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Anxiety and Related Disorders and Concealment in Sexual Minority Young Adults

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Sexual minorities face greater exposure to discrimination and rejection than heterosexuals. Given these threats, sexual minorities may engage in sexual orientation concealment in order to avoid danger. This social stigma and minority stress place sexual minorities at risk for anxiety and related disorders. Given that three fourths of anxiety disorder onset occurs before the age of 24, the current study investigated the symptoms of generalized anxiety disorder, social phobia, panic disorder, posttraumatic stress disorder, and depression in sexual minority young adults relative to their heterosexual peers. Secondarily, the study investigated sexual orientation concealment as a predictor of anxiety and related disorders. A sample of 157 sexual minority and 157 heterosexual young adults matched on age and gender completed self-report measures of the aforementioned disorders, and indicated their level of sexual orientation concealment. Results revealed that sexual minority young adults reported greater symptoms relative to heterosexuals across all outcome measures. There were no interactions between sexual minority status and gender, however, women had higher symptoms across all disorders. Sexual minority young women appeared to be at the most risk for clinical levels of anxiety and related disorders. In addition, concealment of sexual orientation significantly predicted symptoms of social phobia. Implications are offered for the cognitive and behavioral treatment of anxiety and related disorders in this population.
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Anxiety and Related Disorders and Concealment in Sexual
Minority Young Adults
Jeffrey M. Cohen,
PGSP-Stanford Psy.D. Consortium
Christine Blasey,
PGSP-Stanford Psy.D. Consortium
C. Barr Taylor,
Stanford University School of Medicine, Palo Alto University
Brandon J. Weiss,
National Center for PTSD, Veterans Affairs Palo Alto Health Care System, Stanford University
School of Medicine
Michelle G. Newman
The Pennsylvania State University
Abstract
Sexual minorities face greater exposure to discrimination and rejection than heterosexuals. Given
these threats, sexual minorities may engage in sexual orientation concealment in order to avoid
danger. This social stigma and minority stress places sexual minorities at risk for anxiety and
related disorders. Given that three fourths of anxiety disorder onset occurs before the age of 24,
the current study investigated the symptoms of generalized anxiety disorder, social phobia, panic
disorder, posttraumatic stress disorder, and depression in sexual minority young adults relative to
their heterosexual peers. Secondarily, the study investigated sexual orientation concealment as a
predictor of anxiety and related disorders. A sample of 157 sexual minority and 157 heterosexual
young adults matched on age and gender completed self-report measures of the aforementioned
disorders, and indicated their level of sexual orientation concealment. Results revealed that sexual
minority young adults reported greater symptoms relative to heterosexuals across all outcome
measures. There were no interactions between sexual minority status and gender, however, women
had higher symptoms across all disorders. Sexual minority young women appeared to be at the
most risk for clinical levels of anxiety and related disorders. In addition, concealment of sexual
orientation significantly predicted symptoms of social phobia. Implications are offered for the
cognitive and behavioral treatment of anxiety and related disorders in this population.
Address correspondence to Jeffrey Cohen, PGSP-Stanford Psy.D. Consortium, 1791 Arastradero Road, Palo Alto, CA 94304;
jeffreycohen@stanford.edu.
Conflict of Interest Statement
The authors declare that there are no conflicts of interest.
HHS Public Access
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Behav Ther
. Author manuscript; available in PMC 2019 August 23.
Published in final edited form as:
Behav Ther
. 2016 January ; 47(1): 91–101. doi:10.1016/j.beth.2015.09.006.
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Keywords
anxiety; depression; lesbian/gay/bisexual; sexual minorities; concealment
BEHAVIORAL THEORY AND NEUROBIOLOGICAL EVIDENCE suggest that chronic exposure to threat
contributes to anxiety through overactivation of the fear response (Etkin & Wager, 2007;
Marks, 1969; Wolpe, 1958). Socially stigmatized populations, such as lesbian, gay, and
bisexual individuals, hereafter referred to as sexual minorities, face repeated exposure to
threat on the basis of minority status (Herek & Garnets, 2007; Meyer, 2003). Such threat can
include childhood maltreatment, bullying, and physical and sexual assault at rates much
higher than heterosexual peers (Balsam & Hughes, 2013) as well as discrimination and
rejection (Meyer, 2003, 2013). This exposure to violence, discrimination, and rejection often
occurs in social contexts that lack legal protection (Hatzenbuehler, Keyes, & Hasin, 2009).
Only 17 states include sexual orientation and gender identity as protected classes in hate
crimes legislation, and just 16 states prohibit discrimination on the basis of sexual
orientation and gender identity in educational settings (Human Rights Campaign, 2015).
Such threats to the well-being of sexual minorities are conceptualized as minority stress
(Meyer, 2003, 2013), a model which posits that stress results from stigma at the structural
level as well as individual stigma-related processes such as the concealment of sexual
orientation.
Due to dangers associated with sexual minority status, concealment of sexual orientation is
often used as a coping strategy (Meyer, 2003; Pachankis, Cochran, & Mays, 2015). Sexual
orientation concealment may range from explicitly claiming a heterosexual identity to more
subtle forms of impression management in an effort to make one’s sexual orientation
undetectable. A comprehensive model of the consequences of concealing a stigmatized
social identity suggests that preoccupation with the discovery of a stigmatized identity
results in hypervigilance (i.e., a heightened state of sensory sensitivity along with an
exaggerated intensity of behaviors with the goal to detect threats), which is psychologically
stressful (Pachankis, 2007). Although concealment of a stigmatized social identity may
reduce the risk of explicit discrimination (Ragins, Singh, & Cornwell, 2007), sexual
orientation concealment is broadly associated with worse mental health (Schrimshaw,
Siegel, Downing Jr., & Parsons, 2013; Sedlovskaya et al., 2013). However, little work has
looked at the association between sexual orientation concealment and disorder-specific
measures. In a study of veterans and active-duty service members, Cochran, Balsam, Flentje,
Malte, and Simpson (2013) found that participants’ sexual orientation concealment while
serving in the military predicted later symptoms of posttraumatic stress disorder (PTSD) and
depression. In another line of research, sexual orientation concealment was found to be more
closely associated with symptoms of generalized anxiety disorder and major depressive
disorder among sexual minority women relative to sexual minority men (Pachankis,
Cochran, et al., 2015). In a review, Cochran and Mays (2013) reported that the most robust
finding has been higher rates of suicidality and depression among sexual minorities in
comparison to heterosexuals with a 12-month prevalence of 20% of sexual minorities
experiencing major depressive disorder (e.g., Cochran & Mays, 2000; Garofalo, Wolf,
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Wissow, Woods, & Goodman, 1999; Remafedi, French, Story, Resnick, & Blum, 1998;
Russell & Joyner, 2001).
Given the aforementioned stressors, it is understandable that sexual minorities do experience
higher rates of anxiety disorders compared to their heterosexual counterparts; however,
findings are mixed with respect to how such results differ by gender. For example, in the
National Comorbidity Study, there was higher 12-month prevalence of specific phobia and
PTSD and higher lifetime risk of generalized anxiety disorder (GAD), simple phobia, and
PTSD in women with a same-gender sexual partner in the past 5 years relative to women
with an opposite-gender partner only; however, there were no differences in lifetime risk for
any anxiety disorder based on partner gender for men (Gilman et al., 2001). In contrast, in
the Netherlands Mental Health Survey and Incidence Study there was a higher 12-month
prevalence of mood and anxiety disorders among sexual minority men, though not among
sexual minority women (Sandfort, de Graaf, Bijl, & Schnabel, 2001).
