical health symptoms. Practitioners and researchers should consider the specific buffering impacts of protective factors on health outcomes among sexual minority students.

Woodford, M.R., Paceley, M.S., Kulick, A. & Hong, J.S. (2015). The LGBQ social climate matters: Policies, protests, and placards and psychological well-being among LGBQ emerging adults. Journal of Gay & Lesbian Social Services, 27(1), 116-141.

Sexual minority youth, including emerging adults, are at risk for negative health outcomes. Minority stress theory posits that heterosexism can contribute to these outcomes among sexual minorities. Researchers have tested this theory with respect to interpersonal heterosexism; however, little attention has been given to macro-level and environmental forms of heterosexism, especially among lesbian, gay, bisexual, and queer (LGBQ) youth. In this study, we examine the role of objective social climate (LGB state-level policies) and experiential distal and proximal environmental microaggressions on the psychological well-being of LGBQ emerging adults. Furthermore, we examine the role of LGBQ identity salience as a moderating factor on the macro/environmental-heterosexism and well-being relationship. Multivariable linear regression results suggest that living in a state without same-sex marriage laws is associated with greater self-esteem, whereas both distal and proximal environmental microaggressions are risk factors for anxiety and perceived stress. Furthermore, identity salience can ameliorate the effects of distal microaggressions and intensify the effects of proximal microaggressions and same-sex marriage legislation. Implications for practice with sexual minority youth are discussed.

Woodford, M.R., Kulick, A., Garvey, J.C., Sinco, B.R., & Hong, J.S. (2018). LGBTQ policies and resources on campus and the experiences and psychological well-being of sexual minority college students: Advancing research on structural inclusion. Psychology of Sexual Orientation and Gender Diversity, 5(4), 445-456.

Among sexual minority (LGBQ+) college students, research suggests that experiencing heterosexist discrimination can contribute to poor psychological well-being. Institutional policies and resources can also affect students’ well-being and experiences, but structural-level factors have received little empirical attention among this population. We present the results of a cross-sectional study that investigates the association between campus-based structural factors and the experiences and psychological well-being of cisgender LGBQ+ college students. Participants (n = 268, 58% undergraduates; 25% students of color; 62% gay/lesbian) from 58 colleges completed an anonymous online survey addressing experiential heterosexism and psychological well-being. Based on information available on each college’s website/staff interviews, we documented the existence of 11 policies and institution- or student-operated resources/programs designed to promote the inclusion and well-being of sexual and gender minorities (LGBTQ). Combining survey and objective data, we examined participants’ experiences of heterosexist discrimination (victimization, microaggressions), psychological distress (perceived stress, anxiety), and self-acceptance (self-esteem, pride) and associations with each LGBTQ-related policy and resource. Structural equation modeling results suggest nondiscrimination policies inclusive of gender identity and sexual orientation (vs. only sexual orientation), offering at least one for-credit LGBTQ course, and a higher ratio of LGBTQ student organizations to the student population were directly associated with participants reporting lower levels of discrimination, which was associated with less distress and higher self-acceptance. The results underscore the importance of particular structural initiatives on campus in protecting LGBQ+ collegians from discrimination. The findings also highlight the value of studying specific structural initiatives when investigating structural stigma and inclusion.

Public Significance Statement: Sexual minority students face discrimination on college campuses, which can threaten their psychological well-being. This study suggests that campus-based structural initiatives, namely antidiscrimination policies that enumerate both sexual orientation and gender identity (vs. sexual orientation only), offering at least one for-credit LGBTQ courses, and the more LGBTQ student organizations available on campus can lower rates of heterosexist discrimination on campus. By reducing rates of discrimination, these initiatives can also indirectly foster students’ psychological well-being.

Wray, T.B., Pantalone, D.W., Kahler, C.W., Monti, P.M., & Mayer, K.H. (2016). The role of discrimination in alcohol-related problems in samples of heavy drinking HIV-negative and positive men who have sex with men (MSM). Drug and Alcohol Dependence, 166, 226-234.

BACKGROUND: Heavy drinking is a major public health concern among men who have sex with men (MSM), as it is in many other populations. However, the consequences of heavy drinking among MSM may be particularly severe, especially for sexual risk behavior, due to the relatively high prevalence of HIV. Minority stress models suggest that, among members of marginalized groups, discrimination may be associated with heavier alcohol use as these individuals increasingly drink to cope with such experiences. Past studies have provided some support for this association. However, they have not explored the role other drinking motives play, how these relationships might differ across MSM who are HIV-positive versus HIV-negative, or how this relationship extends to alcohol-related problems. METHODS: In this study, we used path modeling to explore associations between perceived discrimination experiences, drinking motives, alcohol use, and alcohol-related problems in samples of heavy drinking MSM with and without HIV. RESULTS: In both HIV-negative and positive MSM, perceived discrimination was significantly positively associated with alcohol problems. Drinking to cope appears to play an important role in this relationship in both samples. Reporting more discrimination experiences was associated with drinking more frequently for sexual reasons among both groups. While the total effect of drinking to facilitate sex was positively associated with alcohol-related problems, sex motives did not mediate associations between discrimination and either drinking outcome. CONCLUSION: These results suggest that interventions addressing discrimination and specific drinking motivations may be useful in helping reduce alcohol use of heavy drinking MSM.

Yang, M.F., Manning, D., van den Berg, J.J., & Operario, D. (2015). Stigmatization and mental health in a diverse sample of transgender women. LGBT Health, 2(4), 306-312.

PURPOSE: Previous research indicates elevated risk for psychological distress in sexual and gender minority populations, and some research suggests that stigma contributes to elevated psychological distress among members of these groups. This study examined the hypothesis that exposure to transgender-related stigma (TRS) is associated with both higher levels of depression and anxiety among transgender women. METHODS: We analyzed data from a diverse sample of 191 adult transgender women living or working in the San Francisco Bay area who were recruited using purposive sampling methods to participate in a cross-sectional survey, which included measures of stigmatization, depression, and anxiety. RESULTS: Higher levels of exposure to TRS were independently associated with higher levels of depression (beta=0.31, P<.001) and anxiety (beta=39, P<.001), adjusting for self-reported health and sociodemographic co-variates. Associations between stigmatization, depression, and anxiety were not moderated by participants’ age or race/ethnicity. CONCLUSION: Findings suggest a need for counseling interventions to address the role of stigmatization as a factor potentially contributing to psychological distress among transgender women. This research further highlights the need to develop a stronger evidence base on effective counseling approaches to improve the mental health of transgender women.

Ylioja, T., Cochran, G., Woodford, M.R. & Renn, K.A. (2018). Frequent experience of LGBQ microaggression on campus associated with smoking among sexual minority college students. Nicotine and Tobacco Research, 20(3), 340-346.

Introduction: Lesbian, gay, bisexual, or queer/questioning (LGBQ) microaggressions refer to oftenunintentional insults, assaults, and invalidations that denigrate sexual minorities. While experiencing hostile discrimination and violence has previously been associated with elevated rates of smoking cigarettes for LGBQ college students, the relationship between LGBQ microaggressions and smoking is unknown. Methods: Data from a national anonymous online survey of sexual and gender minority college students were used to examine the relationship between past month cigarette smoking and interpersonal LGBQ microaggressions. Multivariable logistic regression assessed the relationship between smoking and frequent (chronic) experiences of microaggressions, using a hierarchical procedure to control for demographics, predictors of smoking, and academic factors. Results: Past year frequent LGBQ microaggression was reported by 48% of respondents and was more common among students who smoked in past 30 days. Experiencing past year physical violence was reported by 15% and did not differ by smoking status. Past year frequent experience of microaggressions was associated with increased odds of 1.72 (95% CI 1.03-2.87) for past 30-day smoking after adjusting for age, gender, race, socioeconomic indicators, alcohol misuse, physical violence, as well as academic stress and engagement. Conclusions: The results indicate that frequently experiencing LGBQ microaggressions is a risk factor for LGBQ college students smoking cigarettes. The mechanisms underlying this relationship require additional research, as does identifying positive coping strategies and institutional strategies to address LGBQ microaggressions on campuses. Tobacco control efforts should consider the impact of microaggression on the social environment for the prevention and treatment of tobacco use among LGBQ individuals. Implications: Microaggressions related to sexual minority identity include subtle forms of discrimination experienced during daily interactions that can create hostile and stressful social environments for a socially disadvantaged group. Prior research has demonstrated that LGBQ college students have higher rates of cigarette smoking, and that experiencing identity-based violence is a risk factor. This study revealed that experiencing frequent LGBQ microaggressions on college campus is associated with increased likelihood of current smoking among LGBQ college students.

Zakalik, R.A., & Wei, M. (2006). Adult attachment, perceived discrimination based on sexual orientation, and depression in gay males: Examining the mediation and moderation effects. Journal of Counseling Psychology, 53(3), 302-313.

This study examined perceived discrimination as both a mediator and moderator between adult attachment (anxiety and avoidance) and levels of depression in a gay male sample. Survey data were collected from 234 self-identified gay males through the Internet and in person through community resources across several states. Results from structural equation modeling analyses indicated that perceived discrimination partially mediated the relationship between attachment anxiety (but not attachment avoidance) and depression. Moderation of attachment (anxiety and avoidance) by perceived discrimination on levels of depression was not supported. Additionally, about 23% of the variance in perceived discrimination was explained by attachment, and 47% of the variance in depression was accounted for by attachment and perceived discrimination. Clinical implications, limitations, and areas for future research are also discussed.

Zamboni, B.D., & Crawford, I. (2007). Minority stress and sexual problems among African-American gay and bisexual men. Archives of Sexual Behavior, 36(4), 569-578.

