The Rejection Sensitivity Model as a Framework for Understanding Sexual Minority Mental Health

Systemic inflammation as a driver of health disparities among sexually-diverse and gender-diverse individuals

Sexually-diverse individuals (those who seek sexual or romantic relationships with the same and/or multiple genders) and gender-diverse individuals (those whose gender identity and/or expression differs from their birth-assigned sex/gender) have disproportionately high physical health problems, but the underlying biological causes for these health disparities remain unclear. Building on the minority stress model linking social stigmatization to health outcomes, we argue that systemic inflammation (the body's primary response to both physical and psychological threats, indicated by inflammatory markers such as C-reactive protein and proinflammatory cytokines) is a primary biobehavioral pathway linking sexual and gender stigma to physical health outcomes. Expectations and experiences of social threat (i.e., rejection, shame, and isolation) are widespread and chronic among sexually-diverse and gender-diverse individuals, and social threats are particularly potent drivers of inflammation. We review research suggesting that framing "minority stress" in terms of social safety versus threat, and attending specifically to the inflammatory consequences of these experiences, can advance our understanding of the biobehavioral consequences of sexual and gender stigma and can promote the development of health promoting interventions for this population.

Age Differences in Sexual Minority Stress and the Importance of Friendship in Later Life

OBJECTIVES

This study examined whether younger and middle-aged and older sexual minorities (YSM, MAOSM) experience minority stress differently in relation to social support and depressive symptomatology.

METHODS

Cross-sectional data from 238 sexual minorities (18-80; M = 40.93) comprised the sample, who were strategically separated into cohorts. Group difference and regression methods were used to examine differences in minority stress between groups and the relationships between minority stress-social support-depressive symptomatology within groups.

RESULTS

MAOSM had greater outness and lower IH. Additionally, outness and IH were the best predictors for the MAOSM and YSM group, respectively. MAOSM indicated better adaption to minority stresses, highlighting the importance of friend support as a protective mechanism.

CONCLUSIONS

The minority stress-depressive symptomatology is mitigated by friend support in MAOSM.

CLINICAL IMPLICATIONS

OSM and YSM demonstrate different susceptibility of minority stress on depressive symptomatology, with outness being a stronger indicator in MAOSM and IH being a stronger predictor in YSM. Social support does not work uniformly in different cohorts; however, multiple sources (i.e., family, friends) should be discussed with clients. Clinicians should treat cohort as one of the defining features of a sexual minority's lifelong experience with minority stress.

Ambient Discrimination, Victimization, and Suicidality in a Non-Probability U.S. Sample of LGBTQ Adults

Individuals who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ) are at a higher risk for suicidality compared to the general population. A growing body of research has investigated this risk, particularly with attention to systemic factors such as discrimination and harassment. Unfortunately, research has only examined the impact of direct discrimination on suicidality and has neglected to examine how ambient discrimination (i.e., witnessing or being made aware of discriminatory behaviors directed at someone other than yourself in your group) relates to suicidality. Additionally, although some links exist between discrimination and suicidality, the mechanisms by which these are related are understudied. This study aimed to address these gaps by exploring the effect of ambient discrimination on suicidal ideation and examining psychological pain as a mediator in this relationship. Data were collected from a sample of 200 LGBTQ-identified individuals (M age = 35 years; 53.5% female; 86% White). Results of independent t tests and a one-way multivariate ANOVA revealed greater vulnerability for ambient/direct discrimination and psychache among individuals identifying as transgender, queer, and other. Regression and mediation analyses revealed that while both ambient and direct discrimination predicted suicidal ideation, only direct discrimination accounted for unique variance in the outcome; however, both ambient and direct discrimination contributed unique variance to psychological pain, which fully mediated their relationships to suicidal ideation. Results of this study may begin to provide insight into the pathways of risk and points of intervention for suicidality in the LGBTQ community.