Additional studies, however, have found differences for male and female sexual minorities.
For example, data from the MacArthur Foundation National Survey of Midlife Development
showed a higher prevalence of panic attacks in gay/bisexual men and greater prevalence of
GAD in gay/bisexual women relative to heterosexual peers (Cochran, Sullivan, & Mays,
2003). Furthermore, in the National Epidemiologic Survey on Alcohol and Related
Conditions, there were higher odds of any lifetime anxiety disorder in sexual minority men
and sexual minority women relative to heterosexuals (Bostwick, Boyd, Hughes, & McCabe,
2010). Similarly, in the California Quality of Life survey, there was an increased 12-month
prevalence of GAD and panic attacks in sexual minority men and women relative to their
heterosexual counterparts; however, concurrent HIV/AIDS infection in some of the sample
potentially limits the generalizability of these findings (Cochran & Mays, 2009).
These epidemiological studies lack conclusive findings, potentially due to different
operational definitions of sexual orientation. For example, Gilman et al. (2001) relied on
participants who reported having sex with a same-gender partner within the past five years to
define minority sexual orientation, whereas Cochran and Mays (2009) included both
participants’ self-identification as well as a behavioral report of any past same-gender sexual
partner as indicative of minority sexual orientation. Bostwick et al. (2010) assessed three
self-reported dimensions of sexual orientation: identity, attraction, and behavior. This
resulted in a more comprehensive measurement of sexual orientation. However, the
positioning of sexual behavior as a proxy for sexual orientation was consistent across most
of the aforementioned studies and much of the epidemiological literature. This behavioral
operationalization of sexual orientation fails to capture sexual orientation identity, which
Stein (2010) suggests is particularly relevant to sexual minority young adults, a group that
has not yet received the scrutiny it might deserve. Discrepant findings in prior research may
also be due to cohort effects. Researchers have identified marked differences between the
coming-of-age experiences of sexual minority youth today relative to the experiences of
older sexual minorities (Martin & D’Augelli, 2009).
On average, gay youth become aware of differences in sexual attraction at age 12, and first
disclose a minority sexual orientation at age 17 (Pachankis & Goldfried, 2006). The
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disclosure of sexual orientation is a continual process whereby the sexual minority
individual must choose whether to disclose or conceal in each new social interaction. Young
adulthood is a sensitive period for the development of sexuality and the search for potential
romantic partners is a key developmental task (Erikson, 1997). Disclosing versus concealing
a minority sexual orientation is particularly relevant to emerging adults and has been
theorized to be anxiety provoking (Pachankis, 2007; Pachankis, Goldfried, & Ramrattan,
2008), thus making the investigation of concealment and anxiety in sexual minority young
adults of great import.
Young adults are at particular risk for anxiety disorders, given that three fourths of anxiety
disorder onset occurs by 24 years of age (Kessler et al., 2005). Theories of anxiety disorders
are particularly applicable to the experiences of sexual minorities. The contrast avoidance
model suggests that individuals with GAD engage in chronic worry as a buffer against sharp
increases in negative emotionality (Newman & Liera, 2011). Given that sexual minorities are
likely to experience an unpredictable environment, it is understandable that sexual minorities
may engage in worry as a preparatory strategy to cope with such threats. Individuals with
GAD have also been shown to consider every possible outcome as a means to control
potential future threats, and thus may see worry as adapative (Newman, Llera, Erickson,
Przeworski, & Castonguay, 2013). One study of sexual minorities did find that degree of
worry related to sexual orientation was significantly associated with increased negative
affect and depressive symptoms (Weiss & Hope, 2011). A growing body of research also
argues that exposure to nonviolent racism, which does not meet the DSM Criterion A
definition of trauma, is still traumatic because it is a threat to one’s well-being and produces
symptoms analogous to PTSD (Bryant-Davis & Ocampo, 2005; Waller, 2003). Similarly,
recent research has begun to question Criterion A in the assessment of PTSD in sexual
minorities. Alessi, Meyer, and Martin (2013) found that non-life-threatening traumatic
events can still produce symptoms of PTSD and concluded that adherence to the DSM
definition results in many PTSD-like disorders being missed. Therefore, although the
present research did evaluate symptoms of PTSD in relation to participants’ most stressful
life experience, we did not assess DSM criterion A. Fears of negative evaluation are core
cognitions of social phobia, and considering the societal stigma surrounding minority sexual
orientation, it is easy to understand why a sexual minority person may hide a core aspect of
himself in order to avoid negative evaluation and rejection (Pachankis, 2007). Considering
these theories and that hypervigilance to threat is a core feature across emotional disorders
(Amir, Elias, Klumpp, & Przeworski, 2003; Mathews & MacLeod, 2005; Newman et al.,
2013), and that sexual minority young adults are exposed to threat on the basis of minority
status, research into clinical levels of anxiety and depression in sexual minority young adults
is warranted.
Sexual minority adolescents and young adults, relative to heterosexual peers, are
documented to be at greater risk for experiencing discrimination, violence, and rejection
(Faulkner & Cranston, 1998; Garofalo, Wolf, Kessel, Palfrey, & DuRant, 1998). In a recent
national survey, sexual minorities between the ages of 13 and 21 reported verbal harassment
at school (74.1%), physical harassment at school (36.2%), and experiencing LGBT-related
discriminatory policies at school (55.5%; Gay Lesbian and Straight Education Network,
2013).
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Two studies investigated symptoms of social phobia in sexual minority youth relative to
heterosexual controls. One study found higher social interaction anxiety, in a small, yet
ethnically diverse, sample of sexual minority youth relative to heterosexual youth (Safren &
Pantalone, 2006). In a larger sample of college-aged men, there were significant elevations
in social interaction anxiety and fear of negative evaluation in gay/bisexual men relative to
heterosexuals (Pachankis & Goldfried, 2006). Additionally, sexual orientation concealment
was a correlate of social phobia in sexual minority men (Pachankis & Goldfried, 2006).
Thus, preliminary evidence suggests elevated social-phobia-related symptoms in sexual
minority young people and that concealment of sexual orientation is associated with social
phobia in sexual minority young men.