Minority stress, such as racism and gay bashing, may be associated with sexual problems, but this notion has not been examined in the literature. African-American gay/bisexual men face a unique challenge in managing a double minority status, putting them at high risk for stress and sexual problems. This investigation examined ten predictors of sexual problems among 174 African-American gay/bisexual men. Covarying for age, a forward multiple regression analysis showed that the measures of self-esteem, male gender role stress, HIV prevention self-efficacy, and lifetime experiences with racial discrimination significantly added to the prediction of sexual problems. Gay bashing, psychiatric symptoms, low life satisfaction, and low social support were significantly correlated with sexual problems, but did not add to the prediction of sexual problems in the regression analysis. Mediation analyses showed that stress predicted psychiatric symptoms, which then predicted sexual problems. Sexual problems were not significantly related to HIV status, racial/ethnic identity, or gay identity. The findings from this study showed a relationship between experiences with racial and sexual discrimination and sexual problems while also providing support for mediation to illustrate how stress might cause sexual problems. Addressing minority stress in therapy may help minimize and treat sexual difficulties among minority gay/bisexual men.

Austin, A., & Craig, S.L. (2013). Support, discrimination, and alcohol use among racially/ethnically diverse sexual minority youths. Journal of Gay & Lesbian Social Services, 25(4), 420-442.

Rates of alcohol use for sexual minority youths are nearly twice that of their heterosexual peers, yet specific risk and protective factors associated with alcohol use among sexual minority youths remain unclear. Structural equation modeling is used to examine relations among alcohol use, peer and family support, and discrimination among 207 diverse sexual minority youths. Discrimination had no relationship to alcohol use; however, it was negatively associated with peer and family support. Peer support was associated with greater alcohol use among bisexual youths. This study adds to our understanding of the roles of discrimination, social support, and alcohol use among diverse sexual minority youths.

Everett, B.G., Rosario, M., McLaughlin, K.A., & Austin, S.B. (2014). Sexual orientation and gender differences in markers of inflammation and immune functioning. Annals of Behavioral Medicine, 47(1), 57-70.

BACKGROUND: Sexual minorities have documented elevated risk factors that can lead to inflammation and poor immune functioning. PURPOSE: This study aims to investigate disparities in C-reactive protein (CRP) and Epstein-Barr virus (EBV) by gender and sexual orientation. METHODS: We used the National Longitudinal Study of Adolescent Health to examine disparities in CRP (N = 11,462) and EBV (N = 11,812). RESULTS: Among heterosexuals, women had higher levels of CRP and EBV than men. However, sexual minority men had higher levels of CRP and EBV than heterosexual men and sexual minority women. Lesbians had lower levels of CRP than heterosexual women. CONCLUSIONS: Gender differences in CRP and EBV found between men and women who identify as 100 % heterosexual were reversed among sexual minorities and not explained by known risk factors (e.g., victimization, alcohol and tobacco use, and body mass index). More nuanced approaches to addressing gender differences in sexual orientation health disparities that include measures of gender nonconformity and minority stress are needed.

Gamarel, K.E., Reisner, S.L., Parsons, J.T., & Golub, S.A. (2012). Association between socioeconomic position discrimination and psychological distress: Findings from a community-based sample of gay and bisexual men in New York City. American Journal of Public Health, 102(11), 2094-2101.

OBJECTIVES: We examined the association between discrimination and mental health distress, focusing specifically on the relative importance of discrimination because of particular demographic domains (i.e., race/ethnicity, socioeconomic position [SEP]). METHODS: The research team surveyed a sample of gay and bisexual men (n = 294) at a community event in New York City. Participants completed a survey on demographics, discrimination experiences in the past 12 months, attributed domains of discrimination, and mental health distress. RESULTS: In adjusted models, discrimination was associated with higher depressive (B = 0.31; P < .01) and anxious (B = 0.29; P < .01) symptoms. A statistically significant quadratic term (discrimination-squared; P < .01) fit both models, such that moderate levels of discrimination were most robustly associated with poorer mental health. Discrimination because of SEP was associated with higher discrimination scores and was predictive of higher depressive (B = 0.22; P < .01) and anxious (B = 0.50; P < .01) symptoms. No other statistically significant relationship was found between discrimination domains and distress. CONCLUSIONS: In this sample, SEP emerged as the most important domain of discrimination in its association with mental health distress. Future research should consider intersecting domains of discrimination to better understand social disparities in mental health.

McBee-Strayer, S.M., & Rogers, J.R. (2002). Lesbian, gay, and bisexual suicidal behavior: testing a constructivist model. Suicide and Life-Threatening Behavior, 32(3), 272-283.

The present investigation surveyed 162 self-identified lesbian, gay, and bisexual individuals recruited from LGB-related social organizations or contacted through networking procedures with regard to suicidal behaviors, suicide risk factors, and reasons for living. Approximately 41% of the respondents indicated a serious consideration of suicide including the identification of a specific suicide plan (23%) or a past suicide attempt (36%) with significant intent to die (13%). Forty-six percent of the sample indicated at least some degree of chance of attempting suicide in the future. Grounded in the existential-constructivist theory of suicide (Rogers, 2001), empirically and theoretically identified suicide risk factors were found as a group to predict suicidal ideation (R2 = .16) and attempts (R2 = .17), with abuse-related items independently predicting both suicidal ideation (R2 = .03) and attempts (R2 = .08). Items related to self-identity issues and social acceptance were predictive of suicidal ideation (R2 = .04), while substance abuse was predictive of suicidal ideation (R2 = .05) and attempts (R2 = .13) for males only. The established factor structure of the Reasons for Living Inventory (Linehan et al., 1983) was not supported in the current data, suggesting that it may not be an appropriate measure of reasons for living with LGB individuals.

McLaughlin, K.A., Hatzenbuehler, M.L., & Keyes, K.M. (2010). Responses to discrimination and psychiatric disorders among Black, Hispanic, female, and lesbian, gay, and bisexual individuals. American Journal of Public Health, 100(8), 1477-1484.

OBJECTIVES: We examined associations between perceived discrimination due to race/ethnicity, sexual orientation, or gender; responses to discrimination experiences; and psychiatric disorders. METHODS: The sample included respondents in the 2004-2005 National Epidemiologic Survey on Alcohol and Related Conditions (n = 34 653). We analyzed the associations between self-reported past-year discrimination and past-year psychiatric disorders as assessed with structured diagnostic interviews among Black (n = 6587); Hispanic (n = 6359); lesbian, gay, and bisexual (LGB; n = 577); and female (n = 20 089) respondents. RESULTS: Black respondents reported the highest levels of past-year discrimination, followed by LGB, Hispanic, and female respondents. Across groups, discrimination was associated with 12-month mood (odds ratio [ORs] = 2.1-3.1), anxiety (ORs = 1.8-3.3), and substance use (ORs = 1.6-3.5) disorders. Respondents who reported not accepting discrimination and not discussing it with others had higher odds of psychiatric disorders (ORs = 2.9-3.9) than did those who did not accept discrimination but did discuss it with others. Black respondents and women who accepted discrimination and did not talk about it with others had elevated rates of mood and anxiety disorders, respectively. CONCLUSIONS: Psychiatric disorders are more prevalent among individuals reporting past-year discrimination experiences. Certain responses to discrimination, particularly not disclosing it, are associated with psychiatric morbidity.

Mereish, E.H., Goldbach, J.T., Burgess, C., & DiBello, A.M. (2017). Sexual orientation, minority stress, social norms, and substance use among racially diverse adolescents. Drug and Alcohol Dependence, 178, 49-56.

BACKGROUND: Sexual minority adolescents are more likely than their heterosexual peers to use substances. This study tested factors that contribute to sexual orientation disparities in substance use among racially and ethnically diverse adolescents. Specifically, we examined how both minority stress (i.e., homophobic bullying) and social norms (i.e., descriptive and injunctive norms) may account for sexual orientation disparities in recent and lifetime use of four substances: tobacco, alcohol, marijuana, and prescription drugs. PROCEDURES: A probability sample of middle and high school students (N=3012; aged 11-18 years old; 71.2% racial and ethnic minorities) using random cluster methods was obtained in a mid-size school district in the Southeastern United States. RESULTS: Sexual minority adolescents were more likely than heterosexual adolescents to use substances, experience homophobic bullying, and report higher descriptive norms for close friends and more permissive injunctive norms for friends and parents. While accounting for sociodemographic characteristics, multiple mediation models concurrently testing all mediators indicated that higher descriptive and more permissive injunctive norms were significant mediators of the associations between sexual orientation and recent and lifetime use of the four substances, whereas homophobic bullying was not a significant mediator of the associations between sexual orientation and recent and lifetime use of any of the substances. CONCLUSIONS: Descriptive and injunctive norms, in conjunction with minority stress, are important to consider in explaining sexual orientation disparities in substance use among racially diverse adolescents. These results have implications for substance use interventions among sexual minority adolescents.

Paul, J.P., Boylan, R., Gregorich, S., Ayala, G., and Kyung-Hee, C. (2014). Substance use and experienced stigmatization among ethnic minority men who have sex with men in the United States. Journal of Ethnicity in Substance Abuse, 13(4), 430-447.

Research has documented deleterious effects of racism among ethnic minorities and of homophobia among men who have sex with men (MSM). Less is known about the impact of multiple forms of stigmatization on ethnic minority MSM. This study examined substance use by African American, Asian/Pacific Islander and Latino MSM, and the associations of experienced racism and homophobia from various sources with polydrug use and stimulant drug use. Experienced racism within the general community was associated with higher levels of use; other forms of discrimination were either not associated with polydrug or stimulant use or had more complex relationships with use. Implications for further research and interventions are discussed.

Regnerus, M. (2017). Is structural stigma’s effect on the mortality of sexual minorities robust? A failure to replicate the results of a published study. Social Science & Medicine, 188, 157-165.