The Legal Vulnerability Model for Same-Sex Parent Families: A Mixed Methods Systematic Review and Theoretical Integration

Globally, parents and children in same-sex parent families are impacted by many laws related to the parental sexual orientation. These laws vary considerably from one country to another, ranging from full legal recognition to criminalization. The psychological consequences of living in an ambiguous or hostile legal climate likely interfere with parental health, family functioning, and child development. However, a systematic evidence synthesis of the pertinent literature and its placement within a broader psychological model are currently lacking. The aims of this review were thus (1) to systematically review qualitative and quantitative evidence on the impact of sexual orientation laws on same-sex parent families in key domains and (2) to place these findings within a broader model informed by minority stress and family theories. Our review was preregistered and conducted in line with PRISMA guidelines. We searched for qualitative, quantitative, and mixed methods studies on the impact of sexual orientation laws on target outcomes (parental health, family functioning, child outcomes) via systematic database search (PubMed, Scopus, Web of Science) and forward-backward searches. Fifty-five studies published between 1999 and 2020 were eligible for inclusion and were synthesized using a data-based convergent synthesis design. Thirteen descriptive and three overarching analytical themes were identified through thematic synthesis. Linking our findings with minority stress and family theories, we propose a novel legal vulnerability model for same-sex parent families. The model posits that legal vulnerability constitutes an increased risk for parental and child health as well as family functioning through individual and shared pathways between family members. Additionally, the model introduces counteractions that families engage in on the personal, familial, and systemic level to mitigate the impact of legal vulnerability, as well as moderators on the contextual, familial, couple, and individual level that modulate this impact. Implications for research and clinical practice are discussed.

A Minority Stress Response Model of Health Behaviors in Gay and Bisexual Men: Results from a Taiwanese Sample

Purpose: Health disparities among sexual minority men remain and continue to demand novel interventions. Other than risk reduction, a promising approach is to identify pathways to health-promoting behaviors. In this study, depressive symptoms, internalized homophobia, and sense of community connectedness were hypothesized to result from the experience of harassment and rejection, and in turn either promote or inhibit an individual's tendency toward health-promoting behaviors. We accounted for subgroup differences by examining the hypothesized model in gay and bisexual men separately. Methods: This was a cross-sectional survey study. One thousand three hundred eighty-one gay (81.5%) and bisexual (18.5%) Taiwanese men 18-49 years of age (mean = 26.56, standard deviation = 6) were recruited through a social media advertisement and completed an online survey. Structural equation modeling was employed to simultaneously examine multiple hypothesized paths. Results: Harassment and rejection were associated with greater depressive symptoms, internalized homophobia, and sense of community connectedness, which in turn yielded direct or indirect associations with health-promoting behavior among gay men. For bisexual men, depressive symptoms remained an important mechanism linking harassment and rejection and health-promoting behavior, whereas the roles of internalized homophobia and sense of community connectedness appeared less obvious. Conclusion: These findings cast new light on the behavioral implications of minority stress and elucidate the possible underlying mechanisms. The study suggests that more effort should be invested to understand and promote the drivers of health-promoting behavior to reduce health disparities in this population.

Fear of Stigma Mediates the Relationship between Internalized Stigma and Treatment-Seeking among Individuals with Substance Use Problems

BACKGROUND

Despite the high prevalence and significant health consequences of substance use disorders, rates of treatment seeking are low. Identifying as an "addict" caries a mainstream connotation that the individual is blameworthy, which contributes to unique stressors and stigma that shape how they are viewed and treated. While substantial literature demonstrates this stigmatizing perspective may serve as a barrier to treatment-seeking, other studies present discrepant findings. The current study seeks to examine the role of fear of stigma and anticipation of being stigmatized in the relationship between internalized stigma and help-seeking for substance use disorders.

OBJECTIVE

We examined substance use-related stigma, fear of stigma, and treatment-seeking behaviors in a national sample of young adults with a history of problematic substance use.

METHODS

Participants (N = 171) completed an online, anonymous survey.

RESULTS

When controlling for enacted stigma and severity of alcohol and other drug use problems, more fear of stigma significantly mediated the relationship between higher internalized stigma and more help-seeking intentions. The sequentially mediated paths between internalized stigma and both help-seeking intentions and previous behaviors through fear of stigma and anticipated stigma were not significant.