In sexual minority young adults, there remains a significant gap in understanding the
experience of anxiety beyond social phobia and the role of concealment. We sought to test
the hypothesis that sexual minority young adults would report greater symptoms of GAD,
panic disorder, social phobia, PTSD, and depression, and reach clinical levels of symptoms
at rates higher than their heterosexual peers. Although DSM-5 classifies PTSD as a trauma
and stressor-related disorder, it acknowledges that symptoms following a traumatic event
“can be well understood within an anxiety or fear-based context” (American Psychiatric
Association, 2013; p. 265). Given this, and the historical understanding of PTSD as an
anxiety disorder, we included PTSD symptoms in our research. We assessed for symptoms
of depression given its association with anxiety disorders (Brown, Campbell, Lehman,
Grisham, & Mancill, 2001) as well as prior robust findings suggesting higher rates in sexual
minorities (Cochran & Mays, 2013). Secondarily, we investigated symptoms of disorders in
sexual minority women relative to sexual minority men given the mixed findings in earlier
research. On the one hand, we thought sexual minority men may display greater symptoms
of anxiety and related disorders given social theories that suggest same-gender attraction
among men is more stigmatized (Herek, 1988). On the other hand, we recognized the
existing research (Kessler et al.,2005) that documents that being of female gender raises
one’s risk for anxiety and related disorders. Therefore, we did not have a directional
hypothesis for the comparison of anxiety and related disorders between sexual minority
women and sexual minority men. We also tested the hypothesis that concealment of sexual
orientation would be associated with symptoms of anxiety and related disorders in sexual
minority young adults. Thus, the present study sought to extend current understanding and
conceptualization of anxiety in a population with known exposure to actual threat.
Method
PARTICIPANTS
Participants were 3,350 undergraduate students at a large northeastern university enrolled in
introductory psychology courses. Due to differences in the number of participants who
identified as heterosexual (
n
= 3,193) relative to the number of participants who identified as
a sexual minority (
n
= 157), we randomly selected a subsample of heterosexual participants
(matched on age and gender to sexual minority participants) for all comparisons between
sexual minority and heterosexual participants. This resulted in a final sample size of
N
=
314, with 157 participants identifying as sexual minorities and 157 participants identifying
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as heterosexuals. This sample consisted of 201 self-identified women (64%), 113 self-
identified men (36%). Mean age was 18.8 years (
SD
= 1.10) and did not significantly differ
between sexual minority and heterosexual participants,
t
(314) = 2.67,
p
= .103. Ethnic
distribution was as follows: 71.3% (
n
= 224) White/Caucasian, 13.4% (
n
= 42) Asian/Asian-
American, 6.1% (
n
= 19) African American/Black, 3.2% (
n
= 10) Hispanic/Latino, 1.0% (
n
= 3) Arab/Middle Eastern or Arab American, .3 % (
n
= 1) Pacific Islander, 2.5 % (
n
= 8)
other, and 2.2% (
n
=7) declined to answer.
MEASURES
Generalized Anxiety Disorder Questionnaire (GAD-Q-IV; Newman et al., 2002)
This is a 9-item self-report inventory designed to measure symptomatology of GAD based
on the 4th edition of the
Diagnostic and Statistical Manual of Mental Disorders
(American
Psychiatric Association, 1994). Questions assess the occurrence of excessive and
uncontrollable worry, worry content, the presence of worry for more days than not over at
least 6 months, interference with daily life caused by worry, and the occurrence of six
associated symptoms: restlessness, insomnia, difficulty concentrating, irritability, fatigue,
and muscle tension. The GAD-Q-IV has demonstrated good retest reliability and strong
interrater agreement with a structured diagnostic interview (Newman et al., 2002). Scoring
can be both dimensional as well as criterion-based to arrive at a self-reported diagnosis
(Moore, Anderson, Barnes, Haigh, & Fresco, 2013).
Panic Disorder Self-Report (PDSR; Newman, Holmes, Zuellig, Kachin, &
Behar, 2006)—This is a 24-item self-report measure of panic disorder based on the 4th
edition of the
Diagnostic and Statistical Manual of Mental Disorders
(American Psychiatric
Association, 1994). Sample items include: “During the last six months, have you had a panic
attack or a sudden rush of intense fear or anxiety?” and “Was at least one panic attack
unexpected, as if it came out of the blue?” If participants respond affirmatively to these
initial questions, they complete additional items such as fear of recurrent attacks and the
experience of physiological symptoms. Convergent and divergent validity, as well as good
retest reliability, were demonstrated (Newman et al., 2006). The measure yields a total
dimensional score. Alternatively, the measure can also yield an analogue diagnosis through a
scoring scheme congruent with DSM-IV criteria. This measure was administered for two out
of the three semesters of data collection, thus resulting in a smaller sample that completed
this assessment (
n
= 106 heterosexuals; 98 sexual minorities).
Posttraumatic Stress Disorder Checklist for DSM-S (PCL-5; Weathers et al.,
2013)—This is a 20-item self-report assessment of symptoms of PTSD based on the 5th
edition of the
Diagnostic and Statistical Manual of Mental Disorders
(American Psychiatric
Association, 2013). The PCL-5 is a new measure that has demonstrated good temporal
stability (Keane et al., 2014). Participants were instructed to fill out the PCL-5 in relation to
their most stressful life experience.
Social Phobia Diagnostic Questionnaire (SPDQ; Newman, Kachin, Zuellig,
Constantino, & Casbman-McGrath, 2003)—This is a comprehensive measure to
identify the presence of social phobia (also referred to as social anxiety) based on DSM-IV
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criteria. The 29 items measure subjective levels of fear in social, evaluative, and
performance situations as well as associated impairment and distress. The SPDQ has
demonstrated excellent retest reliability as well as strong convergent and discriminant
validity (Newman et al., 2003). It can also be scored both dimensionally and diagnostically
based on DSM criteria. An additional strength of the SPDQ is that it does not contain any
heterocentric language commonly used in other measures of social phobia (Weiss, Hope, &
Capozzoli, 2013). The measure yields a total dimensional score. Alternatively, the measure
can also yield an analogue diagnosis through a scoring scheme congruent with DSM-IV
criteria.
Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996)—This 21-item
questionnaire assesses symptoms of depression, including hopelessness, irritability, fatigue,
thoughts of death, and feelings of guilt and sadness. Items contain a 0 to 3 scale, and
responses are summed to yield a total score. Scores of 0 to 13 indicate minimal depression,
14 to 19 indicate mild depression, 20 to 28 indicate moderate depression, and 29 to 63
indicate severe depression (Beck, Steer, & Brown, 1996). The BDI-II has demonstrated high
retest reliability (Beck, Steer, & Brown, 1996), and internal consistency (Beck, Steer, Ball,
& Ranieri, 1996).
Sexual Orientation—Participants responded to a single-item measure of sexual
orientation, “How would you most accurately describe your sexual orientation?” Categorical
response options were heterosexual, bisexual, gay, lesbian, queer, and questioning. Of the
157 sexual minorities, 71 (45%) identified as bisexual, 27 gay (17%), 7 lesbian (4%), 5
queer (3%), 47 questioning (30%). Questioning was included in the sexual minority
condition in line with current research on sexual minority young adults (Eisenberg, Gower,
McMorris, & Bucchianeri, 2015; Lytle, De Luca, Blosnich, & Brownson, 2015). Thus, 157
participants (4.7%) identified as a sexual minority and were dichotomized as such in
analyses.
Sexual Orientation Openness/Concealment—Participants completed an additional
measure of sexual orientation openness/concealment. This single item: “How open in
general are you
now
about your sexual orientation?” was taken from Pachankis and
Goldfried (2006). Possible responses were on a 7-point Likert-type scale (1 =
sexual
orientation completely hidden from others
, 4 =
sexual orientation not quite hidden but not
quite open
, 7 =
completely open with others about sexual orientation
). Higher scores
indicate greater openness regarding one’s sexual orientation and, thus, lower concealment.