BACKGROUND: The study of stigma’s influence on health has surged in recent years. Hatzenbuehler et al.’s (2014) study of structural stigma’s effect on mortality revealed an average of 12 years’ shorter life expectancy for sexual minorities who resided in communities thought to exhibit high levels of anti-gay prejudice, using data from the 1988-2002 administrations of the US General Social Survey linked to mortality outcome data in the 2008 National Death Index. METHODS: In the original study, the key predictor variable (structural stigma) led to results suggesting the profound negative influence of structural stigma on the mortality of sexual minorities. Attempts to replicate the study, in order to explore alternative hypotheses, repeatedly failed to generate the original study’s key finding on structural stigma. Efforts to discern the source of the disparity in results revealed complications in the multiple imputation process for missing values of the components of structural stigma. This prompted efforts at replication using 10 different imputation approaches. RESULTS: Efforts to replicate Hatzenbuehler et al.’s (2014) key finding on structural stigma’s notable influence on the premature mortality of sexual minorities, including a more refined imputation strategy than described in the original study, failed. No data imputation approach yielded parameters that supported the original study’s conclusions. Alternative hypotheses, which originally motivated the present study, revealed little new information. CONCLUSION: Ten different approaches to multiple imputation of missing data yielded none in which the effect of structural stigma on the mortality of sexual minorities was statistically significant. Minimally, the original study’s structural stigma variable (and hence its key result) is so sensitive to subjective measurement decisions as to be rendered unreliable.

Ringwalt, C., & Shamblen, S. (2012). Is there an association between adolescent bullying victimization and substance abuse? Journal of Drug Education, 42(4), 447-467.

Bullying is endemic in the nation’s schools and takes a substantial toll on its victims’ physical and social-emotional well-being. We assessed the association between specific reasons for which adolescents believe that they are targeted for bullying and their rates of various types of substance use by analyzing the association between self-reported past 30-day substance use and past 30-day bullying victimization among 53,750 middle and high school students in Oregon. Our results confirm previous estimates of prevalence rates for bullying as well as modest (r < 0.20) associations between bullying victimization and substance use. However, study findings did not reveal a particular reason for bullying victimization that would place adolescents at a relatively high risk of substance use.

Rosario, M., Schrimshaw, E.W., Hunter, J., Gwadz, M. (2002). Gay-related stress and emotional distress among gay, lesbian, and bisexual youths: a longitudinal examination. Journal of Consulting and Clinical Psychology, 70(4), 967-975.

The longitudinal relations between gay-related stress (i.e., gay-related stressful events, negative attitudes toward homosexuality, and discomfort with homosexuality) and emotional distress (i.e., anxious symptoms, depressive symptoms, and conduct problems) were examined at 3 assessment periods (baseline, 6 months, and 12 months) among 140 gay, lesbian, and bisexual (GLB) youths. Although some findings were consistent with the hypothesis that stress would be associated with subsequent distress among GLB youths, the larger number of nonsignificant relations and the presence of relations between distress and subsequent gay-related stress indicate that the hypothesis was unsupported. The authors discuss the potential reasons for the lack of hypothesized relations and offer suggestions for future research.

Rosario, M., Schrimshaw, E.W., & Hunter, J. (2004). Predictors of substance use over time among gay, lesbian, and bisexual youths: an examination of three hypotheses. Addictive Behaviors, 29(8), 1623-1631.

Gay, lesbian, and bisexual (GLB) youths report elevated levels of substance use relative to heterosexual youths, but reasons for this disparity have received scant attention. This report longitudinally examined three hypothesized explanations for cigarette, alcohol, and marijuana use among 156 GLB youths. Counter to two hypotheses, neither a history of childhood sexual abuse nor recent experiences of gay-related stressful life events were associated with increased substance use over time. However, the hypothesis concerning the coming-out process was supported by significant nonlinear associations of involvement in gay-related (recreational and social) activities with changes in alcohol use at 12 months and changes in marijuana use at 6 months and 12 months. Specifically, as involvement in gay-related activities increased, alcohol and marijuana use was found to initially increase, but then, substance use declined as involvement in gay-related activities continued to increase. These findings offer a potential explanation for high levels of substance use among GLB youths and suggest potential areas for intervention to prevent or decrease substance use among these youths.

Selvidge, M.M., Matthews, C.R., & Bridges, S.K. (2008). The relationship of minority stress and flexible coping to psychological well being in lesbian and bisexual women. Journal of Homosexuality, 55(3), 450-470.

This study explores minority stress among lesbian and bisexual women by examining the relationship of sexist and heterosexist events, self-concealment, and self-monitoring to positive psychological well being. The sample was made up of 373 lesbian and bisexual women, including 77 women of color. Results of a multiple regression analysis of the total sample indicated that, considered simultaneously, self-concealment and self-monitoring explained significant variance in positive psychological well being, while sexist and heterosexist events, though present, were not significantly related to positive psychological well being. Results were similar for the women of color alone. This research provides evidence for the resiliency of lesbian and bisexual women and offers some applicable concepts (e.g., self-concealment and self-monitoring) to consider in research and practice with lesbian and bisexual female clients.

Shipherd, J.C., Maguen, S., Skidmore, C., & Abramovitz, S.M. (2011). Potentially traumatic events in a transgender sample: Frequency and associated symptoms. Traumatology, 17(2), 56-67.

The frequency of potentially traumatic events (PTEs) and associated symptoms were examined in a cross-sectional study of 97 transgender participants who had been classified as male at birth. A total of 98% reported at least one PTE and 91% endorsed multiple events. Of those with PTE exposures, 42% reported that at least one event was transgender bias-related. Among those with PTEs, 17.8% endorsed clinically significant symptoms of PTSD and 64% reported clinically significant depressive symptoms. The percentage of transgender individuals in this sample reporting clinically significant symptoms was higher than in trauma-exposed samples of men in the general population, but roughly similar to rates of female trauma survivors. Amount of time spent dressed consistent with gender identity was associated with increased risk for PTE exposure and was positively associated with mental health symptoms. No differences in symptoms were observed when comparing those with and without transgender bias-related PTEs. Overall, transgender individuals endorsed high prevalence of PTE exposure along with elevated PTSD and depressive symptoms, when compared to other traumatized populations.

Szymanski, D.M., & Gupta, A. (2009). Examining the relationships between multiple oppressions and Asian American sexual minority persons’ psychological distress. Journal of Gay & Lesbian Social Services: Issues in Practice, Policy & Research, 21(2-3), 267-281.

Lesbian, gay, bisexual, and questioning (LGBQ) persons come from diverse cultural groups with diverse racial and ethnic identities. However, research examining correlates of oppression among sexual minority persons has used primarily White samples and has failed to attend to and investigate the complexity of Asian American LGBQ persons’ experiences. This study examined the relations between multiple external and internalized oppressions and Asian American sexual minority persons’ psychological distress. Results indicated that when external and internalized racism and heterosexism/ homophobia were examined concomitantly, only racist events and internalized heterosexism/internalized homophobia accounted for unique variance. Research and practice implications are discussed.

Bostwick, W.B., Boyd, C.J., Hughes, T.L., West, B.T., McCabe, S.E. (2014). Discrimination and mental health among lesbian, gay, and bisexual adults in the United States. American Journal of Orthopsychiatry, 84(1), 35-45.

Health disparities among sexual minority groups, particularly mental health disparities, are well-documented. Numerous studies have demonstrated heightened prevalence of depressive and anxiety disorders among lesbian, gay, and bisexual groups as compared with heterosexuals. Some authors posit that these disparities are the result of the stress that prejudice and perceived discrimination can cause. The current study extends previous research by examining the associations between multiple types of discrimination, based on race or ethnicity, gender, and sexual orientation, and past-year mental health disorders in a national sample of self-identified lesbian, gay, and bisexual women and men (n = 577). Findings suggest that different types of discrimination may be differentially associated with past-year mental health disorders. Notably, sexual orientation discrimination was associated with higher odds of a past-year disorder only in combination with other types of discrimination. These findings point to the complexity of the relationship between discrimination experiences and mental health, and suggest that further work is needed to better explicate the interplay among multiple marginalized identities, discrimination, and mental health.

Cerezo, A. (2016). The impact of discrimination on mental health symptomatology in sexual minority immigrant Latinas. Psychology of Sexual Orientation and Gender Diversity, 3(3), 283-292.

At a time when serious xenophobic and heterosexist sentiment is at the forefront of our country’s political climate, it is incredibly important to explore and understand the links between discrimination and mental health for vulnerable communities. The purpose of this study was to carry out a preliminary exploration of the relations between acculturation to the United States (U.S.), discrimination related to ethnic minority and sexual minority statuses, and mental health symptomatology (depression, posttraumatic stress disorder [PTSD], and substance abuse) of sexual minority women who have emigrated to the U.S. from Latin America. A total of 152 women were recruited across the continental U.S. via online and in-person recruitment methods. As hypothesized, findings revealed that increased discrimination was associated with increased symptomatology of depression, PTSD, and substance abuse. However, acculturation was not shown to be associated with mental health for this sample. Recommendations for clinical practice and future research are discussed.

Dinno, A. (2017). Homicide rates of transgender individuals in the United States: 2010-2014. American Journal of Public Health, 107(9), 1441-1447.

OBJECTIVES: To estimate homicide rates of transgender US residents and relative risks (RRs) of homicide with respect to cisgender comparators intersected with age, gender, and race/ethnicity. METHODS: I estimated homicide rates for transgender residents and transfeminine, Black, Latin@, and young (aged 15-34 years) subpopulations during the period 2010 to 2014 using Transgender Day of Remembrance and National Coalition of Anti-Violence Programs transgender homicide data. I used estimated transgender prevalences to estimate RRs using cisgender comparators. I performed a sensitivity analysis to situate all results within assumptions about underreporting of transgender homicides and assumptions about the prevalence of transgender residents. RESULTS: The overall homicide rate of transgender individuals was likely to be less than that of cisgender individuals, with 8 of 12 RR estimates below 1.0. However, the homicide rates of young transfeminine Black and Latina residents were almost certainly higher than were those of cisfeminine comparators, with all RR estimates above 1.0 for Blacks and all above 1.0 for Latinas. CONCLUSIONS: Antiviolence public health programs should identify young and Black or Latina transfeminine women as an especially vulnerable population.

