Article Summary of How does sexual minority stigma “get under the skin”? A psychological mediation framework - Hatzenbuehler - 2009

What areas has science focused on when it comes to mental health issues among sexual minorities?

Three different literatures need to be mentioned that have focused on identifying risk factors that put sexual minorities at risk when it comes to mental health problems:

• Psychiatric epidemiology
• Social generation of stigma through stress
• General psychological processes

Why is it important to integrate these literatures?

There is a need for a framework with psychological pathways that link stigma-related stressors to adverse mental health outcomes. This framework should take into account group-specific stressors as well as general psychological processes. Exclusive focus on any of these processes without considering their interrelationships hinders the development of effective theory of the determinants of mental health disparities among sexual minorities and prevention and intervention efforts.

What are the three hypotheses proposed by the psychological mediation framework?

The psychological mediation framework (PMF) is theoretically based on transactional definitions of stress, stating that both environmental and response components of stress are important in determining health outcomes. It proposes the following hypotheses:

• Sexual minorities face increased exposure to stress due to stigma.
• This stigma-related stress leads to increases (relative to heterosexuals) in general coping/emotion regulation, social/interpersonal, and cognitive processes that cause risk for psychopathology.
• These processes, in turn, mediate the relationship between stigma-related stress and psychopathology.

What is minority stress theory?

Minority stress theory (MST) describes how societal stressors contribute to differences in mental health in LGBT populations. The minority stress theory suggests that difficult social situations cause stress in minority individuals, which builds up over time, resulting in long-term health deficits. Stress is seen as a mediator between social structure/status and illness.

How does the psychological mediation framework differ from minority stress theory?

• The PMF examines the intra- and interpersonal psychological processes through which stigma-related stress leads to psychopathology. It isolates the emotion regulation, social, and cognitive processes that stigma-related stress causes. It looks at the mechanisms by which stressors associated with prejudice and discrimination affect mental health. In short:
  Minority stress theory: status - stress - psychopathology. Psychological mediation framework: stress - psychological mediators - psychopathology.

• MST focuses on group-specific processes that sexual minorities face as members of a stigmatized group, in the form of distal and proximal stressors arising from their minority status. By not including general psychological processes, MST overlooks a lot of risk factors. The PMF does incorporate them and demonstrates that these processes are triggered by stigma-related stress and mediate the association between stress and psychopathology.

• The PMF has important implications for interventions that are not addressed in the MST. MST points to interventions at a societal level, like stigma reduction and policies that eliminate structural forms of prejudice and discrimination. But because MST does not focus on the psychological processes by which stigma-related stress contributes to psychopathology, it remains unclear which processes should be targeted for clinical interventions in sexual minority clients. The PMF points to several psychological processes that are amenable to interventions, such as emotion dysregulation, pessimism/hopelessness, and positive alcohol expectancies.

How do mental problems differ in sexual minorities compared to heterosexual populations?

Sexual minorities have an increased prevalence of mental disorders and comorbid psychiatric conditions, as well as an earlier onset and greater persistence of the disorder:

• Sexual minorities are more likely to have a lifetime history of mental disorder compared to heterosexuals.
• Sexual minorities are more likely to have a current mental disorder.
• Sexual minorities are at increased risk for psychiatric comorbidities across a broad spectrum of internalizing outcomes, including depression and anxiety disorders.
• Youth from sexual minorities are more likely to exhibit externalizing behavior, including alcohol, tobacco and multiple substance use.
• Sexual minorities have higher rates of comorbidity.
• Sexual minorities have onset in certain disorders at a younger age, namely depression in gay men and substance use disorders in lesbians.

What two processes have been proposed to explain the higher rate of mental disorders among sexual minorities?

• Unique, group-specific processes sexual minorities face as members of a stigmatized group. This approach, as discussed by the minority stress theory, emphasizes distal and proximal stress processes as predictors of psychopathology. Sexual minorities experience more stress than heterosexuals, for example through workplace employment discrimination and victimization. This increased exposure to stress may be responsible for higher rates of psychopathology among sexual minorities. 