Sexual minority participants reported a
M
= 4.59
(SD =
2.31).
PROCEDURE
Participants completed the study measures online as part of the psychology subject pool
screening and received partial course credit for their participation. No recruitment materials
identified anxiety or sexual minority status as the focus of this study. Data collection took
place over three semesters from 2014 to 2015. The university’s Institutional Review Board
approved all study procedures.
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DATA ANALYSIS
Analyses were conducted in four steps. First, to test the hypotheses that sexual minority
young adults would report greater symptoms relative to heterosexual peers and to investigate
potential gender differences in the level of symptoms among sexual minorities, differences
in self-report measures of GAD, social phobia, PTSD, and depression were evaluated using
a two-way multivariate analysis of variance (MANOVA) with gender and sexual minority
status as factors. Follow-up univariate analyses were conducted only for effects for which
the omnibus test reached significance. Panic disorder was not included in the MANOVA
given that it was not assessed in the entire sample due to listwise deletion, and a separate
univariate analysis was conducted for this measure with gender and sexual minority status as
factors. Next, the clinical level of symptoms of GAD, panic disorder, social phobia and
depression were calculated. PTSD was excluded from the clinical level of symptom analysis
given that there are currently no empirically determined cutoff scores for the PCL-5 and also
because we did not assess criterion A. For the anxiety disorders, the clinical level of
symptoms was determined by dichotomous criterion scoring consistent with DSM-IV
criteria. For depression, BDI-II scores that fell in the moderate and severe ranges of
depression were considered to be clinical. Clinical levels of symptoms were compared
between sexual minority and heterosexual participants, sexual minority and heterosexual
men, sexual minority and heterosexual women, and sexual minority men and women using
chi-squares. In cases where any of the cell sizes were less than 5, we used Fisher’s exact
tests instead of chi-squares. Then, using only the subsample of sexual minority participants,
a series of hierarchical multiple regression analyses were performed according to steps
outlined by Aiken and West (1991) and Cohen, Cohen, West, and Aiken (2003) to test the
hypothesis that concealment of sexual orientation would predict level of symptom measures.
Gender was the sole predictor in model one. Gender and concealment were both entered as
predictors in model two.
Results
SYMPTOM SEVERITY MEASURES
Means and standard deviations for participant scores on measures of GAD, social phobia,
panic disorder, PTSD, and depression are presented by gender and sexual minority status in
Table 1. The overall multivariate model was significant for sexual minority status,
F
(4, 282)
= 8.25,
p
= .0001, η2 = .105, and gender,
F
(4, 282) = 5.71,
p
= .0001, η2 = .075; however,
the omnibus interaction between gender and sexual minority status was not significant,
F(
4,
282) = 1.1 l,
p
= .350, η2 = .016. Compared to men, women within the whole sample had
more symptoms of GAD,
F
(1, 288) = 22.37,
p
= .0001, η2 = .073, social phobia,
F
(l, 288) =
6.29,
p
= .013, η2 = .022, PTSD,
F
(1, 288) = 5.91,
p
= .016, η2 = .020, depression,
F
(1, 288)
= 23.04,
p
= .023, η2 = .018, and panic disorder,
F
(1, 203) = 9.48,
p
= .002, η2 = .045.
Similarly, sexual minorities scored significantly higher relative to heterosexuals on
symptoms of GAD,
F
(1, 288) = 22.64,
p
= .0001, η2 = .074, social phobia,
F
(1, 288) =
22.67,
p
= .0001, η2 = .074, PTSD,
F
(1, 288) = 15.03,
p
= .0001, η2 = .050, depression,
F
(1,
288) = 23.04,
p
< .0001, η2 = .075, and panic,
F
(1, 203) = 8.36,
p
= .004, η2 = .040.
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CLINICAL LEVEL OF SYMPTOMS
Percentage of participants who reached a clinical level of symptoms for GAD, panic
disorder, social phobia, and depression are presented for sexual minority and heterosexual
participants, overall and by gender, in Table 2. Sexual minorities were significantly more
likely than heterosexual participants to reach a clinical level of symptoms for GAD, χ2 (1 ,
N
= 313) = 11.04,
p
=.001, Cohen’s
d
= .382, social phobia, χ2(1,
N
= 313) = 10.66,
p
= .001,
Cohen’s
d
= .376, and depression, χ2(1,
N
= 313) = 23.92,
p
=.0001, Cohen’s
d
= .575.
Sexual minority women were also significantly more likely to reach a clinical level of
symptoms relative to heterosexual women for GAD, χ2 (1,
N
= 201) = 9.66,
p
= .002,
Cohen’s
d
= .449, social phobia, χ2 (1,
N
= 201) = 7.63,
p
= .006, Cohen’s
d =
.397, and
depression, χ2(1,
N
= 200) = 18.70 ,
p
= .0001, Cohen’s
d
= .642. Compared to heterosexual
men, sexual minority men were significantly more likely to reach a clinical level of
depression, χ2 (1,
N
= 113) = 6.41,
p
= .01, Cohen’s
d
= .490, and marginally more likely
for social phobia
(p
= .058). Finally, compared to sexual minority men, sexual minority
women were more likely to reach a clinical level of GAD
(p
= .015) and marginally more
likely for depression
(p
= .065). There were no significant differences on the clinical levels
of panic disorder for any of the aforementioned comparisons.
CONCEALMENT ANALYSES
Summary statistics of model fit and parameter estimates for the hierarchical multiple
regressions of gender and concealment are presented in Table 3. In model one, gender was a
significant predictor of symptoms for GAD, panic, depression, social phobia, and PTSD. In
model two, for which the predictors were concealment and gender, gender was a significant
predictor of GAD, panic, depression, social phobia, and PTSD, and concealment was a
significant predictor of social phobia symptoms. Thus, lack of sexual orientation openness/
concealment was associated with symptoms of social phobia.
Discussion
This study investigated anxiety and related disorders in sexual minority young adults. Sexual
minorities reported greater dimensional symptomatology of GAD, social phobia, panic,
depression and PTSD and were significantly more likely to reach a clinical level of
symptoms for GAD, social phobia, and depression relative to their heterosexual
counterparts. Our findings of higher symptoms and clinical levels of multiple anxiety and
related disorders in sexual minority young people extends previous work showing higher
symptoms of social phobia in young adults (Pachankis & Goldfried, 2006; Safren &
Pantalone,
Gender differences were also evident across the whole sample for dimensional measures of
all disorders with women exhibiting higher levels of symptoms for GAD, social phobia,
panic, depression, and PTSD. Relative to sexual minority men, sexual minority women were
also more likely to exhibit a clinical level of symptoms of GAD and marginally more likely
to exhibit a clinical level of depression. Sexual minority men were significantly more likely
than heterosexual men to reach a clinical level of symptoms of depression and marginally
more likely to exhibit a clinical level of social phobia. In addition, compared to their
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heterosexual counterparts, sexual minority women were significantly more likely to reach a
clinical level of symptoms for GAD, social phobia and depression. Females have been
extensively documented to be at increased risk for anxiety and related disorders (Kessler et
al., 2005), thus it is understandable that the sexual minority women in our sample reported
greater clinical levels of GAD and depression relative to sexual minority men. Taken
together, these findings suggest that sexual minority young adults may be at risk for elevated
symptoms of GAD, social phobia, depression, panic disorder, and PTSD as well as clinical
levels of GAD, social phobia, and depression, with sexual minority women facing the
highest risk.