Douglass, R.P., Conlin, S.E., Duffy, R.D., & Allan, B.A. (2017). Examining moderators of discrimination and subjective well-being among LGB individuals. Journal of Counseling Psychology, 64(1), 1-11.

Research has found perceived discrimination to be a risk factor for mental health concerns among lesbian, gay, and bisexual (LGB) people, but less clarity exists linking perceived discrimination with well-being outcomes. Building from Meyer’s (2003) minority stress model, the present study examined the links between perceived discrimination and the 3 components of subjective well-being: positive affect, negative affect, and life satisfaction. Self-esteem and stigma consciousness were explored as empirically and theoretically implied moderators. In a sample of 368 LGB people, structural equation modeling results suggested that discrimination was not significantly associated with positive affect or life satisfaction but had a significant positive relation with negative affect. Self-esteem moderated the associations between discrimination and positive and negative affect, and stigma consciousness moderated the link with negative affect. Practical implications and directions for future research are discussed.

Doyle, D.M., & Molix, L. (2014). Perceived discrimination and well-being in gay men: The protective role of behavioural identification. Psychology & Sexuality, 5(2), 117-130.

Gay men regularly experience both individual and structural prejudice and discrimination, which have been shown to negatively impact well-being. The current study examined the potentially protective role of behavioural identification, a dimension of group identity, as a mediator of the relationship between perceived discrimination and well-being among gay men. The results revealed that behavioural identification mediated a positive indirect relationship between perceived discrimination and self-esteem, suppressing the negative association between these two variables. A similar pattern of results was obtained for positive affect. Implications of these results with regard to public policies targeting gay men are addressed.

Doyle, D.M., & Molix, L. (2016). Minority stress and inflammatory mediators: Covering moderates associations between perceived discrimination and salivary interleukin-6 in gay men. Journal of Behavioral Medicine, 39(5), 782-92.

Physical health disparities by sexual orientation are widespread yet under-investigated. Drawing upon theories of biological embedding of social adversity, we tested whether minority stress (in the form of perceived discrimination) is associated with salivary interleukin-6 (IL-6), an inflammatory mediator. Furthermore, we examined whether covering, a strategy involving downplaying a stigmatized social identity, modified this association. A community sample (N = 99) of gay men (n = 78) and lesbian women (n = 21) completed self-report measures of minority stress and identity management and provided saliva samples which were assayed for IL-6. Among gay men, results from generalized linear models supported a hypothesized interaction between perceived discrimination and covering, such that perceived discrimination was predictive of higher levels of IL-6 for those who engaged in less covering but not for those who engaged in more covering. This interaction was robust to a number of potential covariates (alcohol, medication, body mass index, race and age). Results for lesbian women suggested a different pattern: the only statistically significant association detected was between greater perceived discrimination and lower levels of IL-6. Findings from the current study point to an important role for inflammatory processes in understanding and remediating health disparities based upon sexual orientation that stem from exposure to prejudice and discrimination.

Duncan, D.T., Hatzenbuehler, M.L., & Johnson, R.M. (2014). Neighborhood-level LGBT hate crimes and current illicit drug use among sexual minority youth. Drug and Alcohol Dependence, 135, 65-70.

OBJECTIVE: To investigate whether past-30 day illicit drug use among sexual minority youth was more common in neighborhoods with a greater prevalence of hate crimes targeting lesbian, gay, bisexual, and transgender (LGBT, or sexual minority) individuals. METHODS: We used a population-based survey of public school youth in Boston, Massachusetts, consisting of 1292 9th-12th grade students from the 2008 Boston Youth Survey Geospatial Dataset (sexual minority n=108). Data on LGBT hate crimes involving assaults or assaults and battery between 2005 and 2008 were obtained from the Boston Police Department and linked to youths’ residential address. Youth reported past-30 day use of marijuana and other illicit drugs. Wilcoxon-Mann-Whitney tests and corresponding p-values were computed to assess differences in substance use by neighborhood-level LGBT assault hate crime rate among sexual minority youth (n=103). RESULTS: The LGBT assault hate crime rate in the neighborhoods of sexual minority youth who reported current marijuana use was 23.7 per 100,000, compared to 12.9 per 100,000 for sexual minority youth who reported no marijuana use (p=0.04). No associations between LGBT assault hate crimes and marijuana use among heterosexual youth (p>0.05) or between sexual minority marijuana use and overall neighborhood-level violent and property crimes (p>0.05) were detected, providing evidence for result specificity. CONCLUSIONS: We found a significantly greater prevalence of marijuana use among sexual minority youth in neighborhoods with a higher prevalence of LGBT assault hate crimes. These results suggest that neighborhood context (i.e., LGBT hate crimes) may contribute to sexual orientation disparities in marijuana use.

Feinstein, B.A., & Newcomb, M.E. (2016). The role of substance use motives in the associations between minority stressors and substance use problems among young men who have sex with men. Psychology of Sexual Orientation and Gender Diversity, 3(3), 357-366.

Young men who have sex with men (YMSM) report higher rates of substance use than their heterosexual peers and minority stress has been posited as a risk factor for substance use. The associations between specific types of minority stress and substance use have been inconsistent throughout the literature and few studies have examined mechanisms underlying these associations. Drawing on minority stress theory and the motivational model of alcohol use, we propose that one mechanism underlying these associations may be people’s motivations for using substances, including using substances to cope with negative emotions and to enhance pleasure. The goals of the current study were: (1) to examine the associations among minority stressors, substance use motives, and substance use problems; and (2) to examine substance use motives as mediators of the associations between minority stressors and substance use problems. Baseline self-report data were used from a cohort of 370 YMSM enrolled in a larger study of substance use and sexual behavior. Results indicated that using marijuana to cope mediated the association between victimization and marijuana use problems. Using other drugs to cope mediated the associations between victimization and drug use problems and between internalized stigma and drug use problems. Drinking to cope and to enhance pleasure mediated the association between internalized stigma and alcohol use problems. In sum, substance use motives, especially using substances to cope, act as mechanisms through which certain types of minority stress influence substance use problems among YMSM.

Feinstein, B.A., Latack, J.A., Bhatia, V., Davila, J., Eaton, N.R. (2016). Romantic relationship involvement as a minority stress buffer in gay/lesbian versus bisexual individuals. Journal of Gay & Lesbian Mental Health, 20(3), 237-257.

This study examined romantic relationship involvement as a moderator of the associations between discrimination/victimization and depression/anxiety in gay/lesbian versus bisexual individuals. Data from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions were used. Analyses were conducted separately for gay/lesbian versus bisexual individuals (N = 577 lesbian, gay, or bisexual individuals). For gay/lesbian individuals, the only significant association was a positive association between discrimination and anxiety. For bisexual individuals, there were significant positive associations between discrimination and depression/anxiety for those who were single, but not those who were partnered. There was also a significant association between victimization and anxiety, but this association was not moderated by relationship involvement. Findings provide partial support for relationship involvement as protective for bisexual individuals. Promoting the benefits of relationships may contribute to reducing sexual orientation-related health disparities.

Frost, D.M., Lehavot, K., & Meyer, I.H. (2015). Minority stress and physical health among sexual minority individuals. Journal of Behavioral Medicine, 38(1), 1-8.

This study examined the effects of minority stress on the physical health of lesbians, gay men, and bisexuals (LGBs). Participants (N = 396) completed baseline and one year follow-up interviews. Exposure to stress and health outcomes were assessed with two methods: a subjective self-appraisal method and a method whereby two independent judges externally rated event narratives using standardized criteria. The odds of experiencing a physical health problem at follow-up were significantly higher among LGBs who experienced an externally rated prejudice event during the follow-up period compared to those who did not. This association persisted after adjusting for experiences of general stressful life events that were not related to prejudice. Self-appraised minority stress exposures were not associated with poorer physical health at 1-year follow-up. Prejudice-related stressful life events have a unique deleterious impact on health that persists above and beyond the effect of stressful life events unrelated to prejudice.

Gleason, H.A., Livingston, N.A., Peters, M.M., Oost, K.M., Reely, E., & Cochran, B.N. (2016). Effects of state nondiscrimination laws on transgender and gender-nonconforming individuals’ perceived community stigma and mental health. Journal of Gay & Lesbian Mental Health, 20(4), 350-362.

In this study, we investigated the potential effects of statewide nondiscrimination laws on community stigma, as well as its relationship with psychosocial stressors and mental health outcomes. Gender minority individuals (N = 120) completed an online survey containing psychosocial and mental health outcome measures. The experiences of participants who resided in states with and without nondiscrimination laws were compared in regard to perceived community stigma. Hierarchical and logistic regression were used to test the hypothesized relationships between community stigma and lifetime discrimination and victimization; current depression, anxiety, and substance use; and lifetime suicide attempts. Approximately 60% of participants reported residing in a state without nondiscrimination laws (n = 74). These participants reported higher levels of perceived community stigma, and stigma was positively associated with reports of lifetime discrimination and victimization. The observed relationship between stigma and current anxiety symptoms was marginally significant. Logistic regression results indicate that stigma was positively related to the odds of reporting a lifetime suicide attempt. Analyses suggest that statewide nondiscrimination laws are associated with lower rates of perceived stigma at the community level, which, in turn, is associated with lower rates of discrimination, victimization, anxiety, and risk for attempted suicide.

Gonzalez, C.A., Gallego, J.D., & Bockting, W.O. (2017). Demographic characteristics, components of sexuality and gender, and minority stress and their associations to excessive alcohol, cannabis, and illicit (noncannabis) drug use among a large sample of transgender people in the United States. Journal of Primary Prevention, 38(4), 419-445.