CONCLUSIONS

Findings highlight the importance of fear of substance-related stigma as one mechanism by which internalized stigma may motivate individuals to seek treatment for substance use problems.

Future Directions in Understanding and Addressing Mental Health among LGBTQ Youth

Today's LGBTQ youth come of age at a time of dynamic social and political change with regard to LGBTQ rights and visibility, yet remain vulnerable to compromised mental health. Despite advances in individual-level treatment strategies, school-based programs, and state-level policies that address LGBTQ mental health, there remains a critical gap in large-scale evidence-based prevention and intervention programs designed to support the positive development and mental health of LGBTQ youth. To spur advances in research and translation, I pose six considerations for future scholarship and practice. I begin by framing LGBTQ (mental) health disparities in a life course perspective and discuss how research focused on the timing of events could offer insight into the optimum targets and timing of prevention and intervention strategies. Next, I argue the importance of expanding notions of "mental health" to include perspectives of wellbeing, positive youth development, and resilience. I then consider how research might attend to the complexity of LGBTQ youths' lived experience within and across the various contexts they traverse in their day-to-day lives. Similarly, I discuss the importance of exploring heterogeneity in LGBTQ youth experiences and mental health. I also offer suggestions for how community partnerships may be a key resource for developing and evaluating evidence-informed programs and tools designed to foster the positive development and mental health of LGBTQ youth. Finally, I acknowledge the potentials of team science for advancing research and practice for LGBTQ youth health and wellbeing. Throughout, these future directions center the urgent needs of LGBTQ youth.

Mental Health Disparities Mediating Increased Risky Sexual Behavior in Sexual Minorities: A Twin Approach

Increased risky sexual behavior in sexual minorities relative to heterosexual individuals may be partly explained by mental health disparities, and both factors may be further jointly influenced by common genetic and environmental factors. However, these relationships have not been previously investigated. The objectives of the present study were to investigate mental health disparities as a mediator of the relationship between sexual orientation and risky sexual behavior, controlling for genetic and environmental effects in this relationship and testing for sex differences. Participants included 5814 twins from a Finnish twin cohort. Specified latent factors included sexual orientation, mental health indicators, and risky sexual behavior. Twin models were fitted to the factor structure of the data whereby a Cholesky decomposition on the factors was compared to a mediation submodel using OpenMx. Sex differences were tested in the final model. Phenotypically, mental health disparities partially mediated the relationship between sexual orientation and increased risky sexual behavior, with comparable effects in males and females. However, while this indirect route from sexual orientation to risky sexual behavior mainly contained transmitted genetic effects in males, there was a significant proportion of transmitted shared environmental effects in females. This is the first study to demonstrate that the mediation relationships between sexual orientation, mental health disparities, and risky sexual behavior are not confounded by genetic and environmental factors. The significant sex differences need to be recognized in future research and intervention design to improve sexual health in sexual minorities.

Gay-Specific and General Stressors Predict Gay Men's Psychological Functioning Over Time

Gay men experience various stressors, including gay-specific stressors such as discrimination and internalized homonegativity as well as general stressors such as occupational and financial strain. While a robust literature has examined how gay-specific stressors are associated with negative mental health outcomes among gay men, less attention has been paid to the association between general stress and gay men's psychological functioning or to how different types of stressors may interact to affect functioning. The current study sought to address this gap by examining the unique and combined associations between gay-specific external stress (discrimination), gay-specific internal stress (rejection sensitivity, internalized homonegativity, sexual identity concealment), and general stressors (e.g., academic difficulties) and negative affect and alcohol use over time. A total of 147 self-identified gay men living in the greater New York City area participated in a baseline assessment and a 7-week diary study. Univariate and multivariate results revealed that gay-specific external stress, gay-specific internal stress, and general stress were each positively and uniquely associated with higher mean levels of and greater fluctuations in negative affect over time, and general stress was positively associated with greater fluctuations in alcohol use over time. Multiplicative analyses indicated that individuals reporting high levels of stress in multiple domains experienced particularly high mean levels of negative affect. These findings highlight the unique contribution of general stress to gay men's functioning over time and underscore the importance of considering multiple forms of stress (i.e., gay-specific and general stress) and their interactions to better understand gay men's psychological functioning.