We also investigated sexual orientation concealment/openness in relation to disorders given
the developmental importance of sexual orientation disclosure in this cohort. We found that
lack of sexual orientation openness/concealment was associated with symptoms of social
phobia, suggesting that concealment may intensify symptoms of social phobia among male
and female sexual minorities. This finding extends the work of Pachankis and Goldfried
(2006), who found that concealment was correlated with social phobia in sexual minority
men. Our inclusion of other anxiety disorders and depression in this analysis suggests that
this relationship is specific to social phobia. Previous research found that individuals actively
concealing a stigmatized social identity were more likely to focus on keeping this identity
hidden during social interactions (Pachankis & Goldfried, 2006; Smart & Wegner, 1999).
This preoccupation with concealment may lead to social phobia. However, it is also possible
that this relationship may represent a different pathway. Socially anxious individuals may be
less likely to disclose personal information, such as a minority sexual orientation. Behavioral
inhibition, a hallmark of social phobia, may also be the common factor underlying both
social phobia and sexual orientation concealment.
There are limitations to the present study. First, we combined multiple sexual minorities
(lesbian, gay, bisexual, queer, and questioning) for analyses. Although this categorization is
in line with prior research, it prevents comparison between different sexual minority
subgroups. Future researchers may wish to consider conducting separate analyses among
each sexual minority group, particularly given that bisexual individuals often report the
highest symptom severity (Conron, Mimiaga, & Landers, 2010). Second, this study was
cross-sectional and correlational and therefore cannot definitively determine whether
concealment or being a sexual minority are risk factors for the development of anxiety and
related disorders. It is possible that additional variables may be operating. Future researchers
may also wish to test a longitudinal model in which a latent variable is used to represent the
commonalities among anxiety and related disorders. Third, our sample was drawn from a
college population and was also predominantly Caucasian, so it is unclear to what extent
these findings may generalize to sexual minorities who do not attend college, older cohorts,
or for those who have an intersectional identity (e.g., sexual minority and racial minority).
Fourth, we focused on sexual orientation identity given the importance of identity in the
development of young adults. However, this also means our findings may not necessarily
generalize to young men who have sex with men or women who have sex with women, yet
do not identify as a sexual minority. Moreover, the use of self-report measures to determine
clinical symptoms is a limitation of this study due to the overlap of symptoms among
anxiety and related disorders. The use of a structured clinical interview would likely better
Cohen et al. Page 10
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distinguish symptoms between the disorders and aid in differential diagnosis. Finally, our
measures for GAD, social phobia, and panic disorder symptoms reflected DSM-IV criteria
whereas our PTSD measure focused on DSM-5 symptoms without the explicit assessment of
criterion A. We included DSM-IV measures of GAD, social phobia, and panic because GAD
criteria have not changed in DSM-5 and panic and social phobia have changed very little. In
addition, the measures we used for all disorders were the most updated versions of these
questionnaires available.
Overall, this study provides support for the potential risk sexual minority young adults face
for symptoms of anxiety disorders, depression, and posttraumatic stress, with sexual
minority women perhaps being at the most risk for clinical levels of these disorders. Within
sexual minorities, greater sexual orientation concealment was significantly associated with
greater symptom severity of social phobia. Young adulthood is a sensitive period for the
development of sexual identity. Prior research has found that the context in which a sexual
minority person comes out affects mental health (Friedman, Marshal, Stall, Cheong, &
Wright, 2008); thus, we might consider young adulthood and the disclosure of minority
sexual orientation to be a particularly sensitive developmental period for sexual minority
young adults. This population may benefit from structural interventions that target the social
causes of mental health disparities, such as discrimination and stigma. An unsupportive
social climate has been shown to be associated with increased risk for suicide attempts in
LGB youth (Hatzenbuehler, 2011), thus establishing safe and open spaces in educational
settings is an appropriate intervention. At the individual level, clinicians might be well
advised to consider the unique contexts of sexual minority clients and consider culturally
appropriate treatment approaches (e.g., Pachankis, Hatzenbuehler, et al., 2015). Common
targets of cognitive behavioral therapy for anxiety disorders such as avoidance and cognitive
distortions should be considered carefully in the presentation of a sexual minority patient.
For example, avoidance of locations and geographic regions that are known to be hostile to
sexual minorities may in fact be adaptive. Similarly, worries related to discrimination, such
as loss of employment due to sexual orientation, may at first appear to be a cognitive
distortion, but in fact it is possible to be legally fired for being gay in most of the 50 states
(Human Rights Campaign, 2015). Therapist awareness of these factors is important for the
delivery of culturally competent care to this population. Clinicians working with sexual
minority individuals may be well advised to consult treatment guidelines for working with
LGB individuals (American Psychological Association, 2012; Shipherd, 2015).
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Table 1
Means and Standard Deviations on Study Measures Among Sexual Minority and Heterosexual Participants Overall and by Gender
Measure Sexual Minority Heterosexual
M (SD)NM (SD)nM (SD) nM (SD)nM (SD)nM (SD)n
Overall Men Women Overall Men Women
GAD 5.18 155 3.72 60 6.10 95 3.14 157 3.67 53 3.64 104
(4.08) (3.48) (4.19) (3.09) (3.40) (3.23)
Panic 4.09 98 1.82 38 5.53 60 1.67 106 1.04 31 1.96 75
(6.34) (4.39) (6.97) (4.05) (3.14) (4.36)
Social Phobia 12.24 157 10.62 60 13.25 97 8.44 156 7.80 53 9.10 103
(7,80) (7.64) (7.77) (5.76) (5.17) (5.93)
Depression 16.71 157 13.93 60 18.42 97 10.37 156 9.68 53 10.90 103
(12.35) (11.69) (12.49) (9.28) (8.86) (10.02)
PTSD 19.21 141 13.35 51 22.52 90 10.02 150 10.47 52 10.34 98
(20.01) (17.19) (20.88) (14.04) (14.15) (15.35)
Note
. GAD = Generalized Anxiety Disorder; PTSD = Posttraumatic Stress Disorder
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Cohen et al. Page 17
Table 2
Percentage of Participants Meeting Clinical Level of Symptoms for Disorders Among Sexual Minority and Heterosexual Participants Overall and by
Gender
Diagnoses % (n)
Sexual Minority Heterosexual
Overall Men Women Overall Men Women
GAD 26.1 (41)
a
15.0 (9)
c
33.0 (32)
cb
11.5 (18)
a
5.7 (3) 14.4 (15)
b
Panic Disorder 2.5 (4) 0.0 (0) 4.1 (4) 1.9(3) 1.9 (1) 1.9(2)
Social Phobia 22.3 (35)
a
15.0 (9)
*
26.8 (26)
c
8.9 (14)
a
3.8 (2)
*
11.5 (12)
c
Depression 37.6 (59)
a
28.3 (17)
c+
43.3 (42)
d+
19 (21)
a
9.5 (5)
c
15.4 (16)
d
Note
. Same superscripts indicate significant differences between the means
ap
< .01
bp
< .05
cp
= .01,
dp
< .001,
+p
= .065,
*p
= .058;
GAD = Generalized Anxiety Disorder; PTSD = Posttraumatic Stress Disorder.