The current study examined demographics, sexual orientation, gender characteristics, and gender minority stress and their association to excessive alcohol, cannabis, and illicit (noncannabis) drug use among 1210 transgender adults living in the United States. The authors conducted a secondary analysis of data that included 680 transgender women (M age = 32.63, SD age = 12.29) and 530 transgender men (M age = 26.14, SD age = 7.42). A modified version of the Risk Behavioral Assessment quantified participants’ alcohol, cannabis, and illicit drug use in the past 3 months. Overall, 21.5% of participants reported excessive alcohol use; no significant differences were found on the rates of excessive alcohol use between transgender women and men. Cannabis use among our sample was 24.4%; trangender men reported significantly higher rates of cannabis use compared to transgender women. Illicit drug (noncannabis) use among our sample was 11.6%; transgender men also reported significantly higher rates of illicit drug use compared to transgender women. Multivariate analyses suggested that gender dysphoria was significantly associated with: excessive alcohol use for transgender women, cannabis use among both transgender women and men, and illicit (noncannabis) drug use among transgender women. A nonheterosexual orientation was associated with increased odds of cannabis use among transgender women and men; a nonheterosexual orientation was associated with greater odds of illicit substance use among transgender men but not among transgender women. Gender minority stressors were independently associated with excessive alcohol use among transgender men and cannabis use among transgender women. The authors suggest that minority stress may only partially account for substance use among transgender people. Consequently, the authors suggest that in addition to minority stress, other biopsychosocial mechanisms should continue to be examined to identify pathways that may lead to the development of effective substance use prevention efforts and treatment programs.

Hamilton, C.J., & Mahalik, J.R. (2009). Minority stress, masculinity, and social norms predicting gay men’s health risk behaviors. Journal of Counseling Psychology, 56(1), 132-141.

The authors examined the contributions of the minority stress model, traditional masculine gender roles, and perceived social norms in accounting for gay men’s use of alcohol, tobacco, illicit drugs, and risky sexual practices. Three hundred fifteen gay men recruited from listserv communities completed measures assessing internalized homophobia, stigma, antigay physical attack, masculinity, and perceptions of normative health behaviors, along with health risk behaviors of alcohol use, illicit drug use, smoking, and high-risk sexual behaviors. Pearson correlations supported several hypotheses; social norms and masculinity variables were significantly related to health risk behaviors. Four multiple regression analyses indicated that masculinity and perceptions of social norms predicted health risk behaviors. Additionally, a significant interaction was found between minority stress and perceptions of social norms. The clinical implications of the findings, limitations, and suggestions for future research are discussed.

Hatzenbuehler, M.L., Flores, A.R., & Gates, G.J. (2017). Social attitudes regarding same-sex marriage and LGBT health disparities: Results from a national probability sample. Journal of Social Issues, 73(3), 508-528.

This study examined the health consequences for lesbian, gay, bisexual, and transgender (LGBT) populations of exposure to communities with relatively high versus low levels of support for same-sex marriage. We used data from the Gallup Daily tracking survey, the largest probability-based sample of LGBT-identified adults in the United States (N = 11,949 LGBT respondents; N = 352,343 non-LGBT respondents), which was linked to attitudinal responses on same-sex marriage obtained from the 2012 Cooperative Congressional Election Survey (N = 54,535). Controlling for potential confounders, higher levels of local approval of samesex marriage lowered the probability that LGBT (and non-LGBT) individuals reported smoking and fair/poor self-rated health; further, LGBT disparities in smoking were lower in communities where residents were most likely to support same-sex marriage. Findings suggest that local attitudes may be related to the health of LGBT individuals and contribute to sexual orientation health disparities, providing further evidence for the role of structural stigma in shaping LGBT health.

Hershberger, S.L., & D’Augelli, A.R. (1995). The impact of victimization on the mental health and suicidality of lesbian, gay, and bisexual youths. Developmental Psychology, 31(1), 65-74.

Lesbian, gay, and bisexual youths (aged 15-21 yrs) were studied to determine the impact of verbal abuse, threat of attacks, and assault on their mental health, including suicide. Family support and self-acceptance were hypothesized to act as mediators of the victimization and mental health-suicide relation. Structural equation modeling revealed that in addition to a direct effect of victimization on mental health, family support and self-acceptance in concert mediated the victimization and mental health relation. Victimization was not directly related to suicide. Victimization interacted with family support to influence mental health, but only for low levels of victimization.

Jabson, J.M., Donatelle, R.J., & Bowen, D. (2011). Breast cancer survivorship: The role of perceived discrimination and sexual orientation. Journal of Cancer Survivorship, 5(1), 92-101.

Breast cancer disproportionately affects sexual minority women (SMW) compared to heterosexual women and a small but growing literature indicates that SMW may have diminished survivorship outcomes; outcomes that are measurably and importantly different from heterosexual breast cancer survivors. However, it remains unknown how sexual orientation influences breast cancer survivorship outcomes such as quality of life. One possible route of influence is SMW’s perceived discrimination in the health care setting. This cross-sectional study examines SMW perceptions of discrimination as one of the multiple facets of the breast cancer survivorship process. This study assessed SMW breast cancer survivor’s perceptions of discrimination during their breast cancer treatment experience and secondarily, examined the role of this perceived discrimination on SMW’s quality of life. Sixty-eight purposefully sampled sexual minority breast cancer survivors completed assessments of quality of life, perceived discrimination, perceived social support and perceived stress via an online survey. Statistical analyses point to perceived discrimination and perceived social support as important indicators for predicting SMW’s quality of life. Future research on SMW’s breast cancer survivorship should include measures of perceived discrimination.

Jackman, K.B., Dolezal, C., Levin, B., Honig, J.C., & Bockting, W.O. (2018). Stigma, gender dysphoria, and nonsuicidal self-injury in a community sample of transgender individuals. Psychiatry Research, 269, 602-609.

We investigated rates of nonsuicidal self-injury (NSSI) and correlates of past-year NSSI among transgender people to better understand factors contributing to this health disparity. A community-based sample of 332 transgender people participated in quantitative in-person interviews. The mean age of participants was 34.56 years (SD=13.78, range=16-87). The sample was evenly divided between transfeminine spectrum (50.3%) and transmasculine spectrum identities (49.7%) and was diverse in race/ethnicity. We evaluated associations between sociodemographic characteristics, stigma, hypothesized resilience factors, and identity variables with past-year NSSI. 53.3% of participants reported ever having self-injured in their lifetime. Past-year NSSI was reported by 22.3% of the sample and did not significantly differ based on gender identity. In logistic regression models, past-year NSSI was associated with younger age and felt stigma (perceived or anticipated rejection), but not enacted stigma (actual experiences of discrimination), and with gender dysphoria. Efforts to address the high rates of NSSI among transgender people should aim to reduce felt stigma and gender dysphoria, and promote transgender congruence. Future research using a developmental approach to assess variations in NSSI across the life course and in relation to transgender identity development may illuminate additional processes that affect NSSI in this population.

Livingston, N.A., Christianson, N., & Cochran, B.N. (2016). Minority stress, psychological distress, and alcohol misuse among sexual minority young adults: A resiliency-based conditional process analysis. Addictive Behaviors, 63, 125-131.

BACKGROUND: Sexual minority young adults experience elevated rates of distal stress (discrimination, victimization), and related psychological distress and alcohol misuse. However, few studies have examined the degree to which personality trait differences confer risk/resilience among sexual minority young adults. We hypothesized that psychological distress would mediate the relationship between distal stress and alcohol misuse, but that these relationships would be moderated by personality trait differences. METHOD: Sexual minority young adults (N=412) were recruited nationally. Survey measures included demographic questions, minority stressors, Five Factor personality traits, and current psychological distress and alcohol misuse symptoms. We used a data-driven two-stage cluster analytic technique to empirically derive personality trait profiles, and conducted mediation and moderated mediation analyses using a regression-based approach. RESULTS: Our results supported a two-group personality profile solution. Relative to at-risk individuals, those classified as adaptive scored lower on neuroticism, and higher on agreeableness, extraversion, conscientiousness, and openness to experience. As predicted, psychological distress mediated the relationship between distal stress and alcohol misuse. However, personality moderated these relationships to the degree that they did not exist among individuals classified as adaptive. DISCUSSION: In the current study, we found that personality moderated the established relationships between distal stress, psychological distress, and alcohol misuse among sexual minority young adults. Future research is needed to further explicate these relationships, and in order to develop tailored interventions for sexual minority young adults at risk.

McCabe, S.E., Bostwick, W.B., Hughes, T.L., West, B.T., & Boyd, C.J. (2010). The relationship between discrimination and substance use disorders among lesbian, gay, and bisexual adults in the United States. American Journal of Public Health, 100(10), 1946-1952.

OBJECTIVES: We examined the associations between 3 types of discrimination (sexual orientation, race, and gender) and substance use disorders in a large national sample in the United States that included 577 lesbian, gay, and bisexual (LGB) adults. METHODS: Data were collected from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions, which used structured diagnostic face-to-face interviews. RESULTS: More than two thirds of LGB adults reported at least 1 type of discrimination in their lifetimes. Multivariate analyses indicated that the odds of past-year substance use disorders were nearly 4 times greater among LGB adults who reported all 3 types of discrimination prior to the past year than for LGB adults who did not report discrimination (adjusted odds ratio = 3.85; 95% confidence interval = 1.71, 8.66). CONCLUSIONS: Health professionals should consider the role multiple types of discrimination plays in the development and treatment of substance use disorders among LGB adults.

McGarrity, LA., & Huebner, D.M. (2014). Is being out about sexual orientation uniformly healthy? The moderating role of socioeconomic status in a prospective study of gay and bisexual men. Annals of Behavioral Medicine, 47(1), 28-38.