Perceived Attitudes Toward Lesbian, Gay, and Bisexual (LGB) Issues and Mental Health Among Taiwanese LGB Adults: The Mediating Role of Self-Acceptance

Research on structural stigma has associated the poor mental health status among lesbian, gay, and bisexual (LGB) people with discriminatory institutions. Yet, less is known about the role of LGB adults' perceptions of social attitudes toward LGB issues. Moreover, the psychological mediation framework posits LGB people's self-acceptance as a mediator between a stigmatizing environment and individual mental health. This study investigated: (a) how perceived attitudes toward LGB issues from different social realms (society, heterosexual friends, and family members) were associated with LGB people's mental health; and (b) whether self-acceptance mediated the effects of perceived attitudes. In this cross-sectional study, 1527 Taiwanese LGB adults (812 men; 715 women) aged between 20 and 62 years were recruited via Facebook to complete an online survey. The majority of respondents self-identified as homosexual (1129) and 399 as bisexual. The survey consisted of assessment of respondents' mental health and questions to rate individual self-acceptance and perceptions of social attitudes. Path analysis showed that self-acceptance partially mediated the association between mental health and perceived societal acceptance of homosexuality and fully mediated the effect of perceptions of friends' acceptance of homosexuality on mental health. Self-acceptance fully mediated the effects of perceived support for same-sex marriage from friends and families. This research yielded evidence about the interplay between perceived social stigma, self-acceptance, and mental health, particularly in the context of public debate about same-sex marriage. The effects of public discourse about sexual diversity and marriage equality on LGB adults' mental health should be addressed by affirmative policies and practices.

The phenomenology of gender dysphoria in adults: A systematic review and meta-synthesis

Gender dysphoria is distress due to a discrepancy between one's assigned gender and gender identity. Adults who wish to access gender clinics are assessed to ensure they meet the diagnostic criteria for gender dysphoria. Therefore, the definition of gender dysphoria has a significant impact on the lives of individuals who wish to undergo physical gender transition. This systematic review aimed to identify and synthesize all existing qualitative research literature about the lived experience of gender dysphoria in adults. A pre-planned systematic search identified 1491 papers, with 20 of those meeting full inclusion criteria, and a quality assessment of each paper was conducted. Data pertaining to the lived experience of gender dysphoria were extracted from each paper and a meta-ethnographic synthesis was conducted. Four overarching concepts were identified; distress due to dissonance of assigned and experienced gender; interface of assigned gender, gender identity and society; social consequences of gender identity; internal processing of rejection, and transphobia. A key finding was the reciprocal relationship between an individual's feelings about their gender and societal responses to transgender people. Other subthemes contributing to distress were misgendering, mismatch between gender identity and societal expectations, and hypervigilance for transphobia.

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A systematic review of all papers on the lived experience of gender dysphoria

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Twenty papers with 1606 participants were included in a meta-ethnographic synthesis.

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Distress was due to gender and sex incongruence, as well as social factors.

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Results give new insights into the relationships between factors causing distress.

Impact of Status-Based Rejection Sensitivity on Depression and Anxiety Symptoms in Gay Men

Status-based rejection sensitivity refers to the anxious expectation and tendency to perceive rejection in ambiguous social scenarios based on one's minority identification. This study evaluates the implications of sensitivity to rejection based on sexual orientation identity on negative mental health outcomes. Current minority stress models include rejection sensitivity as a factor that may contribute to adverse negative psychosocial outcomes in LGBT persons. This study evaluates the role of rejection sensitivity alongside demographically relevant predictors such as age, race, education, and level of sexuality disclosure in predicting the presence of significant depression and anxiety scores among a sample of gay men. Results indicate that rejection sensitivity, sexuality openness, and anxiety were significant predictors of depression symptoms, whereas age and depression were significant predictors of anxiety symptoms. This study supports the role of rejection sensitivity as a contributor to negative mental health outcomes among gay men, particularly as it pertains to internalizing mental health disorders.