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Cohen et al. Page 18
Table 3
Model Fit Summaries and Parameter Estimates for Hierarchical Regression Models of Sexual Minority Status and Concealment
Measure Model R2R2 Δ F df Predictor βt
GAD .078 .078 12.91
***
152 Gender −.28 −3.59
***
.079 .000 6.44
**
151 Gender −.28 −3.58
***
Con −.02 −.23
Panic .086 .086 8.99
**
95 Gender −.29 −3.00
**
.093 .007 4.85
**
94 Gender −.30 −3.03
**
Con .08 .41
Social Phobia .026 .024 4.07
*
154 Gender −.16 −2.02
*
.081 .055 6.770
**
153 Gender −.16 −2.09
*
Con −.24 −3.04
**
Depression .029 .029 4.59
*
154 Gender −.17 −2.14
*
.031 .002 2.48 153 Gender −.17 −2.14
*
Con .05 −.62
PTSD .038 .045 6.56
*
138 Gender −.21 −2.56
*
.032 .000 3.29
*
137 Gender −.21 −2.56
*
Con .02 .18
Note
. GAD = Generalized Anxiety Disorder; PTSD = Posttraumatic Stress Disorder; Con = Concealment;
*p
< .05,
** p
< .01 ,
*** p
< .001.
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... Being relatively "out" with one's sexuality appears to operate as an important protective factor against mental health problems (Cole et al., 1996;Matheson et al., 2010). Disclosing versus concealing a minority sexual orientation is particularly relevant for emerging adults, and concealment has been theorized as being anxiety-provoking (Cohen et al., 2016). Accordingly, in the present study, gender (as well as sexual orientation) was not found to be a predictor of distress, despite the differences found between the groups. ...
... First, convenience sampling has the potential to lead to self-selection biases, especially toward LGs who are more open about their sexual identity. Further research is necessary to explore the associations between the variables among LGs who have not yet revealed their sexual identity, primarily in light of findings indicating higher distress among those with same-sex orientations who conceal their sexual identity (Cohen et al., 2016). Second, in the current study, we focused on a specific age group: young adults between the ages of 18-25. ...
... Third, we explored differences only by participants' self-definition of their sexual orientation. Other variables unique to the LG community that have been found to be related to high distress, such as social rejection or parental rejection of one's sexual orientation (Cohen et al., 2016), should also be investigated. Finally, the research participants were young adults from Israel. ...
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In the context of sexual minorities and the distress they may experience, recent years have witnessed a trend emphasizing the idea that protective factors may curb risk behaviors, while stressing that not all sexual minorities do experience distress. However, protective factors have been studied less frequently than have risk factors. To the extent that protective factors are identified among those at risk for psychological distress and risk behaviors, strategies can seek to address risk by enhancing these protective factors. The current study aimed to expand the knowledge in this area by simultaneously examining protective and risk factors as well as by examining the association between sexual orientation, psychological distress, sense of coherence (SOC), social support (e.g., parental and peer relationships), and alcohol and cannabis use among Israeli young adults. A self-reported questionnaire was distributed to 496 young adults: 254 heterosexual participants and 242 homosexual participants. As hypothesized, participants with a same-sex orientation reported higher psychological distress, lower SOC, a weaker relationship with their parents, and a greater use of alcohol and cannabis than did heterosexual participants. Regression analyses indicated that low SOC, low family support, and low peer support predicted higher psychological distress. However, sexual orientation was not found to predict distress levels among young adults in Israel. Similarly, no associations were found between alcohol and cannabis use and psychological distress. The results are discussed within the framework of resilience factors that can serve as a barrier to distress and to the use of psychoactive substances among young adults in general and sexual minorities in particular.
... Goh et al. (2019) have found that more than half of sexual minorities (51.1%) would choose to conceal their sexual orientation during interpersonal interactions. Those with SOC may subtly keep their sexual orientation undetectable or even explicitly claim they are heterosexual (Cohen et al., 2016). According to the Minority Stress Theory, SOC may be due to SMS (Meyer, 2003). ...
... First, according to the Minority Stress Theory, SMS and SOC, both as minority stresses, would increase the risk for depression (Meyer, 2003). Previous studies have found that sexual minorities who experienced SMS and SOC were at higher risks of depression (Cohen et al., 2016;Wang et al., 2021). Second, high self-criticism caused by SMS and SOC may also aggravate depression in sexual minorities (Aruta et al., 2021;Joeng & Turner, 2015;Mongrain & Leather, 2006). ...
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Introduction Nonsuicidal self-injury (NSSI), a significant predictor of suicide, is more frequent in sexual minorities (e.g., lesbian, gay, and bisexual) than in heterosexuals. The Minority Stress Model proposed that sexual minority stigma (SMS) may lead to maladaptive behaviors, including NSSI. However, the potential mechanism underlying the relationship between SMS and NSSI remains unclear. Therefore, the current study will examine the relationship between SMS and NSSI, and explore the serial mediating roles of sexual orientation concealment (SOC), self-criticism, and depression. Methods A total of 666 individuals who self-identified as sexual minorities (64.0% male, Mage = 24.49 years, SD = 6.50) completed questionnaires of SMS, SOC, self-criticism, depression, and NSSI, in 2020. Results The findings indicated that (1) SMS, SOC, self-criticism, depression, and NSSI were positively correlated; (2) SOC, self-criticism, and depression independently played partial mediating roles between SMS and NSSI; and (3) SOC, self-criticism, and depression played serial mediating roles between SMS and NSSI. Conclusions The current study supported the relation between SMS and NSSI among Chinese sexual minorities, and also implied a potential mechanism underlying the relation. Specifically, SMS was related to increased NSSI by higher SOC, self-criticism, and depression. SOC had dual-edged effects on NSSI. Policy Implications To reduce NSSI and other psychological problems among sexual minorities, policy makers should take more measures to eliminate SMS. Specifically, policy makers are encouraged to provide more support for changing sexual minorities’ living environment, such as repealing bills that could cause SMS and popularizing the knowledge about sexual orientation.
... Já a ocultação da identidade é mais frequentemente um mecanismo de enfrentamento (Pachankis et al, 2015a), mas este comportamento de esquiva implica hipervigilância, de modo a evitar perseguições supostas ou reais (Cohen et al, 2016). Tal padrão, a longo prazo, pode prejudicar o funcionamento social do indivíduo e aumentar o isolamento e a solidão. ...