BACKGROUND: Stress associated with concealing sexual orientation is a possible mechanism for health disparities among lesbian, gay, bisexual (LGB) individuals. However, disclosing one’s sexual orientation might not be uniformly healthy across social contexts. PURPOSE: The present study tested whether being out is less healthy for gay and bisexual men of lower socioeconomic status (SES) relative to higher SES men. METHODS: Using longitudinal data on gay and bisexual men (N = 564, ages 18-72), we examined whether the association between outness and physical health differs by SES. RESULTS: SES significantly moderated associations between outness and physician visits, nonprescription medication use, and physical symptoms. Outness predicted physical health benefits for higher SES men but health problems for lower SES men. CONCLUSIONS: The common assumption that disclosing one’s sexual orientation is uniformly healthy may be less accurate (or inaccurate) for lower status groups. Future research should explore SES as context for minority stress and LGB health disparities.

Mohr, J.J. (2016). Daily heterosexism experiences and well-being among LGB young adults: The moderating role of attachment style. Journal of Counseling Psychology, 63(1), 76-86.

This study examined within-person links between daily heterosexism experiences and well-being among lesbian, gay, and bisexual young adults, and tested the hypothesis that attachment insecurity amplifies the negative impact of heterosexism on well-being. A sample of 82 lesbian, gay, and bisexual young adults completed a measure of attachment style at the start of the study, and then reported on heterosexism experiences and facets of well-being in Internet surveys at the end of each day for 7-10 consecutive days (total of 706 days in the sample). Multilevel regression was used to test the interaction between attachment variables (anxiety and avoidance) and the presence of everyday heterosexism experiences in predicting 3 facets of daily well-being (self-assurance, anger, and fear). Results indicated that attachment variables moderated the within-person link between daily heterosexism experiences and well-being for anger and fear but not for self-assurance. As hypothesized, daily heterosexism was positively related to daily anger and fear for people with higher levels of avoidance but not those with lower levels of avoidance (controlling for previous day levels of well-being). Contrary to hypothesis, however, daily heterosexism was positively associated with anger and fear for participants with low levels of attachment anxiety but not for those with higher levels of attachment anxiety. Analyses also revealed no links between the attachment variables and frequency of heterosexism experiences.

Newcomb, M.E., Heinz, A.J., & Mustanski, B. (2012). Examining risk and protective factors for alcohol use in lesbian, gay, bisexual, and transgender youth: A longitudinal multilevel analysis. Journal of Studies on Alcohol and Drugs, 73(5), 783-793.

OBJECTIVE: Lesbian, gay, bisexual, and transgender (LGBT) youth are at increased risk for alcohol misuse, but little is known about the psychosocial and demographic factors that are associated with these differences over time. The purpose of this study was to investigate change in alcohol use across development. We aimed to describe group/demographic differences in alcohol use, the effects of psychosocial variables on drinking within persons (i.e., psychological distress, sexual orientation-based victimization, and perceived family support), and the interactions between demographic differences and longitudinal psychosocial variables in predicting rates of alcohol use. METHOD: The current study used data from the longest running longitudinal study of LGBT youth. Hierarchical linear modeling was used to examine both demographic differences and psychosocial predictors of alcohol use in an ethnically diverse sample of 246 LGBT youth (ages 16-20 years at baseline) across five time points over 2.5 years. RESULTS: Drinking increased significantly over time in a linear fashion, although it tended to increase more rapidly among male LGBT youth compared with females. Analyses of group differences revealed lower average rates of drinking for African American and female LGBT youth, and there were no differences between bisexual youth and gay/lesbian youth. Psychological distress and sexual orientation-based victimization were associated with increased alcohol use at each wave of data collection for female LGBT youth only. Perceived family support at each wave was negatively associated with alcohol use for all LGBT youth. CONCLUSIONS: Findings indicate that there is significant heterogeneity in the etiological pathways that lead to alcohol use in LGBT youth and that correlates of drinking are similar to those found in general populations. These crucial findings indicate that existing alcohol interventions also may be effective for LGBT youth and open up a wider array of prevention and treatment options for this at-risk population.

Otis, M.D., & Skinner, W.F. (1996). The prevalence of victimization and its effect on mental well-being among lesbian and gay people. Journal of Homosexuality, 30(3), 93-121.

Research on victimization among oppressed groups such as lesbian and gay people has provided limited insight into its impact on the lives of those who are frequently targeted. This is due in part to small sample sizes and the absence of significant variables known to influence mental well-being. This analysis examines the prevalence and effects of victimization on a large sample (N = 1067) of lesbians and gay men living in a southern state. Multiple regression is used to determine the psychological consequences of victimization as measured by depression. Additional factors thought to contribute, either positively or negatively, to the effect of victimization on mental well-being, i.e., social support, self-esteem, external stress, and internalized homophobia, are also included in the analysis. Results indicate that victimization has a significant positive effect on depression for both lesbians and gay men when controlling for other variables. Self-esteem was found to be the strongest predictor of depression for the entire sample. Social support was found to have a similar effect for lesbians and gay men with partner support and having no support being significant. Gender differences were found for measures of external stress, internalized homophobia, and age.

Paceley, M.S., Goffnett, J., & Gandy-Guedes, M. (2017). Impact of victimization, community climate, and community size on the mental health of sexual and gender minority youth. American Journal of Community Psychology, 45(5), 658-671.

Sexual and gender minority (SGM) youth are at risk of stigma and victimization, which may lead to increased mental health symptoms, including depression, anxiety, and stress. The role of the community in exacerbating or mitigating the frequency of victimization and mental health symptoms among SGM youth has been understudied. Using a minority stress framework, this study examined the association between physical and nonphysical anti-SGM victimization, perceived community climate, and community size and their effects on depression, anxiety, and stress among SGM youth. An online survey was completed by 296 SGM-identified youth (aged 14-18 years). Results revealed that nonphysical forms of victimization were associated with depression, anxiety, and stress above and beyond physical victimization and community variables. Both types of victimization were more common in communities that participants perceived to be hostile and small towns. Practice implications include ways to reduce victimization and improve mental health via community climate and community interventions.

Pachankis, J.E., Hatzenbuehler, M.L., & Starks, T.J. (2014). The influence of structural stigma and rejection sensitivity on young sexual minority men’s daily tobacco and alcohol use. Social Science & Medicine, 103, 67-75.

Stigma occurs at both individual and structural levels, but existing research tends to examine the effect of individual and structural forms of stigma in isolation, rather than considering potential synergistic effects. To address this gap, our study examined whether stigma at the individual level, namely gay-related rejection sensitivity, interacts with structural stigma to predict substance use among young sexual minority men. Sexual minority (n = 119) participants completed online measures of our constructs (e.g., rejection sensitivity). Participants currently resided across a broad array of geographic areas (i.e., 24 U.S. states), and had attended high school in 28 states, allowing us to capture sufficient variance in current and past forms of structural stigma, defined as (1) a lack of state-level policies providing equal opportunities for heterosexual and sexual minority individuals and (2) negative state-aggregated attitudes toward sexual minorities. To measure daily substance use, we utilized a daily diary approach, whereby all participants were asked to indicate whether they used tobacco or alcohol on nine consecutive days. Results indicated that structural stigma interacted with rejection sensitivity to predict tobacco and alcohol use, and that this relationship depended on the developmental timing of exposure to structural stigma. In contrast, rejection sensitivity did not mediate the relationship between structural stigma and substance use. These results suggest that psychological predispositions, such as rejection sensitivity, interact with features of the social environment, such as structural stigma, to predict important health behaviors among young sexual minority men. These results add to a growing body of research documenting the multiple levels through which stigma interacts to produce negative health outcomes among sexual minority individuals.

Pachankis, J.E., Sullivan, T.J., Feinstein, B., & Newcomb, M.E. (2018). Young adult gay and bisexual men’s stigma experiences and mental health: An 8-year longitudinal study. Developmental Psychology, 54(7), 1381-1393.

This study investigated longitudinal trajectories of stigma (i.e., enacted, anticipated, internalized, concealed); stress-sensitive mental health disorder symptoms (i.e., depression, social anxiety); and their associations across 8 annual assessments in a sample of 128 young gay and bisexual U.S. university students. All forms of stigma significantly decreased over time, while depressive symptoms remained stable and social anxiety symptoms significantly increased. Men from higher socioeconomic backgrounds experienced quicker reductions in anticipated stigma, compared to men from lower socioeconomic backgrounds. More self-described feminine men experienced quicker reductions in concealment, compared to more self-described masculine men. Enacted stigma demonstrated contemporaneous associations with depression and social anxiety across 8 years; and anticipated stigma and internalized stigma demonstrated contemporaneous associations with social anxiety across 8 years. Enacted stigma was more strongly associated with depressive symptoms among men who reported greater masculinity compared to those who reported greater femininity. Findings are discussed in terms of common developmental influences across early sexual orientation identity formation, including gay and bisexual young men’s resilience to stigma-based stress; the transition from college; and the rapidly changing social climate surrounding sexual minority individuals. Findings suggest the need for future longitudinal examinations of stigma and mental health among sexual minorities that utilize multiple age cohorts to determine the relative contribution of cohort-specific versus common maturational factors influencing the mental health of this population.

Poteat, V.P., Mereish, E.H., Digiovanni, C.D., Koenig, B.W. (2011). The effects of general and homophobic victimization on adolescents’ psychosocial and educational concerns: The importance of intersecting identities and parent support. Journal of Counseling Psychology, 58(4), 597-609.

Many adolescents experience peer victimization, which often can be homophobic. Applying the minority stress model with attention to intersecting social identities, this study tested the effects of general and homophobic victimization on several educational outcomes through suicidality and school belonging among 15,923 adolescents in Grades 7 through 12 on account of their sexual orientation and race/ethnicity. Parent support also was tested as a moderator of these effects. Homophobic victimization had different effects on suicidality across groups, indicating the importance of considering individuals’ multiple social identities. However, homophobic victimization had universal negative effects on school belonging for all groups. Nearly all indirect effects of general and homophobic victimization on reported grades, truancy, and importance of graduating were significant through suicidality and school belonging across groups. Parent support was most consistent in moderating the effects of general and homophobic victimization on suicidality for heterosexual White and racial/ethnic minority youth. In nearly all cases, it did not moderate the effects of general or homophobic victimization for lesbian, gay, bisexual, transgender, and questioning youth. Furthermore, in most cases, parent support did not moderate the effects of general or homophobic victimization on school belonging. Findings underscore the need for counseling psychologists to work with parents of all youth on ways to provide support to those who experience homophobic victimization. Furthermore, they highlight the need for counseling psychologists to be involved as social justice advocates in the passage and implementation of school policies that address homophobic bullying and other forms of bias-based bullying and harassment.