• General psychological processes that have been shown to predict developmental and clinical outcomes in heterosexual samples. This research focuses on common psychosocial processes that sexual minorities share with their heterosexual peers. Sexual minorities have higher levels of certain common psychological risk factors for psychopathology.

Which group-specific processes can explain the higher rate of mental disorders among sexual minorities?

The MST states that sexual minorities are exposed to multiple forms of stressors, including discrimination, expectations of rejection, concealment/disclosure, and internalized homophobia. Stigma creates unique demands which can be especially stress-inducing. These additional stressors are believed to cause the differences in rates of mental health problems among sexual minorities. 

What is the distal-proximal distinction in the minority stress model?

Stigma-related stress has detrimental effects on the behavioral and mental health of sexual minorities. The MST distinguishes between distal and proximal stressors that have been shown to be more prevalent in sexual minorities and have negative effects on mental health. Distal stressors are prejudice-inspired events, including violence/victimization and discrimination. Proximal stressors are associated with identities that vary in the social and personal meanings that are attached to them, including self-stigmatization (or internalized homophobia), concealment and expectations of rejection.

How can general psychological processes explain the higher rate of mental disorders among sexual minorities?

General psychological processes, in this case, refer to established cognitive, affective, and social risk factors for mental health outcomes. Research in this area examines the psychological processes shared by sexual minorities and their heterosexual peers. Studies show that the general psychosocial processes that carry a risk of psychopathology are more prevalent in sexual minorities than in heterosexuals. LGBT populations show increased general psychological risk factors, including hopelessness, low self-esteem, emotional dysregulation, social isolation, permissive social norms for alcohol and tobacco use, and positive expectancies for drinking.

What is the psychological mediation framework?

The PMF integrates key observations from various literatures and highlights the interrelationships between group-specific and general psychological processes in the development of mental health disparities. It suggests that stigma-related stress makes sexual minorities more vulnerable to general psychological processes known to predict psychopathology. It argues that one risk factor is a consequence of the other and that both contribute to the pathogenesis of mental disorders in LGBT populations. It looks at unique stressors faced by sexual minorities, while emphasizing the common vulnerabilities in psychological and social processes that sexual minorities and heterosexuals share.

How can stigma-related stress affect mental health?

• Maladaptive coping/emotion regulation is triggered by exposure to chronic stigma-related stress and is a risk factor for depression and anxiety. Good emotion regulation is a moderator of the stigma-health association as well as a mediator of the stress-psychopathology relationship (stress leads to maladaptive coping which in turn carries risk for psychopathology). 

• Stressors negatively impact mental health by disrupting interpersonal relationships. Social support has been proven to be a protective mechanism for sexual minorities, but stigma-related stress may actually reduce social support among sexual minorities as it can lead them to isolate themselves from others to avoid future rejection. Sexual minorities have less social support than heterosexuals, including less family connection and adult care and less satisfaction with social support networks. Stigma-related stress predicts less social support, leading to an increase in depressive and anxious symptoms.

• General life stressors (and, in this case, stigma-related stressors) can affect mental health through their influence on cognitive processes. They can initiate changes in cognitions that cause risk for internalizing psychopathology. Cognitive risk factors for internalizing disorders resulting from stigma-related stress include hopelessness, pessimism, and negative self-schema.

How does ego-depleting explain how stigma-related stressors can lead to emotion regulation deficits in sexual minorities?

Both social exclusion and stigma are ego-depleting: a process in which exerting self-control on one task depletes one´s capacity for self-control and impairs performance on subsequent tasks that require the same resource. Stigmatized individuals use and exhaust self-control to manage their devalued social identity, which requires flexible use of emotion regulation strategies in the short term. Over time, however, the effort required can drain individuals´ resources and their ability to understand and adaptively regulate their emotions, making them more vulnerable to depression and anxiety.

What is the role of rumination in explaining the higher risk of depression and anxiety in sexual minorities?

Rumination is an emotion regulation response that may explain the association between stigma-related stress and internalizing disorders. It is defined as a maladaptive emotion regulation strategy in which an individual passively and repeatedly focuses on his/her stress symptoms and the circumstances surrounding these symptoms. Rumination is not only a risk factor for depression and anxiety, but also a consequence of general life stressors. Many factors contribute to rumination, including chronic stress, childhood sexual abuse, and stigma-related stress.