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Resumo: A teoria do estresse de minorias se propõe a explicar os prejuízos de saúde de grupos minoritários de sexo e de gênero que são expostas a estruturas sociais estigmatizan-tes a partir de três processos: estigma imposto, homonegatividade internalizada e ocultação da identidade sexual. A literatura brasileira mostra que essas minorias têm mais problemas de saúde mental quando comparadas com pessoas cisgêneras heterossexuais, corroborando estudos internacionais. Este artigo tem como objetivo analisar o impacto do estresse social na saúde mental de minorias de sexo e de gênero a partir de uma compreensão comportamental da teoria do estresse de minorias, com vistas a subsidiar o desenvolvimento de políticas públicas e tecnologias de intervenção para esta população. Há poucos estudos com o referencial da análise do comportamento que exploram essa definição. O estudo de modelos experimentais como o de supressão condicionada, estado motivacional defensivo e estrese crônico moderado descrevem processos comportamentais relevantes para a compreensão do efeito dos estressores ambientais sobre os desfechos negativos na saúde mental dessa população. Os modelos teóricos que descrevem os processos de punição/fuga-esquiva, ambiente invalidante, esquiva experiencial, desenvolvimento de self instável ou inseguro, por sua vez, permitem uma interpretação analítico-comportamental de alguns processos comportamentais que constituem a subjetividade e o sofrimento psicológico do indivíduo LGBT+, bem como seus mecanismos de enfrentamento aos estressores ambientais e seus efeitos imediatos e atrasados. Tais modelos e conceitos permitem levantar variáveis relevantes e fomentar políticas públicas para o desenvolvimento de protocolos de intervenção no âmbito da análise do comportamento aplicada.
... Minority stressors are hypothesized to exist along a continuum from distal stressors, which are external to the individual (e.g., discrimination), to proximal stressors, which are internal to the individual (e.g., internalized stigma, rejection sensitivity, identity concealment). The associations between each of these minority stressors and depression and anxiety are well documented (Cohen et al., 2016;Feinstein, 2020;Meyer, 2003;Newcomb & Mustanski, 2010;Pachankis et al., 2020). ...
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Bisexual, pansexual, and queer (bi+) individuals are at increased risk for depression and anxiety. These disparities are hypothesized to be due to the unique, minority-specific stressors that they experience. Prior research supports that bi+ stressors are associated with depression and anxiety, but nearly all studies have been cross-sectional, limiting our understanding of how experiencing bi+ stress influences individuals' levels of depression and anxiety as they occur in their day-today lives. To address this gap, we examined the daily associations between bi+ stressors (dis-crimination, internalized stigma, rejection sensitivity, and identity concealment) and depressed/anxious mood in a 28-day diary study. Participants were 208 bi+ individuals who completed daily measures of bi+ stressors and depressed/anxious mood. We tested unlagged (same-day) and lagged (next-day) associations, and we also tested whether internalized stigma, rejection sensitivity, and identity concealment functioned as mechanisms underlying the daily associations between discrimination and depressed/ anxious mood. Participants reported higher depressed/anx-ious mood on days when they reported higher discrimination , internalized stigma, rejection sensitivity, and identity concealment. There were significant unlagged indirect effects of discrimination on depressed and anxious mood via internalized stigma and rejection sensitivity, and there was also a significant unlagged indirect effect of discrimination on anxiety via identity concealment. However, none of the lagged associations were significant. Results suggest that bi+ stress is related to same-day, but not next-day, depressed/anxious mood. The nonsignificant lagged associations could reflect that bi+ individuals are using adaptive coping skills in response to bi+ stress, or that other experiences throughout the day have stronger influences on next-day mood.
... Cross-sectional studies have found that marginalization, concealment, internalized homonegativity, and sexual orientation rejection sensitivity are all associated with social anxiety (Cohen et al., 2016;Feinstein et al., 2012;Mereish & Poteat, 2015;Pachankis et al., 2018). One study found that marginalization (specifically parental rejection), internalized homonegativity, and rejection sensitivity are all associated with social unassertiveness, a factor closely related to social inhibition (Pachankis et al., 2008). ...
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Research suggests that loneliness among sexual minority adults is associated with marginalization, but it is unclear which processes may underlie this relationship. This cross-sectional study examined five possibilities: stigma preoccupation, internalized homonegativity, sexual orientation concealment, social anxiety, and social inhibition. The study also examined the possible protective role of LGBTQ community involvement. Respondents were 7856 sexual minority adults aged 18–88 years from 85 countries who completed an online survey. Results of structural equation modeling indicated that marginalization was positively associated with both social and emotional loneliness, and that part of this relationship was indirect via proximal minority stress factors (especially stigma preoccupation) and, in turn, social anxiety and social inhibition. Moreover, while LGBTQ community involvement was associated with greater marginalization, it was also associated with lower levels of proximal stress and both forms of loneliness. Among those who were more involved in the LGBTQ community, the associations between marginalization and proximal stress were somewhat weaker, as were those between stigma preoccupation and social anxiety, and between social inhibition and social loneliness. In contrast, the associations between concealment and social anxiety were somewhat stronger. Model fit and patterns of association were similar after controlling for the possible confounding effect of dispositional negative affectivity, but several coefficients were lower. Findings underscore the continuing need to counter marginalization of sexual minorities, both outside and within the LGBTQ community, and suggest possible avenues for alleviating loneliness at the individual level, such as cognitive-behavioral interventions targeting stigma preoccupation and social anxiety.
... Enacted stigma cultivates discriminatory environments wherein sexual minorities may internalize shame and conceal their sexual identity as a coping strategy for dealing with discrimination and the realities of violent victimization of cisgender sexual minority men (Frost & Meyer, 2009;Herek et al., 2007). Internalized homophobia, however, can be psychologically taxing, increasing men's vulnerability to depressive symptoms and emotional distress (Cohen et al., 2016;Walch et al., 2016). Despite prior theory and research, few studies have investigated if internalized homophobia operates as a mediator linking enacted stigma to depressive symptoms among cisgender sexual minority men (e.g., Szymanski & Ikizler, 2013). ...
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The present study investigated the dyadic direct and indirect effects of enacted stigma on depressive symptoms via internalized homophobia and whether communal coping moderated the effects of enacted stigma on internalized homophobia and depressive symptoms. Hypotheses were tested using actor-partner interdependence models with a sample of 543 cisgender sexual minority male couples. Results showed both partners' enacted stigma experiences were associated with elevated levels of internalized homophobia via actor and partner effects. Internalized homophobia was only associated with elevated depressive symptoms via actor effects. Indirect effects analysis suggested that internalized homophobia mediated the actor and partner influence of enacted stigma on depressive symptoms. Communal coping moderated the direct effects of enacted stigma on internalized homophobia and attenuated the conditional indirect actor and partner effects of enacted stigma on depressive symptoms. Findings underscore the role of intimate relationship processes in understanding the impacts of enacted stigma on depressive symptoms.
... This discourse then presents not coming out in a highly vocal manner as indicative of shame or dishonesty. Indeed, nondisclosure and active concealment of a gay identity has been associated with denying one's same-sex sexual attractions (Pachankis, 2007); negative outcomes for gay men, such as lower well-being (Sedlovskaya et al., 2013); and increases in depression and social phobia (Cohen et al., 2016). Research has also demonstrated a number of benefits connected to the coming out process, including increases in self-esteem (e.g., Vaughan & Waehler, 2010) and social support Significance of the Scholarship to the Public We show that less shame and guilt predict negative relationships between verbal disclosure (of one's gay identity) and mental health issues (depression and anxiety) among gay White men. ...