Puckett, J.A., Surace, F.I., Levitt, H.M., & Horne, S.G. (2016). Sexual orientation identity in relation to minority stress and mental health in sexual minority women. LGBT Health, 3(5), 350-356.

PURPOSE: Research often erases the distinct experiences of bisexual and queer women through collapsing participants with lesbian or gay women. In addition, queer is often not included as a sexual orientation identity in research, therefore limiting the available information about how this group experiences minority stress. Given these limitations, we sought to compare groups, based on their sexual orientation identity, on experiences of minority stress and mental health to further understand between group differences that often go unaccounted for in research. METHODS: Participants (N = 249; age range 19-77; M = 38.43, SD = 12.98) completed an online survey exploring experiences of minority stress and mental health. RESULTS: We found that the group most at risk for encountering minority stressors depended on the specific stressor being examined. Queer and gay or lesbian women encountered greater victimization, discrimination, and expectations of discrimination than bisexual women. However, bisexual women had higher levels of identity concealment and internalized heterosexism than gay, lesbian, or queer women. While queer women tended to have fewer proximal stressors, they were similar to bisexual women in terms of psychological distress, with both groups scoring higher than gay or lesbian women. CONCLUSIONS: These results highlight the need to examine between group differences in future research. The experiences of minority stress appear to complexly relate to psychological distress in varying ways for different groups of women, with bisexual and queer women having the highest rates of psychological distress although they vary in the types of stressors that they encounter. In addition, the experiences of queer women were divergent from those of gay, lesbian, or bisexual women across many of the stressors, indicating that there is a need to further recognize this distinct group of women in future research.

Puckett, J.A., Maroney, M.R., Levitt, H.M., & Horne, S.G. (2016). Relations between gender expression, minority stress, and mental health in cisgender sexual minority women and men. Psychology of Sexual Orientation and Gender Diversity, 3(4), 489-498.

Lesbian, gay, bisexual, and queer (LGBQ) individuals experience various minority stressors that account for increased mental health issues in comparison to heterosexuals, including experiences of prejudice (victimization and discrimination), expectations of encountering prejudice, internalized heterosexism, and identity concealment. Even so, some individuals may be more likely to encounter select minority stressors (e.g., prejudice) as a product of having a nontraditional gender expression. This study examined the role of gender expression in relation to these minority stressors and mental health in a sample of 383 sexual minority cisgender women and men (Mage = 39.3). Results revealed significant correlations between gender nonconformity and greater experiences and expectations of prejudice, as well as less identity concealment, greater psychological distress, and greater social anxiety. Two multiple mediation analyses were conducted to determine whether these minority stressors accounted for the association between gender nonconformity and mental health indices. Gender nonconformity and the minority stressors accounted for a significant amount of variance in psychological distress, F(10, 363) = 10.94, R2 = .23, as well as social anxiety, F(10, 363) = 9.32, R2 = .20. With all minority stress predictors included in the model, expectations of prejudice was the only significant mediator of the associations between gender nonconformity and mental health, for both psychological distress and social anxiety (B = 0.08, SE = 0.05, 95% confidence interval (CI) [0.01-0.20]; B = 0.03, SE = 0.02, 95% CI [0.004-0.06], respectively). This study highlights the importance of considering gender expression in the conceptualization of LGBQ minority stress.

Romanelli, M., Lu, W., & Lindsey, M.A. (2018). Examining mechanisms and moderators of the relationship between discriminatory health care encounters and attempted suicide among U.S. transgender help-seekers. Administration and Policy in Mental Health, 45(6), 831–849.

This study examined how experiences of service denial and discrimination in three health care settings-doctors’ offices, emergency rooms, and mental health clinics-might contribute to attempted suicide among transgender adults. Mechanisms of this relationship were examined, including treatment receipt and the use of substances to cope with mistreatment. Perceived emotional social support was also tested as a potential protective factor against the deleterious effects of service denial and discrimination on treatment receipt, substance use, and attempted suicide. The analysis included 4190 respondents from the National Transgender Discrimination Survey. Structural equation modeling was employed to test hypothesized relationships. Being denied a greater number of services and discriminated against in more settings were associated with lower levels of treatment receipt. Service denial was also correlated with increased rates of coping-motivated substance use and elevated rates of attempted suicide. Treatment receipt mediated the relationships between service denial/discrimination and substance use. Substance use mediated the relationship between treatment receipt and attempted suicide. Higher levels of support were protective to treatment receipt when denied services in one setting, but no longer retained protective effects when denied in two or three settings. Results have critical implications for service access and delivery and policies that protect transgender help-seekers in the health care system.

Russell, S.T., Ryan, C., Toomey, R.B., Diaz, R.M., & Sanchez, J. (2011). Lesbian, gay, bisexual, and transgender adolescent school victimization: implications for young adult health and adjustment. Journal of School Health, 81(5), 223-230.

BACKGROUND: Adolescent school victimization due to lesbian, gay, bisexual, or transgender (LGBT) status is commonplace, and is associated with compromised health and adjustment. Few studies have examined the long-term implications of LGBT school victimization for young adult adjustment. We examine the association between reports of LGBT school victimization and young adult psychosocial health and risk behavior. METHODS: The young adult survey from the Family Acceptance Project included 245 LGBT young adults between the ages of 21 and 25 years, with an equal proportion of Latino and non-Latino White respondents. A 10-item retrospective scale assessed school victimization due to actual or perceived LGBT identity between the ages of 13 and 19 years. Multiple regression was used to test the association between LGBT school victimization and young adult depression, suicidal ideation, life satisfaction, self-esteem, and social integration, while controlling for background characteristics. Logistic regression was used to examine young adult suicide attempts, clinical levels of depression, heavy drinking and substance use problems, sexually transmitted disease (STD) diagnoses, and self-reported HIV risk. RESULTS: Lesbian, gay, bisexual, and transgender-related school victimization is strongly linked to young adult mental health and risk for STDs and HIV; there is no strong association with substance use or abuse. Elevated levels of depression and suicidal ideation among males can be explained by their high rates of LGBT school victimization. CONCLUSIONS: Reducing LGBT-related school victimization will likely result in significant long-term health gains and will reduce health disparities for LGBT people. Reducing the dramatic disparities for LGBT youth should be educational and public health priorities.

Savin-Williams, R.C., & Ream, G.L. (2003). Suicide attempts among sexual-minority male youth. Journal of Clinical Child and Adolescent Psychology, 32(4), 509-522.

The purpose of this study was to provide data addressing Diamond’s (this issue) 4 problem areas in sexual orientation research by comparing gay, bisexual, and questioning male youth who report attempting suicide with those who do not. Secondary analyses were conducted with 2 datasets, 1 with a gay support group (n = 51) and the other with online youth (n = 681). Reported suicide attempts ranged from 39% among support-group youth, to 25% among Internet gay support group youth, to 9% among Internet non-support group youth. Sexual orientation, behavior, and identity did not predict suicidal attempt status, but suicide attempters experienced higher levels of both generic life stressors (low self-esteem, substance use, victimization) and gay-related stressors, particularly those directly related to visible (femininity) and behavioral (gay sex) aspects of their sexual identity. Support-group attendance was related to higher levels of suicidality and life stressors, as well as certain resiliency factors. Results suggest that there exists a minority of sexual-minority youth who are at risk but that it would be inappropriate to characterize the entire population as such.

Shires, D.A., & Jaffee, K.D. (2016). Structural discrimination is associated with smoking status among a national sample of transgender individuals. Nicotine & Tobacco Research, 18(6), 1502-1508.

INTRODUCTION: Limited evidence suggests that transgender individuals smoke at significantly higher rates than the general population. We aimed to determine whether structural or everyday discrimination experiences predict smoking behavior among transgender individuals when sociodemographic, health, and gender-specific factors were controlled. METHODS: Data from the National Transgender Discrimination Survey (N = 4781), a cross-sectional online and paper survey distributed to organizations serving the transgender community, were analyzed in order to determine the association between current smoking and discrimination experiences and other potential predictors. Logistic regression models were used to establish factors that predict smoking. RESULTS: Participants reported experiencing both structural (80.4%) and everyday (65.9%) discrimination. Multivariate analyses showed that participants who reported attending some college, graduating college, or having a graduate degree were less likely to smoke compared to those with a high school degree or less. Uninsured participants were more likely to report smoking compared to those with private insurance. Those who used alcohol or drugs for coping were also more likely to smoke. Participants whose IDs and records listed their preferred gender were less likely to smoke (OR = 0.84); those who had experienced structural discrimination were more like to report smoking (OR = 1.65). CONCLUSIONS: Further research is needed in order to explore the relationship between smoking and legal transition among transgender individuals. Strategies to prevent smoking and encourage cessation among this vulnerable population are also needed. In addition, comprehensive collection of gender identity data in the context of national surveys, tobacco-related research, and clinical settings is sorely needed. IMPLICATIONS: This study establishes a link between experiences of structural discrimination among transgender individuals and smoking status.

Staples, J.M., Neilson, E.C., Bryan, A.E.B., & George, W.H. (2018). The role of distal minority stress and internalized transnegativity in suicidal ideation and nonsuicidal self-injury among transgender adults. Journal of Sex Research, 55(4-5), 591-603.

Transgender people are at elevated risk for nonsuicidal self-injury (NSSI) and suicidal ideation compared to the general population. Transgender (trans) refers to a diverse group of people who experience incongruence between their gender identity and sex assigned at birth. The present study is guided by the minority stress model and the psychological mediation framework, which postulate that sexual minority groups experience elevated stress as a result of anti-minority prejudice, contributing to negative mental health outcomes. This study utilized these theories to investigate the role of internalized transnegativity-internalization of negative societal attitudes about one’s trans identity-in the relationships of distal trans stress to suicidal ideation and NSSI. A U.S. national sample of trans adults (N = 237) completed a battery of online measures. Structural equation modeling (SEM) was used to compare models with mediation and moderation effects. Results suggested that internalized transnegativity acts as both a mediator and a moderator in the relationship between distal trans stress and suicidal ideation. Log likelihood comparisons suggested moderation models had the superior fit for these data. Results suggest that clinical interventions should directly target individuals’ internalized transnegativity as well as societal-level transnegativity.

Szymanski, D.M. (2009). Examining potential moderators of the link between heterosexist events and gay and bisexual men’s psychological distress. Journal of Counseling Psychology, 56(1), 142-151.

The purpose of this study was to examine (a) the relationship between heterosexist events and psychological distress and (b) the potential moderating roles of social support, avoidant coping, and self-esteem in the relationship between heterosexist events and psychological distress among 210 gay and bisexual men. Findings from the Web-based Internet survey revealed that many gay and bisexual men experienced heterosexist harassment, rejection, and discrimination at least once in a while during the past year and that these experiences were positively related to psychological distress. Results also indicated that self-esteem moderated the relationship between heterosexist events and psychological distress, with significant risk being associated with low self-esteem. No support was found for the moderating roles of social support and avoidant coping in the link between heterosexist events and psychological distress.

Taliaferro, L.A., & Muehlenkamp, J.J. (2017). Nonsuicidal self-injury and suicidality among sexual minority youth: Risk factors and protective connectedness factors. Academic Pediatrics, 17(7), 715-722.

OBJECTIVE: We investigated differences in prevalence of repetitive nonsuicidal self-injury (NSSI), suicidal ideation, and a suicide attempt among youth who identified as bisexual, gay/lesbian, and questioning. In addition, we examined which types of social connections were associated with reduced risk of repetitive NSSI and suicidality among youth who identified with a specific sexual minority group. METHODS: Data came from the 2013 Minnesota Student Survey. The analytic sample included 77,758 students in grades 9 and 11. Connectedness factors included parent connectedness, teacher caring, connectedness to other nonparental adults, school safety, and friend caring. Logistic regression analyses, stratified according to sexual minority group, determined social connectedness factors associated with repetitive NSSI, suicidal ideation, and a suicide attempt, as well as moderating effects of significant connectedness factors on different risk factors (depression, anxiety, bullying, and violence victimization). RESULTS: Approximately 3% identified as bisexual or questioning their sexual orientation, and <1% identified as gay/lesbian. Sexual minority youth, particularly bisexual youth, were significantly more likely than heterosexual youth to report repetitive NSSI and suicidality. Effects of connectedness varied across sexual minority groups and outcomes on the basis of types of connections. Parent connectedness emerged as a robust protective factor for all self-harm behaviors among bisexual and questioning youth. Feeling connected to nonparental adults and safe at school represented additional factors that reduced risk of repetitive NSSI and suicidality among certain groups. CONCLUSIONS: In addition to facilitating connections between youth and parents, clinicians might consider encouraging sexual minority youth to remain connected to trusted nonparental adults who could offer support and care. Schools might consider implementing sociocultural norms of acceptance, tolerance, and positive identity development to reduce risk of self-harm.

Thoma, B.C., & Huebner, D.M. (2013). Health consequences of racist and antigay discrimination for multiple minority adolescents. Cultural Diversity and Ethnic Minority Psychology, 19(4), 404-413.

Individuals who belong to a marginalized group and who perceive discrimination based on that group membership suffer from a variety of poor health outcomes. Many people belong to more than one marginalized group, and much less is known about the influence of multiple forms of discrimination on health outcomes. Drawing on literature describing the influence of multiple stressors, three models of combined forms of discrimination are discussed: additive, prominence, and exacerbation. The current study examined the influence of multiple forms of discrimination in a sample of African American lesbian, gay, or bisexual (LGB) adolescents ages 14-19. Each of the three models of combined stressors were tested to determine which best describes how racist and antigay discrimination combine to predict depressive symptoms, suicidal ideation, and substance use. Participants were included in this analysis if they identified their ethnicity as either African American (n = 156) or African American mixed (n = 120). Mean age was 17.45 years (SD = 1.36). Results revealed both forms of mistreatment were associated with depressive symptoms and suicidal ideation among African American LGB adolescents. Racism was more strongly associated with substance use. Future intervention efforts should be targeted toward reducing discrimination and improving the social context of multiple minority adolescents, and future research with multiple minority individuals should be attuned to the multiple forms of discrimination experienced by these individuals within their environments.

Walls, N.E., Freedenthal, S., & Wisneski, H. (2008). Suicidal ideation and attempts among sexual minority youths receiving social services. Social Work, 53(1), 21-29.

The increased risk of suicidal ideation and attempts among sexual minority youths have been documented in studies using both convenience samples and representative community samples. However, as most youths do not access social services, these studies do not necessarily represent the sexual minority youths that community-based social workers may encounter in their day-to-day practice. As such, the present study on risk and protective factors related to suicidality surveyed 182 sexual minority youths (14 to 21 years of age) who sought assistance at a community-based social services agency in Denver. Similar to existing literature, the findings suggest that risk factors related to suicidality include hopelessness, methamphetamine use, homelessness, and in-school victimization. However, unlike studies of the general youth population, this study found that African American and male sexual minority youths were not at a lower risk of suicidality than sexual minority youths who were, respectively, white or female. In addition, our findings suggest that the presence of gay-straight alliances in schools may function as a protective resource for sexual minority youths. Implications for social work practice are discussed.

Willoughby, B.L., Doty, N.D., & Malik, N.M. (2010). Victimization, family rejection, and outcomes of gay, lesbian, and bisexual young people: The role of negative GLB identity. Journal of GLBT Family Studies, 6(4), 403-424.

Victimization and family rejection of sexual orientation are two salient stressors facing gay, lesbian, and bisexual (GLB) young people. While initial research has established a link between these sexuality-related stressors and GLB youths’ mental health outcomes, the factors that underlie this relationship remain unclear. The current study examines the role of negative GLB identity (i.e., negative feelings about one’s own sexual orientation) in mediating the relationship between sexuality-related stress (i.e., victimization, family rejection) and youth outcomes (i.e., internalizing problems, substance use, and cigarette smoking). Participants included 81 GLB young people (ages 14 to 25 years) recruited through college groups, youth organizations, study advertisements, and friend referrals. Path analyses revealed that victimization and family rejection experiences were related to youths internalizing problems via negative GLB identity. However, stressors and health risk behaviors were not related through negative GLB identity, although some direct relationships between stressors, substance use, and smoking emerged. Limitations and implications of the present study are discussed.

Wilson, S.M., Gilmore, A.K., Rhew, I.C., Hodge, K.A., & Kaysen, D.L. (2016). Minority stress is longitudinally associated with alcohol-related problems among sexual minority women. Addictive Behaviors, 61, 80-83.

Compared to sexual minority men and heterosexual women, sexual minority women report elevated alcohol use in young adulthood. Heavy alcohol use and alcohol use disorders disproportionately affect sexual minority women across the lifespan, yet there is limited research investigating reasons for such associations. The present study investigates longitudinal associations between minority stress and both alcohol use as well as self-rated drinking consequences. Participants (N=1057) were self-identified lesbian (40.5%) and bisexual (59.5%) women between the ages of 18 to 25 recruited from across the U.S. using online advertisements. Participants completed four annual surveys. Hurdle mixed effects models were used to assess associations between minority stress and typical weekly drinking and drinking consequences one year later. Minority stress was not significantly associated with subsequent typical drinking. However, minority stress was significantly associated with having any alcohol consequences as well as the count of alcohol consequences one year later after controlling for covariates. Consistent with extant literature, this study provides evidence for a prospective association between minority stress experienced by sexual minority women and drinking consequences. This study also provides support for the potential impact of efforts to reduce minority stress faced by sexual minority women.

Woodford, M.R., Kulick, A., Sinco, B.R., & Hong, J.S. (2014). Contemporary heterosexism on campus and psychological distress among LGBQ students: the mediating role of self-acceptance. American Journal of Orthopsychiatry, 84(5), 519-529.

Contemporary heterosexism includes both overt and subtle discrimination. Minority stress theory posits that heterosexism puts sexual minorities at risk for psychological distress and other negative outcomes. Research, however, tends to focus only on 1 form at a time, with minimal attention being given to subtle heterosexism. Further, little is known about the connection between minority stressors and underlying psychological mechanisms that might shape mental health outcomes. Among a convenience sample of lesbian, gay, bisexual, and queer (LGBQ) college students (n = 299), we investigated the role of blatant victimization and LGBQ microaggressions, both together and separately, on psychological distress and the mediating role of self-acceptance. We conducted structural equation modeling to examine hypothesized relationships. Heterosexism was measured as blatant victimization, interpersonal microaggressions, and environmental microaggressions. Self-acceptance included self-esteem and internalized LGBTQ pride. Anxiety and perceived stress comprised the psychological distress factor. Our results suggest that students with greater atypical gender expression experience, greater overall heterosexism and victimization, and younger students experience more overall heterosexism, and undergraduates report more victimization. Microaggressions, particularly environmental microaggressions, are more influential on overall heterosexism than blatant victimization. Overall heterosexism and microaggressions demonstrated main effects with self-acceptance and distress, whereas victimization did not. Self-acceptance mediated the path from discrimination to distress for both overall heterosexism and microaggressions. Our findings advance minority stress theory research by providing a nuanced understanding of the nature of contemporary discrimination and its consequences, as well as illuminating the important role self-acceptance plays as a mediator in the discrimination-psychological distress relationship.