How can stigma and discrimination cause social isolation?

• Social exclusion leads to selective memories of negative social information, which becomes a source of avoidance of future interactions.
• People who are particularly alert to signs of danger and rejection often communicate these expectations to others, creating the very rejection they fear.
• The decision to hide one´s stigma can also lead to social avoidance and isolation.

How can stigma-related stress influence alcohol consumption among sexual minorities?

Scientific evidence in this area is limited, but existing research points to the following factors through which stigma-related stress can lead to alcohol use disorder among sexual minorities:

• Coping and emotion regulation. Stigma-related stress challenges an individual's coping resources, leading to the use of alcohol in an attempt to regulate negative affect. Also, stress is associated with stronger coping motives (the strategic use of alcohol to escape, avoid, or otherwise regulate negative emotions) for drinking. Finally, LGBT young adults have more positive alcohol expectancies than heterosexuals (positive expectancies about the effects of alcohol, e.g. that it will reduce tension).
• Social and interpersonal factors. Social norms, in particular, seem to account for the higher rates of alcohol use disorder among sexual minorities.
• Cognitive processes. Drinking motives and alcohol expectancies, e.g. alcohol can reduce the negative affect associated with stigma-related stressors.

How can the bar culture explain higher rates of alcohol consumption among sexual minorities?

Bars were a place the community often relied on for interaction, due to a lack of comfort and safety in heterosexual establishments. Bars are used as a primary social environment, which in turn leads to greater alcohol-related problems among sexual minorities. However, differences in alcohol consumption seem to emerge in adolescence, long before a bar culture emerges. More research is needed to determine whether specific stressors of stigma may play a role in the development of more permissive social norms. 

What is the alcohol expectancy theory?

According to this theory, the combination of strong positive outcome expectancies (expectations of positive and negative reinforcement from drinking alcohol, such as increased sociability and decreased tension) along with low negative expectancies (e.g. that alcohol will lead to cognitive or behavioral impairments) will lead to increased consumption and problems.

How does the PMF contribute to developing preventive interventions for sexual minorities?

Interventions are usually aimed at reducing stigma-related stressors, but more understanding is needed of the many psychosocial processes that stigma-related stress disrupts. The PMF makes two contributions to this: 1) it points to specific psychological processes that should be the target of prevention and intervention efforts, 2) by emphasizing the interrelationships between stigma-related stressors and general psychological processes, the framework provides important insights into how differences in psychiatric morbidity may persist without concerted attention to how each component of the model reinforces the other.

How does the PMF contribute to social/structural interventions?

In addition to social policy changes (allowing same-sex marriage, laws to prevent hate crimes), interventions are needed to change the social environments in which prejudice-driven stressors develop and/or are maintained, including work-place discrimination against LGBT adults, and school violence against young people from sexual minorities.

What does the PMF suggest for individual interventions?

There are few evidence-based treatments that address the unique mental health issues of sexual minorities. The PMF suggests that preventive interventions for depression and anxiety disorders in sexual minorities should focus on reducing the use of maladaptive coping strategies, such as rumination, and improving emotion regulation skills. With regard to alcohol problems, interventions that manipulate alcohol expectancies predict reductions in alcohol consumption.

What does the PMF suggest for joint interventions?

Group-specific stressors and general psychological processes are interrelated and mutually reinforcing, suggesting the importance of joint interventions. Because general psychological processes are triggered by stigma-related stressors, the focus on changing these processes at the individual level will gain little therapeutic traction if changes at the social level are not made simultaneously.

Why are not all minority groups at equal risk for psychopathology?

There are protective qualities associated with membership in a stigmatized group. Stress inoculation theories suggest that exposure to certain types of stress (e.g. those that are controllable) may lead to more resilient outcomes because individuals develop the resources necessary to adaptively respond to stress. Future research should look at psychosocial dimensions that may facilitate a better understanding of why some sexual minorities develop psychological problems as a result of stigma-related stress, while others do not experience psychological problems.