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We examined the relationship between verbal disclosure of sexual orientation and mental health among gay Latino and gay White men. In Study 1, we recruited 164 gay Latino ( n = 81) and gay White ( n = 83) men via Amazon’s Mechanical Turk (MTurk). Participants completed measures assessing the degree to which they verbally disclosed their gay identity to others, as well as their depression and anxiety symptoms. Increased verbal disclosure predicted better mental health among gay White men only; no statistically significant relationships emerged among gay Latinos. In Study 2, we recruited 281 gay Latino ( n = 130) and White ( n = 151) men via MTurk, in which feelings of shame and guilt independently mediated the relationship between verbal disclosure and mental health. Among gay White men, increased verbal disclosure predicted less shame and guilt, which predicted better mental health. These relationships did not emerge for gay Latinos.
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Physicians can play a critical role in helping lesbian, gay, and bisexual-identified (LGB) individuals face minority stress. The current questionnaire study among 305 medical students (62.6% women/37.4% men; Mage = 23.4, SD = 3.2) assessed whether medical students learn about LGB-specific concepts at an Austrian medical university. Students reported that their education contained little content about LGB-specific concepts. The majority of students did not hold negative attitudes toward homosexuality and they would like a larger range of courses concerning LGB-specific topics. The barrier most strongly associated with the intention to ask future patients about their sexual orientation was the belief that sexual orientation was irrelevant for clinical practice. Future education programs on LGB-specific topics may not need to focus on reducing negative attitudes toward sexual minorities, but should contain more facts on LGB individuals' specific healthcare needs and explain to students why a patient's sexual orientation is important to healthcare.
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The first-line psychological treatment for obsessive-compulsive and related disorders (OCRDs) is exposure and response prevention (ERP). As the first study to examine treatment outcomes for sexual minorities, it is crucial to examine: (1) how treatment-seeking individuals who identify as sexual minorities compare to heterosexual individuals in symptom severity at admission, length of stay in treatment, and (2) whether ERP is equally effective for sexual minorities. The current study explored these questions in an intensive/residential treatment (IRT) program for OCRDs. Adult participants (N = 191) completed self-reported measures of OCD severity, distress tolerance, and depression at program admission, in the first four weeks of treatment, and at discharge. No differences were found between groups for treatment outcome, although slight differences (non-significant) emerged at baseline for OCRD severity, distress tolerance, and depression. Sexual orientation was not predictive of OCRD severity at weeks 1–4, and number of days spent in treatment was not associated with sexual orientation. This is the first study exploring whether sexual orientation is predictive of treatment outcomes for individuals diagnosed with OCRDs. Results suggest that outcomes did not differ and participation in the program resulted in an overall improvement of symptoms regardless of sexual orientation, however several study limitations are discussed. Future studies should replicate these findings, attempt to collect a larger sample, incorporate qualitative feedback from treatment, and examine outcomes in gender minorities.
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In this article the author reviews research evidence on the prevalence of mental disorders in lesbians, gay men, and bisexuals (LGBs) and shows, using meta-analyses, that LGBs have a higher prevalence of mental disorders than heterosexuals. The author offers a conceptual framework for understanding this excess in prevalence of disorder in terms of minority stress— explaining that stigma, prejudice, and discrimination create a hostile and stressful social environment that causes mental health problems. The model describes stress processes, including the experience of prejudice events, expectations of rejection, hiding and concealing, internalized homophobia, and ameliorative coping processes. This conceptual framework is the basis for the review of research evidence, suggestions for future research directions, and exploration of public policy implications.
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Previous studies have found that sexual orientation concealment affords escape from stigma and discrimination but also creates a psychological toll. While disclosure alleviates the mental burden of concealment, it invites the stress of navigating a new public identity. Population-based samples that include both "in" and "out" sexual minorities provide an ideal opportunity to resolve limitations and inconsistencies of previous nonprobability investigations into the mental health correlates of concealment and disclosure. Sexual minority participants in the California Quality of Life Survey (n = 2,083) indicated whether and when they first disclosed their sexual orientation to others. Prevalence of 1-year major depressive disorder and generalized anxiety disorder was derived from the Composite International Diagnostic Interview-Short Form. Closeted men (n = 84) were less likely to be depressed than out men, n = 1,047; odds ratio (OR) = 0.41; 95% CI [0.17, 0.996]. Men who were recently out (n = 201) experienced higher odds of major depressive disorder, OR = 6.21; 95% CI [1.53, 24.47], and generalized anxiety disorder, OR = 5.51; 95% CI [1.51, 20.13], as compared to closeted men. Men who were distantly out (n = 846) also experienced higher odds of major depressive disorder than men who were closeted, OR = 2.91; 95% CI [1.10, 7.69]. Recently out women (n = 243) experienced lower odds of depression than closeted women, n = 63; OR = 0.21; 95% CI [0.05, 0.96]. Whether being in or out of the closet is associated with depression and anxiety largely depends on gender. Clinical and policy implications are discussed in terms of the unique stressors facing men and women both in and out of the closet. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
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We tested the preliminary efficacy of a transdiagnostic cognitive-behavioral treatment adapted to improve depression, anxiety, and co-occurring health risks (i.e., alcohol use, sexual compulsivity, condomless sex) among young adult gay and bisexual men. Treatment adaptations focused on reducing minority stress processes that underlie sexual orientation-related mental health disparities. Young gay and bisexual men (n = 63; M age = 25.94) were randomized to immediate treatment or a 3-month waitlist. At baseline, 3-month, and 6-month assessments, participants completed self-reports of mental health and minority stress and an interview of past-90-day risk behavior. Compared to waitlist, treatment significantly reduced depressive symptoms (b = -2.43, 95% CI: -4.90, 0.35, p < .001), alcohol use problems (b = -3.79, 95% CI: -5.94, -1.64, p < .001), sexual compulsivity (b = -5.09, 95% CI: -8.78, -1.40, p < .001), and past-90-day condomless sex with casual partners (b = -1.09, 95% CI: -1.80, -0.37, p < .001), and improved condom use self-efficacy (b = 10.08, 95% CI: 3.86, 16.30, p < .001). The treatment yielded moderate and marginally significant greater improvements than waitlist in anxiety symptoms (b = -2.14, 95% CI: -4.61, 0.34, p = .09) and past-90-day heavy drinking (b = -0.32, 95% CI: -0.71, 0.07, p = .09). Effects were generally maintained at follow-up. Minority stress processes showed small improvements in the expected direction. This study demonstrated preliminary support for the first intervention adapted to address gay and bisexual men's co-occurring health problems at their source in minority stress. If found to be efficacious compared to standard evidence-based treatments, the treatment will possess substantial potential for helping clinicians translate LGB-affirmative treatment guidelines into evidence-based practice. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
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Research on victimization experiences of sexual minority women and men has increased in the past decade. From these studies, it is clear that sexual minority people are at elevated risk for a wide range of victimization experiences over the lifespan, from childhood abuse in the home, to bullying and victimization at school, to physical and sexual assault in adulthood. This chapter provides an overview of this body of literature, highlighting prevalence and correlates of victimization among sexual minority people as well as implications for future research. It begins by considering some methodological challenges of work in this area